- 102: Annals of Oncology 2004, Aug 15 (8):1298
D. Bernardi*, A. Giacalone, M. Spina and U. Tirelli
Division of Medical Oncology A, National Cancer Institute, Centro di Riferimento Oncologico, Via Pedemontana Occidentale 12, 33081, Aviano (PN), Italy
Rituximab-CHOP or 2-weekly CHOP + G-CSF in aggressive lymphoma of the elderly?
We have read with interest the comment by Todeschini et al. [1], focusing on the best treatment for aggressive non-Hodgkin's lymphoma (NHL) in elderly patients: rituximab-CHOP (R-CHOP) or 2-weekly CHOP + G-CSF (CHOP-14). We agree with the authors that the two studies by Coiffier et al. [2] and Pfreundschuh et al. [3] represent important new achievements in the treatment of non-Hodgkin's lymphoma in elderly patients, but we think that there are some issues that should be raised. In our opinion, the best arguments for the use of R-CHOP for aggressive lymphomas in elderly patients come from one well-designed randomized phase III trial, which represents level 1 evidence according to ASCO guidelines [2], positive data from unplanned subgroup analysis of a phase III trial, i.e. level 2 evidence [4], positive data from one pre-post study, i.e. level 3 evidence [5], and positive data from a panel of experts [6]. Overall, evidence tends to show that R-CHOP is superior to CHOP in elderly patients with diffuse large B-cell lymphomas in terms of response, event-free survival and overall survival, with no significant increase in toxicity. Based on this evidence, some countries have decided to consider R-CHOP as standard treatment, even if it appears difficult to consider R-CHOP as standard until a confirmation trial is published. The data in favor of CHOP-14 are based only on one trial that, so far, has been repeatedly published only in an abstract form, with very few data on toxicity. We are waiting for the full paper to be published. Therefore, we think that it is too early to state that CHOP-14 can be considered a standard treatment. Nevertheless, some European groups, like HOVON and DSHNHL, chose CHOP-14 as a standard arm for their trials. In fact, a study from the Dutch group HOVON is ongoing, aimed at assessing in a randomized comparison the efficacy of rituximab combined with 2-weekly CHOP+G-CSF versus 2-weekly CHOP + G-CSF alone in patients older than 65 years, while the RICOVER-60 study by the DSHNHL is comparing CHOP-14 (six or eight cycles) + rituximab versus CHOP-14 (six or eight cycles) alone in patients aged 61–80 years. The results of these trials are also eagerly awaited.
On the other hand, we believe that a Comprehensive Geriatric Assessment (CGA) is crucial in the evaluation of this type of patient, and we strongly recommend that treatment should be CGA-driven, as we recently proposed in a new approach for elderly patients affected by NHL, allowing a patient-tailored treatment with the goal of maintaining a balance between the desire to cure the patient and guaranteeing a good quality of life [7]. This approach, based on a CGA including the ADL and IADL scales, is suitable and highly effective and it does not exclude any elderly patient from potentially curative chemotherapy. The value of CGA is also being prospectively investigated by the EORTC in two phase-II studies in elderly fit (EORTC protocol 20991) and frail (EORTC protocol 20992) patients.
References
1. Todeschini G, Gelio S, Tecchio C. Rituximab-CHOP or two-weekly CHOP + G-CSF in aggressive lymphoma of the elderly? Ann Oncol 2004; 15: 538–539.[Free Full Text]
2. Coiffier B, Lepage E, Brière J et al. CHOP chemotherapy plus Rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med 2002; 346: 235–242.[Abstract/Free Full Text]
3. Pfreundschuh M, Trümper L, Kloess M et al. Two-weekly Chop (CHOP-14): the new standard regimen for patients with aggressive non-Hodgkin's lymphoma (NHL). Ann Oncol 2002; 13 (Suppl 2): 27.
4. Habermann TM, Weller EA, Morrison VA et al. Phase III trial of rituximab-CHOP vs CHOP with a second randomisation to maintenance rituximab or observation in patients 60 years of age or older with diffuse large B-cell lymphoma. Blood 2003; 102: 8 (Abstr).
5. Sehn LH, Donaldson J, Chhanabhai M et al. Introduction of combined CHOP-rituximab therapy dramatically improved outcome of diffuse large B-cell lymphoma in British Columbia. Blood 2003; 102: 88 (Abstr).
6. Pettengell R, Lynch D. Position paper on the therapeutic use of rituximab in CD20-positive diffuse large B-cell lymphomas. Br J Haematol 2003; 121: 44–48.[CrossRef][Medline]
7. Bernardi D, Milan I, Balzarotti M et al. Comprehensive geriatric evaluation in elderly patients with lymphoma: feasibility of a patient-tailored treatment plan. J Clin Oncol 2003; 21: 754.[Free Full Text]