Granulocyte-colony stimulating factor (G-CSF) may improve disease outcome in elderly patients with diffuse large cell lymphoma (DLCL) treated with CHOP chemotherapy

Prediction of survival of diffuse large B-cell lymphoma patients via the expression of three inflammatory genes

Currently, several gene-expression signatures that were used to predict survival of diffuse large B-cell lymphoma (DLBCL) patients, showed a restriction on the practical work for lack of convenient operation. In this study, we screened inflammatory genes whose expression correlated with survival of DLBCL and established a predictive model including IL6, IL1A and CSF3 through multivariate Cox regression based on the expression of these three genes. We validated the model at protein level in our clinical serum cohort composed of 101 patients of DLBCL and 50 healthy controls and 534 DLBCL patients at mRNA level from three independent Gene Expression Omnibus (GEO) data sets. We found our model to be independent of the International Prognostic Index (IPI), moreover, it can augment the predictive power of IPI. In summary, our three-gene model is sufficient to predict survival of DLBCL patients via measuring the concentration of three inflammatory cytokines in peripheral blood.

Granulocyte growth factor use in elderly patients with non-Hodgkin's lymphoma in the United States: adherence to guidelines and comparative effectiveness

PURPOSE

The efficacy of prophylactic granulocyte colony-stimulating factors (G-CSFs) among elderly patients with non-Hodgkin's lymphoma (NHL) receiving CHOP-based chemotherapy has been demonstrated in clinical trials, and G-CSFs are recommended in guidelines. We studied guideline adherence and the effectiveness of G-CSFs in the general population.

METHODS

We used inpatient and outpatient claims from nationally representative databases linked to cancer information from tumor registries. Patients (N = 5884) diagnosed with NHL between 2001 and 2007 who were older than 65 years and who received CHOP-based chemotherapy were included. Adherence to guidelines was measured as the use of G-CSFs within 7 days of the first dose of chemotherapy. The measures of effectiveness were fever, infection, and death during cycle 1 of chemotherapy and time to cycle 2. Multiple-variable models of these outcomes were developed using logistic regression, controlling for demographic, clinical, and provider factors.

RESULTS

G-CSF use increased from 32 % in 2001 to 72 % in 2007. Patients who received G-CSFs were significantly less likely to have outpatient encounters for infection than those who did not receive early G-CSFs (35 vs 47 %; p < 0.0001). Inpatient encounters for infection were similarly prevalent among patients who did or did not receive early G-CSFs (5 vs 4 %; p = 0.2). There was no association between G-CSF use and death during cycle 1.

CONCLUSIONS

Adherence to guidelines increased after publication of clinical trials and exceeded 70 % after publication of guidelines. G-CSFs were effective in preventing outpatient encounters for fever or infection, but not inpatient encounters or deaths during cycle 1.

Cost benefit and clinical efficacy of low-dose granulocyte colony-stimulating factor after standard chemotherapy in patients with non-Hodgkin's lymphoma

High costs of molecule-targeted drugs, such as rituximab, ibritumomab, and tositumomab have given rise to an economical issue for treating patients with non-Hodgkin's lymphoma (NHL). Granulocyte colony-stimulating factors (G-CSFs), which are also expensive, are widely used for treating neutropenia after chemotherapy. In Japan, lenograstim at 2 microg/kg (about 100 microg/body) or filgrastim at 50 microg/m(2) (about 75 microg/body) is commonly administered for patients with NHL after chemotherapy. Therefore, cost-effectiveness is an important issue in treatment for NHL. Patients with advanced-stage NHL who needed chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or a CHOP-like regimen with or without rituximab were enrolled in this randomized cross-over trial to investigate the efficacy and safety of low-dose G-CSF. Half of the patients were administered 75 microg filgrastim in the first course after neutropenia and 50 microg lenograstim in the second course, and the other half were crossed over. Forty-seven patients were enrolled in this cross-over trial, and 24 patients completed the trial. Frequencies and durations of grade 4 leukocytopenia and neutropenia were similar in the two groups. Severe infection was rare and was observed at similar frequency. Frequencies of antibiotics use were also similar. The total cost of G-CSF (cost/drug x duration of administration) was significantly lower in patients who received 50 microg lenograstim. Hence, a low dose of lenograstim might be safe, effective and pharmaco-economically beneficial in patients with advanced-stage NHL.

G-CSF Control of Neutrophils Dynamics in the Blood

White blood cell neutrophil is a key component in the fast initial immune response against bacterial and fungal infections. Granulocyte colony stimulating factor (G-CSF) which is naturally produced in the body, is known to control the neutrophils production in the bone marrow and the neutrophils delivery into the blood. In oncological practice, G-CSF injections are widely used to treat neutropenia (dangerously low levels of neutrophils in the blood) and to prevent the infectious complications that often follow chemotherapy. However, the accurate dynamics of G-CSF neutrophil interaction has not been fully determined and no general scheme exists for an optimal G-CSF application in neutropenia. Here we develop a two-dimensional ordinary differential equation model for the G-CSF-neutrophil dynamics in the blood. The model is built axiomatically by first formally defining from the biology the expected properties of the model, and then deducing the dynamic behavior of the resulting system. The resulting model is structurally stable, and its dynamical features are independent of the precise form of the various rate functions. Choosing a specific form for these functions, three complementary parameter estimation procedures for one clinical (training) data set are utilized. The fully parameterized model (6 parameters) provides adequate predictions for several additional clinical data sets on time scales of several days. We briefly discuss the utility of this relatively simple and robust model in several clinical conditions.

Pegfilgrastim to support CHOP-14 in elderly patients with non-Hodgkin's lymphoma

This study investigated whether pegfilgrastim support would enable on-schedule delivery of dose-dense cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP-14) to elderly patients with non-Hodgkin's lymphoma (NHL). Thirty patients 60 years of age and older with aggressive NHL were evaluated after receiving up to six cycles of CHOP-14 supported with pegfilgrastim. The median age was 68 years (range 61 - 74). Forty-seven per cent of patients received full dose chemotherapy on schedule for all cycles (range 65 - 93). Chemotherapy was delayed in 10 patients and dose reduced in 15 patients. Hematological toxicity was the most common reason for delays and dose reduction. Six of nine patients (67%) achieved a peripheral blood CD34+ count of at least 20 cellsx106 L-1 on day 12 of cycle one. The delivery on schedule of dose-dense CHOP-14 to elderly patients with previously untreated aggressive NHL is safe and efficacious with once per cycle pegfilgrastim support.

Pilot study of modified version of CHOP plus radiotherapy for early-stage aggressive non-Hodgkin's lymphoma of the head and neck

PURPOSE

To evaluate the safety and efficacy of a modified version of cyclophosphamide, doxorubicin, vincristine, prednisone (pirarubicin, cyclophosphamide, vincristine, and prednisone [THP-COP]) plus radiotherapy for early-stage aggressive non-Hodgkin's lymphoma of the head and neck.

METHODS AND MATERIALS

Between December 1993 and December 1999, 41 patients with early-stage non-Hodgkin's lymphoma with intermediate-grade histologic features were enrolled in our study. The mean patient age was 51 years. Of the 41 patients, 27 had Stage I and 14 Stage II disease. The primary site was Waldeyer's ring, a neck node, or an extranodal site in 14, 11, and 16 patients, respectively. The immunophenotype was B cell in 29 and T cell in 12 patients. All patients were in the low-risk category according to the International Prognostic Index. Chemotherapy consisted of 40 mg/m(2) i.v. pirarubicin (THP-Adriamycin), 750 mg/m(2) i.v. cyclophosphamide, and 1.0 mg/m(2) i.v. vincristine, on Day 1 and 40 mg/m(2) p.o. prednisone on Days 1-5. The combination chemotherapy was given twice at a 14-day interval. Radiotherapy was given to involved areas at a fraction size of 2.0-2.5 Gy up to a total of 40 Gy within 4-5 weeks. The mean follow-up period was 63 months.

RESULTS

The 5-year overall survival rate was 89%. The 5-year cause-specific survival and progression-free survival rate was 90% and 81%, respectively. The 5-year progression-free survival rate for patients with Waldeyer's ring primaries was 93%. Patients with tumor <5 cm in size had greater 5-year progression-free survival than those with tumor >5 cm in size (85% vs. 33%, p <0.05, log-rank test). Grade 4 neutropenia was seen in 12% of patients; however, 93% of patients (38 of 41) received chemotherapy as scheduled with the support of granulocyte colony-stimulating factor.

CONCLUSION

Biweekly THP-COP plus radiotherapy is feasible and effective for Stage I-II low-risk non-Hodgkin's lymphoma.

Doxorubicin-based chemotherapy for diffuse large B-cell lymphoma in elderly patients

BACKGROUND

Although many studies of elderly patients with non-Hodgkin lymphoma have focused on the dose intensity of chemotherapy, few studies have restricted the histologic inclusion criteria such that only patients with diffuse large B-cell lymphoma (DLCL) are considered. In the current study, treatment outcomes for elderly patients (age > or = 60 years) were analyzed, with emphasis on the dose intensity of doxorubicin.

METHODS

Between 1994 and 2000, 195 patients with DLCL were treated initially with doxorubicin-based chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone; or cyclophosphamide, vincristine, bleomycin, doxorubicin, procarbazine, and prednisone). Of these patients, 70 were aged 60 years or older.

RESULTS

Elderly patients had poorer treatment outcomes than did young patients (5-year survival, 30% vs. 57%; P < 0.001); however, elderly patients who received doxorubicin at dose intensities > or = 10 mg/m2 per week (n = 25) had outcomes (5-year survival, 52%) that were comparable to those of young patients. Among prognostic factors, only International Prognostic Index score (P = 0.022) and dose intensity of doxorubicin (P = 0.039) were found to have significant effects on the overall survival of elderly patients. When the reasons for doxorubicin dose reduction in 45 elderly patients who ultimately received doxorubicin at dose intensities < 10 mg/m2 per week were analyzed, it was found that 20 patients received reduced doses from the start of treatment because of their old age alone; these dose reductions in the 20 cases resulted in poorer treatment outcomes.

CONCLUSIONS

Elderly patients with DLCL who received doxorubicin at dose intensities > or = 10 mg/m2 per week had treatment outcomes that were comparable to those of young patients; however, physician bias associated with patient age was found to be related to unnecessary dose reductions. Efforts to maintain doxorubicin dose intensities > or = 10 mg/m2 per week and more objective standards for the selection of elderly patients capable of tolerating doxorubicin-based regimens are required.

Pharmacology of cytotoxic agents: a helpful tool for building dose adjustment guidelines in the elderly

Aging is associated with multidimensional changes, including alterations in physiological functions, co-morbidities and poly-medications. These changes may lead to modifications in the absorption, distribution, metabolism and excretion of drugs. The lack of a scientific basis for optimal drug dosing in the elderly is a major problem. The development and validation of guidelines are therefore essential to improve treatment administration and monitoring in elderly patients. Even though it has been widely demonstrated that standard therapies used in adults may be of great benefit in the elderly, there may be a higher incidence of toxicity. This could be avoided by using dosage individualization based on a sound knowledge of the physiological factors implicated in the pharmacokinetic (PK) characteristics of the drugs administered and in their observed pharmacodynamic (PD) effects in each patient. The so-called "population modeling" approach renders such studies feasible by allowing the analysis of PK-PD relationships from sparse observational data.

Chemotherapy in the elderly: supportive measures for chemotherapy-induced myelotoxicity

Not only is the U.S. populace aging, but the incidence of cancer in the elderly also is increasing. Many elderly patients with cancer can obtain the same benefits from standard chemotherapy as younger patients can, but the elderly are more susceptible to the myelotoxicity of chemotherapy, which can limit the dose intensity of their treatments. Nurses can help identify patients at risk before they are treated with chemotherapy and discuss the need for hematopoietic support with other members of the treatment team. They also can provide ongoing patient and family education and teach patients to recognize and report early symptoms of potential problems. Appropriate supportive measures, such as granulocyte-colony-stimulating factor, reduce the risk of chemotherapy-induced neutropenia and related infections and make the use of full-dose chemotherapy possible in elderly patients despite their greater risk of myelosuppression.

Treatment of aggressive non-Hodgkin's lymphoma with chemotherapy in combination with filgrastim

Non-Hodgkin's lymphoma (NHL) is one of the ten most common cancers in the developed world. The incidence has increased significantly over the past two decades and it is a particular burden in patients over the age of 60 years. The gold standard for primary treatment of aggressive NHL is combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). Haematological growth factors, such as granulocyte colony-stimulating factor (G-CSF), can be used to ameliorate chemotherapy-induced neutropenia, thus facilitating delivery of chemotherapy at the planned dose intensity. The International Prognostic Index is able to identify high-risk patients who are unlikely to be cured with standard primary chemotherapy. In these patients, the use of dose-intensive therapy, including high-dose chemotherapy with stem cell support, is being evaluated as potential primary therapy. Stem cell transplantation is currently the treatment of choice for patients with relapsed NHL or those with chemosensitive refractory disease. Autologous peripheral blood stem cells mobilised into the circulation by G-CSF help achieve rapid haematological reconstitution and are now the preferred source of stem cells over bone marrow for this form of therapy. G-CSF is also used to support allogeneic transplantation, which exerts a therapeutic graft-versus-lymphoma effect. Administration of G-CSF following autologous or allogeneic peripheral blood stem cell transplantation accelerates neutrophil recovery.

The role of myelopoietic growth factors in managing cancer in the elderly

More than 50% of all malignancies are diagnosed in patients aged > 65 years and most cancer-related deaths occur in this population. Misconceptions about prognosis and treatment contribute to the undertreatment of elderly cancer patients and consequent poor outcomes. Although older patients have been excluded from cancer treatment trials in the past, response rates to chemotherapy in a variety of common cancers in otherwise healthy elderly patients are comparable to those attained in younger patients. Lower functional reserve in many organ systems alters the pharmacokinetics of chemotherapeutic drugs as well as the patient's response to treatment-induced toxicity. Except for myelosuppression and mucositis, otherwise fit elderly cancer patients are not at significantly enhanced risk of toxicity to chemotherapy. Severe neutropenia and related infection are encountered much more frequently during the treatment of elderly as compared with younger cancer patients. These lead to treatment delays, dose reductions and higher hospitalisation rates. Myelopoietic growth factor support reduces myelosuppression and the associated risk of severe infection, thereby allowing delivery of chemotherapy at full dose intensity. Beneficial responses to granulocyte colony-stimulating factor (G-CSF; filgrastim) in elderly patients have been found in aggressive non-Hodgkin's lymphoma with standard cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) therapy and acute myeloid leukaemia (AML) during induction and consolidation chemotherapy. Granulocyte-macrophage colony-stimulating factor (GM-CSF; sargramostim) has been found to reduce myelosuppression in elderly AML patients receiving induction but not consolidation chemotherapy. These prophylactic treatments produce significant cost benefits because of the reduced hospitalisation and antibiotic use associated with neutropenia. To maximise positive outcomes, elderly patients should be included in clinical trials of new cancer agents. Since myelosuppression is the main risk factor for elderly patients undergoing chemotherapy, optimisation of growth factor support and the development of more effective and safer myelopoietic agents may improve success rates and reduce adverse events. Such information will lead to better management of cancer in older patients.

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.

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.

Diffuse large cell lymphoma

A review of new or emerging ideas concerning diffuse large B-cell lymphomas is presented, with particular emphasis on histologic classification, genetic prognostic factors, first-line and salvage treatments, and specific locations such as neurologic, cutaneous, or gastrointestinal sites. This lymphoma remains the most heterogeneous of all lymphomas for its clinical characteristics and outcome. This heterogeneity is probably secondary to the fact that a large proportion of lymphomas seems to occur from a transformation of an unknown indolent lymphoma.