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Treatment Overview or Chemotherapy > About CHOP

Last update: 07/18/2013

Introduction | Resources & Research News

About CHOP + Rituxan | Enhance CHOP? | Tips for Patients 
What's Next?
Resources and Research News

C = Cyclophosphamide (Cytoxan®) DNA-Altering
H = Doxorubicin (Adriamycin®) or Rubex® or Hydroxydaunomycin Antitumor Antibiotic
O = Vincristine (Oncovin®) Blocks Cell Duplication
P =  Prednisone (Deltasone®) steroidal: anti-inflammatory, Immunosuppressant

R- Rituxan- a monoclonal antibody is commonly added to chemotherapy protocols

A typical course of CHOP treatment consists of 6 - 8 cycles, given every 3 weeks (21 days). 

For cd20-positive lymphomas, Rituxan is added (CHOP-R), generally before CHOP.

CHOP consists of cyclophosphamide, vincristine and doxorubicin as infusions on the first day of each cycle (day 1).  You have Prednisolone (a steroid) taken at home on days 1 - 5, orally.  

About CHOP and Rituxan

TOPIC SEARCH:  ClinicalTrials.gov | PubMed

There's a growing consensus among many experts that CHOP + Rituxan (CHOP+R) is the new gold standard for treating transformed indolent, or aggressive lymphomas that express CD20. [1, 2

Is CHOP+R appropriate as frontline treatment of indolent lymphoma? 

This can only be determined in well-controlled clinical trials.  So far, the data is encouraging 4, but not yet conclusive. Bendamustine + Rituxan is the primary competing protocol for advanced FL with a current need to treat.


Dr. Sharman's CLL & Lymphoma Blog What is R-CHOP?


R-CHOP v. R-CVP in the treatment of follicular lymphoma: a meta-analysis
Treatment Decisions - Factors that Influence
Guideline for Maximum Adult Dose Limits of
Chemotherapy http://bit.ly/dfTc2a
CHOP Guidance by BC Cancer For the Patient http://bit.ly/9KJ3ny
Institute for Safe Medication Practices
Patient Tips for CHOP+R
Abstracts on CHOP + Rituxan
  1. Rituximab Plus Chemo More Effective in Elderly Lymphoma Patients.  
    Updated 02/05/02  Cancer.gov
  2. Immunochemotherapy in indolent non-Hodgkin's lymphoma. Semin Oncol. 2002 Apr;29(2 Suppl 6):11-7. Review. PMID: 12040529  PubMed
  3. Histological conversion of follicular lymphoma with structural alterations of t(14;18) and immunoglobin genes. Leukemia. 1995 Oct;9(10):1748-55. PMID: 7564520  PubMed
  4. Immunochemotherapy in indolent NHL. Semin Oncol. 2002 Apr;29(2 Suppl 6):11-7. Review.
    PMID: 12040529 | Related abstracts
  5. Patients with Low-Grade NHL Treated with Rituximab + CHOP Experience Prolonged Clinical and Molecular Remission. Session Type: Poster Session 605-I  abstracts2view.com/ 
  6. Rituxan plus CHOP extends survival in advanced follicular lymphoma  
    Jan 2005
See also:
  • Clinical Implications of Antibody Mechanisms of Action - Medscape (free login req.)
    "The Groupe d'Etudes des Lymphomes de l'Adulte group compared CHOP with rituximab/CHOP in a group of 399 elderly patients ranging from 60 to 80 years of age with diffuse large B-cell NHL.[22] Administered in the same fashion as described in the Vose study above, the following results were observed at a median follow-up of 2 years (Table 2)."

    Table 2. CHOP Vs CHOP/Rituximab in Elderly Patients With Diffuse Large B-Cell NHL: A GELA Study

    Regimen CR/CRu PR Progression Treatment-Related Death Rate
    CHOP 62% 6% 21% 7%
    CHOP/rituximab 76% 6% 9% 5%

    CHOP, cyclophosphamide, doxorubicin, vincristine, prednisone; NHL, non-Hodgkin's lymphoma; GELA, Groupe d'Etudes des Lymphomes de l'Adulte; CR, complete response; CRu, unconfirmed complete response; PR, partial response

Regarding Risks and Toxicities of CHOP-R

The therapy-limiting toxicity for doxorubicin is cardiomyopathy, which may lead to congestive heart failure and death. Approximately 2% of patients who have received a cumulative (lifetime) doxorubicin  dose of 450-500 mg?m(2) will experience this condition. 

The liposomal formulation of doxorubicin.
Methods Enzymol. 2005;391:71-97. PMID: 15721375
Late-onset neutropenia (LON) following RCHOP chemotherapy in diffuse large B-cell lymphoma 
Lai GG, Lim ST, Tao M, Chan A, Li H, Quek R. Am J Hematol. 2009 Mar 31. PMID: 19415727

...  it is reassuring that LON is self-limiting and unassociated with life-threatening infection. A watchful waiting approach is appropriate in majority of patients who develop LON following RCHOP.
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Dose-dense CHOP: Decreasing the Time between Dose Cycles?

When your receive chemotherapy, your white cell counts will typically drop, and the next round of therapy cannot begin until your counts have come back to normal or near-normal levels. During this time of low counts you are more susceptible to infection.  Long delays between treatment cycles may allow malignant cells to recover and adapt to treatment. 
Based on the results described below for breast cancer, and the rational theory that supports it, we ask treating physicians to consider the use of Neupogen (Filgrastim) for their lymphoma patients in order to raise neutrophil counts when needed so that treatments are not delayed unnecessarily.  We also ask that studies be initiated as soon as possible to determine if  "dose density" can improve outcomes for NHL patients as it has apparently done for breast cancer patients.

Aggressive lymphomas:

Incidence and Predictors of Low Chemotherapy Dose-Intensity in Aggressive Non-Hodgkin's Lymphoma: A Nationwide Study. J Clin Oncol. 2004 Sep 20 PMID: 15381684 | Related articles
Two-weekly or 3-weekly CHOP chemotherapy with or without etoposide for the treatment of YOUNG patients with good-prognosis (normal LDH) aggressive lymphomas: results of the NHL-B1 trial of the DSHNHL. Blood. 2004 Aug 1;104(3):626-33. Epub 2004 Feb 24. PMID: 14982884 | Related articles
Two-weekly or 3-weekly CHOP chemotherapy with or without etoposide for the treatment of ELDERLY patients with aggressive lymphomas: results of the NHL-B2 trial of the DSHNHL.
Blood. 2004 Aug 1;104(3):634-41. Epub 2004 Mar 11. PMID: 15016643 | Related articles
Feasibility and preliminary efficacy of R-CHOP-14 in patients with diffuse large B-Cell lymphoma (DLBCL). 
ASCO 2004 Abstract No: 6584 
Is more better?  Two parallel trials suggest that intensified CHOP is superior to standard CHOP in the management of aggressive NHL. "The authors of these papers conclude that they have defined new "preferred therapies" for histologically aggressive NHL, but the standard therapy today (although not when these trials were started) is not CHOP-21, it is CHOP-21 plus rituximab. Although rituximab may add further to the benefits of CHOP-14 or CHOEP-21 (CHOP plus etoposide), it is possible that the use of rituximab may negate any benefits due to dose intensification. In the rituximab era, it remains unclear whether "more is better," and further trials are required."  bloodjournal.org
Two-weekly CHOP with G-CSF: New Standard Regimens for Elderly Patients with Aggressive Non-Hodgkin's Lymphoma

"Finally, it appears that improvements on CHOP21 for the elderly are emerging from different directions. One approach involves the delivery of CHOP cycles over the shorter period of 14 days with granulocyte-colony stimulating factor (G-CSF) support (CHOP14G), while the other adds the anti-CD20 monoclonal antibody rituximab to CHOP21 (R-CHOP21)."


THE Case for Caution:  Dose Intensive and Dose Dense CHOP Regimens - Abstracts and Commentary CTCLconsult.com 02_01_03 "Even if these dose-dense or intense regimens were to show some advantage they would not be appropriate for a large proportion of patients who are either older or have significant comorbid illness."
Details on Neupogen  bcccancer.bc | neupogen.com professional materials
High-dose intensity cyclophosphamide, epidoxorubicin, vincristine and prednisone by shortened intervals and granulocyte colony-stimulating factor in non-Hodgkin's lymphoma: a phase II study. Br J Cancer. 1998 Sep;78(6):777-80. PMID: 9743300 PubMed
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Alternative Agents for Elderly Patients or Patients with Other (co-morbid) Conditions?

Pegylated liposomal doxorubicin in combination chemotherapy in the treatment of previously untreated aggressive diffuse large-B-cell lymphoma. Med Oncol. 2002;19(1):55-8. PMID: 12025891  PubMed
Cyclophosphamide, pegylated liposomal doxorubicin (Caelyx"), vincristine and prednisone (CCOP) in elderly patients with diffuse large B-cell lymphoma: results from a prospective phase II study. Haematologica. 2002 Aug;87(8):822-7. PMID: 12161358  PubMed
Targeted delivery and triggered release of liposomal doxorubicin enhances cytotoxicity against human B lymphoma cells. Biochim Biophys Acta. 2001 Dec 1;1515(2):144-58. PMID: 11718670  PubMed 
LIPOSOMAL DOXORUBICIN: A phase I/II trial of liposomal doxorubicin (TLC D-99, Myocet) with cyclophosphamide, vincristine, and prednisone in newly diagnosed aggressive non-Hodgkins lymphoma (NHL) Year: 2002 Abstract No: 1133
Liposomal encapsulated anthracyclines: new therapeutic horizons. Curr Oncol Rep. 2001 Mar;3(2):156-62. Review. PMID: 11177748  PubMed
Pixantrone - clinical trials - Might have similar activity against aggressive lymphomas as doxorubicin, with less cardio toxicity   redorbit 
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Dexrazoxane (Zinecard) as a cardio-protectant

Under investigation for treatment of childhood leukemias and lymphomas to see if it can prevent damage to the heart caused by doxorubicin, a drug commonly used to treat childhood leukemia and lymphoma. Results from this part of the study are not yet available.  nih.gov 

About Dexrazoxane  MedlinePlusl | PDF - FDA
Use of dexrazoxane as a cardioprotectant in patients receiving doxorubicin or epirubicin chemotherapy for the treatment of cancer  guideline.gov
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Continuous infusion doxorubicin, instead of bolus

Reduction of doxorubicin cardiotoxicity by prolonged continuous intravenous infusion. Ann Intern Med. 1982 Feb;96(2):133-9.
PMID: 7059060  PubMed
Adriamycin (doxorubicin) Gan To Kagaku Ryoho. 2001 Oct;28(10):1331-8. Review. Japanese. PMID: 11681238  PubMed
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What's Next?

Your treating physicians can also adjust treatments, add or remove agents in response to changing circumstances.  Treatment responses can also be consolidated (maintained) with additional treatments, such as 






adjunct (added) low dose radiotherapy


or stem cell ransplants


Also see Refractory Disease and Drug Resistance

Related abstracts:
Combined therapy in advanced stages (III and IV) of follicular lymphoma increases the possibility of cure: results of a large controlled clinical trial. Eur J Haematol. 2002 Mar;68(3):144-9. PMID: 12068794  PubMed
Durable Remissions Obtained with Zevalin in Recurrent Follicular Lymphoma  CancerConsultants.com Nov_8_02
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Research News

  1. Rituximab Plus Chemo More Effective in Elderly Lymphoma Patients.  Updated 02/05/02  Cancer.gov
  2. Immunochemotherapy in indolent non-Hodgkin's lymphoma. Semin Oncol. 2002 Apr;29(2 Suppl 6):11-7. Review. PMID: 12040529  PubMed
  3. Monitoring of minimal residual disease after CHOP and rituximab in previously untreated patients with follicular lymphoma.
    Blood. 2002 Feb 1;99(3):856-62. PMID: 11806987  PubMed
  4. Successful autologous peripheral blood stem cell transplantation in transformed follicular lymphoma previously treated with radioimmunotherapy (iodine (131)I tositumomab). Bone Marrow Transplant. 2002 Mar;29(6):523-5.
    PMID: 11960274  PubMed
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