State-of-the-art issues in Hodgkin's lymphoma survivorship

Dissection of single-cell landscapes for the development of chimeric antigen receptor T cells in Hodgkin lymphoma

ABSTRACT

The success of targeted therapies for hematological malignancies has heralded their potential as both salvage treatment and early treatment lines, reducing the need for high-dose, intensive, and often toxic chemotherapeutic regimens. For young patients with classic Hodgkin lymphoma (cHL), immunotherapies provide the possibility to lessen long-term, treatment-related toxicities. However, suitable therapeutic targets are lacking. By integrating single-cell dissection of the tumor landscape and an in-depth, single-cell-based off-tumor antigen prediction, we identify CD86 as a promising therapeutic target in cHL. CD86 is highly expressed on Hodgkin and Reed-Sternberg cancer cells and cHL-specific tumor-associated macrophages. We reveal CD86-CTLA-4 as a key suppressive pathway in cHL, driving T-cell exhaustion. Cellular therapies targeting CD86 had extraordinary efficacy in vitro and in vivo and were safe in immunocompetent mouse models without compromising bacterial host defense in sepsis models. Our results prove the potential value of anti-CD86 immunotherapies for treating cHL.

Evolution of breast cancer management after mediastinal hodgkin lymphoma: Towards a breast- conserving approach

PURPOSE

To analyse the clinical and histological characteristics of breast cancers (BC) occurring after Hodgkin lymphoma (HL), as well as their outcome with particular attention to the effectiveness and safety of breast-conservative surgery with radiation therapy (RT).

MATERIALS AND METHODS

This is a retrospective study of 218 patients who developed stage 0 to III BC after treatment for mediastinal HL between 1951 and 2022. Comprehensive demographic, clinical, and therapeutic data were collected for HL and BC, as well as survival and locoregional control. Statistical analyses were performed using R software version 4.1.1.

RESULTS

The median age at HL diagnosis was 24 years [7-79]. BC appeared at a median age of 47 years [22-86], with a median interval of 21 years [5-51] after HL. Locoregional treatment included mastectomy in 117 (56.0 %) and lumpectomy in 92 (44.0 %), with postoperative RT in 99 patients (47.6 %). Isocentric lateral decubitus irradiation (ILD) was performed for 48 patients treated by tumorectomy (63.2 %). With a median follow-up of 29.7 years after HL and 7.7 years after BC, the 5-year overall survival (OS) and locoregional control rates were resp. 89.2 % and 86.4 % for invasive, and 100 % for in situ cancers. The 5-year metastasis-free survival rate was 87.4 % [95 % CI: 82.7-92.4 %]. No late sequelae was reported.

CONCLUSION

Breast-conserving surgery, combined with appropriate RT, can be considered in the treatment of BC after HL despite prior thoracic irradiation. This approach provides comparable outcomes in terms of local control and survival while reducing the risk of long-term complications associated with mastectomy.

Survivorship transitions in blood cancer: Identifying experiences and supportive care needs for caregivers

PURPOSE

Survivorship care often refers to continued healthcare after cancer treatment. Jacobsen and colleagues advocated to expand this to include patients on extended treatments and maintenance/prophylactic therapies, recognizing the care continuum as more complex. Transitions of care for individuals diagnosed with a blood cancer can be complicated. We sought to better understand blood cancer caregivers' experiences as their diagnosed family member encountered "survivorship transitions" across the continuum.

METHODS

We conducted semi-structured interviews with adults caring for a parent or a child with a blood cancer. Caregivers were segmented into survivorship groups based on two transitional contexts: (1) when patients transitioned to a new line of therapy (active treatment or maintenance therapy); (2) when patients ended treatment. We conducted a thematic analysis and triangulated findings to compare transitional experiences.

RESULTS

Caregivers in both groups reported experiencing a "new normal," which included personal, relational, and environmental adjustments. Caregivers in the treatment transitions group (n = 23) also described uncertainty challenges (e.g., losing their "safety net") and disrupted expectations (e.g., feeling "caught off guard" by challenges). Whereas caregivers in the end-of-treatment transitions group (n = 15) described relief coupled with worry (e.g., feeling hopeful yet worried).

CONCLUSIONS

Survivorship transitions for caregivers are riddled with challenges that include difficult readjustments, uncertainty/worry, and unmet expectations. While there seems to be a cohesive experience of "survivorship transitions," each transition group revealed nuanced distinctions.

IMPLICATIONS FOR CANCER SURVIVORS

Tailored supportive resources are needed for caregivers throughout survivorship transitions.

Breast Cancer and Mediastinal Hodgkin's Lymphomas: Multidisciplinary Discussion

Treatment for Hodgkin's lymphoma (HL) has evolved, with modern treatments combining less toxic chemotherapy and radiation, leading to improved long-term disease-free survival. However, there is a higher chance of second cancer, especially breast cancer, following effective HL treatment. The impact of reduced radiation doses and volumes, as well as the use of advanced irradiation techniques, on the risk of second malignancy is not clear. According to medical organizations, the history of chest irradiation is a relative contraindication to breast preservation therapy for women with initial breast cancer, leading to a paradigm of mastectomy. This article proposes a discussion between radiation oncologists and surgeons to review major trials and recent developments on the prevalence of breast cancer following HL therapy, the risk of contralateral cancer, the feasibility of breast conserving surgery (BCS), as well as breast reconstruction modalities.

Patient preferences for first-line treatment of classical Hodgkin lymphoma: a US survey and discrete choice experiment

A cross-sectional online survey, including a discrete choice experiment (DCE), was used to investigate first-line treatment preferences in patients with classical Hodgkin lymphoma (cHL) in the United States; 141 patients (median age 35.0 years) participated. In the DCE, risk of progression at 2 years (progression free survival) had the highest relative importance to patients (31.3%) when considering first-line treatments, followed by 2-year overall survival (OS; 26.9%), on-treatment pulmonary toxicity (23.3%), and on-treatment peripheral neuropathy (18.5%). Marginal rate of substitution analyses demonstrated that a 0.44% and 0.09% increase in 2-year OS was required for patients to accept a 1% increase in the risk of disease progression at 2 years and peripheral neuropathy, respectively. A 2.6% increase in 2-year OS was needed to accept a 7% rather than a 2% risk of pulmonary toxicity. In summary, patients with cHL rated survival attributes as more important than drug-related toxicity when considering first-line treatments.

Cancer worry and empathy moderate the effect of a survivorship-focused intervention on quality of life

OBJECTIVE

This study examined the impact of a survivorship planning consultation (SPC) for patients with Hodgkin's lymphoma and diffuses large B-cell lymphoma on quality of life (QOL). We specifically assessed two potential moderators, cancer worry and perceived empathy, of the intervention effects on QOL.

METHODS

This cluster randomized, four-site trial examined the efficacy of a SPC; physicians received communication skills training and applied these skills in a survivorship-focused office visit using a care plan vs a control arm in which physicians were trained to and subsequently provided a time-controlled, manualized wellness rehabilitation consultation focused only on discussion of healthy nutrition and exercise. We examined the effect of the intervention on patients' QOL and examined potential moderators-cancer worry and perceived physician empathy.

RESULTS

Forty-two physicians and 198 patients participated. There was no main effect of the intervention on any of the QOL dimensions (ps > 0.10). However, cancer worry was a significant moderator of the effects of the intervention on three QOL domains (physical P = .04; social P = .04; spiritual P = .01) and perceived empathy was a significant moderator of QOL (physical P = .004; psychological P = .04; social P = .01). Specifically, the beneficial effects of the intervention were more pronounced among patients who initially reported higher levels of cancer worry and lower levels of physician empathy.

CONCLUSIONS

This study identified two factors, perceived empathy and cancer worry, that were found to impact the QOL of patients who participated in this communication-based survivorship intervention.

Socioeconomic impact of Hodgkin lymphoma in adult patients: a systematic literature review

Hodgkin lymphoma is a highly curable disease with a peak incidence in young adulthood at times where education, family, and social relations are established. We performed a systematic literature review to assess the impact of Hodgkin lymphoma on the socioeconomic status of adolescent and adult survivors (including educational achievements, occupational aspects, marriage, and parenthood). In total, 39 articles were included. Overall, 26-36% of survivors perceived Hodgkin lymphoma as negatively affecting their socioeconomic status. Studies consistently found educational achievements in line with general population. Employment rates for survivors were comparable to the general population, but lower than before Hodgkin lymphoma diagnosis, with a post-diagnosis increase in disability pension and early retirement. Employed survivors encountered problems related to physical restrictions and recruitment. Marriage and parenthood were not substantially affected. In conclusion, current studies suggest acceptable socioeconomic outcomes following a Hodgkin lymphoma diagnosis but the use of standardized reporting methods hampers comparability across studies.

Use of recommended posttreatment services for adolescent and young adult survivors of Hodgkin lymphoma

BACKGROUND

Hodgkin lymphoma (HL) is a leading cancer diagnosis for adolescents and young adults (AYAs), with an overall 5-year survival rate of >80%. However, to the authors' knowledge, little is known regarding posttreatment patterns of care. In the current study, the authors characterized the use of guideline-recommended services in a cohort of AYA survivors of HL in Kaiser Permanente Southern California.

METHODS

Patients with HL who were diagnosed between ages 15 and 39 years between 2000 and 2010 were identified. The authors calculated the number of patients who received recommended short-term care within 2 years after treatment cessation for those who remained enrolled and alive from 2001 through 2015. Use of recommended late-effects screening for breast cancer and cardiovascular disease was examined. Logistic regression was used to evaluate the association between receipt of recommended care and patient, cancer, and treatment characteristics.

RESULTS

A total of 354 patients were identified, with a mean age at the time of diagnosis of 26 years (standard deviation, 6.9 years). Approximately 12% of patients had stage I disease, 59% had stage II disease, 17% had stage III disease, and 13% of patients had stage IV disease. Nearly all patients received chemotherapy (95%), 51% received radiotherapy, and 5% received care from a pediatric oncologist. Overall, approximately 49% of patients received recommended short-term care. Of those patients eligible for cardiovascular screening at 10 years posttreatment (60 patients), 53% received at least 1 screening. Of those patients eligible for breast cancer screening (21 patients), approximately 50% underwent at least 1 screening. Regression results indicated that those patients treated by a pediatric oncologist were >3 times as likely to receive recommended short-term care.

CONCLUSIONS

The results of the current study highlight gaps in the delivery of posttreatment care to AYA survivors of HL. By determining areas in need of improvement, these findings can guide the development of tailored interventions with which to improve care.

Efficacy of a survivorship-focused consultation versus a time-controlled rehabilitation consultation in patients with lymphoma: A cluster randomized controlled trial

BACKGROUND

Survivors of cancer often describe a sense of abandonment after treatment along with heightened uncertainty and limited knowledge of what lies ahead. This study examined the efficacy of a survivorship care plan (SCP) intervention to help physicians to address survivorship issues through communication skills training plus a new consultation focused on the use of an SCP for patients with Hodgkin lymphoma and diffuse large B-cell lymphoma.

METHODS

This 4-site cluster randomized trial examined the efficacy of a survivorship planning consultation (SPC) in patients who achieved complete remission after the completion of first-line therapy (for the SPC, physicians received communication skills training and, using an SCP, applied those skills in a survivorship-focused office visit) versus a control arm in which physicians were trained in and subsequently provided a time-controlled, manualized wellness rehabilitation consultation (WRC) focused only on discussion of healthy nutrition and exercise as rehabilitation after chemotherapy. The primary outcomes for patients were changes in knowledge about lymphoma and adherence to physicians' recommendations for vaccinations and cancer screenings.

RESULTS

Forty-two physicians and 198 patients participated across the 4 sites. Patients whose physicians were in the SPC arm had greater knowledge about their lymphoma (P = .01) and showed greater adherence to physician recommendations for influenza vaccinations (P = .02) and colonoscopy (P = .02) than patients whose physicians were in the WRC arm.

CONCLUSIONS

A dedicated consultation using an SCP and supported by communication skills training may enhance patients' knowledge and adherence to some health promotion recommendations.

Long-term follow up of Hodgkin lymphoma

BACKGROUND

Hodgkin lymphoma (HL) is the paradigm of curable disease. This study analyzed the overall survival (OS) of patients with HL and compared their survival between decades and with the expected survival of a general population.

RESULTS

The median follow-up was 22 years. The median OS was 33 years. The incidence mortality rate for all causes is 2 per every 100 patients per year. The OS of our cohort at 10 years from diagnosis was 76% (95% CI: 72-79) and 52% at 30 years (95% CI: 48-57). Overall SMR (1980-2013) was 2,943 (95% CI: 2,518-3,439). Excluding the primary tumor as the cause of death, the SMR obtained is 2,266 (95% CI: 1,895-2,710). The SMR for those patients diagnosed before the year 2000 was 2,097 (95% CI: 1,732-2,539); and for those diagnosed after 2000 was 5,218 (95% CI: 8,655). The group of patients diagnosed after 2000 had statistically significant more advanced stages, were older and less responsive to treatment.

CONCLUSIONS

Despite the advances achieved, the risk of death remains higher than in the general population, mainly for those patients diagnosed after year 2000, even after almost 40 years of follow-up. This data might suggest a shift to more aggressive forms of disease in recent years.

PATIENTS AND METHODS

A total of 595 patients diagnosed with HL were included between January 1966 and February 2014. The standardized mortality ratio (SMR) was analyzed using the annual rate of mortality in the general Spanish population, adjusted for age, sex and time period.

Protocol for a cluster randomised trial of a communication skills intervention for physicians to facilitate survivorship transition in patients with lymphoma

INTRODUCTION

Survivors of cancer often describe a sense of abandonment post-treatment, with heightened worry, uncertainty, fear of recurrence and limited understanding of what lies ahead. This study examines the efficacy of a communication skills training (CST) intervention to help physicians address survivorship issues and introduce a new consultation focused on the use of a survivorship care plan for patients with Hodgkin's lymphoma and diffuse large B-cell lymphoma.

METHODS AND ANALYSIS

Specifically, this randomised, 4-site trial will test the efficacy of a survivorship planning consultation (physicians receive CST and apply these skills in a new survivorship-focused office visit using a survivorship plan) with patients who have achieved complete remission after completion of first-line therapy versus a control arm in which physicians are trained to subsequently provide a time-controlled, manualised wellness rehabilitation consultation focused only on discussion of healthy nutrition and exercise as rehabilitation postchemotherapy. The primary outcome for physicians will be uptake and usage of communication skills and maintenance of these skills over time. The primary outcome for patients is changes in knowledge about lymphoma and adherence to physicians' recommendations (eg, pneumococcus and influenza vaccinations); secondary outcomes will include perceptions of the doctor-patient relationship, decreased levels of cancer worry and depression, quality of life changes, satisfaction with care and usage of healthcare. This study will also examine the moderators and mediators of change within our theoretical model derived from Leventhal's Common-Sense Model of health beliefs.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Boards at Memorial Sloan Kettering Cancer Centers and all other participating sites. This work is funded by the National Cancer Institute (R01 CA 151899 awarded to DWK and SH as coprincipal investigators). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute (NCI) or the National Institutes of Health (NIH). The study findings will be disseminated to the research and medical communities through publication in peer-reviewed journals and through presentations at local, national and international conferences.

TRIAL REGISTRATION NUMBER

NCT01483664.

Existential challenges experienced by lymphoma survivors: Results from the 2010 LIVESTRONG Survey

We sought to examine the existential challenges that cancer survivors may experience as they strive to make meaning, regain their self-identity, cope with fear of recurrence, and experience feelings of grief and guilt. Lymphoma survivors (n = 429) completed the 2010 LIVE STRONG: survey and provided responses about meaning, cancer worry, security, identity, grief, guilt, and perceived functional impairment due to these concerns. Most survivors (73%-86%) endorsed existential concerns, with 30-39 percent reporting related perceived functional impairment. Concerns were associated with being female, younger, unmarried, and having undergone stem cell transplantation. Lymphoma survivors experience existential challenges that impact their life even years after diagnosis.

Stratification of treatment intensity in relapsed pediatric Hodgkin lymphoma

Risk-adapted, response-based therapies for pediatric Hodgkin lymphoma have resulted in 5-year survival exceeding 90%. Although high-dose chemotherapy and autologous hematopoietic stem cell transplantation (AHSCT) are considered standard for most patients with relapsed or refractory Hodgkin lymphoma, a subset of children with low risk relapse do not require AHSCT for cure. Currently there are no widely accepted criteria defining who should receive standard dose chemotherapy and/or radiotherapy, nor is there a standardized treatment regimen. We propose a risk-stratified, response-based algorithm for children with relapsed or refractory Hodgkin lymphoma that is based on a critical appraisal of published outcomes and prognostic factors.

Increased risk of second lung cancer in Hodgkin's lymphoma survivors: a meta-analysis

BACKGROUND

Patients treated for Hodgkin's lymphoma (HL) have a higher risk of developing second lung cancer (SLC) compared with the general population. The aim of this meta-analysis was to quantify such risk and to analyze contributing risk factors in HL survivors.

METHODS

According to predefined selection criteria, a literature search identified 21 studies that were included in the analysis.

RESULTS

After eliminating overlapping or duplicate data, 793 (76 % males) incidences of SLC were encountered in 74,831 patients (58 % males) with HL over a median follow-up of 11.5 years. The median age at HL diagnosis and the median age at SLC diagnosis were 33.0 and 45.9, respectively. The mean latency between treatment of HL and development of SLC was 11.5 years. The pooled relative risk (RR) of SLC was 4.62 (95 % confidence interval [CI], 3.18-6.70], I (2) = 98 %), with a median absolute excess rate of 10.4 per 10,000 person-years. RR was positively related to study size, male-to-female ratio, institutional versus population-based data sets, and the use of any radiotherapy (RT) or combined modality therapy (CMT), while age at diagnosis of HL was not significant. The highest risk was shown among patients aged 15-24 years (RR = 8.76 [95 % CI, 4.55-16.89]), while the lowest risk occurred in patients ≥55 years at primary treatment (RR = 2.88 [95 % CI, 2.33-3.56]). RR increased by increasing duration of follow-up, reaching the highest value at 10-14 years (RR = 4.17 [95 % CI, 3.62-8.81]), but did not increase after ≥15 years (RR = 4.01 [95 % CI, 2.68-5.98]). RT only, CMT, or chemotherapy only was associated with RR (95 % CI) of 4.88 (3.14-7.60), 5.15 (4.08-6.50), and 2.39 (1.60-3.55), respectively. Patients with SLC demonstrated poor prognosis.

CONCLUSIONS

The current meta-analysis provided a detailed estimate of the risk of SLC among HL survivors. The obtained results may provide guidelines concerning lung cancer screening for this population.

Hodgkin's lymphoma in adults

Management of Hodgkin's lymphoma continues to develop. Outcomes for patients with favourable-risk, early-stage disease are excellent, and serial reductions in intensity of treatment have been made to retain the excellent prognosis while reducing the late effects of treatment. Prognosis is also very good in advanced-stage disease but the rate of relapse is higher than in early-stage disease, and the optimum first-line treatment is unclear. Workers are investigating the role of functional imaging to assess whether treatment can be tailored according to response, with the most intensive therapies reserved for patients predicted to have poor outcomes. In this Seminar we critically appraise the management of Hodgkin's lymphoma in early-stage disease, advanced-stage disease, and at relapse, with a focus on late effects of treatment.

Risk of second breast cancer in female Hodgkin's lymphoma survivors: a meta-analysis

BACKGROUND

Women treated for Hodgkin's lymphoma (HL) have an elevated risk of developing second breast cancer (SBC) compared with the general population. We planned this meta-analysis to quantify the long-term risk of SBC and analyze the contributing risk factors among HL survivors.

METHODS

According to predefined selection criteria, literature search identified 34 studies that were included in the analyses.

RESULTS

After eliminating overlapping or duplicate data, 957 incidences of SBC were encountered in 24,505 females with HL over a median follow-up of 14.9 years. The medians: age at the diagnosis of HL, age at diagnosis of SBC, and latency since HL treatment to the development of SBC were 23.7, 35.0, and 17.7 years, respectively. The pooled relative risk (RR) of SBC was 8.23 (95% CI, 5.43-12.47, I² = 96%), with a median absolute excess rate of 22.9 per 10,000 person-years. The RR was found inversely related to age at diagnosis of HL with the highest rate (68.7; [95%CI, 28.08-168.11], I² = 79%), occurred in young patients (≤ 15 years old), where the RR in older women (≥ 40 years old) was not significant (0.55; [95% CI, 0.09-3.52]). Analysis of RR by 5-year increments since the treatment of HL showed that the risk was highest after 15-19 years of latency (13.87; [95% CI, 7.91-24.30], I² = 89%). Analysis of the effect of treatment modalities showed that the RR rates were (4.70; [95% CI, 3.28-6.75], I² = 74%), (5.65; [95%CI, 2.94-10.88], I² = 91%), and (1.19; [95% CI, 0.50-2.82], I2 = 65%), for radiotherapy (RT) only, combined RT and chemotherapy (CT), and CT only, respectively. To investigate the demonstrated heterogeneity, meta-regression analysis was performed when feasible. In most such analyses, the natural logarithm of RR was inversely associated with age at HL diagnosis.

CONCLUSIONS

We conclude that, the current meta-analysis provided the most recent comprehensive estimate of the risk of SBC in a broad-range of HL survivors. Younger age at diagnosis proved to be a dominant risk factor. The obtained results would serve providing breast cancer screening recommendations for HL survivors.