This information is about a chemotherapy treatment for non-Hodgkin lymphoma (cancer of the lymphatic system) called PMitCEBO. It describes the drugs used, how they are given and some of the possible side effects. If you have any questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer information nurse specialists.

PMitCEBO is named after the initials of the drugs used, which are prednisolone, which is a steroid, and the following chemotherapy drugs:

• mitoxantrone 
• cyclophosphamide 
• etoposide 
• bleomycin 
• vincristine, which used to be known as Oncovin®.

PMitCEBO chemotherapy is usually given to you as a day patient. You will need to have a blood test before you start treatment, either on the same day or a few days beforehand. You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. All of this may take a couple of hours.

The nurse will put a fine tube (cannula) into a vein in your hand or arm. You may find this uncomfortable or a little painful, but it shouldn't take long. Some people have their chemotherapy given through a fine plastic tube that is inserted under the skin, into a vein near the collarbone (a central line), or passed through a vein in the crook of their arm (PICC line). Your doctor or nurse will explain more about this to you.

Once your chemotherapy is ready you will be given an anti-sickness (anti-emetic) drug. The drug can be given by injection through the cannula, central line or PICC line, or may be taken as tablets.

The chemotherapy drugs are given separately:

• Mitoxantrone (a blue fluid) is given by drip (infusion) into your cannula or line.
• Cyclophosphamide (a colourless fluid) is given by infusion.
• Etoposide (a colourless fluid) is given by infusion.
• Bleomycin (a colourless fluid) is given by injection into a drip attached to the cannula or line.
• Vincristine (a colourless fluid) is given by infusion.

If you are having your treatment as a day patient you can then go home. The cannula will be removed before you go. If you have a central or PICC line it will usually stay in place, ready for the next cycle of your chemotherapy. You will be shown how to look after the line.

You will be given a supply of anti-sickness tablets to take home with you. You will also be given a supply of prednisolone to take. Prednisolone tablets can be either white or coated red.

It is important to take all the tablets as prescribed by your doctor. You will be also be given a course of antibiotic tablets to help prevent infection.

Your doctor may use the word 'regimen' (eg the PMitCEBO regimen) when talking about your chemotherapy. This means the whole plan or schedule of the particular treatment that you are receiving.

On the first day of your treatment (day 1), you will be given infusions of the mitoxantrone, cyclophosphamide and etoposide, as described above. Once the three infusions are finished, you can go home.

You will also start taking the prednisolone tablets. These are taken every day for four weeks and then every other day for the next four weeks (weeks 5–8).

One week after you first started your chemotherapy treatment (day 8), you will be given the bleomycin and vincristine, as described above. You can then go home.

You will have no treatment (apart from taking the prednisolone tablets) for the next six days. This completes one cycle of PMitCEBO. Each cycle takes two weeks. Usually 4–8 cycles are given over a period of 2–4 months. This makes up a course of chemotherapy.

Each person's reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described here will not affect everyone who receives PMitCEBO chemotherapy and you are not likely to have every side effect listed.

We have outlined the most common side effects. However, we have not included those that are very rare and therefore unlikely to affect you. If you notice any effects that you think may be due to the drugs, but which are not listed here, please let your nurse or doctor know.

Lowered resistance to infection PMitCEBO can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin seven days after treatment has been given, with your resistance to infection usually reaching its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal levels before your next cycle of chemotherapy is due.

Contact your doctor or the hospital straight away if:

• your temperature goes above 38ºC (100.4ºF)
• you suddenly feel unwell (even with a normal temperature).

You will have a blood test before having more chemotherapy to make sure that your number of white blood cells has returned to normal. Occasionally, it may be necessary to delay treatment if your number of blood cells (blood count) is still low.

Bruising or bleeding PMitCEBO can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding, such as nosebleeds, blood spots or rashes on the skin, or bleeding gums.

Anaemia (low number of red blood cells) While having treatment with PMitCEBO you may become anaemic. This may make you feel tired and breathless. Let your doctor or nurse know if these are a problem.

Feeling sick (nausea) and being sick (vomiting) Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or reduce nausea and vomiting. If the sickness isn't controlled, or if it continues, tell your doctor. They can prescribe other anti-sickness drugs, which may be more effective. Some anti-sickness drugs can cause constipation. Let your doctor or nurse know if this is a problem.

Tiredness Many people feel extremely tired (fatigued) during chemotherapy, particularly towards the end of treatment. This is a very common side effect and it is important to try to get as much rest as you need.

Hair loss This usually starts 3–4 weeks after the first course of treatment. Usually, all of the hair on your head falls out. You may also have thinning and loss of eyelashes, eyebrows and other body hair. Hair loss is temporary and your hair will start to grow again once the treatment has finished. Your nurse can give you advice about coping with hair loss.

Sore mouth and ulcers Your mouth may become sore or dry, or you may notice small ulcers during this treatment. Drinking plenty of fluids and cleaning your teeth regularly and gently with a soft toothbrush can help to reduce the risk of this happening. Tell your nurse or doctor if you have any of these problems, as they can give you special mouthwashes and medicine to prevent or clear any mouth infection.

Taste change Some people have a strange taste in their mouth and at the back of their throat while they have the chemotherapy. This usually passes once the chemotherapy drip or injection has finished. It can help to suck some sweets or something like a peppermint while having the treatment.

You may notice that your food tastes different. Normal taste will usually come back after the treatment finishes.

Diarrhoea If you have diarrhoea it can usually be controlled with medicine. Let your doctor know if it is severe or if it continues. Try to drink as much as 2–3 litres of fluid a day to replace the fluid you are losing.

Constipation Vincristine can sometimes cause constipation and abdominal cramps. If you don't have your bowels open as regularly as normal, or have abdominal cramps, let your doctor or chemotherapy nurse know. It's sometimes necessary to take laxatives when having PmitCEBO. Drinking plenty of fluids and a diet high in fibre with plenty of fruit and vegetables can help to reduce constipation.

Discoloured urine The mitoxantrone is blue and turns the urine a blue/green colour. This can last for up to 24 hours after the drug is given.

Cold sensation along vein This can sometimes happen when the drugs are being given.

Numbness or tingling in hands or feet This is due to the effect of vincristine on nerves and is known as peripheral neuropathy. You may notice that you have difficulty doing up buttons or similar fiddly tasks. This problem usually improves slowly a few months after the treatment is over.

Skin changes Rarely, your skin may darken, but it will usually return to normal a few months after the treatment ends. Bleomycin can cause a rash on the hands and feet and your doctor can prescribe medicine to help with this. Your skin will also be sensitive to sunlight and may burn more easily than normal. You can still go out in the sun, but always wear a high protection-factor suncream and protective clothing.

Flu-like effect This can occur a few hours after you have had bleomycin. If you have headaches or aching joints and muscles, it is important to drink plenty of fluids and rest. Contact your doctor if these symptoms continue.They can give you medicines to help reduce the effect. If the flu-like symptoms are particularly bad, it is possible to have an antihistamine injection before your next injection of bleomycin.

Your liver may be temporarily affected Samples of your blood will be taken from time to time to check that your liver is working normally.

Damage to the heart Large doses of mitoxantrone given over long periods may cause damage to the heart. This is rare with standard doses. It may occur in people who have been treated with certain other drugs. Your doctor will normally check how well your heart is working before giving you mitoxantrone, and sometimes at intervals during your treatment. In this way, treatment can be stopped before any damage to the heart affects your health.

Increased appetite You may notice that you feel hungrier than usual while taking prednisolone. This will stop when you are no longer taking the drug.

Changes in the level of sugar in your blood Occasionally prednisolone may may make your blood-sugar level rise. During treatment you will have regular blood and urine tests to check this. Tell your doctor if you get very thirsty or if you are passing more urine than usual.

Irritation of the stomach lining Prednisolone may irritate the lining of your stomach and should be taken with meals or a glass of milk. Tell your doctor if you have indigestion or any other stomach problems. They can prescribe medicine to relieve these symptoms.

You should not take any antacid medicine without first discussing it with your doctor. The coated prednisolone tablets should not be taken with antacids as they can dissolve the coating.

Fluid retention Prednisolone may affect the salt and water balance in your body. You may notice that your ankles and/or your fingers swell. Let your doctor know if this happens. This is usually only a problem with long-term treatment.

Behavioural changes Occasionally prednisolone may make you experience some feelings intensely and can cause mood swings. Let your doctor know if there are any changes in your mood that are worrying you. You may also find it difficult to sleep when you are taking this drug. Taking the prednisolone earlier in the day can help prevent sleeping problems.

The whites of your eyes may have a slight blue tint This is very rare. If it does happen it is temporary. It is due to the colour of one of the drugs and your eyes will return to normal when the treatment finishes.

Changes to the lungs The bleomycin and cyclophosphamide may cause some changes to lung tissue. Tell your doctor if you notice any coughing or breathlessness.

Risk of blood clots Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it is important to tell your doctor straight away if you have any of these symptoms. However, most clots can usually be successfully treated by using drugs which thin the blood. Your doctor or nurse can give you more information.

Other medicines Some other medicines (including those you can buy in a shop or chemist) can be harmful to take while you are having chemotherapy. Tell your doctor about any medications you are taking, including non-prescribed drugs such as complementary therapies and herbal drugs.

Leakage into the tissue around the vein If this happens with vincristine, the tissue in that area can be damaged. If you notice any stinging or burning around the vein while the drug is being given tell the doctor or nurse immediately.

Changes in nails Your nails may become darker or ridged. These changes grow out over a few months once the treatment has finished.

Some people have hot flushes, dizziness and the feeling of a blocked nose This happens when the cyclophosphamide is given. If you have any of these symptoms tell the doctor or nurse. They can slow the drip down.

Alcohol can be taken in moderation However, it is best to check with your doctor if there is any reason why it is not advisable for you to drink alcohol while you are on your chemotherapy regimen.

Fertility Your ability to become pregnant or father a child is likely to be affected by this treatment. It is important to discuss fertility with your doctor before starting treatment.

Contraception It is not advisable to become pregnant or father a child while taking this treatment, as the developing foetus may be harmed. It is important to use effective contraception while taking this drug, and for at least a few months afterwards. Again, discuss this with your doctor or nurse.

Loss of periods in women Due to the effect of chemotherapy on the ovaries you may find that your periods become irregular and may eventually stop. In younger women this may be temporary, but if you are closer to your menopause it may be permanent. This will cause menopausal symptoms such as hot flushes, sweats and vaginal dryness.

This section is based upon our PMitCEBO chemotherapy factsheet which has been compiled using information from a number of reliable sources, including:

• Martindale: The Complete Drug Reference (35th edition). Eds. Sweetman et al. Pharmaceutical Press, 2007.
• British National Formulary (56th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2008.
• The Chemotherapy Source Book (4th edition). Ed. Perry. Lippincott, Williams and Wilkins, 2007.

For further references, please see general bibliography.