Among elderly patients with indolent B-cell lymphoma, bendamustine-based first-line chemotherapy may yield a superior event-free survival (EFS) rate, as well as fewer toxic events, compared with a cyclophosphamide-based regimen, according to a paper published in the American Journal of Hematology. Overall survival (OS), however, may be similar between both regimens.

Indolent B-cell lymphomas are more common in elderly patients, and cyclophosphamide-based regimens have been the standard treatment for years. However, there is evidence that bendamustine with rituximab (BR) may yield superior progression-free survival (PFS) rates compared with cyclophosphamide-based treatments, including rituximab, cyclophosphamide, vincristine, and prednisone (RCVP) and RCVP with doxorubicin (R-CHOP).

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There is uncertainty as to whether BR yields superior OS rates as well and whether the cost-effectiveness is sufficient for recommending BR over RCVP or R-CHOP in real-world settings. For this observational comparative study, researchers evaluated whether a gradual switch from RCVP/RCHOP to BR yielded superior outcomes among older patients with indolent B-cell lymphoma.

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The analysis cohort included data from 3491 patients, of whom 1748 had follicular lymphoma (FL), 969 had mantle cell lymphoma (MCL), and 774 had marginal zone lymphoma/lymphoplasmacytic lymphoma (MZL/LPL); 1670 patients received R-CHOP/RCVP while 1821 received BR. The researchers matched 1368 patients who received BR in a one to one fashion with 1368 patients who received R-CHOP/RCVP, with balanced confounding variables.

Within the evaluated subset, EFS was superior in the BR group overall (hazard ratio [HR], 0.78; 95% CI, 0.70-0.87), though OS was similar (HR, 1.03; 95% CI, 0.91-1.17). BR use was also linked to fewer hospitalizations (33% vs 45%), intensive care unit admissions (15% vs 19%), infections (21% vs 30%), cardiovascular events (28% vs 35%), cases of thromboembolism (12% vs 17%), transfusions (9% vs 21%), and cases of neuropathy (3% vs 5%).

However, BR was linked to higher rates of rash and higher mean Medicare spending in the first year of treatment ($92,523 vs $75,010 with R-CHOP/RCVP, P <.0001) compared with R-CHOP/RCVP. The rate of secondary cancers was similar between both groups.

In matched subcohort analysis, the EFS improvement noted with BR was present among patients with MCL (HR, 0.64; 95% CI, 0.54-0.76) and patients with FL (HR, 0.83; 95% CI, 0.69-0.98) but not among patients with MZL/LPL (HR, 0.92; 95% CI, 0.73-1.17).

“This real-world assessment of BR application among older patients with [indolent B-cell lymphomas] suggests that first-line bendamustine, despite longer EFS and lower toxicity, did not improve OS, and it still results in frequent hospitalizations, infections, and cardiovascular events during therapy,” the researchers concluded.


1.     Olszewski AJ, Butera JN, Reagan JL, Castillo JJ. Outcomes of bendamustine- or cyclophosphamide-based first-line chemotherapy in older patients with indolent B-cell lymphoma [published online December 17, 2019]. Am J Hematol. doi:10.1002/ajh.25707