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Electronic Health Record Data May Help Identify Older Patients at Highest Risk of Early Death From Chemotherapy for Diffuse Large B-Cell Lymphoma

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Key Points

  • Researchers identified six key risk factors for early death in older patients with DLBCL: disease-related B symptoms, chronic kidney disease, poor performance status, prior use of walking aids or wheelchairs, prior hospitalization within the past 12 months, and upper endoscopy within the past 12 months.
  • Of patients studied, those with 0–1 identified risk factor have very low risk of early death, whereas those who presented with 4 or more were 13 times more likely to die from chemotherapy complications.
  • Administration of prophylactic G-CSF was associated with lower probability of early death in the high-risk group.

Although diffuse large B-cell lymphoma (DLBCL) is a curable disease in most patients aged 65 years or older, these patients are also at higher risk of chemotherapy-related death within the first 30 days of treatment.

To quantify the risk of early fatality and identify risk factors, researchers led by Adam J. Olszewski, MD, Assistant Professor of Clinical Medicine at the Alpert Medical School of Brown University and oncologist at Rhode Island Hospital, looked at Medicare claims linked to Surveillance, Epidemiology, and End Results registry (SEER-Medicare) data for more than 5,500 patients aged 65 and older with DLBCL who were treated with contemporary immunochemotherapy—rituximab (Rituxan), cyclophosphamide, and vincristine in combination with doxorubicin, mitoxantrone, or etoposide. Their findings were published by Olszewski et al in the Journal of the National Comprehensive Cancer Network.

“Identifying the risk of severe complications is challenging given the paucity of data and heterogeneity in physiologic reserve among patients of the same age,” said Dr. Olszewski.

Key Findings

Dr. Olszewski and his fellow researchers identified six key risk factors for early death in older patients with DLBCL: disease-related B symptoms, chronic kidney disease, poor performance status, prior use of walking aids or wheelchairs, prior hospitalization within the past 12 months, and upper endoscopy within the past 12 months. They also found the risk of early death within the first round of treatment was significantly higher in patients 75 years or older.

Of patients studied, those with 0 to 1 identified risk factor have very low risk of early death, whereas those who presented with 4 or more were 13 times more likely to die from chemotherapy complications. Furthermore, researchers noted that administration of prophylactic granulocyte colony-stimulating factor (G-CSF, Neupogen) was associated with lower probability of early death in the high-risk group.

“It is equally important to realize that a majority of older patients without risk factors can safely receive curative immunochemotherapy. Enhanced supportive care and monitoring should be provided for high-risk groups,” said Dr. Olszewski. “The first month of treatment, when patients are compromised both by active lymphoma and toxicities of chemotherapy, is a period of particular concern, as nearly one in four patients were hospitalized during that time. While comprehensive geriatric assessment remains the gold standard for risk assessment, our study suggests that readily available data from electronic medical records can help identify the high-risk factors in practice.”

While further research is warranted, immediate opportunity for lowered rates of chemotherapy-related mortality while treating patients most likely to tolerate the treatment lay in the identification of the six risk factors for early death that can be culled from electronic heath record data and integrated into digital support tools for enhanced decision-making at point of care, the researchers noted. Furthermore, the study indicated an opportunity for preventive intervention with prophylactic G-CSF.

“It is important to identify patients at risk for treatment-related complications particularly for the selection of patients that may benefit from ‘pre-phase’ therapy to mitigate risk. The model proposed by Olszewki et al provides a simple assessment of treatment-related risk,” said Andrew D. Zelenetz, MD, PhD, Medical Director of Quality Informatics and medical oncologist at Memorial Sloan Kettering Cancer Center and NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Panel Chair for Non-Hodgkin’s Lymphomas.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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