BETHESDA, MD — Over the last few years, two combinations have dueled for primacy in treatment of lymphomas: DA-EPOCH-R (dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab) and R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone).
A major study published last year found that the challenger, DA-EPOCH-R, did not improve outcomes in diffuse large B-cell lymphoma, but was associated with significantly greater toxicity. The newer combination appeared to have similar efficacy to the first-line standard therapy.
Researchers at the Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, both in Bethesda, MD, conducted a retrospective review of patients treated with DA-EPOCH-R at Walter Reed to determine whether the combination was more appropriate for patients in certain age groups.1
Results were published in conjunction with the 2020 American Society of Clinical Oncologists Annual Meeting held May 29-31.
Understanding the impact of age on appropriate patient selection is particularly important in aggressive lymphomas as most patients are first diagnosed after age 60.
The team looked at 70 adult patients with lymphoma who were treated with DA-EPOCH-R at Walter Reed between July 2005 and March 2018. Patients had an average age of 55.8, with 49% of patients older than 60 years and nine at least 75 years old.
Patients had a range of lymphoma types including 46 with diffuse large B-cell lymphoma (DLBCL), 12 with transformed lymphoma, four with primary mediastinal B-cell lymphoma, three each with Burkitt lymphoma and T-cell lymphoma, and two with high-grade B-cell lymphoma not otherwise specified.
While patients in all age groups completed about the same median number of cycles, the maximum dose achieved varied substantially.
For patients in the youngest group, under age 45, the median dose level achieved was 3.4. For those 45 to 59, it was 2.5, and for those 60 to 74, it was 1.88. Among the oldest group, those age 75 or more, the median dose level achieved was just 0.88.
In addition to the lower dose level, patients over age 60 were much more likely to require a dose delay and to have more total dose delays. They also experienced gastrointestinal toxicities at a higher rate. No notable differences were seen in peripheral neuropathies or hospitalizations. One patient died from treatment toxicity.
The team concluded that elderly patients can complete all planned courses of DA-EPOCH-R, but they do not achieve the dose intensity reached in younger patients, are likely to need delayed doses, and suffer more toxicity.
- Banaag S, Singla M, Kwok M, Chen D. “Toxicity and tolerability of DA-EPOCH-R for aggressive lymphomas in the elderly: A retrospective cohort study.” Abstract e20030. 2020 ASCO Annual Meeting. May 29-31, 2020.