Original Article
Clinical
Non-Hodgkin Lymphomas: Impact of Rituximab on Overall Survival of Patients with Diffuse Large B-Cell and Follicular Lymphoma

https://doi.org/10.1016/j.arcmed.2015.07.004Get rights and content

Background and Aims

Information comparing treatment outcome for diffuse large B cell (DLBCL) and follicular (FL) non-Hodgkin lymphoma (NHL) patients treated with schemes with and without rituximab from low- and middle-income countries is scarce. Clinical characteristics, response to therapy and long-term outcome of DLBCL and FL patients were studied.

Methods

Patients with DLBCL and FL diagnosed over 8 years at a reference center in northeast Mexico were included. Kaplan-Meier method was used to determine overall survival (OS) and progression-free survival (PFS). Cox regression model was used to evaluate the association between risk factors, rituximab therapy and clinical outcome.

Results

One hundred-sixteen patients with DLBCL and 65 with FL in advanced stages were included. Median age was 57.8 and 56 years, respectively. Clinical characteristics between groups receiving or not receiving rituximab were comparable. Stages III and IV were found in 63.8% of DLBCL and 84.6% in FL patients, respectively. OS and PFS at 60 months were 63.8 and 51.2% in DLBCL and 70.6 and 33.8% in FL. No difference in OS was found in DLBCL and FL when rituximab-based regimens vs. non rituximab-based regimens were compared, but a statistically significant difference was documented in PFS in FL patients.

Conclusion

Addition of rituximab to CHOP-like regimens did not improve OS in DLBCL and FL NHL subtypes. In comparison to developed countries, diagnosis of NHL was made a decade earlier and in advanced clinical stages. Cost-efficiency of adding rituximab to therapy for these patients should be assessed.

Introduction

Non-Hodgkin lymphoma (NHL) is an aggressive chronic lymphoproliferative disorder of the immune system that comprises many subtypes, each with a distinct epidemiology, etiology, histology, and clinical features, which can make diagnosis difficult (1).

Diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma (FL) are the most common subtypes found worldwide, and an increased incidence has been observed in recent years (2). Gender, age and race have been associated with specific NHL subtypes and clinical features as well as with response to treatment and overall survival. African-American patients with diffuse large B-cell lymphoma (DLBCL) in the U.S. present at a younger age, at a more advanced stage, and have lower survival rates (3). In the follicular subtype, clinical stages III and IV at diagnosis are found more frequently than stages I and II and are associated with a higher relapse rate, yet having a higher OS than that observed for DLBC (4).

In these two lymphomas, low socioeconomic status and education level are associated with a shorter OS, finding a higher mortality rate in younger patients with an advanced clinical stage, probably as a consequence of less understanding of the severity of the disease (5) and inadequate insurance coverage in this disadvantaged group 6, 7.

Quality of life has been studied in DLBCL and FL in different age groups, finding a greater impact in social and functional status in patients <60 years of age, the worsening of older patients' status being associated with age and not with the disease itself (8).

Addition of rituximab to CHOP-like regimens has been studied in developed countries; in contrast, there is scarce information comparing this treatment modality to conventional CHOP in patients from developing countries. Analyzing the cost-effectiveness of adding rituximab to standard chemotherapy schemes in terms of OS and PFS, particularly in a budget-restricted environment, seems an important approach to be studied (9).

Studies have demonstrated different response rates in DLBCL and FL subtypes, finding a better PFS in DLBCL and an increased OS in FL with standard R-CHOP (10).

We documented the characteristics of DLBCL and FL observed in patients diagnosed, staged and treated at a public reference center in northeast Mexico.

Section snippets

Materials and Methods

A retrospective observational study was conducted in the Hematology Service, Internal Medicine Division, of the Hospital Universitario “Dr. José E. González” of the School of Medicine of the Universidad Autónoma de Nuevo Leon, in Monterrey, Mexico including all patients diagnosed from January 2006 to December 2013 with DLBCL and FL in advanced clinical stages confirmed by biopsy. Advanced clinical stage was defined as B-symptoms at the time of diagnosis and Ann Arbor stages III and IV, and I

Results

During this 7-year study, 347 cases of NHL were diagnosed; 140 (40.34%) were DLBCL and 86 (24.78%) corresponded to FL. The remaining 121 (34.87%) cases were distributed among other NHL subtypes.

Discussion

The purpose of this study was to document treatment response with emphasis on the role of rituximab in the context of a low socioeconomic group as well as the clinical and histological features of the most frequent NHL subtypes in an open population in northern Mexico.

We found a younger age of presentation of DLBCL and FL and an advanced clinical stage at diagnosis than observed in high-income populations. This has been found in other Latin American countries 13, 14. In our study, age at

Acknowledgments

We thank Sergio Lozano-Rodriguez, M.D. for his review of the manuscript.

We thank Dr. José Javier Sánchez-Hernández and Neri Alvarez-Villalobos, M.D. for their review of the statistical analysis.

Conflict of Interest: The authors confirm that there are no conflicts of interest in the present manuscript.

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