Response to the letter from Gozzetti et al. entitled: “Oral low-dose fludarabine and cyclophosphamide with rituximab as initial treatment for elderly patients with chronic lymphoproliferative disorders”

Abstract

We agree with the comments made by Gozzetti et al . in their recent correspondence entitled: “ Oral low-dose fl udarabine and cyclophosphamide with rituximab as initial treatment for elderly patients with chronic lymphoproliferative disorders ” . Toxicity of standard-dose fl udarabine, cyclophosphamide and rituximab (FC-R) [1,2] in the elderly population ( 70 years) can be a major concern. In our article, the treatment of elderly patients with dose-reduced FC-R [3] was considered as a potential option, and certainly use of the dose-reduced FC-R ( “ old-FCR ” ) as discussed in the recent publication by Gozzetti et al . [4] provides support for using a dose-reduced FC-R schedule as frontline therapy in this cohort of patients. Furthermore, as they mention, the comprehensive geriatric assessment (CGA) as used to assess elderly patients for chemotherapy is another helpful tool [5]. Older patients, especially those with quite complex and often multiple comorbidities, would benefi t from an assessment using the CGA as it incorporates a multidisciplinary team review. As mentioned in our article [3] and in the correspondence by Gozzetti et al ., the introduction of newer, eff ective and oral targeted therapies such as ibrutinib, and ABT-199, will probably change the treatment algorithm in the elderly patient, given that these drugs also possess a favorable toxicity profi le. However, for the time being, chemotherapy remains the major component of our therapies, and treatment with dose-reduced FC-R is an attractive option that would also warrant larger clinical trials.