Chemoimmunotherapy

In a prospective trial, 560 patients older than 60 years and not eligible for SCT were randomly assigned to receive induction therapy with either R-CHOP or R-FC (rituximab, fludarabine, cyclophosphamide) for six to eight cycles. Patients with disease response (n = 316) were then randomly assigned to receive maintenance therapy with either rituximab or interferon alfa.[3]

In a prospective trial, 560 patients older than 60 years and not eligible for SCT were randomly assigned to receive induction therapy with either R-CHOP or R-FC (rituximab, fludarabine, cyclophosphamide) for six to eight cycles. Patients with disease response (n = 316) were then randomly assigned to receive maintenance therapy with either rituximab or interferon alfa.[3]

Focusing on the randomized induction therapy (n = 560), with a median follow-up of 7.6 years, the median overall survival (OS) was 6.4 years in the R-CHOP group and 3.9 years in the R-FC group (P = .0054).[3][Level of evidence A1]

In a prospective trial, 560 patients older than 60 years and not eligible for SCT were randomly assigned to receive induction therapy with either R-CHOP or R-FC (rituximab, fludarabine, cyclophosphamide) for six to eight cycles. Patients with disease response (n = 316) were then randomly assigned to receive maintenance therapy with either rituximab or interferon alfa.[3]

Focusing on the randomized maintenance therapy (n = 316 responders), with a median follow-up of 8 years, the median OS was 9.8 years in the rituximab group and 7.1 years in the interferon alfa group (P = .009).[3][Level of evidence A1]

A randomized trial compared bendamustine and rituximab (BR) with R-CHOP. Progression free-survival (PFS) improved in patients who received BR (35 months) compared with patients who received R-CHOP (22 months) (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.28–0.79; P = .004). There was no difference in OS.[4][Level of evidence B1]

A randomized trial compared bendamustine and rituximab (BR) with R-CHOP. Progression free-survival (PFS) improved in patients who received BR (35 months) compared with patients who received R-CHOP (22 months) (hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.28–0.79; P = .004). There was no difference in OS.[4][Level of evidence B1]

This trial failed to show any benefit for rituximab maintenance therapy after BR.

A prospective randomized trial of 487 patients compared VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, prednisone) with R-CHOP.[5]

A prospective randomized trial of 487 patients compared VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, prednisone) with R-CHOP.[5]

With a median follow-up of 82 months, the median OS was longer in the VR-CAP group (90.7 months) than in the R-CHOP group (55.7 months) (HR, 0.66; 95% CI, 0.51−0.85; P = .001).[5][Level of evidence A1]

A prospective randomized trial from the European MCL Network included 497 patients younger than 65 years. The trial compared six cycles of R-CHOP with six cycles of alternating R-CHOP and R-DHAP (rituximab, dexamethasone, cytarabine, and cisplatin), with both groups then receiving autologous SCT.[1,2][Level of evidence B1] This trial is often referenced by subsequent articles to assert a role for cytarabine in induction therapy, but the ultimate lack of survival advantage casts doubt on this assertion. This regimen is clearly not applicable for older, less fit patients with comorbidities who are not eligible for transplant.

A prospective randomized trial from the European MCL Network included 497 patients younger than 65 years. The trial compared six cycles of R-CHOP with six cycles of alternating R-CHOP and R-DHAP (rituximab, dexamethasone, cytarabine, and cisplatin), with both groups then receiving autologous SCT.[1,2][Level of evidence B1] This trial is often referenced by subsequent articles to assert a role for cytarabine in induction therapy, but the ultimate lack of survival advantage casts doubt on this assertion. This regimen is clearly not applicable for older, less fit patients with comorbidities who are not eligible for transplant.

With a median follow-up of 10.6 years, the 10-year PFS rate was 73% for patients who received R-DHAP and 57% for patients who received R-CHOP (HR, 0.56; P = .038). There was no difference in the 10-year OS rates (60% [R-DHAP] vs. 55% [R-CHOP]; HR, 0.80; 95% CI, 0.61–1.06; P = .12).[6][Level of evidence B1]