You may be given just one type of chemotherapy drug or you may be given two or more such drugs together (combination chemotherapy). It is common to receive chemotherapy and monoclonal antibodies (rituximab) in combination. The selection of treatment is determined by the nature of the problems you are facing as a result of your WM, and your own state of health which will have an impact on your ability to tolerate different treatments. Some treatments can affect the stem cells in your bone marrow and should be avoided if there is a chance of needing a stem cell transplant in the future. You may be offered the chance to participate in a clinical trial.
If you are treated with just one chemotherapy drug, any side effects are likely to be mild. If you are having treatment with a combination of drugs you may have more side effects. Most treatments for WM are given as an outpatient and do not require admission to hospital unless complications such as infections occur. Your doctor or specialist nurse can tell you what to expect and you should always tell them about any side effects you have. Very effective medicines are available to reduce side effects if necessary. Treatment for WM usually spans four to six months. Sometimes the condition seems slow to respond but patience is important, a response is forthcoming in most cases given adequate time, and it is important to avoid switching to a new therapy too soon.
One of the most common side effects of chemotherapy is being more prone to infections. Always let your doctor or nurse know if you have any signs of an infection – such as a cough, fever, shivering or shaking – so it can be treated straight away.
The chemotherapy drugs most commonly used to treat WM are:
Chlorambucil (Leukeran ®)
Chlorambucil is taken as a tablet and is usually given for seven to ten consecutive days per month, for six to eight months. It should be kept in the fridge. It may be given with a steroid called prednisolone and with the monoclonal antibody, rituximab. It is generally avoided in younger patients. Chlorambucil should be avoided for anyone who may be considered for a stem cell transplant in the future as it damages stem cells and makes it difficult to collect them later.
Fludarabine (Fludara ®)
Fludarabine is usually taken as tablets but it may be given as a drip into a vein (intravenous infusion) for up to five days per month. It may be given with other agents such as cyclophosphamide and rituximab. Usually six months of treatment are required. Fludarabine should be avoided for anyone who may be considered for a stem cell transplant in the future as it damages stem cells and makes it difficult to collect them later.
Cladribine (Leustat ®)
Cladribine is a similar type of drug to fludarabine. It is usually given as an injection just under the skin (subcutaneous injection). It may be given with other agents such as rituximab. Each treatment cycle consists of five daily doses of cladribine as a subcutaneous injection, plus four weekly intravenous infusions of rituximab. This is typically repeated just once after two or three months of a rest period. Cladribine should be avoided for anyone who may be considered for a stem cell transplant in the future as it damages stem cells and makes it difficult to collect them later.
Cyclophosphamide may be taken as tablets or given into a vein (intravenously). It is usually given in combination with other agents for example: the DRC regime – Dexamethasone (a steroid), Rituximab and Cyclophosphamide; or the CHOP regimen – Cyclophosphamide, Hydroxydaunorubicin, vincristine (or Oncovin), and Prednisolone. These regimens are not toxic to stem cells and can be used even if a transplant is planned in the future. In general, CHOP chemotherapy is restricted to more aggressive forms of lymphoma that may uncommonly occur in some patients (called high grade transformation).
Bendamustine (Levact ®)
Bendamustine is given as a drip into a vein. It is usually given on day one and two of a four week cycle, in combination with rituximab, which is given only on day one of the cycle. Bendamustine can be used safely in patients who may need a stem cell transplant in the future. It is given for up to six cycles.