Toxicity and tolerability of DA-EPOCH-R for aggressive lymphomas in the elderly: A retrospective cohort study.

Abstract

e20030 Background: There remain concerns regarding appropriate patient selection for dose-adjusted EPOCH-R in the treatment of lymphoma, particularly diffuse large B-cell lymphoma, where efficacy is comparable to R-CHOP but significantly more toxic. As the average age at diagnosis of DLBCL is between 60-70 years old, ability of elderly patients to complete and tolerate therapy is critical in treatment decision. Our aim was to investigate the differences in tolerability and toxicity of DA-EPOCH-R among different age groups. Methods: We conducted a retrospective review of patients treated with DA-EPOCH-R at Walter Reed National Military Medical Center. The institutional pharmacy database was queried to identify adult patients diagnosed with lymphoma and treated with DA-EPOCH-R from July 2005 through March 2018. Chart reviews were performed and information on dose reductions, delays, and adverse treatment effects were recorded and stratified between patients aged < 45 years, 45-59, 60-74 and ≥75 years. Results: 70 patients were identified for review. Average age was 55.8 +/- 15.5 years; 49% of patients were ≥ 60 years, including 9 patients who were ≥ 75 years. Diagnoses included diffuse large B-cell lymphoma (n = 46), transformed lymphoma (n = 12), primary mediastinal B-cell lymphoma (n = 4), Burkitt lymphoma (n = 3), T-cell lymphoma (n = 3), and high-grade B-cell lymphoma, NOS (n = 2). There was no significant difference in the median number of cycles completed between the age groups ( p= 0.2540). However, there was a significant difference in the maximum dose level achieved ( p= 0.0003). The median dose level achieved was 3.4 for patients age < 45 (range 1-5), 2.5 for patients age 45-59 (range 1-5), 1.88 for patients age 60-74 (range 1-4), and 0.88 for patients age ≥75 (range -2 to 2). Patients greater than 60 years were more likely to have any dose delay ( p= 0.001), more total dose delays (p = 0.004), and to experience gastrointestinal (GI) toxicities ( p= 0.014). There were no significant differences seen in peripheral neuropathies ( p= 0.425) nor hospitalizations ( p= 0.242). One patient passed away due to toxicity. Conclusions: This study demonstrates the use of DA-EPOCH-R in a real-world setting for the treatment of aggressive lymphomas. Our data suggest that elderly patients can complete all planned courses of DA-EPOCH-R but do not reach the dose intensity achieved by younger patients. In addition, elderly patients are more likely to require dose delays and experience GI toxicities without significant differences in hospitalizations or peripheral neuropathy.