We write to express our concerns regarding the recent publication in the Annals of Oncology of recommendations for the clinical management of the elderly patient with malignant lymphoma from an ESMO Consensus Conference. In the past, ESMO has always supported a balanced and multidisciplinary approach to the treatment of malignant diseases, and we were therefore surprised and disappointed that these recommendations lacked a clear definition of the role for radiation therapy (RT) and expertise in this area in the authorship of the ‘multidisciplinary panel’ of 25 leading experts [1]. RT remains the most active single modality in the local treatment of most types of lymphoma and an important component of combined modality therapy in improving outcomes for patients. Modern limited and highly conformal RT to even low doses [2, 3] is highly effective and well tolerated by older patients, who often tolerate chemotherapy poorly and thus receive compromised regimens. Notably, the risk of radiation-induced second malignancies, which has largely driven the decreased use of RT, is not relevant in older patients as demonstrated in analyses of large databases. Intensive salvage therapy to frequently refractory and relapsed disease is often precluded in older patients, hence achievement of a durable remission with first-line combined modality treatment is even more crucial in older than in younger patients. Therefore, RT has a particularly important role to play in the often difficult management of lymphomas in older patients, and its omission from the published recommendations is of concern in maintaining the best outcomes for older patients with lymphomas. For patients with localized disease, local RT is an important part of curative treatment, either alone for indolent lymphomas or in combination with brief systemic treatment for aggressive lymphomas. Localized disease is most common in diffuse large B-cell lymphomas (30%–40% of cases), and in these patients even RT alone may be curative, thus providing an attractive treatment option for patients too old or frail to tolerate chemotherapy. For patients with advanced aggressive lymphomas, RT to residual disease after chemotherapy or to bulky and extra-nodal sites may offer a chance to achieve a more favorable outcome. Finally, RT is an excellent palliative treatment for indolent lymphomas in older patients, where doses as low as 4 Gy in two fractions offer durable local control with minor if any side-effects. These aspects of the treatment of lymphomas in older patients are seemingly absent in this ESMO paper in stark contrast to The International Society of Geriatric Oncology published guidelines for the use of RT for elderly patients, including patients with lymphoma [4], and to several recently published ESMO Guidelines on the management of different lymphomas. We hope that ESMO and Annals of Oncology will continue to support and ensure a balanced multidisciplinary approach to the treatment of malignant diseases, including lymphomas. Funding

Recommendations for the clinical management of the elderly patient with malignant lymphoma

Ricardi, U.;
2018-01-01

Abstract

We write to express our concerns regarding the recent publication in the Annals of Oncology of recommendations for the clinical management of the elderly patient with malignant lymphoma from an ESMO Consensus Conference. In the past, ESMO has always supported a balanced and multidisciplinary approach to the treatment of malignant diseases, and we were therefore surprised and disappointed that these recommendations lacked a clear definition of the role for radiation therapy (RT) and expertise in this area in the authorship of the ‘multidisciplinary panel’ of 25 leading experts [1]. RT remains the most active single modality in the local treatment of most types of lymphoma and an important component of combined modality therapy in improving outcomes for patients. Modern limited and highly conformal RT to even low doses [2, 3] is highly effective and well tolerated by older patients, who often tolerate chemotherapy poorly and thus receive compromised regimens. Notably, the risk of radiation-induced second malignancies, which has largely driven the decreased use of RT, is not relevant in older patients as demonstrated in analyses of large databases. Intensive salvage therapy to frequently refractory and relapsed disease is often precluded in older patients, hence achievement of a durable remission with first-line combined modality treatment is even more crucial in older than in younger patients. Therefore, RT has a particularly important role to play in the often difficult management of lymphomas in older patients, and its omission from the published recommendations is of concern in maintaining the best outcomes for older patients with lymphomas. For patients with localized disease, local RT is an important part of curative treatment, either alone for indolent lymphomas or in combination with brief systemic treatment for aggressive lymphomas. Localized disease is most common in diffuse large B-cell lymphomas (30%–40% of cases), and in these patients even RT alone may be curative, thus providing an attractive treatment option for patients too old or frail to tolerate chemotherapy. For patients with advanced aggressive lymphomas, RT to residual disease after chemotherapy or to bulky and extra-nodal sites may offer a chance to achieve a more favorable outcome. Finally, RT is an excellent palliative treatment for indolent lymphomas in older patients, where doses as low as 4 Gy in two fractions offer durable local control with minor if any side-effects. These aspects of the treatment of lymphomas in older patients are seemingly absent in this ESMO paper in stark contrast to The International Society of Geriatric Oncology published guidelines for the use of RT for elderly patients, including patients with lymphoma [4], and to several recently published ESMO Guidelines on the management of different lymphomas. We hope that ESMO and Annals of Oncology will continue to support and ensure a balanced multidisciplinary approach to the treatment of malignant diseases, including lymphomas. Funding
2018
29
4
1069
1070
http://annonc.oxfordjournals.org/
Hematology; Oncology
Specht, L.*; Aleman, B.; Eich, H.; Illidge, T.M.; Kirova, Y.; Mikhaeel, N.G.; Ricardi, U.; Yahalom, J.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/2318/1671012
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