Malignant lymphoma, including Hodgkin's disease and the non-Hodgkin's lymphomas (NHLs), afflicts more than 50,000 persons and results in almost 20,000 deaths annually in the United States. Unfortunately, the findings of a recent study indicated that 48% to 53% of patients with NHL receive a relative dose intensity (RDI) less than 85% of the minimum six-cycle and National Comprehensive Cancer Network guideline standards. Study investigators also found that the RDI of less than 85% was planned in 37.9% of patients.

This was the largest study to date to evaluate practice patterns and treatment complications in NHL patients treated with systemic chemotherapy. Although the study was slated for publication in the Journal of Clinical Oncology on Nov. 1, the journal released the article early on its Web site, www.jco.org. Practice sites were reimbursed by Amgen for their participation in this study.

Pharmacists can play a very significant role with regard to this issue, particularly in larger institutions, said Gary Lyman, M.D., M.P.H., lead author of the study, who is a professor of medicine and oncology at the University of Rochester School of Medicine and Dentistry in New York. They can verify that the dosing schedule is appropriate and being adhered to, explained Lyman, who is also director of the Health Services & Outcomes Research Program at the James P. Wilmot Cancer Center at the University of Rochester Medical Center.

Pharmacists should at least challenge the oncologist, so that deviations from standard therapy are not going unquestioned, Lyman continued. "I'd encourage them to be vigilant, and not simply accept a reduction in dose or delay in scheduling," he said.

"The pharmacist is in an excellent position to bring information such as these study findings to the attention of the prescriber," concurred Leon Cosler, R.Ph., Ph.D., an assistant professor of pharmacoeconomics at Albany College of Pharmacy in New York. He said that a previous analysis of data from patients with early-stage breast cancer demonstrated that those treated with adjuvant chemotherapy are at significant risk of chemotherapy dose attenuation.

"We are seeing a real problem across different cancers, in that patients who need treatment are not always getting it," Lyman said. A multivariate analysis identified the following factors—age older than 60 years, advanced stage disease, the presence of serious comorbidities, poor nutritional status, and no prophylactic use of colony-stimulating factors (CSFs)—as independent predictors of reduced RDI, he added.

"I think the breast cancer study and this study make the point that the appropriate use of CSFs is related to helping patients maintain optimal RDI as planned," said Cosler. He added that pharmacists could at least raise questions as to why chemotherapy doses are being reduced and suggest therapies that might help patients maintain an optimal RDI.

In conclusion Lyman said, "A lot of work remains to be done. We still do not know why one oncologist reduces RDI while another does not. This is a work in progress. We are involved in further studies to examine this issue, and trying to gather detailed information on other issues that may impact on the ability to deliver optimal treatment for responsive and potentially curable malignancies."