Chemotherapy for Hodgkin lymphoma

Chemotherapy uses drugs to destroy cancer cells. These drugs target rapidly dividing cells throughout the whole body. This means that chemotherapy kills cancer cells but it can also damage healthy cells.

With most types of chemotherapy, the drugs travel through the blood to reach and destroy cancer cells all over the body, including cells that may have broken away from the primary tumour. This is described as systemic therapy.

Chemotherapy, usually followed by radiation therapy, is the standard treatment for Hodgkin lymphoma (HL). You may also be offered other treatments.

Your healthcare team will use what they know about the cancer (including the stage and prognostic factors) and about your health to plan the drugs, doses and schedules. You may have chemotherapy to:

• destroy cancer cells in the body
• treat HL that comes back (relapses or recurs) after treatment or that doesn’t respond (is resistant) to treatment
• prepare for a stem cell transplant
• relieve pain or control the symptoms of advanced HL even if it can't be cured (called palliative chemotherapy)

Before you have chemotherapy, your healthcare team may do tests to check your overall health. They will do blood chemistry tests to detemine how well your liver and kidneys are working. They may also do an echocardiogram to see how well your heart is working and lung function tests to check your lungs. These organs need to be healthy if certain drugs are in your treatment plan. The test results can also be used as a baseline to monitor any effects of chemotherapy.

There is a very small chance that treatment for HL will affect your fertility (your ability to get or stay pregnant or to get someone pregnant). If you want to have children in the future, talk to your healthcare team before you start cancer treatment. They can refer you to a fertility clinic and plan your treatment in ways that support your chances of being able to have children after treatment.

Both early-stage and advanced HL are treated with combination chemotherapy, which means different drugs are given at the same time. Most of the chemotherapy drugs used are given into the vein (intravenously). Procarbazine and prednisone are given as pills taken by mouth.

The combinations of chemotherapy drugs offered and the number of treatments given will depend on:

• the stage of HL
• if HL has favourable or unfavourable prognostic factors
• how well HL responds to the first 2 cycles of chemotherapy
• if you’ve already been treated for HL and it has come back or the treatments didn’t work
• your age
• any other medical conditions you may have, such as lung problems
• your preferences, including if you want to have children in the future

ABVD is a chemotherapy combination is the one most commonly used to treat HL. It includes the following drugs:

• doxorubicin
• bleomycin
• vinblastine
• dacarbazine

AVD is doxorubicin, vinblastine and dacarbazine. You may be switched to this combination if the cancer responds well to 2 cycles of ABVD. It may be used if you have lung problems because bleomycin can damage the lungs. Sometimes an immunotherapy drug is added to AVD to treat advanced or relapsed HL.

escBEACOPP, escBEACOPDac and BrECADD are given as escalated doses (esc). This means that the drugs are given in higher doses over a shorter period of time than with a regular chemotherapy cycle:

• escBEACOPP – bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisone
• escBEACOPDac – bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, prednisone and dacarbazine
• BrECADD – brentuximab vedotin (Adcetris), etoposide, cyclophosphamide, doxorubicin, dacarbazine and dexamethasone

These are strong drug combinations. They are not offered to treat people over the age of 60 or to those who have other health problems, especially lung or heart problems, because there is a higher risk of complications.

You may be given different chemotherapy combinations if HL comes back (relapses or recurs) after treatment or doesn’t respond (is refractory) to treatment. Different chemotherapy combinations may also be used if you are going to have a stem cell transplant. These combinations include:

• GDP – gemcitabine, dexamethasone and cisplatin
• DICEP – dexamethasone, cyclophosphamide, etoposide, cisplatin and mesna
• DHAP – dexamethasone, cytarabine and cisplatin
• ICE – ifosfamide, carboplatin and etoposide
• DICE – dexamethasone, ifosfamide, cisplatin and etoposide
• CEPP – cyclophosphamide, etoposide, procarbazine and prednisone
• ESHAP – etoposide, methylprednisolone, cytarabine and cisplatin
• BeGEV – bendamustine, gemcitabine and vinorelbine

During chemotherapy, the healthcare team will check if HL is responding to the drugs. Knowing how well chemotherapy has worked helps them determine a prognosis (the expected outcome of the disease) and plan other treatments.

An imaging test – either a PET scan or a CT scan – is usually done during diagnosis and staging. These tests tell the healthcare team where HL is found in the body. These imaging tests give your healthcare team a baseline to compare to during treatment.

You will have another imaging test after the first few cycles of chemotherapy (called an interim scan). The results of this scan will help your healthcare team adjust your chemotherapy to continue treating the HL but lessen any side effects you may have.

PET-guided therapy means that the healthcare team is using PET scans to check how HL responds to treatment. To do the PET scan, a radioactive sugar is injected into the body. Cancer cells take up this sugar, which makes them visible on the scan. The results are reported in the Deauville Scale, which describes how much cancer is seen on the scan. This scale assigns HL a score from 1 to 5, where 1 means no cancer is seen on the scan and 5 means several areas of cancer are seen on the scan:

• A Deauville score of 1, 2 or 3 is a negative score. This means that chemotherapy has worked and there is little or no cancer left in the body. Your healthcare team may lower the number of drugs used or the number of chemotherapy cycles you will be given.
• A Deauville score of 4 or 5 is a positive score. This means that there are areas of cancer in the body that have not responded well to chemotherapy. Your healthcare team may change the type of chemotherapy drugs used or increase the number of cycles.

If PET scans aren’t available for diagnosis or the interim scan, you will have CT scans. Based on the interim CT scan, your healthcare team may offer more cycles of chemotherapy or fewer chemotherapy treatments followed by radiation therapy to reduce the risk that HL will come back. Another imaging test is usually done at least 3 weeks after chemotherapy is finished. The healthcare team will use the results of this test to decide if you should have more treatment such as radiation therapy.

Supportive drugs are sometimes used to lessen the harmful side effects of cancer treatment by protecting cetain cells or organs. Supportive drugs are not used to treat cancer.

Chemotherapy for HL can cause a low white blood cell count, which increases the risk for infection. If white blood cell counts are very low, chemotherapy may be stopped or the dose has to be lowered. Your healthcare team may give you a granulocyte colony-stimulating factor (G-CSF) while you are taking chemotherapy. G-CSFs can reduce your risk of infection and allow you to receive the full dose of chemotherapy.

Filgrastim (Neupogen and biosimilar drugs) and pegfilgrastim (Neulasta and biosimilar drugs) are G-CSFs that tell the body to make neutrophils, which are a type of white blood cell.

Find out more about supportive drugs.

Side effects of chemotherapy will depend mainly on the drug, the dose, how it's given and your overall health. Tell your healthcare team if you have side effects that you think are from chemotherapy. The sooner you tell them of any problems, the sooner they can suggest ways to help you deal with them.

Possible side effects of chemotherapy drugs for HL include:

• fatigue
• low blood cell counts
• loss of appetite
• nausea and vomiting
• sore mouth and throat
• diarrhea
• constipation
• hair loss
• skin problems
• fertility problems
• lung problems
• heart problems

Find out more about chemotherapy and side effects of chemotherapy. To make the decisions that are right for you, ask your healthcare team questions about chemotherapy.

Details on specific drugs change regularly. Find out more about sources of drug information and where to get details on specific drugs.