Lymphoma, non-Hodgkin - Treating non-Hodgkin lymphoma

Non-Hodgkin lymphoma is usually treated with cancer-killing medication or radiotherapy, although some people may not need treatment straight away.

In a few cases where the initial cancer was very small and was removed during a biopsy (see diagnosing non-Hodgkin lymphoma for more information), no further treatment may be needed.

Your treatment plan

The recommended treatment plan will depend on your general health and age, because some of the treatments can cause serious side effects and complications, which can put a significant strain on the body.

Other important factors taken into consideration when deciding the best treatment in your circumstances include:

• your symptoms
• the specific subtype of your lymphoma
• how far the lymphoma has spread (the 'stage')
• how fast it is likely to spread (the 'grade') and where it is likely to spread to

Discussions about your treatment plan will usually take place with several doctors and other health professionals who specialise in different aspects of treating lymphoma. This is known as a multidisciplinary team (MDT). Your personal wishes for treatment will always be taken into consideration in this discussion.

Your MDT will recommend the best treatment options for you. However, you should not be rushed into making a decision about your treatment plan. Before deciding, you may wish to talk to friends, family and your partner.

You will be invited back to see your care team for a full review and discussion about the risks and benefits of any treatments planned before treatment begins.

Your care team may also offer you the opportunity to participate in a clinical trial. Find clinical trials for non-Hodgkin lymphoma.

The main treatment options for non-Hodgkin lymphoma are described below.

Wait-and-see approach

If the disease is low-grade (slow developing) and you are well, a period of 'watchful waiting' is often recommended as some people take many years to develop troublesome symptoms in these circumstances and starting treatment immediately is therefore often felt to be unnecessary.

If watchful waiting is recommended, you will be seen regularly for reviews and invited to come back at any stage if you feel your symptoms are getting worse.

Chemotherapy

Chemotherapy is a widely used treatment for non-Hodgkin lymphoma, which involves using medicine to kill cancer cells. It may be used on its own, combined with biological therapy and/or combined with radiotherapy (see below).

The medication can be given in a number of different ways, depending on the stage of your cancer.

If doctors think that your cancer is curable, you will normally receive chemotherapy through a drip directly into a vein (intravenous chemotherapy). If a cure is unlikely, you may only need to take chemotherapy tablets to help relieve your symptoms.

If there is a risk of the cancer spreading to your brain, you may have chemotherapy injections directly into the cerebrospinal fluid around your spine.

Chemotherapy is usually given over a period of a few months on an outpatient basis, meaning you should not have to stay in hospital overnight. However, there may be times when your symptoms or the side effects of treatment become particularly troublesome, and a longer hospital stay may be needed.

Chemotherapy can have several side effects, the most significant of which is potential damage to your bone marrow. This can interfere with the production of healthy blood cells and cause the following problems:

• fatigue
• breathlessness
• increased vulnerability to infection
• bleeding and bruising more easily

If you experience these problems, treatment may need to be delayed so that you can produce more healthy blood cells. Growth factor medicines can also stimulate the production of blood cells.

Other possible side effects of chemotherapy include:

• nausea and vomiting
• diarrhoea
• loss of appetite
• mouth ulcers
• tiredness
• skin rashes
• hair loss
• infertility, which may be temporary or permanent (see complications of non-Hodgkin lymphoma for more information)

Most side effects should pass once your treatment has finished. You must tell your care team if side effects become particularly troublesome, as there are medicines that can help you cope better with some side effects

When you start treatment, you will be given a '24-hour hotline' number to call so that any problems relating to your treatment can be addressed as soon as possible.

Read more about the side effects of chemotherapy.

High-dose chemotherapy

If non-Hodgkin lymphoma does not get better with initial treatment (known as 'refractory' lymphoma), you may have a course of chemotherapy at a stronger dose.

Following this, you may be considered for something known as high-dose chemotherapy which involves having stem cell or bone marrow transplants after high doses of chemotherapy.

Radiotherapy

Radiotherapy is most often used to treat early-stage non-Hodgkin lymphoma, where the cancer is only in one part of the body.

Treatment is normally given in short daily sessions, Monday to Friday, over the space of several weeks. You should not have to stay in hospital between appointments.

Before radiotherapy begins, the radiographer (radiotherapy specialist) will need to first carefully plan your treatment over one or more appointments. The radiographer uses a machine to 'map' out the lymphoma and decide what parts of your body the radiotherapy should be directed at. This planning may involve making small tattoo marks on your skin or making a special cast to ensure that you are kept in exactly the same position for each treatment session.

Radiotherapy itself is painless, but it can have some significant side effects. These can vary depending on which part of your body is being treated. For example, treatment to your throat can lead to a sore throat, while treatment to the head can lead to hair loss.

Other common side effects include:

• sore and red skin in the treatment area
• tiredness
• nausea and vomiting
• dry mouth
• loss of appetite

Most side effects are temporary, but there is a risk of long-term problems including permanently darkened skin in the treatment area.

Read more about the side effects of radiotherapy.

Monoclonal antibody therapy

For some types of non-Hodgkin lymphoma, you may have a type of medication called a monoclonal antibody.

These medications attach themselves to the surface of cancerous cells and stimulate the immune system to attack and kill the cells. They are often given in combination with chemotherapy to make the treatment more effective.

For some types of non-Hodgkin lymphoma, you may continue having monoclonal antibody treatment regularly for up to two years after initial treatment with a combination of these medications and chemotherapy achieves remission (when the cancer can no longer be detected) because this can reduce the chances of the cancer coming back in the future.

One of the main monoclonal antibody medications used to treat non-Hodgkin lymphoma is called rituximab. This medication is administered directly into your vein over the course of a few hours.

Side effects of rituximab can include:

• flu-like symptoms, such as a headaches, fever and chills
• tiredness
• nausea
• an itchy rash

You may be given additional medication to prevent or lessen these side effects. Side effects should improve over time as your body gets used to rituximab.

As rituximab has been so successful in treating non-Hodgkin lymphoma, scientists are working hard to make more monoclonal antibody treatments for lymphoma and some of these are already at an advanced stage in clinical trials. You may be asked if you want to participate in one of these trials during your treatment.

Steroid medication

Steroid medication is commonly used in combination with chemotherapy to treat non-Hodgkin lymphoma. This is because research has shown that using steroids makes the chemotherapy more effective.

The steroid medication is normally given as tablets, usually at the same time as your chemotherapy. A short course of steroids, lasting no more than a few months, is usually recommended as this limits the number of side effects you could have.

Common side effects of short-term steroid use include:

• increased appetite, which can lead to weight gain
• indigestion
• problems sleeping
• feeling agitated

On rare occasions, you may have to take steroids on a long-term basis. Side effects of long-term steroid use include weight gain and swelling in your hands, feet and eyelids.

The side effects of steroid medication will usually start to improve once treatment finishes. 

Follow-up

After your course of treatment ends, you may have a repeat scan to see how well the treatment has worked. Following this, you will need to have regular follow-up appointments to monitor your recovery and check for any signs of the cancer returning (known as a 'relapse').

These appointments will start off being every few weeks or months, but will become less frequent over time.

Want to know more?

For more information, see:

• Cancer Research UK: treating non-Hodgkin lymphoma
• Cancer Research UK: living with non-Hodgkin lymphoma
• Macmillan: treating non-Hodgkin lymphoma
• Macmillan: living with non-Hodgkin lymphoma