Electronic Health Record Data Can Help Determine Highest Risk of Early Death from Chemotherapy in Older Patients with Lymphoma
As published in JNCCN , a new Brown University study of registry data for older patients with diffuse large B-cell lymphoma treated with contemporary immunochemotherapy found opportunities to mitigate early death using key risk factors in decision-making and providing prophylactic administration of G-CSF; additional studies are warranted.
FORT WASHINGTON, PA — 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, Brown University and Rhode Island Hospital, looked at Medicare claims linked to Surveillance, Epidemiology and End Results registry (SEER-Medicare) data for more than 5,500 patients, ages 65 and older, with DLBCL who were treated with contemporary immunochemotherapy—rituximab, cyclophosphamide, and vincristine in combination with doxorubicin, mitoxantrone, or etoposide. Their findings are published online in the September issue of JNCCN – Journal of the National Comprehensive Cancer Network . Complimentary access to the study is available until November 30, 2016.
“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.
Dr. Olszewski and his fellow researchers identified six key risk factors for early death in older patients with DLBCL: disease-related symptoms (“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 zero to one identified risk factor have very low risk of early death, while those who presented with four 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) 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, Memorial Sloan Kettering Cancer Center , NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel Chair for Non-Hodgkin’s Lymphomas .
For complimentary access to this article, visit JNCCN.org .
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About the National Comprehensive Cancer Network
The National Comprehensive Cancer Network® (NCCN®), a not-for-profit alliance of 27 of the world’s leading cancer centers devoted to patient care, research, and education, is dedicated to improving the quality, effectiveness, and efficiency of cancer care so that patients can live better lives. Through the leadership and expertise of clinical professionals at NCCN Member Institutions, NCCN develops resources that present valuable information to the numerous stakeholders in the health care delivery system. As the arbiter of high-quality cancer care, NCCN promotes the importance of continuous quality improvement and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision-makers.
The NCCN Member Institutions are: Fred & Pamela Buffett Cancer Center, Omaha, NE; Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute, Cleveland, OH; City of Hope Comprehensive Cancer Center, Los Angeles, CA; Dana-Farber/Brigham and Women’s Cancer Center | Massachusetts General Hospital Cancer Center, Boston, MA; Duke Cancer Institute, Durham, NC; Fox Chase Cancer Center, Philadelphia, PA; Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT; Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance, Seattle, WA; The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL; Mayo Clinic Cancer Center, Phoenix/Scottsdale, AZ, Jacksonville, FL, and Rochester, MN; Memorial Sloan Kettering Cancer Center, New York, NY; Moffitt Cancer Center, Tampa, FL; The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, Columbus, OH; Roswell Park Cancer Institute, Buffalo, NY; Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, MO; St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center, Memphis, TN; Stanford Cancer Institute, Stanford, CA; University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL; UC San Diego Moores Cancer Center, La Jolla, CA; UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA; University of Colorado Cancer Center, Aurora, CO; University of Michigan Comprehensive Cancer Center, Ann Arbor, MI; The University of Texas MD Anderson Cancer Center, Houston, TX; University of Wisconsin Carbone Cancer Center, Madison, WI; Vanderbilt-Ingram Cancer Center, Nashville, TN; and Yale Cancer Center/Smilow Cancer Hospital, New Haven, CT.
Katie Kiley Brown, NCCN