Examination of the Prognosis and Health-Related Quality of Life of Elderly Patients with Malignant Lymphoma

Introduction: As the population continues to advance in age, it is necessary to examine aggressive treatment for elderly patients with malignant lymphoma. However, chemotherapy can also reduce the health-related quality of life (QOL) in such patients. Therefore, we examined the impact of a change of treatment on elderly patients 80 years or older and their QOL.

Methods: We enrolled 39 elderly malignant lymphoma patients, aged 80 years or older (median age, 85 years), who were treated in our department between September 2007 and September 2014. We administered a questionnaire survey to assess the QOL in 19 cases using SF36. We re-administered the survey to about 11 cases one year after the initial examination. As controls, we selected 78 patients with malignant lymphoma who were younger than 80 years.

Results: The histological diagnosis was determined by lymph node biopsy in 34 cases, but in 5 cases, the diagnosis remained unknown because of the lack of superficial lymphadenopathy; in such cases the diagnosis was made using bone marrow, pleural effusion or ascitic fluid. Chemotherapy was administered to 34 patients. Eleven of 34 patients died; in ten patients the cause of death was recurrence or refractoriness to chemotherapy, and treatment-related death only occurred in one case. Eight patients exhibited partial response or greater after chemotherapy, but were lost to follow-up as they moved to a local care facility. With respect to the histological classification, there were 19 cases of diffuse large B-cell lymphoma (DLBCL), six cases of follicular, small lymphocytic, or mantle cell lymphoma, two cases of peripheral T-cell lymphoma, four cases of the high-grade group and three cases of Hodgkin's disease. We examined 18 cases of newly diagnosed DLBCL. Eleven cases were treated with dose-modified R-CHOP therapy, and five cases with R-miniCHOP therapy from 2012; two cases underwent palliative care. The International prognostic index (IPI) was High for nine cases, High-intermediate for four cases, Low-intermediate for four cases and Low for one case. The median duration of observation was 487 days, and the remission rate was 87%. The 2-year survival rate was 73%. Eight patients exhibited disease-free survival throughout the follow-up period, and 5 patients ultimately died. One of the fatalities was due to an infection as a consequence of small intestinal perforation after chemotherapy. After the chemotherapy was considered efficacious, six cases changed hospital to a local nursing facility, and were lost to follow-up. With respect to the QOL, while there was no apparent decrease in the social function compared with the patients who were younger than 80 years, physical function (PF) was impaired due to neuropathy (p=0.0006). Furthermore, after the chemotherapy, the mental component summary showed an upward trend for recovery of vitality and mental health (p=0.04), but the physical and role-social components remained impaired and were still below the normal-based scoring.

Discussion: Thirty-four of 39 elderly patients aged 80 years or older received chemotherapy, and only one case experienced a treatment-related death. However, after chemotherapy, several cases intended to change the hospital to local nursing facilities, and it was not possible to investigate the prognosis, including recurrence. We also reported cases for which agreement was not obtained with respect to invasive biopsies, i.e., an abdominal operation. While the patients were stable psychologically, there was a severe decrease of physical function with respect to the QOL. Chemotherapy-induced neuropathy is included among the causative processes, and we should weigh the choice of chemotherapeutic agents that do not contribute to severe neuropathy. With sufficient supportive care, the chemotherapy could be administered safely and would be anticipated to be efficacious. However, invasive biopsy indicated an impossible case, and decrease of physical function, due to side effects, lowered the QOL. It is anticipated that future clinical studies will consider these factors.