Weekly blog -- "Aggressive lymphoma in an elderly patient"

Some take home reading:

This lancet oncology article discusses the challenges in treating elderly patients with hematological malignancies (link)

It also addresses "pre-chemo" treatment for DLBCL including corticosteroids for 7 days to be helpful in patients with poorer ECOG status to see if there is an improvement (but likely not helpful in ECOG 0-1)

For DLBCL reduced dose CHOP with full dose rituximab seems (on the basis of 2012 article) to be the best therapy for suitable patients.  Overall survival quoted in the article ranged from 35-56% at three years.

Standardized geriatric assessment may be helpful in deciding on a treatment strategy (link)

Burkitt's lymphoma may be another animal compared to other DLBCL -- with median survivals measured in months for patients over age 70 (link) ... And with CHOP-R 2 year progression free survival is less than 30%

HyperCVAD isn't tolerated by the majority of elderly patients.

EPOCH has not been tested in the elderly, but has been investigated with some success in the younger populations (link)

Really, a clinical trial is needed.

*****

On to rasburicase -- a pricy little addition to TLS management --

One way to reduce cost is to use less drug -- this meta-analysis suggests one dose may be as good as a full course (link) as does this smaller study (link) and this one where they saved 2 million dollars over 48 patients... (link)  There are more articles on this showing the same thing... (here too)

One could consider adding allopurinol after rasburicase (link) -- though it may not differ to single shot rasburicase

What was interesting is that in 2010 a Cochrane review in CHILDREN could not find an effect for the drug on renal failure or mortality (link)

A meta-analysis in ADULTS was performed (but not meta-analyzed due to heterogeneity) in 2013 which showed that uric acid goes down, but couldn't confirm hard outcomes either (link)

For a drug which costs up to $3600 per 7.5-mg vial (and you get 0.2mg/kg x 5 days if you follow the manufacturer's instructions) that is more than $30,000 per person treated (we pay much less if local data is believable)...  Amazing there is no better RCT data on this drug which is recommended for anyone with "high TLS risk, being >5%" or intermediate TLS risk (1-5%) with comorbidities.

For those interested in cost-benefit articles -- here is one on rasburicase (link) which makes a number of assumptions and states the drug is cost-effective...  I couldn't find the conflict of interest statements from the authors.  Also the cost of the drug modelled was only $2200 for adults (total course).   

Assuming the drug is only 3 times that price.  I'm pretty sure this would yield significantly different conclusions about its cost-effectiveness.  The CER for PREVENTION in ADULTS would be $120,000.

For treatment, that would depend on whether or not it works to prevent the downstream costs... and as I eluded to above, that is unclear.