Impact of age and socioeconomic status on treatment and survival from aggressive lymphoma: a UK population-based study of diffuse large B-cell lymphoma

A German perspective on the impact of socioeconomic status in diffuse large B-cell lymphoma

The prognostic influence of socioeconomic status (SES) on the survival of diffuse large B-cell lymphoma (DLBCL) patients remains controversial. This observational study examines the potential impact of regional SES inequalities on overall survival (OS) among DLBCL patients in Germany. We analyzed data from the German nationwide population-based dataset spanning 2004-2019 sourced from the German Center for Cancer Registry Data (n = 49,465). The primary objective was to assess the 5-year OS among patients with low SES compared to those living in middle and high SES areas. SES was grouped according to quintiles of the German Index of Socioeconomic Deprivation, which summarized nine indicators covering aspects of regional education, employment, and income. DLBCL patients in low SES areas had significantly impaired 5-year OS compared to those in middle and high SES regions (59.2% vs. 61.8% vs. 64.1%, p < 0.0001). Yet, additionally accounting for regional premature mortality removed the impact of SES on survival (Hazard Ratio 0.94, 95% CI 0.87-1.01). Our findings indicate that the prognostic impact of socioeconomic deprivation on long-term survival is not due to variations in diagnosis and treatment of DLBCL itself but rather a higher comorbidity burden.

Epidemiology and Real-World Treatment of Incident Diffuse Large B-cell Lymphoma (DLBCL): A German Claims Data Analysis

INTRODUCTION

The objective of this study was to investigate the prevalence, incidence, and treatment patterns (treatment regimens, switches, duration) for diffuse large B-cell lymphoma (DLBCL) in a real-world setting.

METHODS

This was a retrospective German claims data analysis of patients with DLBCL diagnosed between January 1, 2012, and December 31, 2020. The prevalence and cumulative incidence of DLBCL were found for 2019/2020. Line of treatment  (LOT) and treatment setting from first DLBCL diagnosis to end of follow-up were described. Kaplan-Meier overall survival (OS) estimates since DLBCL diagnosis and start of treatment lines were calculated.

RESULTS

Overall, 2633 incident DLBCL cases were identified (median age 75 years, 51% male). Of these, 2119 patients received at least one DLBCL-related treatment (LOT1), and 1567 patients died during follow-up. In 2019/2020, the prevalence and cumulative incidence of DLBCL was 34.8/36.7 per 100,000 patients and 14.0/12.7 per 100,000 patients, respectively. For LOT1, 1922 patients were given a chemotherapy-based regimen (1530 with CD20 antibodies). A total of 403 patients were administered a second line (LOT2), of which 183 patients received a CD20 antibody-containing chemotherapy regimen and 100 patients received stem cell transplantation or chimeric antigen receptor (CAR)-T therapy. Of the 136 LOT3+ treatments, 74 were chemotherapy regimens (54 with CD20 antibodies) and 18 were kinase inhibitors. The median time between treatment lines was less than 6 months. Among patients with at least LOT2, approximately 50% received more than one LOT during the first year after diagnosis. Approximately 25% of treated patients died within 6 months of treatment initiation. Of the 2633 included patients, the median OS from diagnosis was 31.0 months (treated patients: 46.8 months, untreated patients: 3.0 months).

CONCLUSIONS

Despite advances in the field, high unmet medical need in DLBCL remains. The treatment landscape is very heterogeneous, particularly in second- or later-line treatments, with few patients receiving potentially curative treatment beyond the first line. Treatment for DLBCL, particularly for transplant-ineligible patients, remains challenging.

Real-World Challenges of Managing Diffuse Large B-Cell Lymphoma in a Developing Country

PURPOSE

To highlight challenges and cancer care disparities in patients of diffuse large B-cell lymphoma management in resource-constrained settings.

MATERIALS AND METHODS

This multicenter retrospective study included 738 patients from 12 public and private sector hematology-oncology centers across Pakistan. Patients were divided into limited-resource and enhanced-resource settings as per national diffuse large B-cell lymphoma (DLBCL) guidelines.

RESULTS

The median age at diagnosis was 47 years (range, 14-89). Male:female ratio was 2.5:1. Majority of the patients (69.3%) were treated in limited-resource settings. Computed tomography was used as a staging modality in 442 (60%) patients. Limited-stage DLBCL was present in 13.5% of patients, while 86.3% had advanced-stage disease at diagnosis. First-line regimens included rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone in 56% and cyclophosphamide, doxorubicin, vincristine, prednisone in 34% of patients, while 10% of patients received palliative regimens upfront. Of evaluable data, complete remission was documented in 299 (74.4%) patients, 39 (9.8%) had partial response and 63 (13.5%) had progressive disease. Disease-free survival (DFS) and overall survival (OS) status were not available for 345 (46.8%) patients at the time of data collection. Overall study cohort had a median follow-up of 2.2 years with a median OS of 3.6 years (95% CI, 3.1 to 4.1), median DFS of 3.1 years (95% CI, 2.6 to 3.6), and a 5-year OS of 40% and DFS of 36%.

CONCLUSION

Patients from low- and middle-income countries present at an earlier age and have more advanced disease. Patients were frequently lost to follow-up, and record keeping was inadequate more so in patients treated in limited-resource settings. There is a need to establish a national lymphoma registry, improve record keeping, and standardize treatments to ensure improvement in treatment outcomes.

Long-term outcomes with HLX01 (HanliKang®), a rituximab biosimilar, in previously untreated patients with diffuse large B-cell lymphoma: 5-year follow-up results of the phase 3 HLX01-NHL03 study

HLX01 (HanliKang®) is a rituximab biosimilar that showed bioequivalence to reference rituximab in untreated CD20-positive diffuse large B-cell lymphoma (DLBCL) in the phase 3 HLX01-NHL03 study. Here, we report the 5-year follow-up results from the open-label extension part. Patients were randomised to either rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) or HLX01 plus CHOP (H-CHOP) every 21 days for up to six cycles. The primary efficacy endpoint was overall survival (OS), and secondary efficacy endpoint was progression-free survival (PFS). Of the 407 patients enrolled in HLX01-NHL03, 316 patients (H-CHOP = 157; R-CHOP = 159) were included in the 5-year follow-up for a median duration of 65.1 (range, 2.2-76.5) months. 96.5% of the patients had an International Prognostic Index (IPI) of 1 or 2, and 17.7% had bone marrow involvement. The 5-year OS rates were 81.0% (95% CI: 74.9-87.5%) and 75.4% (95% CI: 68.9-82.6%)( HR: 0.75, 95% CI 0.47-1.20; p = 0.23) while 5-year PFS rates were 77.7% (95% CI: 71.4-84.6%) and 73.0% (95% CI: 66.3-80.3%) (HR: 0.84, 95% CI 0.54-1.30; p = 0.43) in the H-CHOP and R-CHOP groups, respectively. Treatment outcomes did not differ between groups regardless of IPI score and were consistent with the primary analysis. H-CHOP and R-CHOP provided no significant difference in 5-year OS or PFS in previously untreated patients with low or low-intermediate risk DLBCL.

Diffuse Large B-Cell Lymphoma Treated With R-CHOP in a Resource-Limited Setting in South Africa: A Real-World Study

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin's lymphoma worldwide and particularly in Africa, where the incidence of HIV is the highest in the world. R-CHOP is the standard of care regimen for DLBCL, but access to rituximab is limited in developing countries.

METHODS

This is a retrospective cohort study that included all HIV-negative patients with DLBCL who received R-CHOP at a single institution from January 2012 to December 2017. Clinical and demographic data were collected to assess factors that influenced survival.

RESULTS

Seventy-three patients were included. Median age was 55 (17-76), 67.1% of patients were younger than 60 years, and 60.3% were female. Most presented with stages III/IV disease (53.5%) but with good performance status (56.% PS 0 and 1). Progression-free survival at 3 and 5 years was 75% and 69%, and overall survival at 3 and 5 years was 77% and 74%, respectively. Median survival had not been reached with a median follow-up of 3.5 years(0.13-7.9). Overall survival was significantly affected by performance status (P = .04), but not by IPI or age. Survival was significantly associated with response to chemotherapy after 4-5 cycles of R-CHOP (P = 0.005).

CONCLUSIONS

Treatment of DLBCL with R-CHOP is feasible and can achieve good outcomes in resource-limited settings with rituximab-based chemotherapy. Poor performance status was the most important adverse prognostic factor in this cohort of HIV-negative patients.

Mediating Effects of Diagnostic Route on the Comorbidity Gap in Survival of Patients with Diffuse Large B-Cell or Follicular Lymphoma in England

Background: Socioeconomic inequalities in survival from non-Hodgkin lymphoma persist. Comorbidities are more prevalent amongst those in more deprived areas and are associated with diagnostic delay (emergency diagnostic route), which is also associated with poorer survival probability. We aimed to describe the effect of comorbidity on the probability of death mediated by diagnostic route (emergency vs. elective route) amongst patients with diffuse large B-cell (DLBCL) or follicular lymphoma (FL). Methods: We linked the English population-based cancer registry and hospital admission records (2005-2013) of patients aged 45-99 years. We decomposed the effect of comorbidity on survival into an indirect effect acting through diagnostic route and a direct effect not mediated by diagnostic route. Furthermore, we estimated the proportion of the comorbidity effect on survival mediated by diagnostic route. Results: For both DLBCL (n = 27,379) and FL (n = 14,043), those with any comorbidity, or living in more deprived areas, were more likely to experience diagnostic delay and poorer survival. The indirect effect of comorbidity on mortality through diagnostic route was highest at 12 months since diagnosis (DLBCL: Odds Ratio 1.10 [95% CI 1.07-1.13], FL: OR 1.09 [95% CI 1.04-1.14]). Within the first 12 months since diagnosis, emergency diagnostic route accounted for 24% (95% CI 17.5-29.5) and 16% (95% CI 6.0-25.6) of the comorbidity effect on mortality, for DLBCL and FL, respectively. Conclusion: Efforts to reduce diagnostic delay (emergency diagnosis) amongst patients with comorbidity would reduce inequalities in DLBCL and FL survival by 24% and 16%, respectively. Further public health programs and interventions are needed to reduce diagnostic delay amongst lymphoma patients with comorbidities.

Do socioeconomic factors impact management of suspected canine multicentric lymphoma in UK first opinion practice?

BACKGROUND

This study aimed to describe the management of cases of suspected and confirmed canine multicentric lymphoma (ML) in first opinion practice (FOP) and investigate whether socioeconomic factors are associated with initial management.

METHODS

Clinical narratives from electronic health records collected by the Small Animal Veterinary Surveillance Network (SAVSNET) were searched to identify dogs with peripheral lymphadenomegaly in which ML was the major differential. Cases were grouped as either ML confirmed (ML-C) or ML suspected but not confirmed (ML-S). Associations between initial management and socioeconomic factors were assessed via multivariable logistic regression.

RESULTS

Two hundred and sixty-four cases with ML-C and 410 with ML-S were identified. There was an increased probability that owners of ML-C cases resided in less deprived areas. Moreover, a diagnosis was made more commonly in insured dogs. Only insured pets were more likely to be treated with chemotherapy following diagnosis. The majority of dogs in both groups were treated with corticosteroids alone (ML-S, n = 256/410; ML-C, n = 123/264). A small minority were referred (n = 30/674).

CONCLUSION

Socioeconomic inequalities appear to be associated with the diagnosis and management of dogs with suspected or confirmed ML in FOP. Most dogs with suspected multicentric lymphoma (in the UK) are managed in FOP (n = 644/674). Consequently, expanding the knowledge base relevant to this setting offers an opportunity to improve the management of canine lymphoma.

Outcomes of older patients with diffuse large B-cell lymphoma treated with R-CHOP: 10-year follow-up of the LNH03-6B trial

The LNH03-6B trial was a phase 3 randomized trial evaluating the efficacy of first-line rituximab, cyclophosphamide, doxorubicine, vincristine and prednisone (R-CHOP) delivered every 2 weeks (R-CHOP14) or 3 weeks (R-CHOP21) in patients with diffuse large B-cell lymphoma (DLBCL) aged 60 to 80 years with an aaIPI (age-adjusted International Prognostic Index) score ≥1 (registered as NCT00144755). We implemented a prospective long-term follow-up program at the end of this trial. The primary endpoints were progression-free survival (PFS) and overall survival (OS). Relapse patterns, PFS and OS after the first progression (PFS2 and OS2) were secondary endpoints. LNH03-6B was registered with ClinicalTrials.gov #NCT00144755. In the LNH03-6B trial, 304 and 296 patients were assigned to receive 8 cycles of R-CHOP14 or R-CHOP21, respectively. Long-term follow-up data were investigated for 256 of 384 (67%) patients still alive at the primary analysis. With a median follow-up of 10.1 years, 213 patients progressed, and 140 patients died without progression. The 10-year PFS was 40.4% (95% confidence interval, 35.9-44.9). Ten-year OS was based on 302 deaths and estimated at 50% (43-56). Of the 213 patients, 105 (49%) progressed after second-line therapy, and 77 patients died without a second progression (36%). The 1-year PFS2 and 1-year OS2 were estimated at 37.9% (95% confidence interval, 31.4-44.5) and 55.8% (95% confidence interval, 48.8-62.2), respectively. Ten years after randomization, the outcomes of patients treated for DLBCL were similar according to PFS and OS between the RCHOP-14 and R-CHOP21 groups. Progression or relapse led to poor prognosis after second-line chemotherapy in the pre CAR-T-cell era. Novel approaches in first-line and alternative treatments in second-line treatments are warranted in this population.

Human Pegivirus Type 1: A Common Human Virus That Is Beneficial in Immune-Mediated Disease?

Two groups identified a novel human flavivirus in the mid-1990s. One group named the virus hepatitis G virus (HGV) and the other named it GB Virus type C (GBV-C). Sequence analyses found these two isolates to be the same virus, and subsequent studies found that the virus does not cause hepatitis despite sharing genome organization with hepatitis C virus. Although HGV/GBV-C infection is common and may cause persistent infection in humans, the virus does not appear to directly cause any other known disease state. Thus, the virus was renamed “human pegivirus 1” (HPgV-1) for “persistent G” virus. HPgV-1 is found primarily in lymphocytes and not hepatocytes, and several studies found HPgV-1 infection associated with prolonged survival in people living with HIV. Co-infection of human lymphocytes with HPgV-1 and HIV inhibits HIV replication. Although three viral proteins directly inhibit HIV replication in vitro, the major effects of HPgV-1 leading to reduced HIV-related mortality appear to result from a global reduction in immune activation. HPgV-1 specifically interferes with T cell receptor signaling (TCR) by reducing proximal activation of the lymphocyte specific Src kinase LCK. Although TCR signaling is reduced, T cell activation is not abolished and with sufficient stimulus, T cell functions are enabled. Consequently, HPgV-1 is not associated with immune suppression. The HPgV-1 immunomodulatory effects are associated with beneficial outcomes in other diseases including Ebola virus infection and possibly graft-versus-host-disease following stem cell transplantation. Better understanding of HPgV-1 immune escape and mechanisms of inflammation may identify novel therapies for immune-based diseases.

Ideal dose intensity of R-CHOP in diffuse large B-cell lymphoma

INTRODUCTION

The standard of care for diffuse large B-cell lymphoma (DLBCL) is rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). However, its ideal dose intensity varies among cases.

AREAS COVERED

This review provides the latest insights on the dose intensity of R-CHOP for DLBCL patients. Specifically, we discussed the optimal dose intensity for elderly patients, the optimal number of treatment cycles for limited or advanced-stage diseases, and the role of dose-intensified therapies or adding targeted inhibitors.

EXPERT OPINION

Performing a comprehensive or simplified geriatric assessment can distinguish elderly DLBCL patients who will likely benefit from curative R-CHOP. Very elderly or medically unfit patients may need dose reduction in R-CHOP; the Age, Comorbidities, and Albumin index may aid decision-making. Four cycles of R-CHOP followed by two rituximab cycles comprise a new standard for low-risk, limited-stage DLBCL patients. Compared to eight cycles, six cycles of R-CHOP have similar efficacy and fewer toxicities for advanced-stage DLBCL. Dose-intensified therapy is not recommended in most DLBCL cases but may be considered for patients with double (or triple)-hit lymphoma. Applying targeted inhibitors and not merely escalating R-CHOP dose intensity through molecular subtyping will improve the treatment outcome for DLBCL.

Identifying aggressive subsets within diffuse large B-cell lymphoma: implications for treatment approach

INTRODUCTION

While the majority of patients diagnosed with diffuse large B-cell lymphoma (DLBCL) can be cured with front-line chemoimmunotherapy, a subset of patients with high-risk disease remain challenging to treat. Identification of high-risk DLBCL is important as future therapy options are explored.

AREAS COVERED

We discuss the clinical, pathologic and molecular risk stratification in DLBCL and how these factors are incorporated into the decision making for the front-line therapy.

EXPERT OPINION

Clinical and pathological risk stratification has long been the standard for identifying likelihood of future disease progression and overall survival; however, these prediction models lack the granularity of individual patient pathology and response to therapy. Molecular subtypes defined through whole exome sequencing have independent prognostic significance. While identifying molecular drivers of aggressive disease has provided the opportunity to analyze novel therapy combinations with front-line chemoimmunotherapy, only modest benefit has been observed when targeting DLBCL subtypes. Combining clinical, pathologic, and molecular data will likely result in significant improvement in our ability to identify the most aggressive DLBCL subsets. Novel therapies and trial designs will continue to play an important role as we target these at-risk populations in the future.

Ofatumumab with iphosphamide, etoposide and cytarabine for patients with transplantation-ineligible relapsed and refractory diffuse large B-cell lymphoma

The efficacy of salvage treatment of diffuse large B-cell lymphoma (DLBCL) patients who relapse or progress (rrDLBCL) after initial therapy is limited. Efficacy and safety of ofatumumab with iphosphamide, etoposide and cytarabine (O-IVAC) was evaluated in a single-arm study. Dosing was modified for elderly patients. Patients received up to six cycles of treatment. The primary end-point was the overall response rate (ORR). Patients were evaluated every two cycles and then six and 12 months after treatment. Other end-points included progression-free survival (PFS), event-free survival (EFS), overall survival (OS) and safety. Seventy-seven patients received salvage treatment with O-IVAC. The average age was 56.8 years; 39% had an Eastern Cooperative Oncology Group (ECOG) performance status of at least 3; 78% had disease of Ann Arbor stage 3 or 4; 58% received one or more prior salvage therapies. The ORR for O-IVAC was 54.5%. The median duration of study follow-up was 70 months. The median PFS and EFS were 16.3 months each. The median OS was 22.7 months. Age, ECOG performance status and the number of prior therapy lines were independent predictors of survival. Treatment-related mortality was 15.5%. O-IVAC showed a high response rate in a difficult-to-treat population and is an attractive treatment to bridge to potentially curative therapies.

Artificial Neural Networks Predicted the Overall Survival and Molecular Subtypes of Diffuse Large B-Cell Lymphoma Using a Pancancer Immune-Oncology Panel

Simple Summary

This research predicted the overall survival of patients and cell-of-origin molecular subtypes of diffuse large B-cell lymphoma from Tokai University using gene expression data. A pancancer immune profiling panel was analyzed using artificial neural networks, and high accuracy of prediction was found. Additionally, the results were explained with other machine learning techniques and conventional bioinformatics analyses.

Abstract

Diffuse large B-cell lymphoma (DLBCL) is one of the most frequent subtypes of non-Hodgkin lymphomas. We used artificial neural networks (multilayer perceptron and radial basis function), machine learning, and conventional bioinformatics to predict the overall survival and molecular subtypes of DLBCL. The series included 106 cases and 730 genes of a pancancer immune-oncology panel (nCounter) as predictors. The multilayer perceptron predicted the outcome with high accuracy, with an area under the curve (AUC) of 0.98, and ranked all the genes according to their importance. In a multivariate analysis, ARG1, TNFSF12, REL, and NRP1 correlated with favorable survival (hazard risks: 0.3–0.5), and IFNA8, CASP1, and CTSG, with poor survival (hazard risks = 1.0–2.1). Gene set enrichment analysis (GSEA) showed enrichment toward poor prognosis. These high-risk genes were also associated with the gene expression of M2-like tumor-associated macrophages (CD163), and MYD88 expression. The prognostic relevance of this set of 7 genes was also confirmed within the IPI and MYC translocation strata, the EBER-negative cases, the DLBCL not-otherwise specified (NOS) (High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements excluded), and an independent series of 414 cases of DLBCL in Europe and North America (GSE10846). The perceptron analysis also predicted molecular subtypes (based on the Lymph2Cx assay) with high accuracy (AUC = 1). STAT6, TREM2, and REL were associated with the germinal center B-cell (GCB) subtype, and CD37, GNLY, CD46, and IL17B were associated with the activated B-cell (ABC)/unspecified subtype. The GSEA had a sinusoidal-like plot with association to both molecular subtypes, and immunohistochemistry analysis confirmed the correlation of MAPK3 with the GCB subtype in another series of 96 cases (notably, MAPK3 also correlated with LMO2, but not with M2-like tumor-associated macrophage markers CD163, CSF1R, TNFAIP8, CASP8, PD-L1, PTX3, and IL-10). Finally, survival and molecular subtypes were successfully modeled using other machine learning techniques including logistic regression, discriminant analysis, SVM, CHAID, C5, C&R trees, KNN algorithm, and Bayesian network. In conclusion, prognoses and molecular subtypes were predicted with high accuracy using neural networks, and relevant genes were highlighted.

Excess Mortality by Multimorbidity, Socioeconomic, and Healthcare Factors, amongst Patients Diagnosed with Diffuse Large B-Cell or Follicular Lymphoma in England

(1) Background: Socioeconomic inequalities of survival in patients with lymphoma persist, which may be explained by patients' comorbidities. We aimed to assess the association between comorbidities and the survival of patients diagnosed with diffuse large B-cell (DLBCL) or follicular lymphoma (FL) in England accounting for other socio-demographic characteristics. (2) Methods: Population-based cancer registry data were linked to Hospital Episode Statistics. We used a flexible multilevel excess hazard model to estimate excess mortality and net survival by patient's comorbidity status, adjusted for sociodemographic, economic, and healthcare factors, and accounting for the patient's area of residence. We used the latent normal joint modelling multiple imputation approach for missing data. (3) Results: Overall, 15,516 and 29,898 patients were diagnosed with FL and DLBCL in England between 2005 and 2013, respectively. Amongst DLBCL and FL patients, respectively, those in the most deprived areas showed 1.22 (95% confidence interval (CI): 1.18-1.27) and 1.45 (95% CI: 1.30-1.62) times higher excess mortality hazard compared to those in the least deprived areas, adjusted for comorbidity status, age at diagnosis, sex, ethnicity, and route to diagnosis. (4) Conclusions: Deprivation is consistently associated with poorer survival among patients diagnosed with DLBCL or FL, after adjusting for co/multimorbidities. Comorbidities and multimorbidities need to be considered when planning public health interventions targeting haematological malignancies in England.

Investigating the inequalities in route to diagnosis amongst patients with diffuse large B-cell or follicular lymphoma in England

INTRODUCTION

Diagnostic delay is associated with lower chances of cancer survival. Underlying comorbidities are known to affect the timely diagnosis of cancer. Diffuse large B-cell (DLBCL) and follicular lymphomas (FL) are primarily diagnosed amongst older patients, who are more likely to have comorbidities. Characteristics of clinical commissioning groups (CCG) are also known to impact diagnostic delay. We assess the association between comorbidities and diagnostic delay amongst patients with DLBCL or FL in England during 2005-2013.

METHODS

Multivariable generalised linear mixed-effect models were used to assess the main association. Empirical Bayes estimates of the random effects were used to explore between-cluster variation. The latent normal joint modelling multiple imputation approach was used to account for partially observed variables.

RESULTS

We included 30,078 and 15,551 patients diagnosed with DLBCL or FL, respectively. Amongst patients from the same CCG, having multimorbidity was strongly associated with the emergency route to diagnosis (DLBCL: odds ratio 1.56, CI 1.40-1.73; FL: odds ratio 1.80, CI 1.45-2.23). Amongst DLBCL patients, the diagnostic delay was possibly correlated with CCGs that had higher population densities.

CONCLUSIONS

Underlying comorbidity is associated with diagnostic delay amongst patients with DLBCL or FL. Results suggest a possible correlation between CCGs with higher population densities and diagnostic delay of aggressive lymphomas.

Impact of Central Nervous System International Prognostic Index on the Treatment of Diffuse Large B Cell Lymphoma

Background

The central nervous system international prognostic index (CNS-IPI) is being used widely for the identification of patients with diffuse large B cell lymphoma (DLBCL) with a high risk of central nervous system (CNS) relapse. The aim of our study is to confirm the value of the CNS-IPI in predicting CNS relapse in our young study population and to evaluate its impact on the selection of patients for CNS prophylaxis.

Methods

We retrospectively reviewed patients diagnosed with DLBCL who were treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (RCHOP) regimen from January 2010 till December 2018. Correlation between CNS-IPI and cumulative incidence of CNS relapse and time to CNS relapse was examined through Kaplan-Meier plots. Median time to CNS relapse and median overall survival after CNS relapse were also estimated using the Kaplan-Meier plots. 

Results

A total of 354 patients were included. The median age was 46 years. Overall, 5% of the patients developed CNS relapse. Median survival after CNS relapse was seven months. Two-year CNS relapse rates according to CNS-IPI were 0.7%, 5.1%, and 26% for low, intermediate, and high-risk, groups respectively.

On multivariate analysis, poor performance status (p=0.045), involvement of two or more extranodal sites (p= 0.021), involvement of bone marrow (p= 0.029), and renal or adrenal glands (p= 0.006) significantly correlated with CNS relapse. Considering the CNS-IPI and high-risk anatomical sites (breast, uterus, testis, and epidural space), 26% of our patients with DLBCL would have needed prophylaxis.

Conclusion

Although CNS-IPI helps in better selection of DLBCL patients for CNS prophylaxis, it can possibly increase the number of patients exposed to unnecessary prophylaxis. More investigational biomarkers are needed to better refining high-risk patients.

Socioeconomic inequalities in treatment and relative survival among patients with diffuse large B-cell lymphoma: a Hong Kong population-based study

The influence of socioeconomic status (SES) on access to standard chemotherapy and/or monoclonal antibody therapy, and associated secular trends, relative survival, and excess mortality, among diffuse large B-cell lymphoma (DLBCL) patients is not clear. We conducted a Hong Kong population-based cohort study and identified adult patients with histologically diagnosed DLBCL between 2000 and 2018. We examined the association of SES levels with the odds and the secular trends of receipt of chemotherapy and/or rituximab. Additionally, we estimated the long-term relative survival by SES utilizing Hong Kong life tables. Among 4017 patients with DLBCL, 2363 (58.8%) patients received both chemotherapy and rituximab and 740 (18.4%) patients received chemotherapy alone, while 1612 (40.1%) and 914 (22.8%) patients received no rituximab or chemotherapy, respectively. On multivariable analysis, low SES was associated with lesser use of chemotherapy (odd ratio [OR] 0.44; 95% CI 0.34-0.57) and rituximab (OR 0.41; 95% CI 0.32-0.52). The socioeconomic disparity for either treatment showed no secular trend of change. Additionally, patients with low SES showed increased excess mortality, with a hazard ratio of 2.34 (95% CI 1.67-3.28). Improving survival outcomes for patients with DLBCL requires provision of best available medical care and securing access to treatment regardless of patients' SES.

Survival Predictors of Head and Neck Burkitt's Lymphoma: An Analysis of the SEER Database

OBJECTIVE

To analyze population-level data for Burkitt's lymphoma of the head and neck.

STUDY DESIGN

Retrospective study of a national cancer database.

SETTING

Academic medical center.

METHODS

The SEER database (Surveillance, Epidemiology, and End Results) identified all patients with primary Burkitt's lymphoma of the head and neck from 1975 to 2015. Demographic, clinicopathologic, and treatment characteristics were analyzed. Multivariable Cox regressions analyzed factors associated with survival while controlling for baseline differences.

RESULTS

A total of 920 patients with a mean (SD) age of 37.6 years (25.0) were identified. A majority of patients were White (82.8%) and male (72.3%). The most primary common sites included the lymph nodes (61.3%), pharynx (17.7%), and nasal cavity/paranasal sinuses (5.2%). The majority of patients received chemotherapy (90.5%), while fewer underwent surgery (42.1%) or radiotherapy (12.8%). Choice of treatment differed significantly among patients of different ages, year of diagnosis, primary site, nodal status, and Ann Arbor stage. Overall 10-year survival was 67.8%. On multivariable Cox regression, patients with older age (hazard ratio [HR], 1.05 per year; P < .001) and higher stage at presentation had increased risk of mortality (P < .001). Furthermore, cases diagnosed between 2006 and 2015 (HR, 0.35; P < .001) and 1996 and 2005 (HR, 0.53; P = .001) had lower mortality when compared with those diagnosed between 1975 and 1995. Treatment including surgery and chemotherapy tended to have the best survival (P < .001).

CONCLUSION

Burkitt's lymphoma of the head and neck diagnosed in more recent years has had improved survival. Factors significantly associated with survival include age, Ann Arbor stage, and treatment regimen. Treatment including surgery and chemotherapy was associated with the highest survival.

Obinutuzumab Plus Chemotherapy Compared with Rituximab Plus Chemotherapy in Previously Untreated Italian Patients with Advanced Follicular Lymphoma at Intermediate-High Risk: A Cost-Effectiveness Analysis

Objective

To assess the cost-effectiveness of obinutuzumab (O-chemo) in comparison to rituximab (R-chemo) in patients with untreated advanced follicular lymphoma (FL) at intermediate or high risk from an Italian National Health Service (NHS) perspective.

Methods

A previously developed four-state Markov model was adapted to estimate lifetime clinical outcomes and costs of Italian patients with advanced FL and an FL international predictive index score ≥2 in treatment with O-chemo and R-chemo. Life expectancy was derived from the GALLIUM and PRIMA clinical trials. Progression-free survival (PFS), early progressive disease (PD), and treatment duration were extrapolated by fitting parametric distributions to empirical data in GALLIUM and late PD to data in PRIMA. Expected survival was weighed by published utilities. Costs updated to 2020 Euros and health gains occurring after the first year were discounted at an annual 3% rate. Probabilistic sensitivity analysis (PSA) was carried out.

Results

O-chemo was associated with an incremental survival increase (0.97 life-years [LYs]), even when weighted for quality (0.88 quality-adjusted LYs [QALYs]), and incremental costs (around €15,000), driven by longer treatment during PFS state relative to R-chemo. The incremental cost-effectiveness ratio and incremental cost-utility ratio are both widely accepted by the Italian NHS (around €15,500/LY and €17,000/QALY gained, respectively). PSA simulations confirmed the robustness of results given sensible variations in assumptions.

Conclusion

O-chemo has superior clinical efficacy compared to rituximab, and should be considered a cost-effective option in first-line treatment of patients with advanced FL at intermediate or high risk in Italy. Incremental cost-effectiveness ratios are below the threshold considered affordable by developed countries.

The Prognostic Impact of Comorbidities in Patients with De-Novo Diffuse Large B-Cell Lymphoma Treated with R-CHOP Immunochemotherapy in Curative Intent

BACKGROUND

Patient-related factors, namely comorbidities, impact the clinical outcome of patients with diffuse large B-cell lymphoma (DLBCL).

METHODS

The prevalence and prognostic impact of comorbidities were examined using the validated scores Charlson Comorbidity Index (CCI) and Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) in 181 patients with DLBCL at initial diagnosis before treatment with rituximab, cyclophosphamide, vincristine, doxorubicin and prednisone (R-CHOP).

RESULTS

Pronounced comorbidities as defined by CCI and HCT-CI scoring of ≥2 were detected in 9.9% and 28.2% of patients, respectively, and occurred more frequently at advanced age (p < 0.001). Higher CCI scoring was associated with lower complete response rate (p = 0.020). Both advanced CCI and HCT-CI were significantly associated with shortened overall survival (3-year OS: CCI ≥2 vs. 0-1, 38.9% vs. 81.3%, p < 0.001; HCT-CI ≥2 vs. 0-1, 56.9% vs. 84.9%, p < 0.001). Both comorbidity scores remained independent risk factors in the multivariate analysis (HCT-CI ≥2 HR: 2.6, p = 0.004; CCI ≥2 HR: 3.6, p = 0.001).

CONCLUSION

This study demonstrates the prognostic relevance of comorbidities classified by CCI and HCT-CI in patients with DLBCL undergoing curative treatment with R-CHOP. A structured evaluation of comorbidities might refine prognostication alongside currently used prognostic parameters, namely age, and should be evaluated in prospective trials.

Effects of center type and socioeconomic factors on early mortality and overall survival of diffuse large B-cell lymphoma

Aim: To examine whether the center type and socioeconomic factors significantly impact 1-month mortality and overall survival (OS) of patients with diffuse large B-cell lymphoma (DLBCL). Methods: National Cancer Database (NCDB) was used to identify patients diagnosed with diffuse large B-cell lymphoma from 2006 to 2012 (postrituximab era). Results: Among 185,183 patients, 33% were treated at academic centers. The receipt of therapy at larger volume centers was associated with improved 1-month mortality. Academic centers had better OS than nonacademic centers in univariable analysis. Younger age, private insurance, lower Charlson comorbidity score and lower lymphoma stage were associated with improved 1-month mortality and OS. Conclusion: The receipt of therapy at larger volume centers and socioeconomic factors were associated with improved survival.

Gene-expression profiling of bortezomib added to standard chemoimmunotherapy for diffuse large B-cell lymphoma (REMoDL-B): an open-label, randomised, phase 3 trial

BACKGROUND

Biologically distinct subtypes of diffuse large B-cell lymphoma can be identified using gene-expression analysis to determine their cell of origin, corresponding to germinal centre or activated B cell. We aimed to investigate whether adding bortezomib to standard therapy could improve outcomes in patients with these subtypes.

METHODS

In a randomised evaluation of molecular guided therapy for diffuse large B-cell lymphoma with bortezomib (REMoDL-B), an open-label, adaptive, randomised controlled, phase 3 superiority trial, participants were recruited from 107 cancer centres in the UK (n=94) and Switzerland (n=13). Eligible patients had previously untreated, histologically confirmed diffuse large B-cell lymphoma with sufficient diagnostic material from initial biopsies for gene-expression profiling and pathology review; were aged 18 years or older; had ECOG performance status of 2 or less; had bulky stage I or stage II-IV disease requiring full-course chemotherapy; had measurable disease; and had cardiac, lung, renal, and liver function sufficient to tolerate chemotherapy. Patients initially received one 21-day cycle of standard rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP; rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, and vincristine 1·4 mg/m2 [to a maximum of 2 mg total dose] intravenously on day 1 of the cycle, and prednisolone 100 mg orally once daily on days 1-5). During this time, we did gene-expression profiling using whole genome cDNA-mediated annealing, selection, extension, and ligation assay of tissue from routine diagnostic biopsy samples to determine the cell-of-origin subtype of each participant (germinal centre B cell, activated B cell, or unclassified). Patients were then centrally randomly assigned (1:1) via a web-based system, with block randomisation stratified by international prognostic index score and cell-of-origin subtype, to continue R-CHOP alone (R-CHOP group; control), or with bortezomib (RB-CHOP group; experimental; 1·3 mg/m2 intravenously or 1·6 mg/m2 subcutaneously) on days 1 and 8 for cycles two to six. If RNA extracted from the diagnostic tissues was of insufficient quality or quantity, participants were given R-CHOP as per the control group. The primary endpoint was 30-month progression-free survival, for the germinal centre and activated B-cell population. The primary analysis was on the modified intention-to-treat population of activated and germinal centre B-cell population. Safety was assessed in all participants who were given at least one dose of study drug. We report the progression-free survival and safety outcomes for patients in the follow-up phase after the required number of events occurred. This study was registered at ClinicalTrials.gov, number NCT01324596, and recruitment and treatment has completed for all participants, with long-term follow-up ongoing.

FINDINGS

Between June 2, 2011, and June 10, 2015, 1128 eligible patients were registered, of whom 918 (81%) were randomly assigned to receive treatment (n=459 to R-CHOP, n=459 to RB-CHOP), comprising 244 (26·6%) with activated B-cell disease, 475 (51·7%) with germinal centre B cell disease, and 199 (21·7%) with unclassified disease. At a median follow-up of 29·7 months (95% CI 29·0-32·0), we saw no evidence for a difference in progression-free survival in the combined germinal centre and activated B-cell population between R-CHOP and RB-CHOP (30-month progression-free survival 70·1%, 95% CI 65·0-74·7 vs 74·3%, 69·3-78·7; hazard ratio 0·86, 95% CI 0·65-1·13; p=0·28). The most common grade 3 or worse adverse event was haematological toxicity, reported in 178 (39·8%) of 447 patients given R-CHOP and 187 (42·1%) of 444 given RB-CHOP. However, RB-CHOP was not associated with increased haematological toxicity and 398 [87·1%] of 459 participants assigned to receive RB-CHOP completed six cycles of treatment. Grade 3 or worse neuropathy occurred in 17 (3·8%) patients given RB-CHOP versus eight (1·8%) given R-CHOP. Serious adverse events occurred in 190 (42·5%) patients given R-CHOP, including five treatment-related deaths, and 223 (50·2%) given RB-CHOP, including four treatment-related deaths.

INTERPRETATION

This is the first large-scale study in diffuse large B-cell lymphoma to use real-time molecular characterisation for prospective stratification, randomisation, and subsequent analysis of biologically distinct subgroups of patients. The addition of bortezomib did not improve progression-free survival.

FUNDING

Janssen-Cilag, Bloodwise, and Cancer Research UK.

Socioeconomic inequality in cancer survival - changes over time. A population-based study, Denmark, 1987-2013

Background: Socioeconomic inequality in survival after cancer have been reported in several countries and also in Denmark. Changes in cancer diagnostics and treatment may have changed the gap in survival between affluent and deprived patients and we investigated if the differences in relative survival by income has changed in Danish cancer patients over the past 25 years. Methods: The 1- and 5-year relative survival by income quintile is computed by comparing survival among cancer patients diagnosed 1987-2009 to the survival of a cancer-free matched sample of the background population. The comparison is done within the 15 most common cancers and all cancers combined. The gap in relative survival due to socioeconomic inequality for the period 1987-1991 is compared the period 2005-2009. Results: The relative 5-year survival increased for all 15 cancer sites investigated in the study period. In general, low-income patients diagnosed in 1987-1991 had between 0% and 11% units lower 5-year relative survival compared with high-income patients; however, only four sites (breast, prostate, bladder and head & neck) were statistically different. In patients diagnosed 2005-2009, the gap in 5-year RS was ranging from 2% to 22% units and statistically significantly different for 9 out of 15 sites. The results for 1-year relative survival were similar to the 5-year survival gap. An estimated 22% of all deaths at five years after diagnosis could be avoided had patients in all income groups had same survival as the high-income group. Conclusion: In this nationwide population-based study, we observed that the large improvements in both short- and long-term cancer survival among patients diagnosed 1987-2009. The improvements have been most pronounced for high-income cancer patients, leading to stable or even increasing survival differences between richest and poorest patients. Improving survival among low-income patients would improve survival rates among Danish cancer patients overall and reduce differences in survival when compared to other Western European countries.

Survival Outcomes of Younger Patients With Mantle Cell Lymphoma Treated in the Rituximab Era

PURPOSE

Mantle cell lymphoma (MCL) is a B-cell lymphoma characterized by cyclin D1 expression. Autologous hematopoietic cell transplantation (AHCT) consolidation after induction chemotherapy is often used for eligible patients; however, the benefit remains uncertain in the rituximab era. Herein we retrospectively assessed the impact of AHCT consolidation on survival in a large cohort of transplantation-eligible patients age 65 years or younger.

PATIENTS AND METHODS

We retrospectively studied transplantation-eligible adults age 65 years or younger with newly diagnosed MCL treated between 2000 and 2015. The primary objective was to assess for improved progression-free survival (PFS) with AHCT consolidation and secondarily to assess for improved overall survival (OS). Cox multivariable regression analysis and propensity score-weighted (PSW) analysis were performed.

RESULTS

Data were collected from 25 medical centers for 1,254 patients; 1,029 met inclusion criteria. Median follow-up for the cohort was 76 months. Median PFS and OS were 62 and 139 months, respectively. On unadjusted analysis, AHCT was associated with improved PFS (75 v 44 months with v without AHCT, respectively; P < .01) and OS (147 v 115 months with v without AHCT, respectively; P < .05). On multivariable regression analysis, AHCT was associated with improved PFS (hazard ratio [HR], 0.54; 95% CI, 0.44 to 0.66; P < .01) and a trend toward improved OS (HR, 0.77; 95% CI, 0.59 to 1.01; P = .06). After PSW analysis, AHCT remained associated with improved PFS (HR, 0.70; 95% CI, 0.59 to 0.84; P < .05) but not improved OS (HR, 0.87; 95% CI, 0.69 to 1.1; P = .2).

CONCLUSION

In this large cohort of younger, transplantation-eligible patients with MCL, AHCT consolidation after induction was associated with significantly improved PFS but not OS after PSW analysis. Within the limitations of a retrospective analysis, our findings suggest that in younger, fit patients, AHCT consolidation may improve PFS.

Advances in risk assessment and prophylaxis for central nervous system relapse in diffuse large B-cell lymphoma

Central nervous sytem recurrence of diffuse large B-cell lymphoma is an uncommon but devastating event, making identification of patients at high risk for relapse within the central nervous system essential for clinicians. Modern risk stratification includes both clinical and biological features. A validated clinical risk model employing the five traditional International Prognostic Index risk factors plus renal or adrenal involvement can identify a high-risk patient population with a central nervous system recurrence risk of greater than 10%. Lymphoma involvement of certain discrete extranodal sites such as the testis also confers increased risk, even in stage I disease. Adverse biological risk factors for central nervous system relapse include presence of translocations of MYC, BCL2 and/or BCL6, in so-called double- or triple-hit lymphoma. Immunohistochemically detectable co-expression of MYC and BCL2 in the absence of translocations also portends an increased risk of relapse within the central nervous system, particularly in the setting of the activated B-cell-like subtype of diffuse large B-cell lymphoma. The role, method, and timing of prophylactic therapy remain controversial based on the available data. We review both intrathecal and systemic strategies for prophylaxis in high-risk patients. Our preference is for systemic methotrexate in concert with standard chemoimmunotherapy in the majority of cases. Several novel agents have also demonstrated clinical activity in primary and secondary central nervous system lymphoma and warrant future investigation in the prophylactic setting.

Treatment of localized extranodal NK/T cell lymphoma, nasal type: a systematic review

Extranodal natural killer/T cell lymphoma (ENKTL), nasal type, presents predominantly as a localized disease involving the nasal cavity and adjacent sites, and the treatment of localized nasal ENKTL is a major issue. However, given its rarity, there is no standard therapy based on randomized controlled trials and therefore a lack of consensus on the treatment of localized nasal ENKTL. Currently recommended treatments are based mainly on the results of phase II studies and retrospective analyses. Because the previous outcomes of anthracycline-containing chemotherapy were poor, non-anthracycline-based chemotherapy regimens, including etoposide and L-asparaginase, have been used mainly for patients with localized nasal ENKTL. Radiotherapy also has been used as a main component of treatment because it can produce a rapid response. Accordingly, the combined approach of non-anthracycline-based chemotherapy with radiotherapy is currently recommended as a first-line treatment for localized nasal ENKTL. This review summarizes the different approaches for the use of non-anthracycline-based chemotherapy with radiotherapy including concurrent, sequential, and sandwich chemoradiotherapy, which have been proposed as a first-line treatment for newly diagnosed patients with localized nasal ENKTL.

Risk-dependent curability of radiotherapy for elderly patients with early-stage extranodal nasal-type NK/T-cell lymphoma: A multicenter study from the China Lymphoma Collaborative Group (CLCG)

BACKGROUND

The purpose of this study was to determine the curability of early-stage extranodal nasal-type NK/T-cell lymphoma (NKTCL) in response to radiotherapy and non-anthracycline-based chemotherapy in elderly patients.

METHODS

In this multicenter study from the China Lymphoma Collaborative Group (CLCG) database, 321 elderly patients with early-stage NKTCL were retrospectively reviewed. Patients received radiotherapy alone (n = 87), chemotherapy alone (n = 59), or combined modality therapy (CMT, n = 175). Patients were classified into low- or high-risk groups using four prognostic factors. Observed survival in the study cohort vs expected survival in age- and sex-matched individuals from the general Chinese population was plotted using a conditional approach and subsequently compared using a standardized mortality ratio (SMR).

RESULTS

Radiotherapy conveyed a favorable prognosis and significantly improved survival compared to chemotherapy alone. The 5-year overall survival (OS) and progression-free survival (PFS) were 61.2% and 56.4%, respectively, for radiotherapy compared with 44.7% and 38.3%, respectively, for chemotherapy alone (P < 0.001). The combination of a non-anthracycline-based chemotherapy regimen and radiotherapy significantly improved PFS compared to combination of an anthracycline-based chemotherapy regimen and radiotherapy (71.2% vs 44.2%, P = 0.017). Low-risk patients following radiotherapy (SMR, 0.703; P = 0.203) and high-risk patients who achieved PFS at 24 months (SMR, 1.490; P = 0.111) after radiotherapy showed survival equivalent to the general Chinese population.

CONCLUSIONS

Our findings indicate a favorable curability for this malignancy in response to radiotherapy and non-anthracycline-based chemotherapy, providing a risk-adapted follow-up and counsel scheme in elderly patients.

Long-term improvement of the bio-psycho-social state of cancer patients after 3 weeks of inpatient oncological rehabilitation : A long-term study at the Humanomed Zentrum Althofen

A 3-week cancer rehabilitation program was conducted at the Humanomed Zentrum Althofen, comprising therapy of organic defects, lifestyle modification, and psycho-social support. Therapeutic efficacy was assessed in comprehensive surveys before and after the therapy, and after 6 and 12 months. The study covers a 5-year period with data from 3233 patients. Parameters of subjective health assessed according to the European Quality of Life - 5 Dimensions (EuroQol EQ-5D) standard and signifying quality of life showed significant improvement both immediately after the therapy, and after 6 and 12 months. Anxiety and depression, assessed according to the Hospital Anxiety and Depression Scale, were significantly and persistently diminished, and the sense of coherence elevated. Therapeutic success was somewhat dependent on socio-economic parameters, but was largely independent of income and cancer type. This study thus clearly documents the significant efficacy of a rehabilitation treatment based on bio-psycho-social concepts, which may be further improved by additional ambulant or stationary care.

Clinicopathological Analysis of 320 Cases of Diffuse Large B-cell Lymphoma Using the Hans Classifier

The estimation of clinical prognosis for diffuse large B-cell lymphoma (DLBCL) with a quick, cost-efficient method is necessary because of the clinical heterogeneity of this disease, which leads to death, relapsed or refractory disease in approximately 40% of patients. We analyzed 320 cases diagnosed from 2007 to 2013 treated with R-CHOP therapy at Tokai University Hospital and associated institutions. DLBCL was classified according to the cell-of-origin using the Hans algorithm [germinal center B-cell-like (GCB) vs non-GCB subtypes], and into 6 subgroups derived from combinations of CD10, BCL6 and MUM1 markers. The percentage of GCB and non-GCB (NGCB) subtypes was 35% and 65%, respectively. GCB-DLBCL was characterized by lower BCL2 immunohistochemical expression, extranodal sites ＜1, better therapeutic response, and favorable overall survival (OS) and progression free survival (PFS) (P＜0.01). The most frequent subgroup was NGCB-1 (CD10^-BCL6⁺MUM1⁺, 51%) followed by GCB-1 (CD10⁺BCL6^+or-MUM1⁺, 21%), NGCB-2 (CD10^-BCL6^-MUM1⁺, 13%), GCB-2 (CD10⁺BCL6^+or-MUM1^-, 10%), GCB-3 (CD10^-BCL6⁺MUM1^-, 4%) and NGCB-3 (CD10^-BCL6^-MUM1^-, 2%). In comparison with GCB-2 and GCB-3 (both MUM1^-), the GCB-1 (MUM1⁺) was characterized by favorable PFS (5-year PFS 84% vs 65%, OR 0.368, P＜0.05), independent of high LDH (associated with unfavorable PFS, OR 7.04, P＜0.01) in the multivariate analysis. This predictive value of MUM1 was independent of CD10. Interestingly, triple-negative NGCB-3 tended to have a more favorable prognosis than the other NGCB subgroups. In conclusion, the Hans classifier is a valid method to evaluate the prognosis of DLBCL NOS. In the GCB subtypes, GCB subtypes, MUM1-positivity is associated with a more favorable outcome (PFS).

Emergency admission and survival from aggressive non-Hodgkin lymphoma: A report from the UK's population-based Haematological Malignancy Research Network

Background

Non-Hodgkin lymphoma (NHL) is often diagnosed after emergency presentation, a route associated with poor survival and an indicator of diagnostic delay. Accounting for around half of all NHLs, diffuse large B-cell lymphoma (DLBCL) is of particular interest since although it is potentially curable with standardised chemotherapy it can be challenging to identify at an early stage in the primary care setting.

Patients and methods

Set within a socio-demographically representative United Kingdom population of around 4 million people, data are from an established patient cohort. This report includes all patients (≥18 years) diagnosed with DLBCL 2004–2011 (n = 1660). Emergency admissions were identified via linkage to Hospital Episode Statistics using standard methods, and survival was examined using proportional hazards regression.

Results

Two out of every five patients were diagnosed following an emergency admission, and this was associated with advanced disease and poor survival (p < 0.001). Among the 80% of patients treated with curative chemotherapy, survival discrepancies emerged at the point of diagnosis; the adjusted hazard ratio (emergency versus non-emergency) at one month being 4.0 (95% confidence interval 1.9–8.2). No lasting impact was evident in patients who survived for 12 months or more.

Conclusion

Emergency presentation impacts negatively on DLBCL survival; patients presenting via this route have significantly poorer outcomes than patients with similar clinical characteristics who present via other routes.

•

Emergency presentation has a marked impact on non-Hodgkin lymphoma (NHL) survival, not explained by disease stage or treatment.

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Emergency presentation among patients with diffuse large B-cell lymphoma is 50% higher in the United Kingdom than national data on non-Hodgkin lymphomas suggest.

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Survival benefits from earlier diagnosis of potentially curable NHLs could exceed that of new treatments.

Treatment cost and life expectancy of diffuse large B-cell lymphoma (DLBCL): a discrete event simulation model on a UK population-based observational cohort

BACKGROUND

Diffuse large B-cell lymphoma (DLBCL) is the commonest non-Hodgkin lymphoma. Previous studies examining the cost of treating DLBCL have generally focused on a specific first-line therapy alone; meaning that their findings can neither be extrapolated to the general patient population nor to other points along the treatment pathway. Based on empirical data from a representative population-based patient cohort, the objective of this study was to develop a simulation model that could predict costs and life expectancy of treating DLBCL.

METHODS

All patients newly diagnosed with DLBCL in the UK's population-based Haematological Malignancy Research Network ( www.hmrn.org ) in 2007 were followed until 2013 (n = 271). Mapped treatment pathways, alongside cost information derived from the National Tariff 2013/14, were incorporated into a patient-level simulation model in order to reflect the heterogeneities of patient characteristics and treatment options. The NHS and social services perspective was adopted, and all outcomes were discounted at 3.5 % per annum.

RESULTS

Overall, the expected total medical costs were £22,122 for those treated with curative intent, and £2930 for those managed palliatively. For curative chemotherapy, the predicted medical costs were £14,966, £23,449 and £7376 for first-, second- and third-line treatments, respectively. The estimated annual cost for treating DLBCL across the UK was around £88-92 million.

CONCLUSIONS

This is the first cost modelling study using empirical data to provide 'real world' evidence throughout the DLBCL treatment pathway. Future application of the model could include evaluation of new technologies/treatments to support healthcare decision makers, especially in the era of personalised medicine.

Affluence and Private Health Insurance Influence Treatment and Survival in Non-Hodgkin's Lymphoma

BACKGROUND

The aim of this study was to investigate inequalities in survival for non-Hodgkin's lymphoma (NHL), distinguishing between direct and indirect effects of patient, social and process-of-care factors.

METHODS

All cases of NHL diagnosed in Ireland in 2004-2008 were included. Variables describing patient, cancer, stage and process of care were included in a discrete-time model of survival using Structural Equation Modelling software.

RESULTS

Emergency admissions were more common in patients with co-morbid conditions or with more aggressive cancers, and less frequent for patients from more affluent areas. Aggressive morphology, female sex, emergency admission, increasing age, comorbidity, treatment in a high caseload hospital and late stage were associated with increased hazard of mortality. Private patients had a reduced hazard of mortality, mediated by systemic therapy, admission to high caseload hospitals and fewer emergency admissions.

DISCUSSION

The higher rate of emergency presentation, and consequent poorer survival, of uninsured patients, suggests they face barriers to early presentation. Social, educational and cultural factors may also discourage disadvantaged patients from consulting with early symptoms of NHL. Non-insured patients, who present later and have more emergency admissions would benefit from better access to diagnostic services. Older patients remain disadvantaged by sub-optimal treatment, treatment in non-specialist centres and emergency admission.

Myeloid malignancies in the real-world: Occurrence, progression and survival in the UK's population-based Haematological Malignancy Research Network 2004-15

BACKGROUND

Population-based information on cancer incidence, prevalence and outcome are required to inform clinical practice and research; but contemporary data are lacking for many myeloid malignancy subtypes.

METHODS

Set within a socio-demographically representative UK population of ∼4 million, myeloid malignancy data (N=5231 diagnoses) are from an established patient cohort. Information on incidence, survival (relative & overall), transformation/progression, and prevalence is presented for >20 subtypes.

RESULTS

The median diagnostic age was 72.4years (InterQuartile Range 61.6-80.2), but there was considerable subtype heterogeneity, particularly among the acute myeloid leukaemias (AML) where medians ranged from 20.3 (IQR 13.9-43.8) for AML 11q23 through to 73.7 (IQR 57.3-79.1) for AML with no recurrent genetic changes. Five-year Relative Survival (RS) estimates varied hugely; from <5% for aggressive entities like therapy-related AML (2.6%, 95% Confidence Interval 0.4-9.0) to >85% for indolent/treatable conditions like chronic myeloid leukaemia (89.8%, 95% CI 84.0-93.6). With a couple of notable exceptions, males experienced higher rates and worse survival than females: the age-standardized incidence rates of several conditions was 2-4 higher in males than females, and the 5-year RS for all subtypes combined was 48.8% (95% CI 46.5-51.2) and 60.4% (95% CI 57.7-62.9) for males and females respectively. During follow-up (potential minimum 2 years and maximum 11years) myelodysplastic syndrome (MDS) progression to AML ranged from 25% for refractory anaemia with excess blasts through to 5% for refractory anaemia with ring sideroblasts: the median interval between MDS and AML diagnosis was 9.0 months (IQR 4.8-17.4months).

CONCLUSIONS

The marked incidence and outcome variations seen by subtype, sex and age, confirm the requirement for "real-world" longitudinal data to inform aetiological hypotheses, healthcare planning, and future monitoring of therapeutic change. Several challenges for routine cancer registration were identified, including the need to link more effectively to diagnostic and clinical data sources, and to review policies on the recording of progressions and transformations.