Jane Fonda shines celebrity spotlight on non-Hodgkin lymphoma

In an upbeat Instagram post, Jane Fonda recently announced she had non-Hodgkin lymphoma, a cancer of the lymphocytes (white blood cells).

"This is a very treatable cancer. Eighty percent of people survive, so I feel very lucky," the 84-year-old actress and activist wrote Sept. 2, 2022, adding that she had been undergoing treatment for six months.

What Fonda didn’t write was which of the many subtypes of this group of diseases she has – there are more than 60, according to the Leukemia & Lymphoma Society. Treatment and outlook vary greatly depending on the subtype, as well as such factors as how far the disease has progressed and the patient’s age and general health, said Medical Oncologist Peter R. Ward, MD. Some subtypes have high 5-year relative survival rates; some do not.

“The main division is determining whether it’s an aggressive form or indolent (slow-growing) form,” he said. While aggressive may sound more daunting than indolent, reality is not so simple.

“Indolent forms are not necessarily curable. Aggressive forms are more receptive to chemotherapy,” said Dr. Ward, who practices at the Davenport-Mugar Cancer Center at Cape Cod Hospital in Hyannis.

However, some indolent forms can be so mild that they require no immediate action, just watchful waiting to see if the cancer advances to the point where it warrants treatment, Dr. Ward said.

“Treatment might cause side effects worse than their disease,” he added.

An estimated 60 percent of cases are aggressive, with diffuse large C-cell lymphoma (DLBCL) being the most common aggressive subtype, the Leukemia & Lymphoma Society says. The remaining 40 percent are classified as indolent, with follicular lymphoma (FL) the most common. Aggressive forms can produce severe symptoms, and indolent subtypes may display few symptoms, according to the National Cancer Institute.

What is non-Hodgkin lymphoma and how does it differ from Hodgkin lymphoma?

Non-Hodgkin lymphoma (also called non-Hodgkin’s lymphoma or just NHL) and Hodgkin (or Hodgkin’s) lymphoma are types of cancers originating in immune system cells. Here’s what sets them apart:

• Cells: The presence of malignant mature B cells, called Reed-Sternberg cells, distinguishes Hodgkin lymphoma, according to the Dana-Farber Cancer Institute. Non-Hodgkin lymphoma most often derives from B cells, which make antibodies, but can also arise in T cells, which kill bacteria and aid other immune cells, according to the American Cancer Society. Some cases also originate in so-called natural killer cells, which destroy cells infected with a virus or cancer cells, according to the Leukemia & Lymphoma Society.
• Age: Hodgkin lymphoma tends to strike people in their teens and twenties and those over 60, while non-Hodgkin lymphoma may occur at any age, but 60 is the median age, according to Dana-Farber.
• Affected areas: Hodgkin lymphoma often occurs as swollen lymph nodes in the chest, neck and underarms, though can begin in lymphatic tissue anywhere in the body. Non-Hodgkin lymphoma starts in lymph nodes or lymphatic tissue throughout the body, including tonsils, thymus, bones, digestive system and spleen, according to the American Cancer Society.
• Progression: Hodgkin lymphoma spreads from one lymph node to nearby nodes through the lymphatic vessels, and typically doesn’t spread to bones or organs till late stages, if at all, the American Cancer Society says. Non-Hodgkin lymphoma grows in the lymphatic system and may spread to other organs in a less orderly fashion, according to the Centers for Disease Control and Prevention.

Diagnosis

A swollen bump or lump felt on the body or discovered internally via imaging technology usually is the first indication of non-Hodgkin lymphoma, Dr. Ward said. Diagnosis relies upon analysis of a tissue sample, which may be surgical removal of a lymph node or a core needle biopsy to reach less accessible sites. The ease or difficulty of determining the subtype “depends upon the quality of the biopsy,” he said. The more material, the better.

Blood tests and imaging scans (including X-ray, ultrasound, MRI, CT and PET) can help refine the diagnosis and determine the cancer’s stage, which describes how far it has spread, according to the American Cancer Society.

Symptoms

According to the Leukemia & Lymphoma Society, symptoms of non-Hodgkin lymphoma can include:

• A swelling that doesn’t hurt
• Chest or abdominal pain
• Feeling bloated
• Itchy skin and rashes
• Cough
• Fever, fatigue and night sweats

Risk Factors

Most cases of NHL are diagnosed in people aged 80-84 and it’s rarely found in children, according to a Leukemia & Lymphoma Society booklet. NHL occurs more commonly in men and white people. Other risk factors may not be associated with all subtypes. For example, obesity is associated with diffuse large B-cell lymphoma; and smoking, celiac disease and work with electrical equipment or textiles are associated with peripheral T-cell lymphomas. Other risk factors include:

• Autoimmune disease or suppressed immune function. This includes people with lupus, rheumatoid arthritis, HIV/AIDS and organ transplants.
• Farm work and exposure to herbicides and pesticides.
• Exposure to some bacteria and viruses, including HIV (causes AIDS), H. pylori (causes ulcers), hepatitis C and Epstein-Barr virus (causes infectious mononucleosis or “mono”).
• Some genetic conditions, such as Sjogren syndrome and Klinefelter syndrome.

Treatment

Chemotherapy (drugs that kill fast-growing cells) may be given in sequenced rounds over several months, Dr. Ward said. Radiation therapy may be used initially in cases diagnosed in early stages (1 or 2), according to the American Cancer Society. Immunotherapy and targeted therapies, which include use of laboratory-made antibodies to hinder tumor growth or deliver cancer-killing drugs specifically to tumor cells, may be employed in cases where the later-stage cancers that have relapsed or become refractory (resistant to treatment). Dr. Ward said. Multiple cancer drugs and therapies may be administered in combination.

Most of these treatments can be performed at Cape Cod Hospital, which is part of the Dana-Farber Cancer Care Collaborative. Furthermore, the hospital’s cancer program is accredited by the Commission on Cancer of the American College of Surgeons. Dr. Ward said exceptions to local treatment would be cases requiring CAR T-cell therapy, which harvests a patient’s T cells, grows them and alters them to seek out and bind to a specific protein on lymphoma cells, and stem cell transplant, a complex procedure utilizing the cells that create blood cells, according to the National Cancer Institute.

“Bottom line is all of these lymphomas are treatable. Whether they can be cured depends a lot on the patient,” Dr. Ward said.

Survival Rates

A patient’s age and whether they have any chronic diseases can determine how well they may be able handle treatment, he said. Five-year relative survival rates cited for non-Hodgkin lymphoma can be difficult to apply to elderly patients, such as actress Fonda, who are nearing the end of their lives, he added. However, “some patients in their 80s or 90s can be cured,” he said.

Survival rates are percentages based on the number patients alive five years after diagnosis and are divided by the National Cancer Institute into three SEER stages: whether the cancer is contained in one lymph node or organ (localized), has spread to a neighboring node or organ on the same side of the diaphragm (regional) or has spread to organs or bone marrow far from the original site or on both sides of the diaphragm (distant), according to the American Cancer Society. These survival rates are estimates and do not consider all factors.

For the two most common forms of NHL, the American Cancer Society cites these five-year relative survival rates:

• Diffuse large B-cell lymphoma – 74 percent for localized, 73 percent for regional, 57 percent for distant.
• Follicular lymphoma – 97 percent for localized, 91 percent for regional, 86 percent for distant.