DLBCL Treatment in Elderly Patients with Multiple Comorbidities

EP: 1.NCCN Adds Epcoritamab to Clinical Practice Guidelines in Oncology for DLBCL

EP: 2.Overview of B-Cell Lymphoma-Related NCCN Guideline Development

EP: 3.Key Updates in NCCN Guidelines Surrounding DLBCL Treatment

EP: 4.Progressive Treatment Strategies for DLBCL Directed by NCCN Guidelines

EP: 5.High-Level Toxicities Associated with DLBCL Treatment

EP: 6.Utilizing Bispecific Treatment in Relapsed DLBCL Patients

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EP: 7.DLBCL Treatment in Elderly Patients with Multiple Comorbidities

EP: 8.Additional Treatment Strategies and Collaborative Care for Patients with DLBCL

EP: 9.Navigating DLBCL Treatment Strategies for Patients Experiencing Resistance to Therapy

Leo Gordon, MD: The median age of this disease is in the 60s, then we see people aged 85 and 90 years old that may not be able to tolerate aggressive therapy. In the guidelines, that is certainly addressed in almost every recommendation of treatment. We have the caveat based on age or other comorbidities; a patient may not be a good candidate for the treatment we’re recommending. Other options have been put forward. You’ll see in the guidelines the use of something called mini-CHOP, which is basically 50% dosing of the standard R-CHOP [Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone]. I honestly don’t like that because I think it’s basically dose adjustment and we always make dose adjustment as oncologists anyway. So I don’t know that we need a regimen that says we’re allowed to make a dose adjustment. We are allowed to do that without mini-CHOP. And the problem with mini-CHOP is that it locks you into a certain dose. Some people can start off lower and then bring the dose up. Dose intensity is important in this disease. Those are judgment calls. I think that regimen is a judgment regimen. In addition to that, there is the use of other non–Adriamycin [doxorubicin]-containing chemotherapy. For example, in people who might be older or may have some underlying cardiac disease, you can give regimens without Adriamycin.

I will say we have a 94-year old patient right now under my care I’ve been seeing for 13 or 15 years, probably with follicular lymphoma, who had a relapse with a relapse and had never been treated and they had progression transformation to large cell lymphoma. We tried to get Revlimid and Rituxan. Revlimid was associated with a $24,000-per-month co-pay, so that wasn’t feasible. So we used polatuzumab and Rituxan. He had some response to that, and his second-line treatment is epcoritamab, and so we’ll see how he does with that. Those are things that I think we can do. While they’re not written in the guidelines for second line, it is written for third line. But sometimes you have to do what’s best for the patient. And then there’s other regimens that I mentioned earlier, like loncastuximab, selinexor, and tafasitamab and lenalidomide. Those are the other options in people with comorbidities that don’t allow further treatment.

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