CHEMOTHERAPY
Chemotherapy ("chemo") is treatment with drugs (as opposed to radiation, for example). Many different medications are used that either kill cancer cells or prevent them from growing. Because of how they work, chemotherapy drugs may also have a similar effect on certain normal cells.

Common Chemotherapy Drugs
(common brand names are in parenthesis)

DNA-Altering Drugs
These drugs change DNA, the building blocks of genes, to prevent cell growth:
      Carboplatin (Paraplatin®)
      Carmustine (BCNU®)
      Chlorambucil (Leukeran®)
      Cisplatin (Platinol®)
      Cyclophosphamide (Cytoxan®)
      Dacarbazine (DTIC®)
      Ifosfamide (Ifex®)
      Mechlorethamine (nitrogen mustard, Mustargen®)
      Melphalan (Alkeran®)
      Procarbazine (Matulane®)

Anti-tumor Antibiotics
These drugs interact with DNA and decrease cell survival. Drugs that come from natural sources, such as plants or microorganisms, include:
      Bleomycin (Blenoxane®)
      Doxorubicin (Adriamycin®, Rubex®)
      Idarubicin (Idamycin®)

Synthetic drugs that act like doxorubicin, include:
      Mitoxantrone (Novantrone®)

Antimetabolites
These drugs interfere with normal cell growth by inhibiting synthesis of DNA.
      Chlorodeoxyadenosine (Cladribine®)
      Cytarabine (cytosine arabinoside, Ara-C, Cytosar®)
      Fludarabine (Fludara®)
      6-mercaptopurine (Purinethol®)
      Methotrexate (Rheumatrex®)
      6-thioguanine (Thioguanine®)
      Pentostatin (Nipent®)
      Etoposide (VP- 1 6, VePesid®)
      Gemcitabine (Gemzar®)

Hormones
These drugs also affect cell growth
     Topical steroid creams (Diprolene®, Temovate®, Lidex®)
     Prednisone, dexamethasone (Decadron®, Dexasone®)

Drugs That Prevent Cells From Dividing By Blocking Cell Duplication
These drugs damage cell structures that are required for a cell to divide.
     Vinblastine (Velban®)
     Vincristine (Oncovin®)
     Vinorelbine (Navelbine®)

Combining chemotherapy drugs
Chemotherapy for NHL often consists of several drugs given together, called a regimen.  Combinations are used because different drugs damage or kill cancer cells in different ways making them more vulnerable. This provides a more effective way to kill more tumor cells because using the drugs together, rather than individually, greatly augments the impact the drug would accomplish, if used individually or additively. This is called Synergism In addition, drugs added together in lower doses helps reduce the likelihood of side effects without reducing the overall amount of effective chemotherapy. For example, the combination CHOP, currently considered standard therapy for DLBCL, uses drugs that are in less toxic amounts while sustaining a full or augmented (synergistic) capacity to destroy NHL.

Another reason for combination chemotherapy is to prevent drug resistance. A chemotherapy regimen is a combination of anticancer drugs given at a certain dose in specific sequence according to a strict schedule. This schedule should be maintained whenever possible.

Clinical investigators often use the first initials of the drugs in a particular treatment regimen (an acronym) to communicate among themselves using a shorthand reference to the treatment. Some of the most common regimens used for non-Hodgkin's lymphoma are outlined below. Many other combinations are being tested in clinical trials.

Common Chemotherapy Regimens Used to Treat Non-Hodgkin’s Lymphoma
(common brand names are in parenthesis)
Note: Many of these regimens can also include Rituxan

       CVP                                                   Cyclophosphamide (Cytoxan®)
                                                       Vincristine (Oncovin®)
                                                       Prednisone (Deltasone®)

         FND                                         Fludarabine (Fludara®)
                                                        Mitoxantrone (Novantrone®)
                                                        Dexamethasone (Decadron®, Dexasone®)

Chemotherapy Cycles
A single dose of chemotherapy kills only a percentage of the cancer cells, and multiple doses are therefore necessary to kill all the cancer cells. Chemotherapy is scheduled as frequently as possible to minimize tumor growth, prevent the development of resistant cancer cells, and achieve the best outcome.

Chemotherapy is usually given in cycles, that is, each treatment is followed by several weeks of rest and recovery during which no treatment is given. Together, each period of treatment and non-treatment is called a Chemotherapy cycle. The medicines are usually given according to a schedule, with a defined number of days passing between each time the drugs are given.

Clinical trials have determined how often chemotherapy should be given to kill the most tumor cells while minimizing side effects. Chemotherapy for NHL may require as few as three or as many as twelve or more cycles of treatment, depending on factors such as the stage of the disease, the type of lymphoma, the kind of drugs used, the level of response achieved, and the nature and severity of the side effects.

How chemotherapy is given
Depending on the chemotherapy regimen, you may receive drugs in pill form, as an injection, or as an intravenous drip. If you are going to receive intravenous drugs (ones that are given through a vein) for multiple cycles, sometimes your doctor may recommend having a Catheter inserted. An intravenous catheter is a device that is put into a vein to make it easier to give drugs. Catheters may be left in place temporarily or permanently.

There are several types of catheters. One type, called a Hickman-Broviac catheter, consists of one to three tubes inserted through the chest wall into a vein. Six to twelve inches of tubing remain outside the skin. The main advantage of this type of catheter is that blood tests can be drawn and drugs given without having to pierce the skin. Disadvantages include: (a) the possibility of infection if the catheter is not cared for properly and (b) the tubes on the outside of the body make it more obvious that a catheter is in place. If you have this type of catheter, your health care team will show you what needs to be done each day to care for it and to make sure it stays clean. This type of catheter is occasionally, but not commonly, used for patients with lymphoma.

A second type of intravenous catheter, called an Infusa-Port or Portacath catheter, is placed under the skin and appears only as a bump on the chest. The advantage of this catheter is that it is easier for patient care because it only needs to be maintained by a nurse once a month (called "flushing"). However, it also has disadvantages. Each time this type of device is used, an injection through the skin is required, and it may not always be convenient to draw blood samples. These devices may also occasionally clot.

If you need a catheter, discuss the pros and cons of the different types with your doctor. Your situation and personal preferences will be considered in making this decision.

The importance of maintaining the dose and schedule of chemotherapy

Dose intensity is a term used to describe giving the highest possible doses of drug over a specific period of time, while maintaining acceptable side effects. This approach has been shown to be very effective in curing some cancers, including some aggressive lymphomas. Studies have suggested that reducing the dose or delaying chemotherapy may decrease both the chance for a cure and long-term survival in some types of lymphomas.

It is important that patients know that changing the regimen to reduce short-term side effects may actually be harmful in the long run. Some side effects may be unpleasant, but tolerable. Others may be serious but can often be anticipated and prevented. It is very important that chemotherapy schedules be maintained to the greatest extent possible.