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PrintAsk me anything: Lymphoma
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Editor's note: The responses provided in this discussion are intended for educational purposes only and are not a substitute for medical advice from your healthcare team. Questions and responses have been edited for clarity and brevity. See the full discussion here.
By Mayo Clinic staff
Lymphoma is a cancer of the lymphatic system, which is part of the immune system. The lymphatic system includes organs, tissues and tube-like structures that fight, trap and filter foreign substances and waste in the body. Because lymphoma can originate from different immune system cells, there are many types and subtypes. Some types are more common in different age groups.
In the last 10 years, scientists have made significant progress in lymphoma research and treatment. "Throughout my career, I've had the privilege of seeing remarkable advancements in lymphoma treatment. From immunotherapy and targeted therapies to CAR-T cell therapy, these innovative approaches are transforming how we care for patients, offering new hope and better outcomes," says Allison Rosenthal, D.O., a Mayo Clinic Comprehensive Cancer Center hematologist-oncologist specializing in lymphoma.
Dr. Rosenthal answered Reddit users' questions about lymphoma treatment, early detection and the latest research during her "Ask Me Anything" event in November 2024. Here are the highlights:
What is lymphoma?
Q: What is lymphoma? What causes it? Have treatment options changed to be more effective, and how can they be further improved?
A: Lymphoma is the most common type of blood cancer, arising from white blood cells (immune system cells). It most commonly shows up as enlarged lymph nodes, but because it's in the blood, it can also show up in other places like the bones, skin and the gastrointestinal tract.
Treatment options for lymphoma have evolved to be more personalized in recent years. We still use chemotherapy, which is kind of a "dirty" way to fight lymphoma because it kills good cells, too, but we now have more targeted drugs. These drugs either target markers on the surface of lymphoma cells or block pathways that allow the cells to keep growing. We also have immunotherapies like CAR-T cell therapy or bispecific antibodies, which help the immune system find and destroy cancer cells.
Until no one dies from lymphoma or complications of its treatment, we have more work to do. I would love to see us find more precise ways to measure whether any lymphoma remains after treatment and fine-tune treatments to work better for patients with fewer side effects.
Detecting lymphoma early
Q: Lymphoma symptoms seem quite common. How do I know when to see a doctor?
A: The best advice I can give is to seek medical attention if you think something is wrong. You live in your body — no one else does — so it's your responsibility to self-advocate when needed. Generally, symptoms related to lymphoma are nonspecific (you're right) and can be seen with other diagnoses or health conditions. It may be helpful to consider the persistence of symptoms. If you have a cough for a week and other cold symptoms, it's probably not lymphoma. If you have a tooth or an ear infection and lymph nodes in your neck swell up, that may be an appropriate immune system response to an infection or inflammation. However, lymph nodes that get big and stay that way without a reason warrant a medical evaluation.
Q: What are some symptoms or signs that may go unnoticed? Are there preventive tests or anything that can be done early to detect or predict lymphoma?
A: Some common symptoms of lymphoma include fever, chills, drenching night sweats, swollen lymph nodes (usually painless), fatigue, cough and sometimes itching.
There are currently no recommended screening tests for any type of lymphoma. The cancers for which we have screening recommendations (colon, breast, cervical and lung cancer in select circumstances) are recommended because catching something small and early has been proven to help people. There is little to no risk with the screening procedure.
Q: My dad died of lymphoma. Is it hereditary?
A: I am sorry to hear about your dad and his experience with lymphoma. Mostly, lymphomas are not considered genetic or inheritable types of cancer. There might be some association in families with multiple members having chronic lymphocytic leukemia (CLL). There is also an increased risk in identical twins with Hodgkin lymphoma, suggesting a possible family link. There are no genetic tests for lymphoma risk, such as those we have for breast or colon cancer, which are known to have a genetic basis for increased risk and can run in families.
The latest lymphoma treatments
Q: How has lymphoma treatment evolved during your career?
A: In short, a lot. Some examples of big changes in the last 10 years include:
- Chronic lymphocytic leukemia (CLL): We used to give people with CLL chemotherapy first. Now, almost no one gets chemotherapy for CLL because targeted drugs work better and have fewer side effects. These drugs target proteins that control how cancer cells grow, divide and spread.
- Aggressive lymphomas: We now have about five new treatments for patients whose lymphoma relapses or doesn't respond to chemotherapy. These are immunotherapies that help the immune system find and kill cancer cells, including antibody drug conjugates, CAR-T cell therapy, bispecific antibodies and monoclonal antibodies.
- Mantle cell lymphoma: We used to offer stem cell transplants to all young, healthy patients with mantle cell lymphoma as part of their first treatment. However, stem cell transplants aren't used as much anymore because we have recently moved on to better post-chemotherapy maintenance strategies that don't require hospitalization. These include monoclonal antibodies and oral BTK inhibitor drugs. We also use CAR-T cell therapy for mantle cell lymphoma.
- Follicular lymphoma: We now use CAR-T cell therapy and bispecific antibodies to treat follicular lymphoma. We also have more options for some patients who have a short-term response to chemotherapy (less than two years).
- Hodgkin lymphoma: We just changed the optimal therapy for patients with stage III or IV Hodgkin lymphoma. For decades, everyone got ABVD (a chemotherapy combination that includes doxorubicin, bleomycin, vinblastine and dacarbazine) if they had Hodgkin lymphoma. In recent years we have started incorporating new drugs into first treatments like brentuximab vedotin or nivolumab which has improved response rates and decreased the likelihood of recurrence.
These are just some highlights. None of these advances would be possible without the willingness of patients and their families to participate in clinical trials and research. I want to thank all the patients and families who have helped us come this far. Even with all these improvements, those of us who work in academic medicine remain committed to improving outcomes for all patients with lymphoma.
Q: What are the benefits of CAR-T cell therapy compared to other forms of treatment?
A: CAR (chimeric antigen receptor) T cell therapy is currently approved for patients who have already had chemotherapy but experienced lymphoma recurrence. CAR-T can potentially be curative for some types of lymphoma, like diffuse large B cell lymphoma. For other types, like follicular lymphoma or mantle cell lymphoma, it can result in prolonged remission.
Many people think that undergoing CAR-T cell therapy means they won't need chemotherapy. However, chemotherapy is given just before CAR-T cell therapy to prepare the body to accept the new T cells.
One advantage of CAR-T cell therapy is that it's a "one-and-done" treatment, meaning you don't need to get it again. Another advantage is the completeness of the response and how long it can last. It may also work for lymphomas that were resistant to standard chemotherapy options.
Q: Is ABVD still the standard treatment for Hodgkin lymphoma? What’s the current treatment protocol for relapsed Hodgkin lymphoma?
A: This is a timely question as the treatment standards for Hodgkin lymphoma are changing for the first time in years. Right now, the standard treatment depends on the stage:
- Stage I or II Hodgkin lymphoma: We still use ABVD with or without radiation.
- Stage III or IV Hodgkin lymphoma: For several years, we have been using BV-AVD (brentuximab vedotin, doxorubicin, vinblastine and dacarbazine). We now have a new standard using Nivo-AVD (nivolumab, doxorubicin, vinblastine and dacarbazine).
The treatment for Hodgkin lymphoma that doesn't respond to chemotherapy or recurs depends on the patient's age and overall health. For younger, healthy people, we give a second combination of chemotherapy drugs followed by high-dose chemotherapy and an autologous stem cell transplant. The hope is that we can still cure many patients with this treatment plan. There are at least six different options for the second drug combination.
Q: What is the latest treatment for slowly growing follicular lymphoma?
A: The newest treatments for follicular lymphoma are available to patients who have had at least two prior treatments. These are:
- CAR-T cell therapy, a type of immunotherapy that involves modifying a patient's T cells to fight cancer cells better.
- Bispecific-antibody therapy, another type of immunotherapy that activates the immune system to fight lymphoma cells.
Q: My wife had large B-cell lymphoma of the cauda equina. It was not diagnosed or found until after her death. Have there been any advancements in catching this earlier? And how is it treated?
A: I'm sorry to hear your wife lost her life to lymphoma. The cauda equina is a bundle of nerves at the bottom of the spinal cord that looks like a horse's tail (that’s how it got its Latin name). Rarely, lymphoma can infiltrate those nerve roots. This causes problems controlling the lower part of the body, including movement, sensation and messaging to the bowel or bladder. We consider this central nervous system involvement of lymphoma, so we need to use medications that get into the nervous system. The main drug we use is methotrexate, but if symptom onset is fast, radiation can also be used to help with cancer and symptom control. There is also some evidence that CAR-T cell therapy can treat lymphomas that involve the nervous system.
Learn more
Learn more about lymphoma and lymphoma care at Mayo Clinic.
Find a clinical trial at Mayo Clinic.
Join the Blood Cancers and Disorders Support Group on Mayo Clinic Connect, an online community moderated by Mayo Clinic for patients and caregivers.
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