How I treat Elderly 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 elderly 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 elderly patient. Pre-phase with corticosteroids, rigorous supportive care including G-CSF prophylaxis and careful monitoring can be important to prevent adverse events. In unfit elderly patients a dynamic dosing strategy is often applied. For very elderly patients (≥ 80 years) a dose reduced regimen (R-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 elderly patients with DLBCL and our approach to the management of these challenging patients.