Clinical Trial Endorses Chemotherapy Alone for
A clinical trial comparing treatments for early stage aggressive lymphoma has found that an intensive regimen of chemotherapy is better than chemotherapy plus radiation for treating the disease in its early stages, according to a study in the March 24 New England Journal of Medicine.
Dr. Felix Reyes of the Hopital Henri Mondor in Creteil, France, and his colleagues found that an intensive regimen of doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (ACVBP) was superior to cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) plus radiation.
"After a median follow-up of 7.7 years, we found superior event-free and overall survival rates among patients treated with chemotherapy alone," the researchers wrote.
The 5-year estimates of event-free survival were 82 percent for patients receiving chemotherapy alone and 74 percent for those receiving chemotherapy plus radiation. The respective 5-year estimates of overall survival were 90 percent and 81 percent.
The study included 647 previously untreated patients with localized stage I or II aggressive lymphoma. All were between the ages of 15 and 61, and the most common subtype in the group was diffuse large B-cell lymphoma.
"This study indicates that highly effective chemotherapy regimens such as ACVBP are more effective than the older CHOP chemotherapy plus radiation for these patients," comments Dr. Wyndham Wilson of the Lymphoma Section of NCI's Experimental Transplantation and Immunology Branch. "So if you have very active chemotherapy, you don't need radiation for the early stage of the disease."
One of the contributions of this study, he adds, is to illustrate the concept that "good chemotherapy is probably the best you can do for this disease."
Three cycles of CHOP followed by radiation has been considered the standard therapy for localized lymphoma since a 1998 study found it to be superior to CHOP alone in a randomized trial of 400 patients.
Developed by the Groupe d'Etude des Lymphomes de l'Adulte, ACVBP consists of an induction phase with higher doses of doxorubicin and cyclophosphamide than those used in CHOP and a consolidation phase consisting of treatment with the drugs not used during induction. The ACVBP regimen is less well tolerated in elderly patients.
The current research was undertaken based on a previous study of two chemotherapy regimens for intermediate or high-grade lymphoma. In that study, the estimated 5-year rate of overall survival among patients with localized disease who received the ACVBP regimen was 80 percent.
In an accompanying editorial, Dr. James Armitage of the University of Nebraska Medical Center in Omaha discusses efforts to improve the classification of patients with lymphomas based on distinctive biological characteristics, such as patterns of gene activity, that one day can be used to make decisions about treatments.
Dr. Armitage observes, for example, that ACVBP may not have been the best treatment for all patients in the trial. He concludes, "Physicians who treat patients with lymphomas hope that we will continue to move away from the 'one-size-fits-all' approach."
By Edward R. Winstead