About chemotherapy for non Hodgkin's lymphoma

Chemotherapy uses anti cancer (cytotoxic drugs) to destroy cancer cells. They work by disrupting the growth of cancer cells. The drugs circulate in the bloodstream around the body.

If you have follicular lymphoma you would usually have CVP (cyclophosphamide, vincristine and the steroid prednisolone) with rituximab (Mabthera). If your lymphoma has come back since you were first treated, or it is a stage 3 or 4 you may have several different chemotherapy drugs in combination with a monoclonal antibody. You may have more CVP and rituximab or one of the following chemotherapy combinations which are often given with rituximab.

• CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone)
• FAD (fludarabine, doxorubicin, and the steroid dexamethasone)
• FMD (fludarabine, mitoxantrone and dexamethasone)

You will probably have your chemotherapy treatment in the outpatient clinic and go home the same day. With some drugs you may have to stay in hospital overnight.

For some types of low grade lymphomas you may have chemotherapy tablets to take at home. Chlorambucil is a drug that doctors often use for elderly people with low grade lymphoma. You take these for 1 or 2 weeks at a time and then have 2 or 3 weeks off. The treatment usually goes on for about 6 months.

In some situations, doctors may suggest very intensive chemotherapy such as BEAM with a bone marrow or stem cell transplant. This might be suggested if your lymphoma is in remission but likely to come back. Or if your lymphoma has not responded to other treatment. Intensive chemotherapy is still experimental for low grade lymphoma. Your doctor may also suggest this treatment if there is a sign that your lymphoma is transforming.

There is more about all the drugs mentioned here on the next page of this section.

Most high grade lymphomas are treated with a combination of several chemotherapy drugs. For these faster growing high grade lymphomas, you have chemotherapy through a drip into a vein. Each treatment lasts a few days and you stay in hospital while you are having the drugs. Then you go home and have a break for 2 or 3 weeks to allow your body to recover from the effects of the drugs. The number of treatments you have depends on

• Which drugs you are having
• The type of lymphoma you have
• How the lymphoma is responding to treatment
• How your body is coping with the side effects

The treatment usually lasts for at least six months. But sometimes it is given once a week instead of once every few weeks. In this case the treatment lasts for three or four months.

There are lots of different combinations of drugs that can be used. The most common is CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) and it is usually given with the biological therapy rituximab. Rituximab with CHOP is called R-CHOP. Most of the combinations have the chemotherapy drug doxorubicin in them, as this drug works well for many types of high grade lymphoma.

The trouble with chemotherapy drugs is that cancers can become resistant to them. So if your lymphoma comes back, you may need treatment with different combinations of drugs. Again, there are many to choose from. You may have treatment called

• PMitCEBO (prednisolone, mitoxantrone, cyclophosphamide, etoposide, bleomycin and vincristine)
• DHAP (dexamethasone, cytarabine, cisplatin) - sometimes given with rituximab (Mabthera) as R-DHAP
• ESHAP (etoposide, methylprednisolone, cytarabine and cisplatin) - sometimes given with rituximab (Mabthera)
• ICE (ifosfamide, carboplatin, and etoposide) - often given with rituximab (Mabthera) as RICE

There is information about these drug combinations on the next page of this section.

Your doctor might suggest you have very intensive high dose chemotherapy treatment such as BEAM. After BEAM treatment you have a drip of your own or someone else's bone marrow or blood stem cells. You will need the bone marrow or stem cells because the chemotherapy will kill off your own bone marrow cells. Look at the section about NHL and transplants for more information about this type of treatment.

Some types of lymphoma are more likely to spread to the central nervous system before  ̶  the brain and spinal cord. In certain situations, your doctor may want you to have treatment to prevent this. The most common way of giving this treatment is to have injections of a drug called methotrexate into your spinal fluid. But your doctor may suggest treatment with high dose methotrexate instead. 

You may have this preventative treatment if you have

• Lymphoma in the space behind your nose (paranasal sinuses)
• Lymphoma in your testicles
• Lymphoma in your bone marrow
• Lymphoma in the breast

Chemotherapy into the fluid that circulates around the brain and spinal cord is called intrathecal chemotherapy (IT). It is very similar to having a lumbar puncture. You will have to lie flat or with your head slightly lower than your feet for a few hours afterwards. You may have a bad headache or feel sick. To help avoid getting a headache the doctor or nurse will ask you to stay lying down for a while. Tell you doctor or nurse if you have a headache or feel sick and they will give you medicines to help.

There are different types of central lines. A central line is a long, bendy plastic tube that is threaded into a large vein in your chest. They are often used for lymphoma treatment. Some central lines can be placed in your chest and some in your arm. If it is in your arm it is known as a PICC line. A port under the skin of the chest is a portacath. The tube stays in until your chemotherapy treatments have finished. 

To have the tube put in you may be put to sleep for a short time with a general anaesthetic. Or you may be given an injection of local anaesthetic to numb the area where the tube is to go in.

The last six inches or so of the tube hangs out of the chest. It has a clamp and a screw cap on it to seal it off. Your nurse injects the chemotherapy drugs straight into the tube and so straight into your bloodstream. That means you don't have to have any injections with needles each time you have your treatment. You can even have blood taken for blood tests through the central line. Usually the tube can stay in for as long as it is needed. 

PICC stands for Peripherally Inserted Central Catheter. PICC lines start off by going into a vein in your arm. Then the tube runs through the vein and up to a larger blood vessel. Each time you need treatment, the chemotherapy drugs are injected into the line and go straight into your bloodstream. 

Another type of central line is a port or Portacath. This is a small chamber or box which is placed under the skin during a small operation. The chamber is attached to the central line tube inside. So there is no tube coming out of the chest. A special needle is pushed through the skin into the port to give the chemotherapy. 

Your nurse will show you how to look after your central line and keep it clean. 

We don't yet know much scientifically about how some nutritional or herbal supplements may interact with chemotherapy. Some could be harmful. It is very important to let your doctors know if you take any supplements. Or if you are prescribed them by alternative or complementary therapy practitioners.

Talk to your specialist about any other tablets or medicines you take while you are having active treatment. There is information about the safety of herbal, vitamin and diet supplements in the complementary therapies section of CancerHelp UK.

Some studies seem to suggest that fish oil preparations may reduce the effectiveness of chemotherapy drugs. If you are taking or thinking of taking these supplements talk to your doctor to find out whether they could affect your treatment.

Have a look at the chemotherapy section in CancerHelp UK. It explains chemotherapy treatment in more detail including

• What it involves
• How chemotherapy is planned and given
• General side effects
• Living with chemotherapy

If you would like more information about anything to do with chemotherapy, contact one of the non Hodgkin's lymphoma organisations. They will be happy to help. They often have free factsheets and booklets which they can send to you.

You can also contact our cancer information nurses. They would be happy to help.