Bone health and glucocorticoid‐containing lymphoma therapy — a review of risk factors and preventative measures

Abstract

Many patients with B-cell non-Hodgkin lymphomas (NHL) such as diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL) and Hodgkin lymphoma (HL) achieve remission following standard front-line therapy. Regardless of age, stage and risk factors, DLBCL patients in remission after R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone) and without relapse 24 months post treatment will have comparable or near comparable residual life expectancy as the age-and gender-matched general population. 1,2 The vast majority of HL patients are cured with modern positron emission tomography or computed tomography imaging positron emission tomography and computed tomography (PET/CT)-guided treatments. BEACOPPescalated (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisolone) is an effective front-line treatment for high-risk disease resulting in a five-year overall survival of 90% or higher but also a salvage option for patients with incomplete response after ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine). 3,4 Similar to DLBCL observations, HL patients without events in the first two years after treatment have survival very close to that in the background population. 5,6 Despite the chronic nature of FL, survival outlooks are also excellent in this disease, especially for the 80% who do not experience progression of disease within the first 24 months after frontline therapy. 7 The high cure rates, especially for B-cell lymphomas but also for a significant minority of peripheral T-cell lymphomas (PTCL), warrant more pro-active considerations on what can be done to improve survivorship from initial diagnosis. 8,9 Historically in the study of late toxicities the focus has been on HL because of the younger demographic and high cure rates. For example, mammography for early detection of breast cancer secondary to breast irradiation is advocated for female HL survivors. 10 While focus on life-threatening late

Prevention and Treatment of Glucocorticoid-Induced Osteoporosis in Adults: Consensus Recommendations From the Belgian Bone Club

“…In some progressive conditions such as Duchenne muscular dystrophy, glucocorticoids are the standard of care, although they contribute to the high fracture burden in these younger patients ( 51 ). Despite the necessity for prolonged glucocorticoid usage in these conditions, attention to GIOP prevention remains poor, particularly in hematological conditions such as immune thrombocytopenia, autoimmune hemolytic anemias or lymphomas ( 52 – 54 ).…”

Risk of fractures and use of bisphosphonates in adult patients with immune thrombocytopenia—A nationwide population‐based study

“…32,48,49 Some types of lymphoma are underlying sITP, 50,51 and are associated with an increased risk of both fractures and osteoporosis following treatment. [52][53][54] This could contribute to an elevated fracture risk in sITP.…”

Dexamethasone-free antiemetic strategy for highly emetogenic chemotherapy: safety and efficacy-pilot study

“…Among the four main antiemetic category drugs (5-HT3 antagonist, NK-1 receptor antagonist, olanzapine and DEXA), probably DEXA has the lowest risk–benefit 14. American College of Rheumatology suggests that prolonged use of steroids increases the risk of osteoporosis (2.5 mg or more per day for at least 3 months) 15. During chemotherapy administration, the cumulative DEXA dose frequently exceeds these values.…”

“…DEXA use is associated with new-onset diabetes in one-fourth of cancer patients 19. Chronic glucocorticoid use during lymphoma leads to fracture and loss of bone mineral density among lymphoma patients 15. DEXA has been found associated with an increased risk of lymphopenia, chemoresistance, cancer metastasis, relapse and poor therapeutic outcome 20–24.…”