The Nebraska Medical Center has been an international leader in the treatment of lymphoma for decades. Dr. James Armitage explains how medication and bone marrow transplants are used to treat lymphoma. For more information about the internationally known lymphoma program, call 1-800-922-0000 or visit http://www.nebraskamed.com/services/cancer/lymphoma/default.aspx
Lymphomas are cancers of the immune system. It’s sometimes harder to think about that that a cancer of the stomach or breast or lung because you can’t see the immune system. But those are the cells that spread throughout your body whose job is to protect you from germs. But those cells can catch cancer just like any other part of you can. When the immune system catches cancer, the cancer’s either called (usually) a lymphoma or a leukemia, and then sometimes myeloma.
The lymphomas are the solid tumors of the immune system and leukemia’s are the cancers where the cells find the blood and bone marrow. Essentially, all of these diseases can present either as lymphoma or leukemia. We now subdivide them in many many ways; the way they look, based on their clinical symptom, based on all sorts of biological measures of the genes in the cancer cells. And those subdivisions have helped us to take better care of patients because we can find the best treatment for a specific group. The most common lymphomas are Diffuse Large B-Cell lymphoma, the most common. And afflictura lymphoma, the next most common, and Hodgkins, the next most common, but there’s many many different types.
Lymphomas are not rare cancers; immune system cancers overall occur more than 100,000 times a year in the United States. About 70 some thousand of those are lymphomas, or solid tumors of the immune system. And they’re probably the fifth most common kind of cancer.
We treat patients from all around America and patients from all continents. We have carried out a number of important trials in both the biology and treatment of lymphoma patients. We’re one of the first places to become seriously involved in trying to sort out where transplantation fits into the treatment of patients with lymphoma and we still do a large number of transplants for patients who either have a high risk or relapse of lymphoma.
Transplants for lymphomas can be in a whole variety of ways. One distinction between a transplant, that’s really a transplant (where the cells come from a different person). There are times where we do that, but that’s the minority of those treatments for patients with lymphoma a great majority; it’s called an auto (autologus) transplant. So that’s not really a transplant; you take out somebody’s cells (I would argue that we’re the place that figured out how to use cells derived from the blood, which has made the blood much easier and safer actually), but you take those cells out (normal, healthy, metaplacic cells), freeze them, and then you administer some or another combination of intensive therapy with very high doses of drugs which would cause an irreversible injury to the bone marrow. But then, when the treatment is done and the drugs are gone from the body, you rein fuse those now-thawed bone marrow stem cells and they reestablish bone marrow function, and if you have good fortune, you’ve cured somebody who couldn’t otherwise be cured. We know that for certain patients, for example relapse Diffuse Large B-Cell lymphoma or many patients with relapse Hodgkins lymphoma, that’s the best treatment. Is the one most likely to cure you of the disease. And there are a number of many other types of lymphomas where I think we have good data to say it’s an excellent therapy. For example, patients with recurrent Follicular lymphoma.
Different chemo therapy regiment is how most patients with lymphoma can be treated. Some of those really work well and we cure the majority of people, some have a lot to be desired and we’re studying new drugs. And then there are some set of patients who have lymphoma that are less progressive, that grow less rapidly; they’re not making the person ill and particularly if the person is older, the best thing to do might be no specific treatment at all and just watch the situation closely. So it’s not simple how to treat people with lymphoma; there’s lots of different things, there’s lots of different diseases, you can’t treat anyone well unless you know what they have for sure and so you need to have expert amount of pathology and we have among the best in the world here. And so that combination of things is necessary to do the best by patients who have the misfortune to develop a lymphoma.
If you take the Diffuse Large B-Cell lymphoma, which is the most common lymphoma, and we’ve gone from in the 70’s where the cure-rate was probably in the 40’s of percent (or something like that) to today (the cure-rate is almost twice that, for patients with Diffuse Large B-Cell lymphoma, but it’s actually pretty hard to go back and compare because we’re so much better at making the diagnoses now and studies from a long time ago lumped people with different things together. But there’s no question that the results have improved considerately.
We have a lot of other missions here; one is to teach young people to be physicians. And you’re not going to do a good job at teaching them if you’re not showing them how to practice excellent care, and that involves treating patients really well. I feel very badly if patients that we care for don’t feel like they became our friends and we watched out for them. Another thing is straight advanced knowledge; that could be understand the biology of the disease, that could be studying a new drug, that could be finding a better way to use old treatments like standard regiments or transplants. But that’s a really important mission for an academic medical center and for us a really big deal; we’ve published hundreds and hundreds of papers about lymphomas over the years and I hope they have helped advance our ability to understand and treat patients with the disease.
Over the years, we made a big effort to try and understand the most effective, most efficient nicest way to care for patients with these diseases. Particularly, we’re focusing on transplant patients who are here for a long time. And what we did after several iterations was build this building called the Lied Transplant Center, which has patients bedrooms (basically), that were designed by patients, and we now do most of our transplants where patients stay there with a family member, go to a 24-hour day, seven-day a week day hospital (it’s really a hospital, but it’s something you’re going to stay in; stay independently) and that’s the way we deliver care for transplants. And for a number of other situations. It’s a wonderful way to work; the patients, places to stay, our offices, the clinic and the hospital are all within a few feet of each other. Most of the time you move back and forth by elevator. It’s really a wonderful way to practice and I think patients think it’s a wonderful way to get care.
I think that being able to retain some control over your life during the transplant process (for example) is, for most people a really an important thing, as opposed to lying in a hospital bed. We do that too, of course, if you get really sick, you end up in a hospital bed and I think our nursing team is wonderful and you get watched out for in a very good way. But being able to stay out of the hospital and retain some control over your life and be an active participant in your care, is required to make a system like this work. I think it’s something most patients really appreciate.