Comprehensive geriatric assessment is useful in an elderly Australian population with diffuse large B‐cell lymphoma receiving rituximab‐chemotherapy combinations

Abstract

Elderly patients may be heterogeneous in their abilities to tolerate immunochemotherapy-associated toxicities. We describe the morbidity of rituximab-chemotherapy combinations among 205 newly-diagnosed diffuse large B-cell lymphoma (DLBCL) patients aged ≥60 years from 3 tertiary hospitals between 2009 and 2016, and explore the utility of retrospectivelyassigned baseline Comprehensive Geriatric Assessment (CGA) in predicting these toxicities. Seventy-three percent (146/201) experienced grade ≥3 toxicities, 81% (163/201) needed admission, 52% (107/205) had ≥2 unplanned admissions, 82/201 (41%) required dose reductions (DR) subsequent to Cycle 1, 39/166 (23%) had chemotherapy delays and 26/198 (13%) ceased therapy early. CGA was associated with pre-emptive baseline DR and perhaps because of this, did not predict grade ≥3 toxicities, ≥2 unplanned admissions or subsequent DR. Three-year overall survival (OS) of CGA-fit, CGA-unfit and CGA-frail patients was 82%, 60% and 53%, respectively. Three-year progression-free survival (PFS) of CGA-fit, CGA-unfit and CGA-frail patients was 66%, 58% and 46%, respectively. OS of CGA-fit patients was not statistically different from CGA-unfit patients, but was superior to CGA-frail patients (hazard ratio 2Á892, 95% confidence interval 1Á275-6Á559, P = 0Á011). PFS differences were not statistically significant. Baseline DR and early therapy cessation were associated with inferior OS and PFS independent of CGA. Prospective studies are needed to confirm if CGA-adapted treatment strategies minimize morbidity and improves survival.

Outcome and determinants of failure to complete primary R‐CHOP treatment for reasons other than non‐response among patients with diffuse large B‐cell lymphoma

“…In this study, patients who did not complete planned cycles of R‐CHOP presented with an inferior prognostic setting at diagnosis, with advanced age, poor PS scores and a slightly larger proportion of patients with elevated LDH, extranodal disease and stage IV disease, thus primarily representing an older, frail population of DLBCL patients with advanced disease. This is in line with results from a recent study assessing the use of comprehensive geriatric assessment for DLBCL patients where 20% of patients deemed frail ended treatment prematurely, compared to only 9% among patients classed as fit 24 . Old age, poor performance status, presence of comorbidity and extranodal disease all increased the odds of not completing treatment.…”

Geriatric assessment in older patients with a hematologic malignancy: a systematic review

“…The association of geriatric impairments with the ability to complete the proposed treatment was studied in five studies. 25,32,36,38,45 Four out of five studies found an association between geriatric impairments and treatment completion. The risk of treatment non-completion was significantly higher in frail patients (based on a summarized geriatric assessment score or frailty screening tool) than in fit patients.…”

“…The median sample size of the studies was 100 (range, 25-869), and the me(di)an age of included patients ranged from 58 to 86 years. Eight studies focused on acute myeloid leukemia and/or myelodysplastic syndromes, [19][20][21][22][23][24][25]27 two on chronic lymphocytic leukemia, 28,29 13 on lymphoma, [30][31][32][33][34][35][36][37][38][39][40][41][42] seven on multiple myeloma, [42][43][44][45][46][47][48] and 15 studies included various hematologic malignancies. [49][50][51][52][53][54][55][56][57][58][59][60][61][62][63] The median number of domains addressed in the geriatric assessment was four (range, 2-9).…”

“…Overall, the duration of follow-up was sufficient but in nine studies the followup rate was less than 90% 24,30,46 or the adequacy of followup was not reported. 27,32,33,56,57,62 There were no other quality concerns.…”

“…Ten studies assessed geriatric impairments in relation to treatment-related toxicity. 28,29,[32][33][34]37,45,48,55,59 Four out of six studies in which frailty was assessed (based on a summarized geriatric assessment score) reported an association between frailty and treatment-related toxicity. 33,34,45,48 This included hematologic toxicity in one study, 33 non-hematologic toxicity in two studies 45,48 and overall toxicity in one study.…”