Combine lymphoma and Crohn’s disease and it takes a village

Multidisciplinary care – and a patient’s own engagement – was indispensable to successful outcome
September 22, 2022
Emily Solomon, who had a combination of lymphoma and Crohn’s disease.
Emily Solomon’s combination of lymphoma and Crohn’s disease took a team to treat. Photos by Cyrus McCrimmon for UCHealth.

Emily Solomon, a busy working mother of four, wasn’t terribly concerned when she noted a lump near her groin in late 2018. The 48-year-old Denver resident had had surgery for an inguinal hernia two decades before, and the lump was in that neighborhood. Still, she figured it wise to bring it up with Dr. Ann Klein, her physician with the Women’s Integrated Services in Health (WISH) clinic at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. Klein’s clinical evaluation led the doctor to agree with her patient. But just to be sure, Klein suggested, she would order an ultrasound.

Dr. Ann Klein
Dr. Ann Klein

Those results didn’t indicate a hernia, and a subsequent biopsy found something else entirely. The lump was malignant: Solomon had a type of non-Hodgkins lymphoma.

They had caught it early, and the prognosis was good. There was, however, a complication: Solomon had been diagnosed with Crohn’s disease back in 2009, and while the inflammatory bowel disease was in check, it would complicate both her cancer care and the management of her Crohn’s disease. The crux: You treat Crohn’s disease by suppressing the immune system to cool off inflammation; you treat non-Hodgkin’s lymphoma, among other ways, by bringing the immune system into the cancer fight.

Starting on rituximab infusions

Dr. Manali Kamdar, clinical director of lymphoma services with the University of Colorado School of Medicine’s Division of Hematology, took the lead in Solomon’s cancer treatment. This was a slow-growing marginal-zone lymphoma that Kamdar felt would respond to rituximab, an immune-system-stoking monoclonal antibody which she described as “the backbone of how we have managed lymphomas for a very long time.” Solomon would start on rituximab infusions at the University of Colorado Cancer Center at University of Colorado Hospital.

Despite all this, Solomon felt, as she put it, “fit as a fiddle.”

“My husband and I would joke that I’ve got lymphoma and Crohn’s and I look and feel fine,” she said. “Like, you open the hood, and this is what you find.”

As she stepped into the University of Colorado Hospital elevator with husband Jay en route to her first infusion February 2019, Solomon took note of the huge photos of patient success stories and said to herself, “I want that to be me.”

That would be her, but it wouldn’t come easy.

A dose of rescue therapy

Dr. Manali Kamdar
Dr. Manali Kamdar

Just over a year into her series of rituximab infusions, she fell ill with her first-ever Crohn’s flare. Solomon found herself bereft of energy, bedridden, and largely unable to eat. This went on for a solid three months. Her husband Jay, daughters Maddie and Bella, and sons Noah and Aiden brought her meals and kept the household ship afloat during the coronavirus pandemic lockdown. Like so many others during that time, she put off seeking medical care for weeks, until she spiked a fever in late May and felt she had no choice. Emergency Department physicians at University of Colorado Hospital admitted her.

Dr. Blair Fennimore, a CU School of Medicine gastroenterologist with the UCHealth Digestive Health Center – Anschutz Medical Campus, took charge of her Crohn’s disease care. This was “a serious flare-up,” as he described it, and one with potentially serious consequences. If 72 hours of high-dose intravenous steroids or a dose of rescue therapy with an anti-inflammatory biologic didn’t quell her immune system’s attack, a colectomy was a real possibility.

“If the patient doesn’t respond to rescue therapy, you can go to colectomy in a week’s time,” Fennimore said.

Despite the steroids, blood tests showed Solomon’s inflammatory markers to have scarcely budged. She needed a dose of rescue therapy and a miraculous turn around, or she would face surgery. Then there was her lymphoma.

A balance between inflammatory bowel disease medications and cancer care

Emily Solomon, who had lymphoma and Crohn’s disease, with her family. Photo courtesy of Kara Pearson Photography.
Emily Solomon with her family. Photo courtesy of Kara Pearson Photography.

Adalimumab (Humira), which Solomon had been taking for years with success, very slightly increases lymphoma risk. Whether or not Solomon had been one of those rare cases (less than a handful per 10,000 people taking the drug, Fennimore says) in which Humira can lead to cancer didn’t matter now. What did matter was that her lymphoma wouldn’t somehow take advantage of whatever Fennimore would prescribe to tame Solomon’s dangerous Crohn’s inflammation. That left only a couple of inflammatory bowel disease medications on the table. Fennimore conferred with Kandar, and he also presented Solomon’s case at a weekly multidisciplinary conference among Anschutz Medical Campus IBD experts including gastroenterologists, pharmacists, dietitians, a GI psychologist and colorectal surgeons.

During the pandemic lockdown, this was as close as Emily Solomon could get to her family during her nine-day hospital stay. Photo courtesy of Emily Solomon.
During the pandemic, this was as close as Emily Solomon could get to her family during her nine-day hospital stay. Photo courtesy of Emily Solomon.

With their input, Fennimore settled on an anti-inflammatory biologic called ustekinumab (trade name Stelara) – an atypical choice for rescue therapy, but one that balanced the competing needs of her Crohn’s and lymphoma. For more than a week, her husband and kids drove from their Denver home to a hospital parking lot. There they stood far below Solomon’s eighth-floor window and FaceTimed with her as she observed them from on high. This was as close as she could get with the pandemic’s pause on hospital visitors.

Dr. Blair Fennimore
Dr. Blair Fennimore

As the ustekinumab quelled her inflammation, she gained strength and felt better, but not before she had missed Aiden’s fifth-grade continuation and Bella’s high school graduation. On her ninth day, she was healthy enough that, with Fennimore’s blessing, she was discharged so she could be home for son Noah’s high school graduation – as with so many others that year, a socially distanced affair involving a procession of vehicles.

Solomon stayed on the combination of ustekinumab and rituximab. Her Crohn’s disease and her lymphoma have stayed at bay, and by August 2022, she had the honor of ringing the “all-clear” bell at the Colorado Cancer Center. She knows, though, that both Crohn’s and lymphoma are chronic conditions, and while there’s a chance that she can taper from these drugs and remain Crohn’s- and cancer-free, the odds are greater that she’ll stay on them and, with medical advances, other therapies to keep it that way.

Communication is key when dealing with dual diseases

Kamdar considers Solomon’s successful outcomes to have emerged from the fruitful communication among not only medical experts from several disciplines, but with Solomon herself, who took detailed notes throughout her care, asked questions, and stayed engaged.

“Emily is at the fore of all of this,” Kamdar said. “The quality of life that she has is thanks to her and the seamless communication that was possible among these different specialties that could give her the best care.”

Solomon attributes her health to the care at University of Colorado Hospital.

Emily Solomon rings the cancer-free bell surrounded by her family after battling lymphoma while having Crohn's disease. Photo courtesy of Emily Solomon.
Emily Solomon rings the cancer-free bell surrounded by her family after battling lymphoma while having Crohn’s disease. Photo courtesy of Emily Solomon.

“I cannot say enough about the ways in which I benefitted from the UCH system – from the specialty providers and their level of expertise, the research focus that is integral to UCH, and the ways in which all my providers have continually communicated and worked together on my behalf,” she said.

Fennimore, who has seen IBD patients respond well and less well to various therapies, is simply happy for Solomon.

“She’s got her life back, you know? It’s amazing for her,” he said.

About the author

Todd Neff has written hundreds of stories for University of Colorado Hospital and UCHealth. He covered science and the environment for the Daily Camera in Boulder, Colorado, and has taught narrative nonfiction at the University of Colorado, where he was a Ted Scripps Fellowship recipient in Environmental Journalism. He is author of “A Beard Cut Short,” a biography of a remarkable professor; “The Laser That’s Changing the World,” a history of lidar; and “From Jars to the Stars,” a history of Ball Aerospace.