Bendamustine and rituximab is effective and cost-effective in older cases with aggressive lymphomas?

I read with great interest the paper published by Weidmann et al. Their paper is a phase II study in cases ‡80 years with aggressive lymphoma treated by bendamustine plus rituximab (BR) [1]. Majority of these cases (11 of 14) had diffuse large B-cell lymphoma (DLBCL). When we looked at the efficacy of this regimen, complete response (CR) and partial response (PR) were reported in 54% and 15% of the cases, respectively, and disease progression occurred in 31% of the cases. Median overall survival (OS) and progression-free survival (PFS) were found to be 7.7 months. When we looked at the toxicity profile, grade III–IV neutropenia was detected in 17% and 6% of the cases, respectively, and grade IV non-hematotoxicity was 11%. They concluded that BR regimen is an effective regimen and has low toxicity profile in older cases not eligible for combination therapy with rituximab, cyclophosphamide, doxorubicin, vincristin and prednisone (R-CHOP regimen) in the treatment of aggressive lymphomas. These results are acceptable and manageable for toxicity but unacceptable for PFS and OS. Previously, it has been shown that BR regimen is highly effective and less toxic as compared with classic CHOP (combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone) regimen in low-grade lymphomas [2]. However, this high efficacy has not been shown in aggressive lymphomas. We know that lymphoma is an aging disease and accompanying comorbid conditions preclude the use of effective drugs. Additionally, more aggressive biology of this disease in older cases is another problem. For this reason, therapeutic choices in these frail cases cause dilemma in clinical practice. In older cases, the majority of the cases have DLBCL as seen in younger cases, which is prevalent in the Weidmann series. Today, the standard regimen is R-CHOP in DLBCL and other more toxic regimens, except in some special clinical situations, are not more effective than R-CHOP. At this point, recently, Groupe d’étude des lymphomes de l’adulte (GELA) investigators published an important multicentric phase II study titled ‘Attenuated immunochemotherapy regimen (R-mini-CHOP) in elderly patients older than 80 years with diffuse large B cell lymphoma’ [3]. In this study, profile of the letters to the editor Annals of Oncology