Annals of Oncology Advance Access originally published online on May 21, 2008
Annals of Oncology 2008 19(7):1359-1360; doi:10.1093/annonc/mdn355
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letters to the editor |
Comment on: ‘Non-Hodgkin's lymphoma in very elderly patients over 80 years. A descriptive analysis of clinical presentation and outcome’
We read with interest the article by Thieblemont et al. [1] focusing on a descriptive analysis of clinical presentation and outcome in very elderly patients >80 years with non-Hodgkin's lymphoma (NHL). In their report, 28 of 205 assessable patients (13.7%) were included in a clinical trial. We would like to stress these findings, reporting here our experience in 25 patients with high-grade NHL, age >80 years, treated with chemotherapy as a subgroup within a Non-Hodgkin's Lymphoma Cooperative Study Group trial.Twenty-five previously untreated very elderly patients received a combination chemotherapy specifically deviced for patients with aggressive NHL and age >70 years. In particular, they were enrolled as part of a multiinstitutional phase II study evaluating the MVP-BV regimen: mitoxantrone 8 mg/m2 i.v. on day 1, VP16 90 mg/m2 i.v. on day 1 and 200 mg p.o. on days 2–3, prednisone 37.5 mg/m2 p.o. on days 1–8, bleomycin 10 mg/m2 (maximum 15) on day 8, vincristine 1 mg/m2 (maximum 1.5) on day 8, recycling on day 22. All drugs were delivered in an outpatient basis and six cycles per patient were planned. All patients had to have adequate renal, hepatic and haematological functions to be entered in the study. They had signed informed consent and the study was approved by local review board.
The patient’s characteristics are shown in Table 1. Median age was 82 years (range 80–91). The median number of administered cycles was 6 (range 1–6) and the number of delivered cycles was 118 over 150 planned (78.6%). All patients entered on study were assessable for response and toxicity. Objective response was seen in 17 of 25 patients (68%). A complete remission was observed in 13 patients (52%) and four (16%) patients obtained a partial remission. The overall survival was 25 months. After a median follow-up of 17 months, 11 patients were alive and nine of them in complete remission.
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Severe (grades 3–4) toxicity was as follows: leucopenia in five patients (20%), neutropenia in five (20%), anemia in one (4%), thrombocytopenia in two (8%), infection in three (12%), mucositis in two (8%), cardiac in one (4%) and neurological in one (4%). Four patients died during chemotherapy. In particular, two patients died of a documented bacteraemia, one patient of a cerebral incident and one of pulmonary embolism.
As Thieblemont et al. [1] outlined, it is assumed that very elderly patients, i.e. older than 80 years, are more difficult to get on treatment, requiring a specific management. Most of the studies, however, have focused on patients aged between 60 and 80 years with diffuse large B-cell lymphoma. Although our study was designed for patients with >70 years of age, we observed encouraging results in terms of objective response and survival also in the subgroup of patients with 80 years or more.
Thieblemont et al., as reported in the discussion section, found a majority of women (60%) and they outlined that this is in agreement with the distribution of male/female in the overall population >80 years, but not in the NHL population where men are predominant. We found this characteristic at presentation also in our study. In particular, 17 (68%) of patients were female. We agree with the authors when they affirm that another concern is the psychological approach of very elderly patients. In particular, in this setting, we also firmly believe in the protective role that the patient's family play and in the usefulness of an integrated approach with the physician for a better understanding and a better compliance to the treatment. In our experience, whenever possible and indicated, we aimed at involving the patient's family on the occasion of signature of the provided informed consent and later during treatment. Enrolment of very elderly patients in a clinical study is difficult, but not impossible. Without family consensus and support and without adequate home nursing and medical care after chemotherapy administered in hospital, these patients cannot be safely entered in a clinical trial.
In the setting of clinical trials investigating the efficacy and feasibility of various regimens in very elderly NHL patients, the MVP–VB combination chemotherapy with neither anthracycline nor alkylating agents seems effective as first-line treatment and feasible in an outpatient basis with manageable toxicity.
At present, in everyday practice, haematologists and medical oncologists see only a few patients with NHL and age >80 years. In the future, with the progressive increase in life expectancy, there will be a greater incidence of NHL and it will probably be considered as one of various disease requiring possible treatment.
1 Division of Medical Oncolgy, Ospedale Civile, Vittorio Veneto, Treviso, Italy
2 Division of Medical Oncology, Istituto Oncologico Veneto (IOV) IRCCS, Padova, Italy
* (E-mail: domenico.errante{at}ulss7.it)
References
1. Thieblemont C, Grossoeuvre A, Houot R, et al. Non-Hodgkin's lymphoma in very elderly patients over 80 years. A descriptive analysis of clinical presentation and outcome. Ann Oncol (2008) 19:774–779.
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