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Garg M, Puckett J, Kamal-Bahl S, Raut M, Ryland KE, Doshi JA, Huntington SF. Real-World Survival, Healthcare Resource Utilization, and Costs Among U.S. Elderly Patients With Diffuse Large B-Cell Lymphoma (DLBCL) Treated With R-GemOx in the Relapsed/Refractory Setting. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00054-5. [PMID: 38433043 DOI: 10.1016/j.clml.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Little recent real-world evidence exists on overall survival, healthcare resource utilization (HCRU), and costs among R/R DLBCL patients treated with the combination of rituximab, gemcitabine, and oxaliplatin (R-GemOx), a widely-used regimen for patients ineligible for stem cell transplant due to age or comorbidities. PATIENTS AND METHODS This retrospective analysis used 2014 to 2019 U.S. Medicare claims. Individuals aged ≥66 years with a new DLBCL diagnosis between October 1, 2015 and December 31, 2018 and continuous fee-for-service Medicare Part A, B, and D coverage in the 12 months pre- and postindex were followed to identify the sample of patients with evidence of R-GemOx treatment in the second-line (2L) or third-line (3L) setting. Outcomes included overall survival, all-cause and DLBCL-related HCRU, and costs after R-GemOx initiation. RESULTS The final sample included 157 patients who received treatment with R-GemOx in the R/R settings (mean (SD) age 77.5 (6.0) years, 39.5% age>80 years; 66.9% male; 91.1% White). Of these, 126 received R-GemOx in the 2L setting and 31 received R-GemOx in the 3L setting. Median overall survival from R-GemOx initiation was 6.9 months and 6.8 months in the 2L and 3L setting, respectively. Rates of all-cause hospitalization (68.1% [2L] and >90% [3L]) and hospice use (42.9% [2L] and 51.7% [3L]) were high in the 12 months after R-GemOx initiation. All-cause total costs were substantial ($144,653 [2L] and $142,812 [3L]) and approximately 80% of costs were DLBCL-related within 12 months of R-GemOx initiation. CONCLUSION Elderly U.S. Medicare beneficiaries diagnosed with DLBCL who initiated R-GemOx treatment in the R/R setting have poor overall survival, high rates of HCRU, and substantial costs.
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Affiliation(s)
| | | | | | | | | | - Jalpa A Doshi
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT
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Huntington SF, Hoag JR, Zhu W, Wang R, Zeidan AM, Giri S, Podoltsev NA, Gore SD, Ma X, Gross CP, Davidoff AJ. Oncologist volume and outcomes in older adults diagnosed with diffuse large B cell lymphoma. Cancer 2018; 124:4211-4220. [PMID: 30216436 DOI: 10.1002/cncr.31688] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/21/2018] [Accepted: 06/26/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although provider-level volume is frequently associated with outcomes in cancers requiring complex surgeries, whether similar relations exist for cancers treated primarily with systemic therapy is unknown. METHODS Using a population-based cohort analysis of older adults diagnosed with diffuse large B cell lymphoma (DLBCL) during the years 2004-2011, we evaluated the association between oncologist volume and 4 clinical outcomes (receipt of any chemotherapy, receipt of an anthracycline-containing or equivalent regimen, early hospitalization, and overall survival). Our primary explanatory variable was lymphoma treatment volume, defined as the number of patients with newly diagnosed lymphoma for which an oncologist initiated therapy during a 12-month look-back period from each incident DLBCL case. RESULTS We identified 8247 Medicare beneficiaries who were newly diagnosed with DLBCL. Chemotherapy was administered to 6202 (75.2%) beneficiaries, and 71.4% of cytotoxic regimens contained an anthracycline. Beneficiaries who were treated by higher-volume oncologists had increased odds of receiving chemotherapy (adjusted odds ratio [aOR], 1.45; 95% confidence interval [CI], 1.24-1.70; P <.001) and of receiving an anthracycline-containing regimen (aOR, 1.26; 95% CI, 1.06-1.50; P = .009). Receiving care from a higher-volume provider was also associated with decreased hospitalization (aOR, 0.80; 95% CI, 0.69-0.95; P = .007) and improved survival (adjusted hazard ratio, 0.85; 95% CI, 0.79-0.92; P < .001). CONCLUSION In older adults diagnosed with DLBCL, receiving care from a provider with more experience treating lymphoma patients was associated with receipt of guideline-adherent therapy, reduced hospitalizations, and improved survival. Clinical volume may be an important factor in providing high-quality cancer care in the modern era.
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Affiliation(s)
- Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Jessica R Hoag
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Weiwei Zhu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Smith Giri
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Nikolai A Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut
| | - Steven D Gore
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, Connecticut
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Ricciuti G, Finolezzi E, Luciani S, Ranucci E, Federico M, Di Nicola M, Zecca IAL, Angrilli F. Combination of rituximab and nonpegylated liposomal doxorubicin (R-NPLD) as front-line therapy for aggressive non-Hodgkin lymphoma (NHL) in patients 80 years of age or older: a single-center retrospective study. Hematol Oncol 2017; 36:44-48. [DOI: 10.1002/hon.2386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/28/2016] [Accepted: 01/08/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Giuseppina Ricciuti
- Center for the Diagnosis and Treatment of Lymphomas, Department of Hematology, Transfusion Medicine and Biotechnology; Spirito Santo Hospital; Pescara Italy
| | - Erica Finolezzi
- Center for the Diagnosis and Treatment of Lymphomas, Department of Hematology, Transfusion Medicine and Biotechnology; Spirito Santo Hospital; Pescara Italy
| | - Stefania Luciani
- Center for the Diagnosis and Treatment of Lymphomas, Department of Hematology, Transfusion Medicine and Biotechnology; Spirito Santo Hospital; Pescara Italy
| | - Elena Ranucci
- Center for the Diagnosis and Treatment of Lymphomas, Department of Hematology, Transfusion Medicine and Biotechnology; Spirito Santo Hospital; Pescara Italy
| | | | - Marta Di Nicola
- Department of Medical, Oral and Biotechnological Sciences; “G. D'Annunzio” University; Chieti Italy
| | - Isaia Antonio Luca Zecca
- Department of Medical, Oral and Biotechnological Sciences; “G. D'Annunzio” University; Chieti Italy
| | - Francesco Angrilli
- Center for the Diagnosis and Treatment of Lymphomas, Department of Hematology, Transfusion Medicine and Biotechnology; Spirito Santo Hospital; Pescara Italy
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Ha H, Keam B, Kim TM, Jeon YK, Lee SH, Kim DW, Kim CW, Heo DS. Reduced Dose Intensities of Doxorubicin in Elderly Patients with DLBCL in Rituximab Era. Cancer Res Treat 2015; 48:304-11. [PMID: 25865654 PMCID: PMC4720063 DOI: 10.4143/crt.2014.339] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/11/2015] [Indexed: 12/22/2022] Open
Abstract
Purpose The dose intensity of doxorubicin (DID) is important to the survival of diffuse large B cell lymphoma (DLBCL) patients. However, due to expected toxicities, most elderly patients cannot receive full doses of anthracyclines. The purpose of this study was to evaluate the effect of DID on the survival of elderly DLBCL patients (age ≥ 70 years) in the rituximab era. Materials and Methods We analyzed 433 DLBCL patients who were treated with R-CHOP between December 2003 and October 2011 at the Seoul National University Hospital. Of these patients, 19.2% were aged ≥ 70 years. We analyzed the survival outcomes according to DID. Results Significantly poorer overall survival (OS) was observed for patients aged ≥ 70 years (2-year OS rate: 59.9% vs. 84.2%; p < 0.001). DID ≤ 10 mg/m2/wk had a significant effect on the OS and progression-free survival (PFS) in elderly patients (2-year OS rate: 40.0% in DID ≤ 10 mg/m2/wk vs. 62.6% in DID > 10 mg/m2/wk; p=0.031; 2-year PFS: 35.0% vs. 65.7%; p=0.036). The OS on each 1.7 mg/m2/wk doxorubicin increment above 10 mg/m2/wk in elderly patients was not significant among the groups (2-year OS rate: 75.0% in DID 10.0-11.7 mg/m2/wk vs. 66.7% in DID 15.0-16.7 mg/m2/wk; p=0.859). Treatment related mortality was not related to DID. Conclusion DID can be reduced up to 10 mg/m2/wk in elderly DLBCL patients in the rituximab era. Maintenance of DID > 10 mg/m2/wk and judicious selection of elderly patients who are tolerant to DID is necessary.
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Affiliation(s)
- Hyerim Ha
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Min Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon Kyung Jeon
- Department of Pathology, Seoul National University Hospital Seoul, Korea
| | - Se-Hoon Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Wan Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Chul Woo Kim
- Department of Pathology, Seoul National University Hospital Seoul, Korea
| | - Dae Seog Heo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea ; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Terret C, Albrand G, Rainfray M, Soubeyran P. Impact of comorbidities on the treatment of non-Hodgkin’s lymphoma: a systematic review. Expert Rev Hematol 2015; 8:329-41. [DOI: 10.1586/17474086.2015.1024650] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kreher S, Lammer F, Augustin D, Pezzutto A, Baldus CD. R-split-CHOP chemotherapy for elderly patients with diffuse large B-cell lymphoma. Eur J Haematol 2014; 93:70-6. [PMID: 24612334 DOI: 10.1111/ejh.12304] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2014] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Stephan Kreher
- Department of Hematology, Oncology and Tumor Immunology, Charite Universitätsmedizin Berlin, Berlin, Germany
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What determines therapeutic choices for elderly patients with DLBCL? Clinical findings of a multicenter study in Portugal. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:370-9. [PMID: 24629852 DOI: 10.1016/j.clml.2014.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/15/2014] [Accepted: 01/23/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Age is a negative prognostic factor in lymphomas, and elderly patients are often undertreated because of toxicity concerns. The pattern of treatment in elderly patients with diffuse large B-cell lymphoma (DLBCL) in Portugal has not been previously described. PATIENTS AND METHODS We conducted a multicenter retrospective study including 378 elderly patients with DLBCL receiving alkylating agent-containing regimens between 2003 and 2010. We compared the outcome of patients aged 60 to 79 years with patients > 79 years and analyzed the second group according to treatment. RESULTS R-CHOP (rituximab, cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisolone) was prescribed in only 60% of patients and was prescribed significantly less in patients > 79 years, despite no significant differences being found in comorbidities between the 2 age groups. Similarly, dose reductions frequently were instituted because of chronologic age and not always because of toxicity. When different regimens were compared, multivariate analysis showed an independent beneficial effect of R-CHOP in treatment outcomes. Additionally, treatment with anthracyclines and rituximab predicted a better progression-free survival (PFS) and time to progression (TTP) in patients > 79 years. CONCLUSION This was the first characterization of the clinical care of elderly Portuguese patients with DLBCL. We showed that R-CHOP is effective even in patients > 79 years, emphasizing that treatment decisions based on age alone can compromise treatment efficacy and outcome in fit patients.
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Link BK. Chemo-immunotherapy dosing in older patients with diffuse large B-cell lymphoma: is this how we should treat our parents? Leuk Lymphoma 2012; 53:1435-6. [DOI: 10.3109/10428194.2012.672737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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