Non-Hodgkin Lymphoma

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Treating Non-Hodgkin Lymphoma TOPICS

Chemotherapy for non-Hodgkin lymphoma

Chemotherapy (chemo) is the use of anti-cancer drugs that are usually injected into a vein or taken by mouth. These drugs enter the bloodstream and reach almost all areas of the body, making this treatment very useful for lymphoma. In some cases where the lymphoma may have reached the brain or spinal cord, chemo may also be given into the cerebrospinal fluid (CSF). This is called intrathecal chemo.

Depending on the type and the stage of the lymphoma, chemo may be used alone or combined with radiation therapy.

Doctors give chemo in cycles, in which a period of treatment is followed by a rest period to allow the body time to recover. Each chemo cycle generally lasts for several weeks. Most chemo treatments are given on an outpatient basis (in the doctor’s office or clinic or hospital outpatient department), but some may require a hospital stay.

Many chemo drugs are useful in treating lymphoma patients. Often, several drugs are combined. The number of drugs, their doses, and the length of treatment depend on the type and stage of the lymphoma. Some of the drugs commonly used to treat lymphoma include:

One of the most common combination of drugs is called CHOP. This includes the drugs cyclophosphamide, doxorubicin (which has a chemical name beginning with H), vincristine (Oncovin) and prednisone. Another common combination leaves out doxorubicin and is called CVP.

Chemo is often combined with immunotherapy, especially the monoclonal antibody rituximab (Rituxan®).

Sometimes a patient may get one chemo combination for several cycles and later switch to a different one if the first combination doesn’t seem to be working.

Possible side effects

Chemo drugs attack cells that are dividing quickly, which is why they work against lymphoma cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemotherapy, which can lead to certain side effects.

The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. These side effects can include:

  • Hair loss
  • Mouth sores
  • Loss of appetite
  • Nausea and vomiting
  • Diarrhea
  • Low blood cell counts (see below)

These side effects are usually short-term and go away after treatment is finished. If serious side effects occur, the dose of chemo may be reduced or treatment may be delayed.

There are often ways to lessen these side effects. For example, drugs are given that prevent or reduce nausea and vomiting.

Certain drugs have specific possible side effects. For example, drugs such as doxorubicin can damage the heart. Your doctor may order a test of heart function (like a MUGA scan or echocardiogram) before starting you on one of these drugs. Bleomycin can damage lungs. Doctors often test lung function before starting someone on this drug.

Other serious side effects can occur, depending on the chemo drugs used. For example, many chemo drugs can affect fertility (the ability to have children). Nerve damage, causing numbness, tingling, or even pain in the hands and feet, can also occur. Ask your health care team about what side effects you can expect based on the specific drugs you will be getting.

Chemo can also cause side effects that might not occur until years after treatment. For example, in rare cases, people may develop leukemia several years later.

Low blood cell counts: Chemo can cause low blood cell counts because it affects the cells that form blood in the bone marrow. This can lead to:

  • Increased chance of infections (from low white blood cell counts)
  • Easy bruising or bleeding (from low blood platelet counts)
  • Fatigue (from low red blood cell counts)

Infections can be very serious in people getting chemo. Drugs known as growth factors (G-CSF or GM-CSF, for example) are sometimes given to help the white blood cells recover from the effects of chemo and thus reduce the chance of infection. Antibiotics may also be given at the earliest sign of an infection, such as a fever.

If your white blood cell counts are very low during treatment, you can help reduce your risk of infection by carefully limiting your exposure to germs. During this time, your doctor may advise you to:

  • Wash your hands often.
  • Avoid fresh, uncooked fruits and vegetables and other foods that might carry germs.
  • Avoid fresh flowers and plants because they may carry mold.
  • Make sure other people wash their hands before they touch you.
  • Avoid large crowds and people who are sick (wearing a surgical mask offers some protection in these situations).

If your platelet counts are very low, you may be given drugs or platelet transfusions to help protect against bleeding. Fatigue caused by anemia (very low red blood cell counts) can be treated with drugs or with red blood cell transfusions.

Tumor lysis syndrome is a possible side effect of chemo in patients who had large numbers of lymphoma cells in the body before treatment. It occurs most often with the first cycle of chemo. When the cancer cells are killed, they break open and release their contents into the bloodstream. This can overwhelm the kidneys, which cannot get rid of all of these substances at once. This can lead to the build-up of excess amounts of certain minerals in the blood and even kidney failure. The excess minerals can lead to problems with the heart and nervous system. Doctors work to prevent these problems by giving the patient extra fluids and certain drugs, such as sodium bicarbonate, allopurinol, and rasburicase.

Other drugs used to treat lymphoma

As researchers have learned more about the changes in cells that cause cancer, they have been able to develop newer drugs that specifically target these changes. These drugs are often referred to as targeted therapy. These drugs work differently from standard chemotherapy drugs and often have different (and less severe) side effects.

Bortezomib (Velcade®) is a type of drug known as a proteasome inhibitor. It is most often used to treat other cancers of lymphocytes. But it can also be used to treat some lymphomas, usually after other treatments have been tried. Bortezomib is given as an infusion into a vein (IV) or an injection under the skin (sub-q), typically twice a week for 2 weeks, followed by a rest period. Side effects can be similar to those of standard chemo drugs, including low blood counts, nausea, loss of appetite, and nerve damage.

Romidepsin (Istodax®) is in a class of drugs called histone deacetylase (HDAC) inhibitors. It is used to treat some T-cell lymphomas, usually after at least one other treatment has been tried. This drug is given as an IV infusion, usually once a week. Side effects tend to be mild, but can include lowered blood cell counts and effects on the rhythm of the heart.

Belinostat (Beleodaq®) is another HDAC inhibitor used to treat certain T-cell lymphomas after other treatments. It is given as an IV infusion, usually daily for 5 days in arrow, repeated every 3 weeks. Common side effects include nausea, vomiting, tiredness, and low red blood cell counts (anemia).

Ibrutinib (Imbruvica™) is a type of drug known as a kinase inhibitor. It blocks a protein that transmits a signal to some lymphoma cells that helps them grow and survive. It can be used to treat mantle cell lymphoma. This drug is taken by mouth, once a day. Common side effects include diarrhea or constipation, nausea and vomiting, fatigue, swelling, decreased appetite, and low blood counts. Although this drug is approved for use in patients after other treatments have been tried, it is being studied for use earlier in treatment.

Idelalisib (Zydelig®) is another kinase inhibitor that can be used to treat NHL, although this one blocks a different kinase (called PI3K). This drug has been shown to help treat follicular lymphoma and small lymphocytic lymphoma after other treatments have been tried. It is taken as a pill twice a day. Common side effects include diarrhea, fever, fatigue, nausea, cough, pneumonia, belly pain, chills, rash and low blood counts. Less often, more serious side effects can also occur.

More information on chemotherapy and its side effects can be found in the “Chemotherapy” section of our website, or in our document Understanding Chemotherapy: A Guide for Patients and Families.

Last Medical Review: 03/27/2013
Last Revised: 07/30/2014