Treatment of Non-Hodgkin Lymphoma (NHL)
Most people diagnosed with lymphoma have a subtype of non-Hodgkin lymphoma. Non-Hodgkin lymphoma can either be aggressive or indolent.
Aggressive non-Hodgkin lymphoma grows and spreads quickly and usually requires immediate treatment. With modern treatment regimens, almost 70% of people with aggressive non-Hodgkin lymphoma will be considered cured. Research is now largely focused on finding better treatments for the minority of people with aggressive lymphoma who are not cured with initial therapy.
Indolent non-Hodgkin lymphoma grows slowly, and in some cases may not cause symptoms for years. People with indolent disease can often postpone treatment until their symptoms worsen, with no negative effects on survival. But sometimes an indolent lymphoma can turn into aggressive lymphoma, which requires immediate treatment.
Indolent non-Hodgkin lymphoma largely cannot be cured. The past two decades have seen improvements in extending the survival of people who are treated for this type of lymphoma. However, researchers are studying how to improve long-term survival further and working toward potentially curative treatments.
Chemotherapy, radiation therapy, targeted therapy, and immunotherapy are all used in the treatment of non-Hodgkin lymphoma. A stem cell transplant is sometimes used for lymphoma that has recurred, but this procedure has serious side effects. Four CAR T-cell therapies have been approved to treat some types of recurrent lymphoma. However, these newer therapies still can’t cure many people with recurrent lymphoma.
Most research on treatment for non-Hodgkin lymphoma is now focused on targeted therapy and immunotherapy. Researchers are also trying to identify gene changes in different types of lymphoma that might be targets for new drug development.
For example, in 2018, a study led by NCI researchers identified genetic subtypes of diffuse large B-cell lymphoma (the most common type of non-Hodgkin lymphoma) that could help explain why some patients with the disease respond to treatment and others don’t. Further studies may lead to more tailored treatments for patients with this type of lymphoma.
New targeted therapies
A signaling pathway is a series of chemical reactions that control one or more cell functions. Many types of non-Hodgkin lymphoma are driven by a signaling pathway called the B-cell receptor signaling pathway. A drug called ibrutinib (Imbruvica) has been developed to shut down that pathway. It is being used and tested in a number of ways:
The FDA has approved two other drugs that target the B-cell receptor signaling pathway. Acalabrutinib (Calquence) is approved for relapsed mantle cell lymphoma and small lymphocytic lymphoma. An ongoing study at NCI is testing acalabrutinib, in combination with chemotherapy and rituximab, in people with previously untreated diffuse large B-cell lymphoma.
In 2019, zanubrutinib (Brukinsa) was approved for relapsed mantle cell lymphoma. A fourth drug targeting the B-cell receptor signaling pathway, called pirtobrutinib (Jaypirca), is now being tested in clinical trials for several different types of non-Hodgkin lymphoma. In 2023, it was approved for the treatment of mantle cell lymphoma that has gotten worse after two or more previous treatments.
Many other targeted therapies are being tested in non-Hodgkin lymphoma. Some that are approved for specific subtypes are listed below.
However, in lymphoma, resistance to a single agent can occur quickly. Researchers are now testing combinations of targeted therapies to treat non-Hodgkin lymphoma to try to overcome this resistance. For example, ongoing trials led by NCI researchers are testing a five-drug regimen and a six-drug regimen in people with aggressive or indolent B-cell lymphomas whose cancer has relapsed or is resistant to treatment.
Researchers are also trying to make standard treatment regimens less toxic for older patients. In one study, NCI researchers found that the intensity of standard chemotherapy could be reduced in older adults with Burkitt lymphoma, an aggressive type of non-Hodgkin lymphoma, without compromising the potential for a cure.
Immunotherapy uses substances to stimulate or suppress the immune system to help the body fight cancer. Several immunotherapies have shown promise in treating different types of lymphoma.
CAR T cells. CAR T cells are a type of immunotherapy in which a patient’s T cells, a type of immune cell, are changed in the laboratory so they will better attack cancer cells. Four CAR T-cell therapies have been approved for the treatment of non-Hodgkin lymphoma:
To date, CAR T cells have provided long-term remissions for about one third of adults with aggressive lymphoma who receive them. Large randomized trials have been comparing CAR T-cell therapy to autologous stem cell transplantation at first relapse. In one of these trials, more people who received the CAR T-cell therapy were alive four years after treatment compared with those who received chemotherapy followed by stem cell transplantation. Participants in the other trials are still being followed to see if differences in survival emerge over time.
A phase 2 trial tested CAR T cells as initial therapy in people at very high risk of relapse. In early results, over three-quarters of patients had their cancer go into remission. However, long term results are not yet available and CAR T cells are not FDA approved in this setting.
CAR T cells are also being tested in other lymphoma subtypes, both aggressive and indolent, as well as in patients with lymphoma that has spread to the central nervous system.
Immune checkpoint inhibitors. Other immunotherapy drugs, called immune checkpoint inhibitors, work by encouraging the body’s T cells to attack cancer cells. These drugs have been largely ineffective in treating non-Hodgkin lymphoma. However, a new immune checkpoint inhibitor that interacts with a different type of immune cell called a macrophage has been developed. In a small study, almost one-third of people with an aggressive type of lymphoma and 40% of those with an indolent lymphoma had their disease go into remission with the new drug, magrolimab. In both groups, the responses seen were long-lasting.
A phase 2 trial has been testing magrolimab in combination with rituximab and chemotherapy as a treatment for several types of lymphoma. Early results showed that the drug combination can shrink some people’s cancer that had returned or gotten worse after at least one previous treatment A clinical trial underway at NCI is also testing magrolimab in combination with two targeted therapies for several different types of indolent lymphoma.
Immunomodulating drugs. Immunomodulators are drugs that either stimulate or suppress the immune system. One such drug, lenalidomide (Revlimid), has been approved in combination with targeted therapies for previously treated follicular lymphoma and marginal zone lymphoma. It is also often used to treat diffuse large B-cell lymphoma.
Novel immunotherapies. Researchers are also testing novel ways to stimulate the immune system to fight lymphoma. In 2018, a small trial showed that combining radiation therapy with the injection of a compound that stimulates the immune system could shrink some indolent B-cell lymphomas. In 2019, a trial that used a vaccine to draw immune cells into tumors in people with indolent non-Hodgkin lymphoma also showed promising results. A phase 2 trial testing this strategy in combination with an immune checkpoint inhibitor is currently underway.
Immunotherapy drugs called bispecific antibodies are also under development. These drugs bind to lymphoma cells and the body’s own immune cells at the same time to bring them together. This allows the immune cells to kill the lymphoma cells. Five bispecific antibodies are in clinical trials for various types of lymphoma, including:
Glofitamab and epcoritamab have both received accelerated approval from the FDA for the treatment of some lymphomas that have returned or gotten worse after at least two other treatments.
Hodgkin Lymphoma Treatment
Hodgkin lymphoma is much less common than non-Hodgkin lymphoma. It is mostly seen in early adulthood (age 20–39) and in late adulthood (age 65 and older). More than 75% of all adults newly diagnosed with Hodgkin lymphoma can be cured with standard chemotherapy, radiation therapy, or both. Over the last 5 decades, deaths from Hodgkin lymphoma among adults have fallen more rapidly than deaths from any other cancer type.
Researchers are now focusing on adjusting standard treatment regimens to reduce the long-term side effects and improve quality of life for survivors. They are also testing better ways to treat the minority of patients whose cancer does recur.
A protein called CD30 is commonly found on the surface of Hodgkin lymphoma cells. A drug called brentuximab vedotin (Adcetris) that targets this protein has been approved as part of initial treatment for people with advanced Hodgkin lymphoma. Use of this new drug may help older patients avoid what had been the standard treatment with an especially toxic chemotherapy drug.
Clinical trials are now testing brentuximab vedotin combined with other chemotherapy drugs and with immunotherapies. The drug has also been approved by the FDA in combination with chemotherapy for some children and adolescents with Hodgkin lymphoma.
Immune checkpoint inhibitors that help T cells to better kill cancer cells have been effective in some people with recurrent Hodgkin lymphoma. Two such drugs—nivolumab (Opdivo) and pembrolizumab (Keytruda)—have been approved for some patients with Hodgkin lymphoma that has recurred after previous treatments. Researchers are now testing these drugs in combination with other therapies, as well as earlier in treatment for some people with cancer that is likely to recur.
NCI-Supported Research Programs
The Lymphoma Specialized Programs of Research Excellence (Lymphoma SPOREs) are designed to quickly move basic scientific findings into clinical settings. The Lymphoma SPOREs support the development of new immunotherapies, novel targeted therapies, and new methods for determining prognosis for individual patients.
The goal of the International Lymphoma Epidemiology Consortium (InterLymph) is to enhance collaboration among epidemiologists studying lymphoma, provide a forum for the exchange of research ideas, and create a framework for collaborating on analyses that compile data from multiple studies.
The Lymphoma Epidemiology of Outcomes (LEO) Cohort Study was established to address the current and long-term health needs of non-Hodgkin lymphoma patients and survivors. The goal is to support a broad research agenda aimed at identifying novel clinical, epidemiologic, host, genetic, tumor, and treatment factors that significantly influence non-Hodgkin lymphoma prognosis and survivorship.
The Cancer Genome Characterization Initiative (CGCI) is supporting research to identify common gene changes in adult and pediatric cancers. Its results are freely available to the wider cancer research community, to spur the development of new targeted drugs. The HIV+ Tumor Molecular Characterization Project (HTMCP) and Burkitt Lymphoma Genome Sequencing Project (BLGSP) are two active CGCI projects.
Within the Center for Cancer Research, the Lymphoid Malignancies Branch focuses on identifying abnormalities in the immune system and looking at molecular disorders that underlie lymphoid malignancies.
The Clinical Trial Sequencing Project (CTSP) promotes the use of genomics in NCI-sponsored clinical trials. CTSP’s goal is to clarify the molecular basis of response and resistance to therapies studied. Diffuse large B-cell lymphoma is one of the cancer types under study, along with breast and renal cell carcinoma.