Chin Med J (Taipei) 1998;61:S125.

Recent Trends in Chemotherapy for Intermediate and High Grade Non-Hodgkin's Lymphoma

Richard I. Fisher, M.D.

Coleman Professor of Oncology, Director Cardinal Bernardin Cancer Center, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL. 60153.

Abstract

Therapy for aggressive non-Hodgkin's lymphomas has undergone significant evolution in the last 25 years. First generation combination chemotherapy studies produced complete response rates (CRs) of 45-53% with 30-37% long term survivors. New treatment programs aimed at increasing CRs were then developed with the assumption that the additional CRs would also become long term disease free survivors. Initial reports of single institution pilot studies with third generation regimens suggested 68-86% Crs and 58-69% survival; however, with longer follow-up, the survival decreased. Furthermore confirmatory national Phase II trials using these newer regimens produced CRs of only 49-65% and survival of 50-61%. Thus ultimate conclusions concerning the efficacy of these new regimens awaited the results of prospective randomized trials. The Southwest Oncology Group (SWOG) conducted a randomized trial comparing standard therapy, CHOP, to the third generation chemotherapy regimens, m-BACOD, ProMACE-CytaBOM, or MACOP-B. After six years, there is still no difference in response rate, progression-free survival, or overall survival between CHOP and the third generation regimens. For example the 6-year estimates of progression-free survival are CHOP 33%, m-BACOD 36%, ProMACE-CytaBOM 34%, and MACOP-B 32% (p =.41). The 6-year overall survival estimates are CHOP 42%, m-BACOD 40%, ProMACE-CytaBOM 46%, and MACOP-B 41% (p =.89). Furthermore, we have not identified any subset of patients who survived longer with the third generation regimens. However the cost and toxicity of the new regimens were higher. Based on the fact that fewer than 50% of these patients are cured, the best approach for any patient is an experimental approach designed to improve our ability to cure the disease. Examples of this include: 1) increasing the dose intensity of drugs used in standard regimens, 2) preventing the development of drug resistance, and 3) autologous bone marrow transplant and or peripheral stem cell support as rescue from marrow ablative chemotherapy. If a patient is not eligible or doesn't wish to participate in a clinical trial, CHOP as inadequate as it is, remains the gold standard.

[Chin Med J (Taipei) 1998;61:S125.]