Is R-CHOP Really All That "Dead"?

When the German researcher Wolfgang Knauf told MedPage Today that "R-CHOP is dead," I wondered whether he was deliberately borrowing from the great German philosopher Friedrich Nietzsche, who declared back in 1882 that "God is dead."

Without having asked the man, I think the answer is yes. In fact, each time anyone declares either an inanimate object or a non-existent one to be dead in this manner, he is referencing Nietzsche whether he knows it or not.

When Nietzsche said his line, it was scandalous, a shocker for the times. In the world of lymphoma and hematology, Knauf's statement is no less shocking. How can R-CHOP be dead? Isn't it the standard of care the world over for so many B-cell non-Hodgkin's lymphoma patients?

Maybe not for long. The evidence is piling up that clinicians in Germany and in the U.S. are increasingly treating their indolent non-Hodgkin's patients not with R-CHOP, but with bendamustine and rituximab.

The Case

At the most recent meeting of the American Hematological Society, Knauf and colleagues gave a poster presentation indicating that, of 645 patients with indolent lymphomas in Germany, a full 428 of them were treated with this combination as a front-line therapy. These data represent only a portion of the registry the Germans are building. Only a couple of years ago, R-CHOP would have dominated.

The reasons? Lower toxicity with no apparent loss of efficacy, coupled with what appear to be longer progression-free survival times.

Not So Fast

Just like the title of one my favorite Wynton Marsalis tunes, this might be one of those premature autopsies since not everyone is ready to throw in the towel on R-CHOP over bendamustine-rituximab.

An American researcher named Frederick Lansigan, MD, from Dartmouth-Hitchcock Medical Center in New Hampshire tempered the line by saying that CHOP "is going to be dead" (sounds like a threat...). Lansigan himself presented results of a small trial in which patients received bendamustine-rituximab followed by the radio-labelled monoclonal antibody 90 ibritumomab tiuxetan (otherwise known as Zevalin...sort of) and his data also indicated longer progression-free survival times.

Of course, it may be difficult to fully trust Lansigan's presentation since he has commercial interests with Spectrum Pharmaceuticals, the owners of Zevalin and—according to something a little bird told me—the ones anxious to unload Zevalin to another pharmaceutical company.

Dead is Dead

While bendamustine-rituximab may be replacing R-CHOP for the front-line treatment of indolent lymphomas in Germany, it's not happening here in the U.S.—at least not yet. The National Comprehensive Cancer Network's clinical practice guidelines in oncology for follicular lymphoma currently list R-CHOP and RCVP as the only category 1 therapies.

Bendamustine-rituximab and rituximab alone are category 2A. The difference between the categories is significant and speaks to what the consensus is among experts at the NCCN.

Ultimately, one's doctor has to determine which treatment is best suited to each individual patient. So I think maybe the only thing that's dead here is the overuse of the expression "[X] is dead." Let's save it for a time when we can say, with authority, that cancer is dead.