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Simonsen MR, Haunstrup LM, Severinsen FT, Jensen RK, Brown PDN, Maurer MJ, Khurana A, Jensen P, Jørgensen JM, Stauffer Larsen T, Clausen MR, Poulsen CB, Dessau-Arp A, El-Galaly TC, Jakobsen LH. The impact of trial inclusion criteria on outcomes in DLBCL patients treated with R-CHOP in the first line: a Danish nationwide study. Leuk Lymphoma 2024:1-9. [PMID: 39225407 DOI: 10.1080/10428194.2024.2390561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024]
Abstract
Up to 50% of diffuse large B-cell lymphoma (DLBCL) patients are ineligible for participation in clinical trials. Ineligible patients have inferior outcomes, but less is known about the impact of commonly used organ-function-based inclusion criteria on drug efficacy estimates. Data on DLBCL patients treated with CHOP+/-rituximab were retrieved from the Danish Lymphoma Registry. Trial inclusion criteria were extracted from four international DLBCL trials (REMoDL-B, GOYA, POLARIX, and HOVON-84). Differences in overall survival (OS) and 5-year restricted mean survival differences (5 y-RMSDs) between trial eligible and ineligible patients were computed. The effectiveness of adding rituximab to CHOP was quantified by the 5 y-RMSD between CHOP and R-CHOP-treated patients and the impact of individual trial criteria on estimated effectiveness was quantified by Shapley-values. In total, 4,083 R-CHOP-treated and 890 CHOP-treated DLBCL patients were included. Across the trials, 18.6-29.3% of the included R-CHOP-treated patients were deemed ineligible for trial based on organ function and performance status alone. Ineligible patients had significantly worse survival, with adjusted absolute differences in 5-year OS of 9-15%. The impact of individual criteria on the estimated effectiveness of adding rituximab to CHOP was small (Shapley-value range, -2.74-0.31). Using a smaller set of criteria derived from a data-driven approach, the number of eligible patients increased by 16-38% and the 5 y-RMSD increased by 0.7-3.1 months. In conclusion, OS among trial ineligible DLBCL patients is inferior as expected, but relaxing trial criteria would have increased the number of trial participants without making major changes in estimated efficacy for a hypothetical CHOP versus R-CHOP trial. This does not necessarily imply that trial findings based on selected patients are unreliable, as the estimated effectiveness of adding rituximab to CHOP was only slightly affected by omitting selected inclusion criteria.
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Affiliation(s)
- Mikkel Runason Simonsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Laura Mors Haunstrup
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Freja Tang Severinsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus Kuhr Jensen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | | | - Matthew J Maurer
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Paw Jensen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | | | | | | | | | | | - Tarec Christoffer El-Galaly
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lasse Hjort Jakobsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Mathematical Sciences, Aalborg University, Aalborg, Denmark
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2
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Yamasaki S. Appropriate Treatment Intensity for Diffuse Large B-Cell Lymphoma in the Older Population: A Review of the Literature. Hematol Rep 2024; 16:317-330. [PMID: 38921180 PMCID: PMC11204029 DOI: 10.3390/hematolrep16020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
Most patients with diffuse large B-cell lymphoma (DLBCL) are >65 years of age, with the number of patients expected to increase in the coming years. A comprehensive geriatric assessment that carefully evaluates fitness status and comorbidities is essential for selecting the appropriate treatment intensity. Although generally healthy patients or those <80 years of age may benefit from standard immunochemotherapy, unfit/frail patients or patients >80 years old may require reduced-intensity chemotherapy or less-toxic drugs. Some new drugs are currently being tested as single or combined agents for first-line treatment, aiming to improve the outcomes of conventional chemotherapy. This review systematically collates and discusses the outcomes associated with the use of immunochemotherapy in older patients with DLBCL, as well as considering the impact of full-dose immunochemotherapy on quality of life in older and frail patients, summarizing the rationale for reduced dosing in the older population, and presenting recommendations for selecting patients likely to benefit from reduced dosing. If preliminary efficacy and safety data are confirmed in future clinical trials, non-chemotherapy-based immunotherapy approaches could become an alternative potentially curative option in frail patients and those >80 years of age with DLBCL.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Hematology, St. Mary’s Hospital, 422 Tsubukuhonmachi, Kurume 830-8543, Japan; ; Tel.: +81-942-35-3322; Fax: +81-9442-34-3115
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu 874-0838, Japan
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka 810-0065, Japan
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Sekiguchi Y, Tsutsumi H, Gomyo A, Kudo M, Iizaki Y, Maseki N, Kawamura M, Kobayashi K, Nishimura Y, Kanda H, Nitta H, Noguchi M, Kobayashi H. Use of R-mini-CHP in combination with polatuzumab vedotin (pola-R-mini-CHP) as the primary treatment in ≥80-year-old cases with diffuse large B-cell lymphoma. J Clin Exp Hematop 2023; 63:262-265. [PMID: 38148017 PMCID: PMC10861370 DOI: 10.3960/jslrt.23043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Affiliation(s)
| | - Hiroki Tsutsumi
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Ayumi Gomyo
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Masahisa Kudo
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Yoshie Iizaki
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Nobuo Maseki
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Machiko Kawamura
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
- Department of Clinical Laboratory Medicine, Saitama Cancer Center, Saitama, Japan
| | - Kazuhiko Kobayashi
- Department of Inspection Engineering, Saitama Cancer Center, Saitama, Japan
| | - Yu Nishimura
- Department of Pathology, Saitama Cancer Center, Saitama, Japan
| | - Hiroaki Kanda
- Department of Pathology, Saitama Cancer Center, Saitama, Japan
| | - Hideaki Nitta
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
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Mancuso S, Mattana M, Santoro M, Carlisi M, Buscemi S, Siragusa S. Host-related factors and cancer: Malnutrition and non-Hodgkin lymphoma. Hematol Oncol 2022; 40:320-331. [PMID: 35398917 PMCID: PMC9544175 DOI: 10.1002/hon.3002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/24/2022] [Accepted: 04/05/2022] [Indexed: 11/06/2022]
Abstract
Assessment of host-related factors is a crucial aspect in the comprehensive management of cancer patients. A distinct nutritional disturbance linked to cancer has been recognized to be associated with negative outcomes. However, compared to solid tumors, only a limited number of studies have looked specifically at nutritional issues in the field of lymphoma. The aim of this review is to integrate the current knowledge on interactions between malnutrition and lymphoma and address most relevant and pertinent questions. We first provide a literature review on the mutual biological relationship between malnutrition and lymphoma. Next, we explore the overlap between malnutrition, sarcopenia, cachexia and frailty in lymphoma studies. In addition, we summarize the clinical assessment scales used to measure malnutrition in lymphoma subjects. Furthermore, we address the problem of nutritional interventions aimed at patients who are candidates for treatment for lymphoma. Malnutrition can arise as a consequence of lymphoma disease and can in turn promote lymphomagenesis, negatively affect the response to therapy and favor adverse event to treatment. There is increasing evidence that malnutrition, sarcopenia and cachexia in lymphoma are intimately inter-related and are a hallmark of frailty. A variety of different tools are recorded with the apparent ability to describe nutritional status and to impact prognosis in lymphoma patients. Finally, a network of prognostic host- and disease-related factors is proposed where malnutrition can interact with each other in complex ways.
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Affiliation(s)
- Salvatrice Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Hematology Unit, University of PalermoPalermoItaly
| | - Marta Mattana
- Hematology UnitUniversity Hospital “Paolo Giaccone”PalermoItaly
| | - Marco Santoro
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Hematology Unit, University of PalermoPalermoItaly
| | - Melania Carlisi
- Hematology UnitUniversity Hospital “Paolo Giaccone”PalermoItaly
| | - Silvio Buscemi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Hematology Unit, University of PalermoPalermoItaly
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), Hematology Unit, University of PalermoPalermoItaly
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Juul MB, Jelicic J, Anru PL, Engberg H, Hammershøj Jensen P, Kristensen HB, Baech J, Clausen MR, Gang AO, Munksgaard L, El-Galaly TC, Frederiksen H, Stauffer Larsen T. Cardiovascular diseases in elderly survivors of diffuse large B-cell lymphoma: a Danish population-based cohort study. Leuk Lymphoma 2022; 63:2074-2083. [DOI: 10.1080/10428194.2022.2064982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Maja Bech Juul
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Academy of Geriatric Cancer Research, Odense University Hospital, Odense, Denmark
| | - Jelena Jelicic
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Hematology, Vejle Sygehus, Vejle, Denmark
| | - Pavithra Laxsen Anru
- Department of Clinical Research, Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Henriette Engberg
- Department of Clinical Research, Research Unit of Clinical Epidemiology, University of Southern Denmark, Odense, Denmark
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | | | | | - Joachim Baech
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Michael Roost Clausen
- Department of Hematology, Vejle Sygehus, Vejle, Denmark
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lars Munksgaard
- Department of Hematology, Zealand University Hospital, Roskilde, Denmark
| | | | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Academy of Geriatric Cancer Research, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Thomas Stauffer Larsen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Academy of Geriatric Cancer Research, Odense University Hospital, Odense, Denmark
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Johnson PC, Yi A, Horick N, Amonoo HL, Newcomb RA, Lavoie MW, Rice J, Reynolds MJ, Ritchie CS, Nipp RD, El-Jawahri A. Clinical Outcomes, Treatment Toxicity, and Health Care Utilization in Older Adults with Aggressive Non-Hodgkin Lymphoma. Oncologist 2021; 26:965-973. [PMID: 34327767 DOI: 10.1002/onco.13915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although balancing treatment efficacy with risks of complications is critical for older adults with aggressive non-Hodgkin lymphoma (NHL), few studies have described these patients' clinical outcomes, rates of toxicities, and health care utilization. METHODS We conducted a retrospective analysis of adults ≥65 years diagnosed with aggressive NHL and receiving systemic therapy at Massachusetts General Hospital from April 2000 to July 2020. We abstracted patient characteristics, clinical outcomes, treatment toxicity, unplanned hospitalizations, and intensive care unit (ICU) admissions within 6 months of treatment initiation from the medical record. Using multivariable logistic regression, we examined factors associated with rates of grade 3+ nonhematologic toxicity and unplanned hospitalization. RESULTS Among 295 patients (median age, 73 years; 39.0% female), 5-year overall survival (OS) was 74.2%. Five-year OS by age group (65-69, 70-74, 75-79, and 80+ years) was 82.2%, 72.0%, 73.6%, and 66.4%, respectively. Overall, 42.4% experienced grade 3+ toxicity, with 8.1% experiencing grades 4-5. The rates of unplanned hospitalization and ICU admission were 41.0% and 6.1%, respectively. In multivariable analysis, hypoalbuminemia (odds ratio [OR], 4.29; p < .001) and high comorbidity score (OR, 4.22; p < .001) were associated with likelihood of grade 3+ toxicity. Hypoalbuminemia (OR, 2.83; p = .003), high comorbidity score (OR, 3.93; p = .001), and receipt of EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin; OR, 5.45; p = .012) were associated with likelihood of unplanned hospitalization. CONCLUSIONS The majority of older adults receiving upfront therapy for aggressive NHL survive beyond 5 years, yet nearly half experience substantial treatment toxicities and unplanned hospitalizations. Our findings underscore the need for supportive care interventions to enhance the care experience of this population. IMPLICATIONS FOR PRACTICE The results of this study highlight the potential benefits of intensive chemoimmunotherapy for the majority of older adults with aggressive non-Hodgkin lymphoma, even at advanced ages. Nearly half of older adults experienced substantial treatment toxicities and unplanned hospitalizations, emphasizing the unmet need for supportive care interventions in this population. The present study also identified hypoalbuminemia and patient comorbidity score as factors associated with grade 3+ nonhematologic toxicity and unplanned hospitalization. These findings may guide the development and implementation of targeted supportive care interventions in high-risk older adults with aggressive non-Hodgkin lymphoma.
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Affiliation(s)
- P Connor Johnson
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Alisha Yi
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nora Horick
- Department of Statistics, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Hermioni L Amonoo
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Richard A Newcomb
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Mitchell W Lavoie
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Rice
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew J Reynolds
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christine S Ritchie
- The Mongan Institute and the Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan D Nipp
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Division of Hematology & Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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7
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Impact of R-CHOP dose intensity on survival outcomes in diffuse large B-cell lymphoma: a systematic review. Blood Adv 2021; 5:2426-2437. [PMID: 33961018 DOI: 10.1182/bloodadvances.2021004665] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/26/2021] [Indexed: 12/20/2022] Open
Abstract
The dilemma of whether to treat elderly patients with diffuse large B-cell lymphoma (DLBCL) with a full or reduced dose intensity (DI) of R-CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone+rituximab) is often faced by clinicians. We conducted a systematic review assessing the impact of R-CHOP DI on DLBCL survival outcomes, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (PRISMA-P) guidelines. We searched MEDLINE, EMBASE, and Cochrane CENTRAL for studies with ≥100 patients treated with R-CHOP/R-CHOP-like therapies published from January 2002 through November 2020. Studies were included if they reported the impact of R-CHOP DI on survival outcomes. We screened records, extracted data, and reviewed all the studies for quality and statistical appraisal. Of 380 screened records, 13 studies including 5188 patients were reviewed. DI was often calculated as the ratio of the cumulative delivered dose of prespecified drug(s) to the cumulative planned dose multiplied by a time-correction factor. Lower DI (intended or relative) was associated with inferior survival in 7 of 9 studies reporting crude survival analyses. Multivariable analysis using DI as a covariate was performed in 10 studies. Six showed an association (P < .05) with adjustment for other covariates, and 4 did not. Most studies and those larger studies of higher quality showed poorer outcomes associated with reduced DI. In subgroups aged ≥80 years, survival was not consistently affected by reduced DI. DI-specific randomized trials are warranted, but these data support full-dose R-CHOP in elderly and fit patients aged <80 years with DLBCL, but not in those aged ≥80 years, where dose-reduced R-CHOP does not appear to compromise survival.
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