Chemotherapy for Non-Hodgkin Lymphoma

Chemotherapy (chemo) is the use of anti-cancer drugs that are usually injected into a vein (IV) or taken by mouth. Chemo enters the bloodstream and reaches almost all areas of the body, making this treatment very useful for lymphoma.

When might chemo be used?

Chemo is the main treatment for most people with non-Hodgkin lymphoma (NHL). Depending on the type and the stage of the lymphoma, chemo may be used alone or combined with other treatments, such as immunotherapy drugs or radiation therapy.

Which chemo drugs are used to treat non-Hodgkin lymphoma?

Many chemo drugs are useful in treating lymphoma. Often, several drugs are combined. The number of chemo drugs, their doses, and the length of treatment depend on the type and stage of the lymphoma. Here are some of the drugs more commonly used to treat lymphoma (divided into groups based on how they work):

Alkylating agents

• Cyclophosphamide
• Chlorambucil
• Bendamustine
• Ifosfamide

Corticosteroids

• Prednisone
• Dexamethasone

Platinum drugs

• Cisplatin
• Carboplatin
• Oxaliplatin

Purine analogs

• Fludarabine
• Pentostatin
• Cladribine (2-CdA)

Anti-metabolites

• Cytarabine (ara-C)
• Gemcitabine
• Methotrexate
• Pralatrexate

Anthracyclines

• Doxorubicin (Adriamycin)
• Liposomal doxorubicin (Caelyx)

Others

• Vincristine
• Mitoxantrone
• Etoposide (VP-16)
• Bleomycin

Often drugs from different groups are combined. One of the most common combinations is CHOP, which includes the drugs cyclophosphamide, doxorubicin (also known as hydroxydaunorubicin), vincristine (Oncovin) and prednisone. Another common combination leaves out doxorubicin and is called CVP.

Chemo is often combined with an immunotherapy drug, such as rituximab (Rituxan).

Doctors give chemo in cycles, in which a period of treatment is followed by a period of rest 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 might require a hospital stay.

Sometimes a person may be switched to a different chemo combination if the first combination doesn’t seem to be working.

Intrathecal chemo

Most chemo drugs given systemically (IV or by mouth) can’t reach the cerebrospinal fluid (CSF) and tissues around the brain and spinal cord. To treat lymphoma that might have reached these areas, chemo may also be given directly into the CSF. This is called intrathecal chemo.The chemo drugs most often used for intrathecal chemo are methotrexate and cytarabine.

Possible side effects

Chemo drugs can cause side effects. These depend on the type and dose of drugs given and how long treatment lasts. Common side effects can include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea or constipation
• Increased chance of infection (from a shortage of white blood cells)
• Bleeding or bruising after minor cuts or injuries (from a shortage of platelets)
• Fatigue and shortness of breath (from too few red blood cells)

These side effects usually go away after treatment ends. If serious side effects occur, the dose of chemo may be reduced or treatment may be delayed.

Certain chemo drugs can have other possible side effects. For example:

• Platinum drugs such as cisplatin can cause nerve damage (peripheral neuropathy), leading to numbness, tingling, or even pain in the hands and feet.
• Ifosfamide can damage the bladder. The risk of this can be lowered by giving it along with a drug called mesna.
• Doxorubicin can damage the heart. Your doctor may order a test of your heart function (like a MUGA scan or echocardiogram) before starting you on this drug.
• Bleomycin can damage the lungs. Doctors often test lung function before starting someone on this drug.
• Many chemo drugs can affect fertility (the ability to have children).
• Some chemo drugs can increase your risk of developing leukemia several years later.

Tumor lysis syndrome is a possible side effect when chemo is started, especially in people with large or fast-growing lymphomas. Killing the lymphoma cells releases their contents into the bloodstream. This can overwhelm the kidneys, which can’t get rid of all of these substances at once. This can lead to the build-up of certain minerals in the blood and even kidney failure. The excess minerals can lead to heart and nervous system problems. Doctors lower the risk of this happening by giving the person extra fluids and certain drugs, such as sodium bicarbonate, allopurinol, and rasburicase.

Ask your cancer care team about what side effects you can expect based on the specific drugs you will receive. Be sure to tell your doctor or nurse if you do have side effects, as there are often ways to help with them. For example, drugs can be given to prevent or reduce nausea and vomiting.

Other drugs used to treat lymphoma

Other types of drugs can also be useful in treating some types of lymphoma. These drugs work differently from standard chemo drugs. For example, immunotherapy and targeted therapy drugs are helpful for some lymphomas.

Mucosa-associated lymphoid tissue (MALT) lymphoma, which usually starts in the stomach, is linked to infection with the bacterium H. pylori. Treatment of this infection can often make the lymphoma go away. This is most often done with a combination of antibiotics along with drugs called proton pump inhibitors, which lower stomach acid levels.

In a similar way, splenic marginal zone B-cell lymphoma is sometimes linked to infection with the hepatitis C virus. Treating the infection with anti-viral drugs can sometimes shrink these lymphomas, or even make them go away.