Radiation Might be Avoided for Older Patients with Good Prognosis Non-Hodgkin Lymphoma
Non-Hodgkin lymphoma, radiation therapy, CHOP. (Definitions of many terms related to cancer can be found in the Cancer.gov Dictionary.)
Current standards call for radiation therapy in addition to chemotherapy in the treatment of localized, early-stage, aggressive non-Hodgkin lymphoma. But in this trial, chemotherapy alone was just as effective in promoting survival among patients over 60, suggesting that similar patients might be able to avoid the added toxicity of radiation therapy.
Journal of Clinical Oncology, published online January 16, 2007; in print March 1, 2007 (see the journal abstract).
(J Clin Oncol. 2007 Jan 16; [Epub ahead of print])
When patients diagnosed with aggressive non-Hodgkin diffuse lymphoma are in stages I and II, they have a fairly good prognosis, with five-year survival greater than 70 percent. For more than 30 years, combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) has been the standard treatment.
The trial described here, known as GELA NHL 93-4, was one of four major clinical trials conducted during the 1990s to answer two questions about how to treat localized aggressive lymphoma: whether to follow CHOP with radiation therapy, and how many cycles of CHOP were best.
The phase III trial GELA NHL 93-4 involved 576 patients newly diagnosed with early-stage aggressive lymphoma that had not spread (referred to as localized). They were enrolled between March 1993 and June 2002 from 65 different centers, primarily in France and Belgium. All were older than 60 and their median age was 68. The patients were randomly assigned to one of two groups: 299 received four 21-day cycles of CHOP; those who responded to CHOP then received radiation therapy directed at the location of their disease. The other 277 patients in the study received four cycles of CHOP alone.
The study was conducted by the Group d’Études de Lymphomes de l’Adulte (GELA). The principal investigator was Christophe Bonnet, M.D., of the Centre Hospitalier Universitaire in Liege, Belgium.
One month after completing treatment, most patients in both groups had a complete response. After a median of seven years, there was also no difference between the two groups in terms of disease progression (event-free survival) or overall survival.
Specifically, 79 patients in the chemotherapy-alone arm had a relapse of disease, which means a 61 percent chance of surviving five years without any events. Of the patients who also got radiation therapy, 66 had disease relapse, for a five-year event free survival of 64 percent. Overall five-year survival for chemotherapy-alone patients was 72 percent, and 68 percent for those who also received radiation – a difference that was not statistically significant.
The study was conducted in older patients who had otherwise favorable outcome characteristics, and may not apply to those with more risk factors or to younger patients with the same form of aggressive lymphoma, said Wyndham Wilson, M.D., Ph.D., chief of the lymphoma section at the National Cancer Institute’s Center for Cancer Research.
A more significant limitation of this study is that few patients today would be treated with simple CHOP now that the monoclonal antibody called rituximab (Rituxan®) has been shown to be an effective addition (called R-CHOP) in the treatment of various lymphomas.
Based on these and other trial results, the GELA investigators wrote that their group has made the decision “to abandon radiotherapy as first-line treatment of localized aggressive lymphoma.” There is a similar treatment trend in the United States, added Wilson, saying, “I don’t believe radiation therapy is needed by patients with stage I disease.”
This does not mean, however, that radiotherapy doesn’t have a role to play in the local control of some lymphomas, wrote Andrea K. Ng. M.D., and Peter M. Mauch, M.D., from the Dana-Farber Cancer Institute at Harvard in an accompanying editorial; only that other clinical trials using newer chemotherapies such as R-CHOP and the latest radiotherapy techniques must be conducted to explore the issue.
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