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Learning you have blood cancer, specifically large B-cell lymphoma (LBCL), can bring up questions about what comes next. What treatment options are available, and how do they work? The good news is that you have several options, and many of them can shrink tumors and help control symptoms.
In this article, we’ll talk about six main treatment options for LBCL, including chemotherapy, radiation therapy, and some newer types of immunotherapy. We’ll explain how each one works, when doctors use it, and what you can expect. We’ll also share new treatments being studied in research and clinical trials, and how to learn more if you’re interested in participating.
Chemotherapy, also called “chemo,” uses powerful medicines to kill fast-growing cancer cells. It’s usually considered a first-line treatment for people with non-Hodgkin lymphoma (NHL). This includes newly diagnosed cases of LBCL — including those with diffuse large B-cell lymphoma (DLBCL), which is one of the most common subtypes.
The most common chemoimmunotherapy (chemotherapy and immunotherapy) treatment plan is called R-CHOP. The name comes from the first letters of the drugs in the combination:
R-CHOP works well for many people. In fact, R-CHOP use generally cures 60 percent to 70 percent of people with DLBCL, though outcomes vary based on factors like stage and risk score.
Doctors use cancer staging to describe how far the lymphoma has spread. For early-stage lymphoma (stages 1 and 2), R-CHOP is often given for three to six cycles. This treatment might be followed by radiation therapy targeting the affected lymph nodes, depending on tumor size and the results of PET and CT scans.
For some people with newly diagnosed DLBCL, especially those with higher-risk disease, doctors may use a regimen called pola-R-CHP. Pola-R-CHP is like R-CHOP, but it leaves out vincristine and adds polatuzumab vedotin (Polivy) instead. This is an antibody-drug conjugate (ADC), which we’ll talk about later on.
After several cycles of treatment, doctors may use imaging tests like PET and CT scans to see how well treatment is going.
Radiation therapy uses a focused beam of energy to kill cancer cells in a specific spot. It doesn’t treat the whole body like chemotherapy does. Instead, it targets one area. Radiation therapy can be used for LBCL in certain situations.
In early-stage lymphoma (stage 1 or 2), chemotherapy (often with immunotherapy) is usually the main treatment, and radiation therapy may be added to lower the risk of the cancer coming back in some cases. In more advanced lymphoma, it can also be used with chemotherapy to treat a problem area. Radiation therapy can also ease symptoms by shrinking tumors that are pressing on other parts of the body, such as the spinal cord, a bone, or another organ.
Side effects depend on the body part being treated and may include tiredness or skin changes. Your oncology (cancer) team will check you often and may order follow-up scans if needed.
Targeted therapy is a type of treatment that focuses on specific features of lymphoma cells. Instead of treating the whole body, targeted drugs look for markers — special “flags” found on cancer cells. Targeted therapies attach to specific proteins on lymphoma cells, or block signals the cells need to grow. Some also help the immune system find and attack lymphoma.
Many targeted therapies used in LBCL are called monoclonal antibodies. These are lab-made proteins that attach to abnormal B cells (a type of white blood cell) and help your body clear them out. Several different monoclonal antibodies are used to treat some kinds of NHL, including:
A newer type of monoclonal antibody is called a bispecific T-cell engager. One part of the drug attaches to a T cell (a type of immune cell), and the other attaches to a lymphoma cell. This helps the T cells recognize the cancer cell and allows the immune system to attack it more efficiently. Examples include glofitamab (Columvi) and epcoritamab (Epkinly).
ADCs are another type of targeted drug. An ADC has two parts: a monoclonal antibody that finds the cancer cell and a cancer-killing medicine attached to it.
Think of an ADC like a guided delivery system. The antibody brings the drug directly to the lymphoma cell, helping to limit damage to healthy cells. Examples of ADCs used in large B-cell lymphoma include:
These medicines may be used when lymphoma returns after earlier treatment or when a person can’t tolerate more intensive treatment options.
Some people may also receive Bruton’s tyrosine kinase (BTK) inhibitors. These drugs are sometimes used off-label, meaning they’re prescribed for LBCL even though they aren’t officially approved for that exact use. BTK is a protein that helps lymphoma cells stay alive and grow. When BTK is blocked, the cancer cells may weaken and be more likely to die. Examples include:
Targeted therapies work well for many people, even after other treatments stop working. Response rates vary by the drug and lymphoma subtype, but many people see their lymphoma shrink or stabilize. Side effects also differ by medicine. Some may cause tiredness, low blood counts, or a higher risk of infections.
Chimeric antigen receptor (CAR) T-cell therapy is a type of immunotherapy that uses your own T cells to fight lymphoma. The CAR is a special receptor added to your T cells in a lab. It helps the T cells recognize and attach to lymphoma cells more easily.
First, you’ll be attached to a machine that filters your blood and collects your T cells. Your own T cells are then altered in a lab so they carry the CAR. After a short course of low-dose chemotherapy, the CAR T cells are infused back into your bloodstream. Once there, they find and destroy lymphoma cells.
CAR T-cell therapy is mainly used for relapsed or refractory LBCL. Relapsed means the cancer returned after treatment. Refractory means the cancer didn’t respond to multiple types of other treatments. However, clinical guidelines state that CAR T-cell therapy can be used as early as the second line of treatment for some people. Some options include:
CAR T-cell therapy can lead to strong and long-lasting remissions (periods of no active disease), even after other drugs stopped working. Possible side effects may include fever, low blood pressure, or confusion. In rare cases, more severe immune or central nervous system-related effects may occur. Your healthcare team will monitor you closely to catch these early.
A stem cell transplant replaces unhealthy blood-forming cells with healthy ones. Most people with LBCL receive an autologous stem cell transplant, which uses their own stem cells.
Doctors may consider a stem cell transplant for people whose lymphoma has relapsed, especially if it responded well to chemotherapy before the transplant. Stem cell transplants can be effective for some people, but they’re less often used today because many people receive CAR T-cell therapy instead.
Researchers are working on many new treatments for LBCL, and clinical trials are ongoing. Some studies are testing next-generation CAR T-cell therapies that may work faster and cause fewer side effects. Others are studying bispecific antibodies, ADCs, and other immunotherapy-based treatments to treat relapsed or refractory disease. As doctors learn more about the genes and proteins inside lymphoma cells, treatments are becoming more personalized and precise.
To learn more about clinical trials, talk to your healthcare team or visit clinicaltrials.gov.
On MyLymphomaTeam, people share their experiences with lymphoma, get advice, and find support from others who understand.
What LBCL treatments have you tried? Let others know in the comments below.
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