Non-Hodgkin’s lymphoma (NHL) is the sixth most common cancer in the UK; 9443 new cases were diagnosed in the UK in 2002, and it caused 4418 UK deaths in 2003. Incidence rates show distinct geographical variation, with age-standardised incidence rates ranging from 17 per 100,000 in northern America to 4 per 100,000 in south-central Asia. NHL occurs more commonly in males than in females, and the age-standardised UK incidence increased by 10.3% between 1993 and 2002.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of first-line treatments for aggressive, or for relapsed aggressive, non-Hodgkin's lymphoma (diffuse large B-cell lymphoma)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 26 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: allogeneic stem-cell support, chemotherapy (conventional dose salvage, high-dose plus autologous transplant stem-cell support, conventional dose in people with chemosensitive disease), CHOP 14, CHOP 21, CHOP 21 with radiotherapy, CHOP 21 with rituximab, ACVBP, MACOP-B, m-BACOD, PACEBOM, and ProMACE-CytaBOM.
Non-Hodgkin’s lymphoma (NHL) is the sixth most common cancer in the UK, with a 10% increase in incidence between 1993 and 2002.
Risk factors include immunosuppression, certain viral and bacterial infections, and exposure to drugs and other chemicals.Overall 5-year survival is around 55%. The main risk factors for a poor prognosis are older age, elevated serum lactate dehydrogenase levels, and severity of disease.
CHOP 21 has been shown to be superior or equivalent to all other combination chemotherapy regimens in terms of overall survival or toxicity in adults older or younger than 60 years.
Adding radiotherapy to a short CHOP 21 schedule (3 cycles) increases 5-year survival, while reducing the risks of congestive heart failure, compared with longer schedules of CHOP 21 alone.Adding rituximab to CHOP 21 increases response rates and 5-year survival compared with CHOP 21 alone.
CHOP 14 may increase 5-year survival compared with CHOP 21 in people aged over 60 years, but effects are less clear in younger adults. Toxicity is similar for the two regimens.
Consensus is that conventional-dose salvage chemotherapy should be used in people with relapsed NHL. Phase II studies report similar response rates with a number of different chemotherapy regimens.
Adding rituximab to salvage chemotherapy may improve initial response rates, but no more than 10% of people remain disease-free after 3 to 5 years.
High-dose salvage chemotherapy plus autologous bone-marrow transplantation may increase 5-year event-free survival and overall survival compared with conventional-dose chemotherapy in people with relapsed chemotherapy-sensitive disease, but it increases the risk of severe adverse effects.
We don't know whether allogenic bone-marrow transplantation improves survival. Retrospective studies suggest that it increases the risk of graft-versus-host disease and complications of immunosuppression.