Clinical stage I and II Hodgkin's disease: long-term results of therapy without laparotomy. Experience at one institution

Do male lymphoma survivors have impaired sexual function?

PURPOSE

Sexual function in male lymphoma survivors was examined and compared with that of age-matched controls.

PATIENTS AND METHODS

This cross-sectional study included serum gonadal hormone levels (testosterone, sex hormone-binding globulin, luteinizing hormone [LH], and follicle-stimulating hormone) and responses to questionnaires assessing sexual function (Brief Sexual Function Inventory [BSFI]), socioeconomic factors, quality of life, emotional distress, and fatigue. The lymphoma group included 246 men < or = 50 years old at diagnosis who were diagnosed from 1980 to 2002 and treated at the Norwegian Radium Hospital. For each lymphoma survivor, two age-matched controls (n = 492) were drawn from a normative sample with BSFI scores.

RESULTS

The lymphoma survivors had a mean age at survey of 47.4 years, the mean duration of follow-up was 14.8 years, and 79% lived in committed relationships. All BSFI domain scores decreased significantly with age. Lymphoma survivors having low testosterone and/or elevated LH had lower BSFI scores than survivors with normal gonadal hormones. Multivariate analyses showed that increasing age, more emotional distress, poor physical health, and low testosterone and/or elevated LH were significantly associated with reduced sexual function within the lymphoma group. Lymphoma survivors had significantly lower BSFI domain scores than did controls on erection, ejaculation, and sexual satisfaction.

CONCLUSION

Lymphoma survivors had significantly poorer sexual function than normative controls. It is unclear whether the abnormal hormone levels directly cause the reduced sexual function within the lymphoma group or if a mediating factor is involved, such as aging, emotional distress, or perceived health status.

Gonadal function in male patients after treatment for malignant lymphomas, with emphasis on chemotherapy

Gonadal function was assessed in male lymphoma survivors based on serum hormone levels (LH, FSH, testosterone, SHBG), and was related to treatment, age and observation time. Male patients ⩽50 years at diagnosis treated for Hodgkin's (HL) and/or non-Hodgkin's lymphoma (NHL) at the Norwegian Radium Hospital from 1 January 1980 to 31 December 2002 were included. Five treatment groups were defined: 1: radiotherapy only and/or low gonadotoxic chemotherapy (both HL and NHL)(‘No/low’), 2: medium gonadotoxicity chemotherapy for NHL (‘med-NHL’), 3: medium gonadotoxicity chemotherapy for HL (‘med-HL’), 4: highly gonadotoxic chemotherapy for NHL (‘high-NHL’), 5: highly gonadotoxic chemotherapy for HL (‘high-HL’). Gonadal hormone levels were categorised into three groups: 1: All gonadal hormones within normal range (normal), 2: Isolated elevated FSH, with LH, SHBG and testosterone within normal range (exocrine hypogonadism), 3: Testosterone below and/or LH above normal range (endocrine hypogonadism). One hundred and forty-four (49%) of the patients had normal gonadal hormones, 60 (20%) displayed exocrine hypogonadism and almost one-third (n=90, 30%) had endocrine hypogonadism. Compared to those treated with no/low gonadotoxic chemotherapy patients from all other treatment groups had significantly elevated risk for exocrine hypogonadism. Patients from the other treatment groups, except those in the med-NHL group, also had significantly elevated risk for endocrine hypogonadism compared with the group treated with no/low gonadotoxic chemotherapy. Men aged above 50 years at survey were about five times more likely to have endocrine hypogonadism compared with those less than 40 years. Because of the adverse health effects following long-lasting endocrine hypogonadism, gonadal hormones should be assessed regularly in male lymphoma survivors, especially after treatment with alkylating agents and high-dose chemotherapy with autologous stem cell support and in male patients who are 50 years and older.

Post-treatment parenthood in Hodgkin's lymphoma survivors

Attempted and achieved post-treatment parenthood, with or without use of assisted reproduction techniques (ARTs), was assessed in Hodgkin's lymphoma survivors treated from 1971–1998, aged below 50 (females) or 65 (males) at diagnosis, aged 18 to 75 at survey. Four treatment groups were constructed: radiotherapy only, low -, medium - and high gonadotoxic chemotherapy (with or without radiotherapy in the three chemotherapy groups). Using Kaplan–Meier estimates, log-rank tests and Cox regression analyses, factors influencing post-treatment parenthood were investigated, with birth of the first child after treatment as the end point. Forty-five per cent (120/269) of males and 50% (91/184) of females reported attempted post-treatment parenthood. Of these, 76 (63%) males and 68 (75%) females had a child without use of ARTs. In addition 10 males and one female achieved post-treatment parenthood with use of ARTs. Treatment group was significantly associated with post-treatment parenthood, with highest probabilities after radiotherapy only and low gonadotoxic chemotherapy. In univariate analyses, age at diagnosis was a significant factor related to post-treatment parenthood in females.

Quality of life in long-term Hodgkin’s disease survivors with chronic fatigue

The prevalence of chronic fatigue (CF), elevated fatigue levels >six months, is 2.5-3 times higher in long-term Hodgkin disease survivors (HDSs) than in the general population (GP). This is the first study comparing the quality of life (QoL) of chronic fatigued survivors with that of chronic fatigued subjects in the GP. The fatigue questionnaire (FQ) and the SF-36 were mailed to 591 HDSs successfully treated at the Norwegian Radium Hospital from 1971 to 1997. Patient data were compared with nationally representative GP data, adjusted for age, gender and education. The response rate was 80% (N = 475), median follow-up 195 months (range 53-431), mean age 46 years (range 21-74), and 44% were females. HDSs reported significantly poorer QoL than the GP with lower scores on six of eight SF-36 scales (P < 0.001). The subgroup of HDSs with chronic fatigue however (N = 142/475, 30%) had better QoL on five of eight SF-36 scales than subjects with CF in the GP (N = 224/2141, 11%), particularly mental health and emotional role-functioning (P = 0.005 and <0.0001). No differences were found on the physical SF-36 domains. Overall, HDSs reported lower QoL than the GP, in particular the HDSs with CF. Their QoL was similar to that of GP subjects with CF, but with significantly better mental health status. This suggests that CF in long-term survivors may be associated with more physical than psychological aspects of long-term cancer survivorship.

Site of relapse after chemotherapy alone for stage I and II Hodgkin's disease

BACKGROUND

Short course chemotherapy followed by radiotherapy is a standard treatment for early Hodgkin's disease. There is yet no consensus regarding the appropriate radiotherapy portal following chemotherapy. A good guide to the adjuvant radiotherapy field is the site of relapse in patients treated with chemotherapy alone.

PATIENTS AND METHODS

From 1980 to 1996, 61 patients with stage I and II supradiaphragmatic Hodgkin's disease were treated with chemotherapy alone at the Royal Marsden Hospital. We undertook a retrospective review and failure analysis to define the pattern of recurrence.

RESULTS

After a median follow-up of 6.5 years, 24 patients had relapsed giving a 5-year relapse rate of 40%. The 5 and 10-year actuarial survival rates were 94 and 89%, respectively with cause-specific survival being 94% at 5 and 10 years. Two-thirds of the relapses were nodal and supradiaphragmatic. Twenty patients (83%) relapsed in the initially involved sites of disease and this was the sole site of recurrence in 11 (45%) of patients. In retrospect, it appeared that at least 12 recurrences could have been prevented by involved field radiotherapy. Review of detailed imaging data (available in 9 out of 11 patients with recurrences in initial sites of disease) showed that the relapses were always in the initially involved nodes.

CONCLUSION

After chemotherapy alone in early stage HD most initial recurrences are nodal. Loco-regional recurrences are in the originally involved nodes. Based on limited data it appears that involved nodal RT is equivalent to involved field radiotherapy and may halve the risk of recurrence.

Fatigue in long-term Hodgkin's Disease survivors: a follow-up study

PURPOSE

To describe total fatigue (TF) and chronic fatigue (CF) in 476 long-term Hodgkin's disease survivors (HDSs). The development in CF over time was explored in 280 of the patients who had also been assessed 8 years earlier.

PATIENTS AND METHODS

In 2003, the Fatigue Questionnaire was mailed to 610 successfully treated HDSs at the Norwegian Radium Hospital from 1971 to 1997. Mean TF scores and occurrence of CF were compared with general population (GP) values.

RESULTS

Four hundred seventy-six complete forms (81%) were received (median age, 46 years; 56% males, median follow-up time, 195 months). There was a positive association between age and TF (P < .05), whereas presence of B symptoms at diagnosis and treatment before 1980 were associated with CF. Mean TF scores were elevated in HDSs compared with the GP (mean TF score, 14.6; 95% CI, 14.1 to 15.7 v 12.1; 95% CI, 11.9 to 12.3, respectively; P < .001), as was the proportion of persons with CF (30% v 11%, respectively; odds ratio = 3.6; P < .001). The 70 patients with CF 8 years earlier still reported higher TF at follow-up than the 210 patients without CF at the previous assessment (mean TF score, 17.0; 95% CI, 15.6 to 18.3 v 13.1; 95% CI, 12.9 to 14.1, respectively; P < .001). Significantly more patients with persisting CF had B symptoms at diagnosis compared with patients who had recovered (P = .05). No significant association with treatment modality and intensity was found.

CONCLUSION

Fatigue remains a major complaint in HDSs several years after treatment, but the association between treatment and fatigue still remains unclear. Many HDSs may recover from CF, particularly patients without B symptoms at diagnosis.

Mid- and post-ABVD gallium scanning predicts for recurrence in early-stage Hodgkin's disease

PURPOSE

To determine the efficacy of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) for patients with Hodgkin's disease and to identify predictors of outcome with this regimen.

METHODS

Between 1987 and 1998, 175 patients with Stage I-IV Hodgkin's disease received ABVD as part of initial treatment. Overall survival (OS), freedom-from-treatment-failure (FFTF), and progression-free survival (PFS) were calculated using the Kaplan-Meier technique. Log-rank tests were used to identify univariate predictors of OS, FFTF, and PFS. Specifically, restaging gallium scan results and clinical response after chemotherapy were separately evaluated.

RESULTS

The median follow-up time was 64 months. The 5-year OS, FFTF, and PFS rates were 90%, 85%, and 82%, respectively. For Stage I-II patients, restaging gallium scan results and clinical response after chemotherapy were highly predictive of OS, FFTF, and PFS (p < 0.0001). Other significant predictors for higher OS included age <50 (p = 0.002), female gender (p = 0.047), and absence of B symptoms (p = 0.043). Of the 20 patients with a positive restaging gallium scan, 4 received high-dose therapy and 16 continued with conventional-dose therapy or received no further treatment. Of these 16 patients, 11 (69%) were disease-free at last follow-up.

CONCLUSIONS

Although a positive mid- or postchemotherapy gallium scan was an adverse prognostic factor for OS, FFTF, and PFS, continued treatment with conventional-dose therapy may be adequate in selected patients with positive scans.

A population-based study of the outcome for patients with first relapse of Hodgkin's lymphoma

BACKGROUND

Our aims were to evaluate the response to salvage treatment in relation to initial treatment and to evaluate prognostic factors at the time of relapse in an unselected population of relapsing patients with Hodgkin's lymphoma (HL).

PATIENTS AND METHODS

In total, 124 patients younger than 60 yr of age with initial diagnosis of HL in Sweden relapsed between 1985 and 1995.

RESULTS

Fifty-eight patients relapsed after initial treatment with radiotherapy (RT) only, 62 after combination chemotherapy (CT), of whom 30 had received additional involved-field RT, and four after a short course of CT followed by extended-field RT. For 37 patients among the 58 relapsers after initial RT treated according to the recommendations of the National guidelines, the 5-yr Hodgkin-specific survival (HLS) was 85%, overall survival (OS) 73% and event-free survival (EFS) 62%, which is not inferior to survival in patients with primarily advanced stages. It was poorer in the 21 patients who initially had received RT only, even though they had been recommended for more extensive treatment. For patients initially treated with a full course (6-8 cycles) of CT the 5-yr HLS was 60%, OS 58% and EFS 22%. Bulky disease and age at diagnosis strongly affected survival in a multivariate analysis.

CONCLUSIONS

Patients initially treated with RT who relapse have a favourable outcome, provided they have been treated according to the recommendations of the guidelines at the time of diagnosis. Initially bulky disease and, as a consequence, additional RT as part of the initial treatment negatively affect survival at relapse in patients initially treated with a full course of CT.

Risk-adapted therapy for clinical stage I-II Hodgkin's disease: 7-years results of radiotherapy alone for low-risk disease, and ABVD and radiotherapy for high-risk disease

Treatment outcomes were documented for 204 adult patients with clinical Stage I-II Hodgkin's disease who were treated with risk-adapted ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) and radiotherapy (RT) at the Toronto-Sunnybrook Regional Cancer Centre between 1984 and 1994. Forty-nine patients with clinical Stage I disease (excluding bulky mediastinal presentations) and 50 patients with a combination of clinical Stage IIA disease, age 50 years or less, and favourable pathology (lymphocyte predominant or nodular sclerosing histology) were identified as low risk and treated with RT alone to 35 Gy. One hundred and five high-risk patients were treated with chemotherapy (86 with ABVD) followed by RT to 25 Gy. The 7-year cause-specific, overall and disease-free survivals were 95%, 90% and 75% respectively for the low-risk cohort, and 91%, 90% and 88% respectively for the high-risk cohort. In-field relapses accounted for 50% of the failures in both groups. Sixteen of 24 (67%) patients with RT failure and 6/14 (43%) with combined modality therapy (CMT) failure were salvaged. Twenty-eight per cent of the patients treated with RT and 21% of those treated with CMT developed hypothyroidism by 7 years. Fatal complications were recorded in 6% of the low-risk patients managed with RT and 8% of high-risk patients managed with CMT. Septic death and second malignancy accounted for the majority of treatment-related fatalities. Risk-adapted therapy emphasizing RT alone for selected patients with favourable prognostic factors and CMT based on ABVD provides excellent long-term disease control. Further treatment refinements, including the wider application of CMT with lower doses of chemotherapy and RT, will be required to reduce the rate of fatal complications to more acceptable levels.

Late medical sequelae after therapy for supradiaphragmatic Hodgkin's disease

A total of 221 consecutive early stage Hodgkin's disease (HD) patients were given mantle field irradiation only or in combination with chemotherapy in 1971-1991. In 1994 these patients responded to a mailed self-report questionnaire covering items on late medical symptoms. Of 200 patients (91%) who reported that their thyroid function had been tested, 110 patients (55% of those tested) had thyroid hypofunction at follow-up in 1994. Ninety-five patients (86% of patients with biochemical hypothyreosis) had started hormonal substitution. In 1993 and 1994, 101 of these patients who had received mantle field irradiation in 1980-1988 were called in for interview, clinical examination and thyroid function tests. Eighteen patients (18%) had started hormonal substitution treatment earlier, but 58 (70%) of the other 83 patients were found to have biochemical hypothyreosis. Of the 221 patients who completed the questionnaire, 66 patients (30%) reported dyspnoea on exertion for more than 3 years after treatment, 8 patients (4%) reported a history of myocardial infarction, 6 patients (3%) reported pericardial disease and 25 patients (11%) heart valve disease. Increased expenses incurred for dental care were reported by 106 patients (48%), increasing to 55% when Waldeyer's ring had been irradiated. The consequences of late sequelae after mantle field irradiation for future treatment are discussed.

Mantle irradiation alone for clinical stage I-II Hodgkin's disease: long-term follow-up and analysis of prognostic factors in 261 patients

PURPOSE

To evaluate mantle radiotherapy (MRT) alone as the initial therapy of patients with clinical stage (CS) I-II Hodgkin's disease (HD).

PATIENTS AND METHODS

We performed a retrospective study of patients treated with MRT alone for CS I-II supradiaphragmatic HD between 1969 and 1994. Prognostic factor analysis was performed for progression-free survival (PFS) and overall survival (OS). Outcome was also assessed in favorable cohorts defined in the literature.

RESULTS

There were 261 eligible patients. The median follow-up period for surviving patients was 8.4 years (range, 1.8 to 27.4 years). The 10-year OS rate was 73%. Multifactor analysis for OS showed that age was the only important prognostic factor. The 10-year PFS rate was 58%. On multifactor analysis for PFS, the most important prognostic factors were clinical stage, B symptoms, histology, number of sites, and tumor bulk. The 10-year PFS rate for lymphocyte-predominant disease was 81% for stage I and 78% for stage II. In favorable patient cohorts defined in the literature, the 10-year PFS rate ranged from 70% to 73% for the whole group and from 71% to 90% in patients with favorable stage I disease, but only from 48% to 57% in patients with favorable stage II disease. On competing-risks analysis, the cumulative 10-year incidence of first site of failure in the para-aortic/splenic region alone was 10.5%. Sixty percent of relapsed patients remain progression-free at 10 years after chemotherapy salvage.

CONCLUSION

These results support the use of MRT alone in patients with favorable CS I HD and CS I-II HD with lymphocyte-predominant histology. The remainder of patients with CS I-II HD require more intensive treatment.

Reduced health-related quality of life among Hodgkin's disease survivors: a comparative study with general population norms

BACKGROUND

Late complications after curative treatment of Hodgkin's disease are of special relevance because most of the cured are young adults. The aims of the present study were: (1) to compare health-related quality of life (HRQOL) in Hodgkin's disease (HD) survivors with normative data from the general Norwegian population and (2) to examine the relations between disease/treatment characteristics and HRQOL in the HD survivors.

PATIENTS AND METHODS

459 HD survivors aged 19-74 years (mean 44.0, SD 11.8) treated at the Norwegian Radium Hospital 1971-1991 were approached in 1994 and compared to norms from 2214 subjects approached in 1996. The norms are representative of the general Norwegian population. HRQOL was assessed by the Short Form 36 (SF-36), which measures HRQOL in eight separate scales (0 = worst health state, 100 = best health state).

RESULTS

The HD survivors had lower scores than the normal controls on all scales after adjustment for age, gender and educational levels. Statistically significant differences (P < 0.01) were found in general health (10.4), physical functioning (6.1), role limitations (physical, 9.3), physical functioning (3.6) and in vitality (4.7). Patients with disease stage IB-IIB had the lowest scores on all scales. The differences in relation to stage/substage reached statistical significance (P < 0.01) in physical functioning and in role limitations (physical). Time since diagnosis, types of primary treatment or having relapsed were not associated with statistically significant differences in HRQOL.

CONCLUSION

Long-term HD survivors have poorer HRQOL, primarily in physical health, than the general Norwegian population.

Clinical research in a hospital--from the lone rider to teamwork

Clinical research of high international standard is very demanding and requires clinical data of high quality, software, hardware and competence in research design and statistical treatment of data. Most busy clinicians have little time allocated for clinical research and this increases the need for a potent infrastructure. This paper describes how the Norwegian Radium Hospital, a specialized cancer hospital, has reorganized the clinical research process. This includes a new department, the Clinical Research Office, which serves the formal framework, a central Diagnosis Registry, clinical databases and multicentre studies. The department assists about 120 users, mainly clinicians. Installation of a network software package with over 10 programs has strongly provided an internal standardization, reduced the costs and saved clinicians a great deal of time. The hospital is building up about 40 diagnosis-specific clinical databases with up to 200 variables registered. These databases are shared by the treatment group and seem to be important tools for quality assurance. We conclude that the clinical research process benefits from a firm infrastructure facilitating teamwork through extensive use of modern information technology. We are now ready for the next phase, which is to work for a better external technical framework for cooperation with other institutions throughout the world.

Prognostic variables and results of salvage treatment in Hodgkin's disease

Treatment results and prognostic variables were studied in 549 adult patients with Hodgkin's disease after first-line and salvage treatment. After first-line treatment, 479 out of 549 patients (87%) achieved complete remission (CR). During a mean observation time of 74 months, 99 patients (21%) relapsed. Sixty-nine patients (70% of relapsed patients) achieved a second CR. Variables predicting poor response (< CR) and shortened survival after first-line treatment were advanced disease, B-symptoms and age >60 years. In relapsing patients, age >60 years, relapse within 12 months and non-CR after relapse treatment predicted a poor prognosis, and none of these patients were alive after 10 years. Localized disease at diagnosis and relapse, and relapse later than 24 months predicted a good prognosis with 10-year survival after relapse of 68% and 57%, respectively. Patients with a second relapse had 5-year survival of 28% and 10-year survival of 14%. Based on the prognostic variables at first-line treatment and at relapse, selection of patients to more intensive treatment is discussed.