What is non-Hodgkin lymphoma?

Non-Hodgkin lymphoma (which is also known as 'B-cell' and 'T-cell lymphomas') is a cancer of the lymphatic system. The lymphatic system is a network of vessels and glands spread throughout your body. It is also part of your immune system. Clear fluid called 'lymph' flows through the lymphatic vessels and contains infection-fighting white blood cells known as 'lymphocytes'.

In lymphoma, these lymphocytes start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system, such as the lymph nodes (glands). The affected lymphocytes lose their infection-fighting properties making you more vulnerable to infection.

There are 2 main types of lymphocytes:

• B-lymphocytes make antibodies that attack infecting bacteria and viruses.
• T-lymphocytes kill cells that have been infected with a virus and cause the immune response to respond faster to an infection the second time round.

In non-Hodgkin lymphoma, either the B-lymphocytes or the T-lymphocytes (or both) can be affected. B-cell lymphomas are more common.

There are more than 20 types of non-Hodgkin lymphoma, but they can generally be put into one of 2 broad categories:

• high-grade or aggressive non-Hodgkin lymphoma where the cancer develops quickly and aggressively
• low-grade or indolent non-Hodgkin lymphoma where the cancer develops slowly, and you may not experience any symptoms for many years

Most cases of non-Hodgkin lymphoma are treatable, but the success rate will depend on the type of lymphoma being treated. However, you may experience long term problems like infertility or the chance you'll develop a different form of cancer in future.

Survival rates for non-Hodgkin lymphoma vary greatly depending on the exact type, grade and stage of the lymphoma, and the person's age.

What are the symptoms of non-Hodgkin lymphoma?

The most common symptom of non-Hodgkin lymphoma is a painless swelling in a lymph node, usually in the neck, armpit or groin. The swelling is caused by an excess of affected lymphocytes collecting in your lymph node.

Swollen nodes or glands are a common response to infection, so if you have swollen nodes do not panic; it is highly unlikely they are the result of lymphoma.

Other symptoms will usually only begin once the cancer has spread through most or all of your lymphatic system. This causes the lymphatic system to stop working properly, which weakens your immune response.

Symptoms of advanced non-Hodgkin lymphoma include:

• unexplained tiredness or fatigue
• drenching night sweats
• fever for no reason
• unexplained poor appetite and/or weight loss
• trouble getting over infections
• pain in the chest or abdomen (which may be caused by an enlarged spleen)
• unexplained, persistent cough
• itchy skin all over the body

What causes non-Hodgkin lymphoma?

Non-Hodgkin lymphoma is caused when abnormal lymphocyte cells start to multiply. It’s not known why this happens. However, some factors can put you more at risk:

• having a weakened immune system due to conditions such as an inherited immune disorder, an autoimmune disease or HIV/AIDS infection
• taking immunosuppressant drugs after an organ transplant
• exposure to the Epstein-Barr virus (EBV), the virus that causes glandular fever, or to the Human T-cell lymphotropic virus (HTLV)
• a family history of lymphoma
• having an autoimmune condition such as rheumatoid arthritis, lupus or Sjogren's syndrome
• being infected with Helicobacter pylori bacteria (a cause of stomach ulcers)
• having had chemotherapy or radiotherapy for an earlier cancer
• having coeliac disease
• exposure to some chemicals
• eating a lot of meat and fat

However, most people with these risk factors do not develop lymphoma, and many people with lymphoma do not have any of these risk factors.

When should I see my doctor?

See your doctor if you have the symptoms of non-Hodgkin lymphoma. They will do initial tests to rule out cancer. If these tests show you may have cancer, they will refer you to a specialist to confirm whether or not you have non-Hodgkin lymphoma.

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How is non-Hodgkin lymphoma diagnosed?

The usual way to confirm a diagnosis of non-Hodgkin lymphoma is by carrying out a biopsy. This involves removing some or all of an affected lymph node and lymphocytes, which is then studied in a laboratory. Biopsies can be carried out under a local anaesthetic (where the area is numbed), or at times a general anaesthetic may be required (you are put to sleep).

If the biopsy shows you have non-Hodgkin lymphoma, more tests may be carried out to see how far it has spread. These tests include:

• blood tests (there is no direct blood test for lymphoma)
• bone marrow biopsy
• imaging tests such as CT, PET and MRI scans and ultrasound
• lumbar puncture (sometimes called a spinal tap)

How is non-Hodgkin lymphoma treated?

Treatment depends on the type of non-Hodgkin lymphoma, stage of disease, how far it has spread, your health and age, and how fast it is likely to grow.

If the cancer is slow growing, your doctor might recommend monitoring you regularly rather than starting treatment straight away.

The treatment options for non-Hodgkin lymphoma include:

• chemotherapy: using medicines to kill the cancer cells
• steroids: to increase the effects of chemotherapy and help destroy the lymphoma
• radiotherapy: used to treat early stage non-Hodgkin lymphoma, if it's in one part of the body only
• targeted therapies: medicines such as monoclonal antibodies that kill only the cancer cells but not healthy cells
• immunotherapy: medicines that cause your own immune system to fight the cancer cells
• stem cell transplant: may be needed if the lymphoma has come back or if there is a high likelihood it will come back in the future
• surgery: only used in some cases, for example to treat skin lymphomas

Can non-Hodgkin lymphoma be prevented?

There are no proven ways of preventing non-Hodgkin lymphoma.

Complications of non-Hodgkin lymphoma

Being immunocompromised (having a weakened immune system) is a common complication of lymphoma treatment. Even if your lymphatic system is restored to normal, many of the medications that treat non-Hodgkin lymphoma weaken your immune system.

This means you are more vulnerable to infections, and there is an increased risk of developing serious complications from infections. You may be advised to take regular doses of antibiotics to prevent infections occurring in the early stages after treatment. Your immune system will usually recover in the months and years after treatment.

If you think you might have an infection, you must report any symptoms to your care team or doctor immediately because prompt treatment may be needed to prevent serious complications. This is particularly important in the first few months after treatment.

Symptoms of infection include:

• fever
• headache
• aching muscles
• diarrhoea
• tiredness
• a painful blistering rash

You should also make sure that all of your vaccinations are up to date. Your doctor or care team will advise you on this.

Infertility

Many of the treatments for lymphoma can cause infertility. Infertility is often temporary, but in some cases it may be a permanent side effect.

People who are particularly at risk of becoming infertile are those who have received very high doses of chemotherapy and radiotherapy. Your care team will estimate the risk of infertility in your specific circumstances and it is sometimes possible for men to store samples of their sperm, and for women to store their eggs, for use when their treatment is completed.

Use of contraception is strongly recommended during chemotherapy and for one year afterwards as chemotherapy can damage a new embryo (baby).

Other health issues

Treatment for lymphoma can increase your risk of getting conditions such as heart disease, lung disease, kidney disease, thyroid disease, diabetes and cataracts at a younger age than normal. Having a diagnosis of cancer can also increase your risk of suffering from depression. If you are concerned you have any of these conditions discuss management and treatment options with your doctor.

Second cancers

Unfortunately people who have had one cancer are more likely to get a second cancer, which may be the same or different to their first cancer. Chemotherapy and radiotherapy further increase this risk.

This risk will have been considered carefully when your initial treatment was planned — it is one of the reasons why a period of 'watchful waiting' is recommended for many people with low-grade non-Hodgkin lymphoma.

You can help avoiding a second cancer by adopting a healthy lifestyle (not smoking, maintaining a healthy weight with a balanced diet, taking regular exercise). You should also report any symptoms that might suggest another cancer to your doctor at an early stage.

Resources and support

If you need help, talking to your doctor is a good place to start. If you'd like to find out more, or talk to someone else, go to:

• Cancer Council (for people affected by any type of cancer) — call 13 11 20
• Cancer Council Online Community (cancer dedicated online support service) — online help