In their article, Picozzi et al describe how patients with aggressive lymphoma were treated in various community practice centers between 1993 and 1998, and they compare that treatment to "standard treatment." Their main conclusion is that more than 40% of these patients did not receive adequate treatment as defined by today’s standards. The authors attempt to analyze why the physician in charge altered the referenced treatment.
Which Regimen for Patients With Aggressive Lymphoma?
Inadequate choice of therapy was the most common explanation for substandard treatment of these patients, according to the authors. Only 65% were treated with the CHOP regimen (cyclophosphamide [Cytoxan, Neosar], doxorubicin(Drug information on doxorubicin) HCl, vincristine [Oncovin], prednisone), 10% were treated with CNOP (cyclophosphamide, mitoxantrone(Drug information on mitoxantrone) [Novantrone], vincristine, prednisone(Drug information on prednisone)), 11% received another regimen containing doxorubicin, and 14% received a regimen without doxorubicin.
The reasons guiding these choices, however, were not entirely clear to the authors: The only correlation they found was that patients treated with CNOP tended to be older. Nevertheless, if the CHOP regimen cures only approximately 35% of patients with diffuse large-cell lymphoma but offers better or similar efficacy than other treatments with lower toxicity, it should be recommended.
CNOP was used in the hope of decreasing doxorubicin toxicity in elderly patients, although in randomized studies CNOP was associated with a lower survival and a higher toxicity than CHOP. Among the more than 50 phase II or phase III trials conducted in elderly patients, none demonstrated a better efficacy/toxicity ratio than that seen with the CHOP regimen.[3,4] Such a benefit was demonstrated only recently for the combination of rituximab(Drug information on rituximab) (Rituxan) and CHOP.
Cooperative groups have expended much effort in seeking a more efficacious regimen than CHOP, and these efforts must continue. However, until randomized studies demonstrate the superiority of one regimen over another, patients with an aggressive lymphoma who are not enrolled in a clinical trial should adhere to standard treatment with CHOP (or, for diffuse large-cell lymphoma, CHOP in combination with rituximab).
How Many Cycles of CHOP?