Mitchell Sabloff, MD, Assistant Professor of Medicine, Ottawa Hospital, Ottawa, ON.

Non-Hodgkin’s lymphoma is on the rise in the older population. Traditional therapies have had limited impact upon this illness because they are compromised by toxicity and, in many cases, patients’ performance status is suboptimal at initial presentation. There has been some progress recently in addressing these issues with novel therapeutic options, permitting the delivery of more effective therapy while still limiting the toxicity.

Key words: non-Hodgkin’s lymphoma, immunotherapy, treatment, aging.

Pauline T. Truong, MDCM, FRCPC, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Rohit Pai, BSc, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Ivo A. Olivotto, MD, FRCPC, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Breast conserving surgery (BCS) and postoperative radiation therapy (RT) achieve local control and survival equal to mastectomy in women with early stage breast cancer. The incidence of breast cancer increases with age and the number of older women in Canada continues to rise, but the under-representation of older women in BCS trials limits the evidence on which to base optimal therapy decisions. This article reviews breast conservation in older women, with a focus on the necessity of radiation therapy. Multiple randomized trials with and without age subgroup analyses demonstrate that RT after BCS should be considered standard therapy. A low-risk subset in whom radiation therapy may be omitted without compromising local control has not been defined. In women with early breast cancer, age alone should not preclude treatment that optimizes local control. Efforts to include representative samples of older breast cancer subjects in modern clinical trials with endpoints that include cancer control, survival, function, and quality of life are needed.

Key words: age, breast conserving surgery, breast cancer, breast conservation, radiotherapy.

Rituximab, a chimeric monoclonal antibody against the B-cell CD20 antigen, has previously been shown to be effective for the treatment of relapsed or refractory indolent lymphomas and has activity in relapsed or refractory diffuse large-B-cell lymphoma. Currently, the standard treatment for large-B-cell lymphoma is cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP), which is effective in younger patients, but induces complete responses in only 40-50% of elderly patients, with three-year event-free and overall survival rates of 30% and 35-40%, respectively. A recent study has examined the benefits of adding rituximab to the CHOP regimen, to see how this treatment compares to CHOP alone.

The researchers randomized previously untreated patients with diffuse large-B-cell lymphoma, 60-80 years old, to receive either eight cycles of CHOP every three weeks, or eight cycles of CHOP plus rituximab given on day one of each cycle. They found that the rate of complete response was significantly higher in the group that received CHOP + rituximab and with a median follow-up of two years, event-free and overall survival times were significantly higher in this group. In addition, this treatment significantly reduced the risk of treatment failure and death and there was no significant increase in treatment-related toxicity.

Non-Hodgkin's lymphoma is the fifth most common cancer in Canada, and there are expected to be 6,200 new cases diagnosed this year.

Source

1. Coiffier B, Lepage E, Briere J et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. NEJM 2002;346:235-242.

Alexandra Nevin, BSc

It is predicted that 70% of all neoplasms will occur in the geriatric population by the year 2020.¹ Hematologic malignancies represent a significant and clinically devastating proportion of the cancers affecting the sixty-five-plus generation. Within the spectrum of lymphoid-derived hematologic tumors, the umbrella class referred to as non-Hodgkin's lymphoma (NHL) is particularly daunting in terms of both incidence and associated mortality in the general population. Since the 1970s, the National Cancer Institute reports that NHL is one of only five malignancies for which death rates have increased, while the American Cancer Society reports that the absolute incidence of NHL has increased over 65% in the past 30 years. The determination of age-adjusted incidence rates indicates that such trends are due primarily to increases in NHL among older persons.² From a clinical perspective, elderly NHL patients represent a unique group due to the demonstration of certain age-specific characteristics, including histology type predominance, prognosis, and response to current conventional treatment. Recent advances, such as monoclonal antibody treatment, represent a promising therapeutic avenue in future treatment of specific forms of NHL in the elderly.

The Etiology of NHL
The underlying etiology of most types of NHL is still unknown, regardless of the patient's age. However, a number of risk factors have been identified for the general population.