Lymphoma - Hodgkin: Treatment Options

Approved by the Cancer.Net Editorial Board, 09/2017

ON THIS PAGE: You will learn about the different treatments doctors use for people with this type of lymphoma. Use the menu to see other pages.

This section tells you the treatments that are the standard of care for this type of lymphoma. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. To learn more about clinical trials, see the About Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors and other health care professionals often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, nurse practitioners, social workers, pharmacists, counselors, dietitians, and others.

The original treatments for Hodgkin lymphoma, developed in the 1960s and 1970s, were very effective at treating the disease. However, some people who received these treatments developed serious side effects later in life, including infertility (the inability to have children), heart problems (such as heart failure, leaky heart valves, and heart attacks), and secondary cancers, such as lung cancer and breast cancer. These long-term problems were partly caused by the types of chemotherapy and high doses of radiation therapy delivered to large areas of the body used at that time. Learn more about the late effects of treatment for Hodgkin lymphoma.

To avoid or reduce the risk of these problems, current treatment plans for Hodgkin lymphoma are aimed at achieving the best chance of curing the Hodgkin lymphoma while avoiding causing long-term side effects as much as possible. Newer types and doses of chemotherapy and new technologies that allow directing radiation therapy to smaller areas of the body have reduced these risks.

Most people with cHL, even stage I or stage II, often receive chemotherapy. In some patients, this is followed by radiation therapy to the affected lymph node areas. It may be possible to treat some people with early-stage disease (stage I or II) with a relatively short course of chemotherapy with or without radiation therapy. Patients should discuss with their doctor whether chemotherapy can be limited and/or whether radiation therapy is necessary in the treatment plan. For stage III or stage IV disease, chemotherapy is the primary treatment, although additional radiation therapy may be recommended, especially to areas of large lymph nodes.

Descriptions of the most common treatment options for Hodgkin lymphoma are listed below. Treatment options and recommendations depend on several factors, including:

  • The type and stage of lymphoma

  • Possible side effects

  • Results of regular PET-CT scans during treatment

  • The patient’s preferences and overall health

Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options and ask about anything that is unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment, including any potential side effects. Learn more about making treatment decisions.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by ending the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication, or a hematologist, a doctor who specializes in treating blood disorders.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or by taking a pill or capsule by mouth. Many people with Hodgkin lymphoma receive chemotherapy through a port-a-cath placed under the skin. Learn more about catheters and ports in cancer treatment.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles of treatment given over a set number of weeks or months. There are many different types of chemotherapy that may be used to treat Hodgkin lymphoma. A patient may receive 1 drug at a time or combinations of different drugs given at the same time.

First-line chemotherapy

Newly diagnosed Hodgkin lymphoma is often treated with regimens that use a combination of chemotherapy drugs given at 1 time. The most commonly used combination of drugs in the United States is referred to as ABVD. Another combination of drugs, known as BEACOPP, is commonly used in Europe in patients with advanced Hodgkin lymphoma and is sometimes used in the United States. The drugs that make up these 2 common combinations of chemotherapy are listed below. There are other combinations that are less commonly used, which are not listed here.

  • ABVD: Doxorubicin (Adriamycin), bleomycin (Blenoxane), vinblastine (Velban, Velsar), and dacarbazine (DTIC-Dome). ABVD chemotherapy is usually given every 2 weeks for 2 to 8 months.

  • BEACOPP: Bleomycin, etoposide (Toposar, VePesid), doxorubicin, cyclophosphamide (Cytoxan, Neosar), vincristine (Vincasar PFS, Oncovin), procarbazine (Matulane), and prednisone (multiple brand names). There are several different treatment schedules, but different drugs are usually given every 2 to 3 weeks.

  • Brentuximab vedotin (Adcetris): Brentuximab vedotin is an antibody drug conjugate. This means it delivers chemotherapy only to cells that have a special protein on the surface called CD30. The U.S. Food and Drug Administration (FDA) approved brentuximab vedotin combined with doxorubicin, vinblastine, and dacarbazine as a first-line treatment for stage III or IV cHL.

  • Gemcitabine combined with other drugs: Patients older than 65 to 70 years can have trouble taking a regimen of ABVD and especially BEACOPP because of the side effects. If this happens, recent research suggests that gemcitabine combined with other drugs may be a good alternative.

The type of chemotherapy, number of cycles of chemotherapy, and the additional use of radiation therapy are based on the stage of the Hodgkin lymphoma and the type and number of prognostic factors. Talk with your doctor about the specifics of your treatment plan. Usually, doctors choose to monitor how well these treatments are working with repeat PET-CT scans after 2 to 3 months of treatment. If the PET scans show that the treatment is not working, the chemotherapy may be changed. If the PET scans show that treatment is working, then the doctor may decide to lower the subsequent number of drugs used or the total number of treatment cycles.

Second-line chemotherapy

There are several second-line treatments available for Hodgkin lymphoma. These are used if the lymphoma does not go into complete remission with the first treatment or if it relapses after first-line treatment with ABVD or BEACOPP, also known as a recurrence. The goals of second-line treatment may be to control the disease and its symptoms, but in many cases, they are given in preparation for an autologous stem cell transplant (see below) with the intent to achieve complete remission and cure.

  • ICE: Ifosfamide (Ifex), carboplatin (Paraplatin), and etoposide. ICE is usually given every 2 or 3 weeks for 2 to 3 cycles.

  • ESHAP or DHAP: Etoposide, methylprednisolone (Solu-Medrol), high-dose cytarabine (Cytosar-U), and cisplatin (Platinol). Dexamethasone (multiple brand names), high-dose cytarabine, and cisplatin. ESHAP or DHAP regimens are given every 3 weeks for 2 to 3 cycles.

  • GVD, Gem-Ox, or GDP: Gemcitabine (Gemzar), vinorelbine (Navelbine), and doxorubicin. Gemcitabine and oxaliplatin (Eloxatin). Gemcitabine, dexamethasone, and cisplatin. Gemcitabine-based regimens are either given 2 weeks in a row followed by an off-week or every other week.

  • Brentuximab vedotin: This drug is an important treatment option if previous chemotherapy stops working. Brentuximab vedotin is usually given every 3 weeks for up to 16 cycles, although sometimes it is given every 4 weeks. It is being tested as an adjunct or replacement for chemotherapy before stem cell transplantation in patients with recurrent Hodgkin lymphoma. It was also approved in 2015 by the U.S. Food and Drug Administration (FDA) for use in certain patients after stem cell transplantation who are at a high risk for recurrence.

  • Bendamustine (Treanda): Bendamustine is generally given every 4 weeks. Sometimes it is combined with other drugs listed above to treat Hodgkin lymphoma that has come back after treatment.

It is unclear which of these chemotherapy treatments is best for patients with Hodgkin lymphoma. The best treatment may differ depending on the type and stage of the lymphoma. For this reason, many clinical trials are underway to compare these different treatments. These clinical trials are designed to find out which combination works best with the fewest short-term and long-term side effects.

During chemotherapy, your doctors will usually repeat some of the original tests, especially PET-CT scans. These tests are used to watch the lymphoma and see how well treatment is working.

The side effects of chemotherapy depend on the individual and the doses used, but they can include fatigue, risk of infection, nausea and vomiting, peripheral neuropathy (tingling or pain in the fingers and toes), hair loss, loss of appetite, and constipation. These side effects usually go away after treatment is finished. Although the risk of long-term side effects has decreased as treatments have improved, chemotherapy still can cause long-term side effects. People with lymphoma may also have concerns about if or how their treatment may affect their sexual function and fertility. Talk about these topics with the health care team before treatment begins. Learn more about late effects of treatment.

Learn more about the basics of chemotherapy and preparing for treatment. 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 by using searchable drug databases.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A radiation oncologist is a doctor who specializes in giving radiation therapy to treat cancer. Radiation therapy for Hodgkin lymphoma is always 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 number of days or weeks.

Whenever possible, radiation therapy is directed only at the affected lymph node areas. This helps reduce the risk of damaging healthy tissues. Some patients may be able to receive newer radiation therapy techniques. These include:

  • Involved-site radiotherapy, which focuses the radiation on the lymph nodes that contain cancer.

  • Intensity modulated radiotherapy (IMRT), which varies the strength and direction of the radiation beams so less healthy tissue is affected.

  • Controlling breathing during treatment, such as having the patient hold their breath, may enable smaller areas to be effectively treated.

  • Proton therapy, which uses protons rather than x-rays to treat the cancer, may be used for certain patients.

The immediate side effects from radiation therapy depend on the area of the body that is being treated. All patients may experience fatigue or mild skin reactions. Patients who receive radiation therapy to the neck may have a sore mouth and/or throat. Patients who receive radiation therapy to the mediastinum may experience a cough, nausea, or pain with swallowing. Most side effects go away soon after treatment is finished.

Although the risk for long-term side effects has decreased with improvements in treatment, radiation therapy may still cause long-term side effects, also called late effects. This may include thyroid damage if radiation therapy is given to the neck, secondary cancers, and vascular damage, including damage to blood vessels and valves in the heart if radiation therapy is given to the chest. To reduce the risk of long-term side effects, clinical trials are being done to find out the best doses and smallest possible area to receive the radiation therapy.

Learn more about the basics of radiation therapy.

Stem cell transplantation/bone marrow transplantation

A stem cell transplant is a medical procedure in which a patient’s bone marrow is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are blood-forming cells 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 it is stem cells that are typically collected from the blood that are being transplanted, not stem cells from the actual bone marrow tissue.

Stem cell transplantation is not used as a first treatment for Hodgkin lymphoma, but it may be recommended for patients who have lymphoma remaining after chemotherapy or if the lymphoma returns following treatment.

Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the results of any previous treatment and the patient’s age and general health. It is very important to talk with a doctor at an experienced transplant center about the risks and benefits of stem cell transplantation.

The goal of transplantation is to destroy all of the cancer cells in the marrow, blood, and other parts of the body with high doses of chemotherapy and/or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow.

There are 2 types of stem cell transplantation, depending on the source of the replacement blood stem cells: autologous (AUTO) and allogeneic (ALLO).

In an AUTO transplant, the patient’s own stem cells are used. The stem cells are collected from the patient when he or she is in remission after treatment. The stem cells are then frozen until they are needed. An AUTO transplant allows more intense chemotherapy doses to be given so leftover lymphoma cells are destroyed. Returning the saved stem cells to the body then allows the bone marrow and blood cells to recover from the intensive, high-dose chemotherapy.

In an ALLO transplant, stem cells are obtained from a donor whose tissue matches the patient’s on a genetic level. Testing to see if a donor’s tissue matches that of the patient’s is called HLA typing. Most often, a patient’s brother, sister, or other relative serves as the donor, although an unrelated person can be a donor as well. The patient receives chemotherapy to stop his or her immune system from destroying the donor’s cells. In an ALLO transplant, the donor’s immune system is used to destroy the patient’s cancer cells.

It is important to talk with the doctor about the potential risks and benefits of both types of transplants to determine the best choice for an individual patient. Side effects depend on the type of transplant, your general health, and other factors. Learn more about the basics of stem cell and bone marrow transplantation.

Immunotherapy

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.

Nivolumab (Opdivo) and pembrolizumab (Keytruda) are immunotherapies that recently received FDA approval for the treatment of patients with classical Hodgkin lymphoma that has recurred or progressed after multiple previous treatments, including AUTO transplantation and post-transplant treatment with brentuximab vedotin. These drugs are called immune checkpoint inhibitors or PD-1 inhibitors. When these drugs are used alone in people with Hodgkin lymphoma who have had a recurrence after previous treatments, the scans of about 2 of every 3 patients show improvement for an average of 9 months, although it is unlikely that these patients are cured. There are side effects, but they are generally mild. There is some concern that ALLO transplantation may be more dangerous in people who have received 1 of these drugs. Doctors do not yet know if it is safe to combine PD-1 inhibitors with other treatments for Hodgkin lymphoma or if these drugs would be useful in treating Hodgkin lymphoma that has not recurred.

Different types of immunotherapy can cause different side effects. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

Getting care for symptoms and side effects

Hodgkin lymphoma and its treatment often cause side effects. In addition to treatments intended to slow, stop, or eliminate the disease, an important part of care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the lymphoma at the same time that they receive treatment to ease side effects. In fact, patients who receive both at the same time 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 support, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy or radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. During and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible.

Learn more about palliative care.

Progressive Hodgkin lymphoma

Progressive disease is the term used when the cancer becomes larger or spreads while the original lymphoma is being treated. However, progressive disease is uncommon for people with Hodgkin lymphoma.

If progression happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan. Complete recovery from progressive Hodgkin lymphoma is not always possible. 

Often, a doctor will recommend a stem cell transplant (see above). This treatment appears to be more effective for progressive Hodgkin lymphoma than standard chemotherapy. Palliative care is also important to help relieve symptoms and side effects.

For most patients, a diagnosis of progressive Hodgkin lymphoma is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling 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.

Remission and the chance of recurrence

A 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.

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’s 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.

If the lymphoma does return following remission after the original treatment, it is called recurrent lymphoma. Recurrence is uncommon for people with Hodgkin lymphoma. However, if Hodgkin lymphoma does recur, a new cycle of testing much like that done at the time of diagnosis will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about your treatment options.

Most often, the first step is to give a second-line chemotherapy treatment, such as ICE, ESHAP, DHAP, gemcitabine-based treatments, or brentuximab vedotin (see “Chemotherapy” above) to regain control over the recurrent Hodgkin lymphoma. For most patients, this treatment is used to prepare for a stem cell transplant, which provides the best possible chance of curing the disease.

Radiation therapy may be included in the treatment plan, before or after a stem cell transplant, especially if radiation therapy was not used during the initial treatment period.

Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent lymphoma.

Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent lymphoma often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope.

Learn more about dealing with cancer recurrence.

If treatment doesn’t work

Recovery from lymphoma is not always possible. If the lymphoma 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, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important. It is also important to discuss newer treatment options that are being tested in clinical trials. Finding a second opinion may be useful, too.

Patients who have advanced cancer and who are expected to live less than 6 months may want to consider a type of palliative care called 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 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 lymphoma. You may use the menu to choose a different section to read in this guide.