Elderly patients with non-Hodgkin's lymphoma: population-based results in The Netherlands

Diffuse large B-cell lymphoma in elderly: Experience from a tertiary care oncology center in South India

Introduction:

Diffuse large B-cell lymphoma (DLBCL) is the most frequent non-Hodgkins lymphoma in the elderly. With the rising proportion of older persons in India, it is important to study current patterns and management of this disease, given that data in this regard are scarce in Indian settings. The aim of this study was to document the clinical features of DLBCL among elderly patients and their outcome over 7 years at a tertiary care oncology center.

Materials and Methods:

This was a retrospective records review of 119 DLBCL cases between January 2007 and January 2015 aged 60 years and above done at Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India. Clinical staging was done according to Ann Arbor staging as modified by Cotswold's and International Prognostic Index (IPI) calculated.

Results:

The mean age was 69.54 years (±5.44) with male: female ratio of 1.52:1. B symptoms were seen in 33% of patients. Thirty-six percent of the patients had stage II disease. The advanced stage was seen in 12% and bulky disease in 9.5%. Bone marrow was involved in 12%. The most common extranodal site was the head and neck region. The distribution according to the IPI was as follows: Low risk 38 (31.93%), low-intermediate risk 53 (44.54%), high-intermediate risk 20 (16.80%), and high risk 8 (6.72%). Among 119 patients, 98 (64.7%) received treatment with either combination of rituximab, cyclophosphamide, adriamycin, vincristine, epirubicin, and prednisolone. Overall response rate was 63.26% with a complete response rate of 38.77%. The overall survival ranged from 2 to 123 months with the median being 9.5 months.

Conclusion:

In elderly, DLBCL is common in seventh decade and most of them present in an early stage and low IPI. The incorporation of rituximab to anthracycline based chemotherapy shows a significant improvement in survival in elderly DLBCL.

Investigation on treatment strategy, prognostic factors, and risk factors for early death in elderly Taiwanese patients with diffuse large B-cell lymphoma

This study aimed to investigate the treatment strategy, prognostic factors, and risk factors of early death in elderly patients (age ≥ 65 years) with diffuse large B-cell lymphoma (DLBCL) in the rituximab era. Data from elderly patients diagnosed with DLBCL between 2008 and 2014 were collected for analysis. Patients who were younger and had a better performance status were more likely to receive intensive frontline treatment. The median progression-free survival (PFS) and overall survival were 15 and 21 months, respectively. Anthracycline-containing chemotherapy achieved a higher remission rate and showed a trend towards better overall survival but a higher risk of severe neutropenia. Multivariate analysis revealed that very old age (≥81 years), a high-risk age-adjusted international prognostic index (aaIPI) score, and bone marrow involvement were associated with poorer PFS and overall survival. Progression of lymphoma was the major cause of death in the study population. In addition, approximately 25% of patients died within 120 days of being diagnosed. The risk factors for early mortality included very old age, a high-risk aaIPI score, and bone marrow involvement. The appearance of symptoms or signs of tumour lysis syndrome at diagnosis was associated with a trend towards early death.

Treatment of diffuse large B-cell lymphoma in the elderly: regimens without anthracyclines are common and not futile

Anthracycline-containing regimens (ACRs) are recommended for patients with diffuse large B-cell lymphoma (DLBCL). However, over 40% of elderly patients do not receive ACRs, possibly due to expected toxicities. We characterized treatment choices and compared the 3-year overall survival (OS) rates of 8262 Medicare beneficiaries diagnosed with DLBCL in 2000-2006 identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Of the cohort, 45% had ACR with rituximab (ACR-R), 13% had ACR without R, 6% had non-ACR with R (non-ACR-R), 4% had R monotherapy, 3% had non-ACR and 29% had no systemic therapy. Patients not receiving ACR were older and/or had more comorbidities. The unadjusted OS was highest in ACR-R (65%), followed by ACR without R (55%) and non-ACR-R (44%). After adjusting patient covariates, ACR-R showed the best survival (63%). However, OS was comparable between non-ACR-R (52%) and ACR without R (52%). Non-ACR-R could be considered for patients who are poor candidates for ACR.

R-split-CHOP chemotherapy for elderly patients with diffuse large B-cell lymphoma

OBJECTIVES

Chemoimmunotherapy with cyclophosphamide, doxorubicin, vincristine, prednisolone, and rituximab (R-CHOP) is the standard of care for patients with diffuse large B-cell lymphoma (DLBCL). However, management of elderly patients is challenging as critical comorbidities often account for increased number of treatment-related complications.

PATIENTS AND METHODS

In the past 8 yrs, we have treated elderly patients with a full-dose R-CHOP regimen by splitting the administration of cyclophosphamide and doxorubicin over 2 days (R-split-CHOP) to reduce peak plasma level. Here, we retrospectively analyzed the results of 30 patients with newly diagnosed DLBCL.

RESULTS

The overall response rate was found to be 87%, the overall survival probability after 3 yrs was 60.6% (95% CI, 42.1%-79.0%), and the progression-free survival probability was 49.7% (95% CI, 30.4%-68.9%). Grade 3/4 infectious complications were reported in 30% of patients, yet no treatment-related deaths occurred.

CONCLUSION

We suggest that R-split-CHOP could be a valuable option to safely administer full-dose-intensity R-CHOP to elderly patients at risk of treatment-related complications.

Treatment with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone is beneficial but toxic in very elderly patients with diffuse large B-cell lymphoma: a population-based cohort study on treatment, toxicity and outcome

To assess treatment strategies, toxicity and outcome in very elderly patients (aged ≥ 75 years) diagnosed with diffuse large B-cell lymphoma (DLBCL) in the rituximab era, an observational population-based cohort study was performed. From 103 patients with a median age of 81 years, data of clinical characteristics, treatment, toxicity and outcome were evaluated. Advanced stage DLBCL was documented in 74 patients. In 80 patients chemotherapy was initiated; 70 patients received rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP). In this group, 39 patients completed all cycles and 30 patients achieved a complete remission. Severe chemotherapy-related toxicity occurred in 69%. Two-year overall survival was 70% for elderly patients who completed chemotherapy, 28% for those treated with incomplete or suboptimal chemotherapy and 21% for those receiving palliative radiotherapy or supportive care. In conclusion, the ability to complete R-CHOP was associated with better overall survival compared to other treatment strategies at the expense of severe treatment-related toxicity.

Two sides of the medallion: poor treatment tolerance but better survival by standard chemotherapy in elderly patients with advanced-stage diffuse large B-cell lymphoma

BACKGROUND

We investigated treatment of unselected elderly patients with diffuse large B-cell lymphoma (DLBCL) and its subsequent impact on treatment tolerance and survival.

PATIENTS AND METHODS

Data from all 419 advanced-stage DLBCL patients, aged 75 or older and newly diagnosed between 1997 and 2004, were included from five regional population-based cancer registries in The Netherlands. Subsequent data on comorbidity, performance status, treatment, motives for adaptations or refraining from chemotherapy and toxic effects was collected from the medical records. Follow-up was completed until 1st January 2009.

RESULTS

Only 46% of patients received the standard therapy [aggressive chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP)-like chemotherapy]. Motives for withholding chemotherapy were refusal by patient/family, poor performance status or estimated short life expectancy. Of all patients receiving CHOP-like chemotherapy, only 56% could complete at least six cycles. Grade 3 or 4 toxicity occurred in 67% of patients receiving standard therapy. The independent effect of therapy on survival remained after correction for the age-adjusted International Prognostic Index.

CONCLUSIONS

Standard therapy was applied less often in elderly patients with a subsequent independent negative impact on survival. Furthermore, high toxicity rate and the impossibility of the majority of patients to complete treatment were seen. This implies that better treatment strategies should be devised including a proper selection of senior patients for this aggressive chemotherapy.

Tailored therapy in an unselected population of 91 elderly patients with DLBCL prospectively evaluated using a simplified CGA

BACKGROUND

Elderly patients with diffuse large B-cell lymphoma (DLBCL) are a heterogeneous population; clinical trials have evaluated a minority of these patients.

PATIENTS AND METHODS

Ninety-one elderly patients with DLBCL received tailored treatment based on a comprehensive geriatric assessment (CGA). Three groups were identified: I, fit patients; II, patients with comorbidities; III, frail patients. Group I received 21-day cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP-21), group II received R-CHOP-21 with liposomal doxorubicin, and group III received 21-day cycles of reduced-dose CHOP. Fifty-four patients (59%) were allocated to group I, 22 (25%) were allocated to group II, and 15 (16%) were allocated to group III.

RESULTS

The complete response (CR) rates were 81.5% in group I, 64% in group II, and 60% in group III. With a median follow-up of 57 months, 42 patients are alive, with 41 in continuous CR: 31 patients (57%) in group I, seven patients (32%) in group II, and four patients (20%) in group III. The 5-year overall survival, event-free survival, and disease-free survival rates in all patients were 46%, 31%, and 41%, respectively. Multivariate analysis selected group I assignment as the main significant prognostic factor for outcome.

CONCLUSIONS

This approach in an unselected population of elderly DLBCL patients shows that treatment tailored according to a CGA allows the evaluation of elderly patients who are currently excluded from clinical trials.

Anthracyclines: a cornerstone in the management of non-Hodgkin's lymphoma

Since anthracyclines were introduced in the treatment of non-Hodgkin's lymphoma in the late 1960s, they have been acknowledged as a cornerstone in the management of the disease and, in particular, of aggressive lymphomas. The high efficacy of anthracycline-containing regimens must, however, be balanced against the drug-related toxicity, which mainly affects the cardiovascular system and represents a major concern for clinicians, especially in the treatment of elderly patients. Patients' outcomes could be further improved, particularly for those at high risk of cardiotoxicity, by substituting liposomal doxorubicin for conventional doxorubicin. This approach has already been tested and shown to be effective in several cancers, especially in different subsets of patients with diffuse large B-cell lymphoma. The use of liposomal doxorubicin in combination regimens for other conditions, such as follicular lymphoma and splenic marginal zone lymphoma, is also under investigation, and early results are promising.

Diffuse large B-cell lymphoma in the older

The incidence of diffuse large B-cell lymphoma (DLCL) in the older is growing to the point of becoming a health priority in the next decades. Prognostic factors and the biology of the tumor are not very different between younger and older populations. Furthermore, it seems that the response rate is basically similar in both populations, provided an appropriate dose of chemotherapy is administered. However, there seem to be differences with regard to a lower tolerance to treatment and a higher relapse rate in responsive older patients. To analyze these problems we review the most important differences between young and older DLCL patients in terms of immunologic status, treatment toxicity and the presence of other concomitant diseases or organ dysfunctions. We also consider the most relevant clinical studies that may allow us to make the appropriate decisions regarding DLCL therapy in this older population.

Evaluation of clinical staging in chronic lymphocytic leukemia- population-based study

The Rai and Binet staging systems are currently being challenged by the development of new biological methods to characterize the prognosis and management of chronic lymphocytic leukemia (CLL). To evaluate these two systems in recently diagnosed CLL patients, we performed a retrospective population-based study including 344 patients in western Sweden diagnosed between 1995 and 2000. Binet stage A patients had longer median overall survival (OS) (100 months) than stage B (55 months; P < 0.001) and C patients (45 months; P < 0.0005). Median OS for stage B and C could not be separated (P = 0.94). When transferring Rai stages into three groups, a similar pattern was found. Overall response differed only between Binet A and C patients and there was no difference regarding time to next treatment between any of the Binet stages. Finally, in both systems, low stage patients had inferior survival compared to age- and sex-matched controls. Our data emphasize the need for a new risk stratification system for CLL patients.

The impact of gender, age and patient selection on prognosis and outcome in diffuse large B-cell lymphoma - a population-based study

Most studies concerning therapy and prognosis in diffuse large B-cell lymphoma (DLBCL) are based on highly selected patient material. To evaluate treatment, clinical prognostic factors, and outcome in a population-based cohort, we performed a retrospective study comprising 535 de novo DLBCL patients in western Sweden, diagnosed between 1995 and 2000. The median age was 73 years. Treatment with a curative intent was administered to 376 (70%) patients. The International Prognostic Index (IPI) strongly predicted overall (OS) and progression-free (PFS) survival, but high age (>68 vs < or = 68 years) had no significant influence on response rate (p = 0.86) or PFS (p = 0.14). Male sex had a negative impact on both OS (p < 0.001) and PFS (p < 0.001), independent of IPI. In conclusion, a considerable proportion of the patients did not receive curative treatment, but among those treated, the response and PFS were not influenced by age. As men had lower PFS and OS than women, it seems important that gender perspective be taken into account in future studies.

Lymphoma in Older Patients

One half of patients newly diagnosed with lymphoma are older than 60 years and a significant proportion of them older than 80 years. Older patients treated for lymphoma may not tolerate the high-dose therapies used in younger patients, usually because of the presence of concomitant diseases. Diffuse large B-cell lymphoma represents more than 60% of all lymphomas seen in older patients. Clinical presentation and prognostic parameters are identical to those described in young patients. However, response rate is usually lower in elderly patients compared with young patients, even if the patients are treated with the cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) regimen. Therefore, event-free and overall survival rates are shorter in elderly patients, even if disease-free survival rates are not really shorter than in young patients. Rituximab added to the CHOP regimen has recently been shown to dramatically improve the survival of these older patients without increasing the toxicity of the treatment. Patients older than 80 years may also be treated with rituximab plus CHOP, except for those having severe organ failure secondary to other diseases. Very few of these older patients may benefit from a salvage treatment after relapse.

Variations in chemotherapy and radiation therapy in a large nationwide and community-based cohort of elderly patients with non-Hodgkin lymphoma

OBJECTIVE

The objective of this study was to determine the variations in the use of chemotherapy and radiation therapy in a large nationwide and population-based cohort of older patients with non-Hodgkin lymphoma (NHL).

METHODS

We studied a retrospective cohort of 13,570 patients diagnosed with incident NHL at age > or =65 in 1992 through 1999 identified from the Surveillance, Epidemiology and End Results-Medicare-linked database.

RESULTS

Of 13,570 patients with NHL, 52% received chemotherapy within 6 months of diagnosis. A higher proportion (61%) of patients aged 65 to 69 received chemotherapy than those > or =80 (39%). Forty-three percent of black patients received chemotherapy compared with whites (52%) and other ethnicities (54%). A greater proportion of patients with lower comorbidity scores received chemotherapy than those with higher comorbidity scores. In multivariate analysis, there was no significant association between the receipt of chemotherapy and gender or year of diagnosis, but blacks had statistically significant lower odds of receiving chemotherapy than white patients (odds ratio = 0.66, 95% confidence interval: 0.55-0.80). Significant predictors of receiving chemotherapy were age, ethnicity, comorbidity, tumor stage, nodal site, geographic area, and radiation therapy. The percentages of patients receiving radiation therapy, chemotherapy, or both were 11%, 39%, and 13%, respectively; 37% of patients with NHL did not receive any of these treatments within 6 months of diagnosis.

CONCLUSION

There were significant variations in the use of chemotherapy by patient and tumor characteristics and geographic areas. A substantial number of patients with NHL did not receive either chemotherapy or radiation therapy, suggesting that the rate for receipt of these therapies may be improved.

A population-based study of severity of comorbidity among patients with non-Hodgkin's lymphoma: prognostic impact independent of International Prognostic Index

Over 60% of patients aged over 70 years, diagnosed with non-Hodgkin's lymphoma (NHL) in the Netherlands have serious comorbidity. We studied the independent influence of comorbidity on choice of treatment, dose reductions, treatment-related toxicity and prognosis, using data from a random sample of 381 patients from the population-based Eindhoven Cancer Registry. About 45% of patients over 60 years of age with NHL had high impact comorbidity at the time of cancer diagnosis. The proportion of patients with aggressive NHL who received chemotherapy decreased from 85% in patients aged 40-60 years to 70% in those over 60 years. About 65% of systematically treated patients with aggressive NHL suffered from treatment-related toxicity. Toxicity appeared to be more common among females and those with high-intermediate or high International Prognostic Index (IPI) risk. Among patients with aggressive NHL, the chance of dying for those with high impact comorbidity was twice as high compared with those without comorbidity. This was independent of the IPI risk. Dose reductions are frequently unavoidable for patients with severe comorbidity, poor performance status or chemotherapy-related toxicity. Whether the less frequent prescription of (full dose) chemotherapy for patients with advanced age and/or with comorbidity is justified remains a question for debate.

Independent prognostic effect of co-morbidity in lymphoma patients: results of the population-based Eindhoven Cancer Registry

The prevalence of co-morbidity among elderly lymphoma patients is associated with a decrease in the use of chemotherapy. This study assessed the independent prognostic effect of co-morbidity in 1551 unselected lymphoma patients, diagnosed between 1995 and 2001 in the area of the population-based Eindhoven Cancer Registry. The prevalence of serious co-morbidity was 58% for patients with Hodgkin's disease (HD) who were over 60 years of age and 66% for patients with non-Hodgkin's lymphoma (NHL) who were over 60 years of age. The administration of chemotherapy declined in the presence of co-morbidity for elderly patients with early-stage HD and elderly patients with aggressive NHL. Co-morbidity was associated with a 10-20% decline in 5-year survival. Whether less frequent application of chemotherapy in the presence of co-morbidity is justified as far as complications, prognosis and quality of life are concerned requires further investigation.

Long-term results of a multicenter randomized, comparative trial of modified CHOP versus THP-COP versus THP-COPE regimens in elderly patients with non-Hodgkin's lymphoma

In treating elderly non-Hodgkin's lymphoma (NHL) patients, it is particularly important to use drugs that have a low incidence of adverse events and high efficacy. In this multicenter study, THP (pirarubicin)-COP (cyclophosphamide, vincristine, and prednisolone) was compared to two thirds dosage of full CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) regimen with regard to both adverse events and efficacy. For a third group, etoposide (E) was added to the THP-COP regimen (THP-COPE) in order to achieve high dose-intensity. Subjects were 486 previously untreated patients, aged 65 or older (range, 65-92 years; median, 74 years), with NHL. Subjects were randomly assigned to receive THP-COP, two thirds CHOP, or THP-COPE. Four hundred and forty-three patients were assessed for response and followed for 8 years after the last subject registered. The complete remission rates for the THP-COP, CHOP, and THP-COPE groups were 42.5%, 41.4%, and 48.0%, respectively. There was no difference in overall survival or progression-free survival among these 3 groups. In aggressive lymphoma, there was also no difference in complete response (CR) rate (45.3% in THP-COP, 44.9% in CHOP, 48.0% in THP-COPE), overall survival, and progression-free survival among these groups. The 5- and 8-year survival rates for all patients were 29.4% and 18.7%, respectively. The 5- and 8-year survival rates for patients with aggressive lymphoma were 27.4% and 17.4%, respectively. Although long-term survival for patients with aggressive lymphoma on our regimens was not worse compared to previous reports, the CR rate was lower. Because severe adverse events were not observed, higher dose chemotherapy may be directed to achieve better CR rates. In patients with T-cell-type lymphoma, the CR rate was greater after treatment with THP-COP (51.4%) or THP-COPE (57.7%) compared to treatment with CHOP (19.4%). Pirarubicin may be more useful for T-cell lymphoma than doxorubicin. Because adverse cardiac events were reported only in CHOP, adverse cardiac events might be low in the THP group.

Economic assessment in the management of non-Hodgkin’s lymphoma

An increasing need for economic evaluations of non-Hodgkin's lymphoma (NHL) treatments exists. We performed a literature review on the currently available NHL economic evaluations, using PubMed and the Cochrane database. English and Dutch language papers on treatment in adults were selected. A total of 88 publications were found, 44 of which were included. Of these, 6 economic evaluation-specific methodological items are evaluated (study perspective, overhead costs, data sources, charges or prices, sensitivity analysis, presentations of resource use and unit costs), enabling readers to judge the value of these studies. The 11 subjects covered by the economic evaluations are discussed. Many NHL treatments remain to be studied in economic evaluations. Future publications should report on the six methodological items in more detail, and preferably tackle them in the recommended way.

Estimating the optimal utilization rates of radiotherapy for hematologic malignancies from a review of the evidence

BACKGROUND

The objective of this study was to estimate the ideal proportion of new patients with lymphoma who should receive radiotherapy at some time during the course of their illness, based on the best evidence.

METHODS

Available evidence of the efficacy of radiotherapy in most clinical situations for lymphoma were identified through extensive literature reviews and treatment guideline searches. Epidemiologic data concerning the distribution of histologic type, disease stage, and other factors that influence the use of radiotherapy were identified. Decision trees were constructed to merge the evidence-based recommendations with the epidemiologic data to calculate the optimal proportion of patients who should receive radiotherapy according to the best available evidence. Actual radiotherapy utilization rates also were identified.

RESULTS

The proportion of patients with lymphoma in Australia that should receive radiotherapy at some point in their management, according to the best available evidence, was calculated at 65.0%. Multivariate analysis with a Monte Carlo simulation yielded a radiotherapy utilization rate of 64.4%. The actual utilization rates of radiotherapy for lymphoma reported in clinical practice were 22-29%, substantially lower than the optimal rate calculated in this project.

CONCLUSIONS

Further research will be required to identify why more patients who are diagnosed with lymphoma are not treated with radiotherapy.

Fourteen-Day CHOP Supported with Granulocyte Colony-Stimulating Factor in Patients with Aggressive Non-Hodgkin's Lymphoma: Results of a Phase II Study

The safety and efficacy of compressed-cycle (14-day) standard-dose CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) supported with prophylactic recombinant granulocyte colony-stimulating factor (G-CSF; filgrastim) were evaluated in patients with aggressive non-Hodgkin's lymphoma (NHL). Patients with intermediate- or high-grade NHL (Working Formulation groups D-H and J; N = 120), accrued from 25 clinical practices, were given 6 cycles of standard-dose CHOP every 14 days. Granulocyte colony-stimulating factor 5 microg/kg was given daily subcutaneously in each cycle, starting on day 2 and continuing until the absolute neutrophil count was = 10000/microL. The overall response rate was 89%, with complete responses (CRs) in 52 of 120 patients (43%) and partial responses in 55 (46%). These results are consistent with previously reported outcomes from trials in this population. Of the 720 chemotherapy cycles planned for all patients, 615 (85%) were given on time at full dose. The median relative dose intensity (RDI) of cyclophosphamide and doxorubicin was 99%; the RDI of vincristine was 73%. In the 53 patients = 60 years of age, 80% of the chemotherapy cycles were given on time at full dose, with median RDIs similar to those in the entire population. Response rates in the older patients were also similar, with CRs in 24 patients (45%) and partial responses in 21 (40%). Hematologic toxicity was significant but tolerable, with no treatment-related deaths. At a median follow-up of 20.6 months, 77% of patients were still alive. Standard-dose CHOP administered every 14 days with prophylactic G-CSF support was delivered as planned in most patients and produced response rates comparable with those with CHOP given every 3 weeks, without exceptional toxicity.

Total registration of non-Hodgkin's lymphoma and Hodgkin's disease in Scotland: effect of deprivation and caseload on outcome

All cases S16 years of age with a histological diagnosis of non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD) presented in Scotland between 1 January 1994 and 31 December 1996 were registered prospectively in the Scotland and Newcastle Lymphoma Group database by a process of total registration. The census population of Scotland in 1996-1997 was 5.1 million. One thousand seven hundred and sixty three patients were registered with NHL and 350 patients with HD. These patients have been followed up for a median of 47 months in the case of NHL and 51 months for HD cases. Actuarial 5-year survival for adult NHL was 35% and for HD, 75%. Outcome for both NHL and HD was particularly poor in the population over 60 years with median survival of 18 months for NHL and 27 months for HD. When analysis of survival was related to degree of material deprivation using the Carstairs score a significantly poorer survival was seen for NHL with increasing deprivation that could not be explained by a different pattern of age or stage at presentation. Deprivation had no impact on incidence or survival in HD. Analysis of impact of caseload of the physician initiating therapy showed no significant difference in 5-year survival.

Non-Hodgkin's lymphoma in the Netherlands: results from a population-based registry

The Comprehensive Cancer Centre West (CCCW) population based non-Hodgkin's lymphoma (NHL) registry contains information on all newly diagnosed NHL patients living in the region covered by the CCCW. Patients were entered from June 1st 1981 to December 31st 1989. Follow-up is still ongoing, median follow-up is 113 months (1-191 months) for patients alive. In this study, patient and tumor characteristics, data on patterns of care, response and (relative) survival are described. As follicular lymphomas and diffuse large B-cell lymphomas are the most frequently occurring NHL subtypes in the database, a separate analysis is performed to characterize the clinical picture of these disease entities in the CCCW population. Our data illustrate that NHL patients in the general population are substantially older than patients included in trials and hospital based series. Due to older age, treatment is withheld or adapted for a substantial number of patients. The resulting survival and relative survival rates are a reflection of these choices.

Treatment paradigms in aggressive non-Hodgkin's lymphoma in elderly patients

Half of the patients newly diagnosed with lymphoma are > 60 years of age and can thus be defined as elderly. Older patients treated for lymphoma may not tolerate the high-dose therapies used in younger patients, usually because of the presence of concomitant diseases. Diffuse large B-cell lymphoma represents > 50% of all lymphomas seen in elderly patients. Clinical presentation and prognostic parameters are identical to those described in young patients. However, response rate is usually lower in elderly patients compared to young patients, even if the patients are treated with a CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) regimen. Therefore, event-free and overall survival rates are shorter in the elderly patients, even if disease-free survival is not really shorter than in young patients. Rituximab added to the CHOP regimen has recently been shown to dramatically improve the survival of these older patients without increasing the toxicity of the treatment.

Cost analysis of CHOP (-like) chemotherapy regimens for patients with newly diagnosed aggressive non-Hodgkin's lymphoma

Many cost analyses of stem-cell transplantations are available, which is in sharp contrast to the level of cost analyses on first-line chemotherapy for aggressive non-Hodgkin's lymphoma (NHL). Given the scarcity of cost analyses of first-line chemotherapy for NHL, it is difficult to assess the economic impact of upcoming new treatment modalities. Therefore we performed an analysis on costs of diagnosis and treatment of patients with newly diagnosed NHL who were treated with standard CHOP (-like) chemotherapy. As many NHL patients are treated in trials and the economic effects of the trial participation are unknown, our analysis included both patients treated according to trial protocols and patients treated according to standard local practice (SLP). The cost analysis was based on the total medical consumption of the patients. It was found that costs of the trial and SLP groups are within comparable ranges, although costs of diagnostic tests were somewhat higher within the trials. In elderly patients, SLP chemotherapy was discontinued more frequently in case of leucocytopenia or thrombocytopenia. This analysis provides basic information about the costs of first-line standard chemotherapy for patients with newly diagnosed aggressive NHL and the plausible ranges in which these costs may vary. Given the results, we will initiate larger studies to investigate whether trial treatments (showing more or less similar costs as SLP treatments) are more cost-effective for patients with aggressive NHL.

Age-related differences among patients with follicular lymphoma and the importance of prognostic scoring systems: analysis from a population-based non-Hodgkin's lymphoma registry

BACKGROUND

The influence of age on the outcome of follicular non-Hodgkin's lymphoma (FL) was studied in a population-based non-Hodgkin's lymphoma registry.

PATIENTS AND METHODS

This study comprised 214 follicular lymphoma patients. Grade I/II was considered separately from grade III FL. The data were analyzed with respect to three age groups: <60, 60-69 and >or=70 years.

RESULTS

The overall survival rate decreased in the older age groups. Grade III patients showed a statistically significant decrease in overall survival in comparison with grade I/II patients (P = 0.03). Cause-specific survival analysis showed that in the older age groups, there was an increasing influence of concomitant disease on the death rate, especially among grade III FL patients >70 years of age. The survival curve in grade III FL patients was shown to reach a plateau. The prognostic scoring system, according to the Italian Lymphoma Intergroup, fitted better to grade I/II patients, while the International Prognostic Index showed better discrimination amongst grade III patients.

CONCLUSIONS

Separate grading for follicular lymphoma is useful. An age >70 years has a negative impact on outcome, but the contribution of concomitant disease herein is important. Different prognostic scoring systems should be applied to the different grades of FL.

Influence of amifostine on toxicity of CHOP in elderly patients with aggressive non-Hodgkin's lymphoma--a phase II study

Due to concerns about toxicity, many elderly patients with aggressive non-Hodgkin's lymphoma (NHL) are not considered candidates for standard chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). The cytoprotective agent amifostine has the potential to reduce toxicity when added to chemotherapy. The purpose of the current study was to examine the toxicity of CHOP combined with amifostine in elderly patients with aggressive NHL. A prospective phase II study was performed in patients aged 60 years and older. Patients with stage I/II disease received 4 cycles of CHOP followed by involved-field irradiation. Patients with stage III/IV received 6-8 cycles of CHOP. Amifostine (740 mg/m(2)) was administered as a 15-min i.v. infusion immediately before chemotherapy. Forty-one (median age 69.5 years, range 60-87) of 49 consecutive previously untreated patients, aged 60 years and older, with aggressive NHL seen in our center were included in the study. Twenty-one patients had stage I/II disease and 20 had stage III/IV disease. The patients received a total of 207 cycles of amifostine-CHOP. Infusion of amifostine caused mild to moderate transient side effects, including a drop of systolic blood pressure >20 mmHg in 54 cycles and nausea/vomiting in 36 cycles. Hematotoxicity of CHOP consisted of leukopenia grade 4 in only 15.4% of cycles. There were two cases of grade 3 anemia. No thrombocytopenia higher than grade 2 occurred. Febrile neutropenia was rare, occurring in 4.3% of cycles. One patient died after the first CHOP administration because of anthracycline-related acute cardiomyopathy (corresponding to a toxic death rate of 2.4%). The complete response rates were 85 and 75% in stage I/II and stage III/IV patients, respectively. After median follow-up of 33 months (range 17-50 months) the median overall survival was not reached in patients with stage I/II and was found to be 32 months in patients with stage III/IV. At 2 years, 76% of patients with stage I/II and 70% with stage III/IV were alive. Twelve of the 15 patients who died were aged older than 70. Amifostine pre-treatment was associated with a low toxicity of CHOP in elderly patients with aggressive NHL treated with curative intent. Treatment outcomes appeared not to be impaired by the addition of amifostine to CHOP. This schedule merits further testing in a randomized trial.

The Influence of advanced age on the treatment and prognosis of diffuse large-cell lymphoma (DLCL)

The incidence of non-Hodgkin's lymphoma (NHL) in elderly patients has increased in recent years. Approximately 36% of elderly patients with NHL are diagnosed with diffuse large-cell lymphoma (DLCL), an aggressive lymphoma subtype. Some authors have suggested that lymphoma in the elderly is intrinsically different from that seen in younger patients. Diffuse large-cell lymphoma, for example, is curable in about 50% of patients younger than 65 years of age but has a significantly lower cure rate in older subjects. Elderly patients with DLCL represent a group that is difficult to treat because of comorbidity, diminished organ functions, altered drug metabolism, and irregular drug clearance rates. These factors must be carefully considered when evaluating treatment options for older patients. The quality of life (QOL) associated with various regimens should obviously be evaluated, though QOL has so far received little attention in clinical trials. Analyses of the results from numerous phase II and phase III trials in patients with advanced aggressive NHL have demonstrated that overall survival is reduced when chemotherapy regimens more toxic than CHOP (cyclophosphamide/doxorubicin/ vincristine/prednisone) are employed, whereas therapeutic regimens that are less toxic are often less effective. CHOP, therefore, may be regarded as the current gold standard of therapy for elderly patients with DLCL. The addition of granulocyte colony-stimulating factors to CHOP chemotherapy is recommended to limit myelosuppression. Intensive chemotherapy followed by autologous stem cell transplantation has recently been extended to patients older than 60 years, with encouraging results, albeit in a highly selected groups of patients. Other promising lymphoma treatments with improved toxicity profiles are being developed. Clinical trials are recommended to determine if these new therapies are safe and active in elderly patients with DLCL.

Different age limits for elderly patients with indolent and aggressive non-hodgkin lymphoma and the role of relative survival with increasing age

BACKGROUND

There is no consistent definition at what age patients with non-Hodgkin lymphoma (NHL) are considered "elderly." This might hamper well balanced decisions with respect to treatment.

METHODS

From a population-based NHL registry the age groups younger than 60 years, 60-64 years, 65-69 years, 70-74 years, and 75 years and older were analyzed in relation to the revised European-American lymphoma classification and to the age-adjusted International Prognostic Index (IPI). The prognostic value of the variables from the age-adjusted IPI was determined. The relative survival probabilities were calculated.

RESULTS

The incidence of diffuse large B-cell lymphoma (DLBL) increased with advancing age, as was the case for small lymphocytic lymphomas. Follicular lymphomas were less frequently encountered with advancing age. With respect to the so-called indolent lymphomas, a decreasing complete remission rate and overall survival rate (5-year) was observed for patients older than 70 years, whereas patients with DLBL fared worse when older than 65 years and 60 years, respectively. The age-adjusted IPI score was discriminative for prognosis. However, even with an IPI score nil, the age group older than 75 years fared significantly worse (P < 0.009), but less so with the relative survival model. The relative survival at 5 years was 60%, 53%, 48%, 35%, and 32% for the 5 respective age groups.

CONCLUSIONS

Patients with indolent lymphomas become elderly when they are older than 70 years, but when aggressive lymphoma is concerned this occurs when patients are older than 65 years. For patients with an IPI score nil, age older than 75 years is the dominant prognostic factor. The negative influence of concomitant disease on overall survival, although continuously increasing in older age groups, seems to diminish for patients older than 75 years when compared with the general Dutch population.

Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma?

BACKGROUND

Pancreatic lymphoma is a rare neoplasm. The role of surgical resection in curing this disease is poorly defined.

STUDY DESIGN

From March 1983 to July 1997, eight patients with stage I or II primary pancreatic lymphoma were identified and retrospectively reviewed. All patients received chemotherapy, five patients received radiotherapy, and three patients also underwent surgical resection. A review of the published pancreatic lymphoma experience in the English-language literature was also undertaken.

RESULTS

Three patients underwent pancreaticoduodenectomy with successful resection of the lymphoma and are disease free at 64, 62, and 53 months followup. Five patients were treated with nonresectional therapy. Three are disease free at 128, 51, and 24 months. Two patients died of disease at 9 and 37 months. A review of the pancreatic lymphoma experience in the English-language literature identified 122 cases of pancreatic lymphoma. Fifty-eight of these cases represented stage I or II lymphoma, which was treated without surgical resection with a 46% cure rate. Fifteen patients who had surgical resection for localized disease have been reported with a 94% cure rate.

CONCLUSIONS

Based on both our single institution experience and the literature, it is suggested that surgical resection may play a beneficial role in the treatment of localized pancreatic lymphoma, although selection factors cannot be absolutely excluded.

Aggressive lymphoma in the elderly

Persons 65 years of age and older are the fastest growing segment of the United States population. Over the next 30 years they will comprise approximately 20% of the population. There will be a parallel rise in the number of patients with non-Hodgkin's lymphoma. Age has long been known to be an adverse prognostic factor. Clinical trials of older patients are complicated by the effect of comorbid illness, particularly its effect on overall survival. CHOP (cyclophosphamide, Adriamycin, vincristine, prednisone) remains the standard therapy for all patients with aggressive non-Hodgkin's lymphoma. There are a number of regimens which may be beneficial for older patients with significant comorbidity and poor performance status. The randomized trials in the elderly has reaffirmed CHOP and emphasize the need for adequate dosing, maintaining schedule and anthracyclines. Relapsed patients have a poor prognosis but selected fit older patients may benefit from aggressive reinduction regimens and possibly bone marrow transplantation. Future research should include defining the role of comorbidity, measurement of organ dysfunction and assessment of performance status with geriatric functional scales. New drug treatments should also be explored.