I would like to take issue with Dr. Bruce Cheson's response to
a reader's question on the role of high-dose chemotherapy/autologous
bone marrow transplantation (ABMT) in patients with non-Hodgkin's
lymphoma (Oncology News International, December, 1995, page 25).
Granted that this is an extremely broad topic to cover in a limited
space, I nonetheless found Dr. Cheson's response misleading with
regard to two important subgroups of patients: those who fail
to achieve a complete remission with initial chemotherapy and
those who are in first remission but are at very high risk for
relapse and are thus considered for high-dose therapy as "consolidation."
In the first case, Dr. Cheson writes that those patients not responding
to initial treatment (induction failures) achieve a durable remission
with high-dose therapy in less than 10% of cases. This statement
is true for those who are absolutely refractory to initial chemotherapy,
but is not true for those who obtain a partial remission with
In this setting, the majority of patients can be converted to
a complete remission with high-dose chemotherapy and ABMT, and
at least half of them will have durable remissions [1-4].
Regarding patients in first remission, Dr. Cheson cites the study
by Haioun et al (J Clin Oncol 12:2543-2551, 1994), which showed
no advantage for the patients randomized to transplant. However,
he fails to note that the study was flawed from its outset by
the intense consolidation given in the "standard" treatment
arm, the less than maximal doses used in the transplant arm, and
the inclusion of very few "high risk" patients.
Indeed, at the American Society of Hematology (ASH) December,
1995, meeting, the French group presented its updated data with
an expanded number of high-risk patients treated in this study
. These updated data do indeed now indicate an advantage for
disease-free survival (57% vs 36%, P = .01) as well as overall
survival (65% vs 52%, P = .06) in favor of the transplant arm.
Based on these data and other data cited in the references below,
I believe that strong consideration should be given to high-dose
chemotherapy in these two clinical situations.
1. Verdonck LF, Dekker AW, de Gast GC, et al: Salvage therapy
with ProMACE-MOPP followed by intensive chemoradiotherapy and
ABMT for patients with non-Hodgkin's lymphoma who failed to respond
to first-line CHOP. J Clin Oncol 10:1949-1954, 1992.
2. Haioun C, Lepage E, Gisselbrecht C, et al: Autologous transplantation
versus conventional salvage therapy in aggressive non-Hodgkin's
lymphoma (NHL) partially responding to first line chemotherapy:
A study of 96 patients enrolled in the LNH87-2 protocol. Blood
86(suppl 1):211a, 1995 (abstract 833).
3. Prince HM, Crump M, Imrie K, et al: Long-term event-free survival
(EFS) after intensive therapy with etoposide, melphalan, and autotransplant
in patients failing front-line therapy for Hodgkin's disease and
non-Hodgkin's lymphoma. Blood 86(suppl 1):209a, 1995 (abstract
4. Gherlinzoni F, Martelli M, Mazza P, et al: ABMT vs DHAP in
aggressive non-Hodgkin's lymphomas (NHL) partially responding
to first-line chemotherapy. Blood 84(suppl 1):234a, 1994 (abstract
5. Haioun C, Lepage E, Gisselbrecht C, et al: ABMT versus sequential
chemotherapy for aggressive non-Hodgkin's lymphoma (NHL) in first
complete remission (CR): A study of 542 patients (LNH87-2 protocol).
Blood 86(suppl 1):457a, 1995 (abstract 1816).