[email protected] www.lymphomas.org.uk Produced 28.02.2011 Due for revision 28.02.2013
Treatment of high-grade non-Hodgkin lymphoma Lymphomas are described as ‘high grade’ if the cells appear to be dividing quickly. High-grade non-Hodgkin lymphoma is treated with chemotherapy, antibody therapy and radiotherapy. This article is an introduction to the teatment of these lymphomas and aims to outline: ●
the planning of treatment
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the treatment of early-stage high-grade non-Hodgkin lymphoma
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the treatment of advanced high-grade non-Hodgkin lymphoma
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the place of stem cell transplants in high-grade non-Hodgkin lymphoma
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the role of clinical trials.
Planning treatment It is very important that your treatment is carefully planned to give you the best chance of it working well for your particular lymphoma. The most important factors in planning your treatment are: ●
what type of high-grade non-Hodgkin lymphoma you have
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the stage of your lymphoma (ie how much of your body is affected by the lymphoma).
Your treatment will also depend on: ●
your age
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your blood test results
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your general health and whether or not you have other medical conditions
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whether you have experienced unexplained weight loss, fevers or night sweats
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the size of your lymph nodes (the lumps that have appeared).
You and your doctor will discuss the tests you will need for the planning of your treatment. You will be having several different tests, including blood tests and scans.
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[email protected] www.lymphomas.org.uk
You might also need to have tests of how well your heart and lungs are functioning before you have chemotherapy, especially if you are taking part in a clinical trial. If you are having radiotherapy, you will have to visit the radiotherapy department for treatment planning. Some treatments for non-Hodgkin lymphoma can affect your fertility. If this is the case, you should have the chance to talk about fertility with your doctor. Men might want to bank some sperm before starting treatment. It is not common at the present time for women to store eggs but you can discuss the options that might be open to you with your medical team. It can sometimes take a few weeks for the results of all these tests to come back, and you might find the waiting before treatment starts very worrying. Delays will be avoided wherever possible, however, and it is not likely that short delays will make a difference to the success of your treatment. Once the results are back you and the doctor will discuss the test results and you will have the chance to ask questions about the options for treatment. It can help to take someone else with you to these planning appointments to help you remember what has been said. It can also help to write your questions down before your appointment. If you do not understand what is being said, don’t be afraid to ask your doctor to explain it again, perhaps in a different way. Don’t be worried if the people you talk to at the clinic are having different treatments from yours. Your treatment plan will be specially tailored to your exact needs, depending on the factors listed above and the results of all your tests.
Treatment of early-stage disease If you have been told that you have early-stage disease, this means that you have stage IA or IIA non-Hodgkin lymphoma.
Chemotherapy and involved-field radiotherapy Most people with early-stage high-grade non-Hodgkin lymphoma will be treated with chemotherapy. Some people also have involved-field radiotherapy. Chemotherapy means treatment with drugs that kill the lymphoma cells. These are sometimes given as tablets and sometimes into a vein in a drip (intravenously). ‘Involvedfield radiotherapy’ means radiotherapy to the enlarged lymph nodes. Radiotherapy uses high-energy X-rays to kill the lymphoma cells.
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Lymphoma Association, PO Box 386, Aylesbury, Bucks HP20 2GA Registered charity no 1068395
[email protected] www.lymphomas.org.uk
Chemotherapy for high-grade non-Hodgkin lymphoma usually involves having a combination of intravenous drugs. The combination works better than using the drugs on their own. You will hear these treatments referred to using the initials of the drugs used. There are a number of chemotherapy combinations that are used for people with early-stage high-grade non-Hodgkin lymphoma. The most common treatment is called CHOP. This stands for cyclophosphamide, doxorubicin (or hydroxydaunorubicin), vincristine (Oncovin®) and prednisolone. Chemotherapy is given over a period of 3–4 months. Sometimes it will take longer. You will be given your drugs over a few days, followed by rest periods of 2–3 weeks between treatments. You will be given information on the drugs and how they are given, your timetable and what side effects to expect. Some people are given radiotherapy after their chemotherapy. Radiotherapy is given daily over a period of 2–4 weeks.
Treatment of advanced disease Advanced disease means stage III or stage IV non-Hodgkin lymphoma.
Diffuse large B-cell lymphoma The most common high-grade non-Hodgkin lymphoma is called diffuse large B-cell lymphoma. Advanced diffuse large B-cell lymphoma is usually treated with a combination of chemotherapy drugs and antibody therapy. This treatment is called R-CHOP, where the ‘R’ stands for rituximab and CHOP is a combination of four different chemotherapy drugs (see above). Rituximab is a kind of antibody therapy or ‘immunotherapy’. Rituximab will seek out the B cell, which is the blood cell that becomes cancerous in diffuse large B-cell lymphoma. It attaches itself to the cell, and helps your immune system to kill it. This is different from chemotherapy because chemotherapy kills lots of different cells apart from the cancerous cell. R-CHOP is given over a period of 6–8 months.You will not have treatment every day – you will be given your drugs over a few days, followed by rest periods of 2–3 weeks between treatments. R-CHOP is usually given as an outpatient. This means that you go to the hospital to have the treatment but you can go home afterwards. Some people will need to stay in hospital overnight for their first dose of rituximab.
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Lymphoma Association, PO Box 386, Aylesbury, Bucks HP20 2GA Registered charity no 1068395
[email protected] www.lymphomas.org.uk
Other high-grade lymphomas Other advanced high-grade non-Hodgkin lymphomas will be treated with chemotherapy. Some of them will be treated with CHOP or R-CHOP. Some people will have treatment with other chemotherapy combinations that are more suited to their different lymphoma types. These chemotherapy combinations all involve having a mixture of drugs, some given intravenously and some given as tablets. Most courses of chemotherapy for high-grade non-Hodgkin lymphoma will be given over a period of 6–8 months. Some people will need treatment for longer periods. Some types of high-grade non-Hodgkin lymphoma are more likely to involve the central nervous system (the brain and spinal cord). To treat your central nervous system it might be necessary to give chemotherapy directly into the fluid that surrounds the brain and spinal cord. This way of giving chemotherapy is called intrathecal chemotherapy. Intrathecal chemotherapy is given using a procedure called a lumbar puncture.
Radiotherapy Radiotherapy can also be used to treat advanced high-grade non-Hodgkin lymphoma. It is used to treat large nodes or nodes that need extra treatment.
Stem cell transplants It is quite common for people with high-grade non-Hodgkin lymphoma to be offered treatment with a stem cell transplant. Stem cell transplants are offered to people who have a higher risk of relapse or who have disease that does not respond to other treatment. When you have a stem cell transplant you first have high doses of chemotherapy to kill off all the lymphoma cells. This causes permanent damage to your bone marrow and you need a transfusion (or transplant) of stem cells to allow your marrow to recover. Stem cells are immature cells that grow into new blood cells. Stem cell transplants for lymphoma usually involve using your own stem cells, which are collected from you before you have the high-dose chemotherapy (an autologous transplant). Less commonly, stem cells from a donor are used (an allogeneic transplant). A stem cell transplant involves a stay in hospital of 2–4 weeks.
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Lymphoma Association, PO Box 386, Aylesbury, Bucks HP20 2GA Registered charity no 1068395
[email protected] www.lymphomas.org.uk
Clinical trials Clinical trials play a vital role in improving the future treatment of lymphoma. Research continues to improve the way we use the treatments we already know about and tests new treatments as they become available. You might be invited to take part in a clinical trial. Taking part in a trial is entirely voluntary and you can always opt to have the standard treatment if you prefer. Your care will not be compromised if you don’t want to be in a trial.
More information This article is an edited extract from our booklet High-grade non-Hodgkin lymphoma. For more information, or for a copy of the booklet, visit our website at www.lymphomas.org.uk or telephone the Lymphoma Association’s freephone helpline 0808 808 5555. Talk to your key worker if you have any concerns about your health or treatment. The Lymphoma Association cannot provide information about individual diagnosis or treatment. The information provided by the Lymphoma Association is not a substitute for advice from your health professionals.
About our publications: The Lymphoma Association is committed to the provision of high quality information for people with lymphoma, their families and friends. We produce our information in accordance with nationally recognised guidelines. These include the DISCERN tool for information about treatments, the NHS Toolkit for producing patient information, and the Campaign for Plain English guidelines. Our publications are written by experienced medical writers, in close collaboration with medical advisers with expertise in the appropriate field. Textbooks and professional journals are consulted to ensure that information is as up to date as possible. References are provided where they have been used. Some publications are written by professionals themselves, acting on guidance provided by the Lymphoma Association. Our publications are reviewed every two years and updated as necessary. Our publications are reviewed by a panel of volunteers with experience of lymphoma. Publications are also reviewed by members of the Lymphoma Association helpline team, who have many years collective experience of supporting those with lymphoma. In some instances, our publications are funded by educational grants from pharmaceutical companies. These sponsors do not have any involvement in the content of a publication. They are not invited to see the content and have no editorial input. © Lymphoma Association Views expressed in this publication are those of the contributors. The Lymphoma Association does not necessarily agree with or endorse the comments included here.
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