How I treat elderly patients with diffuse large B-cell lymphoma

Enormous progress has been made in the treatment of diffuse large B-cell lymphoma (DLBCL), mostly due to the anti-CD20 antibody rituximab. More than 50% of elderly DLBCL patients can be expected to be cured by modern immunochemotherapy. The standard chemotherapy partner of rituximab is the CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen. Elderly patients need particular attention and thorough evaluation if they are suited for the standard treatment or if they are candidates for palliative treatment. Rigorous supportive care including anti-infectious prophylaxis and growth factor support are mandatory. Whether there is still a role of additive radiotherapy in the R-CHOP era is under debate. While further intensification of chemotherapy might hardly be feasible in elderly patients, dose and schedule of rituximab appear to be optimizable. Patients failing after R-CHOP are a particular challenge as are frail patients who are not fit enough for R-CHOP. Further progress can be expected from novel antibodies and small molecules that interfere with signal transduction pathways essential for the survival of the lymphoma cell. To achieve this goal, prospective trials with large numbers of patients are necessary for which the continuous commitment of patients and physicians is indispensable.

Prophylaxis of chemotherapy-induced febrile neutropenia with granulocyte colony-stimulating factors: where are we now?

Updated international guidelines published in 2006 have broadened the scope for the use of granulocyte colony-stimulating factor (G-CSF) in supporting delivery of myelosuppressive chemotherapy. G-CSF prophylaxis is now recommended when the overall risk of febrile neutropenia (FN) due to regimen and individual patient factors is ≥20%, for supporting dose-dense and dose-intense chemotherapy and to help maintain dose density where dose reductions have been shown to compromise outcomes. Indeed, there is now a large body of evidence for the efficacy of G-CSFs in supporting dose-dense chemotherapy. Predictive tools that can help target those patients who are most at risk of FN are now becoming available. Recent analyses have shown that, by reducing the risk of FN and chemotherapy dose delays and reductions, G-CSF prophylaxis can potentially enhance survival benefits in patients receiving chemotherapy in curative settings. Accumulating data from ‘real-world’ clinical practice settings indicate that patients often receive abbreviated courses of daily G-CSF and consequently obtain a reduced level of FN protection. A single dose of PEGylated G-CSF (pegfilgrastim) may provide a more effective, as well as a more convenient, alternative to daily G-CSF. Prospective studies are needed to validate the importance of delivering the full dose intensity of standard chemotherapy regimens, with G-CSF support where appropriate, across a range of settings. These studies should also incorporate prospective evaluation of risk stratification for neutropenia and its complications.