1. Patients above the age of 80 years are either unfit or frail. If < 80 years but unfit, start with a 25% to 50% dose reduction for cycle 1, and in those younger than 80 years of age, attempt to escalate to at least 75% of standard dose with subsequent cycles if tolerated
2. Use simplified CGA testing to evaluate ADL, IADL. ECOG and Hb< 12 gm predict TRM
3. Mini-R CHOP TRM 8% with prephase steroids 60 mg day minus 7 to minus 4. OS 59&, PFS at 2 yr 47%. Standard CHP 18% TRM.
4. Mini R CHOP over 80 years if anthracycline not contraindicated
5. G-RCVP or R-CEOP if cardiac issues. BR is inferior. R CEOP produced inferior results in non GCB subtype
6. Supportive care: manage blood glucose carefully, more frequent follow-up, consider Bactrim and acyclovir prophylaxis.
7. ESA: erythropoietin could be considered in the very elderly or unfit who are experiencing significant treatment-related anemia. erythropoietin could be considered in the very elderly or unfit who are experiencing significant treatment-related anemia.
8. vitamin D enhances rituximab-mediated cellular cytotoxicity. Vitamin D supplementation to maintain levels >30 ng/mL is recommended in this particularly vulnerable population.
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