CHOP Disappearing as Standard of Care for Indolent NHL

Charles Bankhead

May 2013, Vol 4, No 4 - Hematologic Malignancies

A long-standing treatment standard for indolent non-Hodgkin lymphoma (NHL) has fallen victim to the chopping block, so to speak, at least in Germany.

The use of the cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), vincristine (Oncovin), and prednisone (Deltasone; CHOP) regimen with or without rituximab (Rituxan; R-CHOP) has declined rapidly with the emergence of bendamustine (Treanda), which is used either alone or with ri­tuximab.

An analysis of a German patient registry showed that 16% of patients with NHL received CHOP, as opposed to more than 70% who received bendamustine-based therapy.

 “The use of CHOP continues to decline in Germany, and it will soon be dead,” said Wolfgang Knauf, MD, PhD, a hematologist with Onkologische Gemeinschaftspraxis in Frankfurt. “CHOP or R-CHOP can no longer be considered standard of care.”

Rituximab remains popular as first-line systemic therapy for patients with indolent NHL, either as monotherapy or in various combinations, often with bendamustine, Dr Knauf said.

The findings and Dr Knauf’s observations came from the examination of data from a clinical registry of patients with B-cell lymphoid malignancies. Investigators at 106 participating centers in Germany have contributed data for 2579 patients. The registry has a target enrollment of 1000 patients with indolent NHL, 1000 with aggressive lymphomas, 1000 with chronic mye­logenous leukemia, and 500 patients with multiple myeloma.

Registries provide data that are useful for evaluating trends in the management of diseases, including the success of new therapies in clinical practice, said Dr Knauf. He reported findings for 645 patients with indolent NHL who were treated with systemic therapy as first-line treatment.
The results showed that 7% of patients had stage I disease at diagnosis, 15% had stage II, 24% had stage III, and 54% had stage IV disease.

Rituximab was a component of first-line therapy for 606 (94%) patients and bendamustine for 455 (71%) patients. The 2 drugs were used in tandem as first-line treatment for 428 (66%) of these patients. R-CHOP was first-line systemic therapy for 105 (16%) patients.

The use of the bendamustine–rituximab combination as first-line therapy increased from 62% of cases in 2009 to 68% in 2011. In contrast, the use of R-CHOP decreased from 19% in 2009, continuing a decline that began before the registry, said Dr Knauf.

The registry data included 121 patients who received second-line systemic therapy. The bendamustine–ri­tuximab combination was used in 60% of these cases, bendamustine monotherapy in 7%, and R-CHOP in 7%.

Dr Knauf acknowledged that small subgroups of patients might still benefit from R-CHOP, but the bendamustine–rituximab combination has established itself as standard therapy for most patients with indolent NHL.