(R)-EPOCH Chemotherapy Regimen: Non-Hodgkin Lymphoma Treatment

The EPOCH chemotherapy regimen is the gold standard for treatment of all B-cell non-Hodgkin lymphoma types.

These include Burkitt lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), diffuse large B-cell lymphoma, follicular lymphoma, and mantle cell lymphoma. (NCI) It is often combined with rituximab, which is called R-EPOCH.

Read on for more information about R-EPOCH chemotherapy, its administration, side effects, and more.

What are the medications involved in R-EPOCH chemo?

• R – Rituximab
• E – Etoposide Phosphate
• P – Prednisone
• O – Vincristine Sulfate (Oncovin)
• C – Cyclophosphamide
• H – Doxorubicin Hydrochloride (Hydroxydaunorubicin)

It’s also very common to receive fluids, anti-nausea medications, as well as antihistamines like Benadryl. Your doctors and nurses will always tell you what they’re giving you. Always feel free to ask questions.

How is R-EPOCH chemo administered?

According to MD Anderson, there are four ways chemo can be administered:

• A peripheral IV line (PIV, or just “IV”) is a short catheter that’s typically placed in the forearm. It starts and ends in the arm itself. This is what you probably think of when you think of someone getting fluids.
• A PICC line is longer than an IV, and it’s generally placed in the upper arm. Its tip ends in the largest vein of the body, which is why it’s considered a central line. PICC stands for “peripherally inserted central-line catheter.”
• A CVC is the same as a PICC line, except it’s placed in the chest or neck. CVC stands for “central venous catheter.”
• A port is a catheter that’s implanted surgically under the skin on the chest. It’s another type of central line.

Be sure to discuss your infusion options with your doctor based on your needs. lifestyle, and concerns.

R-EPOCH is usually administered over several days rather than getting each medication all at once on a single infusion day. R-EPOCH may be given as entirely inpatient, or as an outpatient sent home with a continuous chemo pump. This largely depends on you and your doctor’s preferences.

Depending on how closely your team wants to monitor you, you may need to check into the hospital for your infusions. In other cases, you may go into the clinic several days in a row to start your infusions and be sent home with a chemo pump hooked up to your PICC line or port to continue them at home.

Someone who lives near their infusion center may have no problems driving back and forth for 5 or 6 days in a row each cycle, but those who live far away may find it easier to go ahead and stay at the hospital. Discuss what works best for you with your doctor.

What can I expect at an R-EPOCH infusion?

• You’ll arrive at your infusion center and check in. Depending on how busy it is, you may have to wait. Many patients suggest bringing a book, laptop or something else to keep you entertained both for any potential waiting time and for during the actual infusion itself.
• You’ll see a doctor or nurse. They’ll probably ask you how you have been feeling and maybe go over your blood work and any other preliminary test results with you if they haven’t already. If it’s your first infusion especially, feel free to ask any lingering questions you may have.
• You will take oral steroids. If you haven’t already, you’ll take your first dose of prednisone. You’ll take this orally twice a day on infusion days.
• Your infusion will begin. You might start off with pre-medication like anti-nausea, antihistamine, fluids, etc.
  • Your nurse will begin infusing rituximab first. Infusion times vary based on tolerability.
  • After this, doxorubicin, etoposide, and vincristine are (usually) mixed into the same infusion bag and given continuously over 24 hours on Days 1, 2, 3 & 4 for a total of 96 hours. If you’re outpatient, this will done by chemo pump at home.
  • Then, you’ll get cyclophosphamide as an infusion over two hours on Day 5 at the infusion center.
  • On Day 6, you’ll get Neupogen (daily until counts come up) or Neulasta once after each infusion cycle to boost your white blood cell count back to normal.
  • Your infusions are done for this cycle, but you’ll usually still get blood work drawn weekly until your counts level out.

What are the signs of an allergic reaction to R-EPOCH?

Signs of allergic reaction to R-EPOCH

As with any drug(s), there is the risk for allergic reaction. Be sure to tell your doctor if you experience any signs of allergic reaction during your infusion. These signs include, but are not limited to:

• fever and chills – these are the most common reactions and occur in most individuals
• nausea
• itching or rash
• throat irritation or watering from the nose
• swelling of hands, feet or face
• shortness of breath
• dizziness or headache

Whether you think you’re having an allergic reaction or not, you should always bring up any sensations to a nurse or doctor. If something is too uncomfortable during infusions, they can sometimes adjust your dosage or even stop a medication altogether, depending on your situation. It’s always better to say something.

Most patients on rituximab experience feeling fever and chills during their infusions, but these stop when use stops.

What are the possible side effects from R-EPOCH chemo?

• nausea
• fatigue
• constipation
• mouth sores and sore throat
• loss of appetite
• stomach/digestive pain
• muscle weakness
• joint pain
• neuropathy
• low white blood cell counts (neutropenia)
• low potassium
• swelling in legs, feet, face, stomach (from steroids and fluids)
• sensitivity to sun
• bone pain (from Neupogen)
• lightheadedness

Will I lose my hair on R-EPOCH?

Unfortunately, yes. In almost all cases of R-EPOCH treatment, patients lose their hair, eyelashes, and everything else. Hair will usually start to fall out shortly after your first few days of infusions, and most definitely will start falling out by Week 2 or 3.

Hair will start to shed more and eventually it will start to come out in clumps. Something many people don’t realize is this can be painful. Arielle Rosen, a non-Hodgkin lymphoma survivor says, “Your scalp hurts. At least for me it did. It was so painful. So I had very very white-gray hair naturally, now it’s a bit darker grown back in, but you could see the red of my scalp, and I just wanted it off.”

When your hair begins to fall out, depending on your viewpoint, it may be traumatic for you. Remember that it’s okay to feel sad about it. It’s part of you.

Many patients TPS has talked to feel a sense of empowerment from shaving their heads when it starts to fall out. It can give you a sense of control in an otherwise helpless situation. Others let it fall out on its own. Both are totally acceptable. Just be careful that it doesn’t get matted, which can be uncomfortable.

Does R-EPOCH cause infertility?

According to studies in female fertility, R-EPOCH can cause the loss of a menstrual cycle during and after chemo for some time. It may or may not come back after treatment ends. Factors like age and overall health also affect your fertility after chemo.

Crystal Zunino, a stage 2 PMBCL survivor says, “We still don’t know if I can have kids. We’ve been trying, but we don’t know. I didn’t some lab work. My ovaries are functioning, but they don’t know if I’ll be able to get pregnant.”

TPS founder and non-Hodgkin lymphoma survivor, Stephanie Chuang says, “The thing I thought of right after my mortality was my fertility. At the time of diagnosis I was two months from getting married. Being 31 and thinking about family life meant that chemo scared me on another level outside of its general impact on my body.”

Stephanie underwent IVF treatment, and now has a miracle baby girl, who was conceived naturally!

It’s not a definite yes or no. Fertility nor infertility are guaranteed with R-EPOCH chemo. It’s always best to bring the topic up to your oncologist if they haven’t already mentioned it to you.

How long does R-EPOCH treatment last?

A common treatment timeline is 6-8 cycles of R-EPOCH. This can vary depending on your staging and overall health. Each cycle looks something like this:

• Day 1 is the first day of your first cycle – This is your first round or infusion of chemo. It can last upwards of 8 hours depending on your wait time, infusion center size, how your body responds to the medication, etc. for the first cycle. This is the rituximab infusion. This time should decrease as your cycles go on.
• Days 2-4 – This is your 24-hour continuous infusion of doxorubicin, etoposide, and vincristine for a total of 96 hours. You (or a loved one) won’t likely have to go to the clinic these days.
• Day 5 – This is when you go back to the infusion center to unhook from your chemo pump and get your cyclophosphamide infusion. This can last upwards of 2 hours.
• Day 6 – You’ll go in for blood work most likely on this day and receive a white blood cell count booster.
• Day 7 on to Day 21-28 – Rest and recovery.

R-EPOCH is typically repeated every 21 – 28 days. You’ll have infusion days (Day 1-5 or 6), and then a period of rest before another infusion. Rest days are connected to the infusion that came before them and are part of that Cycle.

You reach your second Cycle on Day 1 of your second set of infusions. Each Cycle may be repeated up to 8 times, depending upon the stage of the disease. This means you can count on a month or so for each Cycle. So, generally, R-EPOCH can last up to ~8 months, depending upon response, tolerability, and number of cycles prescribed.

What advice do other patients have about R-EPOCH?

• Patrick Mulick, Primary Mediastinal, Stage 2

“Keep going. Know that your attitude is going to be half the battle. Keep going and stay positive. Believe in yourself. It’s a journey that has its ups and downs, but you just have to keep going.

Sometimes, you can’t see the light at the end of the tunnel – you might not even know that there is a light at the end of the tunnel – but you have to keep going and trust in the process.”

• Donna Sedeghi, Primary Mediastinal, Stage 1-2

“Remember that no matter how bad things may seem at first, you really don’t know the outcome until you get there. Going through chemo to fight cancer was not nearly as bad as I made myself believe it would be. None of my original fears came true, and I have come out on the other side better than before.

Most importantly, no matter how bad this ordeal was in the midst of it, I understand why it happened. The person I am today as a result of this experience is the person I needed to be. For that, I am grateful.”

• Brianna Banachoski, Anaplastic Large Cell, Stage 2B, Alk+

“Follow the directions your doctor gives you. If they tell you your white blood cell count is going to be low, and they tell you to keep yourself safe from infection, do it. Wash your hands, keep yourself away from crowds and be careful.

If your platelets are going to be low, don’t floss. Don’t do anything dangerous that might lead to you bleeding. Follow those rules because that can prevent so many complications in and of itself. The last thing you want to deal with when you’re going through cancer already is unnecessary complications.”

• Stephanie Chuang, Diffuse Large B-Cell, Stage 3

“If it helps, think of how the treatment is working whenever you are feeling side effects, including that hair loss. The drugs, the radiation, whatever it may be – they’re working to kill the cancer cells. It’s an unpleasant experience, as well, but they can exist in tandem. Feeling negative and positive emotions at the same time are not mutually exclusive.

Most importantly: you will get through this. None of us goes through the same experience. We don’t have the same results. But this experience largely gives us a different perspective on life if you let it. It can be terrible for sure, but you do have some control over your own outcome in how you approach treatment. Don’t be afraid to reach out to others. We’re all part of this club none of us signed up for. Hugs to you all.”