Abstract
Background:
Incidence of Diffuse Large B-Cell Lymphoma (DLBCL), one of the most common lymphoid malignancies worldwide, increases with age. With improving life expectancy, its incidence among the elderly population is predicted to rise further. Elderly patients pose unique challenges- multiple co-morbidities, variable life expectancy, poor social support systems, and increased risk of therapy-related toxicity. Management decisions in geriatric patients are usually based on data obtained in younger patients. R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone) is the standard chemotherapy for younger patients with DLBCL. Unfortunately, among the patients aged 80 or more, data on the use of R-CHOP and its comparison with other treatment regimens are meager. Also, new data on alternate chemotherapy regimens including R with Bendamustine (R-Benda) and R with low dose CHOP (R-miniCHOP) are emerging. Thus, there is a need for development and validation of treatment strategies for DLBCL in this patient population. Objective of this study is to provide a descriptive data including co-morbidity profile, chemotherapy regimen offered, tolerance of chemotherapy, and outcome of the treatment among the DLBCL patients aged 80 or more.
Methodology:
A retrospective chart review of 33 DLBCL patients (N) aged 80 or more treated in the last 4 years in a tertiary community hospital.
Results:
| . | Age . | Charlson Co-morbidity Index (CCI) . | Serum Lactate Dehydrogenase . | Serum Albumin . | Serum Beta2 Microglobulin . | Median Ki67 . |
|---|---|---|---|---|---|---|
| Valid N | 33 | 30 | 23 | 24 | 9 | 11 |
| Mean | 83.33 | 2.87 | 611.91 | 2.85 | 6.77 | 0.70 |
| Median | 83.00 | 2.00 | 302 | 2.95 | 4.85 | 0.75 |
| Standard Deviation | 5.50 | 1.94 | 1033.15 | 0.78 | 5.79 | 0.19 |
| Minimum | 69 | 0 | 84 | 1.60 | 1.90 | 0.40 |
| Maximum | 93 | 9 | 5038 | 4.20 | 19.70 | 0.95 |
| . | Age . | Charlson Co-morbidity Index (CCI) . | Serum Lactate Dehydrogenase . | Serum Albumin . | Serum Beta2 Microglobulin . | Median Ki67 . |
|---|---|---|---|---|---|---|
| Valid N | 33 | 30 | 23 | 24 | 9 | 11 |
| Mean | 83.33 | 2.87 | 611.91 | 2.85 | 6.77 | 0.70 |
| Median | 83.00 | 2.00 | 302 | 2.95 | 4.85 | 0.75 |
| Standard Deviation | 5.50 | 1.94 | 1033.15 | 0.78 | 5.79 | 0.19 |
| Minimum | 69 | 0 | 84 | 1.60 | 1.90 | 0.40 |
| Maximum | 93 | 9 | 5038 | 4.20 | 19.70 | 0.95 |
| . | ECOG Performance Score . | International Prognostic Index (IPI) . | BMI . | Hemoglobin . | Platelets . | WBC . | ANC . |
|---|---|---|---|---|---|---|---|
| Valid N | 25 | 16 | 8 | 31 | 30 | 31 | 28 |
| Mean | 2.16 | 2.56 | 25.70 | 11.58 | 240.73 | 8.73 | 5971 |
| Median | 2.00 | 3.00 | 25.95 | 11.60 | 201 | 8.20 | 5400 |
| Standard Deviation | 1.17 | 1.03 | 2.910 | 1.94 | 129.64 | 3.47 | 2935 |
| Minimum | 0 | 1 | 20.98 | 8.20 | 62 | 3.60 | 1400 |
| Maximum | 4 | 4 | 29.40 | 15.10 | 716 | 16.10 | 12800 |
| . | ECOG Performance Score . | International Prognostic Index (IPI) . | BMI . | Hemoglobin . | Platelets . | WBC . | ANC . |
|---|---|---|---|---|---|---|---|
| Valid N | 25 | 16 | 8 | 31 | 30 | 31 | 28 |
| Mean | 2.16 | 2.56 | 25.70 | 11.58 | 240.73 | 8.73 | 5971 |
| Median | 2.00 | 3.00 | 25.95 | 11.60 | 201 | 8.20 | 5400 |
| Standard Deviation | 1.17 | 1.03 | 2.910 | 1.94 | 129.64 | 3.47 | 2935 |
| Minimum | 0 | 1 | 20.98 | 8.20 | 62 | 3.60 | 1400 |
| Maximum | 4 | 4 | 29.40 | 15.10 | 716 | 16.10 | 12800 |
| . | Valid N . | Categories . | Percentage . |
|---|---|---|---|
| Sex | 33 | Male Female | 54.5 45.5 |
| Prior Malignancy | 33 | No Yes | 81.8 18.2 |
| Ann Arbor Staging | 22 | 1 2 3 4 | 22.7 18.2 22.7 36.4 |
| B symptoms | 29 | No Yes | 62.1 37.9 |
| Node Status | 33 | Nodal Extranodal Nodal and Extranodal | 6.1 42.4 51.5 |
| Chemotherapy offered | 28 | No Yes | 17.9 82.1 |
| Intent of Therapy | 20 | Curative Palliative | 85 15 |
| Chemotherapy regimen | 22 | R-miniCHOP R R-Bendamustine R-CHOP RCVP RCNOP | 22.7 9 18.18 36.36 9 4.54 |
| Adverse effect of Chemotherapy | 16 | No Yes | 18.75 81.25 |
| Hospital admission during Chemotherapy | 19 | No Yes | 47.36 52.63 |
| Growth factors required during Chemotherapy | 20 | No Yes | 25 75 |
| Dose delay | 17 | No Yes | 70.58 29.42 |
| Dose modification | 17 | No Yes | 64.70 35.29 |
| Chemotherapy stopped prior to completion | 18 | No Yes | 66.67 33.33 |
| Radiation therapy | 19 | No Yes | 52.63 47.36 |
| Result of chemotherapy | 15 | Complete Response (CR) Partial Response (PR) Progression | 40 40 20 |
| Relapse | 7 | No Yes | 57.14 42.85 |
| Death | 10 | No Yes | 20 80 |
| . | Valid N . | Categories . | Percentage . |
|---|---|---|---|
| Sex | 33 | Male Female | 54.5 45.5 |
| Prior Malignancy | 33 | No Yes | 81.8 18.2 |
| Ann Arbor Staging | 22 | 1 2 3 4 | 22.7 18.2 22.7 36.4 |
| B symptoms | 29 | No Yes | 62.1 37.9 |
| Node Status | 33 | Nodal Extranodal Nodal and Extranodal | 6.1 42.4 51.5 |
| Chemotherapy offered | 28 | No Yes | 17.9 82.1 |
| Intent of Therapy | 20 | Curative Palliative | 85 15 |
| Chemotherapy regimen | 22 | R-miniCHOP R R-Bendamustine R-CHOP RCVP RCNOP | 22.7 9 18.18 36.36 9 4.54 |
| Adverse effect of Chemotherapy | 16 | No Yes | 18.75 81.25 |
| Hospital admission during Chemotherapy | 19 | No Yes | 47.36 52.63 |
| Growth factors required during Chemotherapy | 20 | No Yes | 25 75 |
| Dose delay | 17 | No Yes | 70.58 29.42 |
| Dose modification | 17 | No Yes | 64.70 35.29 |
| Chemotherapy stopped prior to completion | 18 | No Yes | 66.67 33.33 |
| Radiation therapy | 19 | No Yes | 52.63 47.36 |
| Result of chemotherapy | 15 | Complete Response (CR) Partial Response (PR) Progression | 40 40 20 |
| Relapse | 7 | No Yes | 57.14 42.85 |
| Death | 10 | No Yes | 20 80 |
ANOVA was used for data analysis. A statistically significant difference in mean CCI between those who completed planned chemotherapy course (2.00) and those who did not (4.75) was observed (p= 0.017). Similarly, difference in the mean CCI among those achieving CR (2.00), PR (2.17) and Progression (7.00) was statistically significant (p= 0.005). There were significant differences in the mean pre-chemotherapy ECOG PS between those who completed planned chemotherapy course (1.27) vs. those who did not (2.75), (p= 0. 001) and those achieving CR (1.60), PR (1.00) and progression (3.00), (p=0.012). No significant association was found between CCI or pre-chemotherapy ECOG PS with various factors like type of chemotherapy offered, incidence of adverse effects, and dose delay/modification.
Conclusion:
Very elderly patients (≥80 years) with DLBCL having good ECOG PS or lower CCI are more likely to complete planned chemotherapy course and achieve remission. CCI might be a good marker for evaluation of co-morbidities in very elderly patients and could serve as a predictive tool for patient outcomes. We intend to analyze data of DLBCL patients aged 65 – 79 years and perform comparative study with existing cohort.
No relevant conflicts of interest to declare.
Author notes
Asterisk with author names denotes non-ASH members.
