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This information is about two similar chemotherapy treatments for non-Hodgkin lymphoma (a type of cancer of the lymphatic system) called R-CHOP and CHOP. If you have any questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer support service nurses.
R-CHOP is named after the chemotherapy drugs used in the treatment. It involves the monoclonal antibody rituximab, and the drugs: cyclophosphamide, doxorubicin, originally called Adriamycin®, vincristine, originally known as Oncovin® and prednisolone, which is a steroid.
CHOP uses the same chemotherapy drugs as R-CHOP, but without the rituximab. Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.
Rituximab (Mabthera®) belongs to a group of drugs known as monoclonal antibodies. It is used to treat several different types of B-cell non-Hodgkin lymphoma.
Monoclonal antibodies are used to try to destroy some types of cancer cells, while causing little harm to normal cells. They are designed to recognise certain proteins that are found on the surface of some cancer cells. The monoclonal antibody recognises the protein and locks onto it (like a key in a lock). This may then trigger the body’s immune system to attack the cancer cells and can sometimes make the cells destroy themselves.
Rituximab locks onto a protein called CD20, which is found on the surface of one of the main types of normal white blood cells (B-cell lymphocytes). It is also present on the surface of most of the abnormal B-cell lymphocytes that occur in some types of non-Hodgkin lymphoma. Rituximab acts by attacking both abnormal (malignant) and normal B-cell lymphocytes. The body can however, replace any normal white blood cells that are damaged quite quickly.
Both R-CHOP and CHOP can usually be given to you as a day patient. However, the first treatment of R-CHOP may take longer (see below) and may mean an overnight stay in hospital.
You will need to have a blood test before you start treatment – either on the same day, or a few days beforehand. You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy. All of this may take a couple of hours.
The nurse will put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful but it should not take long. Some people have their chemotherapy given through a thin plastic tube, which is inserted under the skin into a vein near the collarbone (a central line) or passed through a vein in their arm (a PICC line). Your doctor or nurse will explain more about this to you.
Once your chemotherapy is ready you will be given anti-sickness (anti-emetic) drugs. These are often given by injection through the cannula or your line, but they can be given as tablets. You will also be given drugs to prevent an allergic reaction that some people have when rituximab is given.
The first dose of rituximab is given slowly into the vein as an infusion over a few hours, as some people can have an allergic reaction to it (see Possible side effects, below). If you do have a reaction the drip can be stopped and started again more slowly when the symptoms have reduced. You may need to stay in hospital overnight for the first treatment so that you can be monitored. You should be able to have your second and subsequent doses of rituximab more quickly as an outpatient. It may however take about four hours for all the drugs to be given.
Both R-CHOP and CHOP are given by injection into the tubing of a drip, or through your line. The prednisolone is taken as tablets.
The R-CHOP drugs to be given into the vein are usually given in the following order, although the exact order doesn't make any difference:
CHOP is given in the same way, but without the rituximab.
When all the drugs have been given the cannula will be removed or your line will be capped. You will be given a supply of anti-sickness tablets to take home with you. You should take these regularly if you have been told to do so, even if you are not feeling sick, as some medicines are much more effective at preventing sickness than stopping it once it has started.
You will also be given a course of prednisolone tablets. These can be either white or coated red. The first dose of prednisolone is usually given before the rituximab (if you are having R-CHOP). It is important to take all the tablets as prescribed by your doctor.
Your doctor may use the word 'regimen' (eg the R-CHOP regimen) when talking about your chemotherapy. This means the whole plan or schedule of the particular treatment that you are receiving.
If you are having R-CHOP you will be given rituximab, doxorubicin, vincristine and cyclophosphamide (as described) on the first day of your treatment. On the same day you will begin a five-day course of prednisolone tablets. When you have finished the tablets you will have a rest period with no treatment for the next 16 days. This completes what is called a cycle of your treatment. Each cycle takes 21 days, so this way of giving R-CHOP is called R-CHOP21.
If you are having CHOP the treatment is given in the same way, but you will not be given rituximab.
After the rest period the same treatment will be repeated again, which begins the next cycle of your chemotherapy. Usually 6–8 cycles are given over a period of 3–4 months. This makes up a course of treatment.
Sometimes each cycle of R-CHOP is given over 14 days (two weeks), which is known as R-CHOP14. The drugs are given in the same way as R-CHOP21, but the rest period is shorter. Instead of a 16-day break between treatments, there are only 9 days.
The rest period between treatments allows your body to recover from any side effects that may occur. Having a shorter rest period may mean that your body doesn’t have enough time to recover fully before the next cycle of chemotherapy.
One of the main side effects is a reduction in the number of white blood cells that are produced by the bone marrow. To help counteract this you will be given injections of a drug called G-CSF (granulocyte-colony stimulating factor). This is a type of protein that stimulates the bone marrow to produce more white blood cells. The injections are given under the skin (subcutaneously).
You may be asked to take part in a research trial, comparing R-CHOP given every three weeks with R-CHOP given every two weeks. The trial is called R-CHOP21 vs. R-CHOP14 and it is being offered to people with newly diagnosed B-cell non-Hodgkin's lymphoma. Your doctor or nurse will give you further information about the trial.
Each person's reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described in this information will not affect everyone who is having this treatment.
We have outlined the most common side effects, so that you can be aware of them if they occur. However, we have not included those that are rare and therefore unlikely to affect you. If you do notice any effects that you think may be due to the drugs, but which are not listed in this information, please let your nurse or doctor know.
Flu-like symptoms Some people find that rituximab can cause a high temperature and chills, weakness, muscle aches, tiredness, dizziness and headache. These can occur while the drug is being given, but do not usually last long.
Low blood pressure This may happen during the infusion of rituximab, so your blood pressure will usually be regularly checked. People who normally take drugs to lower their blood pressure may be advised by the doctor to take these at least 12 hours before rituximab is given. (It is important not to alter your blood pressure medication without first discussing it with your doctor).
Allergic reactions It is not unusual to have a slight allergic reaction to rituximab. Signs of this include skin rashes and itching, a feeling of swelling in the tongue or throat, irritation of the nasal passages, wheezing, a cough and breathlessness. You will be monitored closely during your treatment, but let your nurse or doctor know if you have any of these effects. To reduce the chance of developing an allergic reaction, certain drugs (antihistamines) can be given before the infusion. The infusion can also be slowed down or stopped until the reaction is over.
Flushing You may have a sudden feeling of warmth and some reddening in your face. This can happen for a short period of time during the infusion of rituximab.
Lowered resistance to infection The chemotherapy drugs can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin seven days after treatment has been given, with your resistance to infection usually reaching its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily, and will usually have returned to normal levels before your next cycle of chemotherapy is due.
Contact your doctor or the hospital straightaway if:
You will have a blood test before having more chemotherapy to make sure that your number of white blood cells has returned to normal. Occasionally, it may be necessary to delay treatment if your number of blood cells (blood count) is still low.
Bruising or bleeding Chemotherapy can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding.
Anaemia (low number of red blood cells) While having the treatment you may become anaemic. This may make you feel tired and breathless. Let your nurse or doctor know if these are a problem.
Feeling sick (nausea) and being sick (vomiting) Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or reduce nausea and vomiting. If the sickness is not controlled, or if it continues, tell your doctor. They can prescribe other anti-sickness drugs which may be more effective. Some anti-sickness drugs may cause constipation. Let your doctor or nurse know if this is a problem for you.
Constipation Vincristine (and some anti-sickness drugs) may cause constipation. Let your doctor or nurse know if this is a problem.
Tiredness Many people feel extremely tired (fatigued) during chemotherapy, particularly towards the end of treatment. This is a very common side effect and it is important to try to get as much rest as you need.
Hair loss This usually starts 3–4 weeks after the first course of treatment. Hair usually falls out completely. You may also have thinning and loss of eyelashes, eyebrows and other body hair. Hair loss is temporary and your hair will start to grow again once the treatment has finished.
Sore mouth and ulcers Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Drinking plenty of fluids and cleaning your teeth regularly and gently with a soft toothbrush can help to reduce the risk of this happening. Tell your doctor if you have any of these problems, as they can prescribe special mouthwashes and medicine to prevent or clear any mouth infection.
Taste changes You may notice that your food tastes different. Normal taste will usually come back after the treatment finishes.
Irritation of the stomach lining Prednisolone can reduce the stomach's protective layer, making it more prone to irritation by stomach acid. Tell your doctor if you have indigestion or any other stomach problems. They can prescribe medicine to relieve these symptoms. The red prednisolone tablets are coated to protect the stomach, however the white tablets should be taken with meals or a glass of milk.
Increased appetite You may notice that you feel hungrier than usual while taking prednisolone. This will stop when you are no longer taking the drug.
Irritation of the bladder Cyclophosphamide may irritate your bladder. It is useful to drink plenty of fluid (up to about two litres) on the day following chemotherapy to help prevent this. If you notice any blood in your urine tell your doctor. Doxorubicin is red and due to this your urine may become a pink-red colour. This may last up to 24 hours after your treatment and is quite normal.
Numbness or tingling in hands or feet This is due to the effect of vincristine on nerves and is known as peripheral neuropathy. Tell your doctor if you notice these symptoms. The dose of vincristine may need to be reduced. This problem usually improves slowly a few months after treatment is over.
Changes in the level of sugar in your blood Occasionally prednisolone may cause your blood-sugar level to rise. During treatment you may have regular blood or urine tests to check this. Tell your doctor if you get very thirsty or if you are passing more urine than usual.
Fluid retention Prednisolone may affect the salt and water balance in your body. You may notice that your ankles and/or your fingers swell. Let your doctor know if this happens. This is usually only a problem with long-term treatment.
Skin changes Rarely, your skin may darken. If it does, it usually goes back to normal a few months after the treatment has finished. During treatment and for several months afterwards you will be more sensitive to the sun and your skin may burn more easily. You can still go out in the sun, but always wear a high protection factor suncream and cover up with clothes.
Sometimes areas of skin which have been treated with radiotherapy may become red and sore. Let your doctor know if this happens.
Changes in nails Your nails may become darker and white lines may appear on them. These changes usually grow out over a few months once the treatment has finished.
Behavioural changes Occasionally prednisolone may cause you to have some strong feelings and to have mood swings. Let your doctor know if there are any changes in your behaviour which are worrying you.
Changes in the way your heart works This is very rare with usual doses of doxorubicin but may occasionally happen when high doses are used. You may have tests to see how well your heart is working before you start treatment.
Always let your doctor or nurse know about any side effects that you have. There are usually ways in which they can be controlled or improved.
Risk of blood clots Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it is important to tell your doctor straightaway if you have any of these symptoms. However, most clots can be successfully treated by using drugs which thin the blood. Your doctor or nurse can give you more information.
Other medicines Some other medicines can be harmful to take when you are having chemotherapy. Let your doctor know about any medications you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.
Leakage into the tissue around the vein If this happens while doxorubicin or vincristine are being given, the tissue in that area can be damaged. If you notice any stinging or burning around the vein while the drug is being given tell your doctor or nurse immediately.
Fertility Your ability to become pregnant or father a child is likely to be affected by this treatment. It is important to discuss fertility with your doctor before starting treatment.
Contraception It is not advisable to become pregnant or father a child while taking this treatment, as the developing foetus may be harmed. It is important to use effective contraception while taking these drugs, and for at least a few months afterwards. Again, discuss this with your doctor or nurse.
Loss of periods in women Due to the effect of chemotherapy on the ovaries you may find that your periods become irregular and may eventually stop. In younger women this may be temporary but if you are closer to your menopause it may be permanent. This will result in menopausal symptoms such as hot flushes, sweats and vaginal dryness.
This section is based upon our R-CHOP and CHOP chemotherapy factsheet which has been compiled using information from a number of reliable sources, including:
For further references, please see the general bibliography.
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