Non-Hodgkin’s Lymphoma: Stages and Prognosis

Medically Reviewed by Arefa Cassoobhoy, MD, MPH on September 25, 2023
5 min read

When you’re diagnosed with non-Hodgkin’s lymphoma (NHL), the next step is to find out the stage of your cancer. That tells you how much lymphoma is in your body, where it is, and if it has spread outside your lymph system, the network that carries immune cells throughout your body.

Your doctor uses that information to decide the best treatment plan for you. It might also help predict the outlook for your condition, also called the prognosis. Though everyone’s NHL is different, knowing your stage can help you understand what to expect after your diagnosis.

To describe your cancer stage, doctors often use a number -- it could be Roman numerals I, II, III, or IV. Stage I means the least amount of cancer. Stage IV is the most advanced. You may see an “E” after stages I, II, or III -- that stands for extranodal. It means the lymphoma is in one area outside your lymph system.

Stage I means the lymphoma is in one lymph node, in a group of nodes that are close to each other, or in an organ that has lymphoid tissue, such as the tonsils. In stage IE, the cancer is in one area outside your lymph system.

Stage II is when the cancer is in two or more groups of lymph nodes either above or below your diaphragm, the thin sheet of muscle below your heart and lungs that separates your chest from your belly. Lymphoma is called stage IIE if it’s in one organ and the nearby lymph nodes. It might also have spread to other nodes that are on the same side of your diaphragm.

Stage III NHL is in lymph nodes on both sides of your diaphragm. If the cancer is also outside the lymph system, it’s called stage IIIE. Stage III lymphoma that’s also in your spleen is stage IIIS. If it’s stage IIIS and has spread outside your lymph system, it’s stage IIIE+S.

Stage IV lymphoma has spread outside your lymph nodes to many places in your body. NHL tends to spread to the bone marrow, liver, lungs, and the fluid around the brain.

Sometimes doctors just call NHL limited or advanced. Stage I and some stage II lymphomas fall into the limited group. Advanced disease includes stage II with a large tumor in the chest (bigger than 10 centimeters or more than 1/3 the width of your chest) and all stage III and IV lymphomas.

You may also hear the term “bulky disease” if you have a large tumor in your chest. It might mean you need more intense treatment.

Talk with your doctor about what your cancer stage means and how it impacts your treatment.

Your prognosis is a best guess at your chances of recovering from lymphoma after treatment. Your doctor will think about a few things, called prognostic factors, to get an idea of your odds. They include:

  • Your age
  • The stage of your cancer
  • The amount of an enzyme called lactate dehydrogenase (LDH) in your blood, which goes up when you have more lymphoma in your body
  • Whether the cancer is outside your lymph system
  • Your overall health

Depending on the type of NHL you have, your doctor might also consider other things, such as:

  • Your levels of hemoglobin, a protein that carries oxygen in your blood
  • Numbers of white blood cells
  • Ki-67 level -- for people with mantle cell lymphoma, it’s a way to know how fast the cancer cells are growing
  • The number of areas with cancer in the lymph nodes

Doctors often use a statistic called the 5-year relative survival rate to talk about an NHL prognosis. This means they compare the percentage of people with NHL who live for at least 5 years after their diagnosis to those who don’t have NHL.

The 5-year relative survival rate for NHL was 74% from 2008 to 2014. This means that people diagnosed with NHL are about 74% as likely as those who don’t have NHL to live for at least 5 years after their diagnosis.

Something to keep in mind about these numbers: Today, there are new and better treatments for NHL, which could affect the odds of surviving the disease. Plus, everyone’s NHL and overall health are different, and there’s no sure way to know how things will go for you. Talk to your doctor about survival statistics, prognosis, and what they might mean in your case.

The best treatment for you depends on:

  • Your stage and prognostic factors
  • The type of NHL you have
  • Any gene changes found in your cancer cells
  • Specific proteins found in your cancer cells
  • Your overall health
  • Symptoms of lymphoma-related problems you have
  • Your treatment preferences

But there are some standard treatment approaches for specific stages of NHL:

Stage I and stage II: You’ll most likely have chemotherapy, with or without other treatments, such as immunotherapy, targeted therapy, and radiation therapy. Surgery may be an option for people with some subtypes of NHL, but this is rare.

If you have a subtype of NHL that grows very slowly, you may not need treatment right away. In this case, your doctor may watch the lymphoma closely over several months and then start treatment if it starts to grow.

Stage II with bulky disease, stage III, and stage IV: Chemotherapy, along with immunotherapy, targeted therapy, and/or radiation therapy, are the treatments doctors usually recommend for these stages of NHL.

You might need intrathecal chemotherapy if there’s a risk the lymphoma could spread to the fluid around your brain and spinal cord. To have this treatment, your care team will put a thin needle between the bones of your lower back and put the chemo drugs right into your spinal fluid.

A stem cell transplant might be an option for some types of NHL, or if the disease comes back after treatment. This procedure involves taking out and saving immature blood cells called stem cells. You can use your own stem cells or get them from a donor. Then, you get high doses of chemotherapy and radiation to kill all the lymphoma cells in your body. After that, the stem cells go into your body, where they grow and rebuild healthy blood cells over time.

Tumor lysis syndrome may be a risk if you have bulky disease. It happens when chemotherapy kills a lot of cancer cells in a short time, and the cell waste quickly builds up in your blood. Your doctor will use drugs, extra fluids, and blood tests to help prevent and watch for signs of tumor lysis syndrome.

Clinical trials: There are many different treatments for NHL, and scientists are testing new ones in research studies called clinical trials. If you join one, you will get the best standard treatment available, and maybe a new treatment that the researchers are testing. Talk to your doctor if you’d like to learn more about clinical trials or find one that may be right for you.