title: CNS prophylaxis and treatment in non-Hodgkin's lymphoma: variation in practice and lessons from the literature.
abstract: Practices regarding central nervous system (CNS) prophylaxis and treatment for non-"high-grade" lymphomas are not standardized. We designed a survey to address the CNS surveillance, prophylaxis and treatment (S + P + T) habits of Ontario oncologists, to compare tertiary with community care and gauge interest in a randomized controlled trial (RCT). We mailed 145 questionnaires to oncologists/hematologists registered at the Royal College of Physicians and Surgeons of Ontario between 1980 and 1999. The questionnaire posed questions of S + P + T for a variety of histologies, locations and risk factors. Results showed that 49/77 respondents treated adult NHL, (19 community, 30 tertiary care). Surveillance LP's were commonly done in testicular, orbital, sinus and epidural sites of presentation (76, 69, 71, 80%, respectively), but these were less commonly prophylaxed (45, 33, 29 and 41%). HIV associated NHL received surveillance and prophylaxis by 51 and 33% of respondents. Stage IV disease, increased LDH and extranodal-sites warranted infrequent S + P. IT chemotherapy via LP was the most commonly used form of prophylaxis (74%) or treatment (84%). Twenty percent used systemic agents that cross the blood brain barrier for prophylaxis, and 45% for treatment. A vast heterogeneity of practice within and between tertiary care and community physicians' practices was documented. Ninety percent of physicians indicated willingness to participate in a RCT. In conclusion, CNS surveillance and prophylaxis in non-"high-grade" NHL is highly variable, probably because there are poorly defined risk factors, inconclusive prophylaxis efficacy and the inconvenience/toxicity of therapy. Patients at high risk by International prognostic index criteria are at an increased risk for CNS relapse. A RCT comparing standard chemotherapy with or without CNS prophylaxis in selected patients is needed.
authors.affiliation: Department of Medicine, University of Toronto, Toronto Sunnybrook Regional Cancer Centre, 2075 Bayview Avenue, Toronto, Ont., Canada. rena.buckstein@tsrcc.on.ca
authors.forename: Rena
authors.initials: R
authors.lastname: Buckstein
authors.forename: Wendy
authors.initials: W
authors.lastname: Lim
authors.forename: Edmee
authors.initials: E
authors.lastname: Franssen
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Imrie
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000627:therapeutic use; D016543:Central Nervous System Neoplasms / Q000188:drug therapy / Q000517:prevention & control* / Q000532:radiotherapy / Q000556:secondary*; D015658:HIV Infections / Q000150:complications; D006801:Humans; D008228:Lymphoma, Non-Hodgkin / Q000188:drug therapy* / Q000473:pathology; D008297:Male; D009367:Neoplasm Staging; D009864:Ontario; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D012307:Risk Factors; D011795:Surveys and Questionnaires
chemical_list: D000970:Antineoplastic Agents