Lymphoma - Hodgkin: Types of Treatment

Approved by the Cancer.Net Editorial Board, 04/2019

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

This section explains the types of treatments that are the standard of care for Hodgkin lymphoma. “Standard of care” means the best treatments known. When making treatment plan decisions, you 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. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

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. For some people, 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. People with Hodgkin lymphoma 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 common types of treatments used for Hodgkin lymphoma are listed below. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.

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

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. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for Hodgkin lymphoma because there are different treatment options. Learn more about making treatment decisions.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are 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.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or by taking a pill or capsule by mouth.

The types of systemic therapies used for Hodgkin lymphoma include:

  • Chemotherapy

  • Immunotherapy

Each of these types of therapies is discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes radiation therapy.

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. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

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 a combination 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 to treat 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; not all combinations are listed here.

  • ABVD: Doxorubicin (available as a generic drug), bleomycin (available as a generic drug), vinblastine (Velban), and dacarbazine available as a generic drug). ABVD chemotherapy is usually given every 2 weeks for 2 to 8 months.

  • AAVD: This regimen is similar to ABVD, but brentuximab vedotin (Adcetris) replaces bleomycin. AAVD is given every 2 weeks for 6 months.

  • BEACOPP: Bleomycin, etoposide (available as a generic drug), doxorubicin, cyclophosphamide (available as a generic drug), vincristine (Vincasar PFS), 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 (Gemzar) 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 comes back 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 (available as a generic drug), and etoposide. ICE is usually given every 2 or 3 weeks for 2 to 3 cycles.

  • ESHAP or DHAP: ESHAP is etoposide, methylprednisolone (Solu-Medrol), high-dose cytarabine (available as a generic drug), and cisplatin (available as a generic drug). DHAP is dexamethasone (available as a generic drug), high-dose cytarabine, and cisplatin. ESHAP or DHAP regimens are given every 3 weeks for 2 to 3 cycles.

  • GVD, Gem-Ox, or GDP: GVD is gemcitabine, vinorelbine (Navelbine), and doxorubicin. Gem-Ox is gemcitabine and oxaliplatin (Eloxatin). GDP is 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 people with recurrent Hodgkin lymphoma. It was also approved in 2015 by the FDA for use in certain people 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 people with Hodgkin lymphoma. The best treatment may differ depending on the type and stage of the lymphoma. For this reason, many clinical trials are being done 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. These late effects, which can develop 10 or more years after treatment ends, may include second cancers, especially among those who were treated with radiation therapy, and diseases of the heart or blood vessels. People with lymphoma may also have concerns about if or how their treatment may affect their sexual health 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.

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 the FDA has approved for the treatment of cHL that has recurred or progressed after multiple previous treatments, including AUTO transplantation (see "Bone marrow transplantation" below) 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 the lymphoma is cured.

There are side effects from these immunotherapy treatments, but they are generally mild. It is important to talk with your doctor about all immunotherapy side effects. There is some concern that allogeneic bone marrow transplantation (see below) 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. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

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 people 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 people.

The immediate side effects from radiation therapy depend on the area of the body that is being treated. All people treated with radiation therapy may experience fatigue or mild skin reactions. Those who receive radiation therapy to the neck may have a sore mouth and/or throat. Radiation therapy to the mediastinum may cause 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 damage to the thyroid gland 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.

Bone marrow transplantation/stem cell transplantation

For Hodgkin lymphoma, a bone marrow transplant is a medical procedure in which bone marrow that has been damaged or affected by cancer is replaced by highly specialized cells. These cells, called hematopoietic stem cells, 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. This is 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.

Bone marrow transplantation is not used as a first treatment for Hodgkin lymphoma, but it may be recommended for people 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. They will also 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) transplant. In an AUTO transplant, the patient’s own stem cells are used. The stem cells are collected when the patient 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.

Allogeneic (ALLO) transplant. 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 their 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. Side effects depend on the type of transplant, your general health, and other factors. Learn more about the basics of bone marrow transplants.

Physical, emotional, and social effects of cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer 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 changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

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. Clinical trials might also 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 bone marrow/stem cell transplant. 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 people, a diagnosis of progressive Hodgkin lymphoma is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel 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 is 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 returns 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 the 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 people, this treatment is used to prepare for a bone marrow/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 bone marrow transplant, especially if radiation therapy was not used during the previous 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. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope.

Learn more about dealing with cancer recurrence.

If treatment does not 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 health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported 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.

People who have advanced cancer and who are expected to live less than 6 months may want to consider 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. Use the menu to choose a different section to read in this guide.