What is the initial treatment for non-Hodgkin lymphoma (NHL)?

From the Guidelines

The initial treatment for non-Hodgkin lymphoma (NHL) is R-CHOP chemotherapy, which combines rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisone, administered in cycles every 21 days for 6-8 cycles, as this regimen has been shown to be effective in improving morbidity, mortality, and quality of life in patients with NHL, particularly those with diffuse large B-cell lymphoma (DLBCL) 1.

Key Considerations

• The treatment approach may vary depending on the specific subtype, stage, and individual patient factors, such as age, overall health status, and presence of comorbidities.
• For indolent (slow-growing) NHL like follicular lymphoma, treatment may range from watchful waiting for asymptomatic patients to rituximab alone or rituximab combined with chemotherapy for those with symptoms or advanced disease.
• Some patients with early-stage disease may receive radiation therapy alone, although this is not always the case, and the decision to use radiation therapy should be made on a case-by-case basis, considering the potential benefits and risks, as well as the patient's individual circumstances 1.

Treatment Decisions

• Treatment decisions should be coordinated by a hematologist-oncologist and may require supportive care to manage side effects like neutropenia, nausea, and fatigue.
• The effectiveness of R-CHOP stems from its multi-targeted approach: rituximab targets CD20 on B-cell surfaces, while the chemotherapy drugs attack rapidly dividing cells through different mechanisms.
• The choice of treatment should prioritize the patient's quality of life, morbidity, and mortality, and should be based on the most recent and highest-quality evidence available, such as the study published in 2010, which provides guidance on the diagnosis, treatment, and follow-up of diffuse large B-cell non-Hodgkin's lymphoma 1.

Additional Considerations

• The International Prognostic Index (IPI) score can help identify patients with different prognoses, and those with very limited disease (IPI score = 0) may have a good prognosis with a 10-year overall survival rate of 87-95%, whether treated with an abbreviated course of doxorubicin-based chemotherapy followed by radiation therapy or with chemotherapy alone 1.
• Dose-dense chemotherapy may be effective in some patients, but the risk of toxicity needs to be accurately balanced against the potential benefits, and it is not recommended for very limited stages of aggressive NHL 1.

From the Research

Initial Treatment for Non-Hodgkin Lymphoma (NHL)

The initial treatment for non-Hodgkin lymphoma (NHL) depends on the subtype and stage of the disease.

• For diffuse large B-cell lymphoma, a subtype of NHL, the standard first-line therapy is rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) 2.
• The R-CHOP regimen has been shown to be effective in treating NHL, with a complete response rate of 94% in patients with CD20-positive B-cell NHL 2.
• Other treatment options for NHL include chemotherapy with or without rituximab, bendamustine, and lenalidomide 3.
• The choice of treatment depends on the specific subtype of NHL, as well as the patient's overall health and medical history.

Targeted Therapies and New Agents

• Targeted therapies, such as ibrutinib, have shown promise in treating NHL, particularly in patients with relapsed or refractory disease 2, 4.
• New agents, such as lenalidomide, SGN-40, and bevacizumab, are being evaluated in clinical trials for the treatment of NHL 4.
• These agents offer new hope for patients with NHL, but more research is needed to determine their safety and efficacy.

Chemotherapy and Radiotherapy

• Chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) is a common treatment for NHL 5, 3.
• Radiotherapy may be used in combination with chemotherapy to treat NHL, particularly in patients with stage I intermediate or high-grade disease 5.
• The optimal radiotherapy dose and schedule are still being studied, but adapting the radiotherapy dose to the response after chemotherapy may be a effective approach 5.