Optimal Length of Treatment of Non-Hodgkin Lymphoma Debated

August 2011 Vol 4, No 4, Special Issue
Caroline Helwick

Several studies addressed key questions in the treatment of non- Hodgkin lymphoma (NHL). One evaluated a shorter, more intense rituximab (Rituxan)-based regimen, and another evaluated the benefit of autologous stem-cell transplantation (ASCT) in high-risk patients. The 21-day regimen of R-CHOP (rituximab plus cyclophosphamide, doxorubicin [Adriamycin], vincristine [Oncovin], and prednisolone) is still the standard of care for this patient population.

Rituximab revolutionized the care of NHL and is essentially part of the treatment for all patients with this disease, but researchers continue to evaluate various schedules for delivering the drug.

One debate during ASCO 2011 has focused on whether the standard 21- day regimen can be shortened to 14 days; however, investigators from the United Kingdom reported no advantage with the 14-day regimen.

This randomized phase 3 trial involved 1080 patients with diffuse large B-cell NHL, all of whom were to receive R-CHOP. Treatment-naïve pa - tients were randomly assigned to receive either 8 cycles of R-CHOP for 21 days or 6 cycles of R-CHOP for 14 days plus granulocyte colony-stimulating factors, succeeded by 2 cycles of single-agent rituximab.

David Cunningham, MDAfter a median follow-up of 37 months, the rates of overall survival (OS) and progression-free survival (PFS) were similar, as were objective re - sponse rates, reported David Cunningham, MD, of the Royal Marsden Hospital, who presented the results for the UK National Cancer Research Institute Lymphoma Clinical Study Group.

No subgroup appeared to derive a greater benefit from accelerated RCHOP. Neutropenia and febrile neutropenia were more frequent in patients receiving the 21-day regimen, probably because the 14-day group received growth factors, although thrombocytopenia was more frequent with R-CHOP-14, probably because of greater dose intensity. According to Dr Cunningham, the results do not support a shift in clinical practice from R-CHOP-21 to R-CHOP-14.

Transplant Improves Outcomes in High-Grade Aggressive NHL

Julie M. Vose, MD, of the University of Nebraska Medical Center, Omaha, discussed the UK trial’s findings and agreed. But she added that in Julie M. Vose, MDyounger patients at high risk for recurrence, R-CHOP-21, followed by autologous transplantation of peripheral stem cells, should be offered as a standard of care.

This strategy was shown to be effective in the phase 3 intergroup SWOG S9704 trial of 253 patients with NHL that was presented at the meeting by Patrick J. Stiff, MD, of Loyola University Medical Center, Chicago.

ASCT after CHOP-based induction therapy improved PFS in patients who had an aggressive form of the disease, as indicated by their high or highintermediate International Prog nostic Index score.

Patients responding to CHOP, with or without rituximab, had a 2-year PFS rate of 69% with ASCT compared with 56% with the induction therapy alone, which translates to a 72% increase in PFS (P = .005).

The 2-year OS rates were similar between the 2 groups, at 74% and 71%, respectively; however, many patients in the control arm underwent a salvage transplant, which may have confused this analysis, Dr Stiff pointed out. The survival benefit was most apparent in patients with high Interna tional Prognostic Index scores for whom the 2-year PFS rate was 75% with transplant compared with 41% with standard care and the 2-year OS rates were 82% and 64%, respectively.

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