Early Stem Cell Transplants Studied for High-Risk Non-Hodgkin’s Lymphoma

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THE TOPLINE

  • Examined whether bone-marrow or stem-cell transplant after initial chemotherapy rather than after first relapse would improve survival for high-risk lymphoma patients
  • Found that pre-emptive transplant delays relapse but does not extend survival time, except for highest-risk patients

Autologous bone marrow transplantation (ABMT) and autologous stem cell transplantation (ASCT) have had an important role in the treatment of aggressive lymphoma for several decades. Most non-Hodgkin’s lymphoma (NHL) patients who relapse receive ABMT or ASCT after their second round of chemotherapy, which has proven effective at prolonging survival and delaying further relapse. Could bone-marrow or stem-cell transplantation immediately after initial chemotherapy — rather than after the first relapse — further improve the survival of patients with advanced-stage, aggressive lymphomas?

Research conducted by a team including Fox Chase President and CEO Richard I. Fisher, MD, and published in the New England Journal of Medicine in October 2013, suggests the picture is mixed. The study, developed by the SWOG cancer clinical trials cooperative group and funded by the National Cancer Institute, examined 253 high-risk NHL patients who had responded to an initial round of chemotherapy and assigned them to a control group (receiving further chemotherapy) or a transplant group (receiving ASCT).

A larger percentage of patients in the transplant group survived with no lymphoma relapse up to the two-year endpoint (69 percent compared with 55 percent in the control group), but the overall survival rates (including patients who had relapsed but survived to the two-year mark) were not significantly different between the groups — probably because many patients in the control group who relapsed were given a transplant following their second round of chemotherapy. Pre-emptive transplantation, then, appeared to be no more effective than post-relapse transplantation at prolonging survival for most patients.

However, secondary analysis suggested a major benefit for a subset of patients: those with the highest risk. These patients in the transplant group experienced 82 percent overall survival after two years, compared with an overall survival of 64 percent for the highest-risk patients in the control group. “For younger, otherwise healthy patients with high-risk lymphoma, initial treatment with R-CHOP [standard-of-care chemotherapy] followed immediately by ASCT seems a reasonable alternative” to the usual regimen, suggests Fisher.

He notes, though, that the world of lymphoma treatment is poised to change dramatically: “Our understanding of the biology of aggressive lymphomas has been altered in the last few years as a result of molecular profiling. Thus, we will likely see the development of novel targeted treatments that will also be studied in these patients.” ■