Treatment of diffuse large B-cell lymphoma in the elderly: regimens without anthracyclines are common and not futile

2024 Update: Advances in the risk stratification and management of large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease with varying clinical outcomes. Our understanding of its molecular makeup continues to improve risk stratification, and artificial-intelligence and ctDNA-based analyses have the potential to enhance risk assessment and disease monitoring. R-CHOP and Pola-R-CHP are used in the frontline setting; chimeric antigen receptor therapy (CART) is now the new standard-of-care for most with primary refractory disease; both CART and autologous stem cell transplantation are utilized in the relapsed and refractory setting. In this review, we summarize the classification and management of DLBCL with an emphasis on recent advances in the field.

Diffuse Large B-Cell Lymphoma (DLBCL): Early Patient Management and Emerging Treatment Options

Diffuse large B-cell lymphoma (DLBCL) represents a curable disease with a 60-70% chance of cure with current R-CHOP chemoimmunotherapy. However, 30-40% of patients are refractory or relapsing. Many attempts failed to improve the outcome of DLBCL patients, including the intensification of R-CHOP regimen, consolidation, or maintenance therapy since the introduction of R-CHOP in 2000. Better understanding of both molecular biology of lymphoma cells and the tumor microenvironment raised the hope for future improvement of DLBCL patients' survival. Novel molecular findings have initiated clinical trials exploring targeted therapy based on driver genetic alterations with an intent to improve survival of high-risk subsets of patients. But the preliminary results remain ambiguous. The approach "agnostic" to specific molecular alterations of lymphoma cell includes antibody-drug conjugates (especially polatuzumab vedotin), immunotherapy comprising different antibodies with immunomodulatory effect (tafasitamab, lenalidomide), and T-cell engaging therapy (bispecific antibodies, early use of CAR T-cell). This approach could increase the cure rates and change the current therapeutic paradigm. However, better prognostic stratification, smarter designs of clinical trials, modification of endpoints including the use of ctDNA are needed. This review covers the complexity of DLBCL management.

How I treat cardiovascular complications in patients with lymphoid malignancies

The prognosis of several lymphoid malignancies has improved through development of novel therapies, combination with traditional chemotherapies, and delineation of appropriate therapeutic sequencing. Toxicities that are arising because of prolonged or multiple sequential therapeutic interventions are becoming increasingly impactful. Among the broad spectrum of complications that patients with lymphoid malignancies may experience, cardiovascular toxicities are significant in terms of morbidity and mortality. The entire cardiovascular system can be affected, but cardiomyopathy, heart failure, and arrhythmias remain of greatest concerns with the use of anthracyclines, hematopoietic stem cell transplantation, and radiation therapy in patients with lymphoid malignancies. These aspects will be covered in this article within the framework of case-based discussions. Key to the management of cardiovascular complications in patients with lymphoid malignancies is awareness and preparedness across the cancer continuum. Baseline risk stratification helps to direct surveillance and early intervention efforts before, during, and after cancer therapy, which are paramount for the best possible outcomes. Along these lines, the overall goal is to enable the best possible therapies for lymphoid malignancies without the complications of clinically significant cardiovascular events.

The use of frailty assessments in treating older adults with aggressive lymphomas

Non-Hodgkin lymphomas (NHL) are most commonly diagnosed among people aged 65-74 years, with a median age at diagnosis of 67 years. The percentage of NHL-related deaths is highest among people aged 75-84 years, with a median age at death of 76 years from cases between 2014 and 2018. In light of these recent data, attending physicians of patients with NHL will recognize that the majority of their patients will be of advanced age, with many suffering from a spectrum of frailties. The excess rate of death among older adults with NHL may be related to a range of different factors such as more challenging biologic features, undertreatment received due to a patient's chronology and treatment-related toxicity. The aim of this review is to provide an updated overview of the knowledge generated over recent years regarding epidemiology, prognosis and treatment options in older adults with lymphoma, focusing on Diffuse Large B-cell Lymphoma (DLBCL) where the most robust evidence base is available.

Diffuse Large B-Cell Lymphoma in the Elderly: Current Approaches

PURPOSE OF REVIEW

Older patients with diffuse large B-cell lymphoma (DLBCL) may face challenges in treatment due to comorbidities and tolerance of chemotherapy.

RECENT FINDINGS

Older patients are at increased risk for treatment-related toxicity if they are unfit or frail by comprehensive geriatric assessment (CGA); however, treatment with non-anthracycline chemotherapy is associated with inferior outcomes in fit and unfit patients. Many older patients remain curable with standard R-CHOP chemotherapy. Careful assessment of frailty, function, and comorbidities using CGA may aid clinicians in initial therapy choices.

Frontline treatments in extremely elderly patients with diffuse large B-cell lymphoma: a population-based study in Taiwan, 2010-2015

Background

The standard frontline therapy for patients with diffuse large B cell lymphoma (DLBCL) is R-CHOP. However, patients older than 80 years are excluded from clinical trials. The importance of rituximab and anthracycline remains unknown in extremely elderly DLBCL patients. Here, we incorporated data from the Taiwan Cancer Registry Database (TCRD), National Health Insurance Research Database (NHIRD), and National Death Registry to evaluate the clinical benefits of rituximab and anthracycline in elderly patients. From the TCRD and NHIRD, we included DLBCL patients aged older than 60 years who received R-CHOP, R-CVP, CHOP, or CVP between 2010 and 2015.

Results

Of the 3228 eligible patients, 2559 were between 60 and 79 years (the 60–79 group), and 669 were older than 80 years (the 80+ group). The proportions of patients in the different Ann Arbor stages and the practice settings were similar in both groups. The male-to-female ratio and the Charlson comorbidity index (CCI) scores in the 80+ group were higher than those in the 60–79 group. Patients in the 60–79 group received R-CHOP more frequently than those in the 80+ group. In the 60–79 group, the median age of the patients receiving R-CVP or CVP was older than those receiving R-CHOP or CHOP. In the analysis of overall survival (OS) and time to treatment failure (TTF), R-CHOP, female sex, younger age, lower Ann Arbor stage, lower CCI score, and care at a medical center predicted a favorable prognosis in the 60–79 group. However, only R-CHOP, younger age, and lower Ann Arbor stage remained independent favorable prognostic factors in the 80+ group.

Conclusions

Our population-based study demonstrated the clinical benefits of rituximab and anthracycline in extremely elderly Asian patients with DLBCL.

Is bendamustine-rituximab a reasonable treatment in selected older patients with diffuse large B cell lymphoma? Results from a multicentre, retrospective study

Despite bendamustine-rituximab (BR) showed disappointing efficacy in diffuse large B cell lymphoma (DLBCL), it is still occasionally used as first-line treatment in older DLBCL patients instead of recommended R-CHOP. This multicentre, retrospective study was aimed to clarify circumstances in which BR may be justified in this setting. Patients ≥ 65 years with ECOG performance status (PS) ≥ 2 or ≥ 75 years regardless of PS were included. A total of 140 patients were analysed (BR, 68; R-CHOP, 72). BR patients were older (p < 0.001) and were diagnosed more often with high-risk disease (p = 0.03); no difference regarding comorbidities or PS was seen. Compared with R-CHOP, BR was associated with marked inferior overall survival (OS) (16.3 vs. 75.4 months; p = 0.006) and progression-free survival (PFS) (11.0 vs. 62.3 months; p < 0.001). In multivariate analysis, only high age-adjusted Charlson Comorbidity Index (aaCCI) was associated with inferior PFS in R-CHOP patients (hazard ratio 2.67; p = 0.012). Comparing the subgroup of BR and R-CHOP patients with high aaCCI, there was no difference in OS (p = 0.73) or PFS (p = 0.75). Due to the observed non-superiority of R-CHOP in older DLBCL patients with comorbidities, we propose that this subgroup may be treated alternatively with BR, whereas all other older patients are clearly R-CHOP candidates.

Treatment approaches for older and oldest patients with diffuse large B-cell lymphoma - Use of non-R-CHOP alternative therapies and impact of comorbidities on treatment choices and outcome: A Humedica database retrospective cohort analysis, 2007-2015

INTRODUCTION

We characterized real-world treatment patterns in older (65-74 years) and oldest (75-85 years) patients with diffuse large B-cell lymphoma (DLBCL) receiving initial therapy (R-CHOP, non-R-CHOP regimens). Impact of comorbidities on treatment choice, and overall and progression-free survival (OS, PFS) were assessed by age.

PATIENTS AND METHODS

Using the Humedica database, we identified 1436 newly diagnosed patients with DLBCL who received frontline therapy from 1/07-9/15. The 885 patients ≥65 years of age were further evaluated for baseline demographics, comorbidities, initial therapy, and PFS/OS.

RESULTS

Of 885 patients, 406 (45.9%) were age 65-74, and 479 (54.1%) age 75-85, years. First line therapy was R-CHOP (61.8%) or non-R-CHOP (38.2%). Although Charlson Comorbidity Index (CCI) scores were similar at baseline, congestive heart failure and myocardial infarction were more common in those receiving non-R-CHOP regimens. Survival outcomes were superior for those receiving initial R-CHOP, versus non-R-CHOP, therapy (median PFS 53.9 versus 27.8 months; two-year PFS 71.2% versus 51.6%, p < .0001; median OS not reached versus 45 months; two-year OS 81.3% versus 62.9%, p < .0001, respectively). Only 10.4% (R-CHOP) and 12.1% (non-R-CHOP) of patients received second line therapies. Two-year OS by age (65-74, 75-85 years) was 66.4% and 39.1%, respectively with R-CHOP (p = .0045), and 74.3% and 54.5%, respectively with non-R-CHOP (p = .004), therapy. Age ≥ 75 years and CCI of 2+ were associated with shorter OS and PFS.

CONCLUSIONS

This study identified real-world first line treatment patterns for older patients with DLBCL. Our findings support the feasibility of administering standard R-CHOP therapy, even to oldest patients with DLBCL.

The Use of Optimal Treatment for DLBCL Is Improving in All Age Groups and Is a Key Factor in Overall Survival, but Non-Clinical Factors Influence Treatment

Introduction: Diffuse large B cell lymphoma (DLBCL) is an aggressive form of non-Hodgkin lymphoma for which a cure is usually the therapeutic goal of optimal treatment. Using a large population-based cohort we sought to examine the factors associated with optimal DLBCL treatment and survival. Methods: DLBCL cases were identified through the population-based Victorian Cancer Registry, capturing new diagnoses for two time periods: 2008–2009 and 2012–2013. Treatment was pre-emptively classified as ‘optimal’ or ‘suboptimal’, according to compliance with current treatment guidelines. Univariable and multivariable logistic regression models were fitted to determine factors associated with treatment and survival. Results: Altogether, 1442 DLBCL cases were included. Based on multivariable analysis, delivery of optimal treatment was less likely for those aged ≥80 years (p < 0.001), women (p = 0.012), those with medical comorbidity (p < 0.001), those treated in a non-metropolitan hospital (p = 0.02) and those who were ex-smokers (p = 0.02). Delivery of optimal treatment increased between 2008–2009 and the 2012–2013 (from 60% to 79%, p < 0.001). Delivery of optimal treatment was independently associated with a lower risk of death (hazard ratio (HR) = 0.60 (95% confidence interval (CI) 0.45–0.81), p = 0.001). Conclusion: Delivery of optimal treatment for DLBCL is associated with hospital location and category, highlighting possible demographic variation in treatment patterns. Together with an increase in the proportion of patients receiving optimal treatment in the more recent time period, this suggests that treatment decisions in DLBCL may be subject to non-clinical influences, which may have implications when evaluating equity of treatment access. The positive association with survival emphasizes the importance of delivering optimal treatment in DLBCL.

A population-based multistate model for diffuse large B-cell lymphoma-specific mortality in older patients

BACKGROUND

Despite effective therapies, outcomes for diffuse large B-cell lymphoma (DLCBL) remain heterogeneous in older individuals due to comorbid diseases and variations in disease biology.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, the authors conducted a multistate survival analysis of 11,780 patients with DLBCL who were aged ≥65 years at the time of diagnosis (2002-2009). Cox proportional hazards models were used to specify the impact of prognostic factors on overall survival and cause-specific deaths, and the Aalen-Johansen estimator was used to project the course of DLBCL over time with or without standard therapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP).

RESULTS

Advanced age (hazard ratio [HR] for ages 71-75 years: 1.25; HR for ages 76-80 years: 1.46; HR for ages 81-85 years: 1.88; and HR for age ≥86 years: 2.26), DLBCL stage (HR for Ann Arbor stage II: 1.28; HR for stage III: 1.54; and HR for stage IV: 1.95), Charlson Comorbidity Index (CCI) ≥1 (HR for CCI of 1, 1.15; and HR for CCI >1, 1.37), and not being married (HR, 1.12) were associated with an increased risk of DLBCL-specific death. Being female (HR, 0.91) and of higher socioeconomic status (HR, 0.91) were associated with a lower risk of DLBCL-related mortality after therapy. For patients treated with R-CHOP (3610 patients), the risk of death due to DLBCL was 14.0% and 18.6%, respectively, at 2 and 5 years of treatment and plateaued afterward, confirming a 5-year "cure" point while receiving R-CHOP among older patients.

CONCLUSIONS

Conducting a survival analysis over a large data set, the current study evaluated competing risks for death within a multistate modeling framework, and identified age, sex, and CCI as risk factors for DLBCL-specific and other causes of death.

Evaluation of treatment patterns and survival among patients with diffuse large B-cell lymphoma in the USA

AIM

To evaluate treatment patterns of diffuse large B-cell lymphoma (DLBCL).

PATIENTS & METHODS

First-line and relapsed/refractory treatment patterns and survival outcomes following first-line therapy in adult patients newly diagnosed with DLBCL were evaluated.

RESULTS

A total of 1436 DLBCL patients initiated treatment and mainly received a combination regimen versus monotherapy (92.1 vs 7.9%). Patients who received monotherapy were older with more comorbidities and had shorter progression-free survival than patients receiving combination therapy (median: 31.3 vs 55.8 months). In the second-line setting (n = 164), rituximab-based combination regimens were most common; 25% underwent stem cell transplantation, and were younger with fewer comorbidities.

CONCLUSION

These results illustrate the need for new treatment options for patients unable to tolerate initial combination therapy and transplant-ineligible patients who require salvage therapy.

Primary testicular lymphoma: A SEER analysis of 1,169 cases

Primary testicular lymphoma (PTL) is a rare lymphoid malignancy. The present retrospective study aimed to investigate the demographic characteristics and survival of patients with PTL, as well as the associated prognostic factors, using a population-based database. All adults diagnosed with PTL in the Surveillance, Epidemiology, and End Results database were identified between 1973 and 2013. The Kaplan-Meier method was used to estimate cause-specific survival (CSS). Log-rank test or multivariate Cox regression model was used to assess the influence of demographic and clinical parameters on CSS. A total of 1,169 patients with PTL were identified from the database, and the median age was 70 years. The predominant histological subtype was diffuse large B-cell lymphoma, which affected 82.9% (970/1,169) of patients, and 68.6% (802/1,169) of patients had early stage disease (stages I–II). Patients >70 years, those diagnosed at the earlier time period, or those who had advanced-stage symptoms had the worst 5-year CSS rates; however, treatment with rituximab significantly improved the 5-year CSS. In conclusion, this retrospective study presented data from the largest cohort of patients with PTL and described the effects of rituximab on the CSS of patients with PTL.

A Case Report of Nongerminal Center B-Cell Type Diffuse Large B-Cell Lymphoma Treated to Complete Response with Rituximab and Ibrutinib

Diffuse large B-cell lymphoma (DLBCL) is a molecularly heterogeneous disease consisting of different subtypes with varying clinical behaviors. For example, the activated B-cell-like (ABC) type of DLBCL has lower cure rates with traditional chemotherapy regimens. The molecular pathway promoting tumorigenic growth of the ABC type includes a dependence on intracellular signaling by Bruton's agammaglobulinemia tyrosine kinase (BTK). This specific pathway has led to the investigation of the utility of ibrutinib in treatment of this type of lymphoma at relapse or in combination with standard chemotherapy. In elderly patients stricken with this disease, standard combination chemotherapy can pose significant toxicity. Some reduced intensity regimens have activity but significantly less favorable long-term outcomes and still pose significant toxicity to elderly patients. In the following case, we demonstrate induction of complete response in an elderly patient with significant comorbidities with nongerminal center B-cell type (NGCB) DLBCL treated with rituximab, ibrutinib, and prednisone. Toxicity included atrial fibrillation that ultimately led to heart failure as well as sepsis which ultimately led to the patient's demise. Despite this fact, the response to treatment appeared durable. This case illustrates the utility and limitations of molecularly targeted therapies to treat aggressive lymphoma in frail elderly patients.

Role of anthracycline and comprehensive geriatric assessment for elderly patients with diffuse large B-cell lymphoma

Survival outcome for elderly patients with newly diagnosed diffuse large B-cell lymphoma remains suboptimal in the rituximab era. In this systematic review, we summarize available evidence relevant to the inclusion of anthracycline in upfront chemoimmunotherapy for these elderly patients and highlight the need of prospective clinical trials. With limited prospective data, we find that pretreatment comprehensive geriatric assessment accurately predicts survival and treatment-related toxicities, suggesting its potential role in guiding overall treatment decision-making.

Predictors of Chemotherapy Related Toxicities in Elderly Lymphoma Patients: Experience from a Tertiary Cancer Centre

Identification of baseline parameters that predict chemotherapy related morbidities in elderly lymphoma patients can help in tailoring treatment. However, there is a paucity of tools to predict the risk of chemotherapy related toxicity in elderly lymphoma patients from India. We retrospectively analyzed 203 lymphoma patients more than 60 years of age for predictors of grade III or higher haematological and non-haematological toxicity due to chemotherapy. Eighty-five (42%) and seventy-one (35%) lymphoma patients developed grade III or IV haematological and non-haematological toxicities respectively. On multivariate analysis baseline absolute lymphocyte counts (ALC) less than 1300/µl, chemotherapy with anthracyclines and presence of two co-morbid conditions were significant in predicting serious haematological toxicities. For non-haematological toxicities baseline ALT levels more than 40 U/l was the only significant factor. This is the first report from India on the study of factors predicting serious chemotherapy related adverse effects in elderly lymphoma patients. Patients with low ALC, elevated ALT, multiple co-morbidities and receiving anthracyclines should be closely monitored for chemotherapy related toxicities.

Role of radiation therapy in primary mediastinal large B-cell lymphoma in rituximab era: A US population-based analysis

The use of radiation (RT) in primary mediastinal large B-cell lymphoma (PMBCL) may predispose young patients to the risk of cardiopulmonary toxicities and secondary malignancies. We used Surveillance, Epidemiology and End Results (SEER) 18 database to compare the overall survival (OS) differences among adult patients treated with and without RT after rituximab approval in the US. Multivariate analyses were performed using Cox proportional hazards regression to compare OS based on the use of RT while adjusting for age, year of diagnosis, race, stage and gender. PMBCL patients (n = 258), who received RT (48%), were similar in terms of age, gender, race, and stage at diagnosis to patients who did not receive RT. The five year OS was similar between patients treated with versus without RT (82.5% vs. 78.6%, P = 0.47). In a multivariate analysis, the use of RT did not influence OS in the rituximab era (HR 0.83; 95% CI 0.43-1.59; P = 0.56). Rituximab may reduce the benefit of RT in select patients such as those who achieve a metabolic complete remission at the end of chemotherapy.

Efficacy and tolerability of anthracycline-based therapy in elderly patients with diffuse large B-cell lymphoma

INTRODUCTION

Although diffuse large B-cell lymphoma (DLBCL) can be cured with rituximab and anthracycline-based therapy, within the elderly population there are additional factors to consider in selecting a treatment regimen including comorbid conditions, decreased drug metabolism, decreased hematologic reserve, reduced performance status, and regimen-related toxicity.

PATIENTS AND METHODS

We performed a retrospective cohort analysis of patients with DLBCL aged ≥ 65 years at time of diagnosis treated with either an anthracycline-containing regimen (ACR; n = 59) or a non-ACR (n = 13) to assess factors that led to treatment selection, tolerability, and outcomes.

RESULTS

The mean age was 73 years in the ACR and 77 years in the non-ACR group (P = .009), and median left ventricular ejection fraction (LVEF) at diagnosis was 60% in the ACR group and 45% in the non-ACR group (P < .001). With an ACR, elderly DLBCL patients had a median overall survival of 28 months and a 2-year progression-free survival (PFS) of 64%. After an ACR, 14 patients [24%] (out of 59 total patients) had a decrease in LVEF, 7 patients [15%] (% is based off of those who we had the data collected, so this is out of 45 with this specific data) required a dose reduction of the anthracycline, and 15 patients [33%] (% is based off of those who we had the data collected, so this is out of 45 with this specific data) could not complete the regimen as planned. Hospitalization due to toxicity occurred in 20 patients [44%] (% is based off of those who we had the data collected, so this is out of 45 with data) of patients in the ACR group and 3 patients [75%] (% is based off of those who we had the data collected, so this is out of 4 with this specific data) in the non-ACR group, and was the only predictor of overall survival.

CONCLUSION

Results of this study suggest that elderly patients with DLBCL experience meaningful PFS with ACRs, but a third experience toxicity requiring therapy modification. Future studies should examine larger patient populations and define treatments with outcomes similar to ACR that also decrease toxicity and hospitalization in the elderly DLBCL population.

Factors that influence treatment decision-making in elderly DLBCL patients: a case vignette study

Elderly patients with diffuse large B-cell lymphoma (DLBCL) are frequently not treated with standard immunochemotherapy, and this influences survival negatively. The purpose of this study was to gain more insight into treatment decision-making by hematologists. Case vignettes concerning patients with DLBCL were presented to hematologists in the Netherlands. Patient characteristics (age, comorbidity) differed per case. Respondents were asked in each case if they would treat the patient with curative intent by means of full-dose chemotherapy or chemotherapy with dose reduction or if they would not treat the patient with curative intent. The vast majority of respondents would treat an elderly patient diagnosed with DLBCL without a relevant medical history with full-dose chemotherapy irrespective of age. In the presence of comorbidity, lack of social support, cognitive disorders, and untreated depression dose reductions in advance are frequently applied or patients are not treated with curative intent. This is most pronounced for patients aged older than 80 years. Respondents working in a university hospital more frequently refrain form full-dose chemotherapy with curative intent compared to respondents working in tertiary medical teaching hospitals or general hospitals. Patients without a relevant medical history are generally treated with curative intent irrespective of age. Cognitive disorders, comorbidity, and depression reduce the change of being treated with curative intent. This is most prominent in the eldest patient category.

Disease characteristics, patterns of care, and survival in very elderly patients with diffuse large B-cell lymphoma

BACKGROUND

Although the combination of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is considered standard therapy for diffuse large B-cell lymphoma (DLBCL), patterns of use and the impact of R-CHOP on survival in patients aged >80 years are less clear.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to characterize presentation, treatment, and survival patterns in patients with DLBCL who were diagnosed between 2002 and 2009. Chi-square tests compared characteristics and initial treatments among patients with DLBCL who were aged >80 years and ≤80 years. Multivariable logistic regression models examined factors associated with treatment selection in patients aged >80 years; standard and propensity score-adjusted multivariable Cox proportional hazards models examined relationships between treatment regimen, treatment duration, and survival.

RESULTS

Among 4635 patients with DLBCL, 1156 (25%) were aged >80 years. Patients aged >80 years were less likely to receive R-CHOP and more likely to be observed or receive the combination of rituximab, cyclophosphamide, vincristine, and prednisone (P<.0001 for both). Marital status, stage of disease, disease site, performance status, radiotherapy, and growth factor support were associated with initial R-CHOP in patients aged >80 years. In propensity score-matched multivariable Cox proportional hazards models examining relationships between treatment regimen and survival, R-CHOP was the only regimen found to be associated with improved overall survival (hazard ratio, 0.45; 95% confidence interval, 0.33-0.62) and lymphoma-related survival (hazard ratio, 0.58; 95% confidence interval, 0.38-0.88).

CONCLUSIONS

Although patients with DLBCL who were aged >80 years were less likely to receive R-CHOP, this regimen conferred the longest survival and should be considered for this population. Further studies are needed to characterize the impact of treatment of DLBCL on quality of life among patients in this age group.