The chemotherapy regimen R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) is the standard of care for newly diagnosed patients with diffuse large B-cell lymphoma (DLBCL). Treatment with R-CHOP can cure approximately 60% of patients, states Brad S. Kahl, MD.
Two molecular subtypes of DLBCL, the ABC subtype and GCB subtype, have different responses to R-CHOP therapy, says Kahl. Overall, patients with the ABC subtype have a worse prognosis. Strategies that may help improve the outcomes of patients with the ABC subtype include adding the immunomodulatory drug lenalidomide or ibrutinib, an oral Bruton’s tyrosine kinase (BTK) inhibitor, to R-CHOP.
Dose-adjusted R-EPOCH (rituximab plus etoposide, prednisolone, vincristine, cyclophosphamide, and doxorubicin) may help deliver the maximum amount of chemotherapy safely to the patient, says Richard R. Furman, MD. The continuous infusion with EPOCH therapy may also provide an advantage over the bolus infusion of CHOP chemotherapy for inducing responses.
Furman typically reserves R-EPOCH for individuals likely to have poor response to R-CHOP. Treatment with R-EPOCH involves hospitalization for each cycle of chemotherapy and monitoring of patient neutrophil counts in order to make the necessary dose adjustments.
Many clinicians reserve dose-adjusted R-EPOCH for individuals with DLBCL who have overexpression of MYC and BCL2, also known as double-hit lymphoma, notes Kahl, although the efficacy of R-EPOCH versus R-CHOP has not been established.
Brentuximab vedotin is an antibody-drug conjugate that targets CD30 and has demonstrated high single-agent activity in Hodgkin lymphoma and anaplastic large cell lymphoma. An ongoing study is evaluating the effectiveness of adding brentuximab vedotin to R-CHOP in individuals with DLBCL. In a phase II trial, combining brentuximab vedotin with standard R-CHOP yielded objective responses in 80% of patients with advanced DLBCL.