This information is about a chemotherapy treatment called R-CVP which is used to treat low grade non-Hodgkin lymphoma (a cancer of the lymphatic system). If you have any further questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer support service nurses.

R-CVP is named after the drugs used in the treatment. It includes the monoclonal antibody rituximab (Mabthera®) and the chemotherapy drugs cyclophosphamide, vincristine and prednisolone, which is a steroid

Chemotherapy is the use of anti-cancer drugs (cytotoxic) drugs to destroy cancer cells.

Rituximab

Rituximab belongs to a group of drugs known as monoclonal antibodies. It’s used to treat several different kinds of B-cell non- Hodgkin lymphoma.

Monoclonal antibodies are used to try to destroy some types of cancer cells, while causing little harm to normal cells. They recognise certain proteins that are found on the surface of some cancer cells. The monoclonal antibody recognises the protein and locks onto it (like a key in a lock). This can trigger the body’s immune system to attack the cancer cells and cause the cells to destroy themselves.

Rituximab locks onto a protein called CD20, which is found on the surface of one of the main types of normal white blood cells (B-cell lymphocytes). It is also present on the surface of most of the abnormal B–cell lymphocytes that occur in some types of non-Hodgkin lymphoma. Rituximab attacks both abnormal (malignant) and normal B-cell lymphocytes. However, the body quickly replaces any normal white blood cells which are damaged, so the risk of side effects from this is very small.

R-CVP can usually be given to you as a day patient. The first treatment of R-CVP can take longer so you may need to stay overnight in hospital.

Before you start treatment you’ll need to have a blood test on the same day, or a few days beforehand. You’ll also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood tests are normal the pharmacy will prepare your treatment. All of this may take several hours.

The nurse will put a thin flexible tube (cannula) into a vein in your hand or arm, through which your chemotherapy will be given. You may find this uncomfortable or a little painful, but it should not take long.

Some people have their chemotherapy given through a thin flexible tube, which is inserted under the skin into a vein near the collarbone (a central line) or passed through a vein in their arm (a PICC line). Your doctor or nurse will explain more about this to you.

Once your treatment is ready you will be given anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula or into your line, but can also be given as tablets. You will also be given drugs to prevent an allergic reaction that some people have when rituximab is given.

The first dose of rituximab is given slowly into the vein as an infusion over a few hours. This is because some people can have an allergic reaction to it (see possible side effects). If you have a reaction the drip can be stopped and started again more slowly when the symptoms have reduced. You may need to stay in hospital overnight for the first treatment so that your medical team can keep an eye on you to check that you don’t have an allergic reaction. After this you should be able to have your rituximab more quickly and all your treatment as an outpatient.

It may take about four hours for all the drugs to be given.

• Rituximab (a colourless fluid) is given as a drip (infusion).
• Vincristine (a colourless fluid) is given as an injection into your cannula, or through your line.
• Cyclophosphamide (a colourless fluid) is usually given in the same way as vincristine. However, It can also be given as a drip.

Going home

When the drugs have been given the nurse will remove your cannula or put a cap on your line to close it off. You’ll be given anti-sickness tablets to take home with you. You should take these regularly (as directed) even if you are not feeling sick. Some medicines are more effective at preventing sickness than stopping it once it has started.

You will also be given a course of prednisolone tablets. The first dose of the prednisolone is usually given with your chemotherapy. It’s important to take all the tablets as prescribed by your doctor.

Your doctor may use the word regimen (eg the R-CVP regimen) when talking about your chemotherapy. This means the whole plan or schedule of the particular treatment you are having.

You will be given rituximab, cyclophosphamide and vincristine on the first day of your treatment. On the same day you will begin a five day course of prednisolone tablets. When you have finished the tablets you will have a rest period with no treatment for the next 16 days. This completes what is called a cycle of treatment. Each cycle takes 21 days.

After the rest period the same treatment will be repeated again, which begins the next cycle of chemotherapy. Usually 6–8 cycles are given over a period of 4–6 months. This makes up a course of treatment.

Each person’s reaction to their treatment is different. Some people have very few side effects, while others may experience more. The side effects described here will not affect every one who is having R-CVP.

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

Flu like symptoms Some people find that rituximab can cause a high temperature and chills, weakness, muscle aches, tiredness, dizziness and headache. These can occur while the drug is being given, but do not usually last long.

Low blood pressure This may happen during the infusion of rituximab, so usually your medical team will check your blood pressure regularly. People who normally take drugs to lower their blood pressure may be advised by their doctor to take these at least 12 hours before the rituximab is given. It’s important not to change your blood pressure drugs without first discussing it with your doctor.

Allergic reactions It’s not unusual to have a slight allergic reaction to rituximab. Signs of this include skin rashes and itching, a feeling of swelling in your tongue or your throat, irritation of your nasal passages, wheezing, a cough and breathlessness. You will be closely monitored during your treatment, but let your nurse or doctor know if you have any of these effects. To reduce the chance of developing an allergic reaction, you may be given drugs called antihistamines before the infusion. The infusion can also be slowed down or stopped until the reaction is over.

Flushing You may have a sudden feeling of warmth and some reddening in your face. This can happen for a short period of time during the infusion of rituximab.

Lowered resistance to infection The chemotherapy drugs 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 straightaway if:

• your temperature goes above 38ºC (100.5ºF)
• you suddenly feel unwell (even with a normal temperature).

You‘ll have a blood test before having more chemotherapy, to make sure that your cells have recovered. Occasionally, it may be necessary to delay your treatment if the number of blood cells (the blood count) is still low.

Bruising or bleeding Chemotherapy 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, and bleeding gums.

Anaemia (low number of red blood cells) While having the treatment you may become anaemic. This can make you feel tired and breathless. Let your nurse or doctor know if this affects you.

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 is not controlled, or if it continues, tell your doctor. They can prescribe other anti-sickness drugs which may be more effective. Some anti-sickness drugs may cause constipation. Let your doctor or nurse know if this is a problem.

Abdominal cramps and constipation Vincristine may cause constipation. Let your doctor or nurse know if this is a problem. It usually helps to drink plenty of fluids, eat a high fibre diet and take gentle exercise.

Loss of appetite A dietician or specialist nurse at your hospital can give advice and tips on boosting your appetite, coping with eating problems and maintaining your weight.

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

Hair loss This usually starts 2–4 weeks after the first cycle of treatment. Hair usually thins rather than falling out completely. Hair loss is temporary and your hair usually starts to grow again when your treatment is over.

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 doctor if you have any of these problems, as they can prescribe special mouthwashes and medicine to prevent or clear any mouth infection and to help relieve pain.

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

Irritation of the bladder Cyclophosphamide may irritate your bladder. It’s useful to drink plenty of fluid (up to about two litres/four pints) on the day following chemotherapy to help prevent this. If you notice any blood in your urine, tell your doctor.

Numbness or tingling in your hands or feet This is due to the effect of vincristine on nerves and is known as peripheral neuropathy. Tell your doctor if you notice these symptoms. The dose of vincristine may need to be reduced. This problem usually improves slowly a few months after treatment is over.

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.

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 cause your blood-sugar level to rise. During treatment you may have regular blood or urine tests to check this.

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.

Skin changes Rarely, your skin may darken. If it does, it usually goes back to normal a few months after the treatment has finished.

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

Changes in nails Your nails may become darker and white lines may appear on them. These changes usually grow out over a few months once treatment ends.

Changes in behaviour You may experience mood swings, difficulty sleeping and perhaps anxiety or irritability because of your steroids. Let your doctor know if there are any changes in your behaviour which are worrying you.

Always let your doctor or nurse know about any side effects that you have. There are usually ways in which they can be controlled or improved.

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’s important to tell your doctor straightaway if you have any of these symptoms. However, most clots can usually be successfully treated by using drugs to thin the blood. Your doctor or nurse can give you more information.

Other medicines Some other medicines can be harmful to take when you’re having chemotherapy. Let your doctor know 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 while vincristine is being given 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 your doctor or nurse immediately.

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

Contraception It's not advisable to become pregnant or father a child while taking this treatment, as the developing foetus may be harmed. It’s important to use effective contraception while taking these drugs, and for at least a few months afterwards. 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’re closer to your menopause it may be permanent. This will result in menopausal symptoms such as hot flushes, sweats and vaginal dryness.

This section is based upon our R-CVP 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 (54th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2007.

For further references, please see general bibliography.