Diffuse Large B-Cell Lymphoma

Transcription

1 Diffuse Large B-Cell Lymphoma Date: September 2011 Date Presented to Cancer Committee: April 12, 2012 By Shelly Smits, RHIT, CCS, CTR Conclusions by Ian Thompson, MD Data Source: Cancer registry information on diffuse large B-cell lymphoma (DLBCL) diagnosed Reason for Report: To determine compliance with NCCN Guidelines in the Staging and Treatment of DLBCL, as well as comparing survival between local patients and national numbers. Patients Studied: During this time period, there were 92 cases of DLBCL diagnosed or treated by PeaceHealth St. Joseph Medical Center physicians. As the graph below shows, 33 (36%) of patients diagnosed with DLBCL were extranodal or within other organs. Most of these patients were treated in the community; however 4% of the patients went elsewhere for treatment after being diagnosed here as seen in the following graph.

2 When evaluating work-up and treatment, it is important to look at class of case. Of the 92 cases of DLBCL for this period, 4 cases were diagnosed here but had all of their treatment elsewhere. It was hard to tell if all work-up was done here or at the treating facility so these were deleted from the work-up evaluation. There were also 5 patients who were diagnosed elsewhere and treated here. Again, not all information was known on these patients. There were two additional cases where patients were diagnosed here, started treatment elsewhere and returned here to finish their treatment. Finally one patient originally was misdiagnosed with an MS plaque. All of these cases were excluded from the final work-up analysis leaving 80 cases to evaluate. Staging: The table below shows the percentage of work-up items recommended as essential by the NCCN guidelines that were done. These numbers were tallied on what could be found in the patients medical record. Not all information from the medical oncology records (Medical Oncology was not part of the Centricity EMS at that time) was available for 2005 & Essential Work-up of DLBCL Diagnosed ** LDH CT's PET MUGA/Echo BM bx Perf Status B-symp CBC Hep-B Beta 2* IPI

3 *Category 2B recommendation indicating lower level of recommendation ** Please see comments in Summary. Stage at diagnosis: The majority of all DLBCL cases were Stage 4 at diagnosis; however in extranodal cases category, the majority were Stage 1 at diagnosis. Below are graphs comparing PeaceHealth St. Joseph Medical Center to other hospitals participating in the National Oncology Data Base (NCDB) at the Commission on Cancer. Their data is shown here for the years

4 Treatment: For all stages of DLBCL, the NCCN guidelines recommend R-CHOP 3-6 cycles, plus or minus radiation therapy. For those patients who are not candidates for chemotherapy, involved field radiation therapy is recommended. All stages recommend restaging to access response rate before either completing more cycles of RCHOP or initiating radiation therapy. Below is the distribution of treatments given to these lymphoma patients who were diagnosed from by stage. First course treatment of DLBCL St. Joseph cases diagnosed Stage Stage Stage Stage I II III IV Unknown Chemo 1 Chemo/Prednisone Chemo/Predn/transpl 1 Rad 3 2 Rad/chemo/Predn Rad/chemo Rad/Prednisone 1 Surg Surg/chemo/Predn Surg/rad 1 Surg/rad/chemo/Predn No Tx 2 2

5 45% of patients were treated with Chemotherapy, nearly always with Prednisone. 29% of patients were treated with Chemo plus Radiation 25% of patients had procedures coded as Surgery, which may have been an excisional biopsy which included 9% of patients treated by Surgery alone. Survival: Observed survival is calculated for the years For Nodal Disease the distribution of cases and 3 year survival is as follows: Nodal DLBCL Observed Survival Diagnosed St. Joseph vs. NCDA Case count 3 yr survival St. St. NODA Joes Joes NODA Stage I n/a Stage II Stage III Stage IV Unknown

6 For Extra-Nodal Disease the distribution of cases and 3 year survival is as follows: Extra-Nodal DLBCL Observed Survival Diagnosed St. Joseph vs. NCDA Stage I Stage II Stage III Stage IV Case count St. NODA Joes 3 yr survival St. NODA Joes n/a 44.88

7 Demographics: Average age of patients: 67 Nodal = 67 Extranodal = 67 Median age: 72 Nodal = 72 Extranodal = 73 Age range: Nodal = Extranodal = Sex: Male = 53 Female = 39 Conclusions: The work up and staging for DLBCL in this community does not comply with NCCN essential elements. Only the statement of B symptoms, CT and CBC approach 100% of compliance. Less than 2/3rds of the patients had PET, MUGA, and bone marrow biopsy. Less than 1/3 rd of the patients had Performance status stated, IPI, and Hep B, and Beta 2 microglobulin blood tests. However, there is significant uncertainty as to how essential the Staging tests listed by NCCN really are for a community based Cancer Program such as St. Joseph s. Medical Oncologists comments indicate that every patient has a performance status determination prior to choosing therapy. It just may not be stated explicitly in a dictation, but can almost always be inferred by the dictated H&P. Lab tests were felt by the Oncologists to be more expeditious without a panel, The incidence of Hep B is low in this community, such that there is very little likelihood of a reactivation, making that test of minimal benefit. LDH may predict response rate, but would not affect therapy decisions.

8 Essentially all patients had a CT or a CT/PET. Whether this local pattern of staging tests explains the discrepancy in Extra-Nodal Stage 1 and Nodal Stage 4 disease in our community is subject to conjecture, but the overall staging mix is quite compatible with the national numbers. But most importantly,, the treatment of DLBCL is fairly standard across the stages of the disease, so the Essential work-up is of questionable essential benefit in a community setting, even though it may be essential for academic institutions doing clinical research.. Only 4 patients (5%) had no treatment and an additional 5 patients (6%) had surgery without chemotherapy and/or radiation. Hence treatment is in excellent compliance with NCCN Guidelines. Of course, the best measure of excellent treatment is survival of the diagnosed patients. The St. Joes patients have essentially the same or improved survival for those with Nodal DLBCL and dramatically improved survival for Extra-nodal DLBCL References: 1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-Hodgkin s Lymphomas, V Available at Accessed November National Cancer Database. Commission on Cancer. Available at Restricted access to CoC members. Login required. Accessed December 2011.