The blog is not meant as a substitute for medical advice or to take the place of the information provided by your doctors and nurses. Always consult them for any questions or concerns you have.

That said, what I wanted to know when I was diagnosed with HL in 2007 was what was ABVD going to REALLY be like. I didn’t want to hear about it second hand, I wanted to hear it straight from someone who went through it. And if that was what was on MY mind, it had to be on other people’s minds too.

Hence this blog.

A little bit about your author. She’s a runner with a dark sense of humor and was diagnosed with HL when she was 26 years old in 2007. She was stage III/IV-A bulky and underwent eight cycles of ABVD chemotherapy. As of April 2010, she’s been in remission for three years despite a poor initial prognosis given the extent of her disease.

With that here are the articles on this site:

• A Brief History of Dr. Hodgkin and His Disease. You want to know the history of the disease you’ve been diagnosed with? Go here.
• ABVD for Newbies. Here’s the heart of the site — what you can expect from ABVD.
• Mediports. Since so many people ask questions about them, my information on ports.

Please feel free to leave comments (comments are held for moderation just to avoid spam).  The webmaster checks in from time to time to update the info and to approve comments.

Hodgkin’s Lymphoma:  Cancer.gov - Everything you need to know about Hodgkin’s.  Stats, treatment info, clinical trials, research, etc.

E-Medicine.com: Hodgkin’s Disease – Great information on Hodgkin’s, though written more for medical professionals.

Hodgkin’s Lymphoma: Biology and Treatment Strategies for Primary, Refractory, and Relapsed Disease – Article for doctors published in the 2003 journal Hematology.

Hodgkin’s Lymphoma: Basing the Treatment on the Evidence - Article for doctors published in the 2001 journal Hematology.

Cancer and Exercise – “Exercise is now being recognized as an important component of the fight against cancer. There is evidence that exercise can be of benefit in three ways to manage cancer and its symptoms.”

Anatomy of the Human Body – Useful for when you’re trying to understand your radiology reports.  You may also like:

• Mediastinal Lymph Node Stations
• CT Depictions of Regional Nodes (lung cancer specific, but the anatomy is the same)

Physical and psychosocial responses to exercise in cancer patients: A two year follow-up survey with prostrate, leukemia, and general carinoma – Excellent small study on exercise in cancer patients.

Hodgkin’s Disease Facts and Figures – Just what it says.  Also explains the difference between HD and N-HL.

But I know you’re wondering … how do you feel after ABVD?

One thing you MUST keep in mind is that EVERYONE reacts a little bit differently to even the exact same chemo. So my experience is not going to be your exact experience and visa versa.

It’s very difficult to describe exactly how you feel on chemo.  I’m a lawyer, so I write descriptions and explanations of things for a living, and even I have trouble articulating what chemo was like.  It was sort of like a cross between having a stomach flu and just being completely out of it, like you didn’t even really care you were alive.

My experience was this:  I was treated on a Friday morning.  I would start feeling uneasy Thursday night.  I started to dread chemo more and more by the end.

Friday morning I would start feeling sick AT the treatment center before anything even happened.  I think this was all in my head.  I would get treated and feel almost immediately terrible.  Nausea mainly.  All I wanted to do was lay down.  It made no sense to sit up and try and distract myself.  The best thing to do was go straight to bed and lay there and try to sleep.  I usually wasn’t nauseated so long as I was laying down.

I never actually threw up, but I often felt nauseated for a few days and I didn’t want to eat.  I would eat nothing at all on Fridays, then pick at my dinner Saturday and Sunday. By Monday, I would feel well enough to eat a normal amount and maybe go for a run.  By Wednesday I would be at 95% and would be pretty normal … until the cycle would begin again.

One big tip that I really wished someone had told me before my first ABVD:  Anti-nausea drugs work best before you are nauseated.  Once you feel sick, your fighting an uphill battle.  Take your drugs around the clock for the first few days even if you feel fine.

Honestly, most of the time during ABVD, I felt good.  Really, I had about twelve good days, and three really bad days.  It seems from talking to other Hodge patients that most people don’t feel immediately sick like I did, but rather the side effects hit later.  I will say that my first treatment basically established the pattern, and the rest were very similar.  I didn’t find I felt “worse” as treatment went on, but I think that may be because I was sick to begin with.

Anyway, I hope that gives you an overview of what to expect from ABVD and hopefully allays some of your fears.

Anyway so you probably will be treated at an out-patient cancer center.  If you can go check out the treatment room ahead of time, go for it.  My cancer center’s treatment room had chairs with TVs attached.  You can also bring your ipod, laptop, whatever entertains you.  You probably will be in a room with other people, so of course you do want to be polite (i.e. bring headphones if you want to listen to music).

Should you bring someone with you to chemo?  Up to you.  I think it’s helpful to have someone at least come pick you up and drop you off since the drugs may hit you quickly or they may give you Ativan or something like that for anxiety, but other than that, it’s up to you.  If it makes you feel better, definitely bring a friend or family member. Just warn them that it will be boring.

So what happens on chemo day?  In a nutshell this was a typical “chemo day” for me.

Go see my oncologist.

I didn’t always see him before treatment for an office visit, but every other treatment or so I had a short office visit with my doc. By the way, most cancer patients refer to their doc as their “onc.” If you go on a cancer forum and hear people complaining about their “onc” — they are talking about their cancer specialist.  Anyway, usually this was a feel-the-nodes session and a chance to whine incessantly about the side effect of the week to the guy I considered the architect of my misery.   If I recall, this was also my chance to beg the boss for no more Dacarbazine. I was convinced Dacarbazine was the be all end all of all my problems, so I hated it and kept trying to talk my onc into dropping it.  If your oncologist is anything like mine, good luck with that.  =)

Seriously — this is your chance to talk to your oncologist about your side effects, for him to make any dose adjustments (hopefully not necessary), and for him just to check up on how your doing.

Time for some blood.  Accessing the port or starting an IV.

Thoroughly disappointed that I would indeed be getting the damned Dacarbazine, again, I would then go get my port accessed and hooked up.  Access is a nice word for “stab” — if you want to know more about ports check out my port post over in the side bar.    If you decided to go without a port, they will start a peripheral line in your arm, hand, wherever they can locate a good vein. They will also draw some blood (through the IV or port) and check your counts. This is the threshold that determines whether you can get chemo; too low of counts, and they can’t treat you.  Low counts aren’t real likely during your very first chemo, but they could be later on.  They will look at:

• Your Reds (RBCS), to check for anemia, including your hemoglobin. If you are low, your doctor MAY withhold treatment, mine never did and I was extremely anemic in the beginning.
• Your platelets.  These make your blood clot. I had some trouble with low platelets from time to time if I recall, but my oncologist always went forward with treatment anyway.
• Your Whites (WBCs). They will especially focus most not on the total but on something called your ANC. What is an ANC?  You don’t really need to know, but if you’re curious ANC refers to the percentage of neutrophils (white blood cells that fight infection) and cells that will become neutrophils multiplied by the white blood count (WBC). It breaks down as follows:
  • ANC below 2000 is considered to be neutropenia
  • ANC between 1000-1500 fairly low risk of infection. Chemotherapy will usually be given in this range, but not below it. But it depends on your doc.
  • ANC between 500-1000 – moderate risk of infection
  • ANC below 500 – severe neutropenia – high risk of infection
• They will also do a basic check of your electrolytes and kidney and liver functions before they decide to go forward with treatment.  You know, just to make sure there’s nothing wrong.

Getting your counts depends on the speed of the lab; in general, I would have mine in fifteen or twenty minutes.

(If your counts are too low, you’ll likely just go home and your oncologist will either wait for your counts to come up or he/she will start treating you with WBC boosters such as Neulasta. I never had a chemo delayed.  My oncologist gave Neulasta whether I needed it or not because he wanted to stay on the plan. What the plan was, I have no idea, I was not privy to the plan which was talked of with much secrecy and awe.)

They get your weight, bp, etc. and the oncologist writes the order, and the pharmacy makes it up.

They will do a basic vital check — blood pressure, pulse, and weight. There is a formula based on weight and height used to calculate your chemo dosage exactly — my oncologist weighed me each time and calculated the dose from there. The pharmacy then custom mixes your chemotherapy drugs. It used to take about 30 to 45 minutes to fill the order.

The Pre-Meds and Fluids.

Once your “premeds” are ready, you can go get hooked up to an IV pole.  IV poles exist solely to annoy you.  I know — I dragged one around for three days for my first ABVD session because I was treated in the hospital and my oncologist was worried about tumor lysis so I had to get round the clock fluids. I tripped over said pole, I kicked it, I hated it.  Luckily you’ll only be hooked up for about three hours.

Because ABVD commonly causes nausea and vomiting when you don’t treat with anti-emetics, most doctors will pretreat you for nausea and vomiting. An anti-emetic is just a fancy term for an anti-nausea drug, by the way.  I got Zofran, Aloxi, and Decadron as my pre-chemo anti-nausea drugs.  Other drugs can include Antzamet, Kytril, and Emend.  I used to take Emend (a pill), then get IV Zofran and Aloxi, then start taking Ativan, Compazine, Kytril …. I had a huge arsenal of literally thousands of dollars worth of anti-nausea drugs at my disposal.

Just as an aside, I want to point out again that because I suffer from GERD (acid reflux) independently of HL, I had a lot more nausea than most people.  Chances are you will do way better than me as far as nausea goes.

It usually takes about thirty minutes to get these pre-meds.  They shouldn’t make you feel anything.  Mine never had any taste or anything.

Time for the actual chemo.  Leading off the Red Devil – Adriamycin

As I mentioned before, ABVD stands for the name of four drugs — Adriamycin, Bleomycin, Vinblastine, and Dacarbazine.  They are almost always given in that order.

The red drug, Adriamycin, is usually given first. It comes out in a large syringe (I used to call it a turkey baster). To prevent mouth sores, you can suck on ice or Popsicles while getting Adriamycin, or at least you could at my chemo center. The nurse will “push” Adriamycin — that means slowly inject it into your IV line. Warning that it is REALLY RED and it will usually turn your urine RED too, so don’t freak out when / if it happens. The first time it happened I was like um, uh oh. Now you won’t be like, um, uh oh because YOU will know even if no one remembers to tell you.

Of the drugs, Adriamycin one supposedly hits the Hodge the hardest. A lot of cancers get treated with Adriamycin (including breast cancer), and it’s sometimes called “The Red Devil.”  Since so many cancers used Adriamycin, a lot is known about it.  Adriamycin will probably cause your hair loss and may affect your heart muscle (though the Hodgkin’s dose even at eight cycles keeps you below the point where heart damage is likely), so your doc will monitor for those things. 

Adriamycin has a taste, and if you happen to be one of the people who can taste it, you’ll quickly note that it’s a bad taste, so you may want to suck on hard candy in addition to the popsicle.  I used to gag over Adriamycin; I found sour flavored candies were the most helpful.  Of course, now I also hate sour-flavored candies because I associate them with chemo.  Oh well.

That’s another good point I want to bring up — do NOT eat your favorite foods on or around chemo day because you can start associating them with chemo.  Stick to bland stuff or stuff you won’t care if you never eat again. People don’t believe me when I tell them this and then they come back and say geez Jenny I wish I had listened to you. You WILL associate foods and drinks and tastes and smells with chemo. Be careful of favorite foods around chemo! You don’t have to forgo them for the entire six months or however long, just don’t consume them the morning of treatment, during the infusion, or in the couple days afterward when you are most likely to feel yucky.

Next up … Bleomycin

Bleomycin — which I always shorten to just “Bleo” — also comes out in a turkey baster (or syringe if you prefer to call it that), but the baster is much smaller than the Adriamycin. Bleo is pushed in slowly the same way as the Adriamycin.

Bleo is a clear, utterly harmless looking drug that’s known for causing pulmonary effects — again not immediately but down the line a ways.  There really isn’t anything worth noting about it, other than the first time you get chemo, they will give you a test dose and wait to see if you have an allergic reaction.  I didn’t have any reaction.  In fact, reactions are EXTREMELY rare, so this is a better safe than sorry safeguard.  I wouldn’t freak out about it. That test dose does add some time to your first chemo that you won’t have at the later sessions, however.

Some people get fevers from Bleo; if this is you, you can try tylenol.  I didn’t have that problem.  Bleo just messed up my lungs … but that’s another story for another day.

Vinblastine

Vinblastine is basically identical in appearance and in method of administration to Bleo, except they don’t do a test dose and I think I recall the syringe was a touch smaller for the Vinblastine dose. Sometimes my chemo nurses did not push Vinblastine slowly, but instead gave it rapidly through the IV. It didn’t seem to matter either way.

Vinblastine doesn’t appear to have any taste and is clear.  Vinblastine’s main side effect is nerve damage.  This would show up somewhere down the line and wouldn’t be immediately apparent. I had absolutely no problems from Vinblastine.

The Dastardly Dacarbazine

I absolutely hated Dacarbazine.  I decided it was the drug that made me the most miserable.  This is the last drug of the four and it’s given differently than the others.  The first three are “pushes” — Dacarbazine is a drip.

Dacarbazine is given at a specific rate of speed, over approximately an hour or so (assuming you have a port; if you don’t Dacarbazine may take a long time to get). The Dastardly D drug comes out in a brown bag usually to protect it from sunlight. This is the one that apparently is most likely to make you sick to your stomach.  Dacarbazine causes nausea and vomiting in about 90%+ of people treated with it who don’t receive anti-emetics.  The use of anti-emetic drugs like I listed above makes Dacarbazine very tolerable and many Hodge patients don’t have ANY problems with nausea and vomiting.  Me, not so much.

That’s it.  You’re done!

Once you’ve gotten all your drugs, they will flush your port (if you have one), unhook you, and you’re usually good to go.

And that is pretty much all there is to it to ABVD chemo. It takes about 3 hours from start to finish.

Now let’s look at how you might feel after chemo.

OK.  So we’ve established you have Hodgkin’s Disease and you have to get chemotherapy.  I’m very sorry and I say that with the deepest sincerity. (I’m probably the twentieth person to tell you that and I’m sorry for that too!)  I have been through what you are about to go through and frankly I wouldn’t wish it on my very worst enemy in the entire world.

That said, what you’re about to go through is something literally thousands of people have been through.  We made it through ABVD and so will you!  THIS IS DOABLE.  THIS IS NOT THE END OF THE WORLD.  YOU CAN, AND WILL, BE OK! There is absolutely no reason to think otherwise. You can, and you will, win.

First, let’s go over a little bit about what ABVD is.  You can get much more information from your oncologist, but a little knowledge can help you discuss things a little more intelligently with your doctors and nurses and ask better questions.

ABVD is a four drug regimen. Someone once told me a joke that ABVD sounds like a sexually transmitted disease that honor students get. Get it? AB-VD? OK, maybe not the best joke. Anyway, the drugs are Adriamycin, Bleomycin, Vinblastine, and Dacarbazine. Yeah, the creators of ABVD weren’t exactly creative when they came up with the name. 

The drugs are usually given in that order (A, B, V, D).  An ABVD cycle last 28 days and consists of two treatments given two weeks apart. I know! No one told me there were TWO chemo treatments in each cycle — I think that is total false advertising.  Anyway, after the second treatment, the cycle starts anew.  Therefore, if you are slated for six cycles of ABVD, you will be treated twelve times over about six months, with treatment say every other Friday.

Each of the four drugs work against the Hodge a little bit differently, and each has it’s own side effects.  They are given in very precise doses and at precise intervals.  They are designed to work in combination with each other.  ABVD is an old regimen — around since the 70s (it is probably older than you are…. it is older than me!) — and your medical team know exactly how much of each drug you need to get to hopefully cure you.  This isn’t an experimental treatment. ABVD has a very good track record of getting people into remission. (However, if you’re like me and your stage III/IV, you may want to ask your oncologist about other options available like BEACOPP because some studies show it is superior to ABVD for us advanced stagers.)

OK, now you know a little bit about ABVD, let’s now address fear.  Every single one of us who has been through this has felt the same dread you’re feeling.  We all may try and cope differently — for example I joked much more than usual — but no one wants to go through chemotherapy.  It’s a big unknown and it’s something depicted in popular media, film, and literature as terrifying.  When someone said chemo to me, I would picture in my mind this image of a completely hairless, lifeless, wasted away person with their head in a toilet throwing up non-stop.

Here is the good news — like I pointed out earlier, that’s not what ABVD is like! Or at least it wasn’t that way for anyone I’ve ever talked with about it.  I can also say CHOP-R (Non-Hodgkin’s lymphoma’s chemotherapy regimen) also isn’t like that.  (I know because my dad had N-HL two years before I was diagnosed with Hodgkin’s Disease.)  ABVD is basically a moderate chemotherapy course – the worst thing about ABVD is how long a therapy course it is.

So what can you expect from ABVD?

The one thing I am going to promise you is I’ll be honest. I’m not going to sugar-coat stuff or tell you everything is going to be awesome. That’s not fair to you. But I’m also not going to scare you. I’m just going to try and be honest.

Hair loss. You probably will lose your hair. (Probably around the second or third cycle.) Sorry. =( This is one side effect they haven’t made much progress on alleviating. HOWEVER, not everyone loses their hair, so you may want to wait and see before you make any drastic decisions. My hair thinned considerably, but I still had enough at the end to tie back into a ponytail and I did the maximum amount of ABVD at eight cycles.

I would be prepared for hair loss with a wig, scarf, etc, but I wouldn’t shave my head as a preemptive strike just in case your lucky. Your stylist may be a good source.

Some nausea. You will probably be nauseated, at least sometimes and at least a little.  People have differing amounts, however. I seemed to get more than my fair share of nausea, but I never actually threw up. I think I had more nausea because I suffer from GERD anyway. (We’ve established how lucky I am. haha.) There are MANY excellent anti-nausea medications out there — they may not prevent every twinge, but if used properly you should DEFINITELY not be spending your days throwing up. I think I only actually threw up once and I was nauseated a lot.

Fatigue. You will be tired. However, although ABVD causes fatigue, MANY people are able to work at least part-time through it, some even full-time. It really varies from person to person. I ran and worked part-time and traveled through my 8-month course.

Feeling bleh. For want of a better term, you are going to feel bleh sometimes. It is hard to describe. Kind of like how you feel when you have a stomach flu, I guess.

Those are the big side effects of ABVD.

All right, so that’s a little introduction to ABVD.  I hope you aren’t quite so scared now.  Part two of this article explains what to expect on chemo day.

Let me say first that for me the time between diagnosis and actually starting chemotherapy was probably one of the toughest times for me. It was this seemingly endless period of tests and scans and doctor’s appointments … An endless bombardment of information. It was all too much to process — the whole being diagnosed with cancer, the whole idea of having to undergo chemotherapy and treatment. I felt overwhelmed, angry, sad, frustrated. Probably all sorts of things you’re feeling right now. I’m just letting you know you’re totally normal in that regard.

OK, so if you’re like me, you’re the average Hodge patient, you probably don’t know much at all about how chemotherapy is given or what to expect.  I scored an advantage in my dad had undergone a very similar chemo regimen for Non-Hodgkin lymphoma called CHOP-R two years before I was diagnosed with HL (we won the true bad luck lottery in my house…).  But for most people, this is going to be your first encounter with chemo.  And let’s be honest, chemo doesn’t have a good reputation. I mean, no one wants to do chemo. You see chemo in the movies and you think of some poor person with no hair and their head in a toilet and you’re thinking oh my God how am I ever going to make it through four or six or eight months of THAT?!?!?

The good news is ABVD isn’t going to be like that. OK, there’s a good chance you’re going to go bald. And there’s a good chance you’re going to be sick to your stomach at some point. But there’s a good chance you may never actually throw up. And you may not be nauseated hardly at all given the quality of the drugs. Anyway, I hope this series of posts helps alleviate some of your fears by providing you information. I’ve divided this post into three “chapters.”

Chapter One: Scared witless?  So are we all.

Chapter Two: How ABVD is actually given.

Chapter Three:  How am I going to feel after ABVD.

One thing to always remember — I’m just a patient.  If you have medical questions, you need to ask your medical team. OK, so without further ado: Scared witless? So were we all.

So you have cancer and your doc starts talking about this thing called a port.  No, unfortunately I’m not talking about ship ports.   I’m talking about a mediport for chemotherapy.

People keep asking me questions about my port — mainly people starting or going through chemotherapy. People seem to be more curious about the port than anything else (I even find lots of people searching about them arrive here through random searches of Google or Yahoo). So … in the interest of hopefully cutting down on how many emails I get about ports … Here’s what I can tell you. As always, your mileage may vary.

What is a port?

A port is short for “mediport.” A port is a small device that is implanted under your skin so that medicine may be delivered directly into your blood system. Blood can also be drawn out of the port to be sampled. The port is sometimes also called a venous access catheter.

Why would I want or need a port?

There are a few reasons you might want or need a port.

1) Certain chemotherapy drugs (including those used to treat Hodgkin’s Disease) can cause serious irritation to the veins when they are infused. When the drug is injected through the port rather than into another vein (such as one in your arm), the drug doesn’t directly enter the skin and the likelihood to cause irritation is drastically reduced.

2) Frequent use of the peripheral veins (i.e. those in your arms and hands) can cause scarring and make the veins difficult or impossible to access. The port “saves” a lot of wear and tear on these veins. Most blood draws and treatments can be given through the port.

3) If you are getting frequent treatment or need frequent blood draws, a port (as opposed to another device) allows you to swim, shower, and basically maintain regular activities.

How does it work?

The port is placed completely under the skin, usually on the chest below the collarbones, but other locations can be used as well if desired or necessary. The port forms a small bump under the skin. This raised part is called the port’s reservoir. The reservoir has a plastic membrane or bubble of self-sealing rubber in it called a septum. The septum leads directly into a large vein or artery.

A nurse uses a special needle called a Huber (or “butterfly”) needle to “access” the port. The nurse places the Huber needle through the reservoir and into the septum. This allows access to the large vein. The nurse can then either draw blood, inject medication, or simply leave the needle in place for future use.

What does it look like?

I took some pictures of my port to show people what it looks like.  I’ve found most people are really curious and have never seen a port before.  I had no clue what one looked like and had trouble finding any pictures — so hopefully this helps “explain” what a port looks like and gives you more of an idea of what to expect.  (If you’re like me, you like to know EXACTLY what you’re in for.)

First, this is what a port looks like when it’s actually hooked up and accessed.  The dressing is placed over the top of it to keep it clean and dry.  The clear tube coming out of the port is what gets hooked up to the IV machine or to the syringe for chemo.  I took this picture on one of the few days I actually had my port left accessed at home.

This is what the port looks like all hooked up for chemo or any other infusion. A port can be used not only to deliver chemo, but for routine blood draws and even to just give you nice drugs like fluids. When it is not hooked up, it looks like a little bump underneath the skin about the size of a nickel with a scar above it. That’s it.  (When the port is accessed, you can’t get it wet.  But sometimes I would have to see my oncologist the day before chemo and he’d draw labs … to avoid the second stick the next morning when I got chemo, I’d sometimes leave the port accessed over night.)

What does a port itself actually look like?

A port looks something like the image to the left.  This is the reservoir part.  Ports come in different sizes.  The standard adult size port is about the size of a quarter.  I have a pediatric port because my mediastinal lymphadenopathy was so large that a standard size port wouldn’t fit.  My port is about the size of a dime.

There is a catheter (the long tube like extension attached to the reservoir) attached to the port that leads from the port itself into a large vein or artery.

How long can you keep a port?

A port can be kept indefinitely.  Reasons to remove a port include problems with it (such as infection) or simply because it isn’t needed anymore.

When not used regularly, a port needs to be occasionally flushed with heparin to keep it functioning properly.

How did they put it in?

My port was placed using just local anesthetic.  It was done in a surgery room in the radiology department.  The surgeon made two incisions — one on the right side of my chest below the collar bone and a second incision in my neck on the same side.  The chest incision was the “pocket” where the port itself was placed.  The second smaller incision was for tunneling the catheter.

I think the standard procedure is to actually put the port on the left.  Mine went on the right side because I had so many masses in my chest.

Did it hurt to put it in?

Not really.  It was more unpleasant than painful.  I had the option for more anesthesia than just local, but to be honest for me the risk of anesthesia would outweigh the mild unpleasantness factor.

The painful part was injecting the lidocaine.  That felt like getting stung over and over by a bee.  Pleasant?  No.  Painful?  A little, but totally doable.

When the surgeon was actually working on the port, it felt like he was tugging at me.  Not painful, just strange.

Does accessing the port hurt?

Accessing the port still requires a needle stick.  It hurts probably just as much as getting an IV in the arm, but the advantage of the port for me is there was only one time that required two sticks.  I have lost count of how many times I’ve needed to be stuck more than once for an IV or blood draw.

What does the scar look like?

See above.  Although there was also an incision on my neck, I don’t seem to have any scar there.  That incision was quite small.

Does having a port effect your daily life?

I run with my port, I shower … I usually forget it’s there except for when a seat belt occasionally rubs up against it or something.  I like the port because my veins aren’t very good and the port saves a lot of needle sticks.

Anyway, I hope this helps demystify the port!

Dr. Thomas Hodgkin

Hodgkin’s Disease is one of the best known medical eponyms. The fellow who’s name got attached to this relatively rare ((The incidence of Hodgkin’s Disease is about 3 cases per 100,000 people per year, and it accounts for less than 1 percent of all cases of cancer in the United States. The American Cancer Society states: “The American Cancer Society estimates that in 2007 there will be about 8,190 new cases of Hodgkin disease in this country. And about 1,070 people will die of the disease. Because of better treatment, death rates have fallen by more than 60% since the early 1970s.”)) cancer especially known for attacking younger people ((Hodgkin’s has a biomodal distribution; it is most often seen in people aged 15 to 34 or over the age of 60. In young adults, it is the most common kind of cancer.)) was named Thomas Hodgkin. Hodgkin was born in to a Quaker family in Middlesex, England on August 17, 1798. In 1819, he entered medical school at St. Thomas’s and Guy’s Medical School (affiliated today with King’s College in London). In 1823, he earned his M.D. Two years later, Dr. Hodgkin was appointed lecturer in morbid anatomy and curator of the Pathology Museum at Guy’s Hospital Medical School.

Physically, Hodgkin was dark haired, with a slight and wiry build. He had a hot temper, but was greatly appreciated as a lecturer. Hodgkin’s passion seems to have been pathology. In 1829, Hodgkin published a work that became a classic in pathology, The Morbid Anatomy of Serous and Mucous Membranes. This work focused on unexpected intra-thoracic and intra-abdominal tumors and how cancer spread.

In 1832, Dr. Hodgkin described the disease that now bears his name in a paper entitled On Some Morbid Appearances of the Absorbent Glands and Spleen. The paper was published in the journal of the Medical and Chirurgical Society in London. The disease would be rediscovered in 1865 — right as the Civil War ended — by Dr. Samuel Wilks who recognized Hodgkin’s work and named the disease after him in a paper entitled Cases of enlargement of the lymphatic glands and spleen, (or, Hodgkin’s disease) with remarks.

Hodgkin was one of the early advocates of preventive medicine, publishing On the Means of Promoting and Preserving Health in 1841.

Although the most brilliant pathologist of his day, Hodgkin was an abject failure in business. After staying up all night caring for a very rich patient, Hodgkin received a blank check for his work. He filled in the blank with 10 pounds, then added insult to injury by saying that the patient didn’t seem to be able to afford more. Many of his friends were reluctant to ask him to consult on their cases because he would refuse to charge them.

Hodgkin was a social progressive. He opposed slavery, advocated for reforms in medical education, and founded the the British and Foreign Aborigines Protection Society. His liberal views along with his hot temper made him enemies in the medical profession.

Dr. Hodgkin died of a terrible illness sadly familiar to many Civil War soldiers — dysentery — on April 5, 1866 in Jaffa, Palestine. His grave reads: “Here rests the body of Thomas Hodgkin M.D. of Bedford Square, London. A man distinguished alike for scientific attainments, medical skills and self-sacrificing philanthropy.”

Hodgkin’s Disease – The Early Years

Dr. Hodgkin was the first to note that Hodgkin’s Disease seemed to form in the intra-thoracic region and would spread through contiguous lymph node chains. He also noted that involvement of the spleen seemed a symptom of advanced disease.

Dr. Hodgkin also recognized that the “father of microscopical anatomy,” Marcelle Malpighi published the first actual recorded description of Hodgkin’s disease in his paper De viscerum structuru exercitatio anatomica in the year 1666. Hodgkin’s Disease was not the first cancer discovered, ((Cancer is an ancient disease. Bone remains of mummies have revealed growths suggestive of bone cancer. The Edwin Smith Papyrus found in Egypt that dates back to 1600 BC actually describes 8 cases of tumors or ulcers of the breast that were treated by cauterization, with a tool called “the fire drill.” The writing explains that there was, “no treatment.”)) but it was among the first and one of the first to be accurately described.

Hodgkin only examined his disease grossly; he did not undertake to use the primitive microscopes of the day to explore the tissue further. As previously mentioned, a year before his death, Dr. Wilks assigned Hodgkin’s name to the disease. Hodgkin’s Disease proved to be interesting because it was difficult to classify — was it an infection? a cancer? an inflammatory process? The disease additionally attracted much attention and infamy due to it’s frequency in young adults.

Several pathologists who followed Hodgkin and Wilks did examine biopsies of Hodgkin’s Disease under the microscope, but it was Dorthy Reed (1874-1964), a fellow at Johns Hopkins, who first classified the unusual giant cells unique to Hodgkin’s Disease. Dr. Reed failed to recognize that they represented a neoplasm, however, thinking they were inflammatory. The unique giant cells that make up Hodgkin’s Disease are today known as Reed-Sternberg cells (Dr. Carl Sternberg (1872-1935) had also done work describing them independently in Germany in 1898).

Pathologists were eventually able to tie the giant Reed-Sternberg cells ((R-S cells are the major thing that differentiate Hodgkin’s Disease from non-Hodgkin’s Lymphoma. The R-S cell is very large and often has more than one large nuclei.)) to the malignant process. Hodgkin’s Disease is a cancer, ((Hippocrates used the terms carcinos and carcinoma to describe non-ulcer forming and ulcer-forming tumors. He used the word that referred to a crab because crab the disease often presented with finger-like spreading projections from a cancer called to mind the shape of a crab.)) sometimes called Hodgkin’s Lymphoma. ((A lymphoma is a cancer of the lymphatic system, a set of interconnected organs and tissues that helps the body fight diseases and infections. There are two major types, the much more common Non-Hodgkin’s Lymphomas and Hodgkin’s Disease. Connected along the thin network of vessels of the lymph system are groups of small, bean shaped and sized organs called lymph nodes. Lymph nodes are found in the neck, chest, armpits, abdomen, and groin. The lymphatic system also includes the tonsils, thymus, spleen, and bone marrow.))

Reed-Sternberg cells are interesting because they only make up 1 to 2% of a Hodgkin’s Disease tumor. Hodgkin’s Disease is the only malignancy where the size of the masses aren’t a result of the number of cancerous cells. ((Most of the Hodgkin’s Disease mass consists of benign inflammatory cells including small T lymphocytes, histiocytes, plasma cells, eosinophils, and neutrophils. The inflammation is produced by cytokines which are in turn produced by the tumor cells.)) (This is one reason why there is so much inflammation with Hodgkin’s Disease and often scar tissue).

In 1925, Hodgkin’s Disease, Non-Hodgkin’s Lymphoma, and the leukemias were finally differentiated officially as different diseases.

Hodgkin’s Disease: The First Curable Cancer

Although early pathologists did not recognize that Hodgkin’s Disease was a malignancy, it’s ability to kill was well known. Ninety percent of people with Hodgkin’s Disease would die within three years time; almost all would die within five years.

Through the early 20th century, doctors experimented with using radiation to try and control Hodgkin’s Disease. They had limited success. They began to then experiment with nitrogen mustard. Now my military readers are probably asking mustard? Isn’t that the stuff that was so terrible and killed so many in WWI? Yes. Ironically, the development of the nitrogen mustard drug used in Hodgkin’s disease stemmed from the use of mustard compounds during World War I and from a terrible explosion during World War II in Bari, Italy that exposed servicemen to toxic effects. The Bari incident showed that nitrogen mustard could cause suppression of the bone marrow and of the lymphatic system. By the mid-1940s, doctors were beginning to control Hodgkin’s Disease and shrink the tumors.

The big breakthrough came in the middle 1960s. By 1964, doctors had come up with a combination chemotherapy regimen that utilized the mustard known as MOPP. MOPP consists of cyclophosphamide, vincristine, methotrexate, and prednisone.

The current staging system was also set up by the mid-1960s. The Ann Arbor Staging for Lymphomas also applies to Hodgkin’s Disease. Stage is closely associated with prognosis. The stages for lymphoma are:

• Stage I indicates that the cancer is located in a single region, usually one lymph node and the surrounding area. Stage I often will not have outward symptoms.
• Stage II indicates that the cancer is located in two separate regions, an affected lymph node or organ within the lymphatic system and a second affected area, and that both affected areas are confined to one side of the diaphragm – that is, both are above the diaphragm, or both are below the diaphragm.
• Stage III indicates that the cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
• Stage IV indicates diffuse or disseminated involvement of one or more extralymphatic organs, including any involvement of the liver, bone marrow, or nodular involvement of the lungs.

To this letters are often appended:

• A or B: the absence of constitutional (B-type) symptoms is denoted by adding an “A” to the stage; the presence is denoted by adding a “B” to the stage. The B symptoms include night sweats, fevers, and weight loss of 10% of more. Many symptoms associated with Hodgkin’s Disease (itching, pain on drinking alcohol) are not official B-symptoms.
• E: is used if the disease is “extranodal” or has spread from lymph nodes to adjacent tissue.
• X: is used if the largest deposit is >10 cm large (“bulky disease”), or whether the mediastinum is wider than 1/3 of the chest on x-ray.
• S: is used if the disease has spread to the spleen.

(So if you assigned your author all the different letters that applied to her case, she would have Stage III-AEXS Hodgkin’s Disease.)

By the way there are also four known sub-types of Classical Hodgkin’s Disease:

• lymphocyte predominance (approximately 5% of cases)
• nodular sclerosis (approximately 70%)
• mixed cellularity (approximately 20%)
• lymphocyte depletion (5%)

(Your author had the NS sub-type.)

By 1967, the results from MOPP were coming in and they were astounding: an 81% complete remission rate. In 1968, Adriamycin ((Adriamycin is the red drug. It is used for many different kinds of cancers. It’s generic name is doxorubicin. Adriamycin is in the class of chemo drugs known as Anthracyclines.)) became available for the first-time and in 1972 Dacarbazine ((Dacarbazine is also known by it’s brand name, DTIC. Dacarbazine is an alkylating antineoplastic agent. It is used mainly now for Hodgkin’s Disease and for certain kinds of melanoma.)) was approved for use. Because MOPP caused severe side effects (including sterility and severe suppression of the bone marrow leading to secondary leukemias), in 1972-73 a group from Italy led by Bonadonna came up with the current “gold standard” for Hodgkin’s Disease: ABVD Chemotherapy. ABVD combined a vinca-alkaloid known as Vinblastine ((Vinblastine is a mitotic inhibitor. It derives from the perwinkle plant.)) (similar to Vincristine in MOPP), an anti-tumor antibiotic called Bleomycin, and Adriamycin, and Dacarbazine. In head to head trials, ABVD proved not only less toxic, but also provided superior rates of cure.

The last major step in treating Hodgkin’s Disease came in 1992 when a German group came up with a new regimen for highest risk patients known as BEACOPP. Along with the Stanford V regimen (a combination chemotherapy and radiation regimen), these two treatments are now sometimes used in place of ABVD in advanced disease.

With modern chemotherapy, sometimes combined with radiation to areas of disease, about 80% of patients with Hodgkin’s Disease can today be cured.

As you would expect, Hodgkin’s Disease is still an evolving field, especially in terms of treating patients who have relapsed disease. Much of the work currently involves effective treatments for Hodgkin’s Disease that reoccurs despite first-line therapies. Also, there has been focus on trying to predict which patients are most likely to relapse. The use of radiation remains an issue as does attempting to lessen the toxicities from chemotherapy.

A Few Famous Hodgkin’s Disease Survivors You’ve Probably heard of

• Paul Allen
• Mario Lemieux
• Arlen Specter
• and a host of wonderful people you’ve never heard of, but are just as important, and just as valuable

So there you have it — a brief history of Dr. Hodgkin and his disease. ((The World Health Organization in 2001 tried to officially name Hodgkin’s Disease, Hodgkin’s Lymphoma. Personally, I think Hodgkin’s Disease sounds better and my doc uses the term “Disease”, so I am going to keep referring to it as Hodgkin’s Disease.))