Ask the Expert: Hodgkin Lymphoma | Transcript | Hodgkin Lymphoma | Patient Power


Ask the Expert: Hodgkin Lymphoma

Beth Kart Probert:

Well, and the second part was do you think there's a higher chance of relapse once you have done that before and became refractory?  So you might have wrapped that up in the first part of it.  It was basically would someone have a higher chance of relapse?   

Dr. Burke:

So if a patient has primary refractory Hodgkin lymphoma the question is is that patient at higher risk of relapse after getting into remission than somebody who doesn't have primary refractory Hodgkin lymphoma but has just relapsed later, and the answer is that it's better not to be primary refractory. That is, if I have Hodgkin lymphoma and I get chemo and I go into remission for two years and then I relapse, my prognosis is better than someone who didn't respond at all to that initial therapy but then eventually did get into remission and get a transplant.  So that's the prognostic significant of that primary refractory disease.  

Beth Kart Probert:

Okay. Thank you.  Moving on to the next question.  Could collecting stem cells for autotransplant while in PR or stable disease lead to relapse due to cancer cells being collected as well?  

Dr. Burke:

I mean, I think the answer is yes.  That's sort of the theoretical risk of collecting stem cells.  And most transplanters that I work with—and I will say I'm not a transplanter, I don't do that—but they prefer that their patients be in complete remission when they collect stem cells who then go on and do a transplant.  You know, I think it's an individualized decision on whether to take a patient who is responding to salvage therapy and getting into a partial remission but still has some residual disease and historically that kind of patient has been acceptable to undergo an autologous transplant.  

That said we have more options for effective drug therapies now than we did 10, 15, 20 years ago when autologous transplants were being done without those options.  And so it maybe 10, 15, 20 years ago we would just take a patient who was in partial remission and transplant them.  In my experience and the transplant docs that I work with, we will often not accept a partial remission if that's what we get at the start, and we'll try to use another cocktail and use another regimen to get a patient into a complete remission before going on to collect cells and do a transplant.  But sometimes you don't have a choice and you do the best you can with a partial remission. 

Beth Kart Probert:

Thank you. That was very interesting.  Our next question.  So could you talk about the emerging evidence which is showing prior anti?PD?1 therapy seems to translate to a greater sensitivity to chemotherapy in general and also to a higher PFS in allogeneic transplant.  Let me know if you'd like me to repeat that. 

Dr. Burke:

Well, I'm more familiar with the first part of the question, which is that there's some data that's come out at the last couple of meetings suggesting that patients who are treated with a checkpoint inhibitor can still, even at the first sign of progression of disease on a scan—meaning you get your checkpoint inhibitor, your scan looks a little bit worse—that perhaps continuing the checkpoint inhibitor therapy may make good sense because even after that first progression scan you can see patients having a stabilization of their disease and it just seems that patients may be living longer after this checkpoint inhibitor therapy. 

And so part of that might be that if somebody gets a checkpoint inhibitor then they go on to receive other drug therapies after that, that those other drug therapies seem to be working well.  Now—and patients do seem to have improved PFS, and the question is progression?free survival so that people are living longer with control of their cancer. That's kind of what I was getting at earlier when I said that these patients who have relapsed multiple times and are getting the checkpoint inhibitor therapy seem to be living longer than we would have expected in the past with our older therapies.  So that seems to be what's being observed in practice. 

As regards to allotransplant question, repeat the question for me.  Was the implication that—go ahead and repeat the question for me. 

Beth Kart Probert:

Okay.  Will do.  So sensitivity, greater sensitivity to chemotherapy in general and also a higher PFS in allogeneic transplants.  So does it seem to translate to a greater sensitivity to chemotherapy in general?  

Dr. Burke:

So that's where I was getting at with my first comments.  

Beth Kart Probert:

Right.  

Dr. Burke:

That patients who get a checkpoint inhibitor and then, say, progress, seem to be responding well to additional chemotherapy after that.  Now, most chemotherapy after that is a clinical trial because there's not a lot of options for patients getting sort of standard checkpoint inhibitor therapy unless they're receiving it on clinical trials earlier in the course of their disease.  

Does it make patients more sensitive to an allotransplant?  I'm not aware of that data.  It may be data that I'm not as aware of.  Again, I'm not an allotransplant doctor, so I'm not sure about that.  

Beth Kart Probert:

Okay.  And thanks for that feedback.  So we have time for like one or two more questions. And first one is how big of a role is diet in staying away of recurring Hodgkin lymphoma?  

Dr. Burke:

To my knowledge, not much.  I am not aware of real good scientific data that states that one can modify diet to prevent a relapse in Hodgkin lymphoma patients.  

My advice to patients is that they should eat as healthy of a diet as possible because, A, they're most likely to be cured of Hodgkin lymphoma and die from something else and you want to say healthy, and, B, Hodgkin lymphoma patients are at risk for other long?term problems, so cardiac disease if you've gotten radiation therapy to your chest, other cancers developing later and life, and so you want to do everything you can to stay healthy, minimize the risk of heart disease, minimize the risk of getting other cancers.  

And so my advice is to eat a really healthy diet, but I can't say that it's for the purpose of preventing the Hodgkin lymphoma from coming back, because to my knowledge I'm not aware of good data that says it will do that.  But there are good data that may help you keep healthy in many other ways and keep yourself alive for a long time.  

Beth Kart Probert:

And that at the end of the day is very important.  

Dr. Burke:

It's what it's all about.  

Beth Kart Probert:

Yeah. So I think we have time for one more question.  Is there any correlation of HL and autoimmune Hoshimoto's?  

Dr. Burke:

Not to my knowledge that I have heard of.  So that would be a new one on me.  

Beth Kart Probert:

Okay.  And something we could follow up with at another time.  Okay. So let's squeeze in one more question then.  

Dr. Burke:

Let me add one more thing to that.   

Beth Kart Probert:

Sure.  

Dr. Burke:

When we treat Hodgkin lymphoma with radiation therapy to the neck a lot of people get hypothyroid long term, but I'm not aware of someone having Hashimoto's thyroiditis being for sure at increased risk of Hodgkin lymphoma.  Now, there are associations between autoimmune disease and lymphoma in general, but truly if it's just thyroid—that somebody with sort of thyroiditis only, you know, hypothyroidism, which is really common, had a high risk of getting Hodgkin lymphoma, which by itself is quite rare, only 4?or 5,000 new cases a year, so I'm not aware of that other than the general association between autoimmune disease and lymphoma.  Sorry.  

Beth Kart Probert:

No, I'm so glad you added that.  Thank you. 

So let's take one more.  How do I make my immune system stronger?  And I realize that's a really broad question, but maybe you can trim it down a little bit. 

Dr. Burke:

No, it's actually a very common question that I face in clinic, you know, can I do with my immune system?  I think it's important to distinguish what patients think of as making their immune system stronger by taking vitamins and eating healthy and exercising, that's one thing.  And then the immune?stimulating checkpoint inhibitors, those are really dramatically different.  Those are very serious drugs with proven benefits to patients with relapsed Hodgkin lymphoma, but very significant risks.  And basically you could get—you know, overstimulation of your immune system can damage any organ in your whole body and in the worst?case scenario lead to death.  So these are not trivial drugs, and that's a much different thing.  It's stimulating the immune system, but that's not something that should be tried at home by anybody other than an oncology professional. 

So I think, you know, can you stimulate your immune system by things like diet and exercise, and that's kind of the vibe I think the question is leaning toward, I'm not sure there is too much you can do.  The science behind this is that these dang cancer cells called Reed?Sternberg cells are very smart, and what they have in them is these mutations in their genes that cause these cancer cells to be inherently resistant to a patient's own immune system.  So these cancer cells are making these proteins on the surface of the cell that is preventing the T?cell from killing it.  

And what we do with these checkpoint inhibitors is release these T?cells, make them more powerful and basically release this inhibitory effect that the cancer cells have on the T?cells so then the T?cells can actually come in and kill them.  But can a human being naturally make that process happen?  To my knowledge, no.  We know how to do it better now with drugs, but I'm not sure that a patient can do that on their own, no.   

Beth Kart Probert:

That was a really great understanding, and thank goodness we do have the drugs that can stimulate that.  That's wonderful.  

Dr. Burke:

Big leap forward in Hodgkin lymphoma.  

Beth Kart Probert:

Yeah, that truly is.  And so we just have a little, just short few moments left.  Do you have any last words, Dr. Burke, for the Hodgkin lymphoma patients watching that may be was a topic we didn't cover?   

Dr. Burke:

Yeah, I think if I had to summarize what I think about of the disease for the newly diagnosed patients out there, there is a lot of hope.  The prognosis is really quite good, and we expect a significant majority of patients to be cured.  We are finding better treatments and incorporating those earlier, and we're also trying to reduce the side effects of those treatments by leaving out therapies when they're not necessary.  So that's where really a lot of the field is.  

For those unfortunate patients who have had their lymphomas relapse, you're not alone. Even though you're in the minority, there are a lot of people out there like you, and there's a lot of hope with these new drugs and checkpoint inhibitors.  And still transplant can cure many of those patients.  And so just keep hanging in there, and there's hope and new stuff on the way.   

Beth Kart Probert:

That has been very encouraging and really your contribution today and the information you shared has just been tremendous, and I really want to thank you today for your time. I'd like to thank our sponsor and to remind our audience that a replay will be completed soon, and then you'll receive it via email.  

So, again, this is Beth Probert, and I want to thank everyone for joining us.  And remember, knowledge can be the best medicine of all.  Thank you. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on May 29, 2019