Multicenter Analysis of 150 Very Elderly Non-Hodgkin's Lymphoma (NHL) Patients: Impact of Comorbidities and Response to Initial Therapy on Survival
Authors: Evens Andrew M , Nabhan Chadi , Helenowski Irene , Larsen Annette , Ramsdale Erika E. , Karmali Reem , Feliciano Josephine L. , Parsons Benjamin , McKoy June M , Gregory Stephanie A. , Smith Sonali M 
Published: October 2019

Abstract
Abstract 3124

Background:
The incidence of NHL increases exponentially with rising age. The most rapidly growing segment of the population is persons > age 65 years, especially > age 80. As a percentage of US population, the age group >80 years has increased by >250% from 1960 to 2000. Furthermore, persons >80 years will more than double within 20 years. However, little data is available regarding the characteristics or outcomes of very elderly NHL patients (pts).

Methods:
We completed a multicenter retrospective analysis of very elderly NHL pts (=/> 80) diagnosed (dx) between 9/99-9/09 at 4 Chicago centers. Detailed pt and disease characteristics were collected including comorbidities, which were assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pts were also classified if they were “fit” (i.e., preserved activities of daily living (ADLs), <3 grade 3 CIRS-G, no grade 4, and no geriatric syndrome: dementia, delirium, depression, incontinence, falls, neglect/abuse, or failure to thrive).

Result:
We identified 150 pts (F:M 1.14) with a median age of 84 years (80-96). 74 pts had aggressive NHL histology: DLBCL n=56 (systemic n=49, primary CNS n=5, gastric n=1, PEL n=1), T-cell n=11 (peripheral n=7, Sezary n=4) and MCL n=7. 76 pts had indolent NHL: follicular n=32, mycoses fungoides n=16, MZL n=17, CLL/SLL n=8 and lymphoplasmacytic n=4. Disease characteristics at dx included: B symptoms 20%, PS 2–3 18%, marrow involvement 35%, >1 extranodal 20%, elevated LDH 38%, anemia 41%, thrombocytopenia 16%, renal insufficiency 25%, and 36% had a history of coronary artery disease. Additionally, 28% had prior malignancy. Comorbidities were common; 77% of pts had a cumulative CIRS score >6, while 74% had a grade 3–4 CIRS-G in at least 1 category. Furthermore, 33% were classified as “not fit” at NHL dx, 12% had loss of ADLs, while 22% had a geriatric syndrome at time of NHL dx. 57% had stage III/IV disease. Pts with aggressive B cell histology received a rituximab (R)-containing regimen 85% of the time, while 84% of all aggressive NHL received at least one cycle with an anthracycline. Initial therapy for B cell indolent NHL were: observation (24%), R alone (35%), R-chemotherapy (CT) (31%), radiation (8%), and CT alone (2%). Among all pts, the overall response to first treatment was 68% (CR 49%). With 40-month median follow-up (1-120), 3-year EFS (event-free survival) and OS (overall survival) for all pts were 43.8% and 70.3%, respectively (stage I/II: EFS 49% and OS 81%; stage III/IV: EFS 42% and OS 65%; p=0.039 and p=0.09, respectively). Among aggressive NHL (n=74), 3-year EFS and OS were 55% and 64% (stage I/II: EFS 86% and OS 94%; stage III/IV: EFS 45% and OS 57%; p=0.0006 and p=0.03, respectively), while for indolent NHL (n=76), the 3-year EFS and OS were 34% and 77%, respectively (Figures 1–3). Prognostic factors predicting survival are shown in Table 1. In multivariate regression analyses, no response to initial therapy (i.e., SD/PD) predicted for significantly inferior EFS and OS (HR 5.45 [2.02-13.65], p=0.0007 and HR 6.88 [1.66-28.44], p=0.008, respectively).

Conclusion:
Long-term survival of very elderly NHL was feasible with 64% and 77% 3-year OS for aggressive and indolent histologies, respectively. However, comorbidities as well as a designation of “unfit” portended a significantly inferior outcome in univariate models. Primary resistance to initial therapy occurred in 32% of pts and also predicted for poor prognosis. Given the rising incidence and prevalence of very elderly NHL, prospective examination of this subset of pts is strongly warranted.

Disclosures:
No relevant conflicts of interest to declare.