Watchful Waiting
Chemotherapy
Biological Therapy
Radiation Therapy
Stem Cell Transplantation

Your doctor can describe your treatment choices and the expected results. You and your doctor can work together to develop a treatment plan that meets your needs.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat non-Hodgkin lymphoma include hematologists, medical oncologists, and radiation oncologists. Your doctor may suggest that you choose an oncologist who specializes in the treatment of lymphoma. Often, such doctors are associated with major academic centers. Your health care team may also include an oncology nurse and a registered dietitian.

The choice of treatment depends mainly on the following:

• The type of non-Hodgkin lymphoma (for example, follicular 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 doctor 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.

If you have indolent lymphoma with symptoms, you will probably receive chemotherapy and biological therapy. Radiation therapy may be used for people with Stage I or Stage II lymphoma.

If you have aggressive lymphoma, the treatment is usually chemotherapy and biological therapy. Radiation therapy also may be used.

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 stem cell transplantation.

You may want to know about side effects and how treatment may change your normal activities. Because chemotherapy and radiation therapy often damage healthy cells and tissues, side effects are common. Side effects may not be the same for each person, and they may change from one treatment session to the next. Before treatment starts, your health care team will explain possible side effects and suggest ways to help you manage them.

At any stage of the disease, you can have supportive care. Supportive care is treatment to control pain and other symptoms, to relieve the side effects of therapy, and to help you cope with the feelings that a diagnosis of cancer can bring. See the Supportive Care section.

You may want to talk to your doctor about taking part in a clinical trial, a research study of new treatment methods. See the Taking Part in Cancer Research section.

Watchful Waiting

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 doctor agree that watchful waiting is a good idea, the doctor will check you regularly (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.

The side effects depend mainly on which drugs are given and how much. The drugs can harm normal cells that divide rapidly:

• Blood cells: When chemotherapy lowers your levels of healthy blood cells, you are more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team gives you blood tests to check for low levels of blood cells. If levels are low, there are medicines that can help your body make new blood cells.
  
  
• Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may be somewhat different in color and texture.
  
  
• Cells that line the digestive tract: Chemotherapy can cause poor appetite, nausea and vomiting, diarrhea, trouble swallowing, or mouth and lip sores. Ask your health care team about medicines or other treatments that help with these problems.

The drugs used for non-Hodgkin lymphoma also may cause skin rashes or blisters, and headaches or other aches. Your skin may become darker. Your nails may develop ridges or dark bands.

Your doctor can suggest ways to control many of these side effects. You may find it helpful to read NCI's booklet Chemotherapy and You.

Biological Therapy

People with certain types of non-Hodgkin lymphoma may have biological therapy. This type of treatment helps the immune system fight cancer.

Monoclonal antibodies are the type of biological therapy used for lymphoma. They are proteins made in the lab that can bind to cancer cells. They help the immune system kill lymphoma cells. People receive this treatment through a vein at the doctor's office, clinic, or hospital.

Flu-like symptoms such as fever, chills, headache, weakness, and nausea may occur. Most side effects are easy to treat. Rarely, a person may have more serious side effects, such as breathing problems, low blood pressure, or severe skin rashes. Your doctor or nurse can tell you about the side effects that you can expect and how to manage them.

You may find it helpful to read NCI's booklet Biological Therapy.

Radiation Therapy

Radiation therapy (also called radiotherapy) uses high-energy rays to kill lymphoma cells. It can shrink tumors and help control pain.

• External radiation: A large machine aims the rays at the part of the body where lymphoma cells have collected. This is local therapy because it affects cells in the treated area only. Most people go to a hospital or clinic for treatment 5 days a week for several weeks.
  
  
• Systemic radiation: Some people with lymphoma receive an injection of radioactive material that travels throughout the body. The radioactive material is bound to monoclonal antibodies that seek out lymphoma cells. The radiation destroys the lymphoma cells.

The side effects of radiation therapy depend mainly on the type of radiation therapy, the dose of radiation, and the part of the body that is treated. For example, external radiation to your abdomen can cause nausea, vomiting, and diarrhea. When your chest and neck are treated, you may have a dry, sore throat and some trouble swallowing. In addition, your skin in the treated area may become red, dry, and tender. You also may lose your hair in the treated area.

You are likely to become very tired during external radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise people to try to stay as active as they can.

People who get systemic radiation also may feel very tired. They may be more likely to get infections.

If you have radiation therapy and chemotherapy at the same time, your side effects may be worse. The side effects can be distressing. You can talk with your doctor about ways to relieve them.

You may find it helpful to read NCI's booklet Radiation Therapy and You.

Stem Cell Transplantation

If lymphoma returns after treatment, you may receive stem cell transplantation. A transplant of your own blood-forming stem cells allows you to receive high doses of chemotherapy, radiation therapy, or both. The high doses destroy both lymphoma cells and healthy blood cells in the bone marrow.

Stem cell transplants take place in the hospital. After you receive high-dose treatment, healthy blood-forming stem cells are given to you through a flexible tube placed in a large vein in your neck or chest area. New blood cells develop from the transplanted stem cells.

• Autologous stem cell transplantation: This type of transplant uses your own stem cells. Your stem cells are removed before high-dose treatment. The cells may be treated to kill lymphoma cells that may be present. The stem cells are frozen and stored. After you receive high-dose treatment, the stored stem cells are thawed and returned to you.
  
  
• Allogeneic stem cell transplantation: Sometimes healthy stem cells from a donor are available. Your brother, sister, or parent may be the donor. Or the stem cells may come from an unrelated donor. Doctors use blood tests to be sure the donor's cells match your cells.
  
  
• Syngeneic stem cell transplantation: This type of transplant uses stem cells from a patient's healthy identical twin.

You may find it helpful to read NCI's fact sheet Bone Marrow Transplantation and Peripheral Blood Stem Cell Transplantation: Questions and Answers.

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