Treatment patterns and outcomes of unfit and elderly patients with Mantle cell lymphoma unfit for standard immunochemotherapy: A UK and Ireland analysis

Mantle cell lymphoma (MCL) presenting in elderly, unfit patients represents a clinical challenge. Front-line 'attenuated' or low-intensity immunochemotherapy is often employed, although outcomes are relatively unexplored. We report outcomes of attenuated immunochemotherapy in 95 patients with MCL across 19 centres in the UK and Ireland considered unfit for full-dose rituximab-bendamustine or rituximab-cyclophosphamide, doxorubicin, vincristine, prednisolone (R-CHOP). Regimens examined were rituximab-cyclophosphamide, vincristine, prednisolone (R-CVP) (n = 19), dose-attenuated R-CHOP (n = 22), dose attenuated rituximab-bendamustine (n = 24) and rituximab-chlorambucil (n = 30). The primary outcome was progression-free survival (PFS). The secondary outcomes included overall response, overall survival (OS) and toxicity. The median (range) age was 79 (58-89) years and 50% were aged >= 80 years. The median (range) Cumulative Illness Rating Scale-Geriatric score was 6 (0-24). The median PFS for all patients was 15 months [95% confidence interval (CI) 8 center dot 7-21 center dot 2) and median OS was 31 center dot 4 months (95% CI 19 center dot 7-43 center dot 2). By multivariable analysis (MVA), the only clinical factor associated with an inferior PFS was blastoid morphology [hazard ratio (HR) 2 center dot 90, P = 0 center dot 01). Notably, higher treatment intensity (R-CHOP/R-bendamustine composite) provided an independently superior PFS compared with R-CVP/R-chlorambucil (MVA HR 0 center dot 49, P = 0 center dot 02). Factors associated with inferior OS by MVA were Eastern Cooperative Oncology Group Performance Status (HR 2 center dot 14, P = 0 center dot 04), blastoid morphology (HR 4 center dot 08, P = 0 center dot 001) and progression of disease at <24 months status (HR 5 center dot 68, P < 0 center dot 001). Overall, survival after front-line dose-attenuated immunochemotherapy is unsatisfactory. Clinical trials investigating novel agents such as Bruton tyrosine kinase and B-cell lymphoma 2 inhibitors in this specific clinical setting are warranted.

Automated summary

This study looked at the outcomes of attenuated immunochemotherapy in elderly, unfit patients with mantle cell lymphoma. The study found that the median progression-free survival was 15 months, and that higher treatment intensity provided a better progression-free survival compared to lower intensity regimens. Overall, survival after front-line dose-attenuated immunochemotherapy was found to be unsatisfactory, indicating a need for further research on novel agents in this specific clinical setting.