Longer remissions with early stem cell transplants for non-Hodgkin lymphoma

Performing early stem cell transplants in patients with aggressive non-Hodgkin lymphoma does not improve overall survival in high-risk patients, according to a new study. However, early transplantation appears to be beneficial among the small group of patients who are at the very highest risk.

The traditional first-line therapy for aggressive non-Hodgkin's lymphoma is a combination of four chemotherapy drugs. In recent years, physicians have added a fifth drug, the monoclonal antibody rituximab. This five-drug regimen is known as R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisolone). The treatment typically puts patients into remission. But many patients relapse and go on to get an autologous stem cell transplant after second-line chemotherapy.

The study was designed to determine whether doing an early stem cell transplant—without first waiting to see whether a patient relapses—would increase survival. The lead author of the study was Patrick Stiff, MD, director of Loyola University Medical Center's Cardinal Bernardin Cancer Center, in Maywood, Illinois. The study was developed by the SWOG cancer research cooperative group and published in the New England Journal of Medicine (2013; 369:1681-1690).

The study included 397 patients who were in defined groups of high risk or intermediate-high risk of relapsing. After initial chemotherapy, those who responded were randomly assigned to receive an autologous stem cell transplant (125 patients) or to a control group (128 patients) who received three additional cycles of the R-CHOP regimen. Enrollment began in 1999 and ended in 2007. (Some of the patients in the beginning of the study did not receive rituximab.)

After 2 years, 69% of the transplantation patients had no disease progression, compared with 55% of the control group—a statistically significant difference. However, the difference in 2-year survival rates (74% in the transplantation group and 71% in the control group) was not statistically significant. This is probably because patients in the control group who relapsed were later offered stem cell transplants, Stiff and colleagues wrote.

But while stem cell transplants did not improve overall survival among the entire group of high-risk and intermediate-high risk patients, the subset of high-risk patients did appear to receive both a remission and a survival benefit. A retrospective analysis of the data showed that, among these high-risk patients, the 2-year survival rate was 82% in the transplantation group and 64% in the control group.

"Early transplantation and late transplantation achieve roughly equivalent overall survival in the combined risk groups," the researchers concluded, yet "early transplantation appears to be beneficial for the small group of patients presenting with high-risk disease."

Stiff said this finding "hopefully will trigger discussions between such patients and their physicians as to the feasibility of doing early transplants."

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