Chemotherapy for non-Hodgkin lymphoma
Chemotherapy is the main treatment for most types of NHL. It uses cytotoxic drugs to destroy cancer cells. Cytotoxic means toxic to cells.
Chemotherapy can be given into a vein (intravenously) or taken as tablets. With both these methods, the chemotherapy gets into the bloodstream and is carried to lymphoma cells wherever they are in the body.
Most people have their chemotherapy as an outpatient. Sometimes just one chemotherapy drug is given, but most treatments involve having a combination of two or more chemotherapy drugs in a single day. This is then followed by a rest period of a few weeks without chemotherapy. The rest period allows your body to recover from any side effects before the next treatment.
A course of chemotherapy treatment usually lasts several months. During this time you’ll have regular check-ups at the hospital.
Our section on cancer treatments discusses chemotherapy treatment and its side effects in detail.
Chemotherapy for indolent lymphomas
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There are several chemotherapy treatments that work well for indolent lymphoma. The most commonly used treatments include:
CVP - A combination of the chemotherapy drugs cyclophosphamide and vincristine (Oncovin®) given into a vein, and steroid tablets called prednisolone.
CHOP - A combination of the chemotherapy drugs cyclophosphamide, doxorubicin (Adriamycin) and vincristine, given into a vein, and prednisolone tablets.
Chlorambucil (Leukeran®) - A chemotherapy drug taken as tablets.
Fludarabine - A chemotherapy drug often given in combination with another chemotherapy drug. Fludarabine can be given into a vein or as tablets.
Bendamustine - A chemotherapy drug given into a vein.
In addition to chemotherapy, many indolent lymphomas are treated with a monoclonal antibody called rituximab (Mabthera®). When chemotherapy and rituximab are given together, the letter ‘R’ is added to the treatment name – for example, R-CVP or R-CHOP.
Chemotherapy for aggressive lymphomas
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The most commonly used chemotherapy treatment for aggressive lymphomas is a combination of drugs called CHOP.
People with aggressive B-cell lymphomas are usually also given a monoclonal antibody called rituximab alongside their chemotherapy. When rituximab is combined with CHOP chemotherapy it’s called R-CHOP.
We have more information about CHOP and R-CHOP.
Giving chemotherapy into a vein (intravenous chemotherapy)
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In order to have treatment given into your bloodstream (intravenously), you’ll need to have a tube put into your vein. You may have one of the following:
A cannula - A small, plastic tube put into a vein in the back of your hand or your lower arm.
A PICC line (peripherally inserted central catheter) - A long, thin tube put into a vein just above the bend in your arm and threaded up to a large vein in your chest.
A central line (central venous catheter) - A long, thin tube put into a large vein in your chest. The other end of the tube is tunnelled under your skin and comes out on your chest.
An implantable port - A thin tube put into a large vein in your chest. The tube ends in a small port just under the skin of your chest.
If your chemotherapy is given through a cannula, this is put in just before each chemotherapy session and taken out before you go home. You’ll need to have a new one put in before each treatment.
Unlike cannulas, PICC lines, central lines and ports can stay in until your treatment finishes.
PICC lines can usually be put in under a local anaesthetic in the clinic.
A central line or a port may be put in under a local or a general anaesthetic.
If you have a PICC line, central line or implantable port, your nurses will show you how to look after it.
Giving chemotherapy into the spinal fluid (intrathecal chemotherapy)
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With some types of aggressive NHL, and when NHL is found in certain areas of the body such as the testicles, there’s a higher risk of lymphoma cells getting into the brain. If you have a lymphoma like this, you may be given additional treatment to reduce your risk. This is called prophylactic treatment.
One way of reducing the risk of lymphoma cells spreading to the brain is to put chemotherapy into the spinal fluid. This is called intrathecal chemotherapy. It’s done in a similar way to a lumbar puncture but before removing the needle, the doctor puts a small amount of liquid chemotherapy into the spinal fluid. The chemotherapy drug most commonly used is Methotrexate.
Intrathecal chemotherapy can also be used to treat lymphoma that has already spread to the brain.
Most people have intrathecal treatment as an outpatient, but for a few people it may mean an overnight stay in hospital.
High doses of methotrexate can also be given into a vein to treat or prevent lymphoma in the brain. In this situation, intrathecal chemotherapy may not be needed.
Side effects of chemotherapy
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Chemotherapy can cause side effects, but it can also make you feel better by relieving symptoms caused by the lymphoma.
Not all chemotherapy drugs cause the same side effects. If your treatment involves having just one chemotherapy drug, any side effects you have will usually be mild. But if you’re having treatment with a combination of chemotherapy drugs, you may have more side effects. These can usually be controlled with medicines. Your doctor or specialist nurse will tell you about the side effects your treatment is likely to cause.
Low resistance to infection
While chemotherapy drugs are acting on the lymphoma cells in your body, they also temporarily reduce the number of white blood cells in your blood. You may hear the doctors or nurses using the words ‘neutropenia’ and ‘neutropenic’. These are the medical terms for having a low number of white blood cells in your blood.
Usually, the number of white blood cells will return to normal in time for you to have your next treatment. You’ll have a blood test before each chemotherapy treatment to check this. If your white blood cell count is still low, your treatment may have to be delayed. You may be given injections of a growth factor to boost your number of white blood cells.
While your white blood cell numbers are low, you’re more at risk of infection. There are a few precautions you can take to help protect yourself during this time:
only eat food that is thoroughly cooked
wash your hands after using the toilet and before preparing food or eating
avoid anyone who has an infection such as a cold or flu, and keep away from crowded places where you may come into contact with infection.
If you get an infection when your white blood cell numbers are low, there’s a risk you could become seriously unwell very quickly. It’s important to contact your doctor or the hospital straight away if:
your temperature goes above 38°C (100.4°F)
you suddenly feel unwell, even with a normal temperature.
Bruising and bleeding
Chemotherapy can temporarily reduce the number of blood-clotting cells (platelets) in your blood. If this happens you may bruise easily, have nosebleeds, and bleed more heavily from minor cuts and grazes. Sometimes people develop a rash of tiny pinprick-sized reddish-purple marks on their skin (petechiae).
If you notice any of these symptoms, contact your doctor or the hospital immediately, as you may need a platelet transfusion.
Sometimes people become anaemic during chemotherapy. Anaemia means having lower than normal levels of red blood cells (haemoglobin) in your blood. If you become anaemic, you may lack energy or be more breathless than usual during activities such as walking or climbing stairs. If anaemia is causing you troublesome symptoms, you may be given a blood transfusion to increase your number of red blood cells.
Feeling sick (nausea)
Your doctor will prescribe anti-sickness (anti-emetic) drugs to prevent or greatly reduce nausea (feeling sick) and vomiting (being sick). These usually work well but tell your doctor or specialist nurse if you continue having problems. They can often prescribe another anti-sickness drug that works better for you.
Feeling tired (fatigue)
Tiredness can build up over a course of treatment. If this affects you, try to cut down on unnecessary activities and ask your family or friends to help with jobs such as shopping and housework. Balancing rest periods with gentle exercise can help reduce fatigue.
Some chemotherapy drugs can cause temporary hair loss. This varies depending on the type of treatment you have. Chlorambucil tablets don’t usually cause noticeable hair loss, but CVP chemotherapy often causes hair thinning. CHOP chemotherapy usually causes complete hair loss.
If hair comes out during chemotherapy, it usually grows back over a period of 3–6 months after treatment finishes. Your doctor or specialist nurse can tell you if the drugs you’re taking are likely to cause hair loss.
People who lose their hair often choose to wear a wig, hat or scarf. Hospital inpatients can get a free wig from the NHS. Your doctor or nurse will be able to arrange for a wig specialist to visit you. People being treated as outpatients usually have to pay for their wigs.
Some chemotherapy drugs can make your mouth sore or cause ulcers. You may not be able to prevent this, but keeping your mouth (and dentures if you wear them) clean during treatment will help. A soft-bristle toothbrush will be gentler on your mouth than a regular one. If you use a mouthwash, avoid those with alcohol in them as they can irritate the lining of your mouth.
Eating can be difficult if you have a sore mouth. Try to avoid highly spiced, salty or crunchy foods. Soft and moist foods are easier to eat.
It’s important to tell your doctor or specialist nurse if you have a sore mouth during chemotherapy. They’ll check for any infection in your mouth, and can prescribe mouthwashes and medicines to help you feel more comfortable.
Some chemotherapy drugs used to treat NHL, such as cyclophosphamide, doxorubicin and vincristine, can cause changes to your taste. You may notice that some foods lose their taste or that foods you usually enjoy taste different or even unpleasant. This is temporary and normal taste usually comes back within a few weeks of your last chemotherapy treatment.
You may become constipated during chemotherapy. This can be caused by some chemotherapy drugs, particularly vincristine, and by anti-sickness drugs given with chemotherapy. Drinking plenty of fluids, eating more fibre and keeping active can help prevent or reduce constipation. You may also need to take medicines (laxatives). Your doctor can prescribe these or you can buy them at a pharmacy.
If you have constipation that isn’t getting better, it’s important to contact your doctor for advice.
Change in sensation in hands and feet (peripheral neuropathy)
Some chemotherapy drugs used to treat NHL, such as vincristine, can cause changes in sensation in your hands and feet. This is called peripheral neuropathy. You may notice tingling or numbness, and have difficulty with fiddly tasks, such as doing up small buttons. It’s important to tell your doctor if you have these side effects.
Peripheral neuropathy may continue for some months after treatment is over before gradually getting better.
Risk of blood clots
Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it’s important to tell your doctor straight away if you have any of these symptoms. Clots can be treated with drugs that thin the blood. Your doctor or nurse can give you more information.
It’s not advisable to become pregnant or father a child while having chemotherapy, as the drugs may harm the developing baby. It’s important to use effective contraception during your treatment and for a few months afterwards. You can discuss this with your doctor or specialist nurse.
If you have sex within 48 hours of having chemotherapy, use a condom. This will protect your partner from small amounts of chemotherapy that may be present in semen or vaginal fluid.
Many couples have had healthy babies after one of them has been treated for NHL. But, unfortunately, some chemotherapy treatments for NHL can cause infertility. Your doctor or specialist nurse will talk to you about this before you start your treatment. If you have a partner, you may find it helpful to see the doctor together so you can discuss any fears or concerns you both have. You may find it helpful to make a list of any questions you have so you can be clear about your treatment and its possible effect on fertility.
You may stop producing sperm, although you’ll still be able to orgasm and ejaculate normally. It’s usually possible for men to store sperm before starting treatment. Your doctor or nurse will give you more information about this.
Most women’s periods stop or become irregular during treatment. Your periods may return to normal once the treatment is over, so it’s very important to continue to use contraception during and after your treatment. The nearer a woman is to her natural menopause, the more likely it is that chemotherapy will stop her periods permanently.
Women whose periods stop can be given hormone replacement therapy (HRT). This doesn’t restore fertility, but helps reduce menopausal symptoms.
It may be possible to store fertilised eggs with the chance of re-implanting them later. This could be worth considering if you and your partner want a child, and you are going to have chemotherapy that’s likely to affect your fertility. Your treatment will need to be delayed for several weeks while the eggs are collected. Your specialist will advise you about any potential risk in delaying treatment.
It’s sometimes possible to store unfertilised eggs so they can be fertilised and re-implanted when needed. However, this is much less successful than storing fertilised eggs and it’s not widely available.
Research is looking into whether or not it’s possible to remove and store ovarian tissue, and re-implant it after your treatment has finished, but this is still experimental. It’s important to talk to your cancer specialist about how treatment could affect your fertility before your treatment starts.