High-grade NHL treatment and side effects

Updated 10 Aug 2017

The treatment that’s best for you will depend on the stage of the high-grade non-Hodgkin lymphoma (NHL), your individual condition and your general health.

Treatment for high-grade NHL can involve chemotherapy, radiotherapy, chemo-immunotherapy and growth factor injections. The amount of chemotherapy you have will depend on the stage of the cancer. If you don’t respond to treatment or you relapse, you may have more treatment, which could involve more chemotherapy or a stem cell transplant.

Your healthcare team will always discuss your treatment options with you, explain why a certain treatment has been recommended, and take your wishes into account when planning your treatment.

Types of treatment

If you have high-grade NHL, you might have a range of different types of treatment.

Chemotherapy

During chemotherapy treatment, you’ll take drugs that stop the cancer cells growing and dividing.

Radiotherapy

Radiotherapy is a treatment that uses radiation, usually x-rays, to kill the cancer cells by damaging the genetic material.

Biological therapies

It’s likely that your treatment plan will include a biological therapy called rituximab. This identifies a protein on the surface of the affected B cells and kills them. Rituximab is given as an infusion (a drip into the vein).

While you’re taking the drug, you might have some immediate side effects, like a temperature, rash, shortness of breath or tightness in the chest. You’ll be given paracetamol and anti-histamine before you start taking the drug to reduce the chance of this happening. Most patients don’t have any reactions. However, if you do have a reaction, you’ll be given some more anti-histamine. If you keep having problems, your healthcare team might give you a different drug to take instead.

If you’re on anti-hypertensive drugs (drugs to lower your blood pressure) let your treatment team know – they might ask you not to take your normal dose on the day you’re having rituximab.

> Find out more information on clinical trials

> See a list of clinical trials on the UK Clinical Trials Gateway

Steroids

Steroids are very effective in killing lymphoma cells and are often included in treatment regimes, alongside chemotherapy and biological therapies, but can sometimes be used alone to shrink down the lymphoma. They’re also used to prevent sickness and to help improve appetite and stop allergic reactions.

Growth factor injections (GCSF)

Growth factor injections encourage your bone marrow to make white blood cells.

You might have these injections as part of your treatment if:

  • you’re at a high risk of developing infections
  • you’ve had chemotherapy before, which caused you to be admitted to hospital
  • you’re having higher doses of chemotherapy.

These injections are given subcutaneously (under the skin) for five days – although the number of days can vary depending on which regime you’re being treated with.

Supportive care

You might need supportive care alongside your other treatment. Supportive care involves dealing with complications of your illness or your treatment. This includes things such as dealing with nausea, preventing gout, avoiding/treating constipation, mouth care, blood transfusions, pain management and diet planning.

Watch Dr Kirit Ardeshna talk about how treatment is planned.

Initial treatment

Your initial treatment may involve a combination of chemotherapy, radiotherapy or immunotherapy.

Treatment regimens

There are many different treatment regimens used to treat high-grade NHL. Your healthcare team will talk you through the different options and explain why they’re recommending a certain treatment plan.

Which drugs you take will depend on where the lymphoma is in your body and on other factors like the stage of the cancer.

R-CHOP

The most common combination of drugs is called R-CHOP, which includes the following drugs:

  • rituximab
  • cyclophosphamide
  • hydroxydaunorubicin
  • Oncovin™, which is the trade name for a drug called vincristine
  • prednisone, a steroid tablet.

If you’re not fit enough to have R-CHOP, you might be given a modified version of these drugs. You’ll be given this as an outpatient as an infusion (through a drip).

> Find out more about R-CHOP from Macmillan Cancer Support

Staging and your treatment.

The stage of your high-grade NHL will affect the initial treatment you have.

Stage I high-grade NHL

Because high-grade lymphomas tend to be fast growing, only a small number of patients are at Stage I when they start their treatment. If you are, you’ll usually receive three courses of R-CHOP chemotherapy and radiotherapy treatment to the affected area.

Stage II, III and IV high-grade NHL

Most people with high-grade NHL will fall into this group. Your treatment will usually involve six courses of R-CHOP.

Watch Dr Kirit Ardeshna talk about the types of treatment for high-grade NHL

Treatment of high-grade NHL in the central nervous system

Having lymphoma in extranodal parts of your body (parts of your body outside the lymphatic system) can increase your risk of getting lymphoma in your central nervous system (CNS).

The risk of CNS involvement is higher if lymphoma is found in the breast or testicle.

Doctors use two different terms to refer to high-grade NHL which is in your CNS:

  • primary CNS lymphoma: the lymphoma is only in your CNS
  • NHL with CNS involvement: the lymphoma is in your body and in your CNS.

Chemotherapy aimed at the CNS

Your brain has a natural protection to stop toxins (such as chemotherapy drugs) from entering your CNS – this is called the ‘blood brain barrier’. But if you have a high risk of the lymphoma affecting your CNS or if you have lymphoma cells in your CNS, the chemotherapy drugs need to break through this barrier. Certain drugs, like cytarabine (or AraC) or methotrexateare able to do this. These can be given intravenously (into a vein) or intrathecally (directly into the spinal fluid). You’ll usually take these drugs in high doses as an inpatient in the hospital.

During intrathecal therapy, you’ll have a lumbar puncture to inject a small amount of the chemotherapy drugs into your spinal cord. You may be advised to lie down for an hour or so after the treatment to try to reduce the chance of developing a headache.

Watch Dr Kirit Ardeshna, Consultant Haematologist at University College London Hospitals, talk about treatment of high-grade NHL in the central nervous system.

Side effects

You’re unlikely to have all of the potential side effects. Let your healthcare team know about any side effects you have, as often they’ll be able to help you manage them – for example, by prescribing you anti-nausea drugs.

Side effects of chemotherapy

Some of the possible side effects of chemotherapy include:

  • achy feeling
  • alopecia (hair loss)
  • diarrhoea or constipation
  • fatigue (extreme tiredness)
  • infections
  • loss of appetite
  • bruising
  • risk of bleeding
  • shortness of breath
  • mouth sores
  • nausea (feeling sick) and vomiting.

There is also a risk that having chemotherapy can give you an increased risk of getting a new, second cancer. Your healthcare team will be able to discuss this with you.

Side effects of Oncavin™ (vincristine)

  • a tingling or numbness in your fingers or toes, which might make it hard to do things like doing up buttons – you’ll be assessed for this before each chemotherapy session and if it’s severe you might take a lower dose of Oncavin™ or stop taking it entirely
  • constipation – your healthcare team might give you some laxative medication to help with this.

> To find more information about side effects, download or order our booklet on chemotherapy

Side effects of steroids

  • mood changes such as hyperactivity, or feeling emotional, elated, low or listless
  • increase in appetite
  • insomnia – to help with this, try taking your tablets in the morning rather than the evening
  • changes in blood sugar, causing you to pass water often, have an unexplained thirst or feel dizzy and light-headed.

If this happens, contact your healthcare team.

Watch Dr Kirit Ardeshna talk about the side effects of treatment for high-grade NHL

Infections during your treatment

While you’re having treatment, you have more chance of developing an infection, and a minor infection could become more serious.

Symptoms of infection include:

  • a raised temperature (usually above 38°C)
  • coughing or a sore throat
  • confusion or agitated behaviour, especially if this comes on suddenly
  • fast heartbeat and breathing
  • difficulty in passing urine or not producing urine
  • suddenly increasing pain
  • shivering or shaking and feeling cold
  • quickly becoming more ill.

Symptoms of infection can be less obvious because of your illness, or if you are taking paracetamol-based medicines. If you’re in any doubt you should contact your healthcare team straight away.

Remission

Once you’ve finished your treatment, you’ll have an FDG PET/CT scan to see if all the lymphoma cells have been destroyed. This scan can tell the difference between residual scar tissue in your body (which is unimportant), and lymphoma cells (which might need some extra treatment).

Complete remission

Complete remission is when there are no lymphoma cells in your body. You may hear your specialist mention the term ‘complete metabolic response’.

Partial remission

Partial remission is when the amount of lymphoma in your body has gone down by more than 50%. However, there’ll still be some lymphoma cells in your body.

Refractory high-grade NHL

Occasionally, the high-grade NHL won’t respond to initial treatment. This means that a remission hasn’t been achieved. This is called refractory high-grade NHL, and you’ll need to have more treatment. If there’s a clinical trial available, you may also be asked if you’d consider taking part.

Watch Dr Kirit Ardeshna talk about the tests used to see if remission has been achieved

Relapse, refractory NHL and further treatment

If your initial treatment hasn’t worked, or you have a relapse (the high-grade NHL returns after you’ve been in remission) you’ll need to have more treatment. Relapse is most likely to happen in the first two or three years after finishing treatment, but it could happen later.

You might hear doctors using some different names for the cancer in these cases. These are usually defined as:

  • refractory high-grade NHL: you haven’t responded to initial treatment, or the NHL has come back within three months of finishing treatment
  • relapsed high-grade NHL: you’ve relapsed three months after the end of treatment.

Further treatment

 

Chemotherapy

You’ll have a different type of chemotherapy to the one you had in your initial treatment. You might hear this second round of chemotherapy being called ‘salvage chemotherapy’.

Together, you and your healthcare team will discuss treatment options and you’ll choose an alternative treatment plan. The ones below are commonly used for second- or third- line treatment and are drugs that you might take before stem-cell transplant:

  • ESHAP
  • ICE
  • IVE
  • mini-beam.

Stem cell transplants

For some patients, an autologous stem cell transplant might be an option. This is a stem cell transplant using your own stem cells.

You’ll only be offered a stem cell transplant if you have relapsed or refractory high-grade NHL which has responded to second-line chemotherapy and if your doctors think you’re fit enough. This is because a stem cell transplant will only work if your body has responded well to chemotherapy before.

If you have a second relapse, an allogeneic stem cell transplant (a transplant using donor cells) may be possible.

Your consultant will discuss all these treatment plans with you in detail if you’re going to have a transplant.

> For more information on stem cell transplants, download or order our booklet The seven steps: blood stem cell and bone marrow transplants

Palliative care

Occasionally treatment is unsuccessful. Palliative care is used when no further curative treatment options are available. It involves a multi-disciplinary holistic approach to care. Patients are provided relief from their symptoms, pain and distress. Palliative care includes physical, psychological, emotional, social and spiritual support both for the patient and their family.

Watch Dr Kirit Ardeshna talk about treatment for relapsed and refractory high-grade NHL

Follow-up

After your treatment, you’ll have follow-up checks with your healthcare team. It’s really important that you go to these appointments. Your team will monitor your condition and check for relapse, which is most common in the first two years after the end of your treatment. After two years in remission, the chance of relapse decreases.

In the first year after your treatment you’ll have regular check-ups. Then they’ll get less frequent, or you’ll be able to book an unscheduled appointment as and when you need to. Your consultant will explain how often you’ll have check-up appointments, as this will be different depending on which treatment centre you’ve been visiting.

You and your healthcare team will discuss at which point you can be discharged and your GP will be your main point of contact.

When you have completed your treatment, there are some specific signs or symptoms you should look out for. If you get any new swellings you should contact the hospital team.

It’s also a good idea to tell the hospital team of any changes in your general health or other new signs or symptoms you notice. This is because, depending on which sites in your body are affected, there are many different symptoms which might be related to your condition. It is always advisable to contact the experts and let them decide whether they are significant.

Outlook

Every person is different, so your consultant and healthcare team are the best people to ask about your likely outlook (your prognosis).

Your outlook will depend on what stage of high-grade NHL you have, what treatment you have and how the disease responds to treatment. Your consultant is the best person to ask about your outlook, as they know you and your treatment.

For the majority of people with high-grade NHL, the cancer responds well to treatment. Most people can expect to achieve remission with initial treatment, and you may not need more treatment after this. Depending on the amount and type of treatment you’ve had, it may take some time for you to get back to your normal health. Unfortunately, it’s more difficult to treat patients with either refractory or relapsed DLBCL. However, there are still many further treatments that can still lead to a full remission.

Watch Dr Kirit Ardeshna, Consultant Haematologist at University College London Hospitals, talk about the outlook and everyday life for patients on treatment for high-grade NHL.

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