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survival rate of 78 %. 1 Dr . Lossos explained to Rizzo that there was a chance for cure , but that he had to stop playing baseball to receive treatment . Rizzo was started on standard of care ABVD ( doxorubicin [ Adriamycin ], bleomycin , vinblastine , and dacarbazine ) therapy .
“ In Anthony ’ s case – because we needed to think of his future – use of BEACOPP was not a consideration ,” Dr . Lossos said . BEACOPP , more commonly used in Europe , has been shown to result in better initial tumor control for Hodgkin lymphoma , but ABVD is less toxic and has similar long-term outcomes . 2
Bleomycin , which is used in both regimens , has the potential for interstitial pulmonary fibrosis , so Dr . Lossos and the care team closely monitored Rizzo with pulmonary function tests .
Rizzo started to show improvement after the first cycle of chemotherapy and was in complete remission after six cycles . His kidney function returned to normal . He was back to playing baseball by 2010 .
Uncovering a Diagnosis
Running back James Conner was diagnosed with stage IIb Hodgkin lymphoma in 2015 , while playing football for the University of Pittsburgh .
“ James had been seeing a few different physicians for a host of symptoms that he thought were related to sinuses or allergies ,” said Stanley Marks , MD , chair of UPMC Hillman Cancer Center in Pittsburgh , who treated Conner . Later , after receiving his cancer diagnosis , Conner also acknowledged that he had been experiencing night sweats but thought that this was a symptom of an infection .
According to Dr . Marks , Conner became concerned when he was lifting weights and looked in a mirror and saw that his face and chest were bright red .
“ This time , his physicians discovered he had superior vena cava syndrome caused by a large mass in his chest that was pushing on the veins in the upper part of his body ,” he explained . “ He was referred to UPMC Hillman ’ s director , Robert Ferris , MD , PhD , a head and neck surgical oncologist , for a biopsy on the lymph nodes in his neck .”
Athletes and Blood Clots
Blood clots may seem more “ benign ” than a diagnosis of a hematologic malignancy , but , as seen in the stories of professional athletes such as Chris Bosh and Serena Williams , these complications can threaten careers and – in rare instances – lives .
As Stephan Moll , MD , of the University of North Carolina , explained to UNC Health Talk , there are several factors that make venous thromboembolism ( VTE ) particularly risky in athletes . First , VTE is often overlooked in this population . The symptoms of blood clots ( such as pain , swelling , skin discoloration , and shortness of breath and chest pain in the case of pulmonary embolism ) can masquerade as acute conditions such as a muscle strain or shin splints .
Athletes are at risk for developing VTE for a variety of reasons , including prolonged travel time to games , compression of veins due to unusually large muscles or unusual anatomy , or an increased risk of injury or surgery with contact sports .
While typical treatment of VTE includes anticoagulation , or thrombolytics or thrombectomy for extensive clots , the treatment for athletes must be tailored to their unique circumstances and risk of injury . For example , anticoagulation can be scheduled to maximize therapeutic time before the day of play , then blood thinners are interrupted on the day of play and resumed after the
Next , Conner was referred to Dr . Marks . The swollen lymph nodes in Conner ’ s neck were initially missed because his neck was so muscular , Dr . Marks noted , adding that the running back was fortunate that the blockage in his chest did not result in a catastrophic event before he received his cancer diagnosis .
Dr . Marks said that the optimal management of stage IIb Hodgkin lymphoma can be controversial . Standard of care is a six-month regimen of chemotherapy , but some physicians also recommend chest radiation , particularly in cases with masses as large as Conner ’ s .
“ In his case , we decided against radiation because he had responded so well to the initial treatment . Adding radiation to his chest could be detrimental to his lungs or heart and his football career ,” Dr . Marks said . “ I talked this over with James and his mother , and I also ran the case by four other experts around the country and all agreed with that assessment .”
Conner was started on ABVD and , similarly to Rizzo , was monitored for lung injury because of bleomycin and heart injury because of doxorubicin .
Not long before Dr . Marks began treating Conner , research had demonstrated that an interim PET scan after two cycles of ABVD predicted outcome for Hodgkin lymphoma , and could indicate whether a patient would benefit from escalated therapy . 3 “ Fortunately , his scan was negative after two months and I was assured that we made the right decision not to give him radiation treatments ,” Dr . Marks said .
Another study published around the same time suggested that patients who have negative findings on an interim PET scan after two cycles of ABVD could safely drop bleomycin from the regimen . 4 If Conner had been diagnosed just a few years later , Dr . Marks said , he would likely have substituted brentuximab vedotin for bleomycin , a combination that has shown better progression-free survival compared with ABVD , regardless of interim PET findings . 5
During his cancer treatment , Conner continued to work out with the University of Pittsburgh football team . He then completed his college career , was drafted
game to limit the risk of excessive bleeding in the case of injury on the field .
After a clot , anticoagulation strategies should be adjusted to balance the risks of recurrent VTE and bleeding events when the athlete is deemed healthy enough to return to play . Professional athletes may also have the resources to undergo personalized pharmacokinetic and pharmacodynamic studies to guide anticoagulation in this population . However , few data exist to guide decisions about resuming anticoagulation or returning to play after VTE . Generally , Dr . Moll noted , delays in resumption of anticoagulation or use of prophylactic anticoagulant doses may be necessary , although these practices could increase the risk for recurrent VTE .
Athletes who experience VTE are not necessarily barred from play , given the availability of direct oral anticoagulants , and , in consultation with hematologists or team physicians , they can weigh the risks and benefits of play .
Sources
1 . UNC Health Talk . The Athlete-Blood Clot Connection . October 8 , 2019 . Accessed July 12 , 2021 . https :// healthtalk . unchealthcare . org / the-athlete-blood-clot-connection /.
2 . American College of Cardiology . Athletes and Anticoagulation : Return to Play After DVT / PE . October 19 , 2016 . Accessed July 12 , 2021 . https :// www . acc . org / latest-incardiology / articles / 2016 / 10 / 19 / 15 / 13 / athletes-and-anticoagulation . by the Pittsburgh Steelers , and will play this year for the Arizona Cardinals .
Playing With a Chronic Condition
Billy Garrett Jr ., the first known NBA player with sickle cell disease ( SCD ) has shown that it is possible to maintain a career in professional sports while living with a chronic hematologic condition .
SCD is associated with anemia that limits oxygen delivery and can cause metabolic acidosis , explained pediatric hematologist Dr . Hsu . Dr . Hsu treated Garrett during his college basketball career at DePaul University , and is still involved with his care as Garrett transitions to an adult provider .
According to Dr . Hsu , three unique factors have allowed Garrett to become a successful athlete . First , Garrett has the sickle hemoglobin-C disease ( SC ) disease , a less severe form of SCD . Second , Garrett comes from a family of elite basketball players who have encouraged and motivated him to maintain great physical condition his whole life . Third , Garrett has practiced excellent self-care and taken medications that limited the effects of his disease .
Dr . Hsu and Garrett worked with his coaches at De- Paul to set up guidelines for Garrett ’ s success .
“ He has learned over the years to take frequent rest breaks , for example ,” Dr . Hsu said . “ We worked with coaches to build in the time off the court during scheduled timeouts when he can catch his breath and hydrate .”
Garrett also prioritizes good temperature control to avoid concerns about vasoconstriction due to cold or excessive dehydration . “ He knows that he has to gradually adjust himself to new environments ,” Dr . Hsu said . “ He brings an oxygen concentrator on plane trips so that even the mild hypoxia that can occur on a commercial aircraft would not cause a problem for him later .”
Dr . Hsu said that Garrett was hesitant to take any medication that could be considered a performanceenhancing drug . For example , the SCD drug voxelotor modifies hemoglobin and increases the affinity between oxygen and hemoglobin . Increasing hemoglobin allows higher amounts of oxygen to reach the muscles , which , in athletes , could improve stamina and performance .
“ Theoretically , voxelotor could increase a hemoglobin level by 1 g / dL but we didn ’ t want to do that – his hemoglobin is already high enough ,” Dr . Hsu said .
Also , any treatment that required monthly infusions , such as crizanlizumab , was not a good option for Garrett ’ s schedule . Instead , Garrett was able to benefit from another fairly new drug , L-glutamine , which has been shown to reduce acute complications of SCD . 6
“ We settled on L-glutamine because it did not raise hemoglobin , but works on red cell metabolism ,” Dr . Hsu explained .
These treatment advances , combined with Garrett ’ s dedication to self-care and disease management , have allowed him to play in the NBA ’ s minor league for several years , including signing a 10-day contract with the New York Knicks in 2019 .
Amateur Athletes
Treatment advances are extending to younger athletes , like the amateur athletes who Dr . Stevens sees in her practice . Most commonly , she treats children or adolescents diagnosed with acute myeloid leukemia ( AML ) or acute lymphocytic leukemia ( ALL ).
22 ASH Clinical News August 2021