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R-CHOP vs CHOP-R?
I have been diagnosed with mediastinal B-cell non Hodgkins lymphoma. Both specialists I saw recommended the same chemo regimen (R-CHOP) for 6-8 cycles but one of them prefers to give the R at the end of the 6-8 cycles. Is this common and if yes what are the benefits?
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Hi.  The original R-CHOP regimen described by Coiffier, et. al. in 2002 has Rituximab (R) being given on Day 1 of the regimen, together with the cytotoxic drugs (CHOP).  The addition of Rituximab to CHOP in this manner increases the complete response rate (76% [R-CHOP] vs. 63% [CHOP]). R-CHOP also increases the "three year failure -free survival rate (FFS)" to 53%, from 46% for CHOP.  Three year FFS refers to the percent of patients surviving for three years without disease recurrence or disease progression.

Rituximab may be given after finishing all cycles of CHOP (called "maintenance Rituximab" or MR), and this also has advantages over plain CHOP, but the benefits do not exceed those that can be obtained by giving Rituximab up front with CHOP (R-CHOP).  The study by Habermann, et. al. in 2006 compared patients with diffuse B-cell Non-Hodgkins Lymphoma given either R-CHOP, CHOP, R-CHOP plus MR and CHOP plus MR.  The two year failure free survival rate were as follows:

R-CHOP - 77%
R-CHOP plus MR - 79%
CHOP plus MR - 74%
CHOP alone - 45%

So there may be a slight advantage in two-year FFS in favor of R-CHOP over CHOP-MR (77% vs 74%). The 2 percent difference between the FFS of R-CHOP and R-CHOP+MR is not statistically significant.

In summary, it makes little difference whether Rituximab is given initially with CHOP or after all cycles of CHOP are finished. What matters is for Rituximab to be added to the regimen.
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