Chemotherapy is the primary treatment for non-Hodgkin lymphoma, though people may also receive it with immunotherapy.

Chemotherapy remains the first-line treatment for non-Hodgkin lymphoma (NHL), a cancer of the lymphatic system. Cancer staging helps determine treatment, including the number and dosage of drugs a person receives and treatment duration.

This article outlines chemotherapy for non-Hodgkin lymphoma, including types of chemotherapy medications, efficacy, side effects, and more.

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Healthcare professionals administer chemotherapy based on the type and stage of NHL.

The cancer stage depends on the number of affected lymph nodes and how far the cancer has spread to other organs or bones.

NHL can be low-grade (indolent) or high-grade (aggressive).

Doctors may recommend that people with aggressive or late-stage NHL start chemotherapy immediately.

A healthcare professional will administer chemotherapy for NHL directly into the bloodstream through a vein. This is known as intravenous (IV) chemotherapy.

People may receive chemotherapy in specific areas, such as the abdomen, chest cavity, central nervous system, and urethra into the bladder.

Low-grade NHL

Low-grade NHL or indolent lymphoma is not curable with conventional therapy. Low-grade NHLs may require intermittent treatment due to relapse.

The most common low-grade lymphoma is follicular lymphoma. Most people present at an advanced stage, and though it is not easily curable, symptom management can improve a person’s quality of life.

Surgical excision or radiotherapy are potential treatment options for people whose low-grade NHL has not spread.

High-grade NHL

High-grade or aggressive NHL can grow and progress rapidly. While it can be fatal, it may be curable if a person receives chemotherapy treatment in the early stages.

The most common high-grade lymphoma is diffuse large B cell lymphoma (DLBCL), which is curable using combined chemotherapy and immunotherapy in about 60-70% of people.

Treatment for high-grade NHL sometimes requires intensive chemotherapy, which may cause short-term side effects.

Preventing cancer spread

Doctors may inject anticancer medication into the cerebrospinal fluid surrounding the brain to prevent cancer from spreading to the brain. This is known as intrathecal chemotherapy.

Doctors may recommend chemotherapy alone or in combination with other treatments, such as immunotherapy, surgery, or radiation.

Common chemotherapy medications that doctors may prescribe for NHL include:

  • Alkylating agents: cyclophosphamide, chlorambucil (Leukeran), bendamustine (Bendeka), ifosfamide
  • Corticosteroids: prednisone, dexamethasone
  • Platinum drugs: cisplatin, carboplatin, oxaliplatin
  • Purine analogs: fludarabine, pentostatin, cladribine (2-CdA)
  • Anti-metabolites: cytarabine (ara-C), gemcitabine, methotrexate, pralatrexate
  • Anthracyclines: doxorubicin (Adriamycin), liposomal doxorubicin (Caelyx)
  • Other: vincristine (Oncovin), mitoxantrone, etoposide (VP-16), bleomycin

Which chemotherapy medication is first-line?

First-line treatments for NHL may involve combinations of drugs from different groups, including:

  • CHOP: This commonly includes cyclophosphamide, doxorubicin (hydroxydaunorubicin), vincristine (Oncovin), and prednisone.
  • CVP: A typical combination of CVP includes cyclophosphamide, vincristine (Oncovin), and prednisone.
  • R-CHOP: This treatment consists of a combination of the immunotherapy drug rituximab (Rituxan) and chemotherapy.

What is the latest chemotherapy medication for NHL?

Metronomic chemotherapy (mCHEMO) is a long-term, low dose administration of oral medication people take by mouth.

Pre-clinical studies in lymphoma models have shown promising results by combining mCHEMO with novel drugs, potentially leading to more effective and tolerable combinations.

However, scientists need to conduct more human studies to determine drug efficacy.

After chemotherapy, some people may be in remission for years. A person may relapse and reach remission many times in their lifetime.

According to a 2017 review, treatment with immunochemotherapy regimens may lead to the disappearance of cancer in 75–80% of people with DBLCL.

While a person with low-grade NHL may need multiple treatments throughout their life, they can often manage symptoms as they would a chronic condition.

Side effects from chemotherapy may occur immediately or develop over time, even years later.

Common short-term side effects include:

  • hair loss
  • taste changes
  • mouth sores
  • appetite suppression
  • nausea
  • vomiting
  • diarrhea
  • constipation
  • infections
  • bleeding
  • bruising easily
  • fatigue
  • shortness of breath

Depending on the drug, chemotherapy medications may have other side effects, such as:

  • nerve complications from platinum drugs, such as cisplatin
  • bladder damage (ifosfamide)
  • heart failure and cardiomyopathy (doxorubicin)
  • lung damage (bleomycin)
  • hypogammaglobulinemia (rituximab)

Other possible long-term side effects include an impact on fertility and an increased risk of developing secondary cancer, such as leukemia.

Additionally, one 2021 study found that depression is common in people with NHL undergoing chemotherapy.

Managing side effects

Medications can reduce some side effects of chemotherapy. For example, a doctor may prescribe antiemetic drugs to manage chemotherapy-induced nausea and vomiting.

To prevent tumor lysis syndrome, a medical team may provide extra fluids and medications such as sodium bicarbonate.

A medical team administers chemotherapy in cycles, usually over several weeks. Within each cycle, a period of rest follows each treatment.

For example, doctors administer R-CHOP treatment over 3–6 cycles, with each treatment at 3-week intervals.

Doctors may stick to a combination of medications for multiple cycles, choosing to change the selected drugs if needed.

Doctors can administer chemotherapy at a medical office, clinic, or hospital. Treatment rarely requires an overnight stay.

The first-line chemo regimen for NHL is CHOP, though doctors may recommend other combinations.

Short-term side effects include temporary hair loss, loss of appetite, and fatigue. Medication may help manage specific side effects, such as nausea and vomiting.

Some side effects may be medication-specific. And while most side effects subside after treatment, some problems, such as fertility challenges, may continue.

Chemotherapy may cure some types of NHL, especially if a person receives a diagnosis when the cancer is in its early stages.