Aspects of Chemotherapy Schedules in Young and Elderly Patients with Aggressive Lymphoma

The CHOP (cyclophosphamide/doxorucibin/vincristine/prednisone) regimen has been established as the standard treatment for diffuse large B-cell lymphoma (DLBCL). With the availability of granulocyte colony-stimulating factor and the tool of autologous stem cell support, different strategies of dose intensification have been pursued to further improve treatment results. Although dose-escalation strategies, including high-dose approaches, have not convincingly been shown to be superior to CHOP-21, dose densification by reducing treatment intervals from 21 days to 14 days (CHOP-14) has led to improved outcome for elderly patients. Furthermore, the implementation of rituximab has been proven to be superior to chemotherapy alone with regard to complete remission, event-free survival, and overall survival rates in elderly patients in a number of randomized trials. Although it has not been formally determined in young patients with poor prognosis, the combined immunochemotherapy with CHOP and rituximab has become an accepted standard for the treatment of DLBCL worldwide. For patients aged > 60 years, 6 courses of CHOP-14 with rituximab (R-CHOP-14) followed by 2 additional courses of rituximab, yielded the best treatment results, without a relevant increase in toxicity compared with CHOP-21. For younger, patients at low risk, 6 courses of R-CHOP-21 is the standard treatment. Young patients at high risk (International Prognostic Index ≥ 2) should be treated with dose-dense regimens and/or autologous stem cell support within clinical trials. The optimal dose and schedule of rituximab has yet to be determined. Aspects of supportive measures meant to ensure optimal adherence to dose-dense regimens are discussed herein.