Treatment for Hodgkin lymphoma (HL) usually includes chemotherapy and in some cases radiotherapy and steroids. If HL doesn't respond well to treatment you may have higher doses of chemotherapy followed by a stem cell transplant.
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Hodgkin lymphoma (HL) treatment and side effects
HL treatment and side effects
Treatment for Hodgkin lymphoma is usually very successful. The treatment you have depends on the results of your tests and what stage the Hodgkin lymphoma is, but typically includes chemotherapy and in some cases radiotherapy, steroids and – if the Hodgkin lymphoma comes back – a stem cell transplant.
Your healthcare team will look at a number of things when deciding what treatment to recommend to you – such as your test results, the symptoms you have, what stage the Hodgkin lymphoma is and your general age and fitness.
If you have any concerns about treatment you should discuss these with your consultant or key worker.
If you have early stage disease (IA and IIA) your treatment will usually be 2–4 cycles of chemotherapy.
You may also have local radiotherapy, specifically on the affected lymph nodes. Radiotherapy is used to try to prevent the disease coming back. Localised radiotherapy is used instead of extra cycles of chemotherapy, which may not be necessary for early stage lymphoma.
Watch Dr Chris Hatton, Consultant Haematologist at Oxford Radcliffe Hospitals NHS Trust, talk about treatment for early stage Hodgkin lymphoma
If you have advanced disease your treatment will usually be six or more cycles of chemotherapy, and possibly radiotherapy.
Watch Dr Chris Hatton talk about treatment for advanced Hodgkin lymphoma
Risks to fertility
After you’ve been diagnosed, and before you begin treatment, it would be a good idea to discuss with your doctor the options available to protect your fertility.
The risk is low for both men and women, but becomes higher for older women as there is a possibility that chemotherapy may lead to an earlier menopause.
All men will be offered the opportunity to store sperm and women will have opportunity to discuss potential egg freezing or embryo preservation. These options should be discussed at the outset of your treatment.
Treatment if you’re under 25 years
If you’re under the age of 25, you can be treated in a TYA centre (teenager/young adult centre). You’ll be treated in a TYA if you’re still attending school and you’ll also have the option if you’ve already left school. These centres also provide psychological and social support, which you can access even if you’re not being treated there. Your healthcare team can refer you to your nearest TYA.
In general, the long-term outlook for people with Hodgkin lymphoma is good, especially if it’s diagnosed early. For younger and older patients the aim is to achieve a cure, and this is achieved in the majority of cases. Treatment is generally well-tolerated and leads to few long-term side effects.
Even in patients who are slightly older (over 50), or more frail, there are still a number of options and trials open to you that your consultant will discuss.
Watch Dr Chris Hatton talk about the outlook for patients with Hodgkin lymphoma
Your healthcare team will describe you as being ‘cured’ if you go into ‘complete remission’, which means that no lymphoma can be seen on your scans. If there’s a reduction in the amount of lymphoma, but it’s not completely gone, this is called ‘partial remission’.
People generally cope well with treatment and have few long-term side effects. However, as with any type of chemotherapy or radiotherapy, there is always at least a small risk of long-term effects. These include an increased risk of second cancers, and problems with the thyroid, heart or lungs. The risk of long-term effects will depend on how many cycles of treatment you’ve had and if you received a transplant or not. However, every case is individual, so your healthcare team will talk to you about this in more detail before your treatment.
Every person is different, so your consultant and healthcare team are the best people to ask about your likely outlook (your prognosis).
Most patients with Hodgkin lymphoma will have chemotherapy. This is usually a combination of drugs known as ABVD, This stands for:
- A Adriamycin™, also known as doxorubicin or hydroxydaunorubicin.
- B bleomycin
- V vinblastine
- D dacarbazine
Some centres may offer a different type of chemotherapy drug combination. Your healthcare team will discuss what’s right for you. All of the drugs used to treat Hodgkin lymphoma work by interrupting the growth of cancerous cells in your body.
How is chemotherapy given?
The treatment is usually given in an outpatient clinic, although you may need to stay overnight in hospital on some occasions and with some particular drugs.
Chemotherapy is usually given in cycles – you’ll have treatment for a day if you’re on ABVD, or for a few days with other regimens.
Chemotherapy is given every two weeks. One cycle (or course) is two lots of the same chemotherapy (ABVD) and is therefore completed in four weeks.
Chemotherapy for Hodgkin lymphoma is usually given as an intravenous (IV) infusion (into a large vein in the arm).
Sometimes it’s given through a central line (an IV line into the chest). Having a central line can be useful, as it means you don’t have to have the treatment injected each time (which can sometimes be uncomfortable after several cycles of treatment).
There are three main types of central line:
- a PICC line, where a long thin tube is passed up a vein in your arm to your chest
- a central line that’s put into the main vein in your chest – the end comes out of the skin on your chest so drugs can be given through it; you might hear it being called a Hickman™ line
- a ‘port’ that’s put into your chest which doesn’t come out through your skin; drugs are injected into it instead.
Central lines can usually be put in using local anaesthetic at an outpatient clinic. Your healthcare team will tell you how to look after your central line. Central lines can be removed easily after your treatment.
You may take steroids as well as chemotherapy drugs. Steroids can make some chemotherapy treatments more effective and reduce any sickness you may get. The steroid normally given to reduce sickness is called dexamethasone, which is given as an injection or as a tablet.
If you’re taking steroids, you should carry a card around with you which makes this clear, so doctors will know in case of an emergency. Your healthcare team should give you one of these cards.
Radiotherapy uses high energy rays to kill cancer cells in a specific area. It can be an effective treatment for diseases which affect a particular part of the body, such as lymphoma.
You will likely be given radiotherapy if you have early stage disease (IA and IIA) in only one or a couple of areas of the body. Or occasionally you might have radiotherapy in later stage disease to try and shrink lymph nodes.
Before you have radiotherapy, you'll have scans so your doctors know exactly where to target it, and they’ll mark this on your body. The actual treatment only takes a short time and it isn’t painful. You lie still inside a doughnut shaped scanner with the treatment area exposed. You normally have radiotherapy as an outpatient for up to three weeks, then have a break for a few days before having another dose.
Radiotherapy doesn’t make you radioactive and it’s fine to be around other people as normal.
Watch Dr Chris Hatton talk about monitoring treatment for Hodgkin lymphoma
Although the outcome for people with blood cancer continues to improve, there's still a long way to go to improve treatments and quality of life for patients.
Therefore if there’s a clinical trial (study) available, your consultant might recommend that you consider this.
A clinical trial is a planned medical research study involving patients. These studies are done with the aim of looking for new treatment options and improving existing treatments.
Taking part in a clinical trial has many advantages, such as the opportunity to have the newest available treatment which may not be offered outside of the trial. You’ll also be very closely monitored and have detailed follow-up.
If you take part in a clinical trial you'll either have the best current treatment available, or one that has the potential to be better. This allows the two treatments to be compared. Your safety and wellbeing is always the first priority.
Taking part in a clinical trial does come with uncertainties, and you may prefer not to take part in one. If you don’t want to be in a trial, or there isn’t a suitable trial available, you’ll be offered the best treatment available at that time which is suitable for your individual condition.
You may experience some side effects from the different types of treatment you have.
For most patients with Hodgkin lymphoma, side effects from chemotherapy aren’t severe and they usually go away when treatment stops. They may include:
- hair loss
- bleeding and/or bruising
- anaemia (which can cause paleness, tiredness and breathlessness)
- mouth sores
- nausea (feeling sick) and vomiting
- poor appetite (loss of taste)
- weight changes.
You’re unlikely to have all of these.
You’ll be given drugs called anti-emetics to stop you feeling sick and to help with the vomiting you might get with certain treatments. If you have any other side effects, tell your healthcare team as they may be able to help.
Some side effects are associated with specific drugs. For example the bleomycin drug in ABVD can cause a cough or breathlessness. Let your doctor know straight away if this occurs during or after treatment has been completed.
Also, the dacarbazine drug in ABVD may cause some pain at the spot where it's given. If this happens there are things which can be done to help, so you should tell your nurse or doctor immediately if you feel pain.
Side effects from steroids can include:
- feeling agitated
- weight gain
- water retention (build-up) around your face and ankles
- increase in appetite
- raised blood sugar, particularly in patients with diabetes.
The side effects from radiotherapy will depend on the area of the body being treated but common side effects are fatigue and redness in the treated area. Your healthcare team will speak to you in more detail about this.
You may also need what’s known as supportive care, during and after treatment. Supportive care includes prevention and treatment of infection, blood transfusions, mouth care, diet, pain management and dealing with complications associated with your illness or your treatment.
Treatment for relapsed HL
In a small number of people, Hodgkin lymphoma doesn’t respond to initial treatment (refractory disease), or returns after at first responding well (relapse). If this is the case for you, it’s important to remember that there’s still a good chance of a successful outcome. In these cases, if you’re otherwise fit and well, your doctor may recommend using higher doses of chemotherapy followed by a stem cell transplant.
A stem cell transplant is also sometimes called a bone marrow transplant. It aims to give patients healthy stem cells to replace those which are destroyed by the high dose chemotherapy. These stem cells then produce normal blood cells.
There are two main types of stem cell transplant:
An autologous transplant is when your own healthy stem cells are collected from your bone marrow before the high dose chemotherapy, then given back to you through a drip afterwards.
An allogeneic transplant uses stem cells from a donor. These are less common, but may be considered for a small number of patients whose autologous transplants weren’t successful, or for patients who didn’t respond well enough to their initial treatment to have an autologous transplant.
If you relapse following an autologous transplant, you’ll probably be given a monoclonal antibody drug, called brentuximab vedotin, before you receive an allogeneic transplant. Antibodies are proteins made by white blood cells that circulate in the blood and help fight infection. A monoclonal antibody will copy the effect of the body’s natural antibodies. These drugs can attach to the proteins on cancer cells and attack them, to help prepare the body before an allogeneic transplant.
The treatment you decide on with your healthcare team will depend on the stage of your Hodgkin lymphoma, your age and general wellbeing. If your condition responds well to initial treatment, there’s a high chance that you won’t need further treatment.
It’s really important that you still come for follow-up checks and monitor yourself for any symptoms, because relapses can happen. The earlier a relapse is identified, the better the chance of a successful outcome.
The amount of follow-up appointments you’ll have may vary, but normally you’ll have check-ups more regularly in the first two years, then slightly less regularly after two years. This is because the risk of relapse is highest in the first two years after you complete your initial treatment. Your healthcare team will explain how often you should come for follow-up checks.
After treatment you may wonder whether there are any specific signs or symptoms you should be looking out for. An obvious reason to contact the hospital team would be any new swellings. Similarly, fever, sweats or weight loss should be reported. It’s a good idea to tell the hospital team of any changes in your general health or any new signs or symptoms you notice.
Vaccines and blood transfusions
Once you’ve completed your treatment and you’re in remission, you shouldn’t receive live vaccines (for example, yellow fever, oral polio vaccine, measles and shingles), as these may cause serious illness. Ask your healthcare team for more advice about vaccines.
Hodgkin lymphoma patients must not receive blood or any other blood product such as platelets that haven’t been irradiated (treated with radiation). It’s important you carry a card to inform other medical teams of this risk. Your healthcare team should give you one of these cards; if you haven’t been offered a card yet, you could speak to your key worker or doctor about it on your next visit.
Watch Dr Chris Hatton talk about follow up, consolidation treatment and relapse.