BEACOPP Escalated

Chemotherapy Protocol
LYMPHOMA
BLEOMYCIN-CYCLOPHOSPHAMIDE-DOXORUBICIN-ETOPOSIDE-PREDNISOLONE-
PROCARBAZINE-VINCRISTINE
(BEACOPP Escalated)
Regimen
• Lymphoma – BEACOPP Escalated -Bleomycin-Cyclophosphamide-Doxorubicin-

Etoposide-Prednisolone-Procarbazine-Vincristine
Indication
• Hodgkin’s Lymphoma
Toxicity
Drug Adverse Effect

Bleomycin Pulmonary toxicity, rigors, skin pigmentation, nail changes
Cyclophosphamide Dysuria, haemorrhagic cystitis (rare), taste disturbances
Doxorubicin Cardiotoxicity, urinary discolouration (red)
Etoposide Hypotension on rapid infusion, alopecia, hyperbilirubinaemia
Weight gain, GI disturbances, hyperglycaemia, CNS
Prednisolone
disturbances, cushingoid changes, glucose intolerance
Procarbazine Insomnia, ataxia, hallucinations, headache
Vincristine Peripheral neuropathy, constipation, jaw pain
The adverse effects listed are not exhaustive. Please refer to the relevant Summary of
Product Characteristics for full details.
Patients diagnosed with Hodgkin’s Lymphoma carry a lifelong risk of transfusion associated
graft versus host disease (TA-GVHD). Where blood products are required these patients
must receive only irradiated blood products for life. Local blood transfusion departments
must be notified as soon as a diagnosis is made and the patient must be issued with an alert
card to carry with them at all times.
Monitoring
Drugs
• FBC, LFTs and U&Es prior to day one of treatment
• Ensure adequate cardiac function before starting therapy. Baseline LVEF should be
measured in patients with a history of cardiac problems, cardiac risk factors or in the
elderly. Discontinue doxorubicin if cardiac failure develops.
• Pulmonary function tests before starting therapy. These should be repeated if

respiratory symptoms develop during treatment, particularly a drop in oxygen
Version 1 (June 2019) Page 1 of 11
Lymphoma- BEACOPP Escalated -Bleomycin-Cyclophosphamide-Doxorubicin-Etoposide-Prednisolone-
Procarbazine-Vincristine
saturation on exercise. Bleomycin should be stopped until the results of such
investigations are known.
Dose Modifications
The dose modifications listed are for haematological, liver and renal function and some
limited drug specific toxicities only. Dose adjustments may be necessary for other toxicities
as well.
In principle all dose reductions due to adverse drug reactions should not be re-escalated in
subsequent cycles without consultant approval. It is also a general rule for chemotherapy
that if a third dose reduction is necessary treatment should be stopped.
Please discuss all dose reductions / delays with the relevant consultant before prescribing, if
appropriate. The approach may be different depending on the clinical circumstances.
Haematological
Dose modifications for haematological toxicity below are for general guidance only. Always
refer to the responsible consultant as any dose reductions or delays will be dependent on
clinical circumstances and treatment intent. Low counts can be a consequence of bone
marrow infiltration as well as drug toxicity.
Cycles should be repeated on day 22 provided the white cell count is greater than 2.5x109/L
and the platelet count is greater than 80x109/L
Day 8 drugs should be given on schedule and at full dose regardless of blood counts.
Dose modifications based on haematological parameters apply to cyclophosphamide and

etoposide only
Doses should be reduced in subsequent cycles if, in any given cycle:

WBC is less than 1.0 x 109 /L for more than four days
Platelets are less than 25 x 109 /L at any time
There is infection, mucositis or other adverse effect that requires a two-week delay in
treatment.
After each such event, the doses of cyclophosphamide and etoposide should be reduced by
one level on a five-level scale from escalated to standard doses as shown below. If toxic
effects occur in two successive cycles, standard doses should be used for all subsequent
cycles.
Level 1 Level 5
Drug escalated Level 2 Level 3 Level 4 standard
dose dose
Cyclophosphamide 1250mg/m2 1100mg/m2 950mg/m2 800mg/m2 650mg/m2
Etoposide 200mg/m2 175mg/m2 150mg/m2 125mg/m2 100mg/m2
Growth factors are mandatory as part of this regimen.
Consider blood transfusion if patient symptomatic of anaemia or has a haemoglobin of less

than 8g/dL. Irradiated blood products must be used in Hodgkin’s Lymphoma patients.

Hepatic Impairment
If abnormal liver function tests are lymphoma related proceed with treatment at full dose
unless there is an overriding clinical reason not to do so.
Bilirubin AST/ALT Dose

Drug
µmol/L units/L (% of original dose)
Clinical decision. Increased
Bleomycin
risk of lung dysfunction
Evidence suggests dose

Cyclophosphamide N/A N/A
modification not necessary
less than *30 and 2-3xULN 75%

more than
Doxorubicin *30-50 and/or 50%
3xULN
51-85 N/A 25%
more than 85 N/A Omit
*30-51 or 60-180 50%

Etoposide more than
more than 51 or clinical decision
180
more than 50 Consider dose reduction

Procarbazine more than
more than 85 or Omit
180
*30-51 or 60-180 50%

Vincristine more than 51 and normal 50%
more
more than 51 and Omit
than180
* Limits reflect local practice and may vary from published sources

Renal Impairment
Creatinine Clearance Dose

Drug
(ml/min) (% of original dose)
more than 50 100%
Bleomycin 10-50 75%
less than10 50%
more than 20 100%

Cyclophosphamide 10-20 75%
less than 10 50%
Consider dose reduction in

Doxorubicin less than10
severe renal failure
more than 50 100%

Etoposide 15-50 75%
less than 15 50%
serum creatinine more than

50%
Procarbazine 177 µmol/L
less than 10 Not recommended
Vincristine N/A no dose adjustment needed
Other
Dose reductions or interruptions in therapy are not necessary for those toxicities that are
considered unlikely to be serious or life threatening. For example, alopecia, altered taste or
nail changes.
Bleomycin
The risk of bleomycin induced pneumonitis is greater in those individuals who are older than
forty years of age, have a history of smoking, those with underlying lung disease, previous
mediastinal radiotherapy, poor renal function or who require growth factors. If pulmonary
symptoms develop stop the bleomycin until they can be investigated fully and a diagnosis
made.
Doxorubicin
Discontinue doxorubicin if cardiac failure develops.
Etoposide
Where significant reductions in albumin levels occur consider reducing the dose of
etoposide.

Vincristine
Reduce the vincristine dose to 1mg if an NCI-CTC grade 2 motor or grade 3 sensory
neurological toxicity occurs. For higher toxicity grades or if toxicity increases despite dose
reduction stop the vincristine.
Regimen
21 day cycle for up to 8 cycles
6 cycles will be set in Aria
Drug Dose Days Administration

10,000
Bleomycin international 8 Intravenous bolus over 10 minutes
units/m2
Intravenous infusion in 500ml
Cyclophosphamide 1250mg/m2 1 sodium chloride 0.9% over 60
minutes
Doxorubicin 35mg/m2 1 Intravenous bolus over 10 minutes
Intravenous infusion in 1000ml
Etoposide 200mg/m2 1, 2, 3 sodium chloride 0.9% over 60
minutes
Prednisolone 40mg/m2 1-14 Oral
Procarbazine 100mg/m2 1-7 Oral

1.4mg/m2 Intravenous bolus in 50ml sodium
Vincristine 8
(max 2mg) chloride 0.9% over 10 minutes
G-CSF 1 dose 9-13 Subcutaneous
Dose Information
• Bleomycin will be dose rounded to the nearest 1000 International Units (up if
halfway)
• The maximum cumulative dose of bleomycin is 500,000 international units in people

less than sixty years of age. Refer to SPC for further information in older patients.
• Cyclophosphamide will be dose banded in accordance with the national dose bands
(multi syringe 20mg/ml)
• Doxorubicin will be dose banded in accordance with the national dose bands (multi
syringe 2mg/ml)
• The maximum lifetime cumulative dose of doxorubicin is 450mg/m². However prior

radiotherapy to mediastinal / pericardial area should receive a lifetime cumulative
doxorubicin dose of no more than 400mg/m².
• Etoposide (intravenous) will be dose banded in accordance with the national dose
bands (20mg/ml)
• Prednisolone is available as 5mg and 25mg tablets the dose will be rounded to the
nearest 5mg (up if halfway)
• Procarbazine is available as 50mg capsules. To facilitate alternate day dosing in

ARIA the dose will be rounded to the nearest 25mg (up if halfway).
- If the calculated daily dose is 125mg please dispense 150mg alternating with
100mg once a day
150mg once a day
200mg once a day
• Vincristine will be dose banded in accordance with the national dose bands (1mg/ml)
• The maximum dose of vincristine is 2mg.

.
Administration Information
Extravasation
• Bleomycin - neutral
• Cyclophosphamide – neutral
• Doxorubicin – vesicant
• Etoposide – irritant
• Vincristine - vesicant
Other
• Prednisolone should be taken in the morning with or after food.
• Procarbazine has weak MAOI activity. Alcohol and foods rich in tyramine (including
some wines and cheeses) should be avoided. Do not use with other MAOIs.
Additional Therapy
• Antiemetics
15-30 minutes prior to chemotherapy (days 1-3)
- ondansetron 8mg oral or intravenous
At least 15 minutes prior to chemotherapy (days 1-3)
- prednisolone 40mg/m2 oral to be administered in clinic on day 1 and self-

administered by the patient on the morning of treatment on days 2 and 3 (this
is part of the chemotherapy schedule as well as an anti-emetic)

As take home medication
- metoclopramide 10mg three times a day when required oral

- ondansetron 8mg to be taken in the evening on days 1-3 then twice a day for
the 2 days after chemotherapy has finished
• Allopurinol 300mg once a day for 7 days oral for the first cycle only
• Growth factor on days 9 to 13. For example:

- filgrastim or bioequivalent 30 million units once a day for 5 days from day 9
subcutaneous
- lenograstim or bioequivalent 33.6 million units once a day for 5 days from day
9 subcutaneous
• Aciclovir 400mg twice a day oral
• Co-trimoxazole 960mg once a day oral on Monday, Wednesday and Friday only
• Fluconazole 100mg once day oral
• Mouthwashes according to local or national policy on the treatment of mucositis
• Gastric protection with a proton pump inhibitor or a H2 antagonist may be considered

in patients considered at high risk of GI ulceration or bleed.
Additional Information
• The National Patient Safety Agency report NPSA/2008/RRR04 must be followed in

relation to intravenous administration of vinca alkaloids.
Coding (OPCS)
• Procurement – X70.3
• Delivery – X72.1, X72.4
References
1. Johnson P, Federico M, Kirkwood A. Fosså, A et al. Adapted Treatment Guided by Interim PET-CT Scan in Advanced
Hodgkin’s Lymphoma N Engl J Med 2016; 374:2419-2429
2. Gallamini A, Tarella C, Viviani S, Rossi A et al. Early Chemotherapy Intensification with Escalated BEACOPP in Patients
with Advanced-Stage Hodgkin Lymphoma with a Positive Interim Positron Emission Tomography/Computed Tomography
Scan After Two ABVD Cycles: Long-Term Results of the GITIL/FIL HD 0607 Trial. J Clin Oncol. 2018 Feb 10;36(5):454-
462
3. Escalated-dose BEACOPP in the treatment of patients with advanced-stage Hodgkin's lymphoma: 10 years of follow-up of
the GHSG HD9 study. J Clin Oncol. 2009 Sep 20;27(27):4548-54. Engert A, Diehl V, Franklin J et al.

REGIMEN SUMMARY
BEACOPP Escalated-Bleomycin-Cyclophosphamide-Doxorubicin-Etoposide-Prednisolone-
Cycle 1 Day 1
1. Warning –Check blood transfusion status

Administration Instructions
Patients with HODGKIN’S lymphoma carry a lifelong risk of transfusion associated graft versus host disease.
Where blood products are required these patients must receive ONLY IRRADIATED BLOOD PRODUCTS for life.
Ensure transfusion departments are notified and the patient has been issued with an alert card to carry with them at
all times.
2. Prednisolone 40mg/m2 oral

Administer 15-30 minutes prior to chemotherapy.
3. Ondansetron 8mg oral or intravenous

Administer 15-30 minutes prior to chemotherapy
4. Doxorubicin 35mg/m2 intravenous bolus over 10 minutes
5. Etoposide 200mg/m2 intravenous infusion in 1000ml sodium chloride 0.9% over 60

minutes
6. Cyclophosphamide 1250mg/m2 intravenous infusion in 500ml sodium chloride 0.9%

over 60 minutes
Take Home Medicines (Day 1 only)
7. Prednisolone 40mg/m2 once a day oral for 13 days

Starting on day 2 of the cycle
8. Procarbazine 100mg/m2 once a day oral for 7 days

Procarbazine is available as 50mg capsules. To facilitate alternate day dosing in ARIA the dose will be rounded to
the nearest 25mg (up if halfway).
If the calculated daily dose is 125mg please dispense 150mg alternating with 100mg once a day
9. Growth Factor as directed

Growth factor as per local formulary choice:
- filgrastim or bioequivalent 30 million units once a day for 5 days starting on day 9 of the cycle subcutaneous
- lenograstim or bioequivalent 33.6 million units once a day for 5 days starting on day 9 of the cycle subcutaneous
10. Metoclopramide 10mg three times a day when required oral
11. Ondansetron 8mg taken on the evening of days 1, 2 and 3 then 8mg twice a day for
the 2 days after chemotherapy
12. Allopurinol 300mg once a day oral for 7 days
13. Aciclovir 400mg twice a day oral for 21 days

14. Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday oral for 21
days
15. Fluconazole 100mg once a day oral for 21 days
Cycle 1 Day 2

minutes
Cycle 1 Day 3

minutes
Cycle 1 Day 8
20. Vincristine 1.4mg/m2 (max 2mg) intravenous bolus in 50ml sodium chloride 0.9%
over 10 minutes
21. Bleomycin 10,000 international units/m2 intravenous bolus over 10 minutes
22. Hydrocortisone 100mg intravenous when required for the treatment of bleomycin
related reactions
Cycles 2, 3, 4, 5 & 6 Day 1
1. Prednisolone 40mg/m2 oral

Administer 15-30 minutes prior to chemotherapy.

3. Doxorubicin 35mg/m2 intravenous bolus over 10 minutes

minutes
5. Cyclophosphamide 1250mg/m2 intravenous infusion in 500ml sodium chloride 0.9%

over 60 minutes
Take Home Medicines (Day 1 only)
6. Prednisolone 40mg/m2 once a day oral for 13 days

Starting on day 2 of the cycle

7. Procarbazine 100mg/m2 once a day oral for 7 days
Procarbazine is available as 50mg capsules. To facilitate alternate day dosing in ARIA the dose will be rounded to
the nearest 25mg (up if halfway).
8. Growth Factor as directed

Growth factor as per local formulary choice:
- filgrastim or bioequivalent 30 million units once a day for 5 days starting on day 9 of the cycle subcutaneous
- lenograstim or bioequivalent 33.6 million units once a day for 5 days starting on day 9 of the cycle subcutaneous
9. Metoclopramide 10mg three times a day when required oral
10. Ondansetron 8mg taken on the evening of days 1, 2 and 3 then 8mg twice a day for
the 2 days after chemotherapy
11. Aciclovir 400mg twice day oral for 21 days
12. Co-trimoxazole 960mg once a day on Monday, Wednesday and Friday oral for 21
days
13. Fluconazole 100mg once a day for 21 days
Cycles 2, 3, 4, 5 & 6 Day 2

minutes
Cycles 2, 3, 4, 5 & 6 Day 3

minutes
Cycles 2, 3, 4, 5 & 6 Day 8
18. Vincristine 1.4mg/m2 (max 2mg) intravenous bolus in 50ml sodium chloride 0.9%
over 10 minutes
19. Bleomycin 10,000 international units/m2 intravenous bolus over 10 minutes
20. Hydrocortisone 100mg intravenous when required for the treatment of bleomycin
related reactions

DOCUMENT CONTROL
Version Date Amendment Written By Approved By
Rebecca Wills
Dr Robert Lown
Pharmacist
Consultant Medical
1 June 2019 None
Oncologist
Dr Debbie Wright
Pharmacist
This chemotherapy protocol has been developed as part of the chemotherapy electronic
prescribing project. This was and remains a collaborative project that originated from the
former CSCCN. These documents have been approved on behalf of the following Trusts;
Hampshire Hospitals NHS Foundation Trust

NHS Isle of Wight
Portsmouth Hospitals NHS Trust
Salisbury NHS Foundation Trust
University Hospital Southampton NHS Foundation Trust
Western Sussex Hospitals NHS Foundation Trust
All actions have been taken to ensure these protocols are correct. However, no responsibility
can be taken for errors which occur as a result of following these guidelines.


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Chemotherapy Protocol

• Lymphoma – BEACOPP Escalated -Bleomycin-Cyclophosphamide-Doxorubicin-

Drug Adverse Effect

• FBC, LFTs and U&Es prior to day one of treatment

• Pulmonary function tests before starting therapy. These should be repeated if

Dose modifications based on haematological parameters apply to cyclophosphamide and

Doses should be reduced in subsequent cycles if, in any given cycle:

Etoposide 200mg/m2 175mg/m2 150mg/m2 125mg/m2 100mg/m2

Growth factors are mandatory as part of this regimen.

Consider blood transfusion if patient symptomatic of anaemia or has a haemoglobin of less

Version 1 (June 2019) Page 2 of 11

Bilirubin AST/ALT Dose

Evidence suggests dose

less than *30 and 2-3xULN 75%

more than 85 N/A Omit

*30-51 or 60-180 50%

more than 50 Consider dose reduction

*30-51 or 60-180 50%

Version 1 (June 2019) Page 3 of 11

Creatinine Clearance Dose

more than 20 100%

Consider dose reduction in

more than 50 100%

serum creatinine more than

Vincristine N/A no dose adjustment needed

Version 1 (June 2019) Page 4 of 11

21 day cycle for up to 8 cycles

6 cycles will be set in Aria

Drug Dose Days Administration

Procarbazine 100mg/m2 1-7 Oral

• The maximum cumulative dose of bleomycin is 500,000 international units in people

• The maximum lifetime cumulative dose of doxorubicin is 450mg/m². However prior

• Procarbazine is available as 50mg capsules. To facilitate alternate day dosing in

• The maximum dose of vincristine is 2mg.

• Prednisolone should be taken in the morning with or after food.

15-30 minutes prior to chemotherapy (days 1-3)

- ondansetron 8mg oral or intravenous

At least 15 minutes prior to chemotherapy (days 1-3)

- prednisolone 40mg/m2 oral to be administered in clinic on day 1 and self-

Version 1 (June 2019) Page 6 of 11

- metoclopramide 10mg three times a day when required oral

• Growth factor on days 9 to 13. For example:

• Aciclovir 400mg twice a day oral

• Fluconazole 100mg once day oral

• Mouthwashes according to local or national policy on the treatment of mucositis

• Gastric protection with a proton pump inhibitor or a H2 antagonist may be considered

• The National Patient Safety Agency report NPSA/2008/RRR04 must be followed in

• Delivery – X72.1, X72.4

Version 1 (June 2019) Page 7 of 11

1. Warning –Check blood transfusion status

2. Prednisolone 40mg/m2 oral

3. Ondansetron 8mg oral or intravenous

4. Doxorubicin 35mg/m2 intravenous bolus over 10 minutes

5. Etoposide 200mg/m2 intravenous infusion in 1000ml sodium chloride 0.9% over 60

6. Cyclophosphamide 1250mg/m2 intravenous infusion in 500ml sodium chloride 0.9%

Take Home Medicines (Day 1 only)

7. Prednisolone 40mg/m2 once a day oral for 13 days

8. Procarbazine 100mg/m2 once a day oral for 7 days