Rising Survival Rates With Hodgkin Lymphoma

Understanding Your Prognosis With Hodgkin Disease

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If you or a loved one are living with Hodgkin lymphoma, you have probably wondered about the survival rates from the disease. Hodgkin lymphoma often affects young people during some of the most productive times of their lives. Amidst juggling jobs and as parents of young children, many people with the disease have questions about the "expected" life expectancy. Thankfully, Hodgkin disease (the older name for this cancer) is one of the most curable forms of cancer.

At the same time that you're probably encouraged by hearing survival rates with Hodgkin lymphoma, it's easy to be skeptical upon hearing yet another headline announcing the "advancements" in treatment. The good news is that—with regard to Hodgkin anyway—this is not just hype or false hope. We will talk about how the life expectancy has improved over time historically, and what treatments have made the difference.

Some of the confusion when talking about survival with blood-related cancers such as Hodgkin lymphoma stems from what people know about other cancers, such as breast cancer. People are often familiar with how breast cancer may recur years or even decades after treatment. With Hodgkin lymphoma, most recurrences occur early on, and these late relapses are uncommon. In other words, those who have survived 5 years with Hodgkin lymphoma are more likely to be long-term survivors than are people with most solid tumors.

Let's talk about the current survival statistics with Hodgkin lymphoma, factors which may affect life expectancy from stage to age at diagnosis, and what you can do yourself to hopefully improve your prognosis.

Hodgkin Lymphoma: A Brief Review

Hodgkin lymphoma is a cancer of the lymphatic system, a part of the immune system.

It often occurs in young adults with two peaks in diagnosis; one between the ages of 15 and 35 and another in people over the age of 55. Hodgkin disease generally begins with the painless enlargement of lymph nodes anywhere in the body, but often in the neck. There are five different types of Hodgkin lymphoma which differ in frequency, the part of the body that they affect, and how they respond to treatment.

A Historical Perspective on the Prognosis of Hodgkin Lymphoma

Hodgkin lymphoma is one of the most "curable" cancers, but this has not always been the case. First recognized in the 19th century, the prognosis until the middle of the last century was poor, with the 5-year survival rate being a dismal 10 percent.

With the advent of radiotherapy, and then combination chemotherapy in the 1960s, the prognosis for the disease improved dramatically, and almost overnight at least half of the people diagnosed were surviving the disease.

Yet improvements in treatment continue. From data released by the National Cancer Institute in April of 2017, the 5-year survival rate for Hodgkin lymphoma (all stages combined) was 69.9 percent in 1975 and 85.4 percent in 2009. Much of this increase is due to advancements in chemotherapy (such as ABVD chemotherapy, and the BEACOPP chemotherapy regimen), radiation therapy, and stem cell therapy.

Survival rates continue to improve, and though rates are significantly lower for those who are diagnosed at older ages or who have more advanced stages of the disease, these are now improving as well. The use of high-dose salvage chemotherapy and stem cell transplantation for those who experience a relapse have further improved survival. The use of targeted therapy with monoclonal antibodies, immunotherapy with checkpoint inhibitors, and nonmyeloablative stem cell transplants offer additional methods of treatment expected to further improve survival in those with more difficult-to-treat Hodgkin lymphomas.

Better management of complications, such as infections related to chemotherapy-induced neutropenia (low white blood cell count), has also been making a difference.

Survival is not the only benefit of improved treatments. Less toxic chemotherapy and small field radiation therapy have been reducing the side effects of treatment and, it's hoped, the long-term side effects of the disease.

Survival With Blood-Related Cancers vs. Solid Tumors

For those who are more familiar with cancers such as breast cancer, it's helpful to take a moment and talk about how the advanced stages (stage III or stage IV) of Hodgkin disease (and some other blood-related cancers) are different prognostically than the advanced stages of many solid tumors (such as breast cancer or pancreatic cancer).

Advanced blood-related cancers, such as stage IV Hodgkin disease, are often still curable. In contrast, most advanced stage solid tumors (such as stage IV breast cancer or stage IV pancreatic cancer) are not curable. Likewise, the prognosis of relapsed Hodgkin lymphoma is also much better than a recurrence of most solid tumors.

Understanding Survival Rates and Life Expectancy Estimates

We will get to the numbers and statistics describing survival shortly but need to define what these rates mean, and some of the limitations inherent in these statistics.

Survival rates are usually described as a percentage followed by a certain amount of time. For example, you may see 1-year, 5-year, or 10-year survival rates. If a disease has a 5-year survival rate it means that 50 percent of people with the disease will be alive 5 years after diagnosis.

Sometimes you may instead see the term "median survival rate." A median survival rate is followed by an amount of time and represents the time after which 50 percent of people would have died and 50 percent of people are still alive. For example, a median survival rate of 13 months would be time after which 50 percent of people have died and 50 percent are still alive. With cancers such as Hodgkin disease, you will see survival rates more often, whereas, with cancers such as pancreatic cancer or lung cancer, median survival is often used.

In looking at these rates, the most important point to make is that they are "averages" and "numbers." Real people aren't statistics. These numbers describe how long someone with any stage of Hodgkin disease and any other factors is expected to live. Yet, even when survival rates are broken down by age and stage, it is impossible to predict how an individual person will do with the disease. Some people do much better than the “average” and some people do not.

Limitations of Survival Rates

As noted above, one of the greatest limitations of survival rates is that they give an average estimate of survival, but nobody is average. In addition, survival rates can be misleading for other reasons.

Looking at 5-year survival rates means we are looking at people who were diagnosed at least 5 years ago. During that time, new treatments have often been developed. At best, survival rates can tell you how the average person did in the past after being treated with therapies that may or may not even be used today. With the advances taking place in cancer treatment, survival rates are becoming less accurate as an estimate in the past. While this can make predictions more difficult, it tells us progress is being made.

Long-term survival is even harder to predict. Many studies distinguish deaths due to Hodgkin disease and deaths due to other causes, yet these measures don't always take into account medical conditions which are unrelated but due to treatment, such as secondary cancers.

Overall Survival Rates and Survival Rate by Stage

There are many different ways of looking at survival rates with Hodgkin lymphoma. Let's look at these in a few ways.

Overall survival rates giving the life expectancy for people with all stages combined include:

  • 1–year overall survival rate of 92 percent
  • 5-year overall survival rate of 87 percent
  • 10-year overall survival rate of 80 percent

5-year survival rates by stage include:

  • Stage I 5-year survival rate is 90 percent
  • Stage II 5-year survival rate is 90 percent
  • Stage III 5-year survival rate is 80 percent
  • Stage IV 5-year survival rate is 65 percent

It's important to note that these rates are an average of all people with a certain stage of Hodgkin disease no matter their age and regardless of other factors that may increase or decrease the chance of survival.

Long-Term Survival With Hodgkin Lymphoma

Long-term survival with Hodgkin lymphoma is difficult to estimate, due to conditions such as secondary cancers which may occur decades after treatment. That said, different studies estimate that somewhere between 15 and 30 years out from treatment, people who have had Hodgkin lymphoma are more likely to die from a cause unrelated to Hodgkin lymphoma than from Hodgkin. In other words, after this period of time people are likely to die of causes that the average public would die from.

Factors Which Affect Survival With Hodgkin Disease

There are many variables which are associated with either an increased or decreased chance of surviving Hodgkin disease. Some of these include:

  • The stage of the disease – Stage I or II disease carries a better prognosis than stage III or stage IV.
  • Age – Younger people tend to do better than those who are older (over the age of 45).
  • Sex – Women tend to have a higher life expectancy than men.
  • The presence of B symptoms – Weight loss, night sweats, and fevers, the so-called B symptoms of lymphoma, are associated with a poorer prognosis (but still, most people can achieve long term survival).
  • Whether a relapse occurs and when – For those who have a relapse in the first year following treatment, the prognosis is poorer.
  • Response to treatment – Those who respond to first-line therapy have a better prognosis than those who do not.
  • Albumin level – A low albumin level (less than 4 g/dL) is associated with a poorer prognosis.
  • White blood cell count (WBC) – An elevated white blood cell count (greater than 15,000 blood cells per mm3) is associated with a poorer prognosis.
  • Low absolute lymphocyte count (ALC) – An absolute lymphocyte count  less than 600 cells per mm3 is associated with a poorer prognosis.
  • Less bulky disease has a better prognosis.
  • Anemia – A low hemoglobin (less than 10.5 g/dL) is linked with a poorer prognosis than those with a higher hemoglobin level.
  • Sed rate - An erythrocyte sedimentation rate (ESR) greater than 30 is associated with a poorer prognosis.
  • The type of Hodgkin lymphoma – Some types of Hodgkin lymphomas are associated with a better survival rate than others (nodular lymphocyte predominant and nodular sclerosing types have a better prognosis in general).
  • General health at the time of diagnosis and other medical conditions 
  • Whether the cancer is recurrent or progressive
  • Health insurance – People who do not have health insurance have a poorer prognosis.

Recurrence and Survival Rates

As we noted above, the timing and frequency of recurrences are much different with Hodgkin lymphoma than with breast cancer. With Hodgkin lymphoma, more than half of recurrences occur within 2 years of the primary treatment and up to 90 percent occur before the 5-year mark. The occurrence of a relapse after 10 years is rare and after 15 years the risk of developing lymphoma is the same as its risk in the normal population. For those who have heard about breast cancers recurring after many years, it may come as some reassurance that this is uncommon with Hodgkin disease. It's also important to note that even with a recurrence, many people with Hodgkin disease will go on to live long lives.

Estimating Your Prognosis

For those wish to have a better idea about their estimated prognosis, there is a tool known as the Hasenclever prognostic tool which is used to estimate prognosis based on seven different factors or risks. Each of these seven factors is thought to reduce 5-year survival by roughly eight percent. These include a serum albumin less than 40 g/dL, a hemoglobin less than 10.5 g/dL, male sex, stage IV disease, a white blood cell count over 15,000/mL, and a lymphocyte count less than 600/mL.

For those without any of these risk factors, the 5-year estimated prognosis (overall) is 89 percent, and for those with 5 or more risk factors, the estimated 5-year survival rate is 56 percent.

Keep in mind that these tools are again used to estimate "average" prognosis, and nobody is average. It's also important to note that even if you have five or more risk factors, the majority—over 50 percent of people—are still alive 5 years after diagnosis.

What Can You Do to Improve Your Prognosis?

With all of the discussions about treatment options, it's sometimes easy to forget that there are simple things you can do yourself to improve your prognosis. It's important to:

  • Eat healthy: What you put in your body can make a difference in how well you tolerate treatments and how well you feel after treatment. If you are having any difficulties, ask your oncologist to set you up with an oncology nutritionist.
  • Exercise: We now have a multitude of studies that have looked at the effect of regular exercise on the outcome of many different cancers, including Hodgkin lymphoma. Even small amounts of exercise are helpful. Keep in mind that it's better to exercise more frequently in smaller amounts than to exercise for long periods less often.
  • Sleep well: We don't know about the effects of sleep disorders on Hodgkin disease, but we know that with breast cancer these conditions may reduce survival. Talk to your oncologist if you are having this very common side effect of treatment.
  • Create a cancer survivor care plan: When you are done with treatment, make sure that you and your doctor fill out a survivor care plan. The risk of secondary cancers is real after Hodgkin treatment, and may even be increasing. Your doctor may recommend earlier or more frequent screening for cancers such as breast cancer and follow up on symptoms of other cancers should they occur.

Hodgkin Lymphoma: Often Curable, Yet a Challenging Disease

It might seem funny to someone who has not experienced cancer, but there is almost a competition between people with different forms of cancer, or at least between those with higher survival rate and lower survival rate cancers. Those with cancers with lower survival rates may consider more survivable cancers as less challenging.

Keep in mind that even though Hodgkin lymphoma is more curable than many other cancers, facing any cancer is terrifying. Having your mortality thrown in your face is something those without cancer may not understand and it doesn't matter if the cancer has a 99 percent survival rate or a 2 percent survival rate. We should note as well that, even when curable, the treatments to control Hodgkin lymphoma are challenging at best. Chemotherapy may continue much longer, and especially with stem cell transplants, to a greater degree, than with many other cancers. There is also the issue of long-term side effects of Hodgkin lymphoma, such as secondary cancers, which will require lifelong monitoring.

As a final note, if you or a loved one have gone through treatment for Hodgkin disease, it's important to talk to your doctor about survivorship. Many cancer clinics now have active cancer rehabilitation programs in which the late effects of cancer treatment, ranging from chronic pain to anxiety, are fully addressed.

Sources:

Ahmadzadeh, A., Yekaninejad, M., Jalili, M. et al. Evaluating the Survival Rate and the Secondary Malignancies after Treating Hodgkin Lymphoma Patients with Chemotherapy RegimensInternational Journal of Hematology Oncology and Stem Cell Research. 2014. 8(2):21-26.

American Cancer Society. Cancer Facts & Figures 2017. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html

Brenner, H., Gondos, A., and D. Pulte. Survival Expectations of Patients Diagnosed with Hodgkin Lymphoma in 2006-2010The Oncologist. 2009. 14(8):806-813.

National Cancer Institute. Surveillance, Epidemiology, and End Results Program. SEER Cancer Statistics Review (CSR) 1975-2014. Released April 14, 2017. https://seer.cancer.gov/csr/1975_2014/

 

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