Poor survival rates in non-Hodgkin's lymphoma patients attributed to lifestyle factors

A new study led by researchers from Mayo Clinic in collaboration with six other U.S. institutions has found that patients with non-Hodgkin's lymphoma who smoked, consumed alcohol or were obese before their cancer diagnosis had poorer overall survival, compared to patients who did not have these risk factors. This association held after accounting for clinical and demographic factors, and also when considering only deaths due to this kind of lymphoma.

“We don't know why this is the case, but suggests alcohol may have different impacts on developing versus surviving non-Hodgkin's lymphoma, and this warrants further research”

For example, non-Hodgkin's lymphoma patients with a 20-plus-year history of smoking had a 76 percent higher risk of death compared to never smokers; patients who consumed more than 43 grams of alcohol per week had a 55 percent higher risk of death compared to nondrinkers; and obese patients (defined as a body mass index of 30 or higher) had a 32 percent higher risk of death compared to patients with normal weight for their height.

While smoking and obesity had already been found to increase the risk of developing non-Hodgkin's lymphoma, this is the first U.S. study to look at their role on survival after being diagnosed with non-Hodgkin's lymphoma, the researchers say. For alcohol, they found that use was associated with poorer survival, which is opposite of the effect for developing non-Hodgkin's lymphoma, where alcohol appears to lower risk.

These findings, published in the March 30 online edition of Cancer, mirror conclusions found in three smaller studies, according to the study's lead investigator, James Cerhan, M.D., Ph.D., a Mayo cancer epidemiologist. These are the first data from North American patients, and the only study to simultaneously look at all three lifestyle factors, he says.

"This now raises the hypothesis that changing these behaviors after diagnosis might improve survival, but this needs to be tested in a clinical study," he says. "In the meantime, patients in active therapy should discuss any lifestyle changes with their health care provider. Long-term survivors outside of therapy should consider the general public health guidelines that recommend smoking cessation, moderate or no alcohol use, and attaining a healthy weight."

Non-Hodgkin's lymphoma is a cancer of the immune system. It is the fifth most common cause of cancer, and the most common hematologic malignancy in the United States.

In this study, information from 1,286 non-Hodgkin's lymphoma patients was collected from 1998 to 2000. Patients were identified from population-based cancer registries in Michigan, Iowa, California, and Washington, and they were interviewed shortly after diagnosis. Participants were asked to report their height and weight the year before they were diagnosed, and half of the participants also were asked information about use of alcohol and smoking history.

Through 2007, 442 (34 percent) patients had died, including 144 of 420 patients with diffuse large B-cell lymphoma and 93 of 328 of patients with follicular lymphoma, the two most common non-Hodgkin's lymphoma subtypes.

Of the 471 patients who provided information about smoking history, 34 percent were former smokers and 19 percent were current smokers at the time of diagnosis. Researchers calculated that both former and current smoking in these patients was associated with an approximately 50 percent higher risk of death. Poorer survival also was linked to longer smoking duration and greater numbers of cigarettes smoked per day.

But there was a piece of good news. "It is important to note that patients who had quit smoking 20 years or more before diagnosis had no higher risk of death than patients who had never smoked," Dr. Cerhan says.

Of the 458 patients with data on alcohol use, 49 percent consumed alcohol one year before diagnosis, and the median intake was 43.1 grams a week (about 3.3 cans of beer, 4.6 glasses of wine, or 2.7 shots of liquor weekly). Researchers found a 55 percent increased risk of death among those who drank more than 43 grams a week compared to never drinkers. In contrast, patients who drank 43 grams or less a week had a risk of death similar to nondrinkers.

Dr. Cerhan notes that the association between drinking and survival is the opposite of what was found for the development of non-Hodgkin's lymphoma. There, alcohol use appears to lower risk of non-Hodgkin's lymphoma. "We don't know why this is the case, but suggests alcohol may have different impacts on developing versus surviving non-Hodgkin's lymphoma, and this warrants further research," he says.

Of the 1,189 who provided usable data about their height and weight, about 5 percent were underweight, 31 percent were normal weight, 39 percent were overweight, and 26 percent were classified as obese. After adjusting for clinical and demographic factors, obese patients had a 32 percent higher risk of death compared to normal weight patients; the risk of death for overweight patients was similar to that for normal weight patients.

Even given these results for lifestyle factors, the strongest predictors of outcome in non-Hodgkin's lymphoma remain age and clinical measures that include issues such as cancer stage, the number of lymph nodes that are affected, and certain biochemical measurements, Dr. Cerhan says.

The study had limitations, such as the original data was designed to look at risk of developing non-Hodgkin's lymphoma and, in this study, those questionnaires were used to evaluate the impact of the same factors on survival. "This raises the concern that people may have changed their behaviors after diagnosis, and we would have missed these changes," Dr. Cerhan says. However, he notes that such a change would most likely bias the study to finding no association with the lifestyle factors.

"Most importantly, we didn't answer the question of whether changing these factors after diagnosis would impact survival," he says. "That is best done with a clinical trial."


Mayo Clinic


  1. Patricia Stowe Patricia Stowe United States says:

    I survived Non-Hodgkins Lymphoma after a Bone Marrow Transplant in 1992.  I have had no reoccurence.  When I was first diagnosed I tried to figure out why I, a 40 year old "female", would have this diagnosis.  About 18-24 months before I was diagnosed I went through the most horrible stress period of my life, lasting more than a year - a divorce from my suicidal, dangerous husband and then having to fight for custody of my ten year old son.  The stress almost killed me; and I think it caused the NHL.  Before I went for the transplant I asked if they could give me names and phone numbers of some survivors.  I called all five of them. and all but one said they had been through an extremely stressful period.  One woman even told me it was bad she couldn't even tell me what it was.  Recently a friend of mine from long ago called me and told me his daughter was diagnosed with NHL and asked if I would call her for encouragement.  When I called her she also confirmed she had been through an extremely stressful period.  My conclusion to all this is that anyone who is going through an extremely stressful period should boost their immune system as much as they can.  When a body is fighting extreme stress the immune system can't protect the body.  I really wish the medical field would do some research and see if stress is the main factor.

    • KIm Garver KIm Garver United States says:

      I am a 44 year old mother of two wonder kids who was also diagosed with Non-Hodgkins lymphoma following a heart wrenching stressful time in my life. I too believe that this brought me to my diagnosis that I tell all my friends to take care of themselves and try not to let stress invade there body! Currently I am undergoing Chemo preparing for a stem cell transplant and looking for ways to reduce stress in my life!!

      • Toni Lauriello Toni Lauriello United States says:

        I am a fellow NHL and transplant surviver, keep strong and stay fighting!Do something just for you each day big or small to remind yourself just how special you are!Goodluck and i will pray for you.

    • E. Briggs E. Briggs United States says:

      I am a female that was diagnosed ith NHL when I was 35 years young.  Yes, I also went through some extremely stressful years with divorce, child custody and working all the time.  Hind sight is so clear. Instead of all that worry and stress I should have lived in the moment.  Lesson learned. Each day is a gift. I had a stem cell transplant in 2003 and have been cancer free ever since.  

      God is great and life is good.

    • Mary Mary United States says:

      Both my husband (prostate cancer) and I (non-hodgkins lymphoma) were diagnosed within 3 yrs. of our 24 yr. old son's death.  Grief almost killed us and later I thought that this degree of stress was the cause of our cancers.  My husband and I were treated and he survived 19 yrs. and I 20 yrs.  I truly believe that stress was the main factor in our cancers.

    • Toni Lauriello Toni Lauriello United States says:

      Read your first sentence and it sent chills up my spine!I went through a bad divorce as well,fighting for my 2 small childen,then remarried the wrong 2nd husband and had 2 more beautiful children.The stress of raising kids with someone who never liked or treated my son well made me worry all the time on top of all the other stresses going on weathered and took its toll on me and my dad swears thats how i got nhl'i am 6 yrs through my cancer a transplant and a severe case of shingles to my head thats left many other health issues as well as renal kidney failure.I thank god for seeing me this so i can still be here watching my kids grow and thrive.I just sometimes feel like i switched bodies with an old lady!Your story made me feel like im not all alone,thankyou

  2. Lisa Hughes Lisa Hughes United States says:

    November will mark my 24th year of surviving NHL. I was pregnant with my first child and thankfully, it was localized in my neck which only required local radiation for 5 weeks. While the excitement of having a first child may have added to the stress, I am also a Crohn's Disease fighter - which I KNOW - regardless what medical experts tell me - is definitely triggered by stress.  So, I have to sometimes wonder if the pregnancy set off my Crohn's pain, which triggered additional body stress, etc.  On a good note, I am what I consider to be very healthy today -- just turned 50 and still and always will battle my Crohn's but I encourage ANYONE who notices a change in their bodies to have it checked immediately.  I was fortunate a nodule appeared in my neck region and continued to get larger which prompted my doctor visit - surgery was scheduled the following week since I was in the perfect point of my pregnancy.  My mother unfortunately waited too long and I lost her to NHL 12 years ago.  Hereditary?  Who knows.  Stress related?  I think so.

  3. Nathan peterson Nathan peterson United States says:

    My brother passed to this cancer he was 42 gone to soon

  4. Linda Compton Linda Compton United States says:

    I have NHL (follicular) went through Chemo treatment in 2011, cancer returned 2013.  Was going to have stem cell but the requirements were to demanding for a single mom with two kids so I opt for Chemo again.  I think STRESS is the contributing factor to my cancer.  Being a single mom alone is stressful but with a stressful hospital job, long hours, two teenagers, financial problems, always struggling..... yeah....STRESS has alot to do with it.  My future plan after Chemo is to quit my job, move away from a stressful EX.  I feel that changing the demographics will bring me more peace.  I could be wrong but something has to change.

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News-Medical.Net.
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