CHOP

CHOP is a cancer drug combination. It includes the drugs we list below, next to each drug, we have how you pronounce the drug name in brackets:

• C - cyclophosphamide (sye-cloh-foss-fah-mide)

• H - doxorubicin (doks-oh-roo-bi-sin)

• O - vincristine (vin-kris-teen) which used to be called Oncovin

• P - prednisolone (pred-ni-suh-lown)

It is a treatment for non-Hodgkin lymphoma (NHL).

How does CHOP work?

Cyclophosphamide, doxorubicin and vincristine are chemotherapy drugs. These drugs destroy quickly dividing cells, such as cancer cells.

Prednisolone is a type of steroid. It treats NHL by stopping the cancer cells growing and killing them. It may also help you feel less sick during treatment.

How do you have CHOP?

You have cyclophosphamide, vincristine and doxorubicin as a drip into your bloodstream (intravenously). You take prednisolone as tablets.

You might have treatment through a long plastic tube that goes into a large vein in your chest. The tube stays in place throughout the course of treatment. This can be a:

• central line
• PICC line
• portacath

If you don't have a central line

You might have treatment through a thin short tube (a cannula) that goes into a vein in your arm. You have a new cannula each time you have treatment.

Risk of tissue damage

When you are having this treatment through a cannula it could damage the tissue if it leaks out of the vein. This is called extravasation. This can happen anywhere along the vein that the drug is going into. It doesn’t happen very often. Tell your nurse straight away if you notice any changes such as swelling, redness, pain, burning, or a stinging feeling.

Your nurse will stop the drug treatment. And they will treat the area to relieve symptoms and reduce tissue damage. Contact your healthcare team if you develop any of these symptoms when you are at home.

Taking your tablets

You swallow the prednisolone tablets whole after a meal, or with milk, as they can irritate your stomach. It is best to take them after breakfast.  

Speak to your pharmacist if you have problems swallowing the tablets.

Whether you have a full or an empty stomach can affect how much of a drug gets into your bloodstream.

You should take the right dose, no more or less.

Talk to your healthcare team before you stop taking a cancer drug or if you miss a dose.

How do you have CHOP?

You have CHOP as cycles of treatment. This means that you have the drug and then a rest to allow your body to recover.

You can have CHOP over 14 days (2 weeks) or 21 days (3 weeks). You may have 6 cycles of treatment in total.

If you are over 80 years of age and have other health conditions you might have a mini-CHOP. This means you have the same drugs but lower doses of each. Each cycle is 21 days (3 weeks). You have up to 6 cycles of mini-CHOP. You might stop before the 6 cycles if the treatment is no longer working or if the side effects get too bad.

A cycle of CHOP and mini-CHOP over 21 days (3 weeks) looks like this:

You then start the next cycle of treatment. 

A cycle of CHOP over 14 days (2 weeks) looks like this:

You then start the next cycle of treatment. 

GCSF injections

You might also have a drug called granulocyte colony stimulating factor (G-CSF). This makes your bone marrow produce white blood cells more quickly after treatment. It helps lower your risk of getting an infection.

You usually start G-CSF on day 6 of your cycle of treatment, and you have it for a few days. Your healthcare team will tell you more about this.

Tests

You have blood tests before and during your treatment. They check your levels of blood cells and other substances in the blood. They also check how well your liver and kidneys are working.

You might have other tests such as an electrocardiogram (ECG) to see how well your heart works.

Before treatment starts, you have a blood test to check for viruses such as hepatitis B, hepatitis C, HIV or cytomegalovirus (CMV) . This treatment can mean that your immune system  doesn't work as well as it normally does. So infection with these viruses can become active again if you’ve had them in the past. 

What are the side effects of CHOP?

Side effects can vary from person to person. They also depend on what other treatments you're having. 

When to contact your team

Your doctor, nurse or pharmacist will go through the possible side effects. They will monitor you during treatment and check how you are at your appointments. Contact your advice line as soon as possible if:

• you have severe side effects 

• your side effects aren’t getting any better

• your side effects are getting worse

Early treatment can help manage side effects better. 

We haven't listed all the side effects here. Remember it is very unlikely that you will have all of these side effects. But you might have some of them at the same time.

Common side effects

These side effects happen in more than 10 in 100 people (more than 10%). You might have one or more of them. They include:

Increased risk of infection

Increased risk of getting an infection is due to a drop in white blood cells. Symptoms include a change in temperature, aching muscles, headaches, feeling cold and shivery and generally unwell. You might have other symptoms depending on where the infection is.

Infections can sometimes be life threatening. You should contact your advice line urgently if you think you have an infection. 

Chicken pox and shingles

Keep away from people who have chicken pox or shingles whilst taking steroids if you have never had these illnesses. They could make you very ill.

If you do come into contact with someone who has them, tell your doctor or nurse straight away.

Bleeding problems

This treatment can cause a drop in the number of platelets in your blood. These blood cells help the blood to clot when we cut ourselves. You may have nosebleeds or bleeding gums after brushing your teeth. Or you may have lots of tiny red spots or bruises on your arms or legs (known as petechiae).

You might also bleed from other parts of the body, but this is less common. Let your healthcare team know If you notice any blood in your poo or in your sick.

Breathlessness and looking pale

You might be breathless and look pale due to a drop in red blood cells. This is called anaemia.

Hair loss

You could lose all your hair. This includes your eyelashes, eyebrows, underarms, legs and sometimes pubic hair. Your hair will usually grow back once treatment has finished but it is likely to be softer. It may grow back a different colour or be curlier than before. 

Inflammation of the bladder

You might feel that you have to pass urine more often than usual or find it difficult to pass urine. And you may have a burning feeling when you do. Or you might feel that you can't wait when you need to go. This is called cystitis. 

It helps to drink plenty of fluids. Don't take any over the counter medicines for cystitis. Contact your advice line instead.

Less commonly, you might have blood in your urine.

Nerve changes

This treatment can cause numbness or tingling in fingers or toes. It is often temporary and can improve after you finish treatment.

Some people have nerve pain (neuralgia) but this is rare. It can feel like a burning, shooting or tingling pain, or a feeling of crawling under the skin.

Tell your healthcare team if you're finding it difficult to walk, feel or complete fiddly tasks such as doing up buttons or if you have nerve pain.

Constipation

Constipation is easier to sort out if you treat it early. Drink plenty and eat as much fresh fruit and vegetables as you can. Try to take gentle exercise, such as walking. Tell your healthcare team if you think you are constipated. They can give you a laxative if needed.

Feeling or being sick 

Feeling or being sick is usually well controlled with anti sickness medicines. It might help to avoid fatty or fried foods, eat small meals and snacks and take regular sips of water. Relaxation techniques might also help.

It is important to take anti sickness medicines as prescribed even if you don’t feel sick. It is easier to prevent sickness rather than treat it once it has started.

High temperature or chills

You might get a high temperature. Or you might feel cold or start shivering (chills). 

Skin and nail changes

You may notice changes in your skin, such as rashes, reddening and it might also be more sensitive to sunlight. This treatment can cause a condition called hand-foot syndrome or palmar plantar syndrome. This is when the skin on your hands and feet may become sore, red, or may peel. You may also have tingling, numbness, pain and dryness.

You may also notice nail changes such as them separating from their nail beds. 

Less commonly, you might have darkened nails or skin, hives or itchy skin. If you’ve had radiotherapy in the past, the area might get sore and inflamed.

It’s important to protect your skin to help prevent a reaction. The best way is to find shade, cover up your skin and wear sunscreen.

Let your healthcare team know of any skin changes. 

Sore mouth

It may be painful to swallow drinks or food. Painkillers and mouth washes can help to reduce the soreness and keep your mouth healthy. 

Diarrhoea

Contact your advice line if you have diarrhoea. For example, in one day you have 2 or more loose bowel movements than usual. If you have a stoma , you might have more output than normal. Your doctor may give you anti diarrhoea medicine to take home with you after treatment.

Try to eat small meals and snacks regularly. It’s best to try to have a healthy balanced diet if you can. You don’t necessarily need to stop eating foods that contain fibre. But if your diet is normally very high in fibre, it might help to cut back on high fibre foods such as beans, nuts, seeds, dried fruit, bran and raw vegetables. 

Drink plenty to try and replace the fluid lost. Aim for 8 to 10 glasses per day.

Tiredness and weakness (fatigue)

You might feel very tired and as though you lack energy.

Various things can help you to reduce tiredness and cope with it, for example exercise. Some research has shown that taking gentle exercise can give you more energy. It is important to balance exercise with resting.

Red or pink urine 

This won't harm you. It’s due to the colour of the chemotherapy and lasts for one or two days.

Inflammation of the veins and blood clots

You might have inflammation of a vein caused by a blood clot in the vein.

Blood clots can develop in the deep veins of your body, usually the leg. This is called deep vein thrombosis (DVT). A blood clot can be very serious if it travels to your lungs (pulmonary embolism), although this isn’t common.

Symptoms of a blood clot include:

•    pain, redness and swelling around the area where the clot is and may feel warm to touch
•    breathlessness
•    pain in your chest or upper back – dial 999 if you have chest pain
•    coughing up blood

Weight gain

You may gain weight while having this treatment. You may be able to control it with diet and exercise. Tell your healthcare team if you are finding it difficult to control your weight. 

Liver changes

You might have liver changes that are usually mild and unlikely to cause symptoms. They usually go back to normal when treatment finishes. You have regular blood tests to check for any changes in the way your liver is working.

Heart changes

Tests such as a heart trace (ECG) might show changes to how your heart works, such as your heart rhythm. Or your heart might also be less able to pump blood around the body.

You have heart tests to check how well your heart is working before you start treatment. You may also have them during and after treatment.

Heart changes can happen during treatment or some months and years after you have finished treatment.

Symptoms of heart changes can include shortness of breath; ankle swelling; chest pain; fast beating; fluttering or pounding heart.

Occasional side effects

These side effects happen in between 1 and 10 out of every 100 people (between 1 and 10%). You might have one or more of them. They include:

• a serious reaction to an infection (sepsis) - signs can include feeling very unwell, not passing urine, being sick, a very high or very low temperature or shivering - contact your advice line straight away if you have any of these symptoms
• loss of appetite
• eye changes such as dry or watery eyes or red, sore, itchy eyes (conjunctivitis)
• inflammation of the food pipe causing pain, burning sensation in your food pipe, difficulty swallowing, feeling sick, or burping
• generally feeling unwell

Rare side effects

These side effects happen in fewer than 1 in 100 people (fewer than 1%). You might have one or more of them. They include:

• a second cancer such as acute leukaemia
• not enough fluid in your body (dehydration)
• inflammation of the large bowel (colon) symptoms include diarrhoea, tummy pain and tenderness, farting, and losing control of when you poo (incontinence) 
• a reaction while you have the drugs – you might get a rash, shortness of breath, redness or swelling of the face and dizziness – tell your team straight away if this happens
• hearing loss which can be partial or total and temporary or permanent
• flushed skin
• low levels of female sex hormones
• raised levels of potassium, sodium and phosphates caused by the breakdown of cancer cells (tumour lysis syndrome)
• damage to small blood vessels in the kidneys (haemolytic uremic syndrome)
• a serious blood clotting condition that can cause you to bleed (disseminated intravascular coagulation). Tell your team straight away if you notice any signs or symptoms such as bleeding, bruising, shortness of breath, feeling as though you may faint or you are confused
• Stevens Johnson syndrome (SJS) or toxic epidermal necrolysis - a severe skin reaction that may start as tender red patches which leads to peeling or blistering of the skin. You might also feel feverish, and your eyes may be more sensitive to light. This is serious and could be life threatening

Other side effects

There isn't enough information to work out how often these side effects might happen. You might have one or more of them. They include:

• changes to your face and appearance (Cushing's syndrome) causing a puffy face, stretch marks, acne, increased facial hair or putting on weight around your tummy

• mood changes such as feeling very low (depressed) or very happy (euphoria)

• high blood sugar levels (hyperglycaemia). Symptoms might include feeling very thirsty, a dry mouth, passing urine very often, feeling tired, blurred vision, weight loss, feeling or being sick, and fruity smelling breath

• high blood pressure symptoms can include blurred vision, headaches, dizziness, nosebleeds and chest pain

• weakening of the bones (osteoporosis) which can cause a break in the bone (fracture)

What else do you need to know?

Other medicines, food and drink

Cancer drugs can interact with medicines, herbal products, and some food and drinks. We are unable to list all the possible interactions that may happen. An example is grapefruit or grapefruit juice which can increase the side effects of certain drugs.

Tell your healthcare team about any medicines you are taking. This includes vitamins, herbal supplements and over the counter remedies. Also let them know about any other medical conditions or allergies you may have.

Contraception and pregnancy

This treatment may harm a baby developing in the womb. It is important not to become pregnant or get someone pregnant while you are having treatment. Women must not become pregnant for at least a year after the end of treatment. Men should not get someone pregnant for at least 6 months after treatment. 

Talk to your doctor or nurse about effective contraception before starting treatment. Let them know straight away if you or your partner become pregnant while having treatment.

Loss of fertility

You may not be able to become pregnant or get someone pregnant after treatment with these drugs. Talk to your doctor before starting treatment if you think you may want to have a baby in the future.

Men might be able to store sperm before starting treatment. And women might be able to store eggs or ovarian tissue. But these services are not available in every hospital, so you would need to ask your doctor about this.    

Breastfeeding

Don’t breastfeed during this treatment. This is because the drugs may come through in your breast milk.

Other conditions

If you are having tests or treatment for anything else, always mention your cancer treatment. For example, if you are visiting your dentist.

Immunisations

Don’t have immunisations with live vaccines while you’re having treatment and for up to 12 months afterwards. The length of time depends on the treatment you are having. Ask your doctor or pharmacist how long you should avoid live vaccinations.

In the UK, live vaccines include rubella, mumps, measles, BCG, yellow fever and one of the shingles vaccines called Zostavax.

You can have:

• other vaccines, but they might not give you as much protection as usual
• the flu vaccine (as an injection)
• the coronavirus (COVID-19) vaccine - talk to your doctor or pharmacist about the best time to have it in relation to your cancer treatment

Members of your household who are aged 5 years or over are also able to have the COVID-19 vaccine. This is to help lower your risk of getting COVID-19 while having cancer treatment and until your immune system recovers from treatment.

Contact with others who have had immunisations - You can be in contact with other people who have had live vaccines as injections. Avoid close contact with people who have recently had live vaccines taken by mouth (oral vaccines) such as the oral typhoid vaccine. Sometimes people who have had the live shingles vaccine can get a shingles type rash. If this happens they should keep the area covered.

If your immune system is severely weakened, you should avoid contact with children who have had the flu vaccine as a nasal spray as this is a live vaccine. This is for 2 weeks following their vaccination.

Babies have the live rotavirus vaccine. The virus is in the baby’s poo for about 2 weeks and could make you ill if your immunity is low. Get someone else to change their nappies during this time if you can. If this isn't possible, wash your hands well after changing their nappy.

For further information about each drug and the possible side effects go to the electronic Medicines Compendium (eMC) website. You can find patient information leaflets for each drug on this website.

You can report any side effect you have to the Medicines Health and Regulatory Authority (MHRA) as part of their Yellow Card Scheme.