Treatment options for Hodgkin’s disease depend on:
- Type of Hodgkin’s disease
- Tumor stage, size, and location
- Patient’s age and overall health status
- Presence or absence of “B symptoms” (weight loss, persistent fever, night sweats)
Certain factors may determine whether more intensive treatment is required. For example, the presence of B symptoms and “bulky” (large mass) tumors usually indicates a more aggressive treatment approach.
Chemotherapy and radiation are the main treatments for Hodgkin’s disease. Stem cell transplantation or a biologic drug may be recommended for patients whose cancer has recurred.
Hodgkin’s disease is staged (I through IV) depending on how far the cancer has spread. Staging is the primary method for determining both treatment options and prognosis.
Stage I. Disease is limited to a single node region (I) or has involved one neighboring area or a single nearby organ.
Stage II. Disease is limited to two or more lymph nodes on the same side of (above or below) the diaphragm or extends locally from the lymph node into a nearby organ.
Stage III. Disease is in lymph nodes on both sides of the diaphragm or has spread to nearby organs, the spleen, or both.
Stage IV. Disease has become widespread involving organs outside the lymph system, such as liver, lung, or bone marrow.
Treatment Options by Stage
Early Stages (I or II). Hodgkin’s disease in stages I or II is usually treated with chemotherapy followed by radiation.
Later Stages (III and IV). Hodgkin’s disease in stages III and IV is usually treated with chemotherapy alone. .
Relapsed Hodgkin's. Treatment is considered successful when the signs and symptoms of cancer disappear. This is referred to as remission. Cancer that does not respond to treatment is called refractory or resistant. Cancer that recurs after remission is called relapsed. Treatments for refractory or relapsed Hodgkin’s include high dose chemotherapy with stem cell transplantation. Patients who are not good candidates for transplantation or who have not been helped by it may benefit from treatment with the biologic drug brentuximab (Adcetris).
Preparing for Side Effects before Treatment
Preventing Infection. Both the disease and some of the treatments suppress the immune system, increasing the risk for infections. Widespread, life-threatening infection is a particular danger if the spleen has been removed and both radiation and chemotherapy are administered. Patients should be vaccinated against pneumococcus, meningococcus, and Haemophilus influenza bacteria before receiving treatment.
Preserving Fertility. Patients who may wish to have children in the future should ask their doctors about fertility-preserving treatments. It is very important to have these discussions before cancer treatment starts. The American Society for Clinical Oncology (ASCO) has guidelines for the best fertility preservation methods for male and female cancer patients. For men, ASCO recommends banking and freezing sperm (sperm cryopreservation) for later use in assisted reproductive therapies.
For women, egg (oocyte) cryopreservation is recommended. This procedure involves harvesting and freezing a woman's eggs (oocytes), and can be followed by in vitro fertilization and freezing of embryos for later use. It requires several weeks of pre-treatment with ovarian stimulation drugs, so timing is very important. For women who will receive radiation therapy to the pelvic region, a surgical procedure that moves the ovaries out of the path of radiation (ovarian transposition) can also help preserve fertility.
Monitoring after Treatment
Relapse of Hodgkin’s disease is not uncommon, even after treatment for early stages. It can occur a decade or more after treatment. Relapse is more likely to occur in early-stage disease, probably because limited radiation normally used in such cases does not destroy all malignancies. Patients who had large tumors in the chest are also at higher risk for recurrence.
Patients need periodic examinations and imaging tests for years after treatment, both to check for signs of relapse as well as to monitor the long-term effects of treatments.
Treatment of Pregnant Women
Because Hodgkin's disease often occurs in young adults, treatment for pregnant women is of particular concern. Therapy must be effective enough to protect the mother without hurting the fetus. Chemotherapy is rarely used early in the term, because it poses a risk for birth defects.
Treatment choice must be individualized, taking into consideration the mother's wishes, the severity and pace of the disease, and the remaining length of the pregnancy. The treatment plan may need to be changed as the pregnancy progresses. If the disease develops in the second half of the pregnancy, it may be possible to postpone chemotherapy or radiation therapy until after an early induced delivery.