Advances at the cutting edge of health care over the last twenty years have been breathtaking. Nearly every field has been affected. Nearly everything doctors do for patients can also have unintended consequences. A big one is the incidental development of Non-Hodgkin Lymphoma, a potentially very serious malignancy.
The History of Non-Hodgkin Lymphoma
Excess cases of Non-Hodgkin Lymphoma started with organ transplants as early as the 1960’s. In particular heart transplant recipients who had been exposed to the virus causing infectious mononucleosis (the EB Virus) had a very high risk of getting a peculiar kind of lymphoma which could be lethal. This was such a problem that even today some transplant programs won’t accept patients who have ever contracted mono. The cause of the lymphoma was thought to be the suppression of the recipient’s immune system with drugs, required to avoid rejection of the new heart.
New Causes for Concern
More recently two reports have told a new cautionary tale. The first relates to a previously very rare problem – Non-Hodgkin Lymphoma (hereafter referred to as lymphoma) of the female breast. Women with breast implants are probably at increased risk of getting lymphoma in the implanted breast. Several investigators are now reporting this association (Plastic and Reconstructive Surgery, online edition, April 15). The unresolved issue is just how big a risk this really is. While the answer is probably “not very,” the number of women getting implants is large and growing, and the procedure for most women is cosmetic.
The second report is very troubling. Crohn’s Disease (Regional Enteritis, or inflammatory disease of the small intestine), Ulcerative Colitis, Rheumatoid Arthritis and its variants (such as Psoriatic Arthritis, recently made famous by the professional golfer Phil Mickelson) can all be treated much more effectively by a class of drugs which modify the immune system: Remicade, Enbrel and Humira, the three most commonly used drugs used to block the body’s Tumor Necrosis Factor, which is thought to be responsible in part for the destructive nature of these diseases.
These drugs have been life-altering for hundreds of thousands of patients and have made miserable diseases more manageable. From the beginning it was clear that a small minority of adults who received these drugs would eventually develop lymphoma. In many cases this lymphoma was relatively mild and easily treated. More recently a much more serious form of lymphoma, hepatosplenic T-cell lymphoma, has been seen in children and young adults receiving these agents (first reported in Inflammatory Bowel Diseases 13:1024, 2007). This form of lymphoma is usually rapidly fatal. Inflammatory bowel disease and rheumatoid arthritis are not rare in children and many receive an anti-TNF drug. Again how big a problem this will turn out to be is not yet clear.
So, what have we created with these new drugs and procedures? All of medicine involves risk/reward considerations. We know the rewards of treating most diseases, but the risks are becoming clear much more slowly.