Tolerance and Response to Initial Systemic Therapy In Older Patients with Follicular Lymphoma (FL): Observations From 186 Unselected Recent Cases In the Practices of US-Based Medical Oncologists (MOs).

Advanced-stage FL is generally considered incurable, but the disease often responds to systemic anticancer treatment (SAT). A number of factors influence the selection of a specific SAT, which must be administered judiciously to older patients, particularly those with known comorbidities. A paucity of information exists to document which SATs are chosen for this population in clinical practice and the resultant clinical outcomes. We attempted to address this issue by aggregating and examining clinical information on individual patients receiving initial treatment for FL.

US community-based MOs were recruited from a database of past participants in our CME activities to provide anonymous information on the presenting symptoms, diagnostic workup, treatment selection, side effects and clinical antitumor responses for all patients in their practices with a new diagnosis of FL since January 1, 2008. Modest, per-patient honoraria were provided to each MO for this work.

From April 14 to July 9, 2010, 38 MOs entered a total of 186 cases of FL into a web-based data bank (minimum 1 case, maximum 15, median 4.5). The median age was 66, with 45% under age 65, 26% from 65 to 74 and 29% age 75 and older. 53% of the patients were women.

42% of patients were minimally symptomatic or asymptomatic at diagnosis (Table 1), and across each of the three age groups the presence of various symptomology was similar. A number of SATs were initiated, including R-CHOP (26%), RCVP (25%), and rituximab monotherapy (13%). 15% of patients were observed without SAT. For patients first treated in 2010, an increase in the use of bendamustine/rituximab was observed, representing 8 of 26 patients (31%) versus 3 out of 80 patients (4%) in 2009. The choice of regimen differed by age, with, for example, more R-CHOP (37%) used for patients under age 65 and more R-CVP (38%) and rituximab monotherapy (28%) selected for patients age 75 and older. Overall, these treatments resulted in complete clinical responses in 57% of patients and “things went very well with expected or fewer toxicities” in 58%. These outcomes are similar to what has been reported in published data from randomized Phase III trials of these regimens. No major differences were observed in the levels of efficacy and side effects between the three age groups (Table 1).

This unselected case series produced, in a rapid manner, information addressing a variety of clinical issues in newly diagnosed FL, including the impact of age on treatment selection and resultant outcomes. These data suggest that MOs are able to individualize SATs for older patients and match the short-term outcomes and tolerability of the therapies selected for younger patients. This risk-benefit differential is of particular palliative importance as this dataset demonstrates a majority of patients present with clinically significant tumor-related symptoms at diagnosis. Additional work of this kind is needed to better understand how physicians adjust the dose and schedule of SATs to prevent and ameliorate toxicity, particularly in older patients.

Gregory:Cephalon Inc: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen Inc: Consultancy; Genentech BioOncology: Consultancy, Speakers Bureau; Novartis Pharmaceuticals: Consultancy; Spectrum Pharmaceuticals: Consultancy. Cheson:Celgene Corporation: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Cephalon Inc: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees; Millenium Pharmaceuticals Inc: Membership on an entity's Board of Directors or advisory committees; Pfizer Inc: Membership on an entity's Board of Directors or advisory committees. Czuczman:Amgen Inc: Membership on an entity's Board of Directors or advisory committees; Biogen Idec: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; Cephalon Inc: Membership on an entity's Board of Directors or advisory committees; Genentech BioOncology: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees; Lilly USA LLC: Membership on an entity's Board of Directors or advisory committees; Millenium Pharmaceuticals Inc: Membership on an entity's Board of Directors or advisory committees; Novartis Pharmaceuticals Corporation: Membership on an entity's Board of Directors or advisory committees.