R-CEOP as first-line treatment for anthracycline-ineligible patients with diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most frequently diagnosed non-Hodgkin lymphoma (NHL) [ 1 ]. Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) is the standard treatment for DLBCL. Nevertheless, doxorubicin, like all anthracyclines, is associated with dose-dependent cardiotoxicity [ 2 ]. Particularly in patients with congestive heart failure and patients previously exposed to anthracyclines, the use of doxorubicin is contraindicated. In the Netherlands, doxorubicin is most frequently replaced by etoposide (R-CEOP) for anthracyclines-ineligible patients, but efficacy data regarding this regimen are scarce. Recently, two population-based studies from Canada reported on the outcome of R-CEOP. R-CEOP was feasible, although the two studies showed conflicting results [ 3 , 4 ]. While one study showed inferior outcome of patients treated with R-CEOP, the other observed no difference in disease-specific survival (DSS) between R-CEOP and R-CHOP. Randomized clinical trials (RCT) would be needed to evaluate the efficacy of R-CEOP unbiased, compared to R-CHOP. However, RCTs among anthracyclines-ineligible patients would be unethical, as patients randomized to the doxorubicin-group would experience severe cardiotoxicity due to their cardiac dysfunction. Therefore, propensity-score-matching using population-based data is needed. The aim of this population-based study was to determine the efficacy of R-CEOP in anthracycline-ineligible patients with DLBCL.