-Author name in bold denotes the presenting author
-Asterisk * with author name denotes a Non-ASH member
Clinically Relevant Abstract denotes an abstract that is clinically relevant.

PhD Trainee denotes that this is a recommended PHD Trainee Session.

Ticketed Session denotes that this is a ticketed session.

4302 Survival Outcomes for High Risk Primary Refractory and Relapsed Large B-Cell Lymphoma (LBCL) within the Veterans Health Administration (VHA)

Program: Oral and Poster Abstracts
Session: 627. Aggressive Lymphomas: Clinical and Epidemiological: Poster III
Hematology Disease Topics & Pathways:
adult, Research, elderly, Lymphomas, epidemiology, B Cell lymphoma, health outcomes research, Clinical Research, health disparities research, Diseases, therapy sequence, Therapies, real-world evidence, Lymphoid Malignancies, Human, Study Population
Monday, December 12, 2022, 6:00 PM-8:00 PM

Lauren Diaz Boyle, DO1*, Supreet Kaur, MD2, Gabriel Roman Souza, MD1, Snegha Ananth, MBBS1, Kana Tai Lucero1*, Alaq Al-Abayechi, MD1*, Jean Pierre Blaize, MD3, Lakene Raissa Djoufack Djoumessi, MD4, Manuel Espinoza, MD5*, Kathleen Franklin, RN1*, Lindsey Lu, PharmD6*, Phillip Nazarewicz, BS1*, Abhishek Pandya, DO1, Michael M. Song, MD, PhD, PharmD7, Brian Warnecke, DO1*, Jennifer Whitehead, MS1*, Madison H. Williams, MD8, Ryan A. Williams, MD8, Michael Mader, MS1* and Zohra Nooruddin, MD1,9

1South Texas Veterans Health Care System, San Antonio, TX
2University of Texas Health San Antonio MD Anderson Cancer Center, San Antonio, TX
3Augusta Oncology, Augusta, Georgia
4National Institute of Health, Bethesda, MD
5Indiana University Hospital, Indianapolis, IN
6University of Texas College of Pharmacy, Austin, TX
7South Texas Veterans Health Care System, Lubbock, TX
8University of Texas MD Anderson Cancer Center, Houston, TX
9Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX


Even in the Rituxan era, patients with primary refractory or relapsed LBCL have poor outcomes. The standard of care for these patients is salvage therapy (ST) as second-line treatment followed by high dose therapy with autologous stem cell transplant (ASCT) in chemosensitive patients with an estimated 30-40% of ST responders deemed eligible to undergo transplant (PMID: 28774879). Currently, chimeric antigen receptor (CAR) T-cell therapy is the standard of care for high risk LBCL (high International Prognostic Index (IPI), HIT status) who do not respond to ST and have manageable safety profiles and high efficacy. Promising CAR T data is also emerging for early chemotherapy failure and as alternative second-line therapy (PMID: 35314842). The purpose of this study is to analyze the treatment patterns and survival outcomes of primary refractory and relapsed population of LBCL within the VHA.


This is a retrospective chart review of 5199 randomly selected patients with an ICD code for lymphoma treated within the VHA between 01/01/2011 and 12/31/2019. Data abstractors included patients with LBCL who completed first-line chemotherapy treatment and had documented post-treatment scans (PET, CT). We defined primary refractory as either stable disease (SD) or progressive disease (PD) based on post-treatment scans and relapsed disease as recurrence of disease within 12 months of post treatment scans. Median overall survival (OS) was calculated using the Wilcoxon-Mann-Whitney test.


A total of 2288 patients met inclusion criteria who received or completed treatment at the VHA. Baseline characteristics are outlined in Table 1. From our analysis, 299 (13.1%) of patients were primary refractory. Median age was 68.9 years and 97% were male. European Cooperative Oncology Group (ECOG) was 0-2 (81.3%). Stage at diagnosis was III-IV (83.9%). Most patients had an IPI score ≥3 (85%). Germinal center B-Cell (GCB) accounted for 48.2% while Activated B-Cell (ABC) was 24.4%. Gene rearrangement was present in 26% of the patients with available data. Of the 119 (63.9%) patients who received second line treatment, only 19 (6.4%) were able to receive high dose chemotherapy and underwent an ASCT and only 3 (1%) of patients received CAR T-cell therapy. One year and two year overall survival was 47.8% and 24.7% respectively. Median OS for this population was 11.0 months.

There were 105 (4.6%) relapsed patients in our cohort. Median age was 64.7 years and 96.2% were male. ECOG was 0-2 (85.7%). Stage at diagnosis was III-IV at 84.8%. Most patients had an IPI score ≥3 (80%). GCB accounted for 37.1% while ABC was 35.2%. Gene rearrangement was present for 20% of the patients with available data. In this group, 16 (15.2%) of patients received high dose chemotherapy and ASCT and only 3 (2.9%) received CAR T-cell therapy. One year and two year overall survival was 72% and 41% respectively. Median OS for this population was 21.3 months.

1403 (61%) of patients had complete response (CR) with a 1 and 2 year survival rate of 97 % and 93 % respectively and median OS of 69.3 months.


This is one of largest data sets studying the rate of primary refractory and relapsed LBCL in the VHA and shows that more than two-thirds of these patients have high risk disease. Furthermore, a significant portion of these veterans did not receive second-line therapy including ASCT as compared to previously reported real world and clinical trial data. It is possible that our patient populations had higher rates of chemoresistance, were deemed ineligible for transplant due to age or performance status, or had higher comorbidities. Emerging data on newer antibodies and CAR T-cell therapy for early chemotherapy failure or second-line therapy might be a more appropriate option for our veteran population. In conclusion, CAR T-Cell therapy will likely replace the treatment paradigm for primary refractory or relapsed disease for early treatment failures in patients with LBCL.

Disclosures: Nooruddin: Astrazeneca: Research Funding.

*signifies non-member of ASH