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Treatments > Lymphoma in Elderly Patients

Last update: 08/31/2015

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In the News | Issues | Resources | Treatment Reports | Tailoring Treatment  | In the News

Elderly patients diagnosed with lymphoma may have special needs.  The good news is that recent evidence suggest that they will often tolerate and respond very well to treatment. Adjustment to treatments may be indicated based on health and performance status.  

... "It has been noted that an 80-year-old in the upper quartile of health based on a geriatric assessment has a similar life expectancy to that of a 
70-year-old in a middle quartile."

... "Important issues that should be highlighted include: (1) information gained from a comprehensive assessment of the health status of the patient, including comorbidity, performance status and functional status, and quality of life that can be used to evaluate and guide management decisions, and (2) unanswered questions that need to be explored in future research."

... "A significant ongoing effort is aimed at determining the feasibility of a cancer-specific geriatric assessment and whether such an assessment affects treatment toxicity and outcome.[1] Clearly, the most challenging goal is to segregate frail older lymphoma patients from a healthier cohort."
 


In the News:

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Alvarez et al. CLML 2014
What Determines Therapeutic Choices for Elderly DLBCL Pts? [Portugal] 

CONCLUSION:  This was the first characterization of the clinical care of elderly Portuguese patients with DLBCL. We showed that R-CHOP is effective even in patients > 79 years, emphasizing that treatment decisions based on age alone can compromise treatment efficacy and outcome in fit patients.
 
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PubMed
Disease characteristics, treatment patterns, prognosis, outcomes and lymphoma-related mortality in elderly follicular lymphoma in US http://1.usa.gov/1DOWg5T

Data from the National LymphoCare Study (a prospective, multicentre registry that enrolled follicular lymphoma (FL) patients from 2004 to 2007) were used to determine disease characteristics, treatment patterns, outcomes and prognosis for elderly FL (eFL) patients. Of 2650 FL patients, 209 (8%) were aged >80 years; these eFL patients more commonly had grade 3 disease, less frequently received chemoimmunotherapy and anthracyclines, ..
 
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Cancer. 2015 : Disease characteristics, patterns of care, and survival in very elderly pts with DLB-cell lymphoma http://1.usa.gov/1vQwPms 

Abstract conclusion statement: Although patients with DLBCL who were aged >80 years were less likely to receive R-CHOP, this regimen conferred the longest survival and should be considered for this population. Further studies are needed to characterize the impact of treatment of DLBCL on quality of life among patients in this age group.
 
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ASCO Post, 2014: Andrew D. Zelenetz, MD, PhD
Treating the Elderly Lymphoma Patient With Elevated Bilirubin” http://bit.ly/1pyOnvs
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Annals of Oncology 2013:
Lymphoma occurring in patients over 90 years of age: characteristics,
outcomes, and prognostic factors. 

A retrospective analysis of 234 cases from the LYSA http://bit.ly/1aEF99t
 
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Best Practice and Research in Clinical Haematology:
Therapeutic strategies in elderly and very elderly patients
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BCEEEF 2011: Treatment of elderly non-Hodgkin's lymphoma patients. 5/23/2011
Prof Pier Luigi Zinzani - University of Bologna, Italy and
Prof Bertrand Coiffier - Hospices Civils de Lyon, France

 

 
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Cancer Chemo and Pharmacology: Addition of rituximab to reduced-dose CHOP chemotherapy is feasible for elderly patients with diffuse large B-cell lymphoma
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Radioimmunotherapy for the Elderly?
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Bexxar is an Effective and Well Tolerated Therapy in Elderly Patients with NHL asco.org

CONCLUSION: Bexxar was efficacious and well tolerated in this population of elderly patients with NHL. Due to physiologic changes in the elderly, conventional chemotherapy may require dose-attenuation; however, Bexxar therapy provides pt-optimized dosing so that the same TBD is given for all age groups. This novel therapy provides a therapeutic choice for pts who may have limited therapeutic options.
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See also Radioimmunotherapy

Issues

Issues and risks of treatment must be weighed against the risk of the disease un-treated.  For example, a smaller chance of curing DLBCL because of advanced age or poor performance could be better than the risk of allowing the disease to progress unchecked. It's our expectation that the oncology team will take these and other factors into consideration when developing a treatment or management plan for you or your loved one.  

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Comorbidities (secondary conditions)
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Performance status (frailty or vitality)
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Cardiac function (strong or compromised)
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Renal (kidney) and Hepatic (liver) function - can affect ability to tolerate full dose
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Risk of treatment-related toxicities (generally increasing with age and decreased performance)
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Ability to tolerate full dose (generally increasing with age and decreased performance)
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cure/remission rates (generally decreasing with age and decreased performance)

Adapted from cancernetwork.com (login may be required)

Resources

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Non-Hodgkin's Lymphoma in the Elderly 
Part 1:  Overview and Treatment of Follicular Lymphoma - cancernetwork.com (login may be required)

cancernetwork.com (login may be required)
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ASCO 2003: Older Patients Less Likely to be Referred to Oncologists, Participate in Clinical Trials  PLWC
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Management of Cancer in the Elderly, Lodovico Balducci, MD, and Martine Extermann, MD  theoncologist
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Management of chronic pain in the elderly: focus on transdermal buprenorphine http://1.usa.gov/1jkKiIN
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Non-Hodgkin's Lymphoma in the Elderly, moffitt.usf.edu  PDF
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Treatment for the Older Non-Hodgkin Lymphoma Patient, Dr. John Leonard, M.D.

LLS PDF
  (10/19/04)

Outcome reports - specific protocols

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Combo Therapy with Tositumomab (Bexxar) and Auto SCT Aids Elderly Lymphoma Patients  cancerpage  

"These data suggest that potentially curative therapies should not be denied to patients based solely on age," lead investigator Dr. Ajay K. Gopal of the University of Washington, Seattle, told Reuters Health. "In addition, targeted therapies with individualized dosing strategies, as in this study, may prove useful to both reduce toxicity and improve outcomes in patients of all ages."
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CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med. 2002 Jan 24;346(4):235-42. PMID: 11807147 

The addition of rituximab to the CHOP regimen increases the complete-response rate and prolongs event-free and overall survival in elderly patients with diffuse large-B-cell lymphoma, without a clinically significant increase in toxicity.
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Short Course of Rituxan®/Chemotherapy Plus Maintenance Rituxan® Provides High Progression-Free Survival as Initial Treatment Diffuse B-Cell NHL Among Patients Ineligible for Standard R-CHOP  cancerconsultants.com 

31% achieved a complete disappearance of detectable cancer (complete response)
38% achieved a partial regression of their cancer (partial response)
Disease stabilization was achieved in 31%
No patient experienced disease progression
Progression-free survival at both one and two years was 92%
Treatment was well tolerated, with low levels of immune cells being the most common side effect
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Hodgkin's lymphoma in the elderly: The results of 10 years of follow-up.
Leuk Lymphoma. 2006 Aug;47(8):1518-22. PMID: 16966262
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Outcomes and diffusion of doxorubicin-based chemotherapy among elderly patients with aggressive non-Hodgkin lymphoma. Cancer. 2006 Aug 24; PMID: 16933332 
 
Conclusions.: By 1999, doxorubicin-based chemotherapy had gained general acceptance for use among the elderly, although nearly 50% of elderly patients still were not receiving it. Given the clinical trial-based evidence of its benefits, in the absence of specific contraindications, most patients, including the elderly, should be treated with regimens that include doxorubicin.
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A Brief Course of Chemo-Immunotherapy FND + Rituximab Is Effective To Induce a High Clinical and Molecular Response In Elderly Patients With Advanced Stage Follicular Lymphoma (FL) at Diagnosis. Session Type: Poster Session 564-I  ASH 2003
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First-line treatment with brief-duration chemotherapy plus rituximab in elderly patients with intermediate-grade non-Hodgkin's lymphoma: phase II trial.
Clin Lymphoma. 2003 Jun; 4(1): 36-42. PMID: 12837153
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A dexamethasone, vinblastine, cyclophosphamide, etoposide, methotrexate and bleomycin (D-VICEMB) protocol as first-line treatment of patients aged 70 years or older affected by intermediate/high grade non-Hodgkin's lymphoma  Medscape
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Elderly Patients with Non-Hodgkin’s Lymphoma Tolerate Autologous Stem Cell Transplantation  cancerconsultants.com
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Alternation of epirubicin and mitoxantrone in CHOP-like regimens retains efficacy and reduces overall toxicity in elderly patients with high and intermediate grade non-Hodgkin lymphomas.
Leuk Lymphoma. 2002 Dec;43(12):2319-24. PMID: 12613518
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Rituximab plus gemcitabine: a therapeutic option for elderly or frail patients with aggressive non Hodgkin's lymphoma? Leuk Lymphoma. 2005 Jan;46(1):71-5. PMID: 15621783
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Rituximab Plus Chemo More Effective in Elderly Lymphoma Patients.  Updated 02/05/02  Cancer.gov
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Rituximab plus gemcitabine: a therapeutic option for elderly or frail patients with aggressive non Hodgkin's lymphoma? Leuk Lymphoma. 2005 Jan;46(1):71-5. PMID: 15621783 
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Continuous infusion of vincristine-doxorubicin with bolus of dexamethasone(VAD) alternated with CHEP in the treatment of patients over 60 years old with aggressive non-Hodgkin's lymphoma.
Leuk Lymphoma. 2001 Feb;40(5-6):529-40. PMID: 11426526  PubMed
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Low-dose fludarabine and cyclophosphamide in elderly patients with B-cell chronic lymphocytic leukemia refractory to conventional therapy. Haematologica. 2000 Dec;85(12):1268-70. PMID: 11114133 
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J Clin Oncol 1998 Jan;16(1):27-34  umbertotirelli 
CHOP is the standard regimen in patients > or = 70 years of age with intermediate-grade and high-grade non-Hodgkin's lymphoma: results of a randomized study of the European Organization for Research and Treatment of Cancer Lymphoma Cooperative Study Group.
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Treatment of large cell lymphoma in elderly patients with a mitoxantrone, cyclophosphamide, etoposide, and prednisone regimen: long-term follow-up results. Cancer. 2003 Jan 1;97(1):97-104. Review.  PMID: 12491510  PubMed
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A phase II study of liposomal vincristine in CHOP with rituximab for elderly patients with untreated aggressive B-cell non-Hodgkin's lymphoma (NHL)  ASH 2002
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Lymphoma in older patients. J Clin Oncol. 2007 May 10;25(14):1916-23. PMID: 17488991

Tailoring treatment for

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Side effects: Elderly patients with non-Hodgkin lymphoma who receive chemotherapy are at higher risk for osteoporosis and fractures. Leuk Lymphoma. 2007 Aug;48(8):1514-21. PMID: 17701582 

Use of chemotherapy was significantly associated with increased risk of fracture and osteoporosis in elderly patients with NHL
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Cancer in the Elderly: Tailoring Treatment , Lodovico Balducci  PubMed
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Features of chemotherapy of malignant tumors in elderly patients
Adv Gerontol. 2002;10:126-30. Review. Russian. PMID: 12577700 | Related abstracts
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Regimen Tailored to Elderly Patients Shows Promise Against NHL  Medscape (free login req.) 02_01_03
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The Influence of advanced age on the treatment and prognosis of diffuse large-cell lymphoma (DLCL). Clin Lymphoma. 2001 Mar;1(4):278-84. Review. PMID: 11707842  PubMed
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The Geriatric Patient: Equal Benefit from Equal Treatment, Lodovico Balducci, MD Medscape
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Use of growth factors in the elderly patient with cancer: a report from the Second International Society for Geriatric Oncology (SIOG) 2001 meeting. Crit Rev Oncol Hematol. 2003 Feb;45(2):123-8. Review.  PMID: 12604125
 
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professional medical advice or to replace your relationship with a physician.
For all medical concerns,  you should always consult your doctor. 
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