High-dose chemotherapy supported by peripheral blood stem cell transplantation in elderly versus younger lymphoma patients: a matched analysis

Comorbidities, not age, impact outcomes in autologous stem cell transplant for relapsed non-Hodgkin lymphoma

High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation is a widely applied treatment for advanced non-Hodgkin lymphoma (NHL), but few studies have analyzed the tolerability and outcomes in older patients compared with younger patients treated in a homogeneous manner. We retrospectively reviewed 152 consecutive patients who underwent autologous stem cell transplantation (ASCT) following BEAM conditioning (carmustine, etoposide, cytarabine, and melphalan) for NHL from January 2000 through August 2004 at our institution. We compared 59 patients age > or =60 years and 93 patients age <60 years. Supportive care was identical for all patients. The frequency of comorbidities was similar between both groups. CD34+ cell doses, days to neutrophil recovery, and days to platelet count >20,000/mm3 were similar in younger and older patients, although days to platelet count >50,000/mm3 were longer in the older patients (median 30.0 days versus 22.5 days, P = .01). Patients over the age of 60 were more likely to develop grade III/IV mucositis than their younger counterparts (37.7% versus17.4%, P = .0063). Otherwise, the frequency of other grade III/IV toxicities were similar between younger and older patients. Treatment-related mortality (TRM) was similar between older and younger patients (8.5% versus 5.4%, P = .45). Although age was not associated with TRM, the Charlson Comorbidity Index Score was significantly correlated with TRM (P = .03). Median disease-free survival was similar between older and younger patients (21.8 months versus 29.9 months, P = .93), as was overall survival (OS) (47.7 months versus 62.5 months, P = .20). After controlling for age, the Charlson Comorbidity Index Score influenced OS [P = .013]. Overall, our cohort of patients with NHL over the age of 60 who underwent ASCT following BEAM conditioning experienced toxicities and survival similar to their younger counterparts. Comorbidities significantly influenced TRM and OS in this retrospective cohort. Future study should focus on improving tolerability of conditioning and careful prospective evaluation of comorbidities and their association with outcomes.

Analysis of treatment practices for elderly cancer patients in Ontario, Canada

PURPOSE

Older patients are underrepresented in many areas of cancer services utilization and in clinical trial enrollment. This study evaluates whether age, when adjusted for sex, comorbidity, stage, tumor site, geography, and time period, is predictive of cancer treatment practice.

METHODS

First, we used the Ontario Cancer Registry (OCR) to examine for any apparent differences in treatment practices between elderly (> or = 70 years) and younger patients in the last three decades. Second, we performed a chart review of 1,505 patients with lung, breast, and colorectal cancers seen in Ontario either at an urban center, the Princess Margaret Hospital, or at a rural center, the Northwestern Regional Cancer Centre. Patients were randomly selected from two time periods, 1977 to 1978 and 1997; and the study population was to comprise at least 50% elderly patients.

RESULTS

OCR data demonstrated that, in some settings, such as colorectal cancer, the proportions of elderly cancer patients who were referred to cancer centers and who received any cancer treatment were lower than their younger counterparts. The chart review data showed that increasing age was a significant negative predictor for receiving any cancer treatment (P < .001, multivariate analysis) and for having a clinical trial discussion with the treating specialist (P < .001, multivariate analysis).

CONCLUSION

Independent of other factors, older age is consistently a cause of disparity in cancer treatment practice and in clinical trial discussion with patients. By increasing the accrual rate of elderly cancer patients in clinical trials, a better understanding of appropriate therapies for this patient population can be obtained and may, thereby, impact on their cancer-related morbidity and mortality.

Low transplant-related mortality with allogeneic stem cell transplantation in elderly patients

Historically, age >60 years was considered a contraindication for allogeneic stem cell transplantation (allo-SCT). In recent years, elderly (>60 years) patients have become eligible for allo-SCT due to the application of reduced intensity conditioning (RIC). The present report summarizes our cumulative experience in a cohort of 17 elderly patients (age 60-67, median 62.5 years) with hematological malignancies treated with 18 allo-SCT procedures, mostly nonmyeloablative. In all, 14 patients received fludarabine and busulfan/busulfex regimen, three patients were conditioned with the fludarabine and low-dose TBI and one patient received busulfan alone. All patients displayed tri-lineage engraftment. The time to recovery of absolute neutrophil count >/=0.5 x 10(9)/l was 9-27 days (median 14 days). The time interval to platelet recovery >/=20 x 10(9)/l was 3-96 days (median 11 days). Veno-occlusive disease occurred only in 3/18 procedures and subsided with conventional treatment. Nonfatal transplant-related complications occurred in 6/18 (33.3%) procedures including: renal failure, arrhythmia, CNS bleeding, cystitis, typhlitis and gastrointestinal bleeding. Transplant-related mortality occurred in 6/18 (33.3%) episodes. Of the 17 patients, 12 (12/18 episodes) were discharged. Five of 17 (29%) patients survived (median follow-up 11 m, range 8-53 m). Our data suggest that RIC-allo-SCT may be safely applied in the elderly, suggesting that allogeneic immunotherapy may become an important tool for treatment of hematological malignancies without an age limit.