How I treat older patients with DLBCL in the frontline setting

Diffuse large B-cell lymphoma (DLBCL) is an aggressive but potentially curable disease and is most common in older people. Rituximab-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) is the standard of care for fit patients without cardiac contraindications. In each individual older patient, the potential gains of treatment should be balanced against the risks of treatment-related morbidity and mortality. A simplified comprehensive geriatric assessment or easily performed assessments such as gait speed and grip strength can be helpful to assess the fitness of an older patient. Prephase with corticosteroids, rigorous supportive care including granulocyte colony-stimulating factor prophylaxis and careful monitoring can be important in preventing adverse events. In unfit older patients, a dynamic dosing strategy is often applied. For very old patients (≥80 years) a dose-reduced regimen (rituximab-miniCHOP) is recommended. When anthracyclines are contraindicated, doxorubicin can be replaced by etoposide or gemcitabine. Most frail patients do not benefit from chemotherapy. Further progress can be expected from non-chemotherapy-based therapies, such as bispecific antibodies, antibody-drug conjugates, and immunomodulatory agents. This article provides an overview of first line treatment in older patients with DLBCL and our approach to the management of these challenging cases.