Most relapses following treatment for diffuse large B-cell lymphoma are detected by abnormalities on physical exam, lab tests, and symptoms—not by routine imaging, according to a study presented at the ASCO Annual Meeting.1 In fact, in a prospective study assessing post-treatment outcomes of patients on surveillance, only 1.5% of relapses were detected in asymptomatic patients by planned scans.
“Our results were surprising, because the current standard of care is to include scans for the follow-up of [diffuse large B-cell lymphoma]. We found that scans detected relapse in only a handful of patients who didn’t have any of those other signs and symptoms. We are getting closer to understanding how to optimize follow-up in this patient population,” said lead author Carrie A. Thompson, MD, a hematologist at the Mayo Clinic in Rochester, Minnesota.
“Scans expose patients to radiation, and that theoretically increases the risk of a second cancer. Surveillance scans can also increase patient anxiety and lead to unnecessary biopsies. While our study found that the majority of relapses are not detected by routine scans, the decision of whether to obtain surveillance scans and how often should be individually tailored to patient characteristics,” she commented.
Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma, with about 20,000 new cases diagnosed each year in the United States. The disease is potentially curable with chemotherapy, but relapses occur in about 20% to 30% of patients who are in remission after initial treatment.
The optimal surveillance strategy is unclear. Current guidelines recommend routine computed tomography (CT) scans every 6 months for 2 years after treatment is finished, and thereafter, as clinically indicated. Patients also undergo physical exams and blood tests during follow-up.
The study sought to identify how relapses in diffuse large B-cell lymphoma were detected. From a cohort of 644 patients with newly diagnosed diffuse large B-cell lymphoma treated with anthracycline-based immunochemotherapy, 537 patients were judged to be in remission after initial treatment and entered post-treatment surveillance. The study was part of a multi-institutional study called University of Iowa/Mayo Clinic Special Program of Research Excellence Molecular Epidemiology Resource.
Median age was 63 years (range, 18–92 years). Management was at the discretion of the treating hematologist/oncologist. Patients were followed for events that included relapse, retreatment, and death. Events were verified by medical records.
Of the 537 patients, 109 relapsed (20%) and 41 died of unrelated causes. About 42% of relapses occurred within the first 12 months following diagnosis, 27% between 12 and 24 months, and 31% after 24 months.
Among the 109 patients who relapsed, 62% consulted their physician at an unplanned visit because they were experiencing symptoms that included enlarged lymph nodes, fever, night sweats, pain, or weight loss. At relapse, 68% had symptoms, 42% had an abnormal physical exam, and 55% had an abnormal blood test. Surveillance CT scans detected relapse in eight patients (1.5%) who were asymptomatic.
“The majority of relapses occur outside of planned follow-up visits and are accompanied by symptoms or abnormalities in physical exam or lab tests. This is important in decision-making,” Dr. Thompson emphasized.
“The optimal way to follow patients with [diffuse large B-cell lymphoma] has been unclear,” said Clifford A. Hudis, MD, ASCO President-Elect, speaking at an official ASCO press briefing before the Annual Meeting. “This large study shows that the vast majority of recurrences are not detected by CT scans, and this is consistent with some other cancers. Physicians should discuss these findings with patients. These data will help physicians develop guidelines for patients in remission from [diffuse large B-cell lymphoma] and spare costs, exposure to radiation therapy, and the impact of false-positive findings.” ■
Disclosure: Drs. Thompson and Hudis reported no potential conflicts of interest.
1. Thompson CA, Maurer MJ, Ghesquieres H, et al: Utility of post-therapy surveillance scans in DLBCL. ASCO Annual Meeting. Abstract 8504. Presented June 1, 2013.
In a separate interview, Andrew D. Zelenetz, MD, PhD, Chief of the Lymphoma Service at Memorial Sloan-Kettering Cancer Center in New York, said that he found the relapse rate of 20% observed in this study to be quite low, and he wanted to know the characteristics of the 537 patients included in the ...