Non-Hodgkin's lymphoma in the elderly: a guide to drug treatment

Clinical Pharmacokinetic and Pharmacodynamic Considerations in Treating Non-Hodgkin Lymphoma

Non-Hodgkin lymphoma (NHL) includes a variety of closely related malignancies that originate from lymphoid precursors. The majority of NHLs are of B-cell lineage, for which traditional therapy involves chemotherapy in combination with the anti-CD20 monoclonal antibody rituximab. Ongoing research into the pathogenesis of NHL subtypes has given rise to the use of novel agents that target specific molecular pathways. While the incidence of NHL extends over a range of ages from pediatric to elderly settings, the majority of diagnoses occur over age 60 years. Increasing the use of concomitant medication coupled with declining organ function among this group of patients creates pharmacokinetic (PK) challenges in administering a number of agents involved in the treatment of NHL. In addition, since many of the new agents are administered orally, there are a number of added PK factors that must be taken into consideration with their prescribing and administration. This article will review the available literature on the PK and pharmacodynamic properties of agents commonly used in the treatment of NHL, and intends to provide information that can assist with properly using these drugs in this setting.

Prevention and management of prostate cancer chemotherapy complications

Prevention and management of the adverse effects of prostate cancer chemotherapy depend on skilled regimen selection, dose adjustment, use of supportive care strategies, and a thorough understanding of the patient- and regimen-related factors that determine the risk for toxicity. Urologists, radiation oncologists, and primary care providers can play an important role before chemotherapy is prescribed by judicious use of treatments that impair bone marrow and other vital organ function. The current role of chemotherapy in prostate cancer is palliative. Successful palliation depends on reducing cancer-related suffering without introducing treatment-related suffering. Thus prevention and management of toxicity is central to the success of chemotherapy in advanced prostate cancer.

Polyethylene glycol-liposomal doxorubicin: a review of its use in the management of solid and haematological malignancies and AIDS-related Kaposi's sarcoma

Polyethylene glycol (PEG)-liposomal doxorubicin is a formulation of the anthracycline doxorubicin in which the drug is encapsulated in PEG-coated liposomes. This alters the pharmacokinetic properties of doxorubicin, prolonging circulation time and enhancing localisation to tumours. In a large randomised trial, intravenous PEG-liposomal doxorubicin was at least as effective as topotecan in patients with ovarian cancer refractory or sensitive to first-line platinum-based chemotherapy. Overall response rates of patients with ovarian cancer refractory to platinum- and paclitaxel-based chemotherapy who received the drug ranged from 18.3 to 27.6% in noncomparative clinical trials. PEG-liposomal doxorubicin also has antitumour activity in patients with metastatic breast cancer pretreated with other chemotherapeutic agents. Overall response rates were similar in patients with pretreated metastatic breast cancer who had received PEG-liposomal doxorubicin or two comparator salvage chemotherapy regimens (vinorelbine or mitomycin C plus vinblastine) in an interim analysis of a large randomised study. In patients with advanced AIDS-related Kaposi's sarcoma, PEG-liposomal doxorubicin monotherapy produced overall response rates ranging from 46 to 77% in randomised trials. The drug was significantly more effective than bleomycin plus vincristine alone or in combination with standard doxorubicin, as measured by tumour response. As a replacement for standard doxorubicin in commonly used combination therapies, PEG-liposomal doxorubicin has shown activity in multiple myeloma and aggressive non-Hodgkin's lymphoma in small, preliminary trials. The most common adverse events associated with PEG-liposomal doxorubicin are myelosuppression, palmar-plantar erythrodysaesthesia, stomatitis and nausea. These can be managed by delaying or reducing dosages. Although preliminary trials are promising, the relative cardiotoxicity of PEG-liposomal doxorubicin compared with the standard formulation has not been clearly established.

CONCLUSIONS

Monotherapy with PEG-liposomal doxorubicin is effective as a second-line chemotherapy in patients with platinum-refractory ovarian cancer and in patients with metastatic breast cancer. However, as with all chemotherapeutic agents, the benefits of treatment need to be weighed against the agent's tolerability profile. Strong comparative data have helped to establish PEG-liposomal doxorubicin as the first-line treatment option in patients with advanced Kaposi's sarcoma. Anticancer activity has also been observed in studies conducted in small numbers of patients with multiple myeloma or non-Hodgkin's lymphoma receiving PEG-liposomal doxorubicin instead of standard doxorubicin in combination regimens, although further data are needed to confirm the clinical relevance of these findings.

Impact of age and colony-stimulating factor use on hospital length of stay for febrile neutropenia in CHOP-treated non-Hodgkin's lymphoma

BACKGROUND

In intermediate-grade non-Hodgkin's lymphoma (NHL) patients, full-dose CHOP improves survival but increases myelosuppression, causing febrile neutropenia hospitalization (FNH) in 28% of patients 65 years of age or greater. Several risk factors for FNH are known, but their relationship to length of stay (LOS), an indicator of the total burden of FNH, is unclear.

METHODS

We conducted a study to identify factors associated with the incidence, recurrence, and duration of hospitalizations for FN and to describe the frequency of administration of colony-stimulating factor (CSF) as primary and secondary prophylaxis and its association with repeated hospitalization episodes.

RESULTS

Compared with patients who did not experience hospitalizations for FN, those who did were significantly older, had more comorbid conditions, were planned for standard dose intensity, and received CSF less often during the first 5 days of cycle 1 (early CSF). Overall, 73% of these hospitalizations occurred within the first 2 cycles of chemotherapy, with 56% occurring within the first cycle. Patients age > or = 65 years accounted for 66% of cycle 1 FNH. Patients receiving early CSF were less likely to experience repeated hospitalizations (0% vs 12%; P<.05). Multiple regression analysis of those hospitalized found a 3.9-day longer LOS for patients age > or = 65 years and a 5.13-day longer LOS for those not receiving early CSF.

CONCLUSIONS

Older NHL patients have a higher risk of hospitalization for FN and longer LOS. The majority of hospitalization days occur in the first 2 cycles of chemotherapy. Early CSF use is associated with decreased risk of repeated hospitalizations and shorter total LOS. Secondary CSF use is also associated with reduced risk of repeated FNH.

Neoplastic masquerade syndromes

Masquerade syndromes are classically defined as entities which emulate inflammatory conditions but which are in fact due to a neoplastic process. Careful history and examination in concert with appropriate ancillary investigations and histopathologic evaluation of tissue specimens are required in order to make the correct diagnosis. Many conditions may result in an appearance mimicking an inflammatory condition. The authors review neoplastic conditions which may be considered masquerades. The most common of these is primary intraocular lymphoma or primary central nervous system lymphoma, occurring predominately in older individuals. Diagnostic strategies, therapy, and prognosis are reviewed in detail. Other conditions that can be considered masquerade syndromes are reviewed as well, including lymphomatous and nonlymphomatous conditions, such as melanoma, retinoblastoma, juvenile xanthogranuloma, metastatic lesions, and paraneoplastic syndromes, among others.