Treatment of diffuse large B-cell lymphoma (DLBCL): from R-CHOP to CAR-T

A fast-growing but curable lymphoma: the standard first treatment, the place of Pola-R-CHP, preventing spread to the brain, and if the disease comes back: stem cell transplant, CAR-T cell therapy and bispecific antibodies

Updated: 28 October 20267 min read24 references
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Key points

  • Diffuse large B-cell lymphoma grows quickly, but it is curable: in most patients the disease does not come back after the first treatment [24, 1, 5].
  • The first treatment for most patients is the R-CHOP regimen: the antibody rituximab with four other drugs, usually 6 cycles, one every 3 weeks [1, 3].
  • In advanced, higher-risk disease, the newer Pola-R-CHP regimen lowered the chance of relapse slightly, but did not clearly lengthen life [6, 1].
  • If the disease comes back more than a year later, more chemotherapy followed by a transplant of the patient's own stem cells can still cure it [1, 9].
  • If it comes back within a year, or does not respond to the first treatment, CAR-T cell therapy has done better than a transplant; for a third treatment and beyond there are also bispecific antibodies [1, 12, 13, 17].

The story of treating this lymphoma: from CHOP to R-CHOP

Diffuse large B-cell lymphoma, a cancer of white blood cells called "B lymphocytes", is the most common type of non-Hodgkin lymphoma; about one in three lymphomas in adults is of this type [24, 1]. It grows quickly and usually shows itself with swollen lymph nodes, fever, drenching night sweats or weight loss [24]; see the symptoms in What are the symptoms of lymphoma?.

Until about 2000, the main treatment was a combination of four chemotherapy drugs called CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone). In advanced disease, it cured about 3 in every 10 patients [2]. For years doctors designed heavier combinations, but in a large study in 1993 none of them was better than CHOP, and they caused more deaths from side effects [2].

The big step forward came from an antibody: rituximab, which sticks to a protein called CD20 on B cells [3]. In 2002, a study in patients aged 60 to 80 showed that adding rituximab to CHOP made the disease disappear completely in more patients and lengthened life, without clearly adding important side effects [3]. Ten years later, about one and a half times as many patients were alive in the rituximab group as in the CHOP-only group [4].

Since then, R-CHOP has been the standard first treatment, and it cures about 6 in every 10 patients [5, 1]. Efforts to improve it continued, and the newer Pola-R-CHP regimen, described below, lowered the chance of relapse slightly in a group of patients [5, 6]. The next big advances were mostly for patients whose disease comes back: stem cell transplant, CAR-T cell therapy and bispecific antibodies [9, 12, 17].

6 in 10
Patients cured by a first treatment with R-CHOP
[5]
One and a half times
As many patients alive ten years later when rituximab was added to chemotherapy
[4]
More than 2 times
As many patients whose disease stayed under control 2 years after CAR-T, compared with chemotherapy and transplant, when the disease came back early
[12]

Treatment today, step by step

  1. 1

    Biopsy and finding out how far the disease has spread

    The diagnosis is made by taking a sample (biopsy) of a lymph node and examining it in a specialist laboratory. A PET scan shows how far the disease has spread and later measures the response to treatment [1]. A few simple factors, such as age, stage and a blood test (LDH), show how serious the disease is [1].

  2. 2

    First treatment: R-CHOP

    Rituximab and four other drugs, given as infusions on one day plus 5 days of prednisone tablets, every 3 weeks [5]. Most patients have 6 cycles (about 4 months); in limited disease without risk factors, 4 cycles are enough [1]. See: The R-CHOP regimen and How many sessions of chemotherapy are there?

  3. 3

    Advanced disease with higher risk: Pola-R-CHP

    In this regimen, the targeted drug polatuzumab vedotin takes the place of vincristine. In patients at intermediate or high risk, it lowered the chance of relapse slightly, but there was no clear difference in length of life [6]. The European guideline suggests it for stage 3 or 4 disease with two or more risk factors and considers R-CHOP an acceptable alternative [1]. See: The Pola-R-CHP regimen

  4. 4

    Older and frailer patients

    Age alone is not a reason to hold back treatment; in the main rituximab study, patients up to 80 received full treatment [3, 4]. At 80 or older, or when physical fitness is low, a geriatric assessment is done and a lighter regimen (such as R-miniCHOP) is chosen [1].

  5. 5

    End of treatment

    A PET scan at the end of treatment shows whether the disease has disappeared completely [1]. After that, regular check-ups for 2 years and attention to late side effects of treatment (heart, bones, nerves, tiredness) are needed [1].

Is treatment needed to prevent spread to the brain?

Sometimes lymphoma comes back in the brain or spinal cord after treatment. Fortunately this risk is low in most patients: nearly 9 in every 10 patients fall into the low-‎ or intermediate-risk groups. In the small high-risk group, about 1 in every 10 people develops this problem within two years [7]. Your doctor estimates your risk with a simple score (which also takes into account involvement of the kidney or adrenal gland) [7].

For years, high-risk patients were given high-dose methotrexate to prevent this kind of relapse. But in a large study of more than 2,000 high-risk patients, this did not clearly lower the risk [8]. This is why the European guideline says the benefit of this prevention is still uncertain; in high-risk patients, a brain MRI and a test of the spinal fluid are recommended [1]. Make the decision with your specialist.

If the disease comes back: transplant or CAR-T?

In about 3 to 4 in every 10 patients, the disease comes back after the first treatment or does not respond to it [1]. This is not the end of the road. The most important point in choosing the next treatment is when the disease came back: less or more than a year after the first treatment [1]. A new biopsy is recommended before the second treatment [1].

Relapse after more than a year: more chemotherapy and a transplant

First, a few more cycles of chemotherapy with rituximab. If the disease responds, high-dose chemotherapy followed by a transplant of the patient's own stem cells [1]. Since 1995 this approach has been shown to lengthen patients' lives [9], and it is still the standard treatment for late relapse [1, 10].

Relapse within a year, or no response: CAR-T

When the disease comes back early, chemotherapy and transplant work less well [10]. In CAR-T cell therapy, the patient's own immune cells (T cells) are collected from the blood, changed in a laboratory so that they recognise the lymphoma cells, and given back to the patient once [20]. In two large studies, CAR-T controlled the disease much better than chemotherapy and transplant, and in one of them it also lengthened patients' lives [12, 13, 14]. The European guideline considers it the main treatment for this group [1].

When intensive treatment is not possible

For people for whom a transplant or CAR-T is not suitable, the lighter R-GemOx regimen (rituximab with two chemotherapy drugs) is used [1, 15]. Adding the bispecific antibody glofitamab to these two chemotherapy drugs almost doubled patients' survival in a large study [16].

Another relapse: bispecific antibodies

These antibodies stick to a lymphoma cell with one arm and to one of the patient's immune cells with the other, bringing the two together. In patients who had been treated twice or more, even after CAR-T, glofitamab and epcoritamab made the disease disappear completely on scans in about 4 in every 10 patients [17, 18]. For a third treatment and beyond, CAR-T (if you have not had it before) and these antibodies are the best options [1].

Ask this before treatment starts
  • "What stage is my disease and how many risk factors does it have?" [1]
  • "Is R-CHOP or Pola-R-CHP better for me?" [1, 6]
  • "Is my risk of the lymphoma coming back in the brain high?" [7]
  • "Have I been tested for hepatitis B before rituximab?" [22]
  • "If the disease comes back, would a transplant or CAR-T be suitable for me?" [1]

When should I call my doctor?

During chemotherapy: report a temperature of 38 °C or higher, chills or any sign of infection straight away; infection during this time can be dangerous [23]. See: Low blood counts and preventing infection. With rituximab: a hepatitis B test is needed before starting; report worsening tiredness or yellowing of the skin or eyes straight away [22]. After CAR-T: report fever, chills, a racing heart, dizziness or low blood pressure, breathlessness, confusion, shaking hands, difficulty speaking or a seizure straight away; stay near the treatment centre for at least 2 weeks and do not drive during that time [21]. With bispecific antibodies: fever and chills are common in the days after the first injections and must be reported straight away [17, 18]. If you have severe breathlessness, a seizure or severe confusion, call your local emergency number.

Frequently asked questions

Can diffuse large B-cell lymphoma be cured?

Yes. About 6 in every 10 patients are cured by a first treatment with R-CHOP [5], and in some of the patients whose disease comes back, a transplant or CAR-T can still clear the disease for years [9, 13]. Most relapses happen in the first few years, and relapse after 5 years is uncommon [4].

How many cycles of R-CHOP are there and how long does it take?

Usually 6 cycles, one every 3 weeks; that is about 4 months. In limited, low-risk disease, 4 cycles are enough [1]. Each cycle is one day of infusions and 5 days of prednisone tablets [5]. See: The R-CHOP regimen

Is Pola-R-CHP better than R-CHOP?

In patients at intermediate or high risk, Pola-R-CHP lowered the chance of relapse slightly, but after 5 years there was no clear difference in length of life [6]. The European guideline suggests it in advanced disease with two or more risk factors and considers R-CHOP acceptable too [1].

What is CAR-T and who is it for?

CAR-T is a treatment that turns the patient's own immune cells into "hunters" of lymphoma cells in a laboratory [20]. Today it is mostly for people whose disease came back less than a year after the first treatment or did not respond to it [1, 12, 14], and for later relapses if they have not had CAR-T before [1, 19]. Its important side effects are fever and low blood pressure (called "cytokine release syndrome") and effects on the nervous system, which are managed in specialist centres [21].

Is a bone marrow transplant still needed?

Yes, for a relapse that happens more than a year later and responds to more chemotherapy [1]. In this transplant, the patient's own stem cells are collected and given back after high-dose chemotherapy [9]. See: Blood stem cell transplant and The stages of a transplant

If I am older, will I still get full treatment?

If you are physically fit, yes; the main rituximab study was in patients aged 60 to 80 [3]. At 80 or older, or with low physical fitness, the doctor chooses a lighter regimen after a geriatric assessment and sometimes gives steroids before starting to improve your general condition [1].

For physicians

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For physicians

Background: SWOG/ECOG (899 evaluable patients): CHOP versus m-BACOD, ProMACE-CytaBOM and MACOP-B, 3-year overall survival 54% versus 50% to 52% (P=0.90), fatal toxicity 1% versus 3% to 6% [2]. GELA LNH98-5 (399 patients aged 60 to 80, 8 cycles): complete response 76% versus 63% (P=0.005), HR for death 0.64 [3]; at 10-year follow-up, PFS 36.5% versus 20% and OS 43.5% versus 27.6%; relapses after 5 years were 7% of all progressions [4].

First line: POLARIX (879 patients, IPI 2 to 5; 6 cycles of Pola-R-CHP or R-CHOP plus 2 cycles of rituximab): 2-year PFS 76.7% versus 70.2% (HR 0.73; P=0.02), 2-year OS 88.7% versus 88.6% [5]; at 5-year follow-up, PFS 64.9% versus 59.1% (HR 0.77) and HR for overall survival 0.85 (95% CI 0.63 to 1.15; not significant) [6]. EHA 2025: stage I–II without risk factors and age under 80, 4 cycles of R-CHOP21 (6 cycles in bulky disease); one risk factor, 6 cycles of R-CHOP21; stage III–IV with two or more risk factors, 6 cycles of Pola-R-CHP with R-CHOP21 as an alternative; age 80 or older or unfit, geriatric assessment and R-miniCHOP or an anthracycline-free regimen; corticosteroid pre-phase [1]. IPI and CNS-IPI: IPI calculator. Doses: R-CHOP · Pola-R-CHP.

CNS prophylaxis: CNS-IPI (2,164 patients treated with R-CHOP, validated in 1,597 patients): 2-year risk of CNS disease 0.6% in the low-risk group (46% of patients), 3.4% in the intermediate-risk group (41%) and 10.2% in the high-risk group (12%) [7]. Lewis 2023 (2,418 high-risk patients, 425 given HD-MTX; retrospective): adjusted HR 0.59 in all patients, but not significant in patients in complete response (HR 0.74; P=0.29); 5-year adjusted risk difference 1.6%; 2-year risk of CNS progression with HD-MTX 7.2% [8]. EHA: the value of CNS prophylaxis is uncertain; MRI and CSF assessment in high-risk patients [1].

Chemosensitive relapse and transplant: PARMA (109 randomised responders): 5-year EFS 46% versus 12% and OS 53% versus 32% with autologous transplant [9]. CORAL (396 patients): response to R-ICE and R-DHAP 63.5% and 62.8%; response in relapse or refractoriness less than 12 months after diagnosis 46% versus 88%, and 3-year EFS 20% versus 45% [10]. LY.12 (619 patients): GDP non-inferior to DHAP for response (45.2% versus 44.0%), with less toxicity and fewer hospital admissions [11].

Second-line CAR-T (relapse at 12 months or less, or primary refractory): ZUMA-7 (359 patients): median EFS 8.3 versus 2.0 months (HR 0.40), 24-month EFS 41% versus 16%; grade ≥3 CRS 6% and grade ≥3 neurological events 21% [12]; 4-year OS 54.6% versus 46.0% (HR 0.73; P=0.03) [13]. TRANSFORM (184 patients, 3-year follow-up): median EFS 29.5 versus 2.4 months (HR 0.375), 36-month PFS 51% versus 26.5%, 36-month OS 63% versus 52% (HR 0.757; 66% crossed over to liso-cel) and crossover-adjusted HR 0.566 [14]. ZUMA-1 (refractory disease): objective response 82% and complete response 54% [19]. EHA: CAR-T for relapse within 12 months [I, A]; it may not be suitable with PS 2 or higher, high tumour burden or rapidly rising LDH [1]. Doses: R-ICE / R-DHAP and transplant · R-GDP · Second-line CAR-T.

Transplant-ineligible patients and later lines: R-GemOx (LYSA, 49 patients): overall response 61% and complete response 44%, but 5-year PFS 12.8% [15]. STARGLO (3-year follow-up): glofitamab + GemOx versus R-GemOx, median OS 25.5 versus 12.5 months (HR 0.60) and complete response 58.5% versus 25.3% [16]. EHA: R-GemOx or pola-BR [III, B]; glofitamab + GemOx [I, A] [1]. Fixed-duration glofitamab monotherapy (155 patients, at least 2 prior lines): complete response 39% (35% after CAR-T), CRS 63% (grade ≥3 4%) [17]. Epcoritamab (3-year follow-up): overall response 59% and complete response 41%, median duration of complete response 36.1 months, CRS 51% [18]. Toxicity of CAR-T and bispecifics: Immunotherapy toxicity lesson. Doses: R-GemOx · Glofitamab + GemOx · Epcoritamab.

Scientific evidence

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Scientific evidence

11 items
Clinical trial

CHOP Chemotherapy plus Rituximab Compared with CHOP Alone in Elderly Patients with Diffuse Large-B-Cell Lymphoma

N Engl J Med · 2002
76% vs 63% (CHOP with rituximab vs CHOP alone)Complete response rate
Clinical trial

Randomized comparison of gemcitabine, dexamethasone, and cisplatin versus dexamethasone, cytarabine, and cisplatin chemotherapy before autologous stem-cell transplantation for relapsed and refractory aggressive lymphomas: NCIC-CTG LY.12

J Clin Oncol · 2014
45.2% vs 44.0%Response rate after two cycles
Clinical trial · Phase 2

Rituximab plus gemcitabine and oxaliplatin in patients with refractory/relapsed diffuse large B-cell lymphoma who are not candidates for high-dose therapy. A phase II Lymphoma Study Association trial.

Haematologica · 2013
61%Overall response rate after 4 cycles
Clinical guideline

Large B-cell lymphoma (LBCL): EHA Clinical Practice Guidelines for diagnosis, treatment, and follow-up.

Hemasphere · 2025
Clinical trial · Phase 3

Five-Year Outcomes of the POLARIX Study Comparing Pola-R-CHP and R-CHOP in Patients With Diffuse Large B-Cell Lymphoma

J Clin Oncol · 2025
64.9% vs 59.1%Five-year PFS
Clinical trial · Phase 3

Glofitamab plus gemcitabine and oxaliplatin for relapsed/refractory DLBCL: 3-year follow-up of STARGLO.

Blood Adv · 2026
25.5 vs 12.5 monthsMedian overall survival
Clinical trial · Phase 3

Survival with Axicabtagene Ciloleucel in Large B-Cell Lymphoma

N Engl J Med · 2023
47.2 monthsMedian follow-up
Clinical trial · Phase 3

Lisocabtagene Maraleucel Versus Standard of Care for Second-Line Relapsed/Refractory Large B-Cell Lymphoma: 3-Year Follow-Up From the Randomized, Phase III TRANSFORM Study

J Clin Oncol · 2025
29.5 months vs 2.4 monthsMedian event-free survival
Clinical trial · Phase 2

Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma

N Engl J Med · 2017
110 of 111 patients (99%)Successful axi-cel manufacture
Clinical trial

Glofitamab for Relapsed or Refractory Diffuse Large B-Cell Lymphoma

N Engl J Med · 2022
39%Complete response
Clinical trial

Efficacy and safety of epcoritamab in relapsed or refractory large B-cell lymphoma: 3-year update from the EPCORE NHL-1 trial.

Ann Hematol · 2026
59% / 41%Overall response rate / complete response

Read more

Related cancer types

References

24 references
Show all references, 13 with a study cardClose the reference list

Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.

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    Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin's lymphomaFisher RI, Gaynor ER, Dahlberg S, et al · N Engl J Med · 1993;328:1002-6
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    CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphomaCoiffier B, Lepage E, Briere J, et al · N Engl J Med · 2002;346:235-42
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    Long-term outcome of patients in the LNH-98.5 trial, the first randomized study comparing rituximab-CHOP to standard CHOP chemotherapy in DLBCL patients: a study by the Groupe d'Etudes des Lymphomes de l'AdulteCoiffier B, Thieblemont C, Van Den Neste E, et al · Blood · 2010;116:2040-5
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    Polatuzumab Vedotin in Previously Untreated Diffuse Large B-Cell LymphomaTilly H, Morschhauser F, Sehn LH, et al · N Engl J Med · 2022;386:351-363
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  6. 6
    Five-Year Outcomes of the POLARIX Study Comparing Pola-R-CHP and R-CHOP in Patients With Diffuse Large B-Cell LymphomaMorschhauser F, Salles G, Sehn LH, et al · J Clin Oncol · 2025;43:3698-3705
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  7. 7
    CNS International Prognostic Index: A Risk Model for CNS Relapse in Patients With Diffuse Large B-Cell Lymphoma Treated With R-CHOPSchmitz N, Zeynalova S, Nickelsen M, et al · J Clin Oncol · 2016;34:3150-6
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  8. 8
    High-Dose Methotrexate as CNS Prophylaxis in High-Risk Aggressive B-Cell LymphomaLewis KL, Jakobsen LH, Villa D, et al · J Clin Oncol · 2023;41:5376-5387
    DOIPubMed Back to text: 1 2
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    Autologous Bone Marrow Transplantation as Compared with Salvage Chemotherapy in Relapses of Chemotherapy-Sensitive Non-Hodgkin's LymphomaPhilip T, Guglielmi C, Hagenbeek A, Somers R, Van Der Lelie H, Bron D, et al · N Engl J Med · 1995;333:1540-1545
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    Salvage regimens with autologous transplantation for relapsed large B-cell lymphoma in the rituximab eraGisselbrecht C, Glass B, Mounier N, Singh Gill D, Linch DC, Trneny M, et al · J Clin Oncol · 2010;28:4184-4190
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    Randomized comparison of gemcitabine, dexamethasone, and cisplatin versus dexamethasone, cytarabine, and cisplatin chemotherapy before autologous stem-cell transplantation for relapsed and refractory aggressive lymphomas: NCIC-CTG LY.12Crump M, Kuruvilla J, Couban S, et al · J Clin Oncol · 2014;32:3490-6
  12. 12
    Axicabtagene Ciloleucel as Second-Line Therapy for Large B-Cell LymphomaLocke FL, Miklos DB, Jacobson CA, Perales MA, Kersten MJ, Oluwole OO, et al · N Engl J Med · 2022;386:640-654
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    Survival with Axicabtagene Ciloleucel in Large B-Cell LymphomaWestin JR, Oluwole OO, Kersten MJ, Miklos DB, Perales MA, Ghobadi A, et al · N Engl J Med · 2023;389:148-157
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    Lisocabtagene Maraleucel Versus Standard of Care for Second-Line Relapsed/Refractory Large B-Cell Lymphoma: 3-Year Follow-Up From the Randomized, Phase III TRANSFORM StudyKamdar M, Solomon SR, Arnason J, et al · J Clin Oncol · 2025;43:2671-2678
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    Rituximab plus gemcitabine and oxaliplatin in patients with refractory/relapsed diffuse large B-cell lymphoma who are not candidates for high-dose therapy. A phase II Lymphoma Study Association trialMounier N, El Gnaoui T, Tilly H, et al · Haematologica · 2013;98:1726-31
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    Glofitamab plus gemcitabine and oxaliplatin for relapsed/refractory DLBCL: 3-year follow-up of STARGLOAbramson JS, Townsend W, Fox CP, et al · Blood Adv · 2026;10:5367-5377
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    Glofitamab for Relapsed or Refractory Diffuse Large B-Cell LymphomaDickinson MJ, Carlo-Stella C, Morschhauser F, Bachy E, Corradini P, Iacoboni G, et al · N Engl J Med · 2022;387:2220-2231
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    Efficacy and safety of epcoritamab in relapsed or refractory large B-cell lymphoma: 3-year update from the EPCORE NHL-1 trialKarimi YH, Cheah CY, Clausen MR, et al · Ann Hematol · 2026;105:79
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    Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell LymphomaNeelapu SS, Locke FL, Bartlett NL, Lekakis LJ, Miklos DB, Jacobson CA, et al · N Engl J Med · 2017;377:2531-2544
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    CAR T Cells: Engineering Patients' Immune Cells to Treat Their CancersNational Cancer Institute · cancer.gov · 2025
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    RITUXAN (rituximab) injection — Prescribing InformationGenentech / U.S. Food and Drug Administration · FDA label (DailyMed) · 2026
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This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.