Chemotherapy for non-Hodgkin lymphoma

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout your body in the bloodstream.

Chemotherapy is a common treatment for non-Hodgkin lymphoma (NHL). You might have a combination of different chemotherapy drugs. You can have chemotherapy into a vein or as tablets, depending on the drug.

We have further information about the chemotherapy drugs on this page. You can select the name of your drug or treatment combination on our A-Z list of cancer drugs.

When you have chemotherapy

Your treatment plan depends on what type of NHL you have. You often have a combination of chemotherapy drugs as your first treatment. Or you might have a single chemotherapy drug on its own.

It is common to have chemotherapy together with a targeted drug such as rituximab. Doctors call this chemoimmunotherapy or immunochemotherapy. 

You might also have chemotherapy:

• as a second treatment if your NHL doesn't go away or comes back
• before a stem cell transplant - this is called high dose chemotherapy, or intensive treatment
• to prevent your NHL spreading to your spine or brain

Types of chemotherapy for non-Hodgkin lymphoma

Doctors put NHL into groups depending on whether they tend to grow faster or slower. This is called the grade. NHL can be:

• low grade - these tend to grow slowly
• high grade - these tend to grow more quickly

The exact type of chemotherapy you have depends on your type of low grade or high grade NHL. And other factors such as:

• how far the NHL has grown - this is the stage
• your age and general health

On this page we provide an overview of the main types of chemotherapy for low grade NHL and high grade NHL. 

Low grade NHL

It is common to combine chemotherapy with rituximab or obinutuzumab for low grade NHL. Chemotherapy options include:

• bendamustine 
• CVP - cyclophosphamide, vincristine and prednisolone
• CHOP - cyclophosphamide, doxorubicin, vincristine and prednisolone
• chlorambucil tablets - this is rare

In some situations, you might have very intensive chemotherapy followed by a stem cell transplant. And in some other situations you might have maintenance treatment after your chemotherapy.

High grade NHL

You usually have a combination of several chemotherapy drugs. The treatment usually lasts for 4 to 6 months. 

There are lots of different drug combinations. Most of them include the chemotherapy drug doxorubicin. This drug works well for many types of high grade NHL.

You might have a targeted drug such as rituximab alongside the chemotherapy. You will see the letter 'R' added to the treatment name - for example R-CHOP.

Treatment combinations include:

• CHOP - cyclophosphamide, doxorubicin, vincristine and prednisolone 
• Pola-R-CHP - cyclophosphamide, doxorubicin hydrochloride, prednisolone and the targeted drugs polatuzumab vedotin and rituximab
• CODOX-M - cyclophosphamide, vincristine, doxorubicin and methotrexate
• IVAC - ifosfamide, etoposide and cytarabine
• DA-EPOCH - dose adjusted etoposide, prednisolone, vincristine, cyclophosphamide and doxorubicin
• DHAP -  dexamethasone, cytarabine and cisplatin

If your NHL comes back, you might need treatment with different combinations of drugs. Again, there are many to choose from. You might have one of the combinations above. Other options include:

• GDP – gemcitabine dexamethasone, cisplatin
• Gem-Ox – gemcitabine and oxaliplatin
• ICE - ifosfamide, carboplatin, and etoposide
• ESHAP - etoposide, methylprednisolone, cytarabine and cisplatin 

You might have an intensive high dose chemotherapy treatment followed by a stem cell transplant. An example of intensive chemotherapy is BEAM. This is carmustine, etoposide, cytarabine and melphalan.

Or you might have CAR T-cell therapy.

Chemotherapy to stop NHL spreading to your spine or brain

Some types of lymphoma are more likely to spread to the central nervous system (CNS). The CNS is your brain and spinal cord. Your doctor might want you to have chemotherapy to prevent this.

There has been much research into this area. Lymphoma specialists continue to debate who needs additional treatment to prevent CNS relapse. And they are also debating the best way to deliver treatment. There is a lot of change in this area at the moment.

The most common treatment is the chemotherapy drug methotrexate. You might have this:

• as an injection into the fluid around your spinal cord - this is intrathecal chemotherapy
• as an infusion into your vein - this is intravenous chemotherapy

When do you have it

You might have treatment to prevent CNS spread if your lymphoma is:

• in certain parts of your body - for example the testicles
• likely to come back after treatment (high risk)

How you have chemotherapy

You usually take chemotherapy in treatment cycles. This means you have the drug for a set period, followed by a break. For example, you might take a drug every day for a week and then not take it for 2 weeks. This 3 week period in total is one cycle of treatment.

The break from treatment is important too. For many cancer drugs, it allows your body to recover.

Some chemotherapy treatments for high grade NHL are quite intense. You might need to stay in hospital for the chemotherapy. Then you might go home and have a break for 2 or 3 weeks. For other treatments, you can have them in the day unit. This means you don't need to stay in hospital. 

You might have chemotherapy:

• by mouth as tablets or capsules
• into a vein - this is intravenous chemotherapy
• into your spine - this is intrathecal chemotherapy 

Taking your capsules or tablets

Speak to your pharmacist if you have problems swallowing the tablets.

Whether you have a full or an empty stomach can affect how much of a drug gets into your bloodstream.

You should take the right dose, no more or less.

Talk to your healthcare team before you stop taking a cancer drug or if you miss a dose.

Into your bloodstream

You have treatment through a thin short tube (a cannula) that goes into a vein in your arm each time you have treatment.

Or you might have treatment through a long line: a central line, a PICC line or a portacath. These are long plastic tubes that give the drug into a large vein in your chest. The tube stays in place throughout the course of treatment. This means your doctor or nurse won't have to put in a cannula every time you have treatment.

Into your spine

For some lymphomas, you have chemotherapy injected into the fluid around your spine and brain. This is called intrathecal chemotherapy.

To have this you have an injection into your spine, in your lower back. It is similar to having a lumbar puncture. 

After intrathecal treatment you have to lie flat or with your head slightly lower than your feet for a few hours. You might have a bad headache or feel sick.

To help you avoid getting a headache, your doctor or nurse asks you to stay lying down for a while. Tell them if you have a headache or feel sick and they will give you medicines to help.

Where you have chemotherapy

You usually have treatment into your bloodstream at the cancer day clinic. You might sit in a chair for a few hours so it’s a good idea to take things in to do. For example, newspapers, books or electronic devices can all help to pass the time. You can usually bring a friend or family member with you.

You have some types of chemotherapy over several days. You might be able to have some drugs through a small portable pump that you take home.

For some types of chemotherapy you have to stay in a hospital ward. This could be overnight or for a couple of days.

Some hospitals may give certain chemotherapy treatments to you at home. Your doctor or nurse can tell you more about this.

Watch the video below about what happens when you have chemotherapy. It is almost 3 minutes long.

Before you start chemotherapy

You need to have blood tests to make sure it’s safe to start treatment. You usually have these a few days before or on the day you start treatment. You have blood tests before each round or cycle of treatment.

Your blood cells need to recover from your last treatment before you have more chemotherapy. Sometimes your blood counts are not high enough to have chemotherapy. If this happens, your doctor usually delays your next treatment. They will tell you when to repeat the blood test. 

Side effects

Common chemotherapy side effects include:

• feeling sick

• loss of appetite

• losing weight

• feeling very tired

• increased risk of getting an infection

• bleeding and bruising easily

• diarrhoea or constipation

• hair loss

Side effects depend on:

• which drugs you have

• how much of each drug you have

• how you react

Tell your treatment team about any side effects that you have.

Most side effects only last for a few days or so. Your treatment team can help to manage any side effects that you have.

Dietary or herbal supplements and chemotherapy

Let your doctors know if you:

• take any supplements
• have been prescribed anything by alternative or complementary therapy practitioners

It’s unclear how some nutritional or herbal supplements might interact with chemotherapy. Some could be harmful.

When you go home

Chemotherapy for non-Hodgkin lymphoma can be difficult to cope with. Tell your doctor or nurse about any problems or side effects that you have. The nurse will give you telephone numbers to call if you have any problems at home.