The use of aggressive, multi-agent chemotherapy for patients with certain low-grade lymphomas is no more effective than using a single drug, according to a recent report in the Journal of Clinical Oncology (Vol. 21,
No. 1: 5-15).

Several kinds of lymphoma are classified as low grade, meaning they are slow growing. About half of all such patients will live longer than five years; some may live more than 20 years.

Years ago it was found that regardless of how many different chemotherapy agents were used to treat lymphomas, patients could not be cured. Because of this, and the often indolent course of the disease, many oncologists were reluctant to use multi-drug chemotherapy in these patients.

Also, many patients with this cancer are elderly and less able to tolerate aggressive chemotherapy.

But the question always remained whether aggressive chemotherapy, if not curative, could be life-prolonging. To answer this, a group of researchers participating in the Cancer and Leukemia Group B (CALGB) in 1980 enrolled 228 patients with low-grade lymphoma and followed them for 20 years.

The patients had follicular lymphoma, the second most common type of lymphoma.

Half the patients were given a standard multi-drug regimen, CHOP-B, which consisted of cyclophosphamide (Cytoxan), doxorubicin (Adriamycin), vincristine (Oncovin), prednisone, and bleomycin. Most of these drugs were given by injection every three weeks. Certain drugs were stopped when patients reached the maximum dosage. The other patients received treatment with only cyclophosphamide, which was given as a pill daily.

Treatment was continued for two years in all patients whose tumors had shrunk. After that, the patients were observed and retreated if their tumors came back.

After 20 years, it was clear that the CHOP-B treatment was no better than the single pill. About 30% of patients were still alive in both groups.

However, even though many patients did not benefit from the aggressive regimen, a small subgroup of patients appeared to be helped. These patients had a follicular lymphoma in which some of the lymphoma cells were larger than others. These are called follicular mixed-cell lymphomas.

The majority of the patients in this study, about 80% of the total, all had follicular small-cell lymphoma.

Nearly 50% of the CHOP-B-treated patients with follicular mixed lymphoma were alive at the end of the study. This was much better than the patients with follicular mixed lymphoma who were treated only with the cyclophosphamide pills. Only 20% of them were alive at the end of the study.

The researchers cautioned they could not be sure of a true benefit for this small group of patients. This group was not broken out at the beginning of the study, so it does not hold up statistically. Yet, other studies had shown a benefit, and the CALGB researchers believe that it would be reasonable to treat patients with follicular mixed lymphoma with CHOP-B.