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More on Lymphoma Treatment in the Elderly: Results from Korea
Abstract & Commentary
Synopsis: In a series from Korea, treatment outcomes for older (age older than 60 years) patients with diffuse large-cell lymphoma were analyzed with particular focus on dose intensity of doxorubicin. Although, overall, older patients did not achieve the same level of complete response, for those who were able to maintain doxorubicin dose intensity, response rates were comparable to younger patients.
Source: Lee KW, et al. Cancer. 2003;98:2651-2656.
Lymphoma occurs more commonly in older patients, and there remains some controversy about response rates and survival for patients in this age group. In recent years there has been an emphasis on chemotherapy dose intensity, and it has been speculated that the difference in treatment responses is due to the delivered dose and not an a priore increased resistance of lymphoma in older patients to treatment. In examining this question, Lee and colleagues from Seoul National University Hospital in the Republic of Korea retrospectively examined the course of 195 patients with diffuse large-cell lymphoma treated at their institution. Of these, 70 were considered "elderly" (aged 60 years or older). All patients were treated with doxorubicin-based chemotherapy (CHOP—cyclophosphamide, doxorubicin, vincristine, and prednisone; or COPBLAM-V—cyclophosphamide, vincristine, bleomycin, doxorubicin, procarbazine and prednisone).
Overall, elderly patients had poorer treatment outcomes than did young patients (5-year survival, 30% vs 57%; P < .001). However, elderly patients who received doxorubicin at dose intensities of > 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 = .022) and dose intensity of doxorubicin (P = .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 dose reductions to less than 10 mg/m2/wk were analyzed, it was found that 20 patients received reduced doses from the start of treatment because of their old age alone.
Comment by William B. Ershler, MD
This analysis highlights an important concept in the explanation for the observed reduced response rates and survival for elderly patients treated for lymphoma. When treated equally, older patients fare as well as younger in parameters such as response rate and survival. However, there is, without question, increased susceptibility to certain adverse consequences of therapy, most notably marrow cytopenias. Accordingly, there remains reluctance among some providers to use full-dose chemotherapy (or even chemotherapy at all) for fear of the risks of neutropenia. In the era of aggressive supportive management, such reluctance may be overcome. Primary, prophylactic marrow stimulatory factor support has become common practice in the treatment of at-risk populations, including the elderly, and current ASCO, EORTC and NCCN guidelines support such an approach.1 Yet, it is noteworthy that a recent European report did not demonstrate improved outcomes in elderly patients treated with up-front G-CSF. Thus, although it seems a logical approach, further investigation is required before older lymphoma patients should routinely be treated with growth factors coincident with their first exposure to chemotherapy.
Dr. Ershler is from Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC.