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Case history

image A 23-year-old man presented with a 1 year history of neck lumps. He had refused to attend appointments for investigations but was eventually persuaded by his family to visit his GP.

He was diagnosed with stage IIA Hodgkin's lymphoma, with no unfavourable features, and referred for consideration of treatment with chemotherapy +/− radiotherapy. The patient attended with his father, aunt and grandmother but not his mother, with whom he was living. He was awaiting an appointment to undergo testing for Asperger's syndrome. His family stated that he was very intelligent. He appeared to interpret speech very literally and it was difficult to tell whether he fully comprehended the information given.

Two doctors agreed that he had capacity to consent for chemotherapy, and he gave signed, informed consent to treatment with doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). Three cycles were planned followed by a PET-CT scan to guide the need for further therapy based on the response to chemotherapy.

A diagnosis of autistic spectrum disorder was confirmed during treatment, when it also became apparent that relations between the patient and his mother had broken down. Consequently, his mother tried to access information about his diagnosis directly from staff. He was assigned a social worker from the young-oncology service to support him during treatment. As he became very distressed waiting for consultations in waiting rooms, arrangements were made for him to wait for clinic appointments in the teen and young adult lounge instead.

As treatment continued, the patient's mental state deteriorated and he was referred to the psycho-oncology service. He was reviewed by a clinical psychologist and diagnosed with an anxiety disorder. His family were referred to points of support such as the National Autistic Society, and strategies for managing anxiety were discussed with his key worker.

The patient completed three cycles of ABVD chemotherapy without significant toxicity; a repeat PET scan showed a complete metabolic response. As he did not require further chemotherapy or radiotherapy, he entered post-treatment surveillance.

What were the aims of treatment for this patient?

What is the evidence base for the treatment?

What is autistic spectrum disorder and how did it affect the patient's treatment?

What issues need to be considered when treating patients with autistic spectrum disorder who are undergoing treatment in the oncology department?

What were the aims of treatment for this patient?

With modern combined modality treatment (chemotherapy and radiotherapy), patients with Hodgkin's lymphoma stage I/II disease and no adverse risk factors achieve 5 year survival rates exceeding 90%.1 The aim of treatment in our patient was to cure the disease using the minimum amount of treatment and disruption given his concomitant diagnosis of Asperger's syndrome and fractured social background.

What is the evidence base for the treatment?

Early-stage Hodgkin's lymphoma was historically treated with radiotherapy alone. The German Hodgkin Study Group, however, demonstrated a considerable reduction ...

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