Hodgkin's Lymphoma in the Young African American Population



Hodgkin's Lymphoma in the Young African American PopulationMonique P. VeneyCoppin State UniversityHodgkin's Lymphoma in the Young African American PopulationRecently while watching an episode of The Dr. Oz Show, I was drawn into the program by one of its guests. On the stage with Dr. Mehmet Oz, was legendary talk show host Montel Williams. Long known for his days battling tough issues on the airwaves and his own recent struggles with multiple sclerosis (MS), Montel was there for a different medical reason this time. Montel Williams’ daughters, Maressa Williams, had recently been diagnosed with Hodgkin’s Disease. As a celebrity figure, many of whom are often the target of sensationalistic tabloid stories and rumors, Montel and his daughter wanted to come on The Dr. Oz Show to tell her story first and to help others who may be affected by the disease and not know it. Maressa herself was not even aware that she had cancer until car accident landed her in the hospital with the need for additional radiologic imaging. Ms. Williams’ was experiencing still experiencing back pain from the accident and the doctors did an MRI and which revealed a surprising to find a Stage 2 Hodgkin’s lymphoma growth.While the diagnosis of cancer is a life altering shock to most anyone’s state of being, to be diagnosed with this disease while being evaluated for a completely different reason is what one may consider a “double-whammy.” In this instance is a young woman at 24 years old in what many consider the prime of life, going to nursing school and seemingly enjoying life, being diagnosed with cancer. Coincidence or not? As I will go on to discuss in this paper, Maressa Williams’ case is not so atypical. She actual is one of the “picture perfect” prototypes for diagnosis with this type of cancer. She fits the profile of associated risk factors that is considered consistent in those diagnosed with Hodgkin’s Lymphoma (HL) or Hodgkin’s Disease (HD). She is young, of mixed race (black and white), and has a significant family history of cancers. In this discussion we will briefly explore the pathophysiology and diagnosis of Hodgkin’s, the epidemiology of the disease and its effects on the young, organizations that have taken an interest in research and education of the disease and role of the nurse practitioner in diagnosis, education and treatment of those with Hodgkin’s.Hodgkin’s Disease or Hodgkin’s Lymphoma as it is more commonly referred to, is a form of cancer involving the lymphatic system and lymphatic organs including the lymph nodes, spleen, bone marrow and other lymphoid tissue (Sommers, 2011). This disease was first identified by British pathologist, Thomas Hodgkin in 1832, for whom the disease was named. During that time Sir Hodgkin identified a number of individuals exhibiting similar symptoms that involved the lymph nodes and lymphatic system. Through further research and study of these individuals, Sir Hodgkin surmised that this type of cancer was progressive in nature and was always distinguished by the presence of a particular type of white blood cell, a B-lymphocyte called the Reed-Sternberg cell (McCance, Huether, Brashers, & Rote, 2010). Hodgkin’s lymphoma is further divided into subtypes and stages (1-4) that are valuable for diagnostic purposes and in treatment options. Hodgkin’s subtypes and staging are also purposeful for predictive value in curing the cancer. The earlier the stage at diagnosis (stage 1 vs. stage 4) and the less differentiated and diffuse the cancer cells are throughout the lymphatic system, the greater the chance survival (McCance et al., 2010). The American Cancer Society lists the 1-year, 5-year and 10-year survival rates, in general, at 92%, 85%, and 80%, respectively, due to earlier detection and advances in treatment and research.The American Cancer Society estimates on their website that in 2013 there will be nearly 9,300 diagnosed new cases of Hodgkin’s disease in the United States and nearly 1,200 people will die from it (). The typical demographic profile of an individual diagnosed with Hodgkin’s is a young person aged 15-35. Incidence of HL does again, however, increase in individuals over the age of 55. Men are more commonly diagnosed with this form of cancer than are women and whites more frequently than blacks and other ethnic groups (Sommers, 2011), however blacks have decreased survival rates as with many other forms of cancer. The prevalence of Hodgkin’s is also presumably associated with a family history of cancer although no specific genetic link has been established. Another common risk factor that is frequently associated in individuals who are diagnosed with HL is a past history of infection with Epstein-Barr virus (EBV) as in those who have had mononucleosis. In a significant number of patients who have Hodgkin’s, EBV antibodies have also been identified (Sommers, 2011). The link between EBV and Hodgkin’s is not conclusive but is strongly suggestive in many references.Hodgkin’s Lymphoma has been well studied and many treatment options exist that make the likelihood of long-term survival great. In that same vein, there are many organizations, resources and agencies that have taken initiatives to educate individuals diagnosed with the disease and the general public. Among them are the American Cancer Society (ACS) whose website is replete with information on many various types of cancer, Hodgkin’s included. The information on the ACS site generally gives an in-depth description of the disease itself, including associated risk factors and statistical information. The site also describes treatment options to include the latest in research and clinical trials information. The information the ACS provides is in language simple enough for the lay public to grasp and to begin their research, however, it should be noted and explained to patients that internet sources, no matter how trusted, should never replace the advice of a healthcare professional that specializes in treatment of HL. Likewise, the Leukemia & Lymphoma Society (LLS), whose mission is to “cure leukemia, lymphoma, Hodgkin’s disease and myeloma, and improve the quality of life of patients and their families”, publishes a booklet on Hodgkin Lymphoma. Their mission statement alone encompasses the substance of their publication. The website & book is a resource for individuals and their families living with the diagnosis of HL. This publication also has information on the epidemiology of the disease, research and treatment options as well as a hotline telephone number where individuals can connect with trained specialists from the LLS. These specialists are a team of oncology professional who can offer information along with assistance in navigating the insurance costs associated with treatment (Leukemia & Lymphoma Society, 2011). Although the ACS and the LLS are two of the more prominent organizations that focus on helping individuals with the disease, there are a host of other agencies such as the Centers for Disease Control and Prevention (CDC), a governmental agency that protects the health of the nation through disease control and prevention measures. More commonly associated with the regulation and containment of communicable diseases, the CDC also provides education and research for non-communicable diseases. The CDC also monitors epidemics or outbreaks of disease to ensure that there are no environmental factors that contribute to a particular rash of disease for a specific population. An internet search turned up other agencies and organizations that explore and support persons diagnosed with HL such PearlPoint Cancer Support. There were no specific agencies aimed at meeting the needs of the young African American patient, however, local resources and web-based blogs can be helpful resources for this population. For any person having been diagnosed with cancer, treatment and support are paramount, however, when a person is young and of an underserved population, the barriers to accessing healthcare and support are multiplied even more. For starters, the very young have different emotional components that have to be addressed. These include feelings of being different from others in their peer group and the alteration in body image that HL cancer diagnosis and treatments will bring. It is well known that most young adults don’t particularly want to be singled out from others in their peer groups. Young adults and teens in particular tend to assimilate with pop culture and what is considered “the in thing” at any given time. Their goal is to fit in as not to appear different from any of their peers. A diagnosis of just about any kind of cancer surely would make them look and feel different. Some of the associated symptoms of HL alone such as fever, fatigue and unintentional weight loss would make them standout from their peer group. The fevers and fatigue may preclude them from being able to participate in normal activities they enjoy such as school, work and socializing. Then there are the multitude of appointments to doctors and specialists for treatment that may also interfere with their normal life and activities.A second very important issue to consider is the perceptions these persons have of themselves once they are diagnosed and then in treatment. These feelings can include guilt, depression, and feelings of low self-worth and body image disturbances related to the effects of the disease itself and the treatments. Chemotherapies used in cancer treatment are notoriously linked to alopecia or hair loss in patients. They not only kill diseased cells but they also manage to sometimes kill healthy cells such as those responsible for hair growth. In fact, one of the biggest fears and concerns 24 year-old Maressa Williams had regarding cancer treatment was losing her thick, long hair. She is not alone. Many cancer patients are warned at the outset of treatment that certain chemotherapeutic agents will cause hair loss from their heads and other places on their bodies. In Diseases and Disorders, the author suggests “having a wig, scarf or hat to cover any hair loss” (Sommers, 2011, p. 462) that may occur from treatment. There are other unpleasant side effects of treatment that Sommers also mentions such as dry mouth, nausea and vomiting, and skin irritation that may also play a role in patients’ perceptions of themselves. The key is to make sure these patients know that they are not alone and that many, if not most, of these symptoms can be managed. The suggestion of support groups should be continually mentioned and encouraged during all phases of diagnosis and treatment (Sommers, 2011).Patient attitudes and perceptions regarding their diagnosis is not the only barrier that may negatively impact those of underserved populations with this disease. Many cancer treatments tend to be lengthy in nature as well as expensive running into the hundreds of thousands of dollars depending on recommended course of treatment and associated procedures. While some patients are fortunate to have health insurance that will cover the cost of treatment, some individuals of our defined population may not. Not having access to healthcare whether it be for financial or other social factors is a huge barrier that exists in many of our underserved communities and populations. Many individuals that are either young or uninsured may mistakenly “explain away” the symptoms they are experiencing because of either fear or ignorance about the impact a cancer diagnosis can have on their lives. Although Hodgkin’s Lymphoma statistically doesn’t strike those of African American descent in the greatest numbers, racial disparities still exist when it comes to survival rates. In a 2012 Annals of Oncology published report, blacks and Hispanics aged 15-44, had a much lower survival rate than whites in the same age and socioeconomic status grouping (Evens, Antillion, Aschebrook-Kilfoy, & Chiu, 2012). The article aimed to explore various factors (age, race, gender) in the incidence and diagnosis of HL and the disparities that exist when these factors are taken into consideration. However, the article stopped short of definitively identifying race alone as a factor in decreased survival rates, but it did allude to lack of access to care and delays in seeking treatment as likely contributors (Evens et al., 2012).As with most disease processes, the nurse practitioner’s role in regards to Hodgkin’s is essential. Nurse practitioners (NPs) are first-line caregivers meaning they may be the first contact with a primary caregiver that someone having Hodgkin’s associated symptoms may seek. It is imperative for the NP to be educated about the disease in general although he or she may not be the caregiver providing treatment for cancers. NPs are primary caregiver of choice for a growing number of individuals and many diseases including cancers are detected in the earlier and most treatable stages by thorough and consistent history-taking and physical assessment. According to Mosby’s Guide to Physical Assessment, subjective HD symptomatology that may be taken in a history of present illness may commonly include “painless enlarged lymph nodes, abdominal pain, sometimes with fever, [and a] history of infectious mononucleosis” (Seidel et al., 2011, p. 234). A nurse practitioner’s own objective physical assessment may include painless cervical lymph node enlargement and unilateral firm “almost rubbery” lymph nodes according to those same Mosby’s assessment guidelines. Other signs and symptoms that may alert the NP to the possibility of a HD or HL diagnosis include: unexplained fever, unintentional weight loss, night sweats, fatigue, itching, and sensitivity to alcohol to name a few as mentioned in various sources detailing Hodgkin’s Lymphoma (Leukemia & Lymphoma Society, 2011). In instances where these symptoms alone or in conjunction with one another cannot otherwise be explained, the practitioner would be well off to order blood work and refer the client to an oncologist who is specialized to biopsy & definitively conclude the diagnosis of Hodgkin’s. The practitioner should err on the side of caution of individuals who fit the “typical Hodgkin’s profile,” (age, ethnicity, family history, past medical history). Although any or many of the of the subjective and objective symptoms presenting alone could account for a multitude of disease processes, when seen in a cluster, a differential diagnosis should include and more attention should be paid to these as possible indication of Hodgkin’s. The family nurse practitioner is not be the health care provider that specializes in diagnosis or treatment of cancers of any origin, however education, prevention and screenings are all in the NP’s scope of practice and responsibilities to the clientele they serve especially in underserved populations. Another area in which the NP can be beneficial in disease prevention is in the research arena. Many opportunities exist for research work to be done by advanced practice nurses on cancer and other diseases. Since nurses are often at the forefront of disease prevention and education, nurse practitioners should also be at the helm in researching diseases affecting the communities and populations they serve. The lack of trust some underserved populations have with the health care system that often precludes them from seeking early care, could potentially be combatted with nurses (well trusted professionals) leading the way in research and education. Nurse practitioners acting as legislative agents for change to a healthcare system that often discriminates against the poor, uninsured and disenfranchised would also be a major benefit to underserved populations and increase the likelihood and incidence of survival from this form of cancer.Hodgkin’s Lymphoma, a cancer of the lymphatic system, is by no means a death sentence if detected and treated in the earlier stages. As TV show host and real life physician Dr. Oz alluded to, it would be one of the “better” cancers to be diagnosed with because of its treatment success and higher rates of cure than many other forms of cancer. As some research has suggested, these survival rates are different when comparisons are made based on race and age. Nurse practitioners working in and with underserved communities and populations have the unique advantage of being able to alter these age and racial disparities by knowing the risk factors, screening for and educating the clientele they serve, thus improving survival rates and outcomes.ReferencesEvens, A. M., Antillion, M., Aschebrook-Kilfoy, B., & Chiu, B. C. (2012, January 11). Racial disparities in Hodgkin’s lymphoma: A comprehensive population-based analysis [Original article]. Annals of Oncology, 1-10. & Lymphoma Society. (2011). Hodgkin lymphoma. White Plains, NY: Leukemia & Lymphoma Society.McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2010). Alterations of cardiovascular function. In Pathophysiology: The biologic basis for disease in adults and children (6th ed., pp. 1091-1208). Maryland Heights, MO: Mosby Elsevier.Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Chapter 9 Lymphatic system. In Mosby’s guide to physical examination (7th ed., pp. 213-237). St. Louis, MO: Mosby Elsevier.Sommers, M. S. (2011). Diseases and disorders: A nursing therapeutics manual (ed.). Philadelphia, PA: F.A. Davis. ................
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