Relapse

• What is relapse?
  
• Why does relapse occur?
  
• How is relapse detected?
  
• Who relapses?
  
• When am I safe from risk of relapse?
  
• Transition to another grade
  
• Transition to another lymphoma
  
• Gray areas
  
• Treatment options
  
• Emotional issues
  
• Getting help
  

Fear of relapse is a nightmare that all of us experience at one time or another. Unfortunately, for some of us there comes a day when the nightmare is still there when we awake.

Depending on the subtype of NHL we have, and what we've learned about it, we may be well prepared intellectually and emotionally for relapse, perhaps with a new treatment plan already selected. Others among us may be utterly broadsided by the news.

This article will begin with a definition of relapse, and then will describe who is likely to relapse, how relapse is detected, in what areas of the body relapse may occur, when it's most likely, and why it occurs. There are indeed instances of test results mistakenly being interpreted as relapse--and we'll discuss what findings may constitute equivocal results--but chiefly this article will focus on true relapse. A discussion of the difficult emotional issues that arise upon relapse, which often are different from those we encounter at first diagnosis, will follow.

What is relapse?

Relapse is the return of disease in a patient who had achieved and maintained a complete remission--defined as the disappearance of all disease--for longer than thirty days after treatment ended.

If signs of disease recur in a survivor who achieved a partial remission-- greater than 50 percent reduction in tumor size--the return of disease is called disease progression, rather than relapse, because full remission was never realized.

If signs of disease return within thirty days following treatment, then by definition no remission was achieved, regardless of the amount of tumor shrinkage observed during treatment.

Tumors that shrink, but neither disappear nor regrow, are categorized as a type of partial remission called stable disease.

It's possible to mistake the after-effects of treatment for symptoms of relapse.

Why does relapse occur?

The most widely accepted theory for relapse is that not all lymphoma cells were killed by the original treatment. Other theories hold that genetic predisposition, continued or recurrent exposure to environmental toxins, or unabated or repeated exposure to an infectious agent are responsible for relapse. Interesting research has been done showing that cancer cells can acquire resistance to chemotherapeutic drugs by turning on genes that block the cellular intake of certain drugs and others related to them, a phenomenon called multiple drug resistance (MDR).

Nonetheless, successes with high-dose treatment followed by bone marrow transplantation or bone marrow rescue suggest that the lingering cancer cell theory is correct.

How is relapse detected?

Some NHL survivors detect swollen nodes, or experience old, familiar feelings of malaise, or notice other recurrent symptoms. These very frightening findings trigger a visit to their oncologist. Other survivors note entirely new symptoms that they wouldn't normally think of as related to NHL, but somehow they know that things just aren't right. Still others may be feeling fine, yet a routine imaging study, blood test, or marrow biopsy shows a return of disease.

It's likely that your oncologist will order one or more tests if either you or she notices anything that hints at a return of disease. Many of these tests, such as a CT scan, bone scan, or gallium scan, will be familiar from your experiences during your initial diagnosis.

Clinical relapse

When symptoms or signs of returned disease are noticed by the survivor, a loved one, or a medical professional, and the return of disease becomes unquestionably apparent during a subsequent physical examination or imaging study, it's called a clinical relapse.

If you have symptoms of recurrence many years after successful treatment, you should consider requesting a re-biopsy of the suspicious area to determine whether this is a relapse, a second primary cancer, or a benign side effect of earlier treatment.

Cytogenic relapse

Cytogenic relapse is relapse detected by one or more tests on the cellular level in the absence of physical symptoms.

Various blood tests, for instance, may detect the spread of NHL from the lymph nodes into the blood stream. Fluorescence in situ hybridization (FISH) and flow cytometry detect cell surface antigens produced by cancerous cells. A bone marrow aspiration or biopsy may detect irregularities in cell appearance or in genetic material that are associated with relapse.

Who relapses?

Very broadly, and only in the context of today's treatments, one can say that low-grade disease relapses more often than intermediate- or high-grade disease, and that, for intermediate- and high-grade disease, those who were diagnosed in the advanced stages of illness are more likely to relapse than those diagnosed in early stages.

With many new treatments being developed for NHL, however, it's not wise, correct, or ethical to adhere to generalities without continually revisiting the progress of research and without noting exceptions. Certain subtypes of NHL, for example, respond very well to treatment and are less likely to relapse than others.

When am I safe from risk of relapse?

For intermediate- and high-grade disease, the longer you remain in remission, the less likely you are to relapse. As with other cancers, you may be considered cured once you have been in remission for five years. Although there is no guarantee that NHL will not re-emerge many years later, it's far less likely as time passes, and indeed, a recurrence at a much later date should be fully evaluated, including re-biopsy, for the possibility of a second primary cancer rather than a relapse of NHL.

For low-grade disease diagnosed at stage III or IV and treated with protocols available at the time of this writing, both long-term stable disease and remission for five or more years is likely to be followed by relapse or disease progression. The exception is low-grade disease treated with bone marrow transplantation, the results of which are too new to evaluate for long-term success.

Where does a relapse occur?

The various subtypes of NHL behave differently. Some types may relapse at the original site of disease; others may relapse at quite different sites. If you are HIV positive or immune-suppressed, you may experience a relapse in the central nervous system. Disease that was not originally found in bone marrow may relapse there, causing pain.

Transition to another grade

Occasionally a relapse is accompanied by a transition to another grade of NHL. Usually the transition is from low-grade disease to a higher grade, but it's also possible for a high-grade NHL to return as a lower grade, although this is less common.

Sometimes biopsied tissue will reveal two grades of NHL in the same patient, in the same lymph node, or in two different organs. When this occurs, usually the treatment is geared to eliminating the higher-grade NHL because it may become rapidly aggressive.

Transition to another lymphoma

Occasionally, a relapse of NHL will, upon biopsy, reveal a mixture of NHL and one of the Hodgkin's lymphomas, or a mixture of B-cell and T-cell NHL. This may be either a reflection of our still imperfect classification systems or a true instance of multiple tumor types.

Gray areas

In the last ten or fifteen years, we have benefited by the tremendous progress made in medical science's ability to detect cancers at much earlier stages than in the past. Nevertheless, we forget at times that our sophisticated imaging tools still provide just a glimpse into the body's complex workings. Consequently, imaging studies sometimes yield equivocal results that must be qualified with additional testing or even with a second biopsy.

Following some types of chemotherapy, for example, fatty lesions can form in the liver. These benign lesions may appear upon CT scanning as liver metastases. Positron emission tomography (PET) scanning can distinguish these lesions from NHL that has spread to the liver.

At times, nodes will appear much smaller after treatment without fully disappearing. They may remain the same size for years, and then disappear. It's thought that these nodes may be scar tissue. Some types of lymphomas are more likely than others to scar (sclerose); ask your doctor if your subtype of NHL may exhibit this characteristic.

Odd lesions on the lungs are sometimes seen on imaging after treatment has ended. If you had radiation therapy targeted to your chest, these lesions may be fibrotic tissue arising from an immune system reaction to radiation therapy.

Treatment options

How your relapse will be treated depends on how your first appearance of disease was treated. Often, oncologists assume that the drugs you were given as first-line treatment will not be the best choice for treating relapse. The thinking is threefold:

• If they were very effective, you would not have relapsed.
• NHL cells can become resistant to drugs, making them ineffective.
• Some drugs are toxic to various organs, and their lifetime dose must be limited.

Upon relapse, it's usually the case that a second drug, a series of drugs, or radiotherapy will be attempted. Because NHL treatments are evolving continually, any attempt to describe herein the specific treatments your doctor might suggest would be quickly outdated.

If you didn't familiarize yourself with clinical trials during your first experience with NHL, now is a good time to do so. Clinical trials are a good way to gain access to new treatments before they are made available to the general public.

Emotional issues

Clearly, relapse is an emotional lowland for almost anyone affected by NHL, including the survivor, the family, friends, and the oncologist.

The emotional issues faced at relapse are different in quality and scope from those encountered at first diagnosis and endured during treatment. What follows are some of the reactions that many NHL survivors describe having.

Fear and terror

Feelings of fear or raw terror may overcome you, even if the odds remain in your favor. A sense that your options are narrowing may grow stronger, even if they are not. Thoughts of death that you may have been able to put aside during and after treatment crowd back in, even if you know that there are still treatment options open to you. Fear of different, stronger treatments may emerge.

Abandonment

There may be a sense that you fought the good fight, and now you deserve peace, contentment, and normalcy. Not only are you not getting these just rewards, you're getting something that could hardly be worse. You may wonder why unethical, unkind humans go about happy and healthy. You may find yourself wishing that certain particularly unpleasant people would get cancer, too.

Anger

Anger over life's unfairness, perhaps kept in check or rationalized during the first round of treatment, may now emerge and may cause you, and those around you, much discomfort. What psychological adjustments you may have made to your illness may go out the window, seeming to be a waste of time. Anger may manifest as rage, irritation, cynicism, or depression.

Grief

Many people grieve from the moment of diagnosis. They grieve for lost health, energy, and diminished opportunities of many kinds, from career opportunities they had to forego to have treatment to loss of fertility or ruptured relationships.

Not surprisingly, an expanded sense of grief may emerge upon relapse. Some people can't help but remember having heard that, for many cancers, failure of first-line treatment entails a poor prognosis. Although you may know that this generality does not apply to all of the NHL subtypes, it's still a frightening thought that makes some people grieve for the life they may lose.

Despair

The initial diagnosis of NHL and first-line treatment often are addressed with a can-do attitude that may be difficult to sustain at relapse, even if your chances of long-term survival are just as good after an additional therapeutic regimen that achieves a solid remission. There's something about facing the battle all over again that might make you weary at the very thought of it. You may feel that the difficult treatment you've already endured was a waste of time. You may question the quality of your life. You may contemplate suicide.

Loss of trust

You may lose trust in the medical system in general or in your oncologist in particular. If a strong faith sustained you during diagnosis and first-line treatment, you might find yourself questioning this faith now. You might lose confidence in your own ability to meet physical and emotional challenges.

Low-grade disease: one person's story

What follows is a description of Nan's emotions surrounding her experience with NHL that was initially high-grade, but relapsed years later as low-grade disease:

Each type of lymphoma has its idiosyncrasies, a different sense of the particular stakes, and of the nature of the journey. I had high-grade lymphoma as a teen, and experienced that urgency, that sense of "must treat or die" that accompanies aggressive diagnosis. I was given three months to live; treatment was necessarily swift and aggressive. And I got lucky. Big stakes, harsh treatment, near-death experience, and the gift of cure.

My survivorship experience with low-grade NHL has been entirely different. Diagnosed in 1986, a nasty test called a lymphangiogram showed that all of my nodes, from my neck to my knees, were both enlarged and abnormal in architecture. The horror I felt plunged to the core of my being, as my poor oncologist, also a friend and colleague, gave me the news. I might look for six years' survival, he said, and he'd do his best to help me.

The glitch however, was that that "help" was to take the form of nothing. Nothing to do! How could that be? My precious daughters were only four and six years old--what good was "maybe six years"? Indeed, Dr. Saul Rosenberg had discovered that for low-grade, nonsymptomatic NHL, the best course was watch and wait, which meant "go home, Nan, and live your life while you wait for the beast to transform into its more aggressive form so we can take our best shot."

This phrase "watch and wait" really pisses me off. I hate it for myself and for the patients I work with. Oncologists tend to agree, but aren't invested enough to actually change the established vernacular. It is a dangerous phrase. Inherent in those three words is the assumption that the disease will come back, will transform to a more aggressive cell type, and will need treatment later. Why would anyone want to assume this? Haven't we discovered the power of words? Even science has begun to study support groups and the impact of hope--not only on an individual's quality of life, but on actual length of life. Where is there hope in telling me that I am to wait until the predetermined worst happens so that I can then do something?

Let's rewrite the speech, shall we? "Nan, you have low-grade lymphoma, which is one form of non-Hodgkin's lymphoma. This type of NHL tends to have a personality of its own, it waxes and wanes, comes and goes, and nobody is certain at this time what sets it off or puts it back. What has been documented is that those in your situation fare equally well without aggressive treatment as with it, sometimes better. There are individuals your age and stage who have lived for years and years without treatment, who continue to live well. Others' NHL becomes bulky or perhaps develops symptoms, at which time we would recommend any number of treatments, from low-grade chemotherapy to trials with monoclonal antibodies and the like. There is every reason to believe you can live long and well with this disease. We must know that wellness is key, and believe that it is just as likely that your nodes will recede--wane--as it is that they will grow or wax. My suggestion today is that you take some time to get used to the diagnosis, then we can explore your options. Here is some reading material, get acquainted with this disease, it's less scary that way. And at the very least, let's consider what you can do to bring your body to its optimum state of wellness, so you are best able to fight the NHL, and to offer you the most quality of life."

Family and friends

The reactions of friends and family may be completely supportive, positive, and loving, or particularly inept. Unless they're kept well informed about your illness and its likely patterns, they may give up on being sustaining, instead treating you as if you have one foot in the grave. They may mourn prematurely; they may practice living without you emotionally. One way to forestall these negative reactions is to inform them from the beginning that NHL can be treated very successfully at relapse.

Employers may begin to lose patience with you at the prospect of yet more absenteeism. Your children may once again exhibit earlier, less adaptive behaviors that they had outgrown, such as aggression, bedwetting, or temper tantrums.

Getting help

Support groups are an inestimable resource for regaining emotional footing and a balanced outlook. If you didn't examine options for finding support during your first experience with NHL, it would be wise to do so now. It's not an overstatement to say that you'll be overwhelmed by feelings of hope and energy when you discover how many other people have gone through what you're experiencing, and came through it in good shape.