Hodgkin lymphoma and primary mediastinal B-cell lymphoma are two aggressive blood cancers that affect young people between their late teens and mid-30s, a group often referred to as Adolescents and Young Adults (AYA).
These lymphomas often grow in the lymph nodes in the chest region. and patients usually see their doctor with symptoms such as enlarged lymph nodes or shortness of breath. There are no screening tests for these cancers at this time.
Symptoms usually subside after time or treatment with antibiotics in otherwise healthy, young patients, but if not, physicians will look further into the cause. Luckily, these types of lymphoma are rare and considered curable. Hematologic (blood) diseases such as lymphoma can often be cured even at stage 4.
The first line of treatment is always a cocktail of systemic drugs, including chemotherapy and other therapies that target proteins that control how cancer cells grow, divide, and spread. This multiagent treatment usually destroys most of the disease. Sometimes, radiation is recommended as a follow-up treatment.
For stage 1 and 2 Hodgkin lymphoma, multiple randomized trials have shown that without a course of radiation, the cure rate is 5%-10% lower, even after systemic drugs have resulted in a complete metabolic response — meaning no signs of lymphoma are visible on a PET-CT scan. Five to 10 of every 100 of these patients will have a recurrence without radiation.
In the past, Hodgkin lymphomas were treated only with radiation, which meant delivering a high dose of radiation to large parts of the chest and nearby lymph nodes in order to kill all microscopic disease. Though an effective treatment for the disease, the level of radiation carried a higher risk of long-term negative side effects such as ischemic heart disease, valvular heart disease and secondary cancers such as breast cancer.
Today, patients undergo systemic treatment first, which allows radiation oncologists to target the area most likely to experience a recurrence: the initial site of disease. Treating patients with chemotherapy first allows providers to reduce the size of the area being treated with radiation and to use lower doses (compared to radiation as the sole treatment). This can help reduce the risk of side effects.
Proton therapy, a more precise way to deliver radiation, can help reduce the risk even further. Because protons are heavy, radioactive particles rather than waves, and have the property of losing energy slowly until a sudden peak, they can be controlled to release most of their dose at the site of the tumor, without depositing more radiation beyond it. This reduces toxicity (and side effects) to healthy organs.
Fertility preservation is one of the most serious concerns for AYAs — young adult patients with cancer. Many patients are not aware that chemotherapy and radiation can affect fertility.
Collaboration between a patient’s providers early on — before starting treatment — can improve fertility outcomes in the future, but options become more limited after treatment has started.
However, proton therapy can be precisely manipulated to avoid delivering radiation to reproductive and hormone-producing organs in both male and female patients to minimize infertility.
Some cancers tend to affect young people more. Common AYA cancers include:
“My most challenging consultations with patients are for lymphoma,” said Yolanda Tseng, MD, who treats lymphomas and central nervous system tumors at Fred Hutch Cancer Center – Proton Therapy. “The extent and location of the cancer determines when I recommend protons or photons, among other things. Each patient has a different toxicity risk based on their initial extent of disease, age, sex, family history and prior medical history. If the tumor overlaps with the heart or if the patient is a young woman, we often consider proton therapy to minimize dose to heart, lungs and breast tissue. This translates into fewer side effects.”
The International Lymphoma Radiation Oncology Group (ILROG) has guidelines determining which type of radiation to choose. According to ILROG, lymphoma patients most likely to benefit from proton therapy include (1) patients with mediastinal disease (cancer in the area between the lungs) that overlaps with the heart; (2) young female patients for whom proton therapy can reduce breast dose and risk for secondary breast cancer; and (3) heavily pretreated (with systemic drugs) patients who are at higher risk for radiation-related toxicity to the bone marrow, heart and lungs.
Tseng recently co-authored a study that identified a fourth group that could benefit from proton therapy: patients with concurrent mediastinal and axillary disease (cancer in the armpit area). The study used pencil beam scanning to deliver radiation to more extensive areas while limiting the dose to the lungs, heart and breast tissue compared to modern photon techniques.
Because doctors consider Hodgkin and mediastinal B-cell lymphoma to be curable, age, sex and extent of disease play important roles in determining the course of treatment. In such cases, physicians put heavier emphasis on reducing potential side effects, especially future cancer risk, because patients are expected to live for many years and physicians want to preserve their quality of life.
When it comes to prostate cancer screening, many men are still confused about when they should be screened.
Fred Hutch experts recommend men at average risk for prostate cancer start screening at age 55 with the prostate-specific antigen (PSA) blood test. PSA tests are so effective that they’re credited with early diagnosis of prostate cancer in about 80% of men with the disease, however, it’s not without controversy.
A PSA test measures a protein released in the blood by prostate cells. A high PSA level can be a sign of prostate cancer, but it can also be due to conditions other than cancer, like an enlarged or inflamed prostate.
“Men who are at higher risk — Black men and those with a family history of the disease — should consider starting screening at age 40,” said Jamie Takayesu, MD, who treats prostate cancer patients with radiation. “Most men do not present with any symptoms, especially early on. If you have a long life ahead of you, that’s one reason to get screened for prostate cancer.”
When detected early, this cancer is usually curable. Therefore, screening can be helpful for younger, healthy men, and there are many treatment plans available if cancer is found, including active surveillance for low‑risk cases.
On the other hand, since PSA tests can identify cancers that might never become harmful, men with significant health issues or a limited life expectancy may decide that screening isn’t necessary for them. Talk with your primary physician about whether or not to do PSA screening.
PSA tests aren’t perfect: false positives (where the test incorrectly indicates you have cancer) can lead to unnecessary worry and/or unnecessary procedures like a biopsy, while false negatives can give you a normal result, missing an existing cancer.
False positives and false negatives are found in multi-cancer detection tests, (MCDs) as well.
“This is true of [the new multi-cancer] screening tests such as the ones marketed directly to consumers,” Takayesu said. “And most [MCDs] have not been validated the way PSA tests have.”
Without a provider to help you interpret results, Takayesu said, people using the new direct-to-consumer MCD blood tests might be lulled into a false sense of security, or conversely, undergo unnecessary procedures for a false positive test.
If you need a primary care provider, or want to discuss screening tests for prostate cancer, our care partner, UW Medicine, offers in-person and telemedicine primary care visits to both new and established patients in Washington state. Learn about UW Medicine Primary Care.
Some men are at higher risk of prostate cancer, including those with a family history of cancer, Black men and men over the age of 70.
Scientists have identified 450 different genes associated with prostate cancer. BRCA, also associated with breast cancer, is the most common.
BRCA refers to two genes — BRCA1 and BRCA2 — that play a key role in repairing damaged DNA. Everyone has these genes, but certain inherited changes or mutations can increase the risk of developing prostate, breast, ovarian and/or pancreatic cancers. It is essential to know your family history of cancer so you can make informed decisions about cancer screenings.
Only a biopsy can determine whether you actually have cancer. Once you have been diagnosed with prostate cancer and choose to receive treatment, there are several options, depending on the stage of your cancer.
Similar to many breast cancers, prostate cancer is hormone-driven: testosterone makes the cancer progress faster once you have it. Therefore, testosterone suppression may be a part of treatment.
Radiation is another common treatment, especially for patients with metastatic disease. For limited metastases, meaning the cancer has spread to just a few other locations in the body, receiving radiation can extend life. For extensive metastases — the cancer has spread throughout the body — radiation can help with pain and other symptoms as well as prevent complications. In these cases, treating the prostate itself can also prevent future urinary issues.
In terms of radiation, there are several options.
Takayesu uses proton therapy for very specific cases such as patients who have concurrent ulcerative colitis or Crohn’s disease for whom surgery is not an option, and/or patients who’ve had a prior kidney transplant.
If you are entering treatment, Fred Hutch radiation oncologists will discuss all options, including proton therapy, to help you make an informed decision.
Learn more about all treatment options for prostate cancer and proton therapy for prostate cancer.
Kyle Turver is a spiritual health professional at Fred Hutch Cancer Center who sees patients and their families on Wednesdays at the proton therapy facility.
A Unitarian Universalist chaplain by training, Turver is available to talk with patients, their caregivers and families one-on-one about how they are doing emotionally as well as offer some of Fred Hutch’s myriad resources. He also counsels staff, giving them a safe place to talk, teaching them coping skills and tactics to help decompress from work.
Turver wasn’t always a chaplain. He began playing guitar and writing music in grade school and high school and his first college degree was in music. He even made a career of it, acting as Worship Director for a church, rehearsing the choir and handling “all things music” for 20 years. During that time, he realized he liked providing guidance and care to others and decided to go into seminary. There, he learned to give one-on-one spiritual and emotional support and later, joined Fred Hutch to counsel patients receiving cancer treatment.
“Being a musician taught me how to be a chaplain more than anything else,” Turver said. “As a musician you learn to listen carefully to your bandmates, to find your contribution to the music. As a chaplain, I listen to the contribution of the patients — their concerns and emotions — and I bring my voice to the conversation in harmony and concert with theirs.”
Although he sometimes brings his guitar to a session, Turver writes and plays music mostly for himself.
“It acts as a way to process emotions, to ground myself,” he said When you’re helping others deal with intense emotions, you need a place to find solace. Music helps me decompress.”
Music also inspires him – as do his patients.
“I’m inspired by my patients’ stories and experiences,” he said. “Each interaction with a patient is an opportunity. My songs reflect our collective thoughts and needs in a more abstract way. Sometimes the resulting music is uplifting, sometimes melancholy. But it always helps.”
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