Treatment of non-Hodgkin's lymphoma in the elderly: an update

Evolution of R-CHOP therapy for older patients with diffuse large B-cell lymphoma

Non-Hodgkin's lymphoma is the fifth most common malignancy in adults in the USA. This disorder is especially relevant in the elderly patient population, as the median age of patients with this disorder is 65 years. Almost half of these disorders in older patients are of a diffuse large B-cell (DLBCL) subtype. The therapy of DLBCL has undergone a renaissance in the past decade, with the addition of rituximab to standard regimens, such as cyclophosphamide- doxorubicin-vincristine-prednisone (CHOP). Over this time, there have been several large Phase III treatment trials in which the CHOP and rituximab-CHOP (R-CHOP) regimens have been prospectively compared, including three trials confined to the elderly patient population. In these trials, it has been demonstrated repeatedly that the addition of rituximab results in an improved outcome, with higher response rates and prolongation in parameters including progression-free, event-free, disease-free and overall survival. In addition, this regimen has been well tolerated, even in older patients. Based upon these data, the R-CHOP regimen has now been established as the standard for initial therapy of DLBCL in older patients with DLBCL. However, issues still remain with regard to the ideal schedule of R-CHOP administration, specifically the optimal number of cycles of therapy (six vs eight), as well as cycle length (14 vs 21 days).

Cancer in older men: a gender-based review

Cancer is a common condition of the older male. Risk factors for developing a malignancy include genetic, environmental and life style features. Cancer epidemiology and prognosis differ depending on the age and gender of the population being studied. In the group of men older than 65 years, the most common malignant tumors are prostate, lung, colon and pancreatic cancer. Treatment options vary depending on the stage of the tumor when it is diagnosed, and the decision for therapeutic versus palliative interventions will depend upon the functional status, comorbidity and personal wishes of the patients.

Prospective Randomized Study Comparing MEMID with a Chop-Like Regimen in Elderly Patients with Aggressive Non-Hodgkin’s Lymphoma

OBJECTIVE

This multicenter phase III study compared the MEMID regimen (mitoxantrone, VP16, methylglyoxal, ifosfamide and dexamethasone) with CEOP, a CHOP-like regimen (cyclophosphamide, epirubicin, vincristine and prednisone), in elderly patients (> or =65 years) with aggressive non-Hodgkin's lymphoma (NHL).

METHODS

One hundred and forty-nine patients were eligible, 72 in the MEMID arm and 77 in the CEOP arm. The primary endpoint was to compare overall survival (OS) between groups, and secondary endpoints were event-free survival (EFS), response rate and toxicity.

RESULTS

Neutropenia (p < 10(-5)), anemia (p < 10(-5)) and thrombocytopenia (p = 0.0006) were significantly more frequent in patients who received MEMID. We observed an objective response rate of 55.5% in the MEMID arm and 64.9% in the CEOP arm (p = 0.24). The median OS and EFS were 15.4 and 8.5 months in the MEMID arm, and 20.3 and 10.5 months in the CEOP arm (p = 0.59 and 0.47), respectively. The median EFS was 15.4 months in the MEMID arm and 20.3 months in the CEOP arm (p = 0.59).

CONCLUSION

The increased toxicity without survival benefit confirms the superiority of CHOP and CHOP-like regimens for elderly patient with aggressive NHL.

The prevalence and correlates of fatigue in older cancer patients

PURPOSE

to assess the prevalence and correlates of fatigue in cancer patients aged 60 and older during outpatient treatment with chemotherapy or pamidronate.

PATIENT AND METHODS

seventy-seven consecutive cancer patients with different tumors age 60+ served by the senior adult oncology program of the H. Lee Moffitt Cancer Center, were enrolled in the study. Inclusion criteria were: (1) age >-60 years; (2) histological diagnosis of malignancy; (3) no major psychiatric or neurological disorder that could interfere with the competition of the measures; (4) ability to understand and to speak English. Assessment included cognition, function, depression and fatigue. The instruments included geriatric depression scale, mini mental state examination and fatigue symptom inventory. The study used a cross-sectional design.

RESULTS

Fifty-six patients (72.7%) reported fatigue at the time of the assessment; seventy-six patients (99%) in the past week. Forty patients (52%) rated their average fatigue as greater than 5. Forty-two patients (54%) reported that they felt fatigue all seven days, for any part of the day in the week before the assessment. Sixty five (84%) patients rated fatigue as interfering with their general level of activity. The fatigue disruptiveness was higher for women than for man (P<0.007). Marital status and educational level were not significantly related to fatigue severity or fatigue disruptiveness (P> or =0.33). A significant positive correlation between depressive symptoms and fatigue severity (r = 0.29, P<0.01) was recorded. Depression was also significantly related to fatigue disruptiveness (r = 0.44, P<0.01). Cognitive status was not correlated with fatigue severity or fatigue disruptiveness. A negative correlation between haemoglobin level and fatigue severity (r = -0.30, P<0.01) and between haemoglobin level and fatigue disruptiveness (r = -0.28, P<0.01) was found. Having had medical care or counselling in the past for anxiety and depression was positively correlated with fatigue disruptiveness (r = 0.29, P<0.01).

CONCLUSION

Fatigue is a common symptom of older cancer patients treated with antineoplastic medical treatment. Female patient showed higher fatigue disruptiveness than male. In this study a positive correlation between depression and fatigue, and a negative correlation between haemoglobin and fatigue, were recorded.

The role of myelopoietic growth factors in managing cancer in the elderly

More than 50% of all malignancies are diagnosed in patients aged > 65 years and most cancer-related deaths occur in this population. Misconceptions about prognosis and treatment contribute to the undertreatment of elderly cancer patients and consequent poor outcomes. Although older patients have been excluded from cancer treatment trials in the past, response rates to chemotherapy in a variety of common cancers in otherwise healthy elderly patients are comparable to those attained in younger patients. Lower functional reserve in many organ systems alters the pharmacokinetics of chemotherapeutic drugs as well as the patient's response to treatment-induced toxicity. Except for myelosuppression and mucositis, otherwise fit elderly cancer patients are not at significantly enhanced risk of toxicity to chemotherapy. Severe neutropenia and related infection are encountered much more frequently during the treatment of elderly as compared with younger cancer patients. These lead to treatment delays, dose reductions and higher hospitalisation rates. Myelopoietic growth factor support reduces myelosuppression and the associated risk of severe infection, thereby allowing delivery of chemotherapy at full dose intensity. Beneficial responses to granulocyte colony-stimulating factor (G-CSF; filgrastim) in elderly patients have been found in aggressive non-Hodgkin's lymphoma with standard cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) therapy and acute myeloid leukaemia (AML) during induction and consolidation chemotherapy. Granulocyte-macrophage colony-stimulating factor (GM-CSF; sargramostim) has been found to reduce myelosuppression in elderly AML patients receiving induction but not consolidation chemotherapy. These prophylactic treatments produce significant cost benefits because of the reduced hospitalisation and antibiotic use associated with neutropenia. To maximise positive outcomes, elderly patients should be included in clinical trials of new cancer agents. Since myelosuppression is the main risk factor for elderly patients undergoing chemotherapy, optimisation of growth factor support and the development of more effective and safer myelopoietic agents may improve success rates and reduce adverse events. Such information will lead to better management of cancer in older patients.

Management of hematologic malignancies in the elderly: 15-year experience at the Aviano Cancer Center, Italy

The optimal management of hemopoietic malignancies in the elderly requires specific strategies targeted at the peculiar clinico-biologic features of such patients. In the time frame spanning from 1983 to 1998, several clinical trials have been performed at the Aviano Cancer Center, Italy, aimed at extending the knowledge of natural history of hemopoietic malignancies in the elderly and evaluating the efficacy and toxicity of different chemotherapy programs specifically devised for older subjects affected by acute myeloid leukemia, myelodysplasia, non-Hodgkin's lymphomas, or multiple myeloma. Here the most relevant results are summarized and information stemmed from such studies. The present report rather than provide a comprehensive review on hematologic neoplasms in the elderly, mainly reflects the 'philosophy' deriving from 15 years of studies of the group in the field of geriatric oncology/hematology. Elaboration of a 'consensus' view will represent the challenge for all the investigators involved in such an important field of research.