Treatment recommendations for elderly diffuse large B-cell lymphoma

This study reviewed treatment recommendations for elderly diffuse large B-cell lymphoma patients. 

Diffuse large B-cell lymphoma (DLBCL) is the most common form of NHL in older patients. Many of these patients are over the age of 65. Chemotherapy is the standard treatment option for DLBCL. Many chemotherapies cannot be tolerated by older patients due to other medical conditions and health issues.

Recently, the International Society for Geriatric Oncology (SIOG) gathered a panel of experts to make recommendations for the treatment of elderly DLBCL patients.

This study reviewed the SIOG recommendations.

The chemotherapy combination CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) has been the standard treatment for DLBCL for many years. This combination is less successful in older patients (over 75 years). The standard treatment has started to include rituximab (Rituxan) along with chemotherapy (R-CHOP). Rituximab is a treatment that binds to a protein on the cancer cell, leading to cell death. In one study, R-CHOP led to a complete response (no sign of disease) in 76% of patients 60 to 80 years old. This was compared to 63% with CHOP. Other trials have also noted improved outcomes with R-CHOP.

Alternative treatments have been explored for frail patients. These include lower-dose chemotherapy and a combination of bendamustine (Treanda) and rituximab. A small study noted a 69% response rate with this combination in the very elderly.

Radiation may be effective in patients with bulky disease (large tumor mass). In one trial, there were trends toward improved survival following radiation. However, it is not as effective in patients with smaller, non-bulky tumors. In these patients, the disease often recurs outside the areas treated with radiation.

Maintenance therapy is a long-term treatment to prevent recurrences. Maintenance with interferon (a treatment that boosts the immune response) was not found to be effective in older patients. Maintenance with rituximab improved time to disease recurrence combined with CHOP, but had no effect on overall survival (time from treatment until death from any cause).

Between 30% and 40% of patients will relapse or will not respond to treatment. When this happens, it is recommended that patients redo the testing used to stage the disease. Patients who have relapsed after more than 12 months have the best outcomes. For many, the goal shifts to disease and symptom control.

Stem cell (immature blood cell) transplantation (SCT) may be considered in some fit older patients. The general health and number of other medical conditions can help with this decision. However, transplant-related mortality is 1.6 times higher in patients over age 60. Those that can undergo SCT have long-term disease control rates of 48% to 59%. For other patients, rituximab or single-agent chemotherapy (such as lenalidomide) can help improve disease control.

Salvage (secondary) therapies must also be chosen based on overall health. Some treatments can lead to kidney or nerve problems. 

This study reviewed the SIOG treatment recommendations for elderly DLBCL patients.