Non-Hodgkin S Lymphoma and Military Veterans

Non-Hodgkin's Lymphoma, or NHL, is a term used to encompass a number of different types of cancers that affect the lymphatic system. The lymphatic system is responsible for defending the body from infections and diseases. As with all cancers, it begins when cells begin to grow out of control. In cases of NHL, the cancer begins in the white blood cells, or lymphocytes, usually in the lymph nodes or tissue.(9) Military vets exposed to agent orange, a herbicide, have a higher likelihood to develop this disease than those not exposed to agent orange.

(2) Primary symptoms of Non-Hodgkin's Lymphoma include; swollen but painless lump(s) on the lymph nodes, neck, armpit, or groin, fever, night sweats, fatigue, and weight loss.(10) Though not as common, those with the disease may experience other symptoms like itchy skin, chest pain or trouble breathing. It should also be noted that symptoms can vary depending on where in the body the lymphoma cells start to grow (ex. lymph nodes, abdomen, skin, chest, brain). (10)

Lymphoma can be the result of DNA mutations which cause normal lymphocytes, to become lymphoma cells. Scientists have not been able to link these DNA changes to any one particular cause however, there are some risk factors that affect the likelihood a person may develop NHL.(18) One of these known risk factors is exposure to dioxin, the byproduct from a powerful blend of chemicals known as Agent Orange. Agent Orange is a blend of tactical herbicides, that the U.S. military used in the jungles of Vietnam to remove the leaves of trees and other dense tropical foliage that provided enemy cover.(2) This defoliant was used by our Armed Forces during the Vietnam War. Dioxins are a closely related group of chemicals. One of the most toxic from this family, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), happened to be the main dioxin found in Agent Orange.(2) Agent Orange was used by military personnel throughout the 1960s and early 1970s, so it is believed that those who served in the following may have been exposed to Agent Orange; Vietnam, The Korean Demilitarized Zone, Thai Air Force bases, and C-123 Aircrafts. (6) It's difficult to know exactly how many of our military personnel have been affected by NHL as a result of this exposure. The VA offers free medical examinations to military veterans who may have been exposed to Agent Orange. As of July 6, 2017, the VA had conducted 756,620 total Agent Orange Registry exams (initial & follow-up exams). (11)

There are a number of therapies that can be utilized to treat Non-Hodgkin's Lymphoma. Chemotherapy (chemo) is one of the therapies used to treat Non-Hodgkin's Lymphoma. Chemo is an anti-cancer drug usually taken my mouth or injected intravenously (IV). Most of the time for this specific disease, multiple chemotherapy drugs are used. The number of drugs and dosage amount varies from patient to patient and depends on the how progressed the disease is when caught (stage) and recommended treatment type. Targeted therapy is another treatment option. Targeted therapy drugs are designed to target one specific area containing gene mutations or proteins on cancer cells and kill them. Most of the time targeted therapy is used alongside chemotherapy. An example of a targeted therapy drug would be, ibritumomab tiuxetan (Zevalin®), which is a combination of a monoclonal antibody and radioactive isotope. (7)

Next, Immunotherapy is known to help treat Non-Hodgkin's alongside the already stated treatments. Immunotherapy is a treatment that helps boost the patient's immune system either on its own or using man-made versions of normal parts of the immune system to destroy cancerous lymphoma cells. An example of an immunotherapy drug that may be used is Rituximab (Rituxan), which is also often used alongside chemotherapy. Another type of therapy is radiation, which is a treatment of cancer using X-rays or similar forms of radiation. Radiation is mostly used when NHL is found in the early stages. (7)

The last form of treatment is stem cell transplant, which also requires surgery. Researchers are continuously working to improve stem cell transplant methods, which includes finding new ways to collect the stem cells before transplantation. Autologous transplants are a type of stem cell transplant that uses the patient's stem cells rather than cells from a donor. While this eliminates the need for a donor and the time it takes to locate a willing donor, this type of transplant carries the risk of reintroducing lymphoma cells back into the patient after treatment. To mitigate this risk, researchers are testing new ways to improve the process by striving to separate out the last remnants of lymphoma cells from the stem cells before they are returned to the patient. Promising progress in helping to remove these remaining cancerous traces from stem cells have been found in some of the new monoclonal antibodies researchers have recently developed. Many of these approaches to lymphoma treatment can be quite intense on the patient and come with a long list of unpleasant side effects. As such, older patients and those in poor health are sometimes advised against treatment because the risk of undergoing such intense treatment outweighs the possibility of successful treatment. To help make stem cell transplants a more tolerable and widely applied option for this population, researchers are studying the effectiveness of a reduced-intensity option, known as a non-myeloablative stem cell transplant, in people with lymphoma. (16)

Another important part of treatment is palliative care. Palliative care hones in on treating the symptoms alone as opposed to the root cause and can be administered in conjunction with treatment to eradicate NHL or simply by itself to make the patient more comfortable. Palliative care treats symptoms like nausea, loss of appetite, shortness of breath, and pain. (16)

There are two types of NHL most commonly diagnosed. The first is known as diffuse large B-cell lymphoma (DLBCL). DLBCL represents about 37% of NHL cases. The second most common is follicular lymphoma which represents 20% of diagnosed NHL cases. One characteristic of DLBCL cases is that they grow very quickly however, up to 50% of those diagnosed end up cured or surviving. On the other hand, those who are diagnosed with follicular lymphoma experience a more slowly progressing version of the disease that cannot be treated until symptoms emerge and, once diagnosed, most are incurable. In some instances, follicular lymphoma can develop into large B-cell lymphoma (DLBCL). (15)

The prognosis of Non-Hodgkin's Lymphoma has been seen as incurable by just chemotherapy alone. Low-grade NHL can progress very slowly and can take years until it starts to affect the body and until treatment is necessary. The symptoms that are seen through the course of NHL determine the treatment route necessary to slow down the progression. About 69% of lymphoma patients receive chemotherapy.There is also the 17% of those who are diagnosed who decide to receive no treatment at all. For those with persistent or recurring NHL, stem cell transplantation is another option that can be employed in hopes of curing some patients. (15) The five-year survival rates vary according to the progression of the disease and how intense the symptoms have become over time. Overall, the 5-year survival rate is 71% for people with NHL. (13) The rate for follicular lymphoma is 86% and for DLBCL lower down to 61%. Over the course of 10 years, the rates decline with follicular lymphoma being 77% and DLBCL being 53%. (15)

There are a handful of agencies currently conducting research and analyzing new data surrounding NHL and Vietnam veterans. The Department of Veterans Affairs is one such group conducting a few studies on Vietnam Veterans. The Vietnam Era Health Retrospective Observational Study (VE-HEROeS) is one of their studies. It looks at the health of Vietnam vets and other military vets who served from 1961 to 1975 and compares it to that of others around the same age who have not served in the military. It takes into account lifestyle factors in addition to military service and general health. To date, researchers have gathered questionnaires from a pool of around 43,000 Vietnam and Vietnam era veterans, and around 11,000 non-military people of the same age range (17). The VA also has an ongoing contract with the non-government agency known as the Health and Medicine Division of the National Academy of Sciences, Engineering, and Medicine which conducts ongoing research and publishes updates every 2 years to their Veterans and Agent Orange Study (12).

In addition to common medical treatments, the Department of Veterans Affairs offers a number of disability benefits and specialized programs specifically for those who were exposed to Agent Orange during deployment. The Agent Orange Registry exam is a free medical evaluation focused on possible health issues related to veterans' military service. Healthcare and compensation are also available for those who meet specific requirements and submit the appropriate paperwork. Coverage can also be extended to qualified dependents and survivors of affected veterans as well.(6)

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