Frontline treatment of diffuse large B-cell lymphoma in elderly: a systematic review of clinical trials in post-rituximab era

Abstract

Treatment of diffuse large B cell lymphoma (DLBCL) remains challenging in elderly population and systematic reviews are lacking in this area. Medline and Cochrane Register of Controlled Trials in addition to conference proceedings were searched for therapeutic clinical trials on frontline treatment of DLBCL in adults ≥60 in post-rituximab era. Forty-one out of 713 reviewed papers met our inclusion criteria. Six cycles of rituximab, cyclophosphamide, vincristine, prednisone (R-CHOP) administered every 21 d remain the standard treatment for fit elderly, with no role for maintenance rituximab. For individuals ≥80, the strongest evidence favors rituximab/ofatumumab-miniCHOP. Numerous alternative approaches including the use of liposomal anthracyclines, dose and regimen adjustment to frailty/comorbidity score, brief duration regimens, and consolidative radioimmunotherapy have produced promising outcomes and could be considered for R-CHOP inappropriate elderly. Phase III randomized trials studying the efficacy of liposomal vincristine, extended-exposure rituximab, and lenalidomide plus R-CHOP are ongoing.

Diffuse large B‐cell lymphoma: a consensus practice statement from the Australasian Lymphoma Alliance

“…For fit older patients aged <80 years, six cycles of R-CHOP21 is suggested with supportive measures as listed below, and geriatric assessment tools may assist in determining fitness. 77 For patients aged >80 years or those unfit for full dose R-CHOP21, R-mini-CHOP is a reasonable option with a reported 2-year OS and PFS of 59% and 47% respectively. 78 For unfit or frail patients regimens such as R-GCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, prednisolone), 79 R-mini-CEOP (with epirubicin) 80 or R-CEEP (rituximab, cyclophosphamide, epirubicin, etoposide, prednisolone) 81 can be considered.…”

“…For fit older patients aged <80 years, six cycles of R‐CHOP21 is suggested with supportive measures as listed below, and geriatric assessment tools may assist in determining fitness 77 . For patients aged >80 years or those unfit for full dose R‐CHOP21, R‐mini‐CHOP is a reasonable option with a reported 2‐year OS and PFS of 59% and 47% respectively 78 .…”

“… The use of a geriatric assessment tool is recommended to guide treatment choice in elderly DLBCL patients (IV, C) Pre‐phase prednisone is recommended in elderly patients (III‐2, B) 83 Prophylactic Granulocyte colony stimulating factor is recommended for all cycles of therapy (III, B) 84 Vitamin D supplementation should be considered in deficient patients (IV, C) 85–87 For fit older patients, six cycles of R‐CHOP21 is recommended with the above supportive measures (I, A) 77 For patients aged >80 years or those unfit for R‐CHOP21, R‐mini‐CHOP is a reasonable option (III‐2, B) Abbreviated therapy (3–4 cycles of R‐CHOP) plus ISRT can be considered in elderly patients with limited stage, non‐bulky disease (II‐B) …”

Impact of therapeutic management and geriatric evaluation on patient of eighty years and older with diffuse large B‐cell lymphoma on survival: A systematic review

“…To our knowledge, this systematic review of the literature in We recognize that this review has limitations, as we could only identify six prospective studies, and we chose to include retrospective studies, studies with small sample size which may lack power and subgroup studies at risk of selections bias. And it is true that given the heterogeneity of the studies reviewed, reaching a conclusion is difficult, but we believe that in this population, given the paucity of randomized clinical trials, 78 their inclusion has provided significant information and could help guiding future prospective studies.…”