Treating newly diagnosed Diffuse Large B-cell Lymphoma in the elderly patient with R-mini-CHOP: A single centre analytical retrospective observational study.

Abstract

Introduction: Diffuse large B-cell lymphoma (DLBCL) forms the bulk of non-Hodgkin lymphoma (NHL) cases encountered in clinical practice among the elderly. For the majority of cases of DLBCL, treatment comprising of Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone (R-CHOP) is suggested as first line chemotherapy. However, chemotherapy in the elderly population may be hampered by multiple factors, including reduced bone marrow reserves, significant comorbidities, and greater side effects from chemotherapy. Treatment as such aims to offer disease control and prolong life whilst minimising treatment related complications in this group of patients. Treatment with R-mini-CHOP, a reduced dose form of R-CHOP offers survival benefits and is recommended for treatment of elderly DLBCL patients and those who are frail. Our study examined local Malaysian experience of treating the newly diagnosed elderly DLBCL patient with R-mini- CHOP.

Materials and methods: We retrieved retrospective data of all DLBCL patients aged >65 years old from the electronic medical records in Pusat Perubatan Universiti Malaya who received R-mini-CHOP. Treatment response was assessed by the overall response rate (ORR), defined as the proportion of patients attaining complete and partial remission after six cycles of treatment. We excluded patients with transformed lymphomas and relapsed refractory disease. For secondary analysis, we examined patients' treatment response according to their baseline demographic characteristics, development of complications during therapy as well as their survival in months from diagnosis.

Results: Our study identified 33 patients in the period of January 2017 till June 2023. The mean age of the sample cohort was 78 years old (Range from 66 to 86 years old). Majority of the samples had advanced stage lymphoma at initial diagnosis with n=21/33 (63.6%) having stage III and IV disease. At the end of treatment, one patient did not have assessment scans and hence was excluded from analysis. n=16/32 patients (50.0%) had attained ORR when analysed by intention to treat, n=14/32 (43.7%) attained complete response and n=2/32 (6.25%) attained partial response. When analysed for treatment response, those who attained ORR were more likely to have Stage 1 or 2 disease (p value = 0.028) and had statistically significant increased progression free survival (28.5 vs 5.5 months, p value <0.01) and overall survival (28.5 vs 9.0 months, p value = 0.03) compared to those who did not attain ORR. In terms of treatment associated complications, n=9/32 (28.1%) of patients developed severe infection necessitating hospitalization, n=14/32 (43.7%) developed at least Grade 2 and above cytopenias, and n=13/32 (41.6%) developed some other adverse side effects, most of which were mild to moderate in terms of severity.

Conclusion: The ORR for our patients treated with R-mini- CHOP was lower than other cohorts. We hypothesise that Rmini- CHOP alone may not offer adequate lymphoma control in our sample, especially for treatment of advanced stage DLBCL. Age alone is not an objective assessment of suitability for treatment; therefore, we suggest the use of geriatric prognostication tools to better ascertain patient groups who would benefit from full dose R-CHOP chemotherapy to improve response and survival.