R-miniCHOP versus R-CHOP in elderly patients with diffuse large B-cell lymphoma: A propensity matched population-based study

For elderly frail patients with diffuse large B-cell lymphoma (DLBCL), an attenuated chemo-immunotherapy strategy of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-miniCHOP) was introduced as a treatment option as from 2014 onward in the Netherlands. Although R-miniCHOP is more tolerable, reduction of chemotherapy could negatively affect survival compared to R-CHOP. The aim of this analysis was to assess survival of patients treated with R-miniCHOP compared to R-CHOP. DLBCL patients ≥65 years, newly diagnosed in 2014-2020, who received ≥1 cycle of R-miniCHOP or R-CHOP were identified in the Netherlands Cancer Registry, with survival follow-up through 2022. Patients were propensity-score-matched for baseline characteristics. Main endpoints were progression-free survival (PFS), overall survival (OS), and relative survival (RS). The use of R-miniCHOP in DLBCL increased from 2% in 2014 to 15% in 2020. In total, 384 patients treated with R-miniCHOP and 384 patients treated with R-CHOP were included for comparison (median age; 81 years, stage 3-4; 68%). The median number of R-(mini)CHOP cycles was 6 (range, 1-8). The 2-year PFS, OS and RS were inferior for patients treated with R-miniCHOP compared to R-CHOP (PFS 51% vs. 68%, p < .01; OS 60% vs. 75%, p < .01; RS 69% vs. 86%, p < .01). In multivariable analysis, patients treated with R-miniCHOP had higher risk of all-cause mortality compared to patients treated with R-CHOP (HR 1.73; 95%CI, 1.39-2.17). R-miniCHOP is effective for most elderly patients. Although survival is inferior compared to R-CHOP, the use of R-miniCHOP as initial treatment is increasing. Therefore, fitness needs to be carefully weighed in treatment selection.

Immunogenicity of the 13-Valent Pneumococcal Conjugated Vaccine Followed by the 23-Valent Polysaccharide Vaccine in Chronic Lymphocytic Leukemia

Patients with Chronic Lymphocytic Leukemia (CLL) have a 29- to 36-fold increased risk of invasive pneumococcal disease (IPD) compared to healthy adults. Therefore, most guidelines recommend vaccination with the 13-valent pneumococcal conjugated vaccine (PCV13) followed 2 months later by the 23-valent polysaccharide vaccine (PPSV23). Because both CLL as well as immunosuppressive treatment have been identified as major determinants of immunogenicity, we aimed to assess the vaccination schedule in untreated and treated CLL patients. We quantified pneumococcal IgG concentrations against five serotypes shared across both vaccines, and against four serotypes unique to PPSV23, before and eight weeks after vaccination. In this retrospective cohort study, we included 143 CLL patients, either treated (n = 38) or naive to treatment (n = 105). While antibody concentrations increased significantly after vaccination, the overall serologic response was low (10.5%), defined as a ≥4-fold antibody increase against ≥70% of the measured serotypes, and significantly influenced by treatment status and prior lymphocyte number. The serologic protection rate, defined as an antibody concentration of ≥1.3 µg/mL for ≥70% of serotypes, was 13% in untreated and 3% in treated CLL patients. Future research should focus on vaccine regimens with a higher immunogenic potential, such as multi-dose schedules with higher-valent T cell dependent conjugated vaccines.

Web-Based Return of Individual Patient-Reported Outcome Results Among Patients With Lymphoma: Randomized Controlled Trial

Background

There has been a cultural shift toward patient engagement in health, with a growing demand from patients to access their results.

Objective

The Lymphoma Intervention (LIVE) trial is conducted to examine the impact of return of individual patient-reported outcome (PRO) results and a web-based self-management intervention on psychological distress, self-management, satisfaction with information, and health care use in a population-based setting.

Methods

Return of PRO results included comparison with age- and sex-matched peers and was built into the Patient-Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship registry. The self-management intervention is an adaptation of a fully automated evidence-based intervention for breast cancer survivors. Patients with lymphoma who completed the web-based questionnaire were equally randomized to care as usual, return of PRO results, and return of PRO results plus self-management intervention. Patients completed questionnaires 9 to 18 months after diagnosis (T0; n=227), 4 months (T1; n=190), 12 months (T2; n=170), and 24 months (T3; n=98).

Results

Of all invited patients, 51.1% (456/892) responded and web-based participants (n=227) were randomly assigned to care as usual (n=76), return of PRO results (n=74), or return of PRO results and access to Living with lymphoma (n=77). Return of PRO results was viewed by 76.7% (115/150) of those with access. No statistically significant differences were observed for psychological distress, self-management, satisfaction with information provision, and health care use between patients who received PRO results and those who did not (P>.05). Use of the self-management intervention was low (2/76, 3%), and an effect could therefore not be determined.

Conclusions

Return of individual PRO results seems to meet patients’ wishes but had no beneficial effects on patient outcome. No negative effects were found when individual PRO results were disclosed, and the return of individual PRO results can therefore be safely implemented in daily clinical practice.

Trial Registration

Netherlands Trial Register NTR5953; https://www.trialregister.nl/trial/5790

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-017-1943-2

Sofosbuvir and Simeprevir for the Treatment of Recurrent Hepatitis C with Fibrosing Cholestatic Hepatitis after Liver Transplantation

Fibrosing cholestatic hepatitis (FCH) is an aggressive form of hepatitis C virus (HCV) recurrence after orthotopic liver transplantation (OLT), which frequently results in graft failure and death. Treatment of FCH remains challenging, and the optimal antiviral therapy is yet to be determined. Between November 2013 and early 2015, 62 patients with HCV cirrhosis underwent OLT at our transplant center, of whom, 5 patients developed recurrence HCV in the form of severe FCH and were treated with sofosbuvir and simeprevir (SOF-SMV) for 24 weeks. All patients achieved significant improvement of HCV viral load and had undetectable viral PCR at 6-8 week of treatment. The HCV RNA remained undetectable throughout treatment course. The first two patients achieved SVR at week 12 after completion of the treatment. There were significant histologic and biomarkers improvements after initiation of the treatment. One patient developed refractory pruritus and acute pancreatitis. The second, fourth and fifth patients had very benign treatment courses with no side effects recorded. The third patient was starting the treatment with multiple comorbid conditions. His course was complicated with hepatic artery thrombosis, and later developed sepsis and renal failure. Therefore, it seems that the combination of SOF-SMV is an efficacious oral regimen in OLT recipient with recurrent hepatitis C and FCH. However, safety profile needs to be carefully evaluated.

Health care utilization (HCU) by breast cancer (BC) and non-Hodgkin lymphoma (NHL) patients (pts) with chemotherapy (CT) induced febrile neutropenia (FN) in the Netherlands

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Background: CT-induced FN can result in reduced CT delivery, unplanned hospitalizations, and increased mortality risk. Changes in clinical practice warrant investigation of current resource use and economic cost of FN; therefore we studied FN-related HCU among BC and NHL pts. Methods: Data from incident adult cancer pts with a primary hospital discharge diagnosis for BC or NHL from 1998–2007 were obtained from the PHARMO Record Linkage System, including pharmacy, hospital and clinical lab data. Eligible pts had ≥12 months medical history available and received CT ≤6 months after cancer diagnosis. Pts developing FN ≤6 months after first CT (“FN pts”) were matched 1:2 on gender, birth year, and CT regimen to pts without FN (“non FN pts”). HCU data (hospitalizations, medical procedures, drug use [number dispensed]) was tallied from entry date (date of FN or matched date for non FN pts) for up to 3 months. Statistics are descriptive with crude odds ratios (OR). Results: 80/1,033 BC pts (8%) developed FN (all were matched). 95/486 NHL pts (20%) developed FN (89 were matched). More FN than non FN pts were hospitalized in the 1st month after the entry date: BC 73% vs 14% (OR=23.0 [95%CI 8.3-63.7]); NHL 78% vs 33% (OR=7.6 [3.9-15.1]). These differences were mainly due to FN-related hospitalizations (BC 55% vs 1%, NHL 47% vs 4%). FN pts also had a longer mean length of stay per all-cause hospitalization: BC 4.6 vs 1.9 days; NHL 10.1 vs 3.0 days. In the 1st month after entry date, the mean number of total drugs dispensed per patient was higher in FN pts than non FN pts (BC 5.8 vs 3.1, NHL 8.5 vs 3.6); use of anti-infectious agents was higher (BC 99% vs 11%, NHL 96% vs 20%), as was number of other non-CT drugs (including corticosteroids, drugs for acid related disorders, laxatives, psycholeptics, analgesics, antithrombotics, and diuretics). More FN than non FN pts had medical procedures (BC 14% vs 3%, NHL 13% vs 8%). HCU differences between FN and non FN pts were maintained after 3 months. Conclusions: This study confirms the high resource utilization currently associated with FN, based on BC and NHL pt data from the Netherlands. Reduction of FN may improve quality of life and save resources.