Treatment of elderly non-Hodgkin’s lymphoma patients

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Published: 1 Apr 2011
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Prof Pier Luigi Zinzani - University of Bologna, Italy and Prof Bertrand Coiffier - Hospices Civils de Lyon, France

Prof Pier Luigi Zinzani and Bertrand Coiffier speak about the challenges faced when treating elderly patients with non-Hodgkin’s lymphomas, specifically diffuse large B-cell lymphoma and follicular lymphoma.

The current standard of treatment for diffuse large B-cell lymphoma is R-CHOP, however this combination can only be tolerated by fitter elderly patients. Clinicians must decide if the patient is fit enough for the intensive curative treatment, and if they are not, should attempt to prolong survival and maximise patient quality of life.

Follicular lymphoma can only be cured in a small proportion of patients and treatment should be aimed at maximising patient quality of life. Profs Zinzani and Coiffier explain that doctors must first decide if to treat the patient or to use the ‘watch and wait’ approach, talk about the impact of maintenance therapy with rituximab and discuss the role low toxicity targeted treatments such as lenalidomide and bortezomib could play in the future of follicular lymphoma treatment.

Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Professor Pier Luigi Zinzani (University of Bologna, Italy) and Professor Bertrand Coiffier (Hospices Civils de Lyon, France)

Treatment of elderly non-Hodgkin’s lymphoma patients

Interviewed by Peter Goodwin

PG: Non-Hodgkin lymphoma is a very important issue being talked about here at the Blood Cancer in the Elderly meeting in Rome. Pier Luigi Zinzani from Bologna, you were one of the speakers at a big session here, and Professor Bertrand Coiffier, you’re also at the same session. I know that diffuse large B-cell lymphoma and follicular lymphoma are big topics, can we start with diffuse large B-cell lymphoma? With respect to older patients, what are the issues there?

BC: The problem in diffuse large cell lymphoma is that it is a curable disease and to cure a patient, the standard for this moment is R-CHOP, even if it’s not sufficient in all patients. The problem for elderly patients, if we speak of patients above 70 or above 80, that they have a lot of other diseases and it’s difficult in some of them to use the full dose of R-CHOP. So the problem is what type of treatment to use and what is the objective of the treatment – to cure or just to palliate, to have a long survival?

PG: What have cancer doctors been doing and what should they be doing?

BC: They are considering that these elderly patients are too old to be treated for cure, it’s not good. They should go for a cure in these patients and they may succeed in curing them so they may have ten, fifteen, twenty years more.

PG: Pier Luigi?

PLZ: Yes, I think the problem is to try to prolong the survival with a good quality of life. For diffuse large B-cell lymphoma, all of you know that the gold standard that Bertrand said before is CHOP plus Rituximab. The real problem is the second line when there is a relapse and in this case we are looking right now and in the last three or four years for new treatments, new target drugs with a low profile in terms of toxicity and with a good activity in terms of elderly patients’ treatment.

PG: From among your elderly patients, how many of them, and indeed which patients, can you treat with curative intent?

PLZ: It depends also by the performance status of the patients and so there are, at this time, several particular scores in terms of geriatric scoring in this case or you can divide the patients into fit and unfit patients for the treatment. Because the most part of patients with an age more than 70 or 75 are with several comorbidities so it’s sometimes so difficult. But in clinical trials, no more than 20-30% of the patients can be treated with a new treatment but the problem is that the daily treatment of the patients, this is very poor.

PG: And how do you recognise the patients who are good for treatment then?

BC: Yes and no. It’s easy to recognise patients if you have seen a lot of them, but there is no definitive characteristic.

PG: What about comorbidities?

BC: The best way to say is the standard is R-CHOP, so what might be the reason for this patient not to get the standard? So we recognise those contraindications to the full dose R-CHOP.

PG: And it’s the CHOP that may cause the toxicity?

BC: Yes, there are two reasons for that. It’s doxorubicin that has some cardiac toxicity and some of these patients already have cardiac problems. The other is that you observe after R-CHOP particularly in the elderly some neutropenia and infection related to neutropenia more frequently than in young patients.

PG: Can I ask both of you about follicular lymphoma because there have been a number of developments there, some of them quite encouraging. What is the problem, or what are the issues with treating older patients with follicular lymphoma.

PLZ: The efficacy of the follicular lymphoma in comparison with diffuse large B-cell lymphoma is it’s so difficult to cure this kind of subset of patient with the lymphoma. You can try to cure no more than 15-20% of the patients because it’s a really indolent disease. You can obtain a good complete response but in the most part of the patients there is a further relapse and then you can have another treatment and then another second relapse and so on. It’s very important not to try to cure the patient but to have a good quality of life with a long survival of the patient. So in this case it’s very important for follicular lymphoma with an age more than 60, 65 or 70 to have a new drug in terms also of maintaining the response during the time with a low toxicity.

PG: And again can you select patients on the basis of age?

BC: In follicular lymphoma the first question for a physician seeing this patient is should I treat this patient because watch and wait is particularly interesting in this population of elderly patients. So in the first question, should I begin a treatment or not, and then the second is which type of treatment and to try to have a good quality of life.

PG: What are the improvements recently that are relevant to patients who are older with follicular lymphoma?

BC: Recently in follicular lymphoma the improvement we have made is the introduction of maintenance therapy with rituximab alone for two years or more. I’m not sure this is a problem for elderly patients because here it’s not to treat to however long but it’s what is the best way for the patient to continue to have a good life, a good quality of life, and to live longer than treating, not treating and if you treat probably with low toxicity drugs like rituximab or other targeted drugs.

PG: So coming out of this conference here in Rome, what would both of you suggest are the practical messages, the ideas that doctors could take home and use to treat their patients more appropriately who are older?

BC: There are two messages, one for diffuse large B-cell lymphoma. The physician has to go for a cure and what are the reasons not to use R-CHOP? For follicular lymphoma the physician has to go for no cure and no treatment in a majority of the patients is the best way to do it.

PLZ: Yes, because sometimes in follicular lymphoma, in elderly patients with follicular lymphoma, it’s better you don’t treat the patient than treat the patient, it’s very important. Watch and wait can be important but at the same time this particular subset of patients it’s important the new drugs, the new target drugs like lenalidomide, like bortezomib, with a different mechanism of action with a good quality of response with a  low profile in terms of toxicity.

PG: So do you think some of these more gentle treatments or potentially more gentle treatments will work?

BC: Yes for the aim. The aim of a patient who is 75 years old with follicular lymphoma is to give to this patient ten years without any problems. So these new drugs are sufficient to do that. It will not cure a patient or a patient 50 years old, it’s insufficient, but at this age it’s OK.

PLZ: An example is that until ten years ago we didn’t treat patients with an age more than 70-75, now we are treating patients also with an age more than 80, for example.

PG: And finally, how important do you think is it to regard older patients with blood cancers as a separate group that needs to be specialised in?

BC: The problem of elderly patients is that they have a lot of other diseases, sometimes very important. So we have to take into account these concomitant diseases before doing the treatment. But we have to treat like a young patient.

PLZ: The main point is to treat like a young patient but it is very important, a good collaboration with other colleagues in internal medicine for this particular patient with an age more than 70-75 concerning the comorbidities. I think in the future it will be very important to have some guidelines concerning how to stratify the patient according to his particular comorbidities and to have different treatment according to the different situations.

PG: Pier Luigi and Bertrand, thank you for joining me on