Current treatments for diffuse large B-cell lymphoma (DLBCL)

Treatment for people who have just been diagnosed with DLBCL is most often chemoimmunotherapy. This gets most people with DLBCL into remission (where there are no lymphoma cells left).

Your doctor or nurse will tell you how many cycles of treatment you will need. A cycle is a period of treatment followed by a period of rest. Typically, people have 6 cycles of chemoimmunotherapy, given every 3 weeks.

You can ask your hospital team why they are recommending a particular treatment and what it will involve.

All these drugs except prednisolone are given through a drip into a vein (by intravenous infusion). You will take prednisolone as a tablet at home.

You will need to go to hospital for your infusion. You won’t normally have to stay overnight but it can take several hours to have your treatment, particularly at first. This is because rituximab has to be given very slowly. Some people react badly if it is infused too quickly. You will be given antihistamine to help stop this happening.

R-CHOP and pola-R-CHP are intensive (strong) treatments. People who are less fit overall may need a gentler alternative. The options include:

• mini-R-CHOP, which is R-CHOP at a lower dose
• R-CVP, which is R-CHOP without doxorubicin
• steroids on their own
• rituximab on its own.

For some people, the aim of less intensive treatment is to cure the DLBCL. For others, it is to keep the DLBCL under control and manage the symptoms. Ask your hospital team about the aim of your treatment.

Some chemotherapy drugs called anthracyclines may not be suitable for people with serious heart problems.

Your doctor may still recommend chemoimmunotherapy but lower the dose of the anthracyclines. Or they might replace them with other chemotherapy drugs.

For example, you may be offered a combination of rituximab, gemcitabine, cyclophosphamide, vincristine and prednisolone. The gemcitabine replaces doxorubicin, the anthracycline used in R-CHOP.

Your doctor may recommend you have radiotherapy after you have had chemoimmunotherapy. This is usually for people with early stage DLBCL (stage 1 or 2) or bulky disease (represented by an X added to your stage). Radiotherapy can also help with pain in a specific area.

You scan results will show doctors where to target the radiotherapy. You will lie down while the machine directs a beam at the affected area. This doesn’t hurt at all.

You will normally have radiotherapy as an outpatient (you won’t need to stay overnight). But you will have radiotherapy each day for several days. Ask your doctor how many radiotherapy treatments you will need.

Radiotherapy doesn’t make you radioactive and it’s fine to be around other people as normal. It can cause some side effects in the days afterwards. The radiotherapy team will talk you through what to expect.

Sometimes one treatment isn’t enough to keep you in remission from DLBCL. You may need more treatment if:

• the first treatment doesn’t completely get rid of the lymphoma cells (a partial remission)
• the DLBCL comes back after a period of remission (relapsed DLBCL)
• the DLBCL does not respond to the first treatment (refractory DLBCL).

If any of these things happen, there are more treatment options.

Having lymphoma cells in parts of your body outside the lymphatic system means you may be at risk of developing lymphoma in your central nervous system. That includes your spinal cord and brain.

You’re at particularly high risk if you have lymphoma in a kidney, adrenal gland, testicle or breast. People with intravascular large B cell lymphoma, double hit lymphoma, or triple hit lymphoma may also be at high risk.

Your doctor may recommend treatment to help prevent the lymphoma spreading to your central nervous system, or to treat it there. This is normally with a chemotherapy drug called methotrexate.

The methotrexate will be given through a drip into a vein, or as an injection into your spinal fluid (like having a lumbar puncture). If you have methotrexate as a drip, you will need to stay in hospital for a few days. If you have it as an injection, you will be a day patient.

There is currently lots of research going on into who needs this treatment most. It is likely that the guidance will change as we learn more. Ask your hospital team whether they are likely to recommend it for you.

There are other types of high grade non-Hodgkin lymphoma that affect B cells. Most are treated in a similar way to DLBCL.

Look for your specific diagnosis to find out about treatment for your condition:

Clinical trials are research studies that involve patients. They are how scientists develop new treatments and improve existing ones. They also give you the chance to have a treatment that may not be available outside of the trial.

Your doctor may suggest you take part in at clinical trial. This is your choice – it cannot happen without your consent.

If you would like to know more about clinical trials and whether a trial is right for you, contact our Clinical Trials Support Service who can support you through the process.

A few people with a low grade (slow growing) non-Hodgkin lymphoma called follicular lymphoma will go on to develop DLBCL. This is called transformation.

If you have transformed lymphoma, your treatment will focus on the fast growing DLBCL, but you may still have some low grade lymphoma as well.

• If you’ve been on active monitoring (watch and wait) and never had any treatment, you will usually have chemoimmunotherapy with R-CHOP or pola-R-CHP.
• If you’ve had treatment for follicular lymphoma in the past, you may be offered a different option.
• You may be offered an auto stem cell transplant (using your own cells) after chemoimmunotherapy, if the lymphoma cells are cleared and you are well enough generally.
• After treatment for the DLBCL, some people may have maintenance treatment with rituximab on its own, to control the low grade lymphoma for as long as possible.

Treatment will aim to cure the DLBCL. It will also control the follicular lymphoma for a while, but unfortunately this slow growing lymphoma is likely to come back in the future. If that happens, you will have treatment designed for follicular lymphoma.

There have been breakthroughs in treatment for DLBCL and other high grade non-Hodgkin lymphomas in the last few years, and more developments are on the way.

Treatments like CAR T-cell therapy, epcoritamab, glofitamab and loncastuximab tesirine are changing how relapsed DLBCL is treated and more developments are expected in the future.

Read about the research we are funding to understand and treat lymphomas.

> Treatment for diffuse large B-cell lymphoma (DLBCL)