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Non-Hodgkin Lymphoma Treatment Options

Your oncologist will explain the non-hodgkin lymphoma treatment choices and the recommended set of treatments for you along with the expected results. 

The choice of lymphoma treatment depends on several factors including:

  • The type of non-Hodgkin lymphoma 
  • Its stage (where the lymphoma is found)
  • How quickly the cancer is growing (whether it is indolent or aggressive lymphoma)
  • Your age
  • Whether you have other health problems

If you have indolent non-Hodgkin lymphoma without symptoms, you may not need treatment for the cancer right away. The oncologist watches your health closely so that treatment can start when you begin to have symptoms. Not getting cancer treatment right away is called watchful waiting, as described below.

If you have indolent lymphoma with symptoms, you will probably receive chemotherapy and possibly immunotherapy and/or targeted therapy. Radiation therapy is only used for lymphoma treatment in a few cases.

If non-Hodgkin lymphoma comes back after treatment, doctors call this a relapse or recurrence. People with lymphoma that comes back after treatment may receive high doses of chemotherapy, radiation therapy, or both, followed by a bone marrow transplant.

Watchful Waiting for Lymphoma Patients

People who choose watchful waiting put off having cancer treatment until they have symptoms. Doctors sometimes suggest watchful waiting for people with indolent lymphoma. People with indolent lymphoma may not have problems that require cancer treatment for a long time. Sometimes the tumor may even shrink for a while without therapy. By putting off treatment, they can avoid the side effects of chemotherapy or radiation therapy.

If you and your oncologist agree that watchful waiting is a good idea, you will most likely be checked every 3 months. You will receive treatment if symptoms occur or get worse.

Some people do not choose watchful waiting because they don’t want to worry about having cancer that is not treated. Those who choose watchful waiting but later become worried should discuss their feelings with the doctor.

Chemotherapy

Chemotherapy for lymphoma uses drugs to kill lymphoma cells. It is called systemic therapy because the drugs travel through the bloodstream. The drugs can reach lymphoma cells in almost all parts of the body.

You may receive chemotherapy by mouth, through a vein, or in the space around the spinal cord. Treatment is usually in an outpatient part of the hospital, at the doctor’s office, or at home. Some people need to stay in the hospital during treatment.

Chemotherapy is given in cycles. You have a treatment period followed by a rest period. The length of the rest period and the number of treatment cycles depend on the stage of your disease and on the anticancer drugs used.

If you have lymphoma in the stomach caused by H. pylori infection, your doctor may treat this lymphoma with antibiotics. After the drug cures the infection, the lymphoma also may go away.

Targeted Therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy. Monoclonal antibody therapy, kinase inhibitor therapy, and immunomodulatory drugs are types of targeted therapy used to treat adult non-Hodgkin lymphoma.

Monoclonal Antibody Therapy for Non-Hodgkin Lymphoma

Monoclonal antibodies are immune system proteins made in the laboratory to treat many diseases, including cancer. As a cancer treatment, these antibodies can attach to a specific target on cancer cells or other cells that may help cancer cells grow. The antibodies are able to then kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion, the same way as chemotherapy. They may be used alone or in combination with other cancer treatments. 

Types of monoclonal antibodies include:

  • Rituximab, used to treat many types of non-Hodgkin lymphoma.
  • Obinutuzumab, used to treat follicular lymphoma.
  • Mogamulizumab, used to treat certain types of relapsed or refractory T-cell lymphoma.
  • Tafasitamab combined with lenalidomide to treat relapsed or refractory diffuse large B-cell lymphoma.
  • Pembrolizumab to treat primary mediastinal large B-cell lymphoma.
  • Polatuzumab vedotin, combined with bendamustine and rituximab to treat relapsed or refractory diffuse large B-cell lymphoma.
  • Brentuximab vedotin, which contains a monoclonal antibody that binds to a protein called CD30 that is found on some lymphoma cells. It also contains an anticancer drug that may help kill cancer cells.
  • Yttrium Y 90-ibritumomab tiuxetan, an example of a radiolabeled monoclonal antibody.

Kinase Inhibitor Therapy for Lymphoma

This treatment blocks certain proteins, which may help keep lymphoma cells from growing and may kill them. Kinase inhibitor therapies include:

Copanlisib, idelalisib, duvelisib, and umbralisib, which block P13K proteins and may help keep lymphoma cells from growing. They are used to treat follicular non-Hodgkin lymphomas that have relapsed (come back) or have not gotten better after treatment with at least two other therapies. Umbralisib is also used to treat marginal zone lymphoma that has relapsed or not gotten better with treatment.

Ibrutinib, acalabrutinib, and zanubrutinib, which are types of Bruton tyrosine kinase inhibitor therapy. They are used to treat mantle cell lymphoma. Ibrutinib and acalabrutinib are also used to treat lymphoplasmacytic lymphoma, and zanubrutinib is being studied to treat it.

Immunomodulatory Drugs for Lymphoma

This type of targeted therapy will modulate, or influence, how the body's immune system responds or works. Lenalidomide is an example of an immunomodulator used to treat adult non-Hodgkin lymphoma.

Immunotherapy for Lymphoma

Immunotherapy, also called biologic therapy, is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. 

CAR T Therapy Is Now FDA Approved for Lymphomas

A new category of immunotherapy, called CAR T therapy, changes the patient's T cells (a type of immune system cell) so they attack certain proteins on the surface of cancer cells. T cells are taken from the patient and special receptors are added to their surface in the laboratory. The CAR T cells are then grown in the laboratory and given back to the patient by infusion (IV). The CAR T cells multiply in the patient's blood and attack cancer cells. CAR T-cell therapy (such as axicabtagene ciloleucel or tisagenlecleucel) is used to treat large B-cell lymphoma that has not responded to treatment. CAR T-cell therapy has also been approved by the FDA to treat advanced mantle cell lymphoma. This new category of immunotherapy is being studied extensively by cancer researchers who are optimistic about other ways this type of immunotherapy can be used for more patients.

Checkpoint Inhibitors for Lymphoma

Immunotherapy drugs called immune checkpoint inhibitors work by blocking checkpoint proteins from binding with their partner proteins. This prevents the “off” signal from being sent, allowing the T cells to kill cancer cells. The PD-1 pathway is a target for several checkpoint inhibitors. Primary mediastinal large B-cell lymphoma that has not been stopped by at least 2 other treatments may be treated with a pembrolizumab (Keytruda).

Radiation Therapy for Lymphoma

Radiation therapy (also called radiotherapy) uses high-energy rays to kill lymphoma cells. It can shrink tumors and help control pain. Radiation treatment for non-Hodgkin lymphoma is usually external-beam radiation therapy directed at a localized tumor or a large lymph node. At Compass Oncology, your medical oncologist will work with the radiation oncology team if they feel that radiation therapy would be beneficial. 

Bone Marrow Transplants for Non-Hodgkin Lymphoma

If lymphoma returns after treatment, a bone marrow transplant may be recommended. In most cases the patient’s own blood-forming stem cells are removed before high doses of chemotherapy, radiation therapy, or both are given to the patient. In some cases a bone marrow donor will be sought. This could be a relative who shares DNA or a donor who appears to be a match. 

The high doses of cancer treatments destroy both lymphoma cells and healthy blood cells in the bone marrow. Afterwards, healthy blood-forming stem cells are replaced in the body. New blood cells develop from the transplanted stem cells. With the new blood cells should also be the absence of lymphoma cells. 

Compass Oncology - The US Oncology Network