What Is R-CHOP Chemotherapy?

R-CHOP is a five-drug treatment for some kinds of lymphoma. This page is for anyone starting it, or caring for someone who is. It covers what each drug does, the tests before treatment, and which warning signs need a call.

R-CHOP looks like a typo. The letters come from older brand and chemical names. NCI spells out all five:

• R is rituximab. It is not chemotherapy. It is an antibody that finds CD20-positive B cells.
• C is cyclophosphamide.
• H is doxorubicin hydrochloride. An older name for it was hydroxydaunomycin. That is where the H came from.
• O is vincristine sulfate. It was once sold as Oncovin. That brand name gave us the O.
• P is prednisone, a steroid.

NCI lists R-CHOP for B-cell non-Hodgkin lymphoma. That includes diffuse large B-cell lymphoma. It also includes advanced follicular lymphoma as a first treatment, and Waldenstrom macroglobulinemia.

Rituximab locks onto CD20, a protein on the surface of B cells. That marks the cell to be destroyed.

Doxorubicin belongs to a drug family called the anthracyclines. NCI says it blocks an enzyme called topoisomerase II. Cells need that enzyme. Blocking it damages the DNA of fast-growing cells.

Cyclophosphamide and vincristine attack dividing cells in other ways. Prednisone is a steroid.

Two tests are not optional, and both trace to specific drug risks.

A heart function test. MedlinePlus warns that doxorubicin may cause serious or life-threatening heart problems. They can start at any time during treatment. They can also start months or years after it ends. Doctors check heart function before and during therapy. They use an electrocardiogram and an echocardiogram. Ask for the number, usually reported as an ejection fraction, and keep it. Future doctors will want the baseline.

Hepatitis B testing. MedlinePlus says your doctor will order a blood test before rituximab. The drug can make a hepatitis B infection more serious or life-threatening. This is not a formality. It can flare in people who were told decades ago that an old infection had cleared.

Each drug carries a distinct signature problem. Learn which symptom belongs to which.

Rituximab: infusion reactions. These can happen during the infusion or within 24 hours after it. Watch for hives, rash, or itching, swelling of the lips, tongue, or throat, or trouble breathing. If swelling of the lips, tongue, or throat or trouble breathing starts after you have already gone home, treat it as a 911 emergency. That combination is what anaphylaxis (a severe, whole-body allergic reaction) looks like, and it does not wait for office hours.

If any of it starts while the drip is running, say so out loud right away. The nurse is right there, and the infusion can be paused in seconds. The team has antihistamines, steroids, and epinephrine on hand.

Doses are given in a medical facility with monitoring. Premedication (medicine given beforehand) is used to blunt the reaction. That is why most reactions happen during the infusion rather than after.

Rituximab: two rarer problems. Report painful sores or ulcers on skin, lips, or mouth, blisters, or peeling skin. There is a second, rarer problem. It is called progressive multifocal leukoencephalopathy, a rare brain infection. MedlinePlus says it usually causes death or severe disability. Its warning signs are new or sudden confusion, or changes in thinking. Others are trouble talking or walking, and loss of balance.

Doxorubicin: the heart. Report shortness of breath or trouble breathing. Report swelling of the hands, feet, ankles, or lower legs. Report a fast, irregular, or pounding heartbeat. These matter years later, not only during treatment.

Doxorubicin: the vein. The drug can leak into surrounding tissue and cause severe irritation or damage. Report pain, itching, redness, swelling, blisters, or sores at the injection site.

Vincristine: the nerves. Report pain, numbness, burning, or tingling in the hands or feet. Report trouble walking, or unsteady walking. Report loss of the ability to move or feel part of the body. Constipation is listed as a serious side effect, not a nuisance. Vincristine slows the bowel.

Vincristine: route. MedlinePlus states it is to be given only into a vein. Like doxorubicin, it damages tissue if it leaks.

Cyclophosphamide: the bladder. Call immediately for pink or red urine, or blood in the urine. Drink plenty of fluids and urinate often during treatment. That flushes out the drug's irritating byproducts. Otherwise they sit in the bladder.

All the chemotherapy components lower blood counts. MedlinePlus says doxorubicin can cause a severe drop in blood cells from the bone marrow. Signals to report are sore throat, fever, and chills. So are unusual bruising or bleeding, and tarry stools. Black, tarry stools go on the 911 line in the list below.

MedlinePlus and CDC give 100.4°F (38°C) or higher as the fever threshold. If your own team gave you a lower number, use theirs.

Reaching it between cycles is an emergency, not a next-morning call. Phone your cancer team right then. If nobody answers quickly, get to an emergency department and tell them you are on R-CHOP. That number, and your after-hours line, are the two things to put on the fridge.

Two deserve a real conversation before cycle one, because the window to act on one of them closes.

MedlinePlus states that cyclophosphamide may cause permanent infertility in men and women. It can interfere with periods and with sperm production. Pregnancy is still possible during treatment. If children are a possibility for you, fertility preservation is a before-treatment decision.

Both cyclophosphamide and doxorubicin carry a risk of second cancers. MedlinePlus notes doxorubicin may raise the risk of leukemia. The risk is higher at high doses, or when it is combined with certain other chemotherapy drugs.

NCI's assessment for diffuse large B-cell lymphoma is direct. Localized disease can be cured with combined-modality therapy. It can also be cured with chemotherapy alone, typically R-CHOP. For advanced-stage disease, 50 percent are cured with rituximab plus doxorubicin-based chemotherapy. That usually means Pola-R-CHP or R-CHOP.

Notice that Pola-R-CHP is now listed alongside R-CHOP. That regimen adds polatuzumab and drops the O. Vincristine comes out. If your team proposes it, the nerve-related side effects above change.

A third regimen appears for a specific situation. NCI describes dose-adjusted R-EPOCH. In primary mediastinal large B-cell lymphoma, it or R-CHOP produced high cure rates. It also avoided radiation to the chest.

• Is my regimen R-CHOP, Pola-R-CHP, or something else, and why that one?
• How many cycles are planned, and how far apart?
• What was my baseline ejection fraction, and when is it rechecked?
• Was I tested for hepatitis B, and what did it show?
• Will I get growth factor support to protect my white counts?
• Is radiation planned after chemotherapy?
• Should I see a fertility specialist before cycle one?
• What is my exact fever threshold and after-hours number?

• Call 911 or go to an emergency department if your lips, tongue, or throat swell, or you struggle to breathe, during a rituximab infusion or in the 24 hours after one. Do not drive yourself.
• Call 911 or go to an emergency department if you have chest pain, a fast or pounding irregular heartbeat, or breathlessness at rest. Doxorubicin damages heart muscle, and this can appear during treatment or years later. Do not drive yourself.
• Call the oncology line at once if you have a temperature of 100.4°F (38°C) or higher, or shaking chills, at any point between cycles. CDC says to call right away and calls a fever during chemotherapy a medical emergency. This needs a live answer now, not a message left for the clinic. Go to an emergency department if that answer does not come.
• Call 911 or go to the nearest emergency department if you have black, tarry stools, vomit blood or material that looks like coffee grounds, or have heavy bleeding. Do not drive yourself if you feel very unwell. MedlinePlus lists these as reasons to call at once (MedlinePlus).
• Call your care team right away, at any hour, if you become newly confused, have trouble talking or walking, or lose your balance. These are the warning signs of the rare brain infection linked to rituximab, and MedlinePlus says to call your doctor immediately (MedlinePlus). If confusion or trouble speaking comes on suddenly, over minutes or hours, call 911, because that can also be a stroke. Do not drive yourself.
• Call your care team right away if you have unusual bruising or bleeding, or pink or red urine. Blood in the urine is the cyclophosphamide bladder effect, and MedlinePlus says to call immediately.
• Call your care team the same day if you have not passed stool for several days and your belly is swollen or painful. Vincristine slows the bowel, and constipation is listed as a serious effect here, not a nuisance.
• Call your care team right away if numbness, burning, or tingling in the hands or feet is new or getting worse, or walking has become unsteady.
• Call your care team within a day or two if you develop mouth or skin sores, blisters, or peeling skin, or pain, redness, and swelling at the injection site.

• https://www.cancer.gov/about-cancer/treatment/drugs/r-chop
• https://www.cancer.gov/types/lymphoma/hp/aggressive-b-cell-lymphoma-treatment-pdq
• https://www.cancer.gov/about-cancer/treatment/drugs/rituximab
• https://www.cancer.gov/about-cancer/treatment/drugs/doxorubicinhydrochloride
• https://medlineplus.gov/druginfo/meds/a607038.html
• https://medlineplus.gov/druginfo/meds/a682221.html
• https://medlineplus.gov/druginfo/meds/a682822.html
• https://medlineplus.gov/druginfo/meds/a682080.html
• https://www.cancer.gov/about-cancer/treatment/side-effects/infection
• https://www.cdc.gov/cancer-preventing-infections/patients/fever.html