- How Curable are Different Types of Lymphoma?
- Survival Rates for Hodgkin Lymphoma
- What is a 5-year relative survival rate?
- Where do these numbers come from?
- 5-year relative survival rates for Hodgkin lymphoma
- Understanding the numbers
- Other prognostic factors
- The aim of lymphoma treatment
- Complete remission
- Partial remission
- Stage 4 Lymphoma: Facts, Types, Symptoms, and Treatment
- Treatment – Non-Hodgkin lymphoma
- High-dose chemotherapy
- International Prognostic Index
- Functional status
- Radiation therapy
- Bone marrow transplantation/stem cell transplantation
- Physical, emotional, and social effects of cancer
- Remission and the chance of recurrence
- Progressive NHL
- Refractory NHL
- If treatment does not work
- Related posts:
How Curable are Different Types of Lymphoma?
My dad died of non-Hodgkin’s lymphoma on Dec. 19, 1994 at the age of 77. He was told in 1992 that he had about six months left, so my sister and I both made trips home that Thanksgiving as it might be his last one. He actually lived another two years. How curable are the various forms of lymphoma? I heard that if Hodgkin’s is detected early enough, it can be rather easy to cure, but the non-Hodgkin’s that my dad had is very difficult to cure, if at all, no matter how early it’s detected. What is the story about this, please?
There are many different types of non-Hodgkin’s lymphoma, and the prognosis depends on the specific diagnosis. Prognosis can also vary within the same subtype. Even in a patient who has a well-defined subtype of lymphoma, the length of survival can be difficult to predict.
For patients with fast-growing lymphomas (such as diffuse large B-cell lymphoma), the disease can be cured with combination chemotherapy. For patients who do not respond to treatment or have early relapses, however, the disease can be fatal in a relatively short amount of time.
The slow-growing lymphomas are not curable with standard chemotherapy, but patients may live with them for many years.
Learn more in the Everyday Health Lymphoma Center.
Survival Rates for Hodgkin Lymphoma
Survival rates can give you an idea of what percentage of people with the same type and stage of cancer are still alive a certain amount of time (usually 5 years) after they were diagnosed. They can’t tell you how long you will live, but they may help give you a better understanding about how likely it is that your treatment will be successful.
Keep in mind that survival rates are estimates and are often based on previous outcomes of large numbers of people who had a specific cancer, but they can’t predict what will happen in any particular person’s case. These statistics can be confusing and may lead you to have more questions. Talk with your doctor about how these numbers may apply to you, as he or she is familiar with your situation.
What is a 5-year relative survival rate?
A relative survival rate compares people with the same type and stage of Hodgkin lymphoma to people in the overall population. For example, if the 5-year survival rate for a specific stage of Hodgkin lymphoma is 80%, it means that people who have that cancer are, on average, about 80% as likely as people who don’t have that cancer to live 5 years after being diagnosed.
Where do these numbers come from?
The American Cancer Society relies on information from the SEER* database, maintained by the National Cancer Institute (NCI), to provide survival statistics for different types of cancer.
The SEER database tracks 5-year relative survival rates for Hodgkin lymphoma in the United States, based on how far the cancer has spread. The SEER database, however, does not group cancers by the Lugano classification (stage 1, stage 2, stage 3, etc.). Instead, it groups cancers into localized, regional, and distant stages:
- Localized: The cancer is limited to one lymph node area, one lymphoid organ, or one organ outside the lymph system.
- Regional: The cancer reaches from one lymph node area to a nearby organ, is found in two or more lymph node areas on the same side of the diaphragm, or is considered bulky disease.
- Distant: The cancer has spread to distant parts of the body such as the lungs, liver, or bone marrow, or to lymph node areas above and below the diaphragm.
5-year relative survival rates for Hodgkin lymphoma
(Based on people diagnosed with Hodgkin lymphoma between 2009 and 2015.)
5-Year Relative Survival Rate
All SEER stages combined
Understanding the numbers
- These numbers apply only to the stage of the cancer when it is first diagnosed. They do not apply later on if the cancer grows, spreads, or comes back after treatment.
- These numbers don’t take everything into account. Survival rates are grouped based on how far the cancer has spread, but your age, overall health, how well the cancer responds to treatment, and other prognostic factors (described below) can also affect your outlook.
- People now being diagnosed with Hodgkin lymphoma may have a better outlook than these numbers show. Treatments improve over time, and these numbers are based on people who were diagnosed and treated at least five years earlier.
Other prognostic factors
Along with the stage of the Hodgkin lymphoma, other factors can affect a person’s prognosis (outlook). For example, having some of these factors means the lymphoma is likely to be more serious:
- Having B symptoms or bulky disease
- Being older than 45
- Being male
- Having a high white blood cell count (above 15,000)
- Having a low red blood cell count (hemoglobin level below 10.5)
- Having a low blood lymphocyte count (below 600)
- Having a low blood albumin level (below 4)
- Having a high erythrocyte sedimentation rate, or ESR (over 30 in someone with B symptoms, or over 50 for someone without B symptoms)
Some of these factors are used to help divide stage I or II Hodgkin lymphoma into favorable and unfavorable groups, which can affect how intense the treatment needs to be. To learn more, see Treating Classic Hodgkin Lymphoma by Stage.
*SEER= Surveillance, Epidemiology, and End Results
The aim of lymphoma treatment
The aim of most lymphoma treatments is to send your lymphoma into remission. Remission means that the amount of lymphoma in your body has reduced or gone altogether. There are different types of remission, depending on how much your lymphoma has been reduced. For some types of lymphoma, treatment aims to get rid of all of the lymphoma and send it into complete remission. For other types of lymphoma, treatment aims to control the lymphoma and send it into partial remission.
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Complete remission means your symptoms have gone and there is no evidence of lymphoma in your body in tests and scans at the end of your treatment. Your doctor might not use the word ‘cure’ because there might be a tiny amount of lymphoma left in your body that can’t be detected using available techniques. However, the longer you are in complete remission, the less likely your lymphoma is to come back (relapse).
Hodgkin lymphoma and high-grade non-Hodgkin lymphoma are usually treated with the aim of sending the lymphoma into complete remission. For most people with these types of lymphoma, the disease is unlikely to relapse after successful treatment.
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Partial remission means your lymphoma has reduced (there are fewer lymphoma cells in your body or it is affecting fewer parts of your body) but it has not gone completely. Usually, partial remission means your lymphoma has reduced by at least half. Sometimes doctors talk about ‘remission with residual abnormality’ (some disease leftover) to describe a partial response to treatment. You might still have some symptoms of lymphoma following a partial remission.
Low-grade non-Hodgkin lymphoma is likely to respond well to treatment but it is unlikely to go into complete remission because the slow-growing cells in low-grade lymphomas are hard to get rid of completely. Low-grade lymphoma is therefore usually treated with the aim of sending it into as good a partial remission as possible. This means that the lymphoma and any symptoms you have are reduced as much as possible. This is sometimes called ‘controlling’ the lymphoma rather than curing it.
Low-grade non-Hodgkin lymphoma can often be controlled for many years and as treatment options improve, remissions are lasting longer. However, low-grade non-Hodgkin lymphoma usually comes back (relapses) or gets worse (progresses) at some point. This might not be for many months or years. Although a relapse can be very distressing, many people are treated successfully again. Most people with low-grade non-Hodgkin lymphoma have several different treatments over the course of their illness. It helps some people to think of it as a long-term (chronic) disease that needs treatment from time-to-time.
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Stage 4 Lymphoma: Facts, Types, Symptoms, and Treatment
Lymphoma isn’t a single disease. The term refers to a group of blood cancers that can develop in your lymphatic system. There are two main types of lymphoma:
- Hodgkin’s lymphoma
- non-Hodgkin’s lymphoma (NHL)
If you’re diagnosed with lymphoma, your doctor will perform tests to learn what stage of the disease you have. Stage 4 is the most advanced stage of lymphoma. The characteristics of stage 4 lymphoma vary, depending on the subtype of lymphoma you have.
According to estimates from the American Cancer Society (ACS), about 8,500 new cases of Hodgkin’s lymphoma will be diagnosed in the United States in 2016.
Hodgkin’s lymphoma is treatable, especially in its early stages. The one-year survival rate for all patients diagnosed with Hodgkin’s lymphoma is about 92 percent. The five-year survival rate is about 86 percent. For people with stage 4 Hodgkin’s lymphoma, the survival rate is lower. But even in stage 4 you can beat the disease.
If you have Hodgkin’s lymphoma that’s spread through one or more organs outside of your lymphatic system, you’ll be diagnosed with stage 4 of the condition. For example, the cancer might have spread to your liver, lungs, or bone marrow.
Non-Hodgkin’s lymphoma (NHL)
NHL accounts for about 4 percent of all cancers in the United States, reports the ACS. An estimated 72,580 people in the country will be diagnosed with it in 2016.
The many subtypes of NHL are categorized as either B cell type or T cell type NHL. The subtypes are further categorized as aggressive or indolent.
Aggressive NHL progresses quickly. According to the Leukemia and Lymphoma Society (LLS), about 60 percent of people with NHL have aggressive subtypes of the disease. Diffuse large B cell lymphoma (DLBCL) is the most common aggressive subtype. It affects about 30 percent of people with NHL in the United States.
Indolent NHL is slow growing. It accounts for about 30 percent of NHL cases in the United States, reports the LLS. Follicular lymphoma is the most common type of indolent NHL.
If you have NHL that’s spread outside of your lymphatic system to an organ that isn’t next to an affected lymph node, you’ve reached stage 4 of the disease. You also have stage 4 NHL if it’s spread to your bone marrow, liver, lungs, brain, or spinal cord.
Chemotherapy is a widely used treatment for non-Hodgkin lymphoma that involves using medicine to kill cancer cells.
It may be used on its own, combined with biological therapy, or combined with radiotherapy.
The medication can be given in a number of different ways, depending on the stage of your cancer.
You’ll normally get chemotherapy through a drip directly into a vein (intravenous chemotherapy), as tablets taken by mouth, or a combination of both.
If there’s 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, which means you get treatment during the day and shouldn’t have to stay in hospital overnight.
But there may be times when your symptoms or the side effects of treatment become particularly troublesome and a longer hospital stay may be needed.
If you’re taking chemotherapy as tablets, you might be able to take these at home.
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:
- feeling very tired (fatigue)
- increased vulnerability to infection
- bleeding and bruising more easily
If you experience these problems, treatment may need to be delayed so 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
- loss of appetite
- mouth ulcers
- 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.
Tell your care team if side effects become particularly troublesome, as there are treatments that can help.
Read more about the side effects of chemotherapy.
If non-Hodgkin lymphoma doesn’t get better with initial treatment (known as refractory lymphoma), you may have a course of chemotherapy at a stronger dose.
But this intensive chemotherapy destroys your bone marrow, leading to the side effects mentioned.
You’ll need a stem cell or bone marrow transplant to replace the damaged bone marrow.
ON THIS PAGE: You will learn about how doctors describe lymphoma’s location and spread. This is called the stage. Use the menu to see other pages.
Staging is a way of describing where NHL is located, if or where it has spread, and whether it is affecting other parts of the body.
Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis. There are different stage descriptions for different types of cancer.
When staging NHL, doctors evaluate:
How many cancerous lymph node areas there are
Where the cancerous lymph nodes are: regional (in the same area of the body) or distant (in other parts of the body)
If the cancerous lymph nodes are on 1 or both sides of the diaphragm, the thin muscle under the lungs and heart that separates the chest from the abdomen
If the disease has spread to the bone marrow, spleen, or extralymphatic organs (organs that are not part of the lymphatic system), such as the liver, lungs, or brain
The stage of lymphoma describes the extent of spread of the tumor using the Roman numerals I, II, III, or IV (1 through 4). This staging system is helpful for the most common subtypes of lymphoma. For other subtypes, the disease has often spread throughout the body by the time it is diagnosed. In these situations, the prognostic factors become more important (see “International Prognostic Index” and “Functional status” below). It is important to remember that even stage IV lymphomas can often be treated successfully.
Stage I: Either of these conditions applies:
The cancer is found in 1 lymph node region (stage I).
The cancer has invaded 1 extralymphatic organ or site (identified using the letter “E”) but not any lymph node regions (stage IE).
Stage II: Either of these conditions:
The cancer is in 2 or more lymph node regions on the same side of the diaphragm (stage II).
The cancer involves 1 organ and its regional lymph nodes, with or without cancer in other lymph node regions on the same side of the diaphragm (stage IIE).
Stage III-IV: There is cancer in lymph node areas on both sides of the diaphragm (stage III), or the cancer has spread throughout the body beyond the lymph nodes (stage IV). Lymphoma most often spreads to the liver, bone marrow, or lungs. Stage III-IV lymphomas are common, still very treatable, and often curable, depending on the NHL subtype. Stage III and stage IV are now considered a single category because they have the same treatment and prognosis.
Progressive/refractory: If the cancer grows larger or spreads while the patient is being treated for the original lymphoma, it is called progressive disease. This is also called refractory NHL.
Recurrent/relapsed: Recurrent lymphoma is lymphoma that has come back after treatment. It may return in the area where it first started or in another part of the body. Recurrence may occur shortly after the first treatment or years later. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above. This is also called relapsed NHL.
The original source for this material is Cheson BD, Fisher RI, Barrington SF, et al.: Recommendations for initial evaluation, staging and response assessment of Hodgkin and non-Hodgkin lymphoma—the Lugano Classification, published in the Journal of Clinical Oncology, September 20, 2014; vol. 32, no. 27: 3059–3067.
International Prognostic Index
In addition to stage, a scale called the International Prognostic Index (IPI) is important in determining the prognosis of aggressive lymphomas. Prognosis is the chance of recovery. Each type of NHL has specific criteria as a part of the IPI. Patients are classified into low-risk or high-risk groups depending on several factors, including:
Age 60 or older
Stage III-IV disease
Blood test results showing higher-than-normal levels of lactate dehydrogenase (LDH), an enzyme found in the blood
Lower overall health, known as performance status (see below)
Cancer in more than 1 organ or site outside the lymph node region
For people with follicular lymphoma, doctors consider the hemoglobin level, which is a part of the blood, the number of lymph node groups involved, LDH level, stage, and age.
Doctors use these factors to estimate the prognosis of a lymphoma. For incurable lymphoma, they help predict how aggressive the lymphoma might be.
To determine someone’s prognosis, the doctor may also test how well they are able to function and carry out daily activities by using a functional assessment scale. The Eastern Cooperative Oncology Group (ECOG) Performance Status or the Karnofsky Performance Scales (KPS) are 2 of those scales.
ECOG Performance Status. A lower score indicates a better functional status. Typically, the better someone is able to walk and care for themselves, the better the prognosis.
Fully active, able to carry on all pre-disease performance without restriction
Restricted in physically strenuous activity but able to walk and carry out light work while standing or sitting, such as light house work or office work
Able to walk and capable of all self-care but unable to carry out any work activities; up and about for more than 50% of waking hours
Capable of only limited self-care; confined to bed or chair for more than 50% of waking hours
Completely disabled; cannot carry out any self-care; totally confined to bed or chair
KPS. A higher score indicates a better functional status.
100: Normal; no complaints; no evidence of disease
90: Able to carry on normal activity; minor symptoms of disease
80: Normal activity with effort; some symptoms of disease
70: Cares for self; unable to carry out normal activity or active work
60: Requires occasional assistance but is able to care for needs
50: Requires considerable assistance and frequent medical care
40: Disabled; requires special care and assistance
30: Severely disabled; hospitalization is indicated, but death is not imminent
20: Very sick; hospitalization necessary; active treatment necessary
10: Approaching death; fatal processes progressing rapidly
Information about the cancer’s type, subtype, and stage, as well as prognostic factors, will help the doctor recommend a treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.
Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).
The types of systemic therapies used for NHL include:
Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes radiation therapy.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.
Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells. It is the main treatment for NHL.
A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. The stage and type of NHL determines which chemotherapy is used. The most common chemotherapy combination for the first treatment of aggressive NHL is called CHOP and contains 4 medications:
Cyclophosphamide (available as a generic drug)
Doxorubicin (available as a generic drug)
Prednisone (multiple brand names)
For patients with B-cell lymphoma, adding an anti-CD20 monoclonal antibody, such as rituximab or obinutuzumab, to CHOP works better than using CHOP alone (see “Targeted therapy,” below). There are other common combinations of chemotherapy regimens, including:
BR, which includes bendamustine (Treanda) and rituximab
Combinations using fludarabine (available as a generic drug)
R-CVP (cyclophosphamide, prednisone, rituximab, and vincristine)
The side effects of chemotherapy depend on the individual drug and the dose used. They can include fatigue, temporary lowering of blood counts, risk of infection, nausea and vomiting, hair loss, loss of appetite, rash, and diarrhea. These side effects can be managed during treatment and usually go away after treatment is finished.
Chemotherapy may also cause long-term side effects, also called late effects. People with lymphoma may also have concerns about if or how their treatment may affect their sexual health and fertility. Talk with the members of the health care team about these topics before treatment begins. Learn more about late effects of treatment.
Learn more about the basics of chemotherapy.
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.
Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.
Talk with your doctor about possible side effects for a specific medication and how they can be managed.
For NHL, monoclonal antibodies are the main form of targeted therapy used in the treatment plan. A monoclonal antibody recognizes and attaches to a specific protein and does not affect cells that do not have that protein. A monoclonal antibody called rituximab is used to treat many different types of B-cell NHL. Rituximab works by targeting a molecule called CD20 that is located on the surface of all B cells and B-cell NHL. When the antibody attaches to this molecule, the patient’s immune system is activated to destroy some lymphoma cells or to make lymphoma cells more susceptible to being destroyed by chemotherapy.
Although the antibody may work well by itself, research shows that it worked better when added to chemotherapy for patients with most types of B-cell NHL. Rituximab is also given after remission for indolent lymphoma to increase the length of the remission. There are 3 other monoclonal antibodies against CD20 that are approved by the FDA for use in lymphomas: obinutuzumab (Gazyva), ofatumumab (Arzerra), rituximab-abbs (Truxima), and rituximab-pvvr (Ruxience). Rituximab-abbs and rituximab-pvvr are called biosimilars, which means they function in a way similar to rituximab (Rituxan). Learn more about biosimilars.
Brentuximab vedotin (Adcetris) is another type of monoclonal antibody, called an antibody-drug conjugate. Antibody-drug conjugates attach to targets on cancer cells and then release a small amount of chemotherapy or other toxins directly into the tumor cells. Brentuximab vedotin combined with chemotherapy is approved to treat adults with certain types of peripheral T-cell lymphoma, such as systemic anaplastic large cell lymphoma, angioimmunoblastic T-cell lymphoma, and peripheral T-cell lymphoma, not otherwise specified, as long as they express the CD30 protein. The drug was previously approved for people with Hodgkin lymphoma who did not benefit from or were unable to have a bone marrow/stem cell transplant and for preventive treatment following a bone marrow transplant for higher-risk Hodgkin lymphoma. Research on the benefits of other newer monoclonal antibodies for lymphoma is ongoing.
Polatuzumab vedotin-piiq (Polivy) is a monoclonal antibody that targets CD79b. Like brentuximab vedotin, it is also an antibody-drug conjugate. Polatuzumab is used in combination with bendamustine and rituximab to treat DLBCL that has come back after at least 2 other treatments.
Radiolabeled antibodies are monoclonal antibodies with radioactive particles attached. The particles are designed to focus the radiation directly to the lymphoma cells. In general, the radioactive antibodies are thought to be stronger than regular monoclonal antibodies but more damaging to the bone marrow. This type of therapy is also called radioimmunotherapy (RIT).
Talk with your doctor about possible side effects for a specific medication and how they can be managed.
Kinase inhibitors (updated 12/2019)
Kinase inhibitors are another type of targeted therapy used to treat NHL.
Acalabrutinib (Calquence) targets the Bruton’s tyrosine kinase pathway. It is approved to treat adults with mantle cell lymphoma who have received at least 1 other treatment. It is also approved to treat adults with small lymphocytic lymphoma, which is the same disease as chronic lymphocytic leukemia. The most common side effects of acalabrutinib are headache, diarrhea, muscle and join pain, upper respiratory tract infection, and bruising.
Copanlisib (Aliquopa) targets the phosphoinositide 3-kinase (PI3K) pathway. It is used to treat adults with follicular lymphoma that has come back after treatment with at least 2 previous therapies. The common side effects of copanlisib include high blood sugar, diarrhea, fatigue, high blood pressure, low white blood cell count, nausea, lung infections, and low blood platelet count.
Duvelisib (Copiktra) also targets the PI3K pathway. It is used to treat adults with small lymphocytic lymphoma that has not been stopped by at least 2 previous therapies. This targeted therapy is also used to treat chronic lymphocytic leukemia. The common side effects of duvelisib include diarrhea, intestinal problems, low white blood cell count, rash, fatigue, pain, cough, nausea, respiratory infection, pneumonia, pain, and anemia.
Ibrutinib (Imbruvica) targets the Bruton’s tyrosine kinase pathway. This drug is approved to treat several B-cell lymphomas, including mantle cell lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma, as well as chronic lymphocytic leukemia and Waldenström’s macroglobulinemia. Common side effects of ibrutinib include diarrhea, muscle and bone pain, rash, nausea, bruising, tiredness, and, less commonly, bleeding, irregular heartbeat (atrial fibrillation), or fever.
Zanubrutinib (Brukinsa) is another Bruton’s tyrosine kinase inhibitor. It is approved to treat mantle cell lymphoma in people who have received at least 1 previous therapy. The common side effects of zanubrutinib are lowered white blood cell counts, lowered platelet count, upper respiratory tract infection, lowered hemoglobin levels, rash, bruising, diarrhea and cough.
Immunomodulatory drugs modulate, or influence, how the body’s immune system responds or works. Lenalidomide (Revlimid) is a thalidomide analog used to treat follicular lymphoma and mantle cell lymphoma that have not been stopped by other treatments. Lenalidomide is also used to treat multiple myeloma and myelodysplastic syndromes.
Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.
In chimeric antigen receptor (CAR) T-cell therapy, some T cells are removed from a patient’s blood. Then, the cells are changed in a laboratory so they have specific proteins called receptors. The receptors allow those T cells to recognize the cancer cells. The changed T cells are grown in large numbers in the laboratory and returned to the patient’s body. Once there, they seek out and destroy cancer cells.
Axicabtagene ciloleucel (Yescarta) is a CAR T-cell therapy that is approved to treat patients with DLBCL who have received at least 2 previous types of treatment. Tisagenlecleucel (Kymriah) is another CAR T-cell therapy that is approved for the treatment of refractory B-cell lymphoma, including DLBCL, after 2 previous systemic treatments or more. Further CAR T-cell therapies are in development and being studied in clinical trials.
Checkpoint inhibitors block specific pathways to stop or slow the growth of cancer. The PD-1 pathway is a target for several checkpoint inhibitors. One of these, pembrolizumab (Keytruda), can be used to treat primary mediastinal large B-cell lymphoma that has not been stopped by at least 2 other treatments.
Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.
Radiation therapy is the use of high-energy x-rays, electrons, or protons to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. Radiation treatment for NHL is usually external-beam radiation therapy, which is radiation given from a machine outside the body.
A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time.
Radiation therapy is usually given after or in addition to chemotherapy, depending on the NHL subtype. It is most often given to people who have localized lymphoma, which means that it involves only 1 or 2 adjacent areas, or to people who have a lymph node that is particularly large, usually more than 7 to 10 centimeters across. It may also be given for the treatment of pain or in very low doses (just 2 treatments) to people with advanced disease who have localized symptoms that can be relieved using radiation therapy.
General side effects from radiation therapy may include fatigue and nausea. Most side effects are related to the region of the body receiving radiation. These side effects may include mild skin reactions, dry mouth, temporary hair loss, or loose bowel movements. People who have had radiation therapy directed at the chest may experience lung inflammation called pneumonitis. People who had radiation therapy directed at the bones may experience low blood counts. Talk with your doctor about what you can expect regarding side effects and how they can be managed.
Most side effects go away soon after treatment is finished, but radiation therapy may also cause late effects, such as second cancers or damage to the heart and blood vessels if they were within the field of radiation. Sexual problems and infertility may occur after radiation therapy to the pelvis. Before treatment begins, talk with your doctor about possible sexual and fertility-related side effects of your treatment and the available options for preserving fertility for both men and women.
Learn more about the basics of radiation therapy.
Bone marrow transplantation/stem cell transplantation
A bone marrow transplant is a medical procedure in which bone marrow or peripheral blood cells containing highly specialized cells, called hematopoietic stem cells, are used as part of a treatment plan. Hematopoietic stem cells are blood-forming cells found in the bloodstream and the bone marrow. This procedure is also called a stem cell transplant. This is because stem cells collected from the blood are typically being transplanted, not cells from the actual bone marrow tissue.
Transplantation is considered an aggressive treatment. It is generally used only for people with NHL whose disease is progressive or recurrent (see Stages). For some NHL subtypes, such as mantle cell lymphoma and some T-cell lymphomas, doctors may recommend transplantation as part of the initial treatment plan to prevent recurrence.
Before recommending transplantation, the doctor will talk with you about the risks of this treatment. Doctors also consider several other factors, such as the type of NHL, results of any previous treatment, and your age and general health. It is important to talk with an experienced doctor at a specialized transplant center about the risks and benefits of this treatment.
There are 2 types of bone marrow transplantation, depending on the source of the replacement blood stem cell:
Allogeneic (ALLO). ALLO transplantation uses donated stem cells from a healthy individual, ideally a sibling or matched unrelated donor. Treatment includes immunochemotherapy, radiation therapy, or immunotherapy plus “graft versus lymphoma” activity, which is where the donor cells recognize and destroy the patient’s lymphoma cells. ALLO transplantation presents higher risks than AUTO transplantation, including graft-versus-host disease, which is when donor cells damage the patient’s tissues or organs.
Autologous (AUTO). AUTO transplantation uses the patient’s own stem cells after high-dose chemotherapy. In AUTO transplantation, the goal is to destroy all of the cancer cells in the marrow, blood, and other parts of the body using high doses of chemotherapy, immunotherapy, and/or radiation therapy. The AUTO stem cells are returned to the patient’s body after the high-dose therapy is completed. The AUTO stem cells then work to create healthy bone marrow.
Side effects of a bone marrow transplant depend on the type of transplant, your general health, and other factors. Learn more about the basics of stem cell and bone marrow transplantation.
Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.
Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.
Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.
Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.
During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.
Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.
Remission and the chance of recurrence
A complete remission is when lymphoma cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED. Partial remission is when the lymphoma has regressed by more than 50% from its pretreatment state but can still be detected.
A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the disease returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the lymphoma does return. Learn more about coping with the fear of recurrence.
As explained in the Stages section, if the cancer returns after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. In most cases, another tissue biopsy is needed to prove that the lymphoma has not changed or transformed into a more aggressive subtype. After this testing is done, you and your doctor will talk about the treatment options.
Treatment for recurrent NHL depends on 3 factors:
Where the cancer is and whether it has transformed into a more aggressive subtype
Type(s) of treatment given before
The patient’s overall health
Often the treatment plan will include the treatments described above, such as chemotherapy, radiation therapy, targeted therapy, immunotherapy, or bone marrow/stem cell transplantation. However, they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat recurrent NHL. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.
People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.
Some people with NHL may not experience a complete remission and will have small amounts of residual disease that is stable. Or, they will have residual disease that is actively growing despite treatment. If there is a small amount of residual disease that is stable, some people with indolent NHL may be observed with watchful waiting for a period of time or be treated with targeted therapy or other drugs. Radiation therapy to the local area may also be a possibility. These patients may have breaks in treatment, sometimes lasting many years. If the lymphoma begins to grow or spread, this is called progression of disease, and active treatment will begin again.
It is important to understand that remission is not always possible in some indolent lymphomas. However, some people can be safely monitored even if there is leftover disease. This is possible as long as there are no symptoms and the lymphoma has not affected blood counts or other organs.
If there is residual disease that is growing despite active treatment, it is called “refractory NHL,” see below.
If standard treatments stop working well for NHL or the lymphoma comes back within 6 months after treatment, this is called refractory NHL. Patients with this diagnosis are encouraged to talk with doctors who are lymphoma experts to discuss options for the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the chosen treatment plan. This discussion may include clinical trials.
Treatment options for refractory NHL depend on 4 factors:
Where the cancer is
The lymphoma subtype
The type of treatment given before
The patient’s overall health
The doctor may suggest chemotherapy, immunotherapy, bone marrow/stem cell transplantation, or a clinical trial. Palliative care will also be important to help relieve symptoms and side effects.
For most people, a diagnosis of refractory NHL is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you fell with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.
If treatment does not work
Recovery from NHL is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, people with advanced NHL, especially those with indolent lymphoma, may continue to live for a long time after a diagnosis of advanced cancer. It is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.