Non-Hodgkin's Lymphoma Treatment Guidelines for Patients – Version II, December 2004

Introduction

With this study, patients have access to information on the way non-Hodgkin’s
lymphoma is treated at the nation’s leading cancer centers. Originally developed for cancer specialists by the National Comprehensive Cancer Network (NCCN), these treatment guidelines have now been translated for the public by the American Cancer Society (ACS). To obtain a printed copy of these guidelines, as well as more information, call the American Cancer Society at 1-800-ACS-2345 or the NCCN at 1-888-909-NCCN, or visit these organizations’ Web sites at www.cancer.org (ACS) and www.nccn.org (NCCN), or visit these organizations' Web sites at www.cancer.org (ACS) and www.nccn.org (NCCN).

Since 1995, doctors have looked to the NCCN for guidance on the highest quality, most effective advice on treating cancer. For more than 85 years, the public has relied on the American Cancer Society for information about cancer. The Society’s books and brochures provide reliable cancer information to hundreds of thousands of patients, their families, and friends. This collaboration between the NCCN and ACS provides an authoritative and understandable source of cancer treatment information for the public.

These patient guidelines will help you better understand your cancer treatment and your doctor’s advice. We urge you to discuss them with your doctor. To make the best possible use of this information, you might ask your doctor the following questions:

• What type of non-Hodgkin’s lymphoma do I have?
• What stage is it?
• Is it a fast growing lymphoma?
• How do the stage and type of lymphoma affect my outlook for cure?
• What are my treatment options?
• What are the risks or side effects associated with each treatment and how will they affect my quality of life?
• What can I do to prepare myself for treatment, reduce side effects, and hasten my recovery?
• When will I be able to return to my normal activities?
  

Making Decisions about Non-Hodgkin's Lymphoma Treatment

In the United States, about 54,370 people (28,850 men and 25,520 women) will be diagnosed with non-Hodgkin’s lymphoma this year. These figures include both adults and children. It is the fifth most common cancer in the United States, excluding nonmelanoma skin cancers.

Although some types of non-Hodgkin’s lymphoma are among the most common childhood cancers, over 95% of non-Hodgkin’s lymphoma cases occur in adults. The average age at diagnosis is in the 60s. The risk of developing most types of non-Hodgkin’s lymphoma increases throughout life, and the elderly have the highest risk.

Although non-Hodgkin’s lymphoma is a serious disease, it can be treated and, in some cases, cured. Care should be provided by a team of health care professionals who are experienced in treating non-Hodgkin’s lymphoma. This team may include a surgeon, medical oncologist, radiation oncologist, pathologist, oncology nurse, radiologist, and social worker often along with your primary care doctor.

This information is written to help you understand your options for treatment of non-Hodgkin’s lymphoma so that you and your cancer care team can work together to decide which treatment best meet your needs.

On the following pages you’ll find flowcharts that doctors call ”decision trees.” The charts represent the most common types of non-Hodgkin’s lymphoma, and each one shows how you and your doctor can arrive at the choices you need to make about your treatment. There are other types of non-Hodgkin’s lymphoma. They are discussed along with treatment on the ACS Website at www.cancer.org.

To reach an informed decision, you will need to understand some of the medical terms that your doctors use. You will find information on what is non-Hodgkin’s lymphoma, the different types of non-Hodgkin’s lymphoma, how lymphoma is diagnosed, staging, and treatment. We've also provided a glossary of medical terms. Words in blue italics are defined in the glossary. When you click on these terms, their definitions will appear in a small pop-up window.

What Is Non-Hodgkin's Lymphoma?

Non-Hodgkin's lymphoma is cancer that starts in lymphoid tissue (also called lymphatic tissue). Lymphoid tissue is the main part of the immune system. It is formed by several different types of cells that work together to fight infections. These cells also react to foreign tissue (such as a transplanted organ). Most of the time they are found in bean shaped organs called lymph nodes.

Other types of cancer can develop in other organs and then spread to lymphoid tissue. But these cancers are not lymphomas. For example, cancer that develops in the lungs and then spreads to the lymph nodes is still called lung cancer. Lymphomas start from lymphocytes in either lymph nodes or other sites of lymphoid tissue such as the bone marrow and can spread from there.

There are 2 main types of lymphomas. Hodgkin’s lymphoma (or Hodgkin’s disease) is named after Dr. Thomas Hodgkin, who first described it. All other types of lymphoma are called non-Hodgkin’s lymphoma. The non-Hodgkin’s lymphomas are very different from Hodgkin’s disease in how they develop and spread and in how they are treated. The information here refers only to the different types of non-Hodgkin’s lymphoma. Each type varies in how it is treated and how it responds to treatment.

Lymphoid Tissue

The main cell type found in lymphoid tissue is the lymphocyte. The 2 main types of lymphocytes are B lymphocytes (or B cells) and T lymphocytes (or T cells). Although both types can develop into lymphomas, B-cell lymphomas are more common. B-cell lymphomas account for 85% of cases of non-Hodgkin’s lymphoma; T-cell lymphomas make up the other 15%.

Normal T cells and B cells do different jobs within the immune system. B cells help protect the body against bacteria by producing immunoglobulins (also called antibodies). The antibodies attach to certain substances on the surface of bacteria and attract certain immune system cells that kill the antibody-coated bacteria.

T cells help protect the body against viruses, fungi, and some bacteria. They recognize specific substances found in virus-infected cells and destroy these cells. T cells can also release substances called cytokines. that attract certain other types of white blood cells, which then digest the infected cells. T cells are also thought to destroy some types of cancer cells, as well as the cells of transplanted organs. Some types of T cells play a role in helping or blocking the work of other immune system cells.

There are several types of T cells, each with a special job, and there are also several stages of B-cell and T-cell development. Each type of lymphoma tends to look like one of the normal lymphocytes at a certain level of development.

This information is helpful because knowing the type of lymphoma a person has is the first step in considering treatment options. So, learning about lymphocytes is the first step in understanding lymphomas, their diagnosis, and their treatment.

Organs That Contain Lymphoid Tissue

Lymph nodes are small, bean-shaped organs found throughout the body and connected by a system of lymphatic vessels. These vessels are like veins, except that instead of carrying blood, they carry lymph (a clear fluid containing waste products and excess fluid from tissues). They also carry immune system cells traveling to lymph nodes from other tissues.

Lymph nodes increase in size when they fight an infection. Lymph nodes that grow in reaction to infection are called reactive nodes (or hyperplastic nodes) and are often tender to the touch. An enlarged lymph node is not usually serious. People with sore throats or colds often have enlarged lymph nodes in the neck. But a large lymph node is also the most common sign of lymphoma.

The spleen is found under the lower part of the rib cage, on the left side of the body. An average adult spleen weighs about 5 ounces. The spleen contains lymphocytes and other immune system cells to help fight infection. It stores healthy blood cells and filters out damaged blood cells, bacteria, and cell waste.

The thymus gland is located in the front of the chest at the base of the neck. While a fetus is growing in the mother’s uterus, the thymus plays a vital role in producing T lymphocytes. The thymus gland’s size (about 1 ounce) and activity peak between 1 and 20 years of age. Although its size and role decline with age, the thymus continues to function throughout life as part of the immune system.

Adenoids and tonsils are collections of lymphoid tissue located at the back of the throat. They produce antibodies against germs that are breathed in or swallowed. They are easy to see when they become enlarged during an infection or if they become cancerous. The stomach and intestinal tract also contain lymphatic tissue.

The bone marrow (the soft inner part of bones) produces red blood cells, blood platelets, and white blood cells, including lymphocytes. Red blood cells carry oxygen from the lungs to the rest of the body. Platelets plug up small holes in blood vessels caused by cuts or scrapes. The main job of white blood cells is fighting infections. In addition to lymphocytes, the other main type of white blood cells is the neutrophil (also known as granulocytes, or “polys”).

The entire report is also available as a PDF file:

NCCN NHL Guidelines.pdf 715 k

You will need Adobe Acrobat to read this file.  Click here to download a current version.

TYPES OF NON-HODGKIN'S LYMPHOMA

The mutual goal of the National Comprehensive Cancer Network® (NCCN®) and the American Cancer Society (ACS) partnership is to provide patients and the general public with state-of-the-art cancer treatment information in understandable language. This information, based on the NCCN's Clinical Practice Guidelines, is intended to assist you in the dialogue with your physician. These guidelines do not replace the expertise and clinical judgment of your physician. Each patient's situation must be evaluated individually. It is important to discuss the guidelines and all information regarding treatment options with your physician. To ensure that you have the most up-to-date version of the guidelines, consult the web sites of the ACS (www.cancer.org) or NCCN (www.nccn.org). You may also call the NCCN at 1-888-909-NCCN or the ACS at 1-800-ACS-2345 for the most recent information.

NCCN Clinical Practice Guidelines were developed by a diverse panel of experts. The guidelines are a statement of consensus of its authors regarding the scientific evidence and their views of currently accepted approaches to treatment. The NCCN guidelines are updated as new significant data become available. The Patient Information version will be updated accordingly and will be available on-line through the NCCN and the American Cancer Society web sites. To ensure you have the most recent version, you may contact the American Cancer Society or the NCCN.

© 2005 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes or downloaded and stored in any information-retrieval system without the express written permission of the NCCN and the ACS. Single copies of each page may be printed out for personal, noncommercial use only.