Non-Hodgkin lymphoma

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A family of different lymphomas

Non-Hodgkin lymphoma (NHL) is a group of cancers of lymphocytes, the white blood cells that help protect the body from infection. The name includes many diseases with different behaviour and treatment. Knowing the exact subtype is more useful than knowing only that someone has non-Hodgkin lymphoma. A diagnosis might be diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma or a less common B-cell, T-cell or natural killer-cell (NK-cell) lymphoma. These names identify which kind of immune cell became cancerous.

Lymphoma is an umbrella term for two broad groups: Hodgkin and non-Hodgkin lymphoma. This guide covers non-Hodgkin lymphoma. Your biopsy report describes a tissue sample examined in the laboratory. Its exact diagnosis helps identify which treatment pathway applies.

Some lymphomas grow slowly and may safely be observed for a time. Others grow rapidly and need prompt treatment, but can sometimes be cured. A slow-growing lymphoma is not necessarily easy to cure, and an aggressive lymphoma is not necessarily incurable. The stage, pathology, symptoms and response to treatment need to be interpreted together.

This guide explains the main adult subtypes and their care. Childhood lymphoma requires a paediatric team and different treatment plans. Hodgkin lymphoma has a separate guide. Chronic lymphocytic leukaemia and small lymphocytic lymphoma are also covered separately because they are closely related forms of the same disease.

What matters first

• Obtain the full biopsy diagnosis and ask whether review by a haematopathologist, a doctor specialising in blood and lymphatic tissue samples, is needed.
• Establish whether the lymphoma is slow-growing or fast-growing and whether it has changed from an earlier lymphoma.
• Assess symptoms, organ function and how quickly treatment is needed.
• Discuss whether the aim is cure, a long remission (a period with little or no detectable lymphoma) or control while preserving quality of life.
• Ask which tests must be completed before steroids or other treatment begin.

Symptoms that need prompt attention

Possible symptoms include a persistent painless lump, unexplained fever, drenching night sweats, weight loss, itching or fatigue. Lymphoma outside the lymph nodes can cause symptoms in almost any organ. These symptoms have many other possible causes; a biopsy is usually needed to establish the diagnosis.

Difficulty breathing, swelling of the face or neck, new weakness or loss of bladder control, confusion, severe abdominal pain or rapidly worsening illness needs urgent assessment. Some lymphomas can cause tumour lysis syndrome, in which rapid cell breakdown disturbs kidney function and blood chemistry. This can occur before treatment as well as after it starts.

Making this information useful to you

A cancer diagnosis can arrive before you have had time to understand the tests. You do not need to learn every treatment name at once. Begin with the exact diagnosis, where the cancer is, and what the team recommends next. A relative or friend can join the appointment if you would find that helpful. Ask for an interpreter when language makes a discussion harder; important decisions should not depend on guessing unfamiliar words.

This guide explains possibilities, not a prescription for your situation. Your blood and tissue test results, scan findings, general health, previous treatment and priorities determine which possibilities apply. Two people with the same cancer name may appropriately receive different treatment. If a recommendation differs from something you have read, ask the team to explain the reason and the evidence behind it.

Keep a list of medicines, allergies and other health conditions, including non-prescription products, vitamins and herbal remedies. Tell the team about previous cancer treatment, pregnancy or breastfeeding, and anything that could affect attending appointments. Do not stop an established medicine without advice. Bring your questions in the order that matters most to you, so that the most important concern is discussed first.

Understand

B cells, T cells and natural killer cells

Most non-Hodgkin lymphomas arise from B cells. These include diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, marginal zone lymphoma and Burkitt lymphoma. T-cell and natural killer-cell lymphomas are less common and often need different medicines. A treatment approved for one group should not automatically be used for another.

Lymphoma can begin in a lymph node or in tissue such as the stomach, skin, brain or bone marrow. A lymphoma in the stomach is not the same disease as stomach carcinoma. Similarly, lymphoma involving bone is different from a primary bone sarcoma. Treatment follows the lymphoma subtype as well as the organ involved.

Slow-growing and fast-growing disease

Follicular and many marginal zone lymphomas are usually indolent, meaning slow-growing. Diffuse large B-cell lymphoma and Burkitt lymphoma are aggressive. Mantle cell lymphoma varies: many people need treatment promptly, while a carefully selected minority with low-burden disease can be observed. T-cell lymphomas also vary widely, from skin-limited disease to rapidly progressive systemic illness.

Transformation means that a previously slower-growing lymphoma has developed a more aggressive form. A rapidly enlarging lump, rising symptoms or an unexpectedly active area on a scan may prompt a new biopsy. Transformation is not diagnosed from a blood test alone and can change the treatment plan substantially.

Stage and outlook

Risk scores combine features such as age, stage, blood results and general fitness. Different subtypes use different scores, such as the International Prognostic Index (IPI) for several aggressive lymphomas, the Follicular Lymphoma International Prognostic Index (FLIPI), or the Mantle Cell Lymphoma International Prognostic Index (MIPI). These help guide discussion and follow-up but cannot predict exactly what will happen to an individual. Pathology, molecular findings and treatment response add important information.

Tests and diagnosis

Getting the right biopsy

A cancer in a lymph node is not automatically lymphoma: other cancers can spread to lymph nodes. Examining a tissue sample helps establish the type of cancer.

An excision biopsy, which removes a lymph node, often gives the best view of the tissue structure. A core biopsy can be appropriate when removing a whole node is difficult or unsafe. Fine-needle aspiration alone often does not provide enough information for a first lymphoma diagnosis. Tell the team about steroids already taken, because they can affect biopsy findings. Do not stop prescribed medicines without advice.

The laboratory examines cell appearance, marker proteins, flow cytometry (a test of proteins on individual cells) where appropriate, and selected chromosome or gene tests. Diffuse large B-cell lymphoma (DLBCL) may require testing for rearrangements involving genes such as MYC and BCL2 and other features that alter classification. Protein expression and a gene rearrangement are different findings. Mantle cell lymphoma commonly involves cyclin D1 and a characteristic chromosome change; follicular lymphoma and T-cell lymphomas require their own diagnostic panels.

A second pathology opinion is particularly helpful for rare subtypes, uncertain findings, suspected transformation or a result that does not fit the clinical picture. Keep the original report and ask how tissue blocks or slides can be made available for review.

Scans and other staging tests

Positron emission tomography combined with computed tomography (PET-CT) combines detailed body images with a tracer that highlights active cells. The tracer, fluorodeoxyglucose (FDG), is a small amount of radioactive glucose-like substance. PET-CT is useful for DLBCL and most follicular lymphomas, which usually take up FDG. CT alone may be more useful for lymphomas with little uptake.

A bone marrow biopsy is needed in selected situations; a good PET-CT can make it unnecessary in some people, but this depends on the subtype and the clinical question.

Blood tests assess the blood count, kidneys, liver, calcium, uric acid and lactate dehydrogenase (LDH), an enzyme that can rise with tissue damage or active lymphoma. Hepatitis B testing is important before anti-CD20 treatment, which targets the CD20 protein on B cells, even if there is no known history of hepatitis. Hepatitis C and human immunodeficiency virus (HIV) testing may also affect care. Heart assessment is commonly needed before anthracycline chemotherapy, a drug family that includes doxorubicin.

When the nervous system needs assessment

Headache, visual change, seizures, confusion or new weakness requires assessment. Brain imaging and tests of cerebrospinal fluid, the fluid around the brain and spinal cord, are used when clinically indicated. Some aggressive lymphomas carry a higher risk of central nervous system (CNS) involvement, meaning disease in the brain, spinal cord or their surrounding fluid. Preventive treatment is not required for every lymphoma and should be discussed individually because its benefits and risks vary.

Measuring response

The team chooses response tests that fit the subtype and treatment. PET-CT results may be described using the Deauville scale, a five-point score comparing tracer uptake with reference areas in the chest and liver. An active area can reflect inflammation or infection as well as lymphoma, particularly soon after treatment. A biopsy or repeat assessment may be needed before changing to a major new treatment. Routine repeated surveillance PET scans after remission are not appropriate for everyone.

Preparing for your appointment

If scans have been performed, bring a CD containing your scan images in Digital Imaging and Communications in Medicine (DICOM) format, the standard used for medical images, together with the software needed to view them, along with the written scan reports. Bring your biopsy report and ask whether the pathology slides or tissue blocks are needed for specialist review or additional tests. Keep originals safe and agree how borrowed material will be returned. Having the actual images allows the team to compare changes and plan treatment accurately.

A repeat test is sometimes needed because an earlier sample was too small, a scan did not cover the necessary area, or a new result will change treatment. Ask what question the test will answer, how it may affect the plan, and when you should expect the result. A result described as uncertain does not automatically mean the cancer is worse. Sometimes discussion between the scan specialist (radiologist), tissue specialist (pathologist) and treating team resolves the uncertainty without another procedure.

Before a scan or procedure, mention kidney problems, previous contrast reactions, implanted devices, diabetes medicines, blood-thinning medicines and the possibility of pregnancy. Follow the testing centre's instructions about food, drink and medicines. If you have not received those instructions, contact the centre rather than making changes yourself.

Planning your treatment

A subtype-specific plan

The plan should name the exact lymphoma, whether treatment is needed now, the intended goal and how response will be assessed. Age alone should not determine care. Fitness, heart and kidney function, other illnesses, frailty, previous treatments and personal priorities all matter. Some people benefit from adjusted doses or a different regimen rather than abandoning an effective treatment altogether.

Active monitoring is planned care for selected indolent lymphomas without troublesome symptoms or threatened organs. It usually includes consultations, examination and blood tests, with scans when indicated. Starting treatment earlier has not been shown to help everyone in this situation. Tell the team about new symptoms rather than waiting for the next scheduled visit.

Treatment methods

Treatment may use chemotherapy, antibodies such as rituximab or obinutuzumab, targeted medicines, radiotherapy, immunotherapy, stem cell transplantation or chimeric antigen receptor (CAR) T-cell therapy, which modifies your immune T cells to recognise lymphoma. Bispecific antibodies bring immune cells close to lymphoma cells. These approaches are not interchangeable: the subtype, previous treatments and specific eligibility determine which can help.

Radiotherapy can sometimes cure a localised indolent lymphoma or be part of treatment for an aggressive lymphoma. In more widespread disease it may help a troublesome site. Its field and dose are tailored to the goal, previous treatment and nearby organs.

Fertility and practical preparation

Discuss fertility before treatment starts whenever time permits. Sperm, egg or embryo preservation may be possible. Certain intensive regimens and transplantation can cause lasting infertility. Pregnancy, contraception and breastfeeding require advice specific to the medicines being used.

Before an intensive course, ask about the expected hospital time, whether a central line (a tube in a large vein) is needed, infection prevention, transfusion support and when to contact the team. For cellular therapy or transplantation, identify a caregiver and discuss the period of close monitoring near the treatment centre. Eligibility assessment should begin early enough to keep later options open.

Questions to ask your care team

• What is the exact cancer type and stage, and are any important results still pending?
• Is the aim to cure the cancer, reduce the chance of recurrence, control it, or relieve a particular symptom?
• What benefit do you expect from this option, and what are the reasonable alternatives for me?
• How will treatment affect everyday activities, fertility, sexual health and the things I most value?
• How will we know whether it is working, and when will we review the plan?
• Who should I contact between visits, including at night or over a weekend?

Clinical trials and newer treatments

A clinical trial can be worth considering at diagnosis or when treatment needs to change. Trials ask a defined question; some compare established treatments and others study a newer approach. Eligibility depends on the cancer, previous treatment, test results and health. Taking part is voluntary, and choosing not to participate does not remove your right to standard care. Ask about extra visits, possible randomisation (allocation to a treatment group by chance), travel, side effects and what happens when the study ends.

Newer treatments are considered using the clinical evidence, recognised guidelines and the exact cancer type, biomarkers (features found by laboratory tests) and previous treatment. Some options have less mature evidence than established treatments. Ask what is known, what remains uncertain and whether a clinical trial would be appropriate.

Your priorities and supportive care

Tell the team what you are hoping treatment will make possible: returning to work, caring for family, keeping independence, reducing pain or attending an important event. These priorities can influence a choice between reasonable options. If the likely benefit is small and the burden is substantial, discussing a less intensive approach is appropriate. Decisions can be revisited when your health or circumstances change.

Supportive and palliative care help with symptoms, sleep, mood, family concerns and planning. They can be provided alongside treatment intended to cure or control cancer. A referral does not mean that active treatment is ending. If the cancer cannot be cured, ask what treatments may help you live longer or more comfortably and how their burdens compare with their likely benefits.

Treatment options

Diffuse large B-cell lymphoma

DLBCL is the commonest aggressive B-cell lymphoma and is often treated with curative intent. Initial treatment commonly includes an anti-CD20 antibody and anthracycline-based chemotherapy. R-CHOP combines rituximab, cyclophosphamide, doxorubicin, vincristine and a steroid, usually prednisolone or prednisone. It remains an established option. Polatuzumab vedotin with rituximab, cyclophosphamide, doxorubicin and prednisolone is an option for appropriate newly diagnosed patients; vincristine is omitted from that combination. Stage, risk, fitness and local clinical pathways influence the choice.

Limited-stage disease may need fewer cycles or a combination with radiotherapy, depending on risk and response. Bulky disease, testicular involvement and certain high-risk pathological subtypes need additional planning. High-grade lymphomas with specific gene rearrangements may be considered for a different intensive regimen. The pathology result should guide that discussion rather than treating all DLBCL identically.

If disease returns within a year of first-line treatment or does not respond, CAR T-cell therapy can be an important option for eligible patients. Salvage treatment means another treatment after lymphoma has returned or not responded. For a later relapse that responds to it, high-dose chemotherapy followed by an autologous stem cell transplant remains an option for selected people. Autologous means using your own previously collected blood-forming cells to restore blood production after the high-dose treatment. A new biopsy is often useful before salvage treatment.

Later-line options include CAR-T therapy, bispecific antibodies such as epcoritamab or glofitamab, polatuzumab-containing treatment, tafasitamab with lenalidomide, loncastuximab tesirine and other chemotherapy or antibody combinations. Glofitamab with gemcitabine and oxaliplatin is an option for appropriate patients with relapsed or refractory DLBCL classified as not otherwise specified, meaning it does not fit a more specific subtype, who are not candidates for autologous transplantation.

Brentuximab vedotin with lenalidomide and rituximab is another option for selected relapsed large B-cell lymphoma after at least two previous lines when autologous transplantation or CAR-T is unsuitable. These choices require careful attention to the precise indication and previous exposure.

Follicular lymphoma

Follicular lymphoma is often slow-growing. Localised disease can sometimes be treated with radiotherapy with the possibility of long-term disease control or cure. For more widespread disease without symptoms or high tumour burden, observation may be appropriate. When treatment is needed, options include an anti-CD20 antibody alone, an antibody combined with chemotherapy, or lenalidomide with rituximab. Maintenance antibody treatment is considered in selected situations.

The pathological grade and current classification matter. Follicular large B-cell lymphoma, previously called grade 3B, generally follows an aggressive lymphoma approach. Suspected transformation requires a new biopsy and usually a different plan.

After relapse, the best choice depends on how soon the disease returned, previous treatment, symptoms and biopsy findings. Options include a different antibody-based regimen, lenalidomide combinations, bispecific antibodies and CAR-T therapy.

Epcoritamab with lenalidomide and rituximab and tafasitamab with lenalidomide and rituximab are newer options for appropriate relapsed follicular lymphoma. Epcoritamab or mosunetuzumab alone and CAR-T products have treatment-line and eligibility requirements. A newer drug is not automatically better for someone who can obtain a durable remission with a simpler approach.

Mantle cell lymphoma

Mantle cell lymphoma often needs systemic treatment. The team considers fitness, how much lymphoma is present, changes in the TP53 gene and whether the cells have blastoid or pleomorphic features, which describe more aggressive appearances under the microscope. TP53-altered disease can respond less well to conventional chemotherapy and merits early specialist discussion. Selected people with slow, low-burden disease can be monitored initially.

For fit patients, treatment may include an anti-CD20 antibody with cytarabine-containing chemotherapy and a Bruton tyrosine kinase (BTK) inhibitor, which blocks a growth signal in B cells. The role of autologous transplantation is evolving in this setting and should be individualised; it is not automatically required for every patient receiving a modern BTK-inhibitor-containing programme. Maintenance rituximab is used in suitable pathways.

For people who are not candidates for intensive treatment or transplantation, bendamustine with rituximab is an established approach. Acalabrutinib with bendamustine and rituximab is an option for appropriate previously untreated patients who are ineligible for autologous transplantation. Other adjusted regimens may be preferable for frailer patients.

If mantle cell lymphoma returns, treatment can include a BTK inhibitor, CAR T-cell therapy or other antibody and chemotherapy approaches. Pirtobrutinib is a non-covalent BTK inhibitor, which attaches to BTK differently from older drugs in this class. It is an option after at least two previous treatment programmes, including a BTK inhibitor.

Sonrotoclax blocks B-cell lymphoma 2 (BCL-2), a protein that helps lymphoma cells survive. It is a newer option after at least two previous lines including a BTK inhibitor. Its dose escalation and tumour lysis precautions are important. Specialist referral is particularly valuable when lymphoma progresses during BTK-inhibitor treatment.

Marginal zone lymphoma

Marginal zone lymphoma includes mucosa-associated lymphoid tissue (MALT) lymphoma, which starts outside lymph nodes, splenic marginal zone lymphoma in the spleen, and nodal marginal zone lymphoma in lymph nodes. Their initial treatment can differ. In gastric MALT lymphoma in the stomach associated with the bacterium Helicobacter pylori, antibiotics to eradicate the infection can be the first treatment. Response can take time and requires planned follow-up with endoscopy, a camera examination of the stomach, and biopsies. Antibiotics are not a treatment for every MALT lymphoma, and histology, stage and relevant molecular findings matter.

Localised MALT lymphoma may be treated with radiotherapy. Some asymptomatic splenic or nodal disease can be monitored. Rituximab alone or antibody-based systemic treatment is used when symptoms, low blood counts or the amount of lymphoma justify it. Splenectomy, an operation to remove the spleen, has a role in selected splenic cases but is not the default for everyone. Relevant infections, including hepatitis C in some cases, should be assessed and treated appropriately.

Relapsed options include further anti-CD20-based treatment, lenalidomide combinations or targeted medicines such as zanubrutinib in appropriately pretreated patients. Lisocabtagene maraleucel CAR-T therapy is an option for eligible marginal zone lymphoma after at least two previous systemic lines. The risks and logistics of cellular therapy need to be balanced against the behaviour of the disease and other available options.

Waldenström macroglobulinaemia

Waldenström macroglobulinaemia is a lymphoplasmacytic lymphoma: a slow-growing B-cell lymphoma that produces excess immunoglobulin M (IgM), a type of antibody protein. Some people do not need treatment immediately. Treatment is prompted by problems such as anaemia, troublesome symptoms, nerve damage, organ involvement or hyperviscosity, in which excess protein makes the blood unusually thick, rather than by an IgM value alone. Testing for changes in the MYD88 and sometimes CXCR4 genes can help clarify the diagnosis and treatment choice.

Blurred vision, headache, bleeding or confusion can be signs of hyperviscosity and need urgent assessment. Plasma exchange filters and replaces the liquid part of the blood to rapidly lower circulating IgM while lymphoma-directed treatment addresses its production. Rituximab can initially raise IgM, so the team may adjust its timing when this would be dangerous.

Treatment options include a BTK inhibitor or rituximab-based combinations such as bendamustine and rituximab. Choice depends on the required speed of response, mutation findings, other illnesses and whether a fixed course or ongoing treatment is preferred. This disease is different from multiple myeloma, despite both being associated with abnormal proteins.

Primary mediastinal B-cell lymphoma

Primary mediastinal B-cell lymphoma often presents as a mass in the chest and can cause breathlessness or pressure on major veins. Treatment usually aims for cure and uses an intensive antibody-chemotherapy approach such as dose-adjusted EPOCH-R (etoposide, prednisolone or prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab), or another established programme with radiotherapy decisions based on the treatment pathway and response.

Residual masses are common and do not always mean viable lymphoma. PET findings need expert interpretation. For relapsed disease, treatment may include salvage therapy, transplantation, CAR-T or a checkpoint inhibitor such as pembrolizumab in eligible patients. Chest symptoms from obstruction require prompt assessment.

Burkitt lymphoma

Burkitt lymphoma grows very quickly and needs urgent specialist treatment. It is commonly associated with changes in the MYC gene, but a MYC finding alone does not establish this diagnosis. Treatment uses a Burkitt-specific multi-drug programme, often with rituximab, and includes central nervous system-directed treatment. Ordinary R-CHOP is generally inadequate for this disease.

Tumour lysis prevention and close monitoring are essential, sometimes before chemotherapy starts. Treatment intensity is adapted to risk, fitness and organ function. Despite rapid growth, Burkitt lymphoma can be cured. HIV-associated disease also needs coordinated antiretroviral and supportive care, with attention to drug interactions.

Primary central nervous system lymphoma

This lymphoma begins in the brain, spinal cord, eyes or related central nervous system structures. Diagnosis commonly needs a brain biopsy, with eye examination and other tests as appropriate. If the person is clinically stable, the team may avoid steroids before biopsy because steroids can make the diagnosis harder. Urgent symptoms can change that decision.

High-dose methotrexate-based treatment is central to care, often combined with other medicines. Eligible patients may receive consolidation, meaning further treatment to strengthen the response, with autologous transplantation or another planned approach. Radiotherapy has selected roles, but delayed effects on memory and thinking are especially important in older adults. Standard systemic DLBCL treatment alone does not adequately treat this disease. Kidney function, hydration and interactions require close monitoring during high-dose methotrexate.

Peripheral T-cell and anaplastic large cell lymphomas

Peripheral T-cell lymphoma includes several subtypes, such as nodal T-follicular helper lymphomas, peripheral T-cell lymphoma not otherwise specified and systemic anaplastic large cell lymphoma. Pathology should distinguish them and assess relevant markers, including CD30 and, for anaplastic large cell lymphoma, anaplastic lymphoma kinase (ALK), a protein that helps distinguish subgroups. Prognosis and treatment can differ between these categories.

Initial therapy often uses an anthracycline-based combination. Brentuximab vedotin with cyclophosphamide, doxorubicin and prednisolone is an important option for appropriate CD30-positive disease, particularly systemic anaplastic large cell lymphoma. Selected patients may be considered for consolidation with autologous transplantation. The value of transplantation depends on subtype, response and individual risk.

Relapsed disease may be treated with subtype-appropriate medicines, chemotherapy or, for suitable patients, allogeneic transplantation, which uses blood-forming cells from a donor. The evidence and approved indications for individual medicines differ between T-cell subtypes. B-cell antibodies and B-cell CAR-T products should not be assumed to work for T-cell lymphoma.

Cutaneous T-cell lymphoma

Mycosis fungoides and Sézary syndrome are lymphomas that primarily affect the skin, although more advanced disease can involve blood, nodes or organs. Early skin-limited mycosis fungoides is often managed with skin-directed treatment such as medicines applied to the skin, phototherapy (controlled ultraviolet light treatment) or local radiotherapy. It does not automatically require intensive chemotherapy.

More extensive or refractory disease may need systemic treatment, including medicines such as bexarotene, interferon, mogamulizumab or brentuximab vedotin for eligible CD30-positive disease. Extracorporeal photopheresis, in which some white cells are collected, treated with a light-sensitive medicine and ultraviolet light, then returned to the blood, has a role in selected patients, particularly with blood involvement. Skin care, itch control and infection management are integral to treatment. Diagnosis may need several biopsies because early disease can resemble eczema or other skin conditions.

Other uncommon lymphomas

Extranodal NK/T-cell lymphoma requires expert assessment, including Epstein–Barr virus testing in the tissue. Treatment commonly uses radiotherapy and asparaginase-containing systemic therapy in a stage-adapted plan. A conventional anthracycline-only lymphoma regimen is generally not the right approach.

Lymphoblastic lymphoma follows an acute lymphoblastic leukaemia-type programme, including central nervous system-directed treatment. See the acute lymphoblastic leukaemia guide for the shared principles. Small lymphocytic lymphoma follows the chronic lymphocytic leukaemia and small lymphocytic lymphoma pathway.

Post-transplant lymphoproliferative disorders need joint care with the transplant team. Treatment may include carefully adjusting medicines that suppress the immune system, anti-CD20 therapy for suitable B-cell disease and lymphoma-directed treatment. Patients must not stop transplant medicines themselves. Other very rare entities, including adult T-cell leukaemia/lymphoma and primary effusion lymphoma, need dedicated specialist pathways rather than a generic non-Hodgkin regimen.

Managing side effects

Infection and low blood counts

Chemotherapy, antibodies, targeted treatments and cellular therapy can reduce resistance to infection in different ways. Ask for the team's fever threshold and emergency contact instructions. Fever or new severe illness during treatment needs urgent assessment even if the last blood count was satisfactory. Growth factors that help restore blood cells, antiviral medicines, medicine to prevent Pneumocystis pneumonia (an infection that can occur when immunity is weakened), or other measures are prescribed according to the regimen and individual risk.

Hepatitis B can reactivate during anti-CD20 treatment. Screening and, where indicated, preventive antiviral treatment and monitoring are important. Repeated infections or low antibody levels may need specialist assessment; immunoglobulin replacement is used for selected patients rather than routinely for everyone.

Tumour lysis, nerves and heart health

High tumour burden and rapidly growing disease increase tumour lysis risk. Preventive fluids, uric-acid-lowering treatment and repeated blood tests may be needed. Do not assume that an oral targeted medicine is low risk: some require a carefully supervised dose escalation.

Vincristine, polatuzumab and brentuximab can affect nerves. Report tingling, pain, weakness or constipation early. Anthracyclines can affect the heart; BTK inhibitors can cause bleeding, high blood pressure or heart rhythm problems. Tell the team about anticoagulants and planned procedures. Drug interactions should be checked before starting new prescription medicines, supplements or herbal products.

Cellular therapy and bispecific antibodies

CAR-T cells and bispecific antibodies can cause cytokine release syndrome, an excessive inflammatory response from immune cells, which may involve fever, low blood pressure or breathing difficulty. Neurological effects can include confusion, difficulty speaking, tremor or seizures. These treatments require specific monitoring and a clear emergency plan. Symptoms can develop after discharge, and some problems need immediate assessment at the treating centre.

Infections and low blood counts may persist after treatment. Vaccination plans, antimicrobial prevention and follow-up blood tests are individualised. The team will explain driving restrictions and caregiver arrangements when relevant. Keep the treatment alert information with you and show it when seeking urgent care elsewhere.

Daily comfort and recovery

Nausea, mouth soreness, altered taste, diarrhoea and fatigue can often be reduced with early supportive care. Let the team know if you cannot drink, have severe diarrhoea or are losing weight. Steroids can disturb sleep, mood and blood sugar. A dietitian, physiotherapist or specialist nurse can help with practical adjustments without imposing unnecessary restrictions.

Keeping treatment manageable

Keep the team's contact details available and know where to go outside clinic hours. Report side effects early rather than waiting until the next appointment. A short record of symptoms, temperature, fluid intake and medicines can help the team decide what is needed. Do not change cancer medicine doses, restart a stopped treatment, or use leftover antibiotics without instructions. A planned delay or dose adjustment can be an important part of safe treatment.

If you receive treatment that can lower white blood cells, a temperature of 38°C (100.4°F) or higher needs urgent advice. Follow any lower threshold or additional instructions your team gives you. Chills, sudden weakness, confusion or feeling very unwell also need urgent assessment, even without a fever. Do not wait for a blood test appointment or try to hide the fever with medicine before speaking to the team.

Severe breathlessness, chest pain, a new seizure, sudden weakness, heavy bleeding or collapse require emergency care. New severe back pain with leg weakness, numbness around the bottom, or loss of bladder or bowel control also needs immediate assessment. Contact the nearest emergency service when necessary; a website contact form or routine messaging service is not an emergency pathway.

Eating, drinking and energy

Treatment may change appetite, taste, bowel habits and energy. Small, frequent meals and foods containing protein can be easier than large meals. Ask for dietitian support if weight is falling, swallowing is difficult, or you are avoiding many foods. There is no single diet that treats cancer, and severe restriction or prolonged fasting can make it harder to tolerate treatment. Check supplements with your team because some interact with medicines.

Take anti-sickness medicine as prescribed and report vomiting that prevents you keeping down fluids or essential medicines. Seek advice for persistent diarrhoea, dizziness, very little urine or increasing weakness. Fluid recommendations may need adjustment if you have heart or kidney disease. Mouth ulcers, pain or infection that interferes with eating should be treated promptly rather than accepted as unavoidable.

Gentle movement, short walks and planned rest may help fatigue, but activity should match your condition and any surgical or bone-safety restrictions. Fatigue can also reflect anaemia, infection, hormone changes, pain, poor sleep or low mood. Let the team assess a marked or persistent change. Accepting help with shopping, transport or meals can conserve energy for the activities that matter to you.

Live well

Follow-up that fits your lymphoma

Follow-up differs between a curable aggressive lymphoma in remission and an indolent lymphoma being monitored over many years. Appointments usually focus on symptoms, examination, blood tests and recovery. Imaging is used when it will answer a clinical question; more scans do not always improve outcomes. Report a new persistent lump, drenching sweats, unexplained fever, weight loss or a marked change in how you feel.

Keep a treatment summary, including radiotherapy areas, the total anthracycline doses received, transplantation and cellular therapy. This helps later clinicians plan heart assessment, vaccination and screening for late effects. A new symptom is not automatically relapse, but it should not be dismissed as a permanent consequence of treatment without assessment.

Returning to everyday life

Recovery can continue for months after treatment ends. Increase activity gradually and discuss persistent fatigue, sleep problems, nerve symptoms, mood or sexual concerns. A realistic return-to-work plan may involve shorter hours or adjusted duties. The right pace depends on the treatment received and your health, not on a fixed deadline.

Living with a lymphoma that may return can create uncertainty even when you feel well. Clear monitoring plans and knowing whom to contact can help. Psychological support and appropriate peer support are part of cancer care. Family members may need guidance too, particularly when active monitoring is the recommended treatment strategy.

Questions for the next consultation

• What is the exact subtype, and does the pathology need further review?
• Do I need treatment now, and what is its goal?
• Which features make this treatment appropriate for my lymphoma?
• How will we measure response, and what would make us change the plan?
• Could treatment affect fertility, heart health, immunity or daily activities?
• If this treatment stops working, when should a transplant or cellular-therapy team become involved?

Emotional and practical support

Feeling frightened, angry, sad or uncertain is understandable. You do not have to appear positive all the time. Ask about counselling, psycho-oncology (support for the emotional effects of cancer), support groups or a social worker if worry is affecting sleep, relationships or daily life. Persistent depression, panic or thoughts of self-harm need prompt professional help. Caregivers may need their own support and breaks; one person should not have to manage every appointment and household task alone.

It can help to agree who will update relatives and how much information you want shared. Children usually benefit from honest, age-appropriate explanations and reassurance about who will care for them. Ask permission before discussing private medical information with others. If concentration or memory is difficult, use reminders, a calendar and a trusted companion at important consultations.

Relationships, fertility and sexual health

Cancer and treatment can affect desire, comfort, fertility, body image and confidence. These are valid medical concerns. Raise fertility questions before treatment when possible, because some protective options need to be arranged early. The right approach depends on age, the treatment and how urgently it must start. Do not assume that absent periods or reduced fertility means pregnancy is impossible. Ask about contraception and the safe timing of pregnancy for your specific medicines.

Explain any pain, dryness, erection difficulties or changes in intimacy to the team. Appropriate treatments, rehabilitation and counselling can help. You can choose how much to involve a partner. Advice about hormone-containing treatments needs to take the cancer type and treatment into account; do not start them without discussing suitability.

Planning ahead while living well

Ask for a clear follow-up plan and know which symptoms should be reported between visits. Continue care for other conditions and discuss vaccinations with your oncology team; the timing and suitability of live vaccines can change during treatment. Avoid tobacco and ask for practical cessation support if needed. Activity, food and sleep plans should be realistic for your health rather than another source of pressure.

If treatment is long term, arrange periodic discussions about what is helping, what is difficult and what you want next. Planning for future care can protect your preferences and reduce uncertainty for family. You can discuss who should help with decisions if you become too unwell to speak for yourself, while continuing treatment and everyday life now.

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