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Original Article

Non-anthracycline chemotherapy associated with a poor outcome
in elderly Egyptian patients with diffuse large B-cell non-Hodgkin
lymphoma

Ahmed A. Zeeneldin, Yasser A. Sallam, Ayman A. Gaber, Amgad A. Shaheen
Department of Medical Oncology, National Cancer Institute, Cairo University, 12622 Cairo, Egypt.
Correspondence to: Dr. Yasser A. Sallam, Department of Medical Oncology, National Cancer Institute, Cairo University, 12622 Cairo, Egypt.
E-mail: ysallam@hotmail.com

ABSTRACT
Aim: Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) is the standard treatment for
patients with diffuse large B-cell non-Hodgkin lymphoma (DLBCNHL). Nevertheless, anthracyclines are contraindicated for
some patients, e.g. cardiac dysfunction, severe hepatic dysfunction, jaundice. Thus, this study assessed the effectiveness of
non-anthracycline chemotherapy regimen cyclophosphamide, vincristine, and prednisone (CVP) in elderly DLBCNHL patients
vs. the standard CHOP. Methods: This retrospective study included 418 DLBCNHL patients diagnosed between 2003 and 2006
and followed until March 2014. During this period of time, rituximab was not available for all patients, particularly for patients
older than 60 years. Results: CHOP and CVP were administered to 351 (84%) and 67 (16%) patients, respectively. Older age and
comorbidities, particularly cardiovascular and diabetes mellitus, were independent determinants for not receiving CHOP. Patients
received more courses of CHOP treatment than that of CVP (6 vs. 3 courses; P < 0.001) and developed more toxicities (48.4%
vs. 23.9%; P < 0.001), particularly fatigue, alopecia, and gastrointestinal tract toxicities. Complete response rate was higher in
CHOP than in CVP (69.9% vs. 29.9%; P < 0.001). Moreover, early death was signifi cantly higher in CVP group of patients than
in CHOP (43.3% vs. 8.6%; P < 0.001). After a median follow-up of 71 months, the median overall survival (OS) and event-free
survival (EFS) were signifi cantly better in CHOP than in CVP (49.5 vs. 3.7 months and 32.2 vs. 3.5 months; P < 0.001 for
both, respectively). Older age, poor age-adjusted International Prognostic Index scores, not receiving CHOP or consolidative
radiotherapy were independent predictors of poor OS and EFS. Conclusion: Use of the CVP regime to treat DLBCNHL patients
who were unfi t to the standard CHOP treatment was associated with lower remission rates and poorer EFS and OS in this group
of patients.
Key words: Non-Hodgkin’s lymphoma, diffuse large B-cell, anthracycline, chemotherapy, treatment

Introduction National Cancer Institute. DLBCNHL treatment mostly
[6]
[7]
relies on multi-agent combination chemotherapy. The
Non-Hodgkin’s lymphoma (NHL) was the 10th most addition of the anti-CD20 monoclonal antibody rituximab
commonly diagnosed cancer and the 9th cause of
cancer mortality in the world in 2012. In Egypt, to the chemotherapy combination dramatically improved
[1]
[8,9]
NHL was the 4th most common cancer in males and overall survival (OS). Anthracyclines, particularly
doxorubicin are an integral component of these
5th in females and the 5th cause of cancer mortality. [1,2] combination chemotherapy regimens, e.g. cyclophosphamide,
NHL is a diverse group of malignancies with different
[3]
clinical and biological features. Diffuse large B-cell doxorubicin, vincristine, prednisone (CHOP); procarbazine,
NHL (DLBCNHL) is the most common NHL type in methotrexate, doxorubicin, cyclophosphamide, etoposide-
the world, accounting for 30% of NHL and 80% of its cytarabine, bleomycin, vincristine, methotrexate;
aggressive subtypes. In Egypt, DLBCNHL accounts for methotrexate-bleomycin, doxorubicin, cyclophosphamide,
[4]
44.5% of lymphoid malignancies in a population-based vincristine, dexamethasone; methotrexate, doxorubicin,
cancer registry and 50% of NHL subtypes at the Egyptian cyclophosphamide, vincristine, dexamethasone, bleomycin,
[5]
and many others. Intensive chemotherapy with
[10]
more agents failed to show additional benefi t, and the
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CHOP regimen was concluded to be the best available
Quick Response Code: for patients with intermediate and high-grade NHL,
Website:
[7]
www.jcmtjournal.com including DLBCNHL. Reductions in dose intensity
[11]
clearly determine treatment effi cacy. However, patients
with older age, comorbidities, particularly cardiovascular,
DOI:
10.4103/2394-4722.156767 and expected higher morbidity and mortality may
hinder the use of an anthracycline. [12,13] Compared to
76 Journal of Cancer Metastasis and Treatment ¦ Volume 1 ¦ Issue 2 ¦ July 15, 2015 ¦