Ask the Expert: David Fisher, M.D., on Non-Hodgkin’s Lymphoma Diagnosis, Treatment

Health Writer
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Non-Hodgkin’s lymphoma (NHL) is a cancer that first affects the body’s white blood cells, called lymphocytes, located in the lymph system. This is a major part of your immune system, and lymph tissue is found throughout your body, so lymphomas can start nearly anywhere. Similar to other types of cancer, NHL is staged after diagnosis to determine how much the cancer has spread throughout the body and best ways to treat it.

To understand how advanced NHL operates, and what you should know if you’re diagnosed or helping a loved one facing a diagnosis, we asked David C. Fisher, M.D., an oncologist specializing in NHL diagnosis and treatment at Dana-Farber Cancer Institute, Boston, for his insights.

David Fisher
David Fisher, M.D.

Credit: Dana Farber Cancer Institute

HealthCentral (HC): Is NHL unique in any way when it comes to staging?

Dr. Fisher: Yes, we group NHL into two broad categories: aggressive and indolent. The first means that growth is happening rapidly, over a course of days or weeks, while the second is much slower in terms of growth, and you might see changes over months or even years.

From there, once we know the category, we stage in the way that is used for many other cancers, which is determined based on spread. Stage 1, for example, is a lymphoma in only one lymph node or organ, while stage 4 is cancer spread into at least one organ outside the lymph system. That might be the liver, a lung, or the bone marrow.

HC: What’s the difference in treating someone with a more aggressive form, versus a slow-growing type?

Dr. Fisher: It might not sound like it, but in many ways, having a more aggressive form can be an advantage. Because it’s growing so quickly, the cells are larger, so they tend to be easier to treat with chemotherapy or radiation. You can target them more precisely. That’s especially important in advanced NHL, where you may have lymphoma in other organs, or throughout the lymph system.

HC: With the more indolent form of NHL, what should people keep in mind in terms of treatment and recurrence?

Dr. Fisher: Unfortunately, with slow-growing forms of this cancer, relapse rates are nearly 100 percent. That’s because the cells tend to be smaller, and that makes them harder to treat. Even with radiation, some can “hide” or be resistant to the treatment. So, it may take years to treat this type, and might require different chemo options to try and eradicate these cells.

HC: With NHL in either category, is surgery an option? Or is chemo considered a front-line treatment?

Dr. Fisher: Surgery is really only useful for diagnosis. Unlike using surgery to remove solid tumors, as you’d find with some other cancer types, it’s rare that we’d use surgery for NHL. That’s because you have thousands of lymph nodes and we can’t take them all out.

Even if we could, which would be very detrimental to the immune system, invariably something would get left behind. That’s why chemo is considered the main approach, especially for advanced NHL. For early-stage NHL, we might use radiation if the cancer is localized enough.

HC: For those who may have had a family member with NHL, is there increased risk? What should people look for if they’re at higher risk?

Dr. Fisher: There is, but it’s not as large as it sounds. We’ve done family studies with our patients and found that if you have a family member who had NHL within one generation, such as a parent, you may have a risk factor that’s seven times greater than someone who hasn’t. That sounds like a lot of risk, but the incidence of NHL is low enough that it’s not considered a significant difference.

In terms of screening, it can be difficult to detect NHL right away. The most common symptom we see is a swollen lymph node that doesn’t resolve itself over time. But keep in mind how many lymph nodes you have, and that many are internal. Symptoms might present as abdominal discomfort or a cough that won’t go away, based on where the affected lymph node might be. The only way to tell what’s happening is with a CT scan. There’s no blood test, like you might have with a prostate cancer screening.

If you are diagnosed with NHL, remember that even at what’s considered an advanced stage — even at three or four — many of these lymphomas are treatable and curable. That’s not something you can always say with other forms of advanced-stage cancers that have solid tumors. So, if you’re dealing with a diagnosis of an aggressive, advanced stage, it’s often not as bad as it sounds, and there are treatment options that can be very effective.

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