Initial treatment of elderly population with aggressive lymphoma: a narrative review of current evidence and future directions

Background and Objective: Diffuse large B-cell lymphoma (DLBCL), a subtype of non-Hodgkin lymphomas (NHL), is commonly diagnosed in older individuals, and its mortality directly correlates with age. Despite recent advancements in treatment modalities for DLBCL, there is no universally accepted approach for elderly patients. R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) has remained the core therapy for decades but has higher toxicity and lower cure rates in the senior subgroup. This review article discusses the strategies for frailty assessment and subcategorization of the elderly population based on multidomain assessment tools. Further, it outlines potential regimens for the initial treatment of DLBCL based on different levels of frailty. Methods: We conducted a thorough literature review via PubMed and Google Scholars databases to identify the most relevant articles on our subject. Publication dates or languages did not limit our search methodology. Key Content and Findings: The older population is a heterogeneous group with different degrees of frailty and diminished functional reserve. Coexisting comorbidities in the elderly create additional management challenges. The lack of a global and comprehensive functionality assessment guideline is an area of unmet need. Despite these challenges, R-CHOP, or R-CHOP with modified components, and other chemoimmunotherapy regimens that were investigated as frontline therapies in elderly DLBCL have resulted in promising outcomes, particularly if the investigators carefully subcategorized the studied population using multidomain functionality assessment guidelines and consistently followed up with the patients. Conclusions: R-CHOP is still considered the best initial treatment for the senior population 60–80 years old, but with careful genetic and functionality classifications. We recommend attenuated and modified versions of R-CHOP, such as R-miniCHOP, as an alternative option for the fit elderly over >80 years. For elderly patients with cardiac co-morbidities, R-CEOP (substituting doxorubicin with etoposide in R-CHOP) has proven to have curative potential. For fit, unfit, and frail, very elderly DLBCL patients ( ≥ 85 and mostly ≥ 90 years), initial treatment options remain challenging, and patients may be best served with a palliative approach. 13 doxorubicin patients received across all cycles. The study investigated the influence of IDI and RDI with factors including age, Eastern Cooperative Oncology Group performance status (ECOG PS), CIRS-G score, lactate dehydrogenase (LDH), tumor bulkiness, hemoglobulin level, and albumin on outcomes for DLBCL patients years. each