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Chemotherapy (chemo) is one of the main treatments for non-Hodgkin lymphoma (NHL).

Chemo is the use of medicines to treat cancer. It is usually put into a vein (IV) or taken by mouth. Chemo enters your bloodstream and reaches almost all areas of your body. This makes it a very useful treatment for lymphoma.

How is chemo given for non-Hodgkin lymphoma?

Chemo is the main treatment for most people with NHL.

It may be used alone or combined with other treatments, such as immunotherapy or radiation therapy. This depends on the type and stage of the lymphoma.

Chemo is given in cycles. One cycle includes a period of treatment followed by a period of rest to give the body time to recover. Each cycle usually lasts for several weeks. Most chemo treatments are given in the doctor’s office, clinic, or hospital outpatient department. Some treatments may require a hospital stay.

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

Many chemo drugs are useful in treating lymphoma. Several drugs are often combined. The type and stage of your lymphoma will help determine the type and dose of chemo drugs you are given, as well as the length of time you are treated.

Chemo drugs can be divided into groups based on how they work. Some of the drugs more commonly used to treat lymphoma include:

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

Common chemo combinations for NHL

Chemo drugs from different groups are often combined. Sometimes a person may be switched to a different chemo combination if the first combination doesn’t seem to be working.

The most common combinations are sometimes referred to by their abbreviations:

CHOP

This is one of the most common combinations. It includes:

• Cyclophosphamide
• Doxorubicin, also known as hydroxydaunorubicin
• Vincristine (Oncovin)
• Prednisone

CVP

This combination leaves out the doxorubicin used in CHOP. It includes:

• Cyclophosphamide
• Vincristine (Oncovin)
• Prednisone

R-CHOP

For B-cell lymphomas, chemo is most often combined with rituximab (Rituxan), a monoclonal antibody. When this is added to the CHOP chemo combination, it is called R-CHOP.

• Rituximab (Rituxan)
• Cyclophosphamide
• Doxorubicin, also known as hydroxydaunorubicin
• Vincristine (Oncovin)
• Prednisone

This is the standard first-line treatment for diffuse large B-cell lymphoma and several other B-cell lymphomas.

Pola-R-CHP

In 2023, the FDA approved Pola-R-CHP as another first-line option for diffuse large B-cell lymphoma:

• Polatuzumab vedotin (Polivy)
• Rituximab
• Cyclophosphamide
• Doxorubicin, also known as hydroxydaunorubicin
• Prednisone

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. A longer-acting form called liposomal cytarabine (DepoCyt) may also be used, as it does not need to be given as often.

Possible side effects of chemotherapy for NHL

Chemo drugs can cause a variety of side effects. These side effects depend on the type and dose of drugs and how long treatment lasts.

Common side effects

Common side effects of chemo can include:

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

Side effects of specific chemo drugs

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

• Cisplatin and other platinum drugs can cause nerve damage (neuropathy). This can lead to numbness, tingling, or pain in the hands and feet.
• Ifosfamide can damage the bladder. This risk can be lowered by giving it along with a medicine called mesna.
• Doxorubicin can damage the heart. Before starting you on this drug, your cancer care team may order a test of your heart function, such as a MUGA scan or echocardiogram.
• 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

A condition called tumor lysis syndrome can happen when chemo is first started, especially in people with large or fast-growing lymphomas. If it happens, it is usually during the first round of chemo.

When the lymphoma cells are killed, their contents are released into the bloodstream. This can overwhelm the kidneys, which can’t get rid of all these substances at once. It can lead to the buildup of uric acid, potassium, and phosphate in the blood. This can cause kidney failure and heart and nervous system problems.

Doctors lower the risk of this happening by giving extra fluids and certain medicines, such as sodium bicarbonate, allopurinol, and rasburicase.

Managing side effects

Chemo side effects usually go away after treatment ends. Ask your cancer care team what side effects you can expect based on the drugs you’ll receive. Tell them if you have any side effects, so they can help you manage them. For example, medicines are available to help prevent or reduce nausea and vomiting.

If you have serious side effects, the dose of chemo may be reduced or your treatment may be delayed.