How would you counsel a patient with a new diagnosis of high-grade B-cell lymphoma (BCL)?

From the Guidelines

The patient with a new diagnosis of high-grade B-cell lymphoma should be treated with a combination chemotherapy regimen called R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), administered in cycles every 21 days for 6-8 cycles, as this approach has shown considerable single agent activity and potential for cure 1. When counseling the patient, it's essential to explain that high-grade B-cell lymphoma is an aggressive but potentially curable cancer of the immune system.

Key Components of Treatment

• The treatment regimen typically involves a combination of rituximab, which targets CD20 on B-cells, and chemotherapy drugs that disrupt cell division and growth.
• Common side effects include fatigue, hair loss, nausea, increased infection risk, and neuropathy.
• Prompt treatment initiation, regular follow-up appointments, and reporting any concerning symptoms like fever or unusual bleeding are crucial.

Diagnostic Workup

• Patients should undergo a CT-scan of the abdomen, a chest X-ray or a CT-scan of the chest, and a bone marrow aspirate and biopsy to assess the extent of the disease 1.
• A diagnostic spinal tap directly combined with a first prophylactic instillation of cytarabine or methotrexate should be considered in high-risk patients showing more than two adverse parameters according to the international prognostic index (IPI) 1.

Prognosis and Support

• The prognosis should be discussed based on the patient's specific subtype, stage, and risk factors, emphasizing that many patients achieve complete remission with appropriate treatment.
• Additional support would include arranging for a central venous catheter placement, baseline cardiac function testing before starting doxorubicin, and connecting the patient with support resources.
• Throughout treatment, response should be monitored with interim scans, and side effects should be managed proactively to maintain quality of life.

From the FDA Drug Label

The safety and effectiveness of RITUXAN were evaluated in three randomized, active-controlled, open-label, multicenter studies with a collective enrollment of 1854 patients Patients with previously untreated diffuse large B-cell NHL received RITUXAN in combination with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or other anthracycline-based chemotherapy regimens Among all enrolled patients, 62% had centrally confirmed DLBCL histology, 73% had Stage III–IV disease, 56% had IPI scores greater than or equal to 2,86% had ECOG performance status of < 2,57% had elevated LDH levels, and 30% had two or more extranodal disease sites involved Efficacy results are presented in Table 15.

When counseling a patient with a new diagnosis of high-grade B cell lymphoma, it is essential to discuss the following key points:

• The patient's disease type and stage
• The treatment options available, including RITUXAN in combination with CHOP or other anthracycline-based chemotherapy regimens
• The potential benefits and risks of each treatment option
• The importance of closely monitoring the patient's condition and adjusting the treatment plan as needed
• The patient's overall health and well-being, including their ECOG performance status and any potential extranodal involvement It is crucial to approach each patient's situation with caution and consider their individual needs and circumstances when making treatment decisions 2.

From the Research

Counseling a Patient with New Diagnosis of High-Grade B Cell Lymphoma

When counseling a patient with a new diagnosis of high-grade B cell lymphoma, several key points should be considered:

• The patient's treatment options and prognosis will depend on various factors, including their age, overall health, and the specific characteristics of their lymphoma 3, 4.
• Rituximab-based chemotherapy regimens, such as R-CHOP, are commonly used to treat high-grade B cell lymphoma and have been shown to be effective in achieving complete responses and improving survival rates 4, 5, 6.
• The addition of high-dose methotrexate and intrathecal chemotherapy to R-CHOP may be beneficial for patients with certain types of lymphoma, such as intravascular large B-cell lymphoma 5.
• Salvage regimens, such as R-DHAX, may be effective for patients with relapsed or refractory disease 7.
• The route of rituximab administration, whether intravenous or subcutaneous, may impact patient satisfaction and treatment burden, with subcutaneous administration potentially offering improved convenience and reduced administration time 6.

Key Considerations for Treatment

Some key considerations for treatment include:

• The patient's performance status and ability to tolerate aggressive chemotherapy regimens 3, 4.
• The presence of any comorbidities or underlying health conditions that may impact treatment tolerability 7.
• The potential for central nervous system involvement, which may require additional treatment with intrathecal chemotherapy 5.
• The patient's preferences and values, including their willingness to tolerate potential side effects and their desire for convenience and reduced treatment burden 6.

Ongoing Care and Support

Ongoing care and support are crucial for patients with high-grade B cell lymphoma, including:

• Regular follow-up appointments to monitor response to treatment and manage any side effects 3, 4.
• Supportive care measures, such as pain management and emotional support, to improve quality of life 7.
• Education and counseling to help patients understand their diagnosis, treatment options, and prognosis 6.