Risk factors related to death in older patients treated with rituximab-based immunochemotherapy in an outpatient setting

This article highlights key information regarding risk factors related to death (primary endpoint) and hospitalization (secondary endpoint) in Diffuse Large B-Cell Lymphoma (DLBCL) patients treated with outpatient rituximab-based immunochemotherapy. This article was written by Dr Adam J. Olszewski from Alpert Medical School of Brown University, USA, and published in the Journal of the National Comprehensive Cancer Network in September 2016.

Here are the key findings of the study:

Risk of early death in patients

• Day 30 and day 180, after chemotherapy initiation:
  • Risk of death: 2.2% and 10.9% respectively. ​​
• Prediction method used 7 factors to determine risk in patients.
  • Age (>75 years), poor PS, chronic kidney disease, mobility aids (cane, wheelchair, walker), B symptoms, hospitalization and upper endoscopy.
• Prediction of risk in patients correlated to factors:
  • 0-1 factors: Low risk patients (56%); OS=6%
  • 2-3 factors: Intermediate-risk (38%); OS=15%
  • 4 or more factors: High-risk (6%); OS=27%
  • 15% of high-risk patients receiving G-CSF had a higher risk of an early death.
  • Prophylactic G-CSF was not administered
    •  36% (low risk), 32% (intermediate risk) and 33% (high risk) of patients

Risk of hospitalization of patients

• Risk of hospitalization: 23.5% - within 30 days of treatment.

Conclusions

This study provides some key data that could be implemented in an outpatient setting. This prediction score might be used as a tool to select which elderly patients are able to receive anthracycline-based regimens in the future.

Risk Factors for Early Death After Rituximab- Based Immunochemotherapy in Older Patients With Diffuse Large B-Cell Lymphoma

Abstract

Background: Older patients with diffuse large B-cell lymphoma (DLBCL) are at risk of severe chemotherapy-related morbidity and mortal­ity. Our objective was to quantify the risk and identify factors associated with death during the first cycle of immunochemotherapy in this population.

Patients and Methods: Using Medicare claims linked to the population-based SEER registry (SEER-Medicare), we studied pa­tients with DLBCL aged 65 years and older who received immunochemotherapy containing rituximab, cyclophosphamide, and vincristine, in combination with doxorubicin, mitoxantrone, or etoposide in 2003–2012. Risk factors for death and hospitalization within the first 30 days of treatment were studied in multivariable logistic regression models.

Results: We identified 5,530 patients with a median age of 76 years, of whom 94% received doxorubicin-containing immunochemotherapy. Granulocyte colony-stimulating factor (G-CSF) was admin­istered to 66% of patients during the first treatment cycle. Cumulative incidence of death at day 30 was 2.2%. The risk was significantly higher in patients aged 75 years and older and those who had B symptoms, chronic kidney disease, poor functional status, use of walking aids or wheelchairs, and prior hospitalization or upper endoscopy. The group with 0 to 1 risk factors (56% of patients) had a very low (0.6%) risk of early death, whereas the group with 4 or more risk factors (6% of patients) had a risk of 8.3%. Receipt of G-CSF was associated with a lower probability of early death in the high-risk group. The incidence of hospitalization within the first 30 days was 23.5%, peaking at day 8 of the cycle.

Conclusions: Among older patients with DLBCL who receive contemporary immunochemotherapy, 1 in 45 die during the first month of treatment, and 1 in 4 are hospitalized. Factors identifiable from administrative/electronic records can stratify this risk and could be incorporated into decision support tools. Prophylactic G-CSF is not administered to more than one-third of patients, indicating an opportunity for improved preventive interventions.