Treatment

The treatment of Hodgkin lymphoma depends on the size and location of enlarged lymph nodes, the results of blood tests, the type of Hodgkin lymphoma, and the patient’s age, symptoms, and overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. The most common treatment methods for Hodgkin lymphoma are radiation therapy, chemotherapy, or a combination of both methods.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section.

The original treatments for Hodgkin lymphoma, developed in the 1960s and 1970s, were very effective. However, long-term follow-up care of people who received these treatments has shown that they are at risk for side effects later in life, including infertility (the inability to have children) and secondary cancers, such as lung cancer and breast cancer in women. These long-term problems were partly the result of the types of chemotherapy used at that time and partly the result of extensive radiation therapy.

To avoid or reduce the risk of these problems, modern treatment of Hodgkin lymphoma involves newer chemotherapy treatments and the use of much smaller fields of radiation therapy. Most patients with Hodgkin lymphoma, even stage I or stage II, will now be recommended to receive some chemotherapy, followed by radiation therapy to the affected lymph node areas. (For some patients with early stage disease, it may be possible to have treatment with a relatively short course of chemotherapy only, without the need for radiation therapy. This applies to a few, carefully chosen patients and should be discussed with their doctor.) For stage III or stage IV disease, chemotherapy is still the primary treatment although additional radiation therapy may be recommended, especially to areas of large lymph nodes.

Radiation therapy

Radiation therapy is the use of high energy x-rays or other particles to kill cancer cells. Radiation therapy for Hodgkin lymphoma is always external-beam radiation therapy, which is radiation given from a machine outside the body. Whenever possible, radiation therapy is now typically targeted to the affected lymph node areas to reduce the risk of side effects.

Immediate side effects from radiation therapy depend on the area of the body that is being treated. These may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Patients who received radiation to the neck may have a sore mouth and/or throat. Most side effects go away soon after treatment is finished.

Although the risk for long-term damage gets lower as treatments improve, radiation therapy may still sometimes cause long-term side effects, also called late effects. To minimize the risk of long-term side effects, clinical trials are being done to determine the best doses and smallest possible field for radiation therapy.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Many different types of chemotherapy may be used for Hodgkin lymphoma. The most commonly used combinations of drugs in the United States are called "ABVD" and "Stanford V." Another combination of drugs known as “BEACOPP” is now widely used in Europe and is being used more commonly in the United States.

ABVD: doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban), and dacarbazine (DTIC). ABVD chemotherapy is usually given every two weeks for four to eight months.

Stanford V: mechlorethamine (Mustargen, Nitrogen Mustard), doxorubicin, vinblastine, vincristine (Oncovin), bleomycin, etoposide (VePesid, Etopophos, Lastet), prednisone, and G-CSF (granulocyte colony stimulating factor). Chemotherapy is given weekly for two to three months, and usually two to three of these drugs are given each week.

BEACOPP: bleomycin, etoposide, doxorubicin, cyclophosphamide (Cytoxan, Neosar), vincristine, procarbazine (Matulane), and prednisone. The treatment schedule and number of cycles varies according to each patient’s needs.

At the moment, it is unclear which of these chemotherapy treatments is best for patients with Hodgkin lymphoma, and the best treatment may differ according to the type and stage of the disease. For this reason, many clinical trials are underway comparing these different chemotherapy treatments. These clinical trials are designed to determine which combination is the most effective for the treatment of Hodgkin lymphoma and which has the fewest short-term and late side effects.

At various times during the course of chemotherapy, it is usual to have some of the original tests, especially CT scans and PET scans, repeated. These tests are used as a way to monitor the disease and to see how well it is responding to treatment.

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Although the risk of long-term side effects decreases as treatments improve, chemotherapy sometimes causes late and permanent side effects.

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. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to searchable drug databases.

Stem cell transplantation/bone marrow transplantation

A stem cell transplant is a medical procedure in which diseased bone marrow is replaced by highly specialized cells, called hematopoietic stem cells. Hematopoietic stem cells are found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because blood stem cells are typically what is being transplanted (injected into a vein), not the actual bone marrow tissue.

There are two types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). ALLO transplantation may be recommended for patients who have lymphoma remaining in the bone marrow after treatment.

In an ALLO transplant, stem cells are obtained from a donor whose tissue matches the patient’s on a genetic level; this testing is called HLA-typing. Most often, a patient’s brother or sister serves as the donor, although unrelated donors can serve as the donor too. Millions of people worldwide have volunteered to donate stem cells for patients who do not have matched family members; matches can be made by searching a computer registry. In addition, a donation of stem cells derived from umbilical cord blood is sometimes considered if family donors are not available.

In an AUTO transplant, the patient’s own stem cells are used. The stem cells are obtained from the patient when he or she is in remission from previous treatment. The stem cells are then frozen until they are needed, usually after the high-dose treatment (explained below) is completed.

In both types, the goal of transplantation is to destroy cancer cells in the marrow, blood, and other parts of the body and have replacement blood stem cells create healthy bone marrow. In most stem cell transplants, the patient is treated with high doses of chemotherapy and/or radiation therapy to destroy as many cancer cells as possible. This also destroys the patient’s bone marrow tissue and suppresses the patient’s immune system so that, in an ALLO transplant, the donor cells are not rejected by the body. After the high-dose treatment is given, blood stem cells are infused into the patient’s vein to replace the bone marrow and restore normal blood counts from donor cells. Sometimes, ALLO transplants can also be performed after giving lower doses of chemotherapy and/or radiation therapy that are still sufficient to suppress the immune system and allow growth of the donor cells. (These transplants, sometimes termed “mini-transplants” or “reduced intensity transplants” have less immediate side effects, allowing the procedure to be used for older patients.)

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the type of cancer, results of any previous treatment, and patient’s age and general health.

For both ALLO and AUTO transplant types, the replacement cells engraft (begin to make new blood cells) and turn into healthy, blood-producing tissue in two to three weeks. Destroying the patient’s own marrow reduces the body’s natural defenses, temporarily leaving the patient at an increased risk of infection. Until the patient’s immune system is back to normal, patients may need antibiotics and blood transfusions.

In an ALLO transplant, another major risk is that the donor’s cells will recognize the patient’s body as foreign, causing graft-versus-host disease (GVHD). GVHD may be a serious complication of allogeneic transplants and can be fatal. Other side effects may include liver problems, diarrhea, infections, and rashes. However, GVHD can also be a benefit, in that the donor cells can recognize the cancer cells as foreign and destroy these cells, a mechanism that is one of the major reasons why ALLO transplantation generally works so well over the long term. The risk of GVHD can be reduced with exact HLA-type matching and the use of preventative drugs.

In an AUTO transplant, there is little risk of GVHD because the replacement stem cells are the patient’s own cells. However, there is a risk in an autologous transplant that some of the cells that are put back into the patient could still be cancerous.

Learn more by reading the Cancer.Net Feature series, Understanding Bone Marrow and Stem Cell Transplantation.

Progressive and recurrent Hodgkin lymphoma

Progressive disease is present if the cancer becomes larger or spreads while the patient is being treated for the original lymphoma. Progressive disease and recurrence are uncommon in Hodgkin lymphoma. If either occurs, most patients will be advised to receive high-dose therapy with a stem cell transplantation (see above), which appears to be more effective in treating progressive or recurrent Hodgkin lymphoma than another standard chemotherapy treatment.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.