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Molin D. Aging Kairos: treating older Hodgkin patients. Blood 2024; 143:943-945. [PMID: 38483406 DOI: 10.1182/blood.2023023125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2024] Open
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2
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Evens AM. Hodgkin lymphoma treatment for older persons in the modern era. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:483-499. [PMID: 38066840 PMCID: PMC10727079 DOI: 10.1182/hematology.2023000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
There has been a renewed effort globally in the study of older Hodgkin lymphoma (HL) patients, generating a multitude of new data. For prognostication, advancing age, comorbidities, altered functional status, Hispanic ethnicity, and lack of dose intensity (especially without anthracycline) portend inferior survival. Geriatric assessments (GA), including activities of daily living (ADL) and comorbidities, should be objectively measured in all patients. In addition, proactive multidisciplinary medical management is recommended (eg, geriatrics, cardiology, primary care), and pre-phase therapy should be considered for most patients. Treatment for fit older HL patients should be given with curative intent, including anthracyclines, and bleomycin should be minimized (or avoided). Brentuximab vedotin given sequentially before and after doxorubicin, vinblastine, dacarbazine (AVD) chemotherapy for untreated patients is tolerable and effective, and frontline checkpoint inhibitor/AVD platforms are rapidly emerging. Therapy for patients who are unfit or frail, whether due to comorbidities and/or ADL loss, is less clear and should be individualized with consideration of attenuated anthracycline-based therapy versus lower-intensity regimens with inclusion of brentuximab vedotin +/- checkpoint inhibitors. For all patients, there should be clinical vigilance with close monitoring for treatment-related toxicities, including neurotoxicity, cardiopulmonary, and infectious complications. Finally, active surveillance for "postacute" complications 1 to 10 years post therapy, especially cardiac disease, is needed for cured patients. Altogether, therapy for older HL patients should include anthracycline-based therapy in most cases, and novel targeted agents should continue to be integrated into treatment paradigms, with more research needed on how best to utilize GAs for treatment decisions.
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Affiliation(s)
- Andrew M. Evens
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Wilson MR, Haynes E, Parsons K, Hopkins D, Robertson E, Ferguson G, Quinn D, Murray J, Osborne W, Leach M, McKay P. 'ACOPP' chemotherapy for older and less fit patients with Hodgkin lymphoma-A multicentre, retrospective study. Br J Haematol 2023; 202:796-800. [PMID: 37357380 DOI: 10.1111/bjh.18947] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
Management of classical Hodgkin lymphoma in older patients is challenging due to poor tolerance of the chemotherapy regimens used in younger patients. We modified the BEACOPP regimen (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisolone), whereby bleomycin and etoposide were removed and cyclophosphamide dose was reduced, for older patients with co-morbidities. Here we present data from the first 41 patients treated with 'ACOPP' across 3 centres, demonstrating that it can be delivered, with a favourable toxicity profile (TRM 2%) and promising efficacy (2-year PFS and OS, 73% (95% CI: 52-94) and 93% (95% CI: 80-100) respectively).
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Affiliation(s)
- Matthew R Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Euan Haynes
- Department of Haematology, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Katrina Parsons
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - David Hopkins
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - Graeme Ferguson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Daire Quinn
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Jim Murray
- Department of Haematology, Royal United Hospital Bath NHS Trust, Bath, UK
| | - Wendy Osborne
- Department of Haematology, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mike Leach
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
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Barrett A, Collins GP. Older patients with Hodgkin Lymphoma: Walking the tightrope of efficacy and toxicity. Front Oncol 2023; 12:1017787. [PMID: 36713561 PMCID: PMC9880490 DOI: 10.3389/fonc.2022.1017787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/11/2022] [Indexed: 01/15/2023] Open
Abstract
Since its initial description, classical Hodgkin lymphoma (cHL) portends a greatly improved prognosis and the goal of treatment in most patients is cure with minimisation of toxicity from treatment. Outcomes in older patients (>60 years old) lag behind those of their younger counterparts however, and cure remains achievable mostly for those who can tolerate full doses of conventional chemotherapy. This review addresses the difference in biology between younger and older patients with cHL and examines the impact of frailty and comorbidities on outcomes. The toxicities of conventional chemotherapy in anthracycline-fit and -unfit patients are examined, with a particular focus on pulmonary toxicity associated with bleomycin in older patients. New advances are discussed, including the possibility of using more targeted therapies such as the anti-CD30 antibody brentuximab vedotin (BV) and checkpoint inhibitors as a method of reducing dependency on conventional chemotherapy for those less well able to tolerate it. Treatment of older patients with cHL remains an area of unmet need in hematological research, and efforts to rectify this knowledge gap should continue.
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Clinical Dilemmas in the Treatment of Elderly Patients Suffering from Hodgkin Lymphoma: A Review. Biomedicines 2022; 10:biomedicines10112917. [PMID: 36428485 PMCID: PMC9687245 DOI: 10.3390/biomedicines10112917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/02/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Elderly patients make up a significant number of cases of newly diagnosed Hodgkin lymphoma. However, unlike in young patients, the outcomes of elderly patients are poor, and they are under-represented in phase III trials. Prior to treatment initiation, geriatric assessment should ideally be performed to address the patient's fitness and decide whether to pursue a curative or palliative approach. The ABVD regimen is poorly tolerated in unfit patients, with high treatment-related mortality. Alternative chemotherapy approaches have been explored, with mixed results obtained concerning their feasibility and toxicity in phase II trials. The introduction of brentuximab vedotin-based regimens led to a paradigm shift in first- and further-line treatment of elderly Hodgkin lymphoma patients, providing adequate disease control within a broader patient population. As far as checkpoint inhibitors are concerned, we are only just beginning to understand the role in the treatment of this population. In relapsed/refractory settings there are few options, ranging from autologous stem cell transplantation in selected patients to pembrolizumab, but unfortunately, palliative care is the most common modality. Importantly, published studies are frequently burdened with numerous biases (such as low numbers of patients, selection bias and lack of geriatric assessment), leading to low level of evidence. Furthermore, there are few ongoing studies on this topic. Thus, elderly Hodgkin lymphoma patients are hard to treat and represent an unmet need in hematologic oncology. In conclusion, treatment needs to be personalized and tailored on a case-by-case basis. In this article, we outline treatment options for elderly Hodgkin lymphoma patients.
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Pei F, Yu Y, Dong B, Guan H, Dong X, Zhao F. Efficacies and Toxicities of Seven Chemotherapy Regimens for Advanced Hodgkin Lymphoma. Front Pharmacol 2021; 12:694545. [PMID: 34867316 PMCID: PMC8635017 DOI: 10.3389/fphar.2021.694545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background/Aims: Hodgkin Lymphoma (HL) has become one of the most treatable cancers, with more than 80% patients in the advanced stage being cured through improvement of therapeutic regimens. Nevertheless, some treatments were accompanied with toxicities. Methods: In the current study, a network meta-analysis (NMA) was conducted to compare the efficacies and toxicities of different chemotherapy regimens for advanced Hodgkin lymphoma (HL). We reviewed PubMed and EMBASE databases from inception to May 2018, and identified randomized controlled trials (RCTs) in which advanced HL patients received chemotherapy. Fourteen eligible RCTs published between 1992 and 2017 were enrolled in this NMA. These studies included a total of 5,964 HL patients, and assessed at least one of seven different chemotherapy regimens. Direct and indirect evidence was combined to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs), and to establish a surface under the cumulative ranking (SUCRA) curve. Results: A cluster analysis was performed to evaluate efficacies and toxicities of different regimens. The COPP + ABVD (cyclophosphamide + vincristine + procarbazine + prednisone + doxorubicin + bleomycin + vinblastine + dacarbazine) regimen had the highest SUCRA partial response and overall remission rate values, while the ABVD regimen resulted in the lowest incidences of anemia, thrombocytopenia, neutropenia, and leucopenia. Conclusion: Cluster analysis revealed that COPP + ABVD had the best efficacy against advanced HL among the seven regimens, and ABVD had the lowest toxicity.
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Affiliation(s)
- Fajun Pei
- Department of Urology Surgery, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yang Yu
- School of Graduate Studies, Shandong Academy of Medical Sciences, Shandong First Medical University, Jinan, China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Bin Dong
- Department of Medical Imaging, The First People's Hospital of Pingdu, Qingdao, China
| | - Hui Guan
- Department of Radiation Oncology, The Fourth People's Hospital of Jinan, Jinan, China
| | - Xinzhe Dong
- Department of Radiation Oncology, Qilu Hospital of Shandong University, Jinan, China
| | - Fen Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,Shandong University, Jinan, China
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Rodday AM, Hahn T, Kumar AJ, Lindenauer PK, Friedberg JW, Evens AM, Parsons SK. Association of Treatment Intensity With Survival in Older Patients With Hodgkin Lymphoma. JAMA Netw Open 2021; 4:e2128373. [PMID: 34673965 PMCID: PMC8531990 DOI: 10.1001/jamanetworkopen.2021.28373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hodgkin lymphoma is an aggressive blood cancer that is highly curable in younger patients who receive multiagent chemotherapy. Worse survival in older patients may reflect less-aggressive treatment, competing risks of death, or different disease biological factors. OBJECTIVE To examine the association between treatment intensity and cause-specific mortality among older adults with Hodgkin lymphoma. DESIGN, SETTING, AND PARTICIPANTS This was a population-based cohort study of patients aged 65 years or older with Medicare Part A and B fee-for-service coverage who received a diagnosis of Hodgkin lymphoma from 2000 to 2013. The association between treatment intensity and cause-specific mortality was estimated separately for early-stage and advanced-stage disease with Cox proportional hazards models. Multivariable adjustment and propensity score weighting helped control for confounding. Data are from the 1999 to 2016 Surveillance, Epidemiology, and End Results Medicare database. Data analysis was performed from April 2020 to June 2021. EXPOSURES First-line treatment categorized as (1) full chemotherapy regimen, (2) partial chemotherapy regimen, (3) single chemotherapy agent or radiotherapy, or (4) no treatment. MAIN OUTCOMES AND MEASURES The main outcome was 3-year Hodgkin lymphoma-specific and other-cause mortality. RESULTS Among 2686 patients (mean [SD] age, 75.7 [6.9] years; 1333 men [50%]), 1307 had early-stage disease and 1379 had advanced-stage disease. For Hodgkin lymphoma-specific mortality in patients with early-stage disease, hazard ratios (HRs) were higher for partial regimens (HR, 1.77; 95% CI, 1.22-2.57) or no treatment (HR, 1.91; 95% CI, 1.31-2.79) than for full regimens; there was no difference between single-agent chemotherapy or radiotherapy and full regimens. For other-cause mortality in patients with early-stage disease, HRs were higher for partial regimens (HR, 1.69; 95% CI, 1.18-2.44), single-agent chemotherapy or radiotherapy (HR, 1.62; 95% CI, 1.13-2.33), or no treatment (HR, 2.71; 95% CI, 1.95-3.78) than for full regimens. For Hodgkin lymphoma-specific mortality in patients with advanced-stage disease, HRs were higher for partial regimens (HR, 3.26; 95% CI, 2.44-4.35), single-agent chemotherapy or radiotherapy (HR, 2.85; 95% CI, 1.98-4.11), or no treatment (HR, 4.06; 95% CI, 3.06-5.37) than for full regimens. For other-cause mortality in patients with advanced-stage disease, HRs were higher for partial regimens (HR, 1.76; 95% CI, 1.32-2.33), single-agent chemotherapy or radiotherapy (HR, 1.65; 95% CI, 1.15-2.37), or no treatment (HR, 2.24; 95% CI, 1.71-2.94) than for full regimens. CONCLUSIONS AND RELEVANCE This cohort study found variability in the magnitude of the association between treatment intensity and mortality by stage and cause-specific mortality, possibly reflecting competing risks of death. However, full chemotherapy regimens were associated with lower mortality and could be considered for older adults who can tolerate them.
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Affiliation(s)
- Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Theresa Hahn
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Anita J. Kumar
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School Baystate, Springfield
| | | | | | - Susan K. Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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Wahlin BE, Övergaard N, Peterson S, Digkas E, Glimelius I, Lagerlöf I, Johansson A, Palma M, Hansson L, Linderoth J, Goldkuhl C, Molin D. Real‐world data on treatment concepts in classical Hodgkin lymphoma in Sweden 2000–2014, focusing on patients aged >60 years. EJHAEM 2021; 2:400-412. [PMID: 35844675 PMCID: PMC9175745 DOI: 10.1002/jha2.202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 11/08/2022]
Abstract
Treatment for patients > 60 years with classical Hodgkin lymphoma (cHL) is problematic; there is no gold standard, and outcome is poor. Using the Swedish Lymphoma Registry, we analysed all Swedish patients diagnosed with cHL between 2000 and 2014 (N = 2345; median age 42 years; 691 patients were >60 years). The median follow‐up time was 6.7 years. Treatment for elderly patients consisted mainly of ABVD or CHOP, and the younger patients were treated with ABVD or BEACOPP (with no survival difference). In multivariable analysis of patients > 60 years, ABVD correlated with better survival than CHOP (p = 0.027), and ABVD became more common over time among patients aged 61–70 years (p = 0.0206). Coinciding with the implementation of FDG‐PET/CT, the fraction of advanced‐stage disease increased in later calendar periods, also in the older patient group. Survival has improved in cHL patients > 60 years (p = 0.027), for whom ABVD seems superior to CHOP.
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Affiliation(s)
- Björn Engelbrekt Wahlin
- Division of Haematology, Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
- Haematology unit Karolinska University Hospital Stockholm Sweden
| | - Ninja Övergaard
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
| | | | | | - Ingrid Glimelius
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
| | - Ingemar Lagerlöf
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
- Department of Haematology University Hospital of Linköping Linköping Sweden
| | | | - Marzia Palma
- Haematology unit Karolinska University Hospital Stockholm Sweden
| | - Lotta Hansson
- Haematology unit Karolinska University Hospital Stockholm Sweden
| | | | - Christina Goldkuhl
- Department of Oncology Sahlgrenska University Hospital Gothenburg Sweden
| | - Daniel Molin
- Department of Immunology, Genetics and Pathology Uppsala University Uppsala Sweden
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Cheson BD, Bartlett NL, LaPlant B, Lee HJ, Advani RJ, Christian B, Diefenbach CS, Feldman TA, Ansell SM. Brentuximab vedotin plus nivolumab as first-line therapy in older or chemotherapy-ineligible patients with Hodgkin lymphoma (ACCRU): a multicentre, single-arm, phase 2 trial. LANCET HAEMATOLOGY 2020; 7:e808-e815. [PMID: 33010817 DOI: 10.1016/s2352-3026(20)30275-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hodgkin lymphoma is potentially curable. However, 15-35% of older patients (ie, >60 years) have a lower response rate, worse survival outcomes, and greater toxicity than younger patients. Brentuximab vedotin and nivolumab exhibit activity in patients with relapsed or refractory Hodgkin lymphoma. We therefore aimed to evaluate the safety and efficacy of brentuximab vedotin and nivolumab in untreated older patients with Hodgkin lymphoma or in younger patients considered unsuitable for standard ABVD (ie, doxorubicin, bleomycin, vinblastine, and dacarbazine) therapy. METHODS We did a multicentre, single-arm, phase 2 trial at eight cancer centres in the USA. Previously untreated patients with classic Hodgkin lymphoma were eligible for study enrolment if they were 60 years or older, or younger than 60 years but considered unsuitable for standard chemotherapy because of a cardiac ejection fraction of less than 50%, pulmonary diffusion capacity of less than 80%, or a creatinine clearance of 30 mL/min or more but less than 60 mL/min, or those who refused chemotherapy. Patients were also required to have an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2. Patients received brentuximab vedotin at 1·8 mg/kg (dose cap at 180 mg) and nivolumab at 3 mg/kg both intravenously every 21 days for 8 cycles. The primary endpoint was the overall response, defined as a partial metabolic response or complete metabolic response at the end of 8 cycles of treatment. A per protocol analysis was done including all patients who received treatment in the activity and safety analyses. This study is registered with ClinicalTrials.gov, number NCT02758717. FINDINGS Between May 13, 2016, and Jan 30, 2019, the study accrued 46 patients. The median age was 71·5 years (IQR 64-77), with two (4%) of 46 patients younger than 60 years. Median follow-up was 21·2 months (IQR 15·6-29·9), and 35 (76%) of 46 patients completed all 8 cycles of therapy. At the interim analysis on Oct 11, 2019, the first 25 evaluable patients had an overall response rate of 64% ([95% CI 43-82] 16 of 25 patients; 13 [52%] had a complete metabolic response and three [12%] had a partial metabolic response). The trial was closed to accrual on Oct 14, 2019, after the interim analysis failed to meet the predefined criteria. In all 46 evaluable patients, 22 (48%) patients achieved a complete metabolic response and six (13%) achieved a partial metabolic response (overall response rate 61% [95% CI 45-75]). 14 (30%) of 46 patients had 16 dose adjustments, primarily due to neurotoxicity. 22 (48%) of 46 patients had peripheral neuropathy (five [11%] patients had grade 3 peripheral neuropathy). Grade 4 adverse events included increased aminotranferases (one [2%] of 46), increased lipase or amylase (two [4%]), and pancreatitis (one [2%]). One (2%) patient died from cardiac arrest, possibly treatment related. INTERPRETATION Although the trial did not meet the prespecified activity criteria, brentuximab vedotin plus nivolumab is active in older patients with previously untreated Hodgkin lymphoma with comorbidities. The regimen was also well tolerated in the majority of patients in this older population. Future trials should be based on optimising the dose and schedule, perhaps combined with other targeted agents that might permit chemotherapy-free strategies in older patients with Hodgkin lymphoma. FUNDING Seattle Genetics and Bristol Myers Squibb.
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Affiliation(s)
| | - Nancy L Bartlett
- Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO, USA
| | - Betsy LaPlant
- Division of Biomedical Statistics and Bioinformatics, Department of Health Sciences Research, Mayo Clinic Rochester, Rochester, MN, USA
| | - Hun J Lee
- Department of Lymphoma and Myeloma, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Beth Christian
- Hematology Division, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Catherine S Diefenbach
- Clinical Lymphoma Program, Perlmutter Cancer Center at NYU Langone Health, New York, NY, USA
| | - Tatyana A Feldman
- Lymphoma Division, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Stephen M Ansell
- Division of Medical Oncology, Department of Medicine, Mayo Clinic Rochester, Rochester, MN, USA
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10
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Dalal M, Gupta J, Price K, Zomas A, Miao H, Ashaye A. Efficacy and safety of front-line treatments for advanced Hodgkin lymphoma: a systematic literature review. Expert Rev Hematol 2020; 13:907-922. [PMID: 32749937 DOI: 10.1080/17474086.2020.1793666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess evidence on the safety and efficacy of ABVD (doxorubicin [Adriamycin®], bleomycin, vinblastine, and dacarbazine), BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone), and A+AVD (brentuximab vedotin, with doxorubicin, vinblastine, and dacarbazine) for advanced-stage Hodgkin lymphoma (HL). METHODS A systematic literature review (SLR) was conducted on 29 July 2016 (updated 26 July 2018) to identify randomized controlled trials (RCTs) and non-RCTs assessing the treatment of newly-diagnosed advanced-stage HL with ABVD and BEACOPP (and their variants), and A+AVD. RESULTS The SLR identified 62 RCTs and 42 non-RCTs. Five-year overall survival rates for ABVD and BEACOPP were 60-97% and 84-99%, and 5-year progression-free survival rates were 58-81% and 83-96%, respectively. Both regimens were associated with tolerability issues and side effects. Discontinuation or dose reduction of bleomycin resulted in fewer adverse events, without significantly affecting efficacy. A head-to-head trial demonstrated improved efficacy for A+AVD vs ABVD, with an acceptable tolerability profile. No data from head-to-head trials comparing A+AVD with BEACOPP were available, and an indirect treatment comparison was not feasible. CONCLUSION New therapies, such as A+AVD, maintain the efficacy observed with current treatments, and may provide a more tolerable treatment option for patients with advanced-stage HL.
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Affiliation(s)
- Mehul Dalal
- Global Evidence & Outcomes - Oncology, Millennium Pharmaceuticals, Inc. a wholly owned subsidiary of Takeda Pharmaceutical Company Limited , Cambridge, MA, USA
| | - Jatin Gupta
- Global Access, Decision Resources Group , Gurugram, Haryana, 122002, India
| | - Kim Price
- Global Access, Decision Resources Group, 6 Talisman Business Centre, Bicester , Oxfordshire, USA
| | - Athanasios Zomas
- Global Medical Affairs - Oncology, Millennium Pharmaceuticals, Inc. a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Harry Miao
- Clinical Sciences , Millennium Pharmaceuticals, Inc. a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Ajibade Ashaye
- Global Evidence & Outcomes - Oncology, Millennium Pharmaceuticals, Inc. a wholly owned subsidiary of Takeda Pharmaceutical Company Limited , Cambridge, MA, USA
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11
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Rodday AM, Hahn T, Kumar AJ, Lindenauer PK, Friedberg JW, Evens AM, Parsons SK. First-line treatment in older patients with Hodgkin lymphoma: a Surveillance, Epidemiology, and End Results (SEER)-Medicare population-based study. Br J Haematol 2020; 190:222-235. [PMID: 32090325 PMCID: PMC7368808 DOI: 10.1111/bjh.16525] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 01/14/2020] [Indexed: 11/26/2022]
Abstract
While Hodgkin lymphoma (HL) is highly curable in younger patients, older patients have higher relapse and death rates, which may reflect age-related factors, distinct disease biology and/or treatment decisions. We described the association between patient, disease and geographic factors and first-line treatment in older patients (≥65 years) with incident HL using Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1999 to 2014 (n = 2825). First-line treatment initiated at ≤4 months after diagnosis was categorised as: full chemotherapy regimen (n = 699, 24·7%); partial chemotherapy regimen (n = 1016, 36·0%); single chemotherapy agent or radiotherapy (n = 382, 13·5%); and no treatment (n = 728, 25·8%). Among the fully treated, ABVD [doxorubicin (Adriamycin), bleomycin, vinblastine, dacarbazine]/AVD was most common (n = 635, 90·8%). Adjusted multinomial logistic regression identified factors associated with treatment. Older age, Medicaid dual eligibility, not married, frailty, cardiac comorbidity, prior cancer, earlier diagnosis date, histology, advanced disease Stage, B symptoms and South region were independently associated with increased odds of not receiving full chemotherapy regimens. In conclusion, we found variability in first-line HL treatment for older patients. Treatment differences by Medicaid and region may indicate disparities. Even after adjusting for frailty and cardiac comorbidity, age was associated with treatment, suggesting factors such as end-of-life care or shared decision-making may influence treatment in older patients.
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Affiliation(s)
- Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Theresa Hahn
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Anita J. Kumar
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield, MA
| | | | - Andrew M. Evens
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Susan K. Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
- Department of Medicine, Tufts University School of Medicine, Boston, MA
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12
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Armand P, Bello CM, Benitez CM, Bierman PJ, Boughan KM, Dabaja B, Gordon LI, Hernandez-Ilizaliturri FJ, Herrera AF, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Lynch RC, Maddocks K, McConathy J, McKinney M, Metzger M, Morgan D, Mulroney C, Rabinovitch R, Rosenspire KC, Seropian S, Tao R, Winter JN, Yahalom J, Burns JL, Ogba N. Hodgkin Lymphoma, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:755-781. [DOI: 10.6004/jnccn.2020.0026] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The NCCN Clinical Practice Guidelines in Oncology for Hodgkin Lymphoma (HL) provide recommendations for the management of adult patients with HL. The NCCN panel meets at least annually to review comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. Current management of classic HL involves initial treatment with chemotherapy alone or combined modality therapy followed by restaging with PET/CT to assess treatment response. Overall, the introduction of less toxic and more effective regimens has significantly advanced HL cure rates. This portion of the NCCN Guidelines focuses on the management of classic HL.
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Affiliation(s)
| | | | - Weiyun Z. Ai
- 2UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | - Kirsten M. Boughan
- 7Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Leo I. Gordon
- 9Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Jiayi Huang
- 13Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | | | | | - Ryan C. Lynch
- 18Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Kami Maddocks
- 19The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Monika Metzger
- 22St. Jude Children’s Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | - Randa Tao
- 28Huntsman Cancer Institute at the University of Utah
| | - Jane N. Winter
- 9Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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Prognostic role of baseline 18F-FDG PET/CT metabolic parameters in elderly HL: a two-center experience in 123 patients. Ann Hematol 2020; 99:1321-1330. [PMID: 32333153 DOI: 10.1007/s00277-020-04039-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/11/2020] [Indexed: 01/20/2023]
Abstract
Elderly Hodgkin lymphoma (HL) is an aggressive lymphoma subgroup with high 18F-FDG avidity at 18F-FDG-PET/CT but no shared criteria for PET/CT in treatment evaluation and prediction of outcome are available. The aim of our bicentric study was to investigate whether the metabolic baseline PET/CT parameters can predict treatment response and prognosis in elderly HL. We retrospectively included 123 patients who underwent baseline 18F-FDG-PET/CT and end of treatment PET/CT scans. The PET images were analyzed visually and semi-quantitatively by measuring the lesion to liver SUVmax ratio (L-L SUV R), lesion to blood-pool SUVmax ratio (L-BP SUV R), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Survival curves were plotted according to the Kaplan-Meier method. At a median follow-up of 40 months, the median PFS and OS were 29 and 37 months. L-BP SUV R, L-L SUV R, MTV, and TLG were significantly higher in patients with no complete response compared with complete response group at end of treatment. Moreover, these parameters were demonstrated to be independent prognostic factors for PFS together with tumor stage, while only L-L SUV R and L-BP SUV R for OS. End of treatment PET/CT results using Deauville criteria were significantly correlated with outcome survival. End of treatment PET/CT results (using Deauville criteria) and semiquantitative baseline PET/CT parameters were significantly correlated with response to treatment and long-term outcome.
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14
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Carter J, David KA, Kritharis A, Evens AM. Current Treatment Options for Older Patients with Hodgkin Lymphoma. Curr Treat Options Oncol 2020; 21:42. [PMID: 32328822 DOI: 10.1007/s11864-020-00745-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Older adults with Hodgkin lymphoma (HL), commonly defined as age ≥ 60 years, represent approximately 20% of the total HL population. Historically, they have significantly inferior outcomes compared with younger patients. The cause of this is multifactorial, including biologic differences (e.g., mixed cellularity and EBV-related disease); high incidence of advanced stage disease; and frequency of comorbidities and decreased organ reserve leading to poorer tolerability of therapy with increased toxicity, including treatment-related mortality. Pretreatment evaluation for older HL patients should entail a geriatric assessment (GA), with evaluation of functional status and comorbidities (e.g., geriatric cumulative illness rating scale, CIRS-G) to determine fitness. Furthermore, treatment selection should be based in part on GA, with fit older patients receiving curative chemotherapy-based regimens and unfit or frail patients considering less intensive or non-chemotherapy-based platforms. Additionally, there may be consideration for pre-phase of therapy (e.g., pulse steroids) in order to improve performance status. The inclusion of anthracycline therapy appears important, while bleomycin-containing regimens (e.g., ABVD) may be associated with prohibitive pulmonary toxicity, and intensive therapies such as BEACOPP are too toxic. benefit ratio/benefit ratio, a priori omission of bleomycin may also be considered (i.e., AVD), especially for patients older than 70 years of age. In addition, newer regimens for older HL patients integrating novel therapeutic agents into frontline treatment have emerged as effective and tolerable options. Data incorporating brentuximab vedotin sequentially before and after AVD chemotherapy represent the best-reported outcomes in older HL patients to date. In the relapsed/refractory setting, salvage chemotherapy regimens followed by autologous stem cell transplantation should be considered for fit patients, while less intensive treatment, including the use of novel targeted agents, is an option for unfit or frail patients. In this review, we examine the epidemiology, importance of GA, and current treatment options for older HL patients.
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Affiliation(s)
- Jordan Carter
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903, USA
| | - Kevin A David
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903, USA
| | - Athena Kritharis
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903, USA
| | - Andrew M Evens
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ, 08903, USA.
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15
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Sykorova A, Mocikova H, Lukasova M, Koren J, Stepankova P, Prochazka V, Belada D, Klaskova K, Gaherova L, Chroust K, Buresova L, Markova J. Outcome of elderly patients with classical Hodgkin’s lymphoma. Leuk Res 2020; 90:106311. [DOI: 10.1016/j.leukres.2020.106311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 11/27/2022]
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16
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Allen PB, Ayers A, Behera M, Evens AM, Flowers C. A systematic review of therapeutic regimens for older patients with newly diagnosed Hodgkin lymphoma. Leuk Lymphoma 2020; 61:1555-1564. [PMID: 32102579 DOI: 10.1080/10428194.2020.1731497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Classical Hodgkin lymphoma (cHL) in older adults is associated with inferior outcomes and increased toxicity compared to younger patients. Novel therapies like brentuximab vedotin (BV) have yielded promising results, yet their optimal use in older cHL remains unclear. We performed a systematic review to assess outcomes and toxicity associated with frontline regimens in older cHL. We screened 196 references involving chemotherapy without BV and 662 references containing BV and included 9 studies (12 arms) without BV and 6 studies (7 arms) with BV. Progression-free survival (PFS) ranged from 47 to 84% at 2 years in BV-containing arms and 42-79% at 5 years in non-BV containing trials. Pulmonary toxicity was more common in arms receiving >2 cycles of bleomycin, whereas peripheral neuropathy was associated with cumulative BV dose. This review summarizes available treatment outcomes in newly diagnosed older cHL patients and may aid clinicians in decision-making regarding available frontline approaches.Key PointsThis systematic review suggests that >2 cycles of bleomycin is associated with excess pulmonary toxicity in cHL patients older than 60 years of age.Peripheral neuropathy was more frequent in patients receiving BV-containing regimens and was associated with cumulative BV dose.BV-containing regimens are associated with high response rates in advanced-stage patients, but follow-up is limited.
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Affiliation(s)
- Pamela B Allen
- Department of Hematology and Oncology, Winship Cancer Institution of Emory University, Atlanta, GA, USA
| | - Amy Ayers
- Department of Hematology and Oncology, Winship Cancer Institution of Emory University, Atlanta, GA, USA
| | - Madhusmita Behera
- Department of Research Informatics, Winship Cancer Institution of Emory University, Atlanta, GA, USA
| | - Andrew M Evens
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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17
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Zhang J, Fan L, Li JY. [Research progress of treatment in Hodgkin lymphoma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 40:969-972. [PMID: 31856452 PMCID: PMC7342374 DOI: 10.3760/cma.j.issn.0253-2727.2019.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- J Zhang
- Department of Hematology, the First Affiliated Hospital of NanJing Medical University, JiangSu Province Hospital, Nanjing 210029, China
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18
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Evens AM, Carter J, Loh KP, David KA. Management of older Hodgkin lymphoma patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:233-242. [PMID: 31808898 PMCID: PMC6913478 DOI: 10.1182/hematology.2019000028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Hodgkin lymphoma (HL) in older patients, commonly defined as ≥60 years of age, is a disease for which survival rates have historically been significantly lower compared with younger patients. Older HL patients appear to have different disease biology compared with younger patients, including increased incidence of mixed cellularity histology, Epstein-Barr virus-related, and advanced-stage disease. For prognostication, several studies have documented the significance of comorbidities and functional status in older HL patients, as well as the importance of achieving initial complete remission. Collectively, selection of therapy for older HL patients should be based in part on functional status, including pretreatment assessment of activities of daily living (ADL), comorbidities, and other geriatric measures (eg, cognition, social support). Treatment of fit older HL patients should be given with curative intent, regardless of disease stage. However, attention should be paid to serious treatment-related toxicities, including risk of treatment-related mortality. Although inclusion of anthracycline therapy is important, bleomycin-containing regimens (eg, doxorubicin, bleomycin, vinblastine, dacarbazine) may lead to prohibitive pulmonary toxicity, and intensive therapies (eg, bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) are too toxic. Brentuximab vedotin given sequentially before and after doxorubicin, vinblastine, and dacarbazine to fit, untreated advanced-stage older HL patients was recently shown to be tolerable and highly effective. Therapy for patients who are unfit or frail because of comorbidities and/or ADL loss is less clear and should be individualized with consideration of lower-intensity therapy, such as brentuximab vedotin with or without dacarbazine. Altogether, therapy for older HL patients should be tailored based upon a geriatric assessment, and novel targeted agents should continue to be integrated into treatment paradigms.
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Affiliation(s)
- Andrew M Evens
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; and
| | - Jordan Carter
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; and
| | - Kah Poh Loh
- Division of Hematology and Oncology, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Kevin A David
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; and
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19
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Affiliation(s)
- Andreas Engert
- University of Cologne, Faculty of Medicine and University Hospital of Cologne, Department I of Internal Medicine, GHSG, Cologne, Germany
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20
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Salvi F, Luminari S, Tucci A, Massidda S, Liberati AM, Stelitano C, Zanni M, Re A, Centurioni R, Freilone R, Musuraca G, Nassi L, Patti C, Arcari A, Tani M, Pulsoni A, Pavone V, Volpetti S, Peli A, Evangelista A, Spina M, Ladetto M, Merli F. Bleomycin, vinblastine and dacarbazine combined with nonpegylated liposomal doxorubicin (MBVD) in elderly (≥70 years) or cardiopathic patients with Hodgkin lymphoma: a phase-II study from Fondazione Italiana Linfomi (FIL). Leuk Lymphoma 2019; 60:2890-2898. [PMID: 31282794 DOI: 10.1080/10428194.2019.1608529] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This phase-II study assessed activity and toxicity of substituting conventional doxorubicin with nonpegylated liposomal doxorubicin in the conventional ABVD regimen for the treatment of elderly or cardiopathic patients with HL. Stage I-IIA and IIB-IV patients were treated with three courses of MBVD plus radiotherapy, or six courses of MBVD, respectively, plus radiotherapy limited to bulky or residual disease areas. The primary endpoints were CR rate and the rate of cardiac events. Forty-seven patients were enrolled. Median age was 75 years, 13 had stage I-II disease. Overall, CR was achieved by 36 patients (77%, 95% CI: 62-88), 100% and 68% in stage I-II and III-IV, respectively. With a median follow-up of 40 months (IQR: 36-45). Three-year overall survival (OS) and progression-free survival (PFS) were 70% and 43%, respectively. Cardiac events grades 3-5 were reported in two patients. In conclusion, MBVD's activity and safety profile was comparable to historical ABVD data.
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Affiliation(s)
- Flavia Salvi
- Division of Hematology, SS. Antonio e Biagio Hospital, Alessandria, Italy
| | - Stefano Luminari
- Hematology Unit, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy.,Surgical, Medical and Dental Department of Morphological Sciences related to Transplant Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Tucci
- Division of Haematology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Stefania Massidda
- Hematology and Transplant Center, Ospedale Oncologico di Riferimento Regionale Armando Businco, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Anna Marina Liberati
- Oncohematology and autotransplantation Unit, Azienda Ospedaliera Santa Maria, Terni, Italy
| | - Caterina Stelitano
- Division of Hematology, Azienda Ospedaliera "Bianchi Melacrino Morelli", Reggio Calabria, Italy
| | - Manuela Zanni
- Division of Hematology, SS. Antonio e Biagio Hospital, Alessandria, Italy
| | - Alessandro Re
- Division of Haematology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Riccardo Centurioni
- Internal medicine and hematology Unit, Azienda Sanitaria Unica Regionale Marche AV3, Civitanova Marche, Italy
| | | | - Gerardo Musuraca
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Luca Nassi
- Division of Hematology Department of Translational Medicine, Università del Piemonte Orientale and AOU Maggiore della Carità, Novara, Italy
| | - Caterina Patti
- Department of Hematology I, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Annalisa Arcari
- Hematology Unit and Transplantion Center, "Guglielmo da Saliceto" Hospital, Piacenza, Italy
| | - Monica Tani
- Hematology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Alessandro Pulsoni
- Department of Cellular Biotechnologies and Hematology, Policlinico Umberto I "Sapienza" University of Rome, Roma, Italy
| | - Vincenzo Pavone
- Department of Hematology and Bone Marrow Transplant, Hospital Card. G. Panico, Tricase, Italy
| | - Stefano Volpetti
- Department of Haematology, DISM Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Annalisa Peli
- Division of Haematology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Andrea Evangelista
- Clinical and Evaluative Epidemiology Unit, AOU Città della Salute e della Scienza di Torino e CPO Piemonte, Torino, Italy
| | - Michele Spina
- Division of Medical Oncology and Immunorelated Tumors, National Cancer Institute, Aviano, Italy
| | - Marco Ladetto
- Division of Hematology, SS. Antonio e Biagio Hospital, Alessandria, Italy
| | - Francesco Merli
- Hematology Unit, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
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21
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Sureda A, Domingo-Domenech E, Gautam A. Neutropenia during frontline treatment of advanced Hodgkin lymphoma: Incidence, risk factors, and management. Crit Rev Oncol Hematol 2019; 138:1-5. [DOI: 10.1016/j.critrevonc.2019.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 01/15/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022] Open
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22
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Bentur OS, Dann EJ, Paran E, Lavie D, Nachmias B, Ron Y, Dally N, Gutwein O, Herishanu Y, Sarid N, Avivi I, Perry C. Interim PET-CT–guided therapy in elderly patients with Hodgkin lymphoma—a retrospective national multi-center study. Ann Hematol 2019; 98:1665-1674. [DOI: 10.1007/s00277-019-03686-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 04/06/2019] [Indexed: 11/29/2022]
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Abstract
PURPOSE OF REVIEW We aim to summarize the current knowledge on the treatment of elderly Hodgkin lymphoma patients with a focus on evidence from clinical trials and novel drugs. RECENT FINDINGS For elderly Hodgkin lymphoma patients above 60 years without precluding comorbidities a curative treatment approach is warranted. Early favorable stage patients should receive two cycles of multiagent chemotherapy followed by 20 Gy localized radiotherapy. Early unfavorable stage patients should receive four cycles of multiagent chemotherapy followed by 30 Gy localized radiotherapy. For advanced stage patients six cycles of multiagent chemotherapy can be recommended and should be followed by localized radiotherapy on residual disease manifestations. Relapsed or refractory patients should be treated in an individually tailored approach that considers both the patient's objectives and comorbidities. The antibody-drug conjugate brentuximab vedotin is a very effective option for elderly patients with a high response rate albeit limited durability. Anti-programed cell death protein 1 antibodies might also be effective in elderly Hodgkin lymphoma patients with a mechanism of action distinct from chemotherapy. SUMMARY In conclusion, the goal of treatment in newly diagnosed elderly Hodgkin lymphoma patients is curative whenever possible and prospective and retrospective evidence has shown that this is feasible for all disease stages with a variety of multiagent chemotherapy regimen. Relapsed and refractory elderly Hodgkin lymphoma patients can mostly only be treated with the goal of palliation. However, it remains to be seen if novel substances and new combination regimen are able to change that.
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Abstract
PURPOSE OF REVIEW Availability of highly effective novel agents has altered the approach to initial therapy in patients with classical Hodgkin lymphoma (cHL). We will review controversies in the following areas: (1) the role of radiation in early unfavorable disease and the optimal treatment strategies for (2) advanced-stage disease and (3) elderly patients. RECENT FINDINGS Strategies incorporating brentuximab vedotin into frontline treatment of cHL yielded favorable results in non-randomized elderly studies and were compared to ABVD in advanced disease among adults. Meanwhile, four cycles of escalated BEACOPP yielded unprecedented favorable results for the treatment of advanced disease in the German Hodgkin Study Group 18 study. The addition of novel agents to conventional treatment strategies has the potential to improve outcomes in high-risk groups of patients while reducing toxicity. The role of radiation therapy remains in question but may see diminished use with the incorporation of more effective agents in the frontline setting.
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25
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Böll B, Plütschow A, Bürkle C, Atta J, Pfreundschuh M, Feuring‐Buske M, Vogelhuber M, Sökler M, Eichenauer DA, Thielen I, Tresckow B, Fuchs M, Engert A, Borchmann P. Doxorubicin, vinblastine, dacarbazine and lenalidomide for older Hodgkin lymphoma patients: final results of a German Hodgkin Study Group (
GHSG
) phase‐I trial. Br J Haematol 2018; 185:42-52. [DOI: 10.1111/bjh.15741] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/26/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Boris Böll
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Annette Plütschow
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Carolin Bürkle
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Johannes Atta
- Haematology Oncology University Hospital Frankfurt FrankfurtGermany
| | | | | | - Martin Vogelhuber
- Haematology Oncology University Hospital Regensburg RegensburgGermany
| | - Martin Sökler
- Haematology Oncology University Hospital Tübingen Tübingen Germany
| | - Dennis A. Eichenauer
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Indra Thielen
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Bastian Tresckow
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Michael Fuchs
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG) Department of Internal Medicine 1 University Hospital Cologne CologneGermany
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Zhang T, Yao Y, Feng F, Zhao W, Tian J, Zhou C, Wang X, Dong S, Li J, Qi L, Sun C. Comparative effectiveness of different chemotherapy regimens of advanced-stage Hodgkin lymphoma in adults: a network meta-analysis. Cancer Manag Res 2018; 10:6017-6028. [PMID: 30538551 PMCID: PMC6257076 DOI: 10.2147/cmar.s179356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Combined chemotherapy is the cornerstone treatment for patients with advanced Hodgkin lymphoma (HL). The objective of our study was to perform a network meta-analysis of the efficacy of different chemotherapy regimens in adults with advanced-stage HL. Materials and methods We searched for relevant randomized controlled trials (RCTs) in titles/abstracts in PubMed, Embase, and the Cochrane Library. The search was last updated on April 3, 2018. RCTs that assessed the effectiveness of one of the following treatments were included: doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD); four cycles of increased dose of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPPescalated) followed by two or four cycles of standard dose of BEACOPP (4× BEACOPPescalated + 2 or 4× BEACOPPbaseline); brentuximab vedotin plus doxorubicin, vinblastine, and dacarbazine (A+AVD); doxorubicin, vinblastine, mechlorethamine, vincristine, bleomycin, etoposide, and prednisone combined with radiation therapy (Stanford V); mechlorethamine (cyclophosphamide), vincristine, procarbazine, and prednisone (M[C] OPP); sequential or alternating chemotherapy regimens with ABVD as the footstone (eg, COPP/ABVD or mechlorethamine, vincristine, procarbazine, and prednisone [MOPP]/ABVD); eight cycles of BEACOPPescalated; hybrid MOPP/ABV; and M[C]EC (M[C]OPP with epidoxorubicin, bleomycin, vinblastine [EBV], and lomustine, doxorubicin, and vindesine [CAD]). Results Overall, we screened 3,564 citations and deemed 18 reports of 16 trials eligible and included them in our network meta-analysis. A total of 11,928 participants were randomly assigned to one of the 12 combinations of chemotherapy regimens, of which 11,476 participants were analyzed. For the overall survival (OS), no differences were observed within any interventions when the ABVD regimen was used as the reference treatment. Similarly, relative to A+AVD, 8× BEACOPPescalated and 6× BEACOPPescalated also showed no differences (HR =1.07, 95% credible interval (CrI): 0.58–1.95; HR =0.62, 95% CrI: 0.16–1.83; and HR =0.71, 95% CrI: 0.30–1.72, respectively). In terms of complete remission (CR), enough evidence exists to support a maximum clinical treatment effect for 6× BEACOPPescalated (OR =1.88, 95% CrI: 1.20–2.96; and OR =3.43, 95% CrI: 1.87–6.24). Conclusion When compared across the 12 combined chemotherapy regimens, six cycles of BEACOPPescalated may be the optimal treatment for patients with advanced-stage HL.
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Affiliation(s)
- Tingting Zhang
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong Province, People's Republic of China
| | - Yan Yao
- Clinical Medical College, Weifang Medical University, Weifang, Shandong Province, People's Republic of China
| | - Fubin Feng
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Wenge Zhao
- Clinical Medical College, Weifang Medical University, Weifang, Shandong Province, People's Republic of China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu Province, People's Republic of China
| | - Chao Zhou
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China,
| | - Xue Wang
- Clinical Medical Colleges, Qingdao University, Shinan District, Qingdao, Shandong Province, People's Republic of China
| | - Shengjie Dong
- Department of the Joint and Bone Surgery, Yantaishan Hospital, Yantai, Shandong Province, People's Republic of China
| | - Jia Li
- Clinical Medical College, Weifang Medical University, Weifang, Shandong Province, People's Republic of China
| | - Lingyu Qi
- College of First Clinical Medicine, Shandong University of Traditional Chinese Medicine, Ji'nan, People's Republic of China
| | - Changgang Sun
- Department of Oncology, Weifang Traditional Chinese Hospital, Weifang, Shandong Province, People's Republic of China, .,Department of Oncology, Affiliated Hospital of Weifang Medical University, Kuiwen District, Weifang, Shandong Province, People's Republic of China,
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27
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Major A, Jackson MW, Smith DE, Kamdar M, Rabinovitch R. Inferior outcomes and treatment disparities in elderly patients with classical Hodgkin lymphoma: a national cancer data base analysis. Leuk Lymphoma 2018; 60:1234-1243. [PMID: 30501432 DOI: 10.1080/10428194.2018.1522435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Elderly patients with classical Hodgkin lymphoma (cHL) are understudied and poorly defined. The National Cancer Data Base was queried for adults with cHL diagnosed 2004-2013: 22,547 age 18-39, 12,841 age 40-59, and 10,873 age ≥60 were identified. Two-year overall survival (OS) was 97%, 91%, and 65% for the three age cohorts, respectively (p < .0001). Elderly patients age ≥60 had greater advanced comorbidity scores, stage III-IV disease, and lymphocyte-depleted histology. Elderly patients were treated less with chemotherapy, radiotherapy for stage I-II disease, and at academic/research centers (p < .001). There was improved OS in elderly patients who received chemotherapy and/or radiotherapy and were treated at academic/research centers. This largest analysis of elderly cHL demonstrates that patients ≥60 are distinct from those 40-59. Age ≥60 should be a stratification in future trials and merit distinct studies. Improving the poor rate of treatment delivery and directing care to academic centers may improve outcomes.
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Affiliation(s)
- Ajay Major
- a Department of Medicine , Internal Medicine Residency Training Program, University of Colorado School of Medicine , Aurora , CO , USA
| | - Matthew W Jackson
- b Department of Radiation Oncology , University of Colorado School of Medicine , Aurora , CO , USA
| | - Derek E Smith
- c Department of Pediatrics , Cancer Center Biostatistics Core, University of Colorado School of Medicine , Aurora , CO , USA
| | - Manali Kamdar
- d Department of Medicine , Division of Hematology, University of Colorado School of Medicine , Aurora , CO , USA
| | - Rachel Rabinovitch
- b Department of Radiation Oncology , University of Colorado School of Medicine , Aurora , CO , USA
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Affiliation(s)
- Boris Böll
- German Hodgkin Study Group and Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
| | - Helen Görgen
- German Hodgkin Study Group and Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
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Longley J, Johnson PWM. Current treatment paradigms for advanced stage Hodgkin lymphoma. Br J Haematol 2018; 184:60-71. [DOI: 10.1111/bjh.15622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jemma Longley
- Cancer Research UK Centre; University of Southampton; Southampton UK
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Eichenauer DA, Aleman BMP, André M, Federico M, Hutchings M, Illidge T, Engert A, Ladetto M. Hodgkin lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29:iv19-iv29. [PMID: 29796651 DOI: 10.1093/annonc/mdy080] [Citation(s) in RCA: 193] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- D A Eichenauer
- First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - B M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - M André
- Université Catholique de Louvain, Yvoir
- Department of Hematology, CHU UCL Namur, Yvoir, Belgium
| | - M Federico
- Department of Diagnostic, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - M Hutchings
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - T Illidge
- Division of Cancer Sciences, University of Manchester, Manchester
- The Christie NHS Foundation Trust, Manchester, UK
| | - A Engert
- First Department of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - M Ladetto
- Hematology Division, Azienda Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Evens AM, Advani RH, Helenowski IB, Fanale M, Smith SM, Jovanovic BD, Bociek GR, Klein AK, Winter JN, Gordon LI, Hamlin PA. Multicenter Phase II Study of Sequential Brentuximab Vedotin and Doxorubicin, Vinblastine, and Dacarbazine Chemotherapy for Older Patients With Untreated Classical Hodgkin Lymphoma. J Clin Oncol 2018; 36:3015-3022. [PMID: 30179569 DOI: 10.1200/jco.2018.79.0139] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To improve the curability of older patients with newly diagnosed Hodgkin lymphoma. PATIENTS AND METHODS We conducted a multicenter phase II study that administered brentuximab vedotin (Bv) sequentially before and after standard doxorubicin, vinblastine, and dacarbazine (AVD) for untreated patients with Hodgkin lymphoma age 60 years or older. After two lead-in doses of single-agent Bv (1.8 mg/kg once every 3 weeks), patients received six cycles of AVD chemotherapy followed by four consolidative doses of Bv in responding patients. RESULTS Patient characteristics included median age of 69 years (range, 60 to 88 years), 63% male, median Eastern Cooperative Oncology Group performance status 1, 81% stage III to IV disease, 60% International Prognostic Score 3 to 7, median Cumulative Illness Rating Scale-Geriatric comorbidity score of 7 (52% grade 3 to 4); and 12% had loss of instrumental activities of daily living at diagnosis. Thirty-seven (77%) of 48 patients completed six cycles of AVD, and 35 patients (73%) received at least one Bv consolidation. Overall response and complete remission rates after initial Bv lead-in dose were 18 (82%) of 22 and 8 (36%) of 22, respectively, and 40 (95%) of 42 and 34 (90%) of 42, respectively, after six cycles of AVD among 42 response-evaluable patients. Twenty (42%) of 48 patients experienced a grade 3 to 4 adverse event, most commonly neutropenia (44%), febrile neutropenia and pneumonia (8%), or diarrhea (6%); 33% had grade 2 peripheral neuropathy, which was reversible in a majority of patients. By intent-to-treat, the 2-year event-free survival, progression-free survival, and overall survival rates were 80%, 84%, and 93%, respectively. Furthermore, 2-year progression-free survival rates for patients with a Cumulative Illness Rating Scale-Geriatric comorbidity score of ≥ 10 versus < 10 were 45% versus 100%, respectively (P < .001), and with baseline loss versus no loss of instrumental activities of daily living were 25% versus 94% (P < .001), respectively, the latter persisting on multivariable analyses. CONCLUSION Altogether, sequential Bv-AVD was well tolerated and was associated with robust outcomes. Furthermore, geriatric-based measures were strongly associated with patient survival.
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Affiliation(s)
- Andrew M Evens
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ranjana H Advani
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Irene B Helenowski
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michelle Fanale
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sonali M Smith
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Borko D Jovanovic
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory R Bociek
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andreas K Klein
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jane N Winter
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Leo I Gordon
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul A Hamlin
- Andrew M. Evens, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Ranjana H. Advani, Stanford University, Stanford, CA; Irene B. Helenowski, Borko D. Jovanovic, Jane N. Winter, and Leo I. Gordon, Northwestern University Feinberg School of Medicine; Jane N. Winter and Leo I. Gordon, Robert H. Lurie Comprehensive Cancer Center; Sonali M. Smith, University of Chicago, Chicago, IL; Michelle Fanale, University of Texas MD Anderson Cancer Center, Houston, TX; Gregory R. Bociek, University of Nebraska, Omaha, NE; Andreas K. Klein, Tufts Medical Center, Boston, MA; and Paul A. Hamlin, Memorial Sloan Kettering Cancer Center, New York, NY
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J. Bröckelmann* P, A. Eichenauer* D, Jakob T, Follmann M, Engert A, Skoetz N. Hodgkin Lymphoma in Adults. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:535-540. [PMID: 30149835 PMCID: PMC6131364 DOI: 10.3238/arztebl.2018.0535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/26/2018] [Accepted: 04/26/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hodgkin lymphoma is the most common neoplasm in young adults, with an incidence of 2 to 3 cases per 100 000 persons per year. Risk-adapted chemotherapy and radiotherapy usually lead to cure. Finding ways to lessen the treatment- associated morbidity and mortality is a major goal of current research. METHODS For the creation of an updated guideline (DKH grant number 111778), a systematic literature search was carried out in medical databases (MEDLINE, CENTRAL) and guideline databases (GIN) (search dates: January 2012 to June 2017). RESULTS Results from 10 meta-analyses, 89 randomized and controlled trials, and 81 prospective or retrospective trials were evaluated. The use of positron emission tomography (PET) is strongly recommended in the initial diagnostic evaluation, as well as for the guidance of treatment in advanced stages. In early stages, two cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) and involved-site radiotherapy (IS-RT) at a dose of 20 Gy are recommended. For the treatment of intermedi- ate stages, two cycles of escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) + two cycles of ABVD and 30 Gy IS-RT are recommended. In advanced stages, two cycles of escalated BEACOPP are administered, and then PET is performed for the guidance of further treatment: two further cycles of escalated BEACOPP are recommended if the PET is negative and four further cycles if it is positive, followed by radiotherapy of PET- positive residual tumor tissue. The five-year survival of patients with Hodgkin lymphoma is 95%. In case of disease recurrence, high-dose chemotherapy followed by autologous stem-cell transplantation is performed, and targeted drugs including brentuxi- mab vedotin, nivolumab, and pembrolizuab are used. CONCLUSION The highly favorable long-term prognosis of HL necessitates careful consideration of the intensity of treatment as well as thorough follow-up to enable the detection of late sequelae, such as second tumors or organ damage.
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Affiliation(s)
- Paul J. Bröckelmann*
- * Joint first authors
- Department I of Internal Medicine, University Hospital Cologne
- German Hodgkin Study Group (GHSG), University Hospital Cologne
| | - Dennis A. Eichenauer*
- * Joint first authors
- Department I of Internal Medicine, University Hospital Cologne
- German Hodgkin Study Group (GHSG), University Hospital Cologne
| | - Tina Jakob
- Department I of Internal Medicine, University Hospital Cologne
- Evidence-based Oncology, University Hospital Cologne
| | - Markus Follmann
- German Guideline Program in Oncology of the German Cancer Society, Berlin
| | - Andreas Engert
- Department I of Internal Medicine, University Hospital Cologne
- German Hodgkin Study Group (GHSG), University Hospital Cologne
| | - Nicole Skoetz
- Department I of Internal Medicine, University Hospital Cologne
- Evidence-based Oncology, University Hospital Cologne
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Wróbel T, Biecek P, Rybka J, Szulgo A, Sorbotten N, Giza A, Tyczyńska A, Nowara E, Badora-Rybicka A, Adamowicz K, Kulikowski W, Kroll-Balcerzak R, Balcerzak A, Spychałowicz W, Kalinka-Warzocha E, Kumiega B, Drozd-Sokołowska J, Subocz E, Sałek A, Machaczka M, Hołojda J, Pogrzeba J, Dobrzyńska O, Chmielowska E, Jurczak W, Knopińska-Posłuszny W, Leśniewski-Kmak K, Maciej Zaucha J. Hodgkin lymphoma of the elderly patients: a retrospective multicenter analysis from the Polish Lymphoma Research Group. Leuk Lymphoma 2018; 60:341-348. [DOI: 10.1080/10428194.2018.1482539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Tomasz Wróbel
- Department of Hematology, Wroclaw Medical University, Wrocław, Poland
| | - Przemysław Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Justyna Rybka
- Department of Hematology, Wroclaw Medical University, Wrocław, Poland
| | - Anna Szulgo
- Department of Oncology, Center of Oncology of Professor Franciszek Łukaszczyk, Bydgoszcz, Poland
| | - Natalia Sorbotten
- Department of Oncology, Center of Oncology of Professor Franciszek Łukaszczyk, Bydgoszcz, Poland
| | - Agnieszka Giza
- Department of Hematology, Collegium Medicum of the Jagiellonian University, Kraków, Poland
| | - Agata Tyczyńska
- Department of Oncology and Radiotherapy, Gdynia Oncology Center, Gdynia, Poland
| | - Elżbieta Nowara
- Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | | | | | | | | | - Andrzej Balcerzak
- Department of Hematology, University of Medical Sciences, Poznan, Poland
| | - Wojciech Spychałowicz
- Internal Medicine and Oncology Clinic, Silesian Medical University, Katowice, Poland
| | | | - Beata Kumiega
- Department of Hematology, Brzozow Oncology Center, Brzozów, Poland
| | - Joanna Drozd-Sokołowska
- Department of Haematology, Oncology and Internal Medicine, The Medical University of Warsaw, Warsaw, Poland
| | - Edyta Subocz
- Department of Haematology, Military Institute of Medicine in Warsaw, Warsaw, Poland
| | - Agata Sałek
- Department of Hematology KSW No.1 and Medical Faculty, University of Rzeszow, Rzeszow, Poland
| | - Maciej Machaczka
- Department of Hematology KSW No.1 and Medical Faculty, University of Rzeszow, Rzeszow, Poland
| | - Jadwiga Hołojda
- Department of Hematology, Provincial Specialist Hospital, Legnica, Poland
| | - Joanna Pogrzeba
- Department of Hematology, Provincial Specialist Hospital, Opole, Poland
| | - Olga Dobrzyńska
- Department of Hematology, Wroclaw Medical University, Wrocław, Poland
| | - Ewa Chmielowska
- Department of Oncology, Center of Oncology of Professor Franciszek Łukaszczyk, Bydgoszcz, Poland
| | - Wojciech Jurczak
- Department of Hematology, Collegium Medicum of the Jagiellonian University, Kraków, Poland
| | | | - Krzysztof Leśniewski-Kmak
- Department of Oncology and Radiotherapy, Gdynia Oncology Center, Gdynia, Poland
- Department of Oncological Propaedeutics, Medical University of Gdańsk, Gdańsk, Poland
| | - Jan Maciej Zaucha
- Department of Oncology and Radiotherapy, Gdynia Oncology Center, Gdynia, Poland
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
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FitzGerald TJ, Bishop-Jodoin M. Hodgkin Lymphoma: Differences in Treatment Between Europe and the United States/North America: Evolving Trends in Protocol Therapy. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2018; 12:1179554918754885. [PMID: 29434481 PMCID: PMC5802698 DOI: 10.1177/1179554918754885] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 12/27/2017] [Indexed: 02/05/2023]
Abstract
With continued progress and success in clinical care, the management of patients with Hodgkin lymphoma (HL) has undergone continuous revision to improve patient care outcomes and limit acute and late treatment effects on normal tissue imposed by therapy. Hodgkin lymphoma is a disease that affects children, adolescents, and adults. Clinical management strategies are influenced by the patient's age at diagnosis, tumor burden, response to induction therapy, and potential expectation of treatment impact on normal tissue. The approach to patient management varies in many parts of the world and is influenced by treatment availability, physician training, and medical culture. Differences in approach are important to understand for accurately comparing and contrasting outcome studies. In this article, we will identify current areas of common ground and points of separation in patient care management for HL. Opportunities for clinical trial strategies will be defined for future clinical trials.
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Affiliation(s)
- Thomas J FitzGerald
- Department of Radiation Oncology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Radiation Oncology, UMass Memorial Health Care, Worcester, MA, USA.,Quality Assurance Review Center, Department of Radiation Oncology, University of Massachusetts Medical School, Lincoln, RI, USA
| | - Maryann Bishop-Jodoin
- Department of Radiation Oncology, University of Massachusetts Medical School, Worcester, MA, USA.,Quality Assurance Review Center, Department of Radiation Oncology, University of Massachusetts Medical School, Lincoln, RI, USA
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Allen PB, Gordon LI. Frontline Therapy for Classical Hodgkin Lymphoma by Stage and Prognostic Factors. Clin Med Insights Oncol 2017; 11:1179554917731072. [PMID: 28989291 PMCID: PMC5624347 DOI: 10.1177/1179554917731072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/20/2017] [Indexed: 02/04/2023] Open
Abstract
Hodgkin lymphoma is a highly curable malignancy in early and advanced stages. Most patients are diagnosed in their teens or twenties and are expected to live decades beyond their treatment. Therefore, the toxicity of treatment must be balanced with the goal of cure. Thus, treatment has been refined through prognostic models and positron emission tomography-computed tomography (PET-CT)-directed therapy. Stratification by prognostic models defines groups of patients with favorable characteristics who may be treated with less intensive therapy upfront, including fewer cycles of chemotherapy, lower doses of radiation, or omission of radiation altogether. Alternatively, high-risk patients may be assigned to a more aggressive initial approach. The modern use of interim PET-CT allows further tailoring of treatment by response.
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Affiliation(s)
- Pamela B Allen
- Robert H. Lurie Comprehensive Cancer Center and Division of Hematology and Oncology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Leo I Gordon
- Department of Hematology and Medical Oncology, Emory University Winship Cancer Institute, Atlanta, GA, USA
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Skoetz N, Will A, Monsef I, Brillant C, Engert A, von Tresckow B. Comparison of first-line chemotherapy including escalated BEACOPP versus chemotherapy including ABVD for people with early unfavourable or advanced stage Hodgkin lymphoma. Cochrane Database Syst Rev 2017; 5:CD007941. [PMID: 28541603 PMCID: PMC6481581 DOI: 10.1002/14651858.cd007941.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are two different international standards for the treatment of early unfavourable and advanced stage Hodgkin lymphoma (HL): chemotherapy with escalated BEACOPP (bleomycin/etoposide/doxorubicin/cyclophosphamide/vincristine/procarbazine/prednisone) regimen and chemotherapy with ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine) regimen. OBJECTIVES To determine the advantages and disadvantages of chemotherapy including escalated BEACOPP compared to chemotherapy including ABVD in the treatment of early unfavourable or advanced stage HL as first-line treatment. SEARCH METHODS We searched for randomised controlled trials in MEDLINE, CENTRAL and conference proceedings (January 1985 to July 2013 and for the update to March 2017) and Embase (1985 to November 2008). Moreover we searched trial registries (March 2017; www.controlled-trials.com, www.clinicaltrialsregister.eu/ctr-search/search, clinicaltrials.gov, www.eortc.be, www.ghsg.org, www.ctc.usyd.edu.au, www.trialscentral.org/index.html) SELECTION CRITERIA: We included randomised controlled trials examining chemotherapy including at least two cycles of escalated BEACOPP regimens compared with chemotherapy including at least four cycles of ABVD regimens as first-line treatment for patients with early unfavourable stage or advanced stage HL. DATA COLLECTION AND ANALYSIS The effect measures we used were hazard ratios (HRs) for overall survival (OS), progression-free survival (PFS) and freedom from first progression.We used risk ratios (RRs) relative risks to analyse harms: treatment-related mortality, secondary malignancies (including myeloid dysplastic syndrome (MDS) or acute myeloid leukaemia (AML)), infertility and adverse events.Quality of life was not reported in any trial, therefore not analysed. Two review authors independently extracted data and assessed quality of trials. MAIN RESULTS We screened 1796 records and identified five eligible trials in total i.e. one trial could be added on the previous review. These trials included only adults (16 to 65 years of age). We included all five trials with 3427 people in the meta-analyses: the HD9 and HD14 trials were co-ordinated in Germany, the HD2000 and GSM-HD trials were performed in Italy and the EORTC 20012 was conducted in Belgium. The overall risk of performance and detection bias was low for overall survival (OS), but was high for other outcomes, as therapy blinding was not feasible. The remaining 'Risk of bias' domains were low and unclear.All trials reported results for OS and progression-free survival (PFS). In contrast to the our first published review (2011) the addition of results from the EORTC 20012 BEACOPP escalated increases OS (3142 participants; HR 0.74 (95% confidence interval (CI) 0.57 to 0.97; high-quality evidence). This means that only 90 (70 to 117) patients will die after five years in the BEACOPP escalated arm compared to 120 in the ABVD arm. This survival advantage is also reflected in an increased PFS with BEACOPP escalated (3142 participants; HR 0.54 (95% CI 0.45 to 0.64); moderate-quality evidence), meaning that after five years only 144 (121 to 168) patients will experience a progress, relapse or death in the BEACOPP escalated arm compared to 250 in the ABVD arm.There is no evidence for a difference for treatment-related mortality (2700 participants, RR 2.15 (95% CI = 0.93 to 4.95), low-quality evidence).Although the occurrence of MDS or AML may increase with BEACOPP escalated (3332 participants, RR 3.90 (95% CI 1.36 to 11.21); low-quality evidence)), there is no evidence for a difference between both regimens for overall secondary malignancies (3332 participants, RR 1.00 (95% CI 0.68 to 1.48), low-quality evidence). However, the observation time of the studies included in the review is too short to be expected to demonstrate differences with respect to second solid tumours which would not be expected to show significance until around 15 years after treatment.We are very uncertain how many female patients will be infertile due to chemotherapy and which arm might be favoured (106 participants, RR 1.37 (95% CI 0.83 to 2.26), very low-quality evidence). This is a very small sample, and the age of the patients was not detailed. No analysis of male fertility was provided.Five trials reported adverse events and the analysis shows that the escalated BEACOPP regimens probably causes more haematological toxicities WHO grade III or IV ((anaemia: 2425 participants, RR 10.67 (95% CI 7.14 to 15.93); neutropenia: 519 participants, RR 1.80 (95% CI 1.52 to 2.13); thrombocytopenia: 2425 participants, RR 18.12 (95% CI 11.77 to 27.92); infections: 2425 participants, RR 3.73 (95% CI 2.58 to 5.38), all low-quality evidence).Only one trial (EORTC 20012) planned to assess quality of life, however, no results were reported. AUTHORS' CONCLUSIONS This meta-analysis provides moderate- to high-quality evidence that adult patients between 16 and 60 years of age with early unfavourable and advanced stage HL benefit regarding OS and PFS from first-line chemotherapy including escalated BEACOPP. The proven benefit in OS for patients with advanced HL is a new finding of this updated review due to the inclusion of the results from the EORTC 20012 trial. Furthermore, there is only low-quality evidence of a difference in the total number of secondary malignancies, as the follow-up period might be too short to detect meaningful differences. Low-quality evidence also suggests that people treated with escalated BEACOPP may have a higher risk to develop secondary AML or MDS. Due to the availability of only very low-quality evidence available, we are unable to come to a conclusion in terms of infertility. This review does for the first time suggest a survival benefit. However, it is clear from this review that BEACOPP escalated may be more toxic that ABVD, and very important long-term side effects of second malignancies and infertility have not been sufficiently analysed yet.
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Affiliation(s)
- Nicole Skoetz
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Andrea Will
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Ina Monsef
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Corinne Brillant
- University Hospital of CologneCochrane Haematological Malignancies Group, Department I of Internal MedicineKerpener Str. 62CologneGermany50937
| | - Andreas Engert
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
| | - Bastian von Tresckow
- University Hospital of CologneDepartment I of Internal MedicineKerpener Str. 62CologneGermany50924
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Johnson PWM. Response-adapted frontline therapy for Hodgkin lymphoma: are we there yet? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:316-322. [PMID: 27913497 PMCID: PMC6142446 DOI: 10.1182/asheducation-2016.1.316] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Treating Hodgkin lymphoma by using chemotherapy with or without radiotherapy is highly successful, with substantially fewer deaths from lymphoma than from other causes in recent studies of both early-stage and advanced-stage disease. Long-term toxicity is a major consideration in this context, and recent trials have used functional imaging with [18F]fluorodeoxyglucose (FDG) positron emission tomography early in the course of treatment (interim PET) to assess response and modulate subsequent therapy. In early-stage disease, this has allowed omission of consolidation radiotherapy after a good response to doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy, and trials have shown that this can be done without detriment to overall survival, despite a small increase in rates of recurrence of ∼5%. Conversely, escalation to more intensive chemotherapy with bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP) for those with positive interim PET scans seems to be an effective strategy with improved disease control. In advanced-stage disease, several groups have elected to start treatment with ABVD and escalate to BEACOPP or myeloablative therapy for patients who remain PET positive after 2 cycles, which gives rates of disease control of ∼65%. De-escalation by omission of bleomycin and consolidation radiotherapy after a negative interim PET scan seems safe with no increase in recurrence rate, but the performance of interim PET after ABVD is suboptimal, especially for those with very advanced disease at presentation; recurrence rates after a negative scan are ∼15%. The negative predictive value of PET is higher after escalated BEACOPP chemotherapy, and the approach of initially treating with BEACOPP and de-escalating to ABVD for those with negative interim PET scans shows promising early results. Response-adapted therapy has yielded important results for patients with Hodgkin lymphoma and is becoming established as a standard approach.
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Affiliation(s)
- Peter W M Johnson
- Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom
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Abstract
Hodgkin lymphoma (HL) presenting in patients with co-incidental advanced age, pregnancy, or human immunodeficiency virus (HIV) infection is uniquely challenging to manage. In this article we integrate recent evidence and clinical expertise to present recommendations for diagnosis and therapeutic management. Older patients with HL need to be carefully evaluated for comorbidies after which judicious choice of chemotherapy should minimize functional compromise. A pregnant patient with concurrent HL should be staged with minimal use of imaging requiring ionizing radiation and treated in an individualized manner optimally combining the strategies of treatment deferral when appropriate, use of single-agent vinblastine for symptomatic disease and reservation of multi-agent chemotherapy for the small minority of patients with aggressive clinical presentation. Treatment of HL coincident with HIV infection requires a combination of highly active anti-retroviral agents (HAART), standard multi-agent chemotherapy with meticulous attention to drug-drug interactions, and vigorous supportive care to ensure the best chance of cure.
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Affiliation(s)
- Veronika Bachanova
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA.
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Abstract
Hodgkin's lymphoma (HL) is a relatively rare disease accounting for 15 % of all lymphoma. This disease has developed from an incurable disease to the adult malignancy with the most favorable prognosis. With current therapeutic approaches consisting of polychemo- and small-field radiotherapy, up to 80 % of all patients can be cured long term. In refractory or relapsed HL, intensified treatment including high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) is associated with progression-free survival (PFS) of 50 %. Evaluation of novel drugs in multiple relapsed or refractory cases, better treatment options for elderly patients and reducing treatment-related side effects are the main focus of current research. Recent clinical developments and future approaches in the treatment of HL will be discussed in this review.
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Bleomycin in older early-stage favorable Hodgkin lymphoma patients: analysis of the German Hodgkin Study Group (GHSG) HD10 and HD13 trials. Blood 2016; 127:2189-92. [PMID: 26834240 DOI: 10.1182/blood-2015-11-681064] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/20/2016] [Indexed: 11/20/2022] Open
Abstract
Doxorubicin, bleomycin, vinblastine sulfate, and dacarbazine (ABVD) is associated with severe toxicity in older patients, particularly from bleomycin-induced lung toxicity (BLT). Therefore, using bleomycin has been questioned in older Hodgkin lymphoma (HL) patients, especially in early-stage HL. We therefore analyzed feasibility, toxicity, and efficacy of ABVD or AVD in 287 older early-stage favorable HL patients. We included patients ≥60 years of age in the German Hodgkin Study Group HD10 and HD13 trials randomized to either 2 cycles of ABVD (2×ABVD; n = 137) or AVD (2×AVD; n = 82), each followed by involved-field radiotherapy (IF-RT), with patients randomized to 4×ABVD+IF-RT (n = 68). Patients' median age was 65 years (range, 60-75) with comparable patient and disease characteristics. Grade III-IV adverse event rates were similar in patients receiving 2×AVD and 2×ABVD (40% and 39%, respectively), but considerably higher in patients receiving 4×ABVD (65%). Similarly, BLT was rare in patients receiving 2×ABVD/AVD, but occurred in 7/69 (10%) of patients randomized to 4×ABVD, with 3 lethal events. In conclusion, no effects of bleomycin on toxicity rates were detectable in older patients receiving 2 cycles of chemotherapy. However, we found a high risk of severe toxicity of bleomycin in older HL patients receiving more than 2 cycles of ABVD. These trials are registered at www.clinicaltrials.gov and www.isrctn.com as #NCT00265018 (HD10) and #ISRCTN63474366 (HD13).
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Zallio F, Tamiazzo S, Monagheddu C, Merli F, Ilariucci F, Stelitano C, Liberati AM, Mannina D, Vitolo U, Angelucci E, Rota Scalabrini D, Vallisa D, Bellei M, Bari A, Ciccone G, Salvi F, Levis A. Reduced intensity VEPEMB regimen compared with standard ABVD in elderly Hodgkin lymphoma patients: results from a randomized trial on behalf of the Fondazione Italiana Linfomi (FIL). Br J Haematol 2016; 172:879-88. [PMID: 26763986 DOI: 10.1111/bjh.13904] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/22/2015] [Indexed: 01/29/2023]
Abstract
Survival rates for elderly Hodgkin Lymphoma (HL) have not improved substantially in recent years, mainly because of a lack of prospective randomized studies, due to difficulties in enrolling patients. Between 2002 and 2006, 54 untreated HL patients, aged between 65 and 80 years and considered 'non-frail' according to a comprehensive geriatric evaluation, were enrolled into a phase III randomized trial to compare a reduced-intensity regimen (vinblastine, cyclophosphamide, procarbazine, prednisone, etoposide, mitoxantrone, bleomycin; VEPEMB) with standard ABVD (adriamycin, bleomycin, vinblastine, dacarbazine). Primary endpoint was progression-free survival (PFS). Seventeen patients were in early stage (I-IIA), while 37 were advanced stage. Median age was 72 years and median follow-up was 76 months. Five-year PFS rates were 48% vs. 70% [adjusted Hazard ratio (HR) = 2·19, 95% confidence interval (CI) = 0·94-5·10, P = 0·068] and 5-year overall survival (OS) rates were 63% vs. 77% (adjusted HR = 1·67, 95% CI = 0·69-4·03, P = 0·254) for VEPEMB compared to ABVD. Overall treatment-related mortality was 4%. World Health Organization grade 4 cardiac and lung toxicity occurred in four patients treated with ABVD versus no cases in the VEPEMB arm. Standard ABVD regimen resulted in better PFS and OS than the VEPEMB, although the differences were not statistically significant. The low toxicity of both treatments was probably attributable to stringent selection of patients based on a Comprehensive Geriatric Assessment that excluded frail patients.
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Affiliation(s)
- Francesco Zallio
- Haematology Department, SS Antonio & Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Stefania Tamiazzo
- Haematology Department, SS Antonio & Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Chiara Monagheddu
- Unity of Clinical Epidemiology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Francesco Merli
- Haematology, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | | | | | - Anna Marina Liberati
- Department of Surgery and Biomedicine, Division of Onco-haematology with Autologous Transplant, University of Perugia, Perugia, Italy
| | - Donato Mannina
- Division of Haematology, Papardo Hospital, Messina, Italy
| | - Umberto Vitolo
- Haematology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Delia Rota Scalabrini
- Division of Candiolo Cancer Institute, IRCCS University of Torino Medical School, Candiolo, Italy
| | - Daniele Vallisa
- Oncology and Haematology Department, Azienda Unità Sanitaria Locale, Piacenza, Italy
| | - Monica Bellei
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessia Bari
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovannino Ciccone
- Unity of Clinical Epidemiology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Flavia Salvi
- Haematology Department, SS Antonio & Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Alessandro Levis
- Haematology Department, SS Antonio & Biagio and C. Arrigo Hospital, Alessandria, Italy
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Abstract
Abstract
The development of curative systemic treatment of Hodgkin lymphoma was recently voted one of the top 5 achievements of oncology in the last 50 years (http://cancerprogress.net/top-5-advances-modern-oncology). The high expectation of cure (above 80%) with initial therapy, even for advanced disease, is tempered by the recognition of some important limitations: not all patients are cured, especially those in older age groups, and patients have suffered debilitating or, in some cases, fatal long-term side effects. The challenge for modern treatment approaches is to improve the cure rate and, at the same time, minimize the long-term damage resulting from treatment. After several decades during which we have tested a variety of different ways to combine conventional cytotoxic treatments with or without radiotherapy but have identified no effective new approaches, the field is once again moving forward. The developments that hold the greatest promise in this respect are the application of functional imaging with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) to make an early judgment of the success of treatment and the introduction of some highly active new agents such as antibody-drug conjugates.
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Eichenauer DA, Engert A, André M, Federico M, Illidge T, Hutchings M, Ladetto M. Hodgkin's lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2014; 25 Suppl 3:iii70-5. [PMID: 25185243 DOI: 10.1093/annonc/mdu181] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- D A Eichenauer
- First Department of Internal Medicine, University Hospital Cologne and German Hodgkin Study Group (GHSG), Cologne, Germany
| | - A Engert
- First Department of Internal Medicine, University Hospital Cologne and German Hodgkin Study Group (GHSG), Cologne, Germany
| | - M André
- CHU Dinant-Godinne, UCL Namur, Yvoir, Belgium
| | - M Federico
- Department of Oncology, Hematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - T Illidge
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | - M Hutchings
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Ladetto
- Divisione di Ematologia, Azienda Ospedaliera Santi Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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Hodgkin's Lymphoma in Older Patients: an Orphan Disease? Mediterr J Hematol Infect Dis 2014; 6:e2014050. [PMID: 25045458 PMCID: PMC4103506 DOI: 10.4084/mjhid.2014.050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/20/2014] [Indexed: 01/04/2023] Open
Abstract
Hodgkin Lymphoma HL can be cured in the large majority of younger patients, but prognosis for older patients, especially those with advanced-stage disease, has not improved substantially. The percentage of HL patients aged over 60 ranges between 15% and 35%. A minority of them is enrolled into clinical trials. HL in the elderly have some specificities: more frequent male sex, B-symptoms, advanced stage, sub diaphragmatic presentation, higher percentage of mixed cellularity, up to 50% of advanced cases associated to EBV. Very old age (>70) and comorbidities are factor of further worsening prognosis. Like in younger patients, ABVD is the most used protocol, but treatment outcome remains much inferior with more frequent, severe and sometimes specific toxicities. Few prospective studies with specific protocols are available. The main data have been published by the Italian Lymphoma Group with the VEPEMB schedule and the German Hodgkin Study Group with the PVAG regimen. Recently, the Scotland and Newcastle Lymphoma Study Group published the SHIELD program associating a prospective phase 2 trial with VEPEMB and a prospective registration of others patients. Patients over 60y with early-stage disease received three cycles plus radiotherapy and had 81% of 3-year overall survival (OS). Those with advanced-stage disease received six cycles, with 3-year OS of 66%. The role of geriatric and comorbidity assessment in the treatment’s choice for HL in the elderly is a major challenge. The combination of loss of activities of daily living combined with the age stratification more or less 70y has been shown as a simple and effective survival model. Hopes come from promising new agents like brentuximab-vedotin (BV) a novel antibody-drug conjugate. The use of TEP to adapt the combination of chemotherapy and radiotherapy according to the metabolic response could also be way for prospective studies.
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46
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Follows GA, Ardeshna KM, Barrington SF, Culligan DJ, Hoskin PJ, Linch D, Sadullah S, Williams MV, Wimperis JZ. Guidelines for the first line management of classical Hodgkin lymphoma. Br J Haematol 2014; 166:34-49. [PMID: 24712411 DOI: 10.1111/bjh.12878] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- George A Follows
- Department of Haematology, Addenbrookes Hospital, Cambridge University Teaching Hospitals, Cambridge, UK
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47
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Cheson BD. Which Hodgkin's patients in the Unites States should be treated with BEACOPP? Curr Hematol Malig Rep 2014; 9:222-6. [PMID: 24879421 DOI: 10.1007/s11899-014-0213-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The majority of patients with advanced Hodgkin lymphoma are cured with current standard therapy such as Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). However, almost 20% of patients fail to achieve complete remission, and depending upon risk group, 20-30% experience relapse with prolonged follow-up. BEACOPP (bleomycin, etoposide, Adriamycin, cyclophosphamide, prednisone, procarbazine) was developed by the German Hodgkin Study Group (GHSG) to improve upon standard therapy by intensifying treatment and substituting etoposide and procarbazine for vinblastine and dacarbazine, respectively. In the HD9 trial, escalated BEACOPP was shown to be superior to COPP/ABVD with regard to time to treatment failure, but was associated with increased risk of secondary malignancies. Modifications of BEACOPP were developed to maintain efficacy while reducing the adverse effects. While several randomized trials have confirmed prolongation of progression-free survival with BEACOPP compared to ABVD, a survival advantage has been difficult to demonstrate. Given the comparable survival between BEACOPP and ABVD, as well as the greater toxicities of the former, including infertility, myelosuppression, and secondary malignancies, ABVD should remain the standard regimen for patients in the U.S. Newer regimens incorporating novel agents such as brentuximab vedotin may further improve the efficacy of current regimens.
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Affiliation(s)
- Bruce D Cheson
- Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA,
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48
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Eichenauer DA, Böll B, Diehl V. Pharmacotherapy of Hodgkin lymphoma: standard approaches and future perspectives. Expert Opin Pharmacother 2014; 15:1139-51. [DOI: 10.1517/14656566.2014.909411] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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49
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Early Intensification Treatment Approach in Advanced-stage Hodgkin Lymphoma. Hematol Oncol Clin North Am 2014; 28:65-74. [DOI: 10.1016/j.hoc.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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50
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