Targeted and immunotherapy treatments for non-Hodgkin lymphoma

Targeted cancer drugs work by targeting the differences in cancer cells that help them to grow and survive. Other drugs help the immune system to attack cancer. They are called immunotherapies.

Some drugs work in more than one way. So they are targeted as well as working with the immune system. 

Rituximab is an example of a targeted cancer drug that you might have to treat non-Hodgkin lymphoma (NHL).

When you might have targeted and immunotherapy drugs for NHL

You might have a targeted cancer drug on its own. Or you have it together with chemotherapy. Doctors call this chemoimmunotherapy. Or immunochemotherapy.

You might have a targeted or immunotherapy drug:

• as part of your first treatment for NHL
• after your treatment to keep your NHL under control for as long as possible  - doctors call this maintenance treatment
• if your NHL comes back or continues to grow after your first treatment

The targeted or immunotherapy drug might be a standard treatment, or part of a clinical trial.

Types of targeted and immunotherapy treatments for NHL

Types of targeted and immunotherapy drug for NHL include:

• monoclonal antibodies - for example, rituximab
• cancer growth blockers - for example, ibrutinib
• CAR t-cell therapy

Monoclonal antibodies (MABs) for NHL

Monoclonal antibodies (MABs) are the most common type of targeted drug for NHL.

Antibodies are found naturally in our blood and help us to fight infection. MABs mimic natural antibodies but are made in a laboratory. They work by recognising and finding specific proteins on, or in cancer cells.

Many different MABs are available to treat cancer. They work in different ways and some work in more than one way. 

Rituximab (Mabthera)

Rituximab is one of the main MABs for NHL. Doctors use it to treat many different types of NHL.

Rituximab targets a protein called CD20 on the surface of the lymphoma cells. The antibody sticks to all the CD20 proteins it finds. This makes it easier for the cells of the immune system to pick out the marked cells and kill them. Because of the way it works, rituximab is also called a targeted immunotherapy.

You have it as a treatment on its own. Or in combination with chemotherapy. Doctors call this chemoimmunotherapy. For chemoimmunotherapy you will see an 'R' before the name of your chemotherapy treatment. For example R-CHOP. 

Obinutuzumab (Gazyvar)

Obinutuzumab is another type of MAB for NHL. It works in a similar way to rituximab. 

You might have obinutuzumab for a type of NHL called follicular lymphoma. You can have it:  

• as your first treatment for advanced disease
• if rituximab treatment hasn't worked
• if your lymphoma has got worse within 6 months of rituximab treatment

You have obinutuzumab with chemotherapy drugs. It is most common to have it with bendamustine. Or you might have it with: 

• CHOP - cyclophosphamide, doxorubicin, vincristine and prednisolone
• CVP - cyclophosphamide, vincristine and prednisolone 

You might have up to 6 to 8 cycles, depending on which chemotherapy you have. This is followed by obinutuzumab alone as maintenance treatment  for up to 2 years. 

Polatuzumab vedotin (Polivy)

Polatuzumab vedotin (Polivy) is a type of MAB. You might have it as your first treatment for DLBCL. You have polatuzumab vedotin with R-CHP. This is a combination of rituximab, cyclophosphamide, doxorubicin and prednisolone.

Or you can have it for DLBCL if:

• your lymphoma has come back after treatment 
• you are unable to have a stem cell transplant

You have it together with rituximab and bendamustine. 

Mogamulizumab (Poteligeo)

Mogamulizumab is a is a type of MAB. You might have it for mycosis fungoides or Sezary syndrome. These are both types of skin lymphoma.  You might have it if you have had at least one previous course of systemic  treatment .

In Scotland, it is available on the NHS if you can’t have treatment with brentuximab vedotin, or if this treatment hasn't worked.

In England and Wales, it is available on the NHS if:

• your mycosis fungoides is stage 2B or above and you have had at least 2 courses of systemic treatment  
• your have had had at least 1 systemic treatment for Sezary syndrome 

Brentuximab vedotin (Adcetris)

You might have this MAB to treat:

• a type of non Hodgkin lymphoma called anaplastic large cell lymphoma (ALCL)
• some types of cutaneous T‑cell lymphoma (CTCL) 

Brentuximab targets a protein called CD30 that is found on some lymphoma cells. Brentuximab sticks to the CD30 protein and delivers a drug to the cell. The drug then kills the cell.

Bispecific T-cell engagers (BiTEs)

Bispecific T-cell engagers (BiTEs) are a newer type of MAB. They help to boost the immune system to find and kill cancer cells. Examples are:

• glofitamab
• epcoritamab

BiTEs have 2 parts. One part attaches to a type of immune system cell called T cells . The other part attaches to the cancer cells. When they are in the right position they meet (engage) and create a link (bridge). This link helps the T cell recognise the cancer cell and stimulates the immune system to attack it. 

You might have glofitamab or epcoritamab to treat DLBCL that has come back or not gone away after at least 2 previous treatments. 

Cancer growth blockers

Cancer growth blockers are a type of targeted cancer drug.

Our body makes chemicals called growth factors that control cell growth. Cancer growth blockers work by blocking the growth factors that trigger cancer cells to divide and grow.

There are many types of cancer growth blockers that work in different ways. 

Bortezomib (Velcade)

Bortezomib is a treatment for a type of NHL called mantle cell lymphoma. 

Bortezomib is a type of cancer growth blocker called a proteasome inhibitor. Proteasomes are in cells. They help to break down proteins that the cell doesn't need. Bortezomib blocks the proteasomes so the proteins build up inside the cell. The cell then dies.

You might have bortezomib as your first treatment for mantle cell lymphoma if you are not able to have a stem cell transplant. You have it as a treatment on its own, or in combination with chemotherapy.

Ibrutinib (Imbruvica)

Ibrutinib is a type of cancer growth blocker. It is called a tyrosine kinase inhibitor (TKI). It blocks chemical messengers (enzymes) called tyrosine kinases. Tyrosine kinases help to send growth signals in cells. So blocking them stops the cell growing and dividing.

Ibrutinib is a treatment for certain types of NHL including mantle cell lymphoma that has not gone away with treatment, or has come back.

Zanubrutinib (Brukinsa)

Zanubrutinib is a cancer growth blocker called a tyrosine kinase inhibitor (TKI). It blocks chemical messengers (enzymes) called tyrosine kinases. Tyrosine kinases help to send growth signals in cells. So blocking them stops the cell growing and dividing.

You might have zanubrutinib for a type of NHL called:

• Waldenström’s macroglobulinaemia (WM)
• marginal zone lymphoma (MZL)

Other targeted and immunotherapy treatments

Doctors use some other types of targeted and immunotherapy drugs to treat NHL. You might have them on their own or together with chemotherapy.

Other targeted drugs for diffuse large B cell lymphoma (DCBCL) include loncastuximab tesirine.

You might have a drug called lenalidomide for follicular lymphoma. You might have it if your lymphoma has come back or if your treatment is not working.

CAR T-cell therapy

CAR T-cell therapy is a type of immunotherapy. CAR stands for chimeric antigen receptor. You might also hear it called a type of adoptive cell transfer.

CAR T-cell therapy is a very complex and specialist treatment. With this treatment, a specialist nurse collects your T cells . They send these to the laboratory where a change is made to the T cell to become CAR T-cells. After a few weeks, you have a drip containing these cells back into your bloodstream. The CAR T-cells then recognise and attack the cancer cells. 

It is also a possible treatment for adults with relapsed or refractory :

• diffuse large B cell lymphoma (DLBCL)
• primary mediastinal large B cell lymphoma (PMBCL)
• mantle cell lymphoma (MCL)

Having targeted and immunotherapy drug treatment

You have your targeted treatment in one of the following ways:

• as tablets or capsules
• as an injection under your skin
• through a tube into your bloodstream

How you have it depends on the type of drug you have.

Tablets or capsules

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

You should take the right dose, not more or less.

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

Into the bloodstream

You have the treatment through a drip into your arm or hand. A nurse puts a small tube (a cannula) into one of your veins and connects the drip to it.

You might need a central line. This is a long plastic tube that gives the drugs into a large vein, either in your chest or through a vein in your arm. It stays in while you’re having treatment, which may be for a few months.

Injection under your skin

You usually have injections under the skin (subcutaneous injection) into the stomach, thigh or top of your arm.

You might have stinging or a dull ache for a short time after this type of injection but they don't usually hurt much. The skin in the area may go red and itchy for a while.

Side effects

Everyone is different and the side effects vary from person to person. The side effects you have depend on:

• which drug you have
• whether you have it alone or with other drugs
• the amount of drug you have (the dose)
• your general health

A side effect may get better or worse during your course of treatment. Or more side effects may develop as the treatment goes on. For more information about the side effects of your treatment, go to the individual drug pages.

When you go home

Treatment with immunotherapy or targeted cancer drugs can be difficult to cope with for some people. Your nurse will give you a number to call (advice line) if you have any problems at home.