Chemotherapy

What is chemotherapy and how does it work?

Chemotherapy is a type of treatment using drugs that are 'cytotoxic'. This means that they poison cells. Most lymphoma cells are easily killed by chemotherapy. You can read more about how cancer develops on our separate webpage that outlines what lymphoma is.

Chemotherapy works by doing one or both of the following:

• stopping lymphoma cells from dividing so that they die off
• triggering lymphoma cells to die.

Chemotherapy works on cells that are dividing. The drugs don’t have much effect on cells that are not dividing. Lymphoma (and other cancer) cells divide much more often than healthy cells do. This is why chemotherapy has more of an effect on lymphoma cells than on healthy cells.

This animation explains what chemotherapy is, how it works to kill cancer cells and some of the ways in which it is given as treatment for lymphoma.

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How is chemotherapy given?

Chemotherapy is usually given in a number of treatments (‘cycles’). After each cycle, you have a rest period to give your healthy cells time to recover. A whole course of treatment can take between a number of weeks to months. 

Typically for lymphoma, you’d have four to six 6 cycles of treatment – it depends on the type of lymphoma you have, your response to treatment and on the chemotherapy regimen you’re having. Quite often, even if you show a good response, you’ll continue with the remaining cycles to ensure that the lymphoma doesn't come back.

Claire James, Macmillan Haematology Clinical Nurse Specialist

You might have chemotherapy as an inpatient (where you stay in hospital overnight) or as an outpatient (where you go home after each treatment).

Chemotherapy is often given with more than one drug. This is known as a combination regimen. Different drugs work on different phases of the cell cycle. Having them together helps to kill as many lymphoma cells as possible. 

It’s becoming increasingly common for chemotherapy to be given together with targeted treatments.

Your treatment plan should outline:

• the type of chemotherapy drug or drugs you’ll have
• how many treatment sessions you'll have
• how often you'll have treatment
• how you have the treatment. 

I have a type of low grade skin lymphoma and I’ve had three treatments over the past five years, including four cycles of chemotherapy (R-CHOP) over 4 months followed by radiotherapy. My medical team explained that they wanted to give me one cycle of chemotherapy roughly every 28 days. The treatment was successful and I am currently in remission.

David, diagnosed with skin lymphoma

You are most likely to have chemotherapy in one or more of the following ways:

• through a tube or injection into a vein (intravenous (IV) chemotherapy)
• by mouth as a tablet (oral chemotherapy)
• by an injection into the cerebrospinal fluid, which surrounds the brain and spinal cord (intrathecally).

Intravenous (IV) chemotherapy

Intravenous (IV) chemotherapy is injected into a vein. This is the most common way to have chemotherapy for lymphoma.

Usually, IV chemotherapy for lymphoma is given through a cannula, a soft plastic tube with a needle inside it. It can also be given through a line (central venous catheter).

To fit a cannula, a nurse or doctor:

• puts the needle into one of your veins, usually in the lower part of your arm
• removes the needle, leaving only the plastic tube in your vein
• puts a dressing on, to keep the cannula clean and in place.

Some IV drugs are given as a ‘bolus’ or a ‘push’ dose. The chemotherapy drugs are injected through the cannula over a short while, usually between a few minutes up to about 20 minutes. Other drugs are given through a drip (intravenous infusion). This is a tube that runs into a cannula into a vein in your arm.

• The IV chemotherapy drugs are mixed with fluid (usually a saline solution) in a bag.
• The fluid drips slowly from the bag into your vein over a set amount of time. This could be anywhere from 5 minutes to a number of hours, depending on the drug or drugs you have.
• The bag hangs from a metal drip stand so that it stays above your arm to allow the fluid to flow downwards. The stand usually has wheels so that you can walk around with the drip still connected to you.

Sometimes, the drip is controlled by an electric pump. This helps to make sure that the chemotherapy drugs flow at the right speed into your vein. 

The team delivering the chemotherapy will check that the chemotherapy is flowing through your vein as it should be. However, if you feel any pain or discomfort while you’re having IV chemotherapy, or notice swelling in your arm, it’s important that you tell a member of hospital staff. 

Occasionally, the drug goes into the tissues around the vein instead of into the vein itself. This is called ‘extravasation’ and can cause problems if it isn’t stopped quickly. All nurses who give chemotherapy are trained in how to deal with this complication.

You will be given clear guidance by the chemotherapy team at the hospital about how to check the area and what to look out for. You will be followed-up closely by the chemotherapy team who will review the area and escalate for further advice if necessary.

Claire James, Macmillan Haematology Clinical Nurse Specialist

IV chemotherapy through a ‘line’ (central venous catheter)

You might have your IV chemotherapy through a ‘central line’ or ‘line’ (central venous catheter). A line is a tube that is put into one of your larger veins, guided by ultrasound. It runs from your chest to your heart.

A line can also be used to give you drugs and other fluids, and to take blood samples more easily than with regular syringes. This can save the discomfort of repeated needle pricks.

Lines are put in during a small operation done under local or general anaesthetic. Once it’s in place, a line isn’t usually painful.

There are different types of line:

• PICC line (peripherally inserted central catheter), which goes in through a vein in your arm. The end of the line outside your body also ends in smaller tubes (lumens). It is usually used for short-term treatment or until you have a longer-lasting line fitted, if you need one.
• Tunnelled central line, which is usually positioned on your upper chest. Part of it ‘tunnels' under your skin. You might also hear these types of lines called Hickman®, Groshong® line or apheresis line. You can watch a short video about how a central line is put in on the Cancer Research UK website.
• Portacath (‘port’), which is a thin, soft tube. It runs under your skin and into a vein in your chest, ending in a small disc (port) that goes just under your skin. You’re given chemotherapy through a specialised type of needle – it goes through your skin and into the port each time you have treatment. 

Person with a PICC line inserted

Ambulatory chemotherapy

Many hospitals offer ambulatory chemotherapy. This means that you don’t have to stay in hospital for your treatment. Instead, you have it in your home or in accommodation near to the hospital. Some people prefer to have chemotherapy in this way as they feel it gives them more independence, privacy and comfort than staying in hospital.

You have ambulatory chemotherapy by a pump-controlled drip (infusion).

If your hospital offers this type of chemotherapy, your medical team will assess whether ambulatory chemotherapy is suitable for you. They consider a number of factors, including:

• your general health, including any other medical conditions you might have
• the type of chemotherapy drugs you need
• your home environment, for example, having family and friends who can be with you while you’re having treatment and offer support if you need it
• whether you can care for yourself and manage side effects.

In case of an emergency, at all times, you will also need to be:

• contactable and be able to contact the hospital quickly, for example, by mobile phone
• able to travel to the hospital you’re having treatment at (usually within about 30 to 60 minutes), otherwise you might be offered accommodation closer to the hospital
• have someone with you who could drive you to the hospital at any time of the day or night, if you need to go.

I was away from home for a long time, initially in ambulatory care, receiving high dose LEAM chemotherapy, and then in hospital once my neutrophils became very low and the side effects too bad. While I was in ambulatory care, we went out for walks and visited museums together as a family. It was quite surreal to be doing that with the chemotherapy attached to me.

Katherine, diagnosed with anaplastic large T-cell lymphoma

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Chemotherapy and risk of infection

You have a higher risk of developing an infection while you’re being treated with chemotherapy. It can also be harder than usual to get rid of infections, particularly if you have a shortage of a type of white blood cell that helps to fight infection (neutropenia). 

If you develop an infection, you might need treatment with antibiotics to help get rid of it.

It is therefore important that you know:

• the signs of infection to look out for
• who to contact if you think you might have an infection.

If you develop signs of an infection, for example, fevers and generally feeling unwell, you must call your local hotline or other out-of-hours emergency number immediately. You will be advised to attend your local Emergency Department as a matter of urgency to have treatment with antibiotics.

Claire James, Macmillan Haematology Clinical Nurse Specialist

Lowering your risk of infection

While it’s impossible for anyone to be completely clear of the risk of infection, there are things you can do to help lower the risk.

Keep good personal hygiene, and try to minimise your contact with germs. It’s also advisable to protect your skin from scratches and cuts, for example, by wearing gloves when gardening. If you cut or graze yourself, wash your hands and then use tap water to clean the wound.

Spending time with friends and family can help your emotional wellbeing. However, if you have neutropenia, avoid being around people who are unwell with infections (for example a cold, flu, diarrhoea or chickenpox).

You should also follow food safety guidance for storing, preparing and cooking food. Check for a high food hygiene rating if you are eating out or buying food from places like food vans or stalls.

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What side effects might I have?

Although the aim is to kill lymphoma cells, many types of chemotherapy also temporarily affect healthy cells. This is why chemotherapy can cause side effects.

Your medical team should advise you on whether they expect you to have side effects during or soon after your treatment. They should give you information about how to manage these.

Side effects can differ from person to person, even with the same treatment. Side effects also depend on the effects on your blood counts – anaemia (low red blood cells), neutropenia (low neutrophils, a type of white blood cell) and thrombocytopenia (low platelets).

Areas of your body that are most likely to be affected by chemotherapy are those where new cells are frequently made and replaced. For this reason, some of the more common side effects of chemotherapy include:

• Effects on your blood counts – anaemia (low red blood cells), neutropenia (low neutrophils, a type of white blood cell) and thrombocytopenia (low platelets).
• Hair loss – which could be thinning, partial or full loss, both on your head and other areas of your body.
• Digestive problems – such as feeling sick (nausea) and/or being sick (vomiting), and bowel problems, such as diarrhoea, constipation and wind (flatulence).
• Sore mouth (oral mucositis), where the lining of your mouth becomes swollen and painful.

Many people also experience extreme tiredness (fatigue) and cancer-related cognitive impairment (chemo brain), which affects thinking processes such as memory and attention. 

You might be interested in our useful organisations listing, which includes a section on coping with the effects of cancer.

Tumour lysis syndrome

A rare but potentially serious side effect of chemotherapy is tumour lysis syndrome (TLS.) This can happen when chemotherapy kills a lot of cancer cells quickly. The contents of them are released into the bloodstream and can cause problems with your kidneys and heart. 

If you are at risk of developing tumour lysis syndrome, your medical team will prescribe medicines to help prevent it.

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What late effects might I have?

Your medical team should also talk to you about any possible late effects you might get. These are health problems that first appear months or years after treatment has finished. 

The late effects you might get depend on which chemotherapy drug you have, the strength of the dose and how long your treatment goes on for. Your doctor should talk to you about possible late effects before you begin treatment. 

Not everyone gets late effects, but it’s important to know what signs to look out for and to go for any follow-up appointments you’re invited to, to help keep a check on these.

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Follow-up after chemotherapy

After finishing your treatment for lymphoma, you have regular follow-up appointments at the hospital. These involve conversations and physical tests with a member of your medical team.

One of the tests you are likely to have in the first few months after chemotherapy is your full blood count (FBC). This gives information about the numbers and sizes of your blood cells and tells doctors how well your bone marrow (where blood cells are made) is working.
The aim of follow-up is to:

• check your recovery after treatment
• check for signs of the lymphoma coming back (relapse)   
• manage any late effects of treatment.

How often you are followed-up depends on a number of factors. These include the type of lymphoma you had, how long it’s been since you had treatment and whether you were treated as part of a clinical trial.

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Chemotherapy webinar recordings

In addition to our animation explaining what chemotherapy is, we have some webinar recordings you might be interested in. Each of these feature health professionals and people affected by lymphoma.

• What is it like to have chemotherapy? (57 mins, 49 seconds)
• Recovering from chemotherapy (1 hour, 56 seconds). 

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