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study included older patients with a maximum age of 82, receiving non-anthracycline-containing regimens (19%)
poorer PS, and higher aaIPI scores. Patients that are older compared to that in the mentioned studies (29% and
and have poor PS frequently received reduced doses 33%). This may be due to the more developed health
or interrupted and delayed therapy. This reduced dose care system in the US than Egypt as the former ranks
intensity is a key determinant of CR and survival. [6,31] 37th and the latter ranks 63th in overall health system
performance. A high performing health care system
[33]
In the current study, remo val of the anthracycline is capable of providing better supportive therapies
doxorubicin from the CHOP regimen signifi cantly for patients that are elderly, having comorbidities and
reduced the median OS ( unadjusted from 49.5 to progressing on inadequate anti-lymphoma therapy.
3.7 months, i.e. 45.8 months and adjusted from 44 to
9 months, i.e. 35 months) and the 3-ye ar OS (unadjusted OS with CHOP treatment (52% at 3 years) in the
from 54.5% to 3.9% i.e. 50.5% and adjusted from 52% current study is comparable to the 49-57% fi gure
to 19% i.e. 33%) with an increase in the hazards of reported by many authors [Table 7], [6,9,12,18] but was
[12]
death by 4 times. This is similar to Tien et al. and lower than the 60-70% OS reported by Habermann
Link et al. who show ed a 22% and 16% decline in et al., Burton et al., and Khaled et al. All of these
[32]
[29]
[18]
[28]
3-year OS, respectively [Table 7]. The difference in our studies performed prospective trials where patients were
study (33%) may be due to the poorer outcome of patients carefully selected and generally fi t to tolerate therapy. It
is understandable that results from phase III studies do
Table 6: Multivariate analysis of EFS and OS in DLBCNHL not always translate into corresponding outcomes in the
patients general population. [18]
Variables in EFS OS Similar to CR and OS, our current data showed that removal
equation HR (95% CI) P HR (95% CI) P of doxorubicin from the CHOP regimen signifi cantly
Age (≥ 60 vs. 2.1 (1.6-2.9) < 0.001 2.5 (1.8-3.0) < 0.001 reduced EFS. We could not easily fi nd information on
< 60 years) the use of CVP in DLBCNHL to compare our EFS with
First line 2.6 (1.9-3.7) < 0.001 2.6 (1.8-3.8) < 0.001 the studies that comparison of anthracycline-containing
chemotherapy regimens to non-anthracycline-containing regimens only
(non-CHOP showed OS. [12,18] The EFS rate of CHOP treatment in our
vs. CHOP) current study is similar to Sehn et al. and Habermann
[9]
aaIPI (score 1.8 (1.3-2.5) < 0.001 2.0 (1.4-2.7) < 0.001 [32] [28]
0-1 vs. 2-3) et al. However, it was lower than that of Khaled et al.
[29]
Radiotherapy 1.8 (1.3-2.5) < 0.001 2.1 (1.5-3.1) < 0.001 and Burton et al. This may be explained by the difference
(no vs. yes) in study settings between the well-controlled environment
of a clinical trial and the community practice environment.
DLBCNHL: Diffuse large B-cell non-Hodgkin’s lymphoma; The dis ease-free survival of our study (75.9% at 2 years)
CHOP: Cyclophosphamide, doxorubicin, vincristine, and [6]
prednisone; CVP: Cyclophosphamide, vincristine, and was similar to that of Abdelhamid et al. (68.8%) who
prednisone; EFS: Event-free survival; OS: Overall survival; used a similar setting to our study. It was higher than
[30]
HR: Hazard’s ratio; CI: Confi dence interval; aaIPI: Age-adjusted that reported by Hallack Neto et al. This retrospective
international prognostic index; IPI: International prognostic index Brazilian study reported on a relatively small number of

Table 7: Comparison of treatment outcomes in DLBCNHL patients
Authors Regimen n Age CR (%) 2-year (3-year) EFS/PFS (%) 2-year (3-year) OS (%)
Our current study CHOP 251 17-82 69.8 55.3 (46.0) 58.0 (52.0)
CVP 67 45-87 29.9* 18.0 (12.0)* 25.0 (19.0)*
Tien et al. [12] ACR 1090 ≥ 66 (52)
Non-ACR 267 ≥ 66 (29)*
Link et al. [18] ACR 2346 ≥ 66 59 (49)
Non-ACR 460 ≥ 66 40 (33)*
Abdelhamid et al. [6] CHOP 224 18-60 79.5 2-year DFS: 68.8 57 (57)
Hallack Neto et al. [30] CHOP 77 < 60 68.8 2-year DFS: 61.3 5-year OS: 72.8
Habermann et al. [32] CHOP 279 > 60 (46) (60)
Sehn et al. [9] ACR 140 19-86 51% (46%) 52 (50)
Khaled et al. [28] CHOP 40 19-75 67 54 (54) 82 (71)
Burton et al. [29] CHOP 105 22-66 70 4-year PFS: 56 4-year OS: 65
CIOP 106 25-67 52 4-year PFS: 40* 4-year OS: 56 #
*P < 0.05, P ≥ 0.05. EFS: Event-free survival; PFS: Progression-free survival; DFS: Disease-free survival; CHOP: Cyclophosphamide,
#
doxorubicin, vincristine, and prednisone; CVP: Cyclophosphamide, vincristine, and prednisone; ACR: Anthracycline containing
regimen; CIOP: Cyclophosphamide, idarubicin, vincristine, and prednisone; CR: Complete response; DLBCNHL: Diffuse large B-cell
non-Hodgkin’s lymphoma

Journal of Cancer Metastasis and Treatment ¦ Volume 1 ¦ Issue 2 ¦ July 15, 2015 ¦ 81