This year marks the 20th anniversary of World Cancer Day, an initiative led by the International Union for Cancer Control. The aims of this day are to raise awareness, improve education and bring people together to achieve the best care for patients with cancer worldwide. The BSH’s mission to ‘transform patient care through excellence in haematology’ is in line with delivering these aims for patients with blood cancers in the UK and around the world. The BSH lymphoma specialist interest group (SIG) is committed to delivering these aims in the field of lymphoma.
Lymphoma in numbers
Lymphoma is the commonest type of blood cancer, the commonest cancer in the teenage/young adult group (15-24 year olds) and the 6th commonest cancer overall in the UK. Each year, approximately 16000 new cases of lymphoma are diagnosed in the UK, which translates to nearly 44 cases a day. Among these Hodgkin lymphoma is a distinct subtype of lymphoma comprising 6% of all lymphomas while Non-Hodgkin lymphomas make up the remaining majority of cases. Over 40 subtypes of Non-Hodgkin lymphoma are recognised, broadly categorised based on their rate of growth (indolent or aggressive) and cell of origin (B-cell, T-cell, NK-cell). Fortunately most lymphomas are responsive to treatment and some are curable. However despite this around a third of patients with lymphoma will not survive beyond 10 years with currently available treatments.
Diagnosis and staging: The challenges faced by patients and clinicians begin with the complexities of the initial diagnosis. As lymphomas are essentially tumours of lymphocytes, integral to the immune system, they can mimic infection or inflammation and vice-versa. Centralised review of biopsies by a trained haemato-pathologist is highly recommended because of the frequent challenges in making a diagnosis. Discussion of all cases at a multidisciplinary team meeting is considered the gold standard for optimal management of patients. The staging of lymphomas has undergone various iterations over the years with evolution of imaging modalities and treatments. The planning of treatment in each case is reliant on accurate diagnosis and staging making the initial assessments a critical step in the management of this disease.
Management: Indolent lymphomas are often managed without specific treatment initially, while aggressive forms need urgent treatment. Combination chemotherapy, monoclonal antibodies and radiotherapy have been the mainstay of lymphoma treatment over the last 2 decades. While most lymphomas are responsive to treatment, the durability of response and potential for cure are dependent on the individual subtype, with management of T-cell and NK-cell lymphomas posing the greatest challenge.
Novel therapies: In recent years small molecule inhibitors, antibody-drug conjugates, immuno-therapy and cellular therapy have been developed rapidly through clinical trials. Some of these have shown impressive activity, leading to their licensing and incorporation into standard treatment pathways. Examples include Ibrutinib in Mantle Cell Lymphoma and Brentuximab in Hodgkin and T-cell lymphomas. CAR-T cell therapy in relapsed/refractory DLBCL is one of the best examples of successful bench to bedside translation of years of research that is now available to patients with aggressive B-cell lymphomas who otherwise would have limited treatment options. The toxicities of these therapies, particularly immunotherapy and cellular therapy, are significantly different from conventional therapies and efforts are required to educate the multidisciplinary team towards their effects. There is increasing emphasis on minimising late effects of therapy such as second malignancies and infertility in the setting of curable lymphomas without compromising the curative potential of therapy. This is particularly relevant for diseases such as Hodgkin lymphoma where patients are often in the early decades of their life at diagnosis.
The future: Therapeutic challenges remain for most T-cell and NK cell lymphoma and the number of clinical trials available to patients with these diseases has increased significantly in recent years. In contrast, the number of effective therapies available, and in development for B-cell lymphomas requires a concerted effort towards identifying the right treatment for the right patient. It is becoming increasingly clear that there is marked heterogeneity even between individuals with the same lymphoma subtype. The development of laboratory techniques such as high throughput, next generation sequencing over the last decade has been remarkable and these techniques will soon be accessible in diagnostic laboratories within genomic hubs for cancer patients in the UK. Although the immediate benefit to patients may be limited, this represents a potentially exciting step forward in stratified medicine and individualised therapies, as data acquired over time is matched to individual patients. The ability of current sequencing techniques to analyse circulating tumour DNA or ‘liquid biopsies’ from the blood of lymphoma patients represents another exciting area that could soon be applied routinely for diagnosis, risk stratification and monitoring of lymphomas.
The BSH Lymphoma Specialist Interest Group
The BSH Lymphoma Specialist Interest Group (SIG) is composed of experts in the field from across the UK. The current group is chaired by Dr Kate Cwynarski, Consultant Haematologist at University College Hospital, and meets twice a year to identify priority areas for education, debate and discussion within this fast moving and complex field. The SIG holds two annual events, one an educational session within the annual BSH scientific meeting and a second full day meeting of lectures, debates and case discussions directed at a multidisciplinary audience of trainees, nurses and consultants. On alternate years the SIG organises a joint educational meeting with the British Lymphoma Pathology group. Topics range from diagnosis, novel therapies to survivorship and research in this complex field. The aims are to share experience and knowledge in order to raise awareness, bring people together and overcome challenges for the benefit of lymphoma patients, aims aligned with those of the 2020 World Cancer Day and this year’s theme of ‘I Am And I Will’.
Dr Sunil Iyengar
Consultant Haemato-Oncologist, Royal Marsden Hospital
Member of the BSH lymphoma Specialist Interest Group