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An intensive infusion chemotherapy schedule, widely believed to be better for aggressive lymphoma, was compared head to head with the standard and was not better, only harder to tolerate.
Dose-adjusted EPOCH-R gives cyclophosphamide, doxorubicin and etoposide as a 96-hour infusion with the dose raised or lowered by the neutrophil count in the previous cycle. Single-arm series had reported excellent results, and many centres had adopted it for higher-risk diffuse large B-cell lymphoma on that basis. CALGB 50303 randomised it against R-CHOP in untreated disease between 2005 and 2013.
At a median follow-up of five years there was no difference. Progression-free survival gave a hazard ratio of 0.93 (95 per cent confidence interval 0.68 to 1.27, p = 0.65), with two-year rates of 78.9 per cent for dose-adjusted EPOCH-R and 75.5 per cent for R-CHOP; overall survival gave a hazard ratio of 1.09 (0.75 to 1.59, p = 0.64). Grade 3 and 4 adverse events were more common with the infusional regimen, including febrile neutropenia in 35.0 against 17.7 per cent, mucositis in 8.4 against 2.1 per cent and neuropathy in 18.6 against 3.3 per cent. Five treatment-related deaths occurred in each arm.
The authors' own reading is the honest one: the R-CHOP results were better than historical controls, which suggests the trial selected a favourable population and that the answer may not generalise to the highest-risk subgroups. Dose-adjusted EPOCH-R remains standard in primary mediastinal B-cell lymphoma and in HIV-associated lymphoma, where it was tested separately, and is still used in high-grade B-cell lymphoma with MYC and BCL2 rearrangements on non-randomised evidence.
Numbers are from the trial as recorded here; see the source links in the table below. This is orientation, not medical advice: ask your team how closely the trial population matches you.
491 analysed.
two-year rate 78.9 per cent · two-year rate 75.5 per cent
Sourcetwo-year rate 86.5 per cent · two-year rate 85.7 per cent
| Endpoint | Arm | n | Value | HR (95% CI) | p | Source |
|---|---|---|---|---|---|---|
| Progression-free survivalprimary | Dose-adjusted EPOCH-R | - | two-year rate 78.9 per cent | 0.93 (0.68 to 1.27) | 0.65 | link |
| R-CHOP | - | two-year rate 75.5 per cent | ||||
| Overall survival | Dose-adjusted EPOCH-R | - | two-year rate 86.5 per cent | 1.09 (0.75 to 1.59) | 0.64 | - |
| R-CHOP | - | two-year rate 85.7 per cent | ||||
| Febrile neutropenia | Dose-adjusted EPOCH-R | - | 35% | - | - | - |
| R-CHOP | - | 17.7% |
Shares International Prognostic Index (IPI), R-CHOP (lymphoma chemoimmunotherapy), Prednisone, Vincristine and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), Prednisone, Vincristine, Rituximab and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), Failures are hidden, Prednisone, Vincristine and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), The lymphoma regimen alphabet: R-CHOP, pola-R-CHP, DA-EPOCH-R, ABVD, BEACOPP and the rest, Prednisone, Vincristine and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), Failures are hidden, Prednisone, Vincristine and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), Prednisone, Vincristine, Rituximab and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), Prednisone, Vincristine, Rituximab and the tag lymphoma-evidence.
Shares R-CHOP (lymphoma chemoimmunotherapy), Failures are hidden, Prednisone, Vincristine and the tag lymphoma-evidence.