When Standard Chemotherapy Is No Longer Enough in B-Cell Lymphoma, Says Dr. Priyatesh Dwivedi 

The haemato-oncologist from HCG Cancer Centre, Nashik, discusses how newer therapies are reshaping treatment decisions in aggressive lymphomas.

The management of B-cell lymphoma has entered a phase where standard chemotherapy alone is no longer sufficient for a growing subset of patients. In routine oncology practice, clinicians are increasingly confronted with cases that either fail to respond adequately to first-line regimens or relapse after an initial response, prompting a reassessment of long-established treatment pathways.
According to Dr. Priyatesh Dwivedi, Haemato-Oncology and Bone Marrow Transplant specialist at HCG Cancer Centre, Nashik, this shift is most visible in aggressive B-cell lymphomas such as Diffuse Large B-Cell Lymphoma. While chemotherapy-based combinations have remained the foundation of care for decades, real-world outcomes indicate that a proportion of patients either do not achieve durable remission or present with disease biology that is less responsive to conventional approaches.

B-cell lymphoma originates from abnormal proliferation of B lymphocytes, a critical component of the immune system. In India, Diffuse Large B-Cell Lymphoma represents the most frequently diagnosed subtype among non-Hodgkin lymphomas. Data from Indian tertiary care centres and academic institutions consistently show that B-cell lymphomas account for the majority of lymphoma diagnoses, with DLBCL forming the largest share. These cases are characterised by rapid progression and require timely intervention, yet their clinical behaviour can vary significantly between patients.
Dr. Dwivedi explains that treatment decisions today are increasingly influenced by how the disease responds at defined checkpoints rather than by diagnosis alone. Patients who do not achieve adequate response after standard chemotherapy cycles are now evaluated earlier for alternative strategies, including immunotherapy-based approaches. This has altered both the sequencing of treatment and the conversations clinicians have with patients and families at the outset of care.

One of the most significant developments in this context has been the clinical introduction of CAR-T cell therapy in India. This form of treatment involves modifying a patient’s own immune cells to recognise and attack malignant B cells. Indigenous CAR-T therapies, including options developed within the country, have made this modality accessible to a broader segment of eligible patients who previously had limited options after chemotherapy failure. In clinical practice, CAR-T therapy is now considered for relapsed or refractory B-cell lymphomas under carefully selected conditions.
In parallel, newer antibody-drug conjugates and targeted agents are being integrated into treatment protocols. Drugs such as Polatuzumab, when combined with chemotherapy, have expanded therapeutic options in both relapsed disease and selected frontline settings. These combinations represent the first major additions to standard regimens after long periods of limited change, offering clinicians greater flexibility in managing patients with high-risk features.

Dr. Dwivedi notes that the role of bone marrow transplantation also continues to evolve alongside these therapies. While autologous transplant remains an important option for eligible patients, the availability of advanced immunotherapies has refined patient selection and timing. Decisions are now guided by disease response patterns, molecular risk factors, and overall treatment tolerance rather than by rigid algorithms.
From a patient-care perspective, this shift has placed greater emphasis on early assessment, detailed risk stratification, and multidisciplinary planning. Diagnostic precision through biopsies, imaging, and laboratory evaluation has become central to determining which patients may benefit from newer interventions beyond chemotherapy. At the same time, clinicians must balance efficacy with safety, given the complexity and resource intensity of advanced treatments.

Dr. Dwivedi emphasises that while these therapies represent meaningful progress, they are not universal solutions. Access, eligibility criteria, and long-term outcomes continue to be areas of active evaluation. However, the presence of multiple therapeutic pathways has fundamentally changed how clinicians approach cases where chemotherapy alone is insufficient.
In Indian oncology practice, the conversation around B-cell lymphoma has therefore shifted from whether additional options exist to how and when they should be used. This evolution reflects a broader change in cancer care, where treatment decisions are increasingly individualised and guided by disease behaviour rather than by historical convention.

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