C-DR:
So, Lymphomas. Cancers of white
blood cells called lymphocytes. No one
is really quite sure why lymphomas occur. If you look at other types of cancer like lung cancer: smoking; breast
cancer: having breasts, being a woman; you know we can find out certain risk
factors for those types of things. The
thought process is with lymphomas, perhaps there is some sort of infectious or
inflammatory sort of stimulus to your immune system which causes some
lymphocytes to increase, and one of those lymphocytes has got a change in its
wiring. It’s got something a little
different that makes it clone itself over and over and over and over again, and
the clone cell is really the hallmark of most cancers. So once that stimulus goes away the other
cells kind of contract and go back to their normal housekeeping sort of status
but this one cell that had changed its wiring up, just keeps cloning itself
over and over and over. And sometimes lymphocytes, they circulate in your blood,
they live inside lymph nodes and come from your bone marrow. So depending on where the abnormal cells are
would depend on what kind of symptoms you have. The most common thing is for people to have a swollen lymph node, you
know, and say that it doesn't really hurt but its kinda been there and it’s
just kinda odd that it’s there and they usually go through a course of
antibiotics or so and it just doesn't get better and then they get a scan and they
get a biopsy, just exactly as you've done.
So, when you talk
about these lymphomas, again there’s Hodgkins and Non-Hodgkins. This [yours] is a Non-Hodgkins lymphoma and
for one to say they’re better or worse that’s not always the case. They’re different. They’re just different is all. So Hodgkins Lymphoma usually occurs in people
in their teens, 20’s, early 30’s and can occur again later in life, early 60’s
or so. Non-Hodgkins Lymphoma can occur
across the spectrum of ages from childhood to adult. This [yours] is usually one that occurs in
older patients. There are three kinds of
ways, or four really, broad categories to put Non-Hodgkins Lymphoma into. Because, there are more types of Non-Hodgkins
Lymphoma than you can shake a stick at. There’s Follicular, there something called Mantle cell, there’s
something called a Lymphoblastic, there’s a Diffuse large B-cell. There’s lots and lots of different kinds of
Non-Hodgkins Lymphoma’s. But the way you
think of them: slow growing,
intermediate growing, fast growing, and very fast growing. So the very fast growing ones are kind of
like leukemia’s, really what we would call acute leukemia’s. They've come from nothing to causing a world
of symptoms within a few weeks, and if they’re not treated right away people
die within a month or so of that. The
fast growing ones are ones that usually occur and then need treatment within a
few months. And then the slow growing
ones could have been there for a long period of time and nobody ever knew it
until a lymph node popped up or something popped up and someone looked at it
said, hey, this is abnormal let’s investigate it and then they found it out,
because people can live with those without symptoms or problems for many years.
The intermediate ones are somewhere in between those ranges. Follicular lymphomas [what I have] are
generally considered to be slow or intermediate growing ones. With this one [yours] being a grade 2/3
[pathology report finding, this is a ‘grade’ not a ‘stage’] it’s really kind of
on the borderline between a slow to intermediate type of growth.
So, the important part about figuring out where to go from
here always involves doing what’s called a “staging” process. Staging means that we look at your whole body
and we decide where this cancer is located. We've obviously cut out this spot in your neck and we know that that
lymph node there was involved, but because lymphomas are really kind of liquid
tumors involving these abnormal lymphocytes they could involve other lymph
nodes. They could be inside the bone
marrow. Very rarely they could spread to
other organs like your lungs or liver or some places like that. When I examined you I can’t feel any lymph
nodes over on either side of your neck really at this point, there’s still a
little swelling left there [from the surgery]. I can’t feel any under your arms. Your spleen is also a giant lymph node. I can’t completely feel that, […] but it’s not
obviously enlarged when I push there. So
what we tend to do then is get some laboratory, look at a blood count, look at
something called an LDH and then we get some scans to look at your whole
body.
Probably the best way to do that right now is with a scan
called a PET scan. What a PET scan does
is they inject you, through your vein with a kind of sugar. It’s a fluoridated sugar, it’s got a little fluoride
molecule on there. And that sugar is taken
up by cells that are dividing quickly in your body. If you had a cut somewhere those cells are
turning over. If you had an infection in
your skin somewhere those cells are turning over, and pneumonia, something like
that, and cancer cells because cancer cells are dividing more quickly than
normal cells are. That’s the hallmark of
that cloned process. They pick up that
sugar and you do a scan and then you look at it after the sugar’s been given
and it shows up as a bright spot on your body.
And they do a CAT scan and they correlate that CAT scan with where the
bright spots are showing up and they can determine very accurately where all
the cancer is located. So, we’ll do a
PET scan to look at all these other lymph node spots.
The other thing that we do is a bone marrow biopsy. A bone marrow biopsy is a little harder. What they do there is numb up an area in your
pelvic bone, put a needle into that spot, take out a liquid sample of bone
marrow and then a solid core of the bone itself. They look at that under a microscope and they
determine if there are some of these cloned lymphocytes present. For some people I just do that here in the
room because it’s just a little numbing medicine and it’s really not that big
of a deal. For other people where perhaps
it’s a little harder to find that spot […] I have them go and do it with some
sedation medicine. Not general
anesthesia, but a little bit of something to make you sleepy so that you don’t
remember it. Then they put you under a
CT scanner so they can figure out exactly where that needle needs to go. Probably would be the best way to do it for
you. A little sedation. Under a CT scanner. Guide exactly where it needs to go. It’s very quick. It’d take a few minutes really to do once they've got everything positioned correctly. And
it wouldn't hurt you because you’d be ‘out’, you wouldn't remember it. A little sore the next day. Okay?
C-DR: You’ll do just fine on that. So that’s a “staging.” We try to determine where else the cancer
might be located in your body and in the bone marrow. We’ll look at those things. Then the question will come up: What treatment
should we give you. Now the question
with that is a very interesting one because with fast growing lymphomas, in this
fast and very fast growing ones, we can cure those if treated appropriately
right up front. They’re growing quickly,
they respond quickly to our treatments which are chemotherapy treatments,
therefore they die off quickly and because those cells are always in a growth sort
of growth phase, chemotherapy affecting those cells that are dividing quicker
and growing quicker, we kill them off, we get rid of them. The slower growing ones we often times will say,
“Well because they might grow, and they might not, they might sit there for a while and then they
might grow, you don’t necessarily hit them at the right time to kill all of
them off.” So sometimes we don’t cure those but people can live for decades
even with having that cancer. So
sometimes, depending on if we look and we find it only in one spot or if we
find it in lots of spots but we don’t really have symptoms from it the right
thing to do oftentimes is to follow that along and not even give any treatment
for it for a period of time. There are
patients that…
MM: that’s the Watchful Waiting I read about.
C-Dr: Yes. There are patients, that depending on how healthy they are and depending
on what symptoms they have from the lymphoma they might die of something
unrelated to that and might never need treatment for it. You know, I have one patient that came to me
in his 80’s. He had a Follicular
lymphoma along his neck here and he has a bad heart and bad lungs and heart
attacks and things like this. And he got
treated by another Doc and then came to see me because he wasn't, just wasn't doing very well. And so I said we’re
just not going to treat this. That was
four years ago. And he’s now about
86. And he’s still as sick as he always
was. But it’s not from any lymphoma type
of thing. So sometimes the right thing
to do is to do nothing. Okay?
MM: That sounds so
strange.
C-Dr: And it sounds very odd and it sounds very
strange but the issue is I have loads of treatment for this. The problem is that all those treatments
typically will have side effects. And if
they can’t take the disease away completely then the goal would be not to
expose you to those side effects unless there’s a real good reason to do
that.
So, first step: find
the stage. Second step: see if this is causing particular
problems. There are occasions, most of
these Follicular lymphomas we find them at a stage 3 or a stage 4 because they
are slower growing and because you don’t know they are there until they show up
like that. There are rare times when we
might find it in just one spot. If you
just find it in one spot then sometimes doing a little radiation treatment to
that can be curative. Sometimes if it’s
in that more advanced stage then I just kind of watch along and see what kind
of symptoms people have and follow it carefully. But I think until we know all of that, you
know, I won’t know how to counsel you about that. For right now, just off what you’re telling
me you don’t really having a lot of symptoms from this. A lot of people when they show up with a very
advanced lymphoma, unexplained weight loss, fevers, sweats at night. I've had patients that waited so long that
they come in, they've got their lungs filled with fluid, they've got lymph nodes
around here, they got lymph nodes showing up under the skin. Even patients like that with lymphomas I
treat and they get a lot better. So,
lymphomas are very, very treatable diseases.
Sometimes we treat with what’s called immunotherapy. What that is are antibodies geared towards
particular proteins found on the lymphoma cells. They don’t have the same side effects as
chemotherapy does like losing your hair and feeling really tired. It’s just Infusions that we give. Sometimes we treat that with immunotherapy
plus chemotherapy, so, medicines that go throughout your whole body to kill off
those cells. Sometimes a radiation is
added in there and sometimes again we don’t do any treatment right up front.
The other thing about not giving treatment
right up front is that it allows medical science to kind of come out with new
things that can treat even better with less side effects. The medicine that we use a lot now, called Rituxan,
really started to come into play around the year 2000 or so and these days it
was a huge step forward in lymphoma. And
it’s used for lymphoma plus a lot of other diseases. We didn't have that in the past. There’s a newer kind of chemotherapy medicine
called Bendamustine that we didn't have when I finished my training 10 years
ago. If you look in the, well, on
internet today, on CNN, I was kinda reading this morning. I had already known about this drug but
there’s an oral pill used for people with a kind of lymphoma called CLL and
another called Mantle cell lymphoma, that has very few side effects that’s been
used in patients that have gone through all their other options and has an
amazing sort of responses in stability and keeping people alive two years and
longer when these patients may have had diseases that would have killed them within
3 or 4 months. So, that medicine is kind
of on the horizon so we’re always making some strides forward in our treatments.
So if I say to you, hey listen, I don’t think we need to do
treatment right now, and we end up treading water for 2 years, 4 years or
however long we can do that and watch and wait, maybe during that time they
come out with something that’s a huge breakthrough again that has very few side
effects that works very well and then we can say, you know what, we were really
smart not doing anything back then. Let’s
give you this really good drug now, when you need it, and then we’ll go from
there. So, the thing I want to stress
for you right now is that, loads and loads of treatment. This is not a diagnosis that I’m expecting
that will take your life within the next year or two or three. This is something…
MM: Good. This was not in my plan.
C-Dr: Exactly. …that you can live with without treatment. This is something we can treat and people can
often times live a decade or longer with the disease in remission. So there are lots of really good treatments
out there for this, it’s just trying to decide when it’s right to give it to
you, when it’s needed, and what that treatment might be from low intensity to
higher intensity sort of treatments.
MM: Depending on
these first tests.
C-Dr: Exactly, and
that’s why we have to do this up front, the right way to figure out what we’re
dealing with. Okay? Questions?
MM: No, but they’ll
be coming.
C-Dr: They’ll come. Write them all down. I’ll see you back once all these tests are
done and I’ll go through all of them and we’ll answer more questions and come
up with a plan and then at that point if I haven’t answered those other
questions we’ll go over them too.
[…]
C-Dr: You come in and you got all this stress and stuff on
your mind. It’s good that you recorded
it. Half of it will be gone by the time
you walk out the door, half of it will be gone by the time you get home. So you can re-visit it with that [recording].
The internet does have some good resources on there. There’s also some quack type stuff. But if you go to any really, sort of known
institution, larger, Mayo Clinic, National Institutes of Health, National
Cancer Institute, any large university; any of those websites their information
will be good. Anyone that says, “Hey if
you buy this special grape juice from me for $1000 and it will fix you” then just
say okay thanks and walk away from it. Okay? Definitely a treatable
disease. Definitely one that you can
live with. You’re gonna do okay. We’re gonna get you through all of this and
you’ll be coming back and see us.
[…]
C-Dr: It has an
effect on you whether you consciously realize that or not.
<End of relevant information.>
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