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Glimelius I, Ekberg S, Ekström Smedby K, Wästerlid T. Stable use of radiotherapy in lymphoma patients over time - A comprehensive national overview of radiotherapy use in Sweden with focus on older patients. Clin Transl Radiat Oncol 2024; 46:100785. [PMID: 38694236 PMCID: PMC11061694 DOI: 10.1016/j.ctro.2024.100785] [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: 02/28/2024] [Accepted: 04/20/2024] [Indexed: 05/04/2024] Open
Abstract
Background and purpose The role of radiotherapy (RT) in lymphoma is constantly refined with the advent of novel treatments. However, RT is still an effective treatment and tolerability is high. Therefore, we aimed to describe the use of RT in primary treatment of lymphoma over calendar time, with a specific focus on older patients (age ≥ 70 years) with non-Hodgkin lymphoma (NHL) subtypes. Materials & Methods All adult patients diagnosed with lymphoma from 2007 to 2018 in Sweden were included and followed for survival until end of 2020. Patient characteristics and relative survival (RS) were described for patients with NHL by subtype and RT use. Results In the cohort of lymphoma patients aged ≥ 70 years (n = 12,698) 11 % received RT as part of primary treatment. No decline in use of RT over calendar period was seen. Use of RT as monotherapy was associated with stage I-II disease and older age among patients with stage III-IV disease. Patients with indolent lymphomas aged ≥ 70 years who were selected for treatment with RT as monotherapy with a dose of ≥ 20 Gy had 2-year RS rate of 100 % which remained similar at five years. For patients with DLBCL, RT as monotherapy with a dose of ≥ 20 Gy was mostly administered to patients aged ≥ 85 years with a 2-year RS rate of 68 %. Conclusion The use of RT in first-line lymphoma treatment was stable over calendar time. RT monotherapy is associated with encouraging outcomes among patients with NHL aged ≥ 70 years who were selected to receive this.
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Affiliation(s)
- Ingrid Glimelius
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Immunology, Genetics and Pathology, Cancer Precision Medicine, Uppsala University, Sweden
| | - Sara Ekberg
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Karin Ekström Smedby
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Tove Wästerlid
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
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Upreti RP, Mmbaga E, Haugnes HS, Kiserud CE, Del Risco Kollerud R. Most common health problems in general practice among adolescents, and young adults' survivors of lymphoma: a register-based cohort study in Norway. Acta Oncol 2023; 62:1607-1615. [PMID: 37897712 DOI: 10.1080/0284186x.2023.2273894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/17/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The aim was to investigate the distribution of health problems in general practice (GP) among adolescent and young adult (AYA) survivors of lymphoma and to compare problem rates with the general population. METHODS All GP consultations between 2006 and 2020 were identified from the national GP claims register. Diseases and complaints presented 3-10 years after the cancer diagnosis were identified using the International Classification of Primary Care codes (ICPC-2) and compared by applying logistic regression models, presented with odds ratio (OR) and 95%CI. RESULTS A total of 2,500,557 AYAs, of whom 1105 were diagnosed with lymphoma, and over 50 million GP consultations were included. The most common causes of consultation among AYA survivors of lymphoma were related to Hodgkin's disease (13%), pregnancy (11%), respiratory diseases (9%), psychological problems (8%), musculoskeletal system (6%) and fatigue (4%). Almost all these problems were significantly higher among AYA lymphoma survivors compared to the general population (OR ranging from 1.1 to 1.5). CONCLUSION Compared to the general population, young lymphoma survivors have increased contact with the GP for a considerable number of health problems for up to 10 years post-diagnosis. This emphasizes the importance of robust follow-up and a good flow of information between hospital and primary care.
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Affiliation(s)
- Ram Prasad Upreti
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Elia Mmbaga
- Department of Community Medicine and Global Health, University of Oslo, Oslo, Norway
| | - Hege Sagstuen Haugnes
- Department of Oncology, University Hospital of North Norway, Tromsø, Norway
- Institute of Clinical Medicine, UIT- The Arctic University, Tromsø, Norway
| | | | - Ruby Del Risco Kollerud
- Department of rehabilitation, National Advisory Unit on Occupational Rehabilitation, Rauland, Norway
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Eikeland SA, Smeland KB, Simensen VC, Fagerli UM, Bersvendsen HS, Kiserud CE, Fosså A. Chronic fatigue in long-term survivors of Hodgkin's lymphoma after contemporary risk-adapted treatment. Acta Oncol 2023; 62:80-88. [PMID: 36715320 DOI: 10.1080/0284186x.2023.2168215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Chronic fatigue (CF), substantial fatigue for ≥ six months, can manifest as a late effect (LE) after cancer treatment, and may affect several aspects of life. In a Norwegian cohort of Hodgkin's lymphoma survivors (HLS), more than a decade after contemporary risk-adapted treatment regimens with limited use of radiotherapy (RT), we assessed: (1) Prevalence of, (2) factors associated with (3) and implications of CF on socioeconomic status (SES) and work ability (WA). MATERIAL AND METHODS HLS treated between 1997-2006, aged 8-49 years at diagnosis, were invited to participate in a population-based cross-sectional study on late effects in 2018-2019. In a mailed questionnaire, HLS responded to a fatigue questionnaire (FQ), work ability score (WAS) and short-form health survey (SF-36). Disease- and treatment data were extracted from hospital records. Factors associated with CF were identified by uni- and multivariate analysis. To study the implications of CF on SES and WA, a multinomial regression analysis was performed. RESULTS Invitations were extended to 518 HLS and 298 (58%) responded to FQ, of whom 42% had CF with mean (standard deviation [SD]) physical- and mental fatigue scores of 10.2 (4.3) and 5.5 (2.1) respectively. Median age at survey was 45 years, 47% were females. In multivariate analysis female sex (p = 0.03), lower education (p = 0.03), body mass index ≥30 kg/m2 (p = 0.04), and an increasing number of comorbidities (p = 0.01) were associated with CF. No association with disease stage, chemotherapy or RT was found. CF was associated with poorer WAS scores at survey (p < 0.001), unemployment (p = 0.03), and receiving disability pension (p = 0.003). CONCLUSION After risk-adapted treatment, CF is still a frequent LE among long-term HLS, without apparent association with disease or treatment-related parameters. CF is associated with reduced WA and SES. As no apparent risk reduction is seen with contemporary treatment, further studies should emphasize etiological factors of CF and treatment to alleviate this common LE.
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Affiliation(s)
- Siri A Eikeland
- Department of Oncology, National Advisory Unit for Late Effects after Cancer Treatment, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut B Smeland
- Department of Oncology, National Advisory Unit for Late Effects after Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Victoria Charlotte Simensen
- Department of Global Health, Division of Health Care Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Unn-Merete Fagerli
- Department of Oncology, St. Olav's Hospital, Trondheim, Norway.,Department of Cancer Research and Molecular Medicine, NTNU, Trondheim, Norway
| | | | - Cecilie E Kiserud
- Department of Oncology, National Advisory Unit for Late Effects after Cancer Treatment, Oslo University Hospital, Oslo, Norway
| | - Alexander Fosså
- Department of Medical Oncology and Radiotherapy, Oslo University Hospital, Oslo, Norway
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A Real-World Study of Combined Modality Therapy for Early-Stage Hodgkin Lymphoma: Too Little Treatment Impacts Outcome. Blood Adv 2022; 6:4241-4250. [PMID: 35617689 PMCID: PMC9327542 DOI: 10.1182/bloodadvances.2022007363] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/18/2022] [Indexed: 11/25/2022] Open
Abstract
In the real-world setting, CMT led to improved outcomes for patients with PET2-positive and unfavorable disease. Similar to clinical trials, favorable, non-bulky, and PET2-negative subgroups had comparable survival outcomes with chemotherapy-alone.
Multiple clinical trials have assessed de-escalation strategies from combined modality therapy (CMT) to chemotherapy-alone for the treatment of early-stage classical Hodgkin lymphoma (cHL), confirming similar outcomes. The application of these data to the real-world is limited, however. We conducted a retrospective, multicenter cohort study comparing CMT vs chemotherapy-alone in patients with early-stage cHL (stage IA-IIB) treated between January 2010 and December 2020. Positron emission tomography (PET) scans after chemotherapy cycle 2 (PET2) were independently reviewed by a nuclear radiologist (Deauville score ≥4, positive; ≤3, negative). Patient outcomes were compared by using an intention-to-treat analysis. Among 125 patients (CMT, n = 63; chemotherapy-alone, n = 62) with a median follow-up of 59.8 months (95% CI, 48.6-71.0), no differences in overall survival were observed (5-year overall survival, CMT 98.0% vs chemotherapy-alone 95.1%; log-rank test, P = .38). However, there was reduced progression-free survival (PFS) with chemotherapy-alone among all patients (2-year PFS, CMT 95.1% vs chemotherapy-alone 75.3%; log-rank test, P = .005) and in those with bulky (n = 43; log-rank test, P < .001), unfavorable (n = 81; log-rank test, P = .002), or PET2-positive (n = 15; log-rank test, P = .02) disease. No significant differences in PFS were seen for patients with non-bulky (log-rank test, P = .35), favorable (log-rank test, P = .62), or PET2-negative (log-rank test, P = .19) disease. Based on our real-world experience, CMT seems beneficial for patients with early-stage cHL, especially those with PET2-positive and unfavorable disease. Chemotherapy-alone regimens can lead to comparable outcomes for patients with favorable, non-bulky, or PET2-negative disease. We conclude that although results seen in clinical trials are replicated in certain patient subgroups, other subgroups not fitting trial criteria do poorly when radiotherapy is excluded.
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Ntentas G, Dedeckova K, Andrlik M, Aznar MC, Shakir R, Ramroth J, Begum R, Kubeš J, Darby SC, Mikhaeel NG, Cutter DJ. Proton Therapy in Supradiaphragmatic Lymphoma: Predicting Treatment-Related Mortality to Help Optimize Patient Selection. Int J Radiat Oncol Biol Phys 2022; 112:913-925. [PMID: 34762970 PMCID: PMC8865523 DOI: 10.1016/j.ijrobp.2021.10.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/28/2021] [Accepted: 10/28/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE In some patients with Hodgkin lymphoma (HL), proton beam therapy (PBT) may reduce the risk of radiation-related cardiovascular disease (CVD) and second cancers (SC) compared with photon radiation therapy (RT). Our aim was to identify patients who benefit the most from PBT in terms of predicted 30-year absolute mortality risks (AMR30) from CVD and SC, taking into account individual background, chemotherapy, radiation, and smoking-related risks. METHODS AND MATERIALS Eighty patients with supradiaphragmatic HL treated with PBT between 2015 and 2019 were replanned using optimal photon RT. To identify patients predicted to derive the greatest benefit from PBT compared with photon RT, doses and AMR30 from CVD and SC of the lung, breast, and esophagus were compared for all patients and across patient subgroups. RESULTS For patients with mediastinal disease below the origin of the left main coronary artery (n = 66; 82%), PBT reduced the mean dose to the heart, left ventricle, and heart valves by 1.0, 2.7, and 3.6 Gy, respectively. Based on U.S. mortality rates, PBT reduced CVD AMR30 by 0.2%, from 5.9% to 5.7%. The benefit was larger if the mediastinal disease overlapped longitudinally with the heart by ≥40% (n = 23; 29%). PBT reduced the mean dose to the heart, left ventricle, and heart valves by 3.2, 5.6, and 5.1 Gy, respectively, and reduced CVD AMR30 by 0.8%, from 7.0% to 6.2%. For patients with axillary disease (n = 25; 31%), PBT reduced the mean lung dose by 2.8 Gy and lung cancer AMR30 by 0.6%, from 2.7% to 2.1%. Breast and esophageal doses were also lower with PBT, but the effects on AMR30 were negligible. The effect of smoking on CVD and lung cancer AMR30 was much larger than radiation and chemotherapy and the differences between radiation modalities. CONCLUSIONS The predicted benefit of PBT is not universal and limited to certain categories of patients with lymphoma and lower mediastinal or axillary disease. Smoking cessation should be strongly encouraged in smokers who require thoracic RT.
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Affiliation(s)
- Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom.
| | - Katerina Dedeckova
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Oncology, 2nd Faculty of Medicine Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | | | - Marianne C Aznar
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Manchester Cancer Research Centre, University of Manchester, Manchester, United Kingdom
| | - Rebecca Shakir
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Johanna Ramroth
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Rubina Begum
- Guy's and St Thomas' NHS Foundation Trust, Department of Medical Physics, London, United Kingdom
| | - Jiří Kubeš
- Proton Therapy Center Czech, Prague, Czech Republic; Department of Oncology, 2nd Faculty of Medicine Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Sarah C Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - N George Mikhaeel
- Guy's & St Thomas' NHS Foundation Trust and School of Cancer & Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Jones DA, Candio P, Shakir R, Ntentas G, Ramroth J, Gray AM, Cutter DJ. Informing radiotherapy decisions in stage I/IIa Hodgkin lymphoma: modeling life expectancy using radiation dosimetry. Blood Adv 2022; 6:909-919. [PMID: 34872107 PMCID: PMC8945315 DOI: 10.1182/bloodadvances.2021006254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/14/2021] [Indexed: 11/23/2022] Open
Abstract
In recent randomized trials, omitting consolidative radiotherapy (RT) in early-stage Hodgkin lymphoma (ESHL) increased relapses. However, decades of follow-up are required to observe whether lower initial disease control is compensated by reduced risk of late effects. Extrapolation beyond trial follow-up is therefore necessary to inform current treatment decisions. To this end, we developed a microsimulation model to estimate lifetime quality-adjusted life years (QALYs) after combined modality treatment (CMT) or chemotherapy-alone for stage I/IIa ESHL. For CMT, the model included risks of breast and lung cancer, coronary heart disease, and ischemic stroke. Comparative outcomes were assessed for a clinically relevant range of example patients differing by age, sex, smoking status, and representative organs at risk (OAR) radiation doses informed by the RAPID trial. Analysis was performed with and without a 3.5% discount rate on future health. Smoking status had a large effect on optimal treatment choice. CMT was superior for nearly all never smoker example patients regardless of age, sex, and OAR doses. At a maximum, CMT produced a 1.095 (95% CI: 1.054-1.137) gain in undiscounted QALYs for a 20-year-old male never smoker with unilateral neck disease. In contrast, current smokers could substantially gain from chemotherapy-alone treatment. Again at a maximum, a 20-year-old male current smoker with bilateral neck and whole mediastinum involvement gained 3.500 (95% CI: 3.400 to 3.600) undiscounted QALYs with chemotherapy-alone treatment. Overall, CMT was more favorable the younger the patient, when future health discounting was included, and in never smokers.
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Affiliation(s)
| | | | - Rebecca Shakir
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Georgios Ntentas
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, Department of Medical Physics, London, United Kingdom; and
| | - Johanna Ramroth
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | | | - David J. Cutter
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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7
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Murphy-Banks R, Kumar AJ, Lin M, Savidge N, Livne E, Parsons SK. Hodgkin lymphoma survivor perspectives on their engagement in treatment decision-making and discussion of late effects. Support Care Cancer 2022; 30:1399-1405. [PMID: 34524526 PMCID: PMC10642770 DOI: 10.1007/s00520-021-06538-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hodgkin lymphoma has a bimodal age distribution with the first peak occurring within young adulthood and the second, among older adults. Although current therapy provides excellent disease control, survivors are at risk of developing treatment-related late effects (LEs). We sought to understand how survivors in active survivorship care perceived their role in treatment decision-making and when they acquired an understanding of LEs. METHODS Semi-structured interviews were conducted until saturation was reached. Themes were identified through direct content analysis and consensus coding by a multidisciplinary team of coders, including hematology/oncology providers, patient navigators, and survivor stakeholders. RESULTS Seventeen interviews were conducted. Role in initial treatment decision-making fluctuated between passive and active engagement with providers identified as being crucial to this process. Half of interviewees (53%) expressed unmet information needs. Survivors reported having learned about LEs at multiple time points, spanning from before treatment commenced through when a LE was diagnosed. The majority (71%) expressed a desire to have learned about LEs before initial treatment ended. The impact of cancer and fertility discussions were also disclosed. DISCUSSION Participants highlighted the importance of discussions on LEs early in the care continuum. These preliminary data will be incorporated in a planned treatment decision-making tool that incorporates information on potential LEs. IMPLICATIONS FOR CANCER SURVIVORS Patient-centered communication approaches should be embraced to assist in treatment decision-making, while considering long-term health consequences. Survivors must be educated on their risk of LEs and encouraged to disclose their perspectives and preferences with their providers to optimize outcomes.
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Affiliation(s)
- Rachel Murphy-Banks
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., #345, Boston, MA, 02111, USA
- Reid R. Sacco Adolescent & Young Adult Cancer Program, Tufts Medical Center, Boston, MA, USA
| | - Anita J Kumar
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., #345, Boston, MA, 02111, USA
- Reid R. Sacco Adolescent & Young Adult Cancer Program, Tufts Medical Center, Boston, MA, USA
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - Mingqian Lin
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., #345, Boston, MA, 02111, USA
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - Nicole Savidge
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., #345, Boston, MA, 02111, USA
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | - Emma Livne
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., #345, Boston, MA, 02111, USA
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., #345, Boston, MA, 02111, USA.
- Reid R. Sacco Adolescent & Young Adult Cancer Program, Tufts Medical Center, Boston, MA, USA.
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA.
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Lagerlöf I, Fohlin H, Enblad G, Glimelius B, Goldkuhl C, Palma M, Åkesson L, Glimelius I, Molin D. Limited, But Not Eliminated, Excess Long-Term Morbidity in Stage I-IIA Hodgkin Lymphoma Treated With Doxorubicin, Bleomycin, Vinblastine, and Dacarbazine and Limited-Field Radiotherapy. J Clin Oncol 2022; 40:1487-1496. [PMID: 35077204 PMCID: PMC9061145 DOI: 10.1200/jco.21.02407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Balancing disease control and toxicity from chemotherapy and radiotherapy (RT) when treating early-stage classical Hodgkin lymphoma (cHL) is important. Available data on long-term toxicity after RT for cHL mostly refer to RT techniques no longer in use. We aimed to describe long-term toxicity from modern limited-field (LF)-RT after two or four cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). PATIENTS AND METHODS This study included all patients with cHL treated with two or four cycles of ABVD and 30 Gy LF-RT during 1999-2005 in Sweden. Patients (n = 215) and comparators (n = 860), matched for age, gender, and region of residence, were cross-checked against national health registries for malignancies, diseases of the circulatory system (DCS), and diseases of the respiratory system (DRS) from the day of diagnosis of cHL. RESULTS The risk of a malignancy was higher for patients than comparators, hazard ratio (HR) 1.5 (95% CI, 1.0 to 2.4), as was the risk for DCS 1.5 (95% CI, 1.1 to 2.0) and for DRS 2.6 (95% CI, 1.6 to 4.3). The median follow-up was 16 years (range, 12-19 years). Of individual diagnoses in DCS, only venous thromboembolism was statistically significantly elevated. If the first 6 months (ie, time of active treatment for cHL) were excluded and censoring at relapse of cHL or diagnosis of any malignancy, the increased HR for venous thromboembolism diminished. Most of the excess risk for DRS consisted of asthma, HR 3.5 (95% CI, 1.8 to 6.8). Patients diagnosed with DRS were significantly younger than comparators. CONCLUSION Compared with toxicity from earlier RT techniques, excess morbidity was not eliminated, but lower than previously reported. The elevated risk of DRS was driven by diagnosis of asthma, which could in part be explained by misdiagnosis of persisting pulmonary toxicity. Less morbidity in Hodgkin lymphoma treated with chemotherapy and radiotherapy fields smaller than involved field![]()
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Affiliation(s)
- Ingemar Lagerlöf
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology; Uppsala University, Uppsala, Sweden
| | - Helena Fohlin
- Regional Cancer Center of Southeast Sweden and Department of Biomedical and Clinical Sciences, Medical Faculty, Linköping University, Linköping, Sweden
| | - Gunilla Enblad
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology; Uppsala University, Uppsala, Sweden
| | - Bengt Glimelius
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology; Uppsala University, Uppsala, Sweden
| | - Christina Goldkuhl
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marzia Palma
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Åkesson
- Regional Cancer Center of Southeast Sweden and Department of Biomedical and Clinical Sciences, Medical Faculty, Linköping University, Linköping, Sweden
| | - Ingrid Glimelius
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology; Uppsala University, Uppsala, Sweden
| | - Daniel Molin
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology; Uppsala University, Uppsala, Sweden
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Eikeland SA, Smeland KB, Mols F, Fagerli UM, Bersvendsen HS, Kiserud CE, Fosså A. Chemotherapy-induced peripheral neuropathy after modern treatment of Hodgkin's lymphoma; symptom burden and quality of life. Acta Oncol 2021; 60:911-920. [PMID: 33905285 DOI: 10.1080/0284186x.2021.1917776] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chemotherapy-induced peripheral neuropathy (CIPN) is a dose-limiting side effect of Hodgkin's lymphoma (HL) treatment. We aimed to describe the prevalence of CIPN associated symptoms in long-term HL survivors compared to controls, and determine associated factors, including impact on health-related quality of life (HRQoL). MATERIAL AND METHODS A questionnaire, including EORTC QLQ-CIPN-20 for CIPN related symptoms and SF-36 for HRQoL, was completed by 303 HL survivors at a median of 16 years after diagnosis. CIPN results were compared to a normative population (n = 606). CIPN associated factors were identified by linear regression analysis. RESULTS Total CIPN score and subscores were significantly higher in HL survivors compared to controls. In multivariate analysis of HL survivors, a number of comorbidities (p < 0.001) and female gender (p = 0.05) were significantly associated with more CIPN. No association with disease or treatment factors was found. In a multivariate analysis including survivors and controls, the number of comorbidities (p < 0.001) and caseness (p < 0.001) were significantly associated with more CIPN. In HL survivors higher CIPN score was associated with reduced HRQoL (p < 0.001). CONCLUSION HL survivors more than a decade after treatment report higher neuropathy-related symptom burden than controls, with a negative impact on HRQoL. Symptoms may be related to factors other than neurotoxic chemotherapy.
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Affiliation(s)
- Siri A. Eikeland
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Knut B. Smeland
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Floortje Mols
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Unn-Merete Fagerli
- Department of Oncology, St. Olav’s Hospital, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, NTNU, Trondheim, Norway
| | | | - Cecilie E. Kiserud
- National Advisory Unit on Late Effects after Cancer Treatment, Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Alexander Fosså
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Centre for B-cell malignancies, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
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10
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Revisiting IL-6 expression in the tumor microenvironment of classical Hodgkin lymphoma. Blood Adv 2021; 5:1671-1681. [PMID: 33720338 DOI: 10.1182/bloodadvances.2020003664] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/10/2021] [Indexed: 12/22/2022] Open
Abstract
Interleukin-6 (IL-6) can induce therapeutic resistance for several cancer agents currently used to treat classical Hodgkin lymphoma (cHL). We aimed to investigate whether the presence of IL-6+ leukocytes and IL-6+ Hodgkin-Reed-Sternberg (HRS) cells in the tumor microenvironment (TME) was associated with adverse survival outcomes, expression of other immune markers, and serum IL-6 levels. We used a contemporarily treated cohort (n = 136), with a median follow-up of 13.8 years (range, 0.59-15.9 years). We performed immunohistochemistry with an IL-6 antibody on tissue microarrays from diagnostic biopsies of cHL patients. Patients with IL-6+ leukocytes ≥1% (n = 54 of 136) had inferior event-free survival (hazard ratio [HR] = 3.58; 95% confidence interval [CI], 1.80-7.15) and overall survival (HR = 6.71; 95% CI, 2.51-17.99). The adverse survival was maintained in multivariate Cox regression and propensity score-matched analyses, adjusting for well-known poor-prognostic covariates. The presence of IL-6+ HRS cells and high serum IL-6 levels were not associated with survival. IL-6+ leukocytes correlated with increased proportions of IL-6+ HRS cells (P < .01), CD138+ plasma cells (P < .01), CD68+ macrophages (P = .02), and tryptase-positive mast cells (P < .01). IL-6+ HRS cells correlated with increased proportions of CD68+ macrophages (P = .03), programmed death-ligand 1-positive (PD-L1+) leukocytes (P = .04), and PD-L1+ HRS cells (P < .01). Serum-IL-6 lacked correlation with IL-6 expression in the TME. This is the first study highlighting the adverse prognostic impact of IL-6+ leukocytes in the TME in a cohort of contemporarily treated adult patients with cHL.
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ABVD followed by BV consolidation in risk-stratified patients with limited-stage Hodgkin lymphoma. Blood Adv 2021; 4:2548-2555. [PMID: 32516414 DOI: 10.1182/bloodadvances.2020001871] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/24/2020] [Indexed: 01/12/2023] Open
Abstract
Approximately 90% of limited-stage Hodgkin lymphoma (HL) patients are projected to be cured with standard therapy, but many do not live their expected life span because of late treatment-related complications. New treatment paradigms are needed to reduce the use of radiation therapy (RT) as well as conventional chemotherapy drugs while improving upon current standard-of-care survival outcomes. In this phase 2 multicenter study, patients with non-bulky limited-stage HL received doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) followed by brentuximab vedotin (BV) consolidation. Forty-one patients were enrolled, and patient characteristics included median age of 29 years (range, 19 to 67 years), 58% were female, 45% had unfavorable disease, and 98% had stage II disease. Based on positron emission tomography (PET)-based risk stratification, patients received 2 to 6 cycles of ABVD followed by 6 cycles of BV. After ABVD followed by BV, 95% of evaluable patients (37 out of 39; 95% confidence interval [CI], 83%-99%) achieved PET-negative status. In the intent-to-treat patient population, the estimated 3-year progression-free survival (PFS) rate was 92%, and the overall survival (OS) rate was 97%, with a median follow-up of 47 months. All 37 patients who achieved negative PET status after BV consolidation effectively avoided RT and remain in remission with estimated 3-year PFS and OS rates of 100%. In conclusion, BV demonstrates encouraging clinical activity when it follows ABVD therapy in limited-stage HL. Early incorporation of BV may reduce the use of RT as well as conventional chemotherapy drugs while achieving favorable survival outcomes in risk-stratified patients with non-bulky limited-stage HL. This trial was registered at www.clinicaltrials.gov as #NCT01578967.
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12
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Iorio GC, Salvestrini V, Borghetti P, De Felice F, Greco C, Nardone V, Fiorentino A, Gregucci F, Desideri I. The impact of modern radiotherapy on radiation-induced late sequelae: Focus on early-stage mediastinal classical Hodgkin Lymphoma. A critical review by the Young Group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO). Crit Rev Oncol Hematol 2021; 161:103326. [PMID: 33862247 DOI: 10.1016/j.critrevonc.2021.103326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/07/2021] [Accepted: 03/26/2021] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The historically feared radiation-induced secondary cancers and cardiac toxicities observed among mediastinal classical Hodgkin Lymphoma (cHL) patients may still negatively burden the benefit of radiotherapy among long-term survivors. Modern radiotherapy (RT) delivery techniques, including intensity-modulated RT (IMRT) and deep inspiration breath-hold (DIBH) solutions, are drastically changing this scenario. Results of a literature overview are reported and discussed in this paper. MATERIALS AND METHODS Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used. RESULTS This paper contains a narrative report and a critical discussion of organs-at-risk dose-volume metrics linked with radiation-induced toxicities in cHL patients. CONCLUSIONS The scenario of early-stage cHL presents long-life expectancies, thus the goal of treatment should aim at maintaining high cure rates and limiting the onset of late complications. Further evaluations of dosimetric measures and clinical outcomes are warranted to identify patients at higher risk to target treatment tailoring.
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Affiliation(s)
| | - Viola Salvestrini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Paolo Borghetti
- Department of Radiation Oncology, University and Spedali Civili, Brescia, Italy
| | - Francesca De Felice
- Department of Radiation Oncology, Policlinico Umberto I "Sapienza" University of Rome, Rome, Italy
| | - Carlo Greco
- Department of Radiation Oncology, Campus Bio-Medico University of Rome, Rome, Italy
| | - Valerio Nardone
- Department of Radiation Oncology, Ospedale del Mare, Viale della Metamorfosi, Naples, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, General Regional Hospital "F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Department of Radiation Oncology, General Regional Hospital "F. Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Isacco Desideri
- Department of Radiation Oncology, University of Florence, Florence, Italy
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13
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[Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international randomized phase III HD16 trial conducted by the German Hodgkin Study Group]. Strahlenther Onkol 2020; 196:414-415. [PMID: 32060584 DOI: 10.1007/s00066-020-01593-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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14
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Weil CR, Qian Y, Von Eyben R, Daadi SE, Corbelli KS, Rosenberg SA, Advani RH, Hoppe RT. Long-term outcomes of patients with unfavorable stage I-II classic Hodgkin lymphoma treated with Stanford V chemotherapy and limited field irradiation. Leuk Lymphoma 2020; 61:2428-2434. [PMID: 32476541 DOI: 10.1080/10428194.2020.1768385] [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
Management of stage I-II unfavorable risk Hodgkin lymphoma (HL) strives to reduce toxicity while maintaining tumor control. Compared to ABVD or BEACOPP, Stanford V chemotherapy contains less doxorubicin and bleomycin. We report long-term outcomes of patients with stage I-II classic HL with European risk factors treated with Stanford V combined modality therapy (CMT). From our institutional cancer registry, we identified 168 patients with ≥1 European risk factor treated with 8-12 weeks of Stanford V CMT and consolidative radiotherapy between 1990 and 2016. Outcomes were analyzed after classification by EORTC and GHSG unfavorable criteria. With median follow-up of 8.4 years, 10-year overall survival and progression-free survival for the entire cohort were 95% and 88%, respectively. Thirteen of 18 relapses were salvaged successfully. There were no cases of MDS or AML after primary therapy. Long-term outcomes of stage I-II unfavorable risk HL treated with Stanford V CMT are comparable to ABVD or BEACOPP regimens.
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Affiliation(s)
- Christopher R Weil
- Department of Radiation Oncology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Yushen Qian
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Rie Von Eyben
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah E Daadi
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Karen S Corbelli
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Saul A Rosenberg
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA.,Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ranjana H Advani
- Department of Medicine, Division of Medical Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
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Driessen J, Visser O, Zijlstra JM, Lugtenburg PJ, Plattel WJ, Kersten MJ, Dinmohamed AG. Primary therapy and relative survival in classical Hodgkin lymphoma: a nationwide population-based study in the Netherlands, 1989-2017. Leukemia 2020; 35:494-505. [PMID: 32461630 DOI: 10.1038/s41375-020-0875-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/07/2020] [Accepted: 05/13/2020] [Indexed: 01/17/2023]
Abstract
Population-based studies of classical Hodgkin lymphoma (cHL) in contemporary clinical practice are scarce. The aim of this nationwide population-based study is to assess trends in primary therapy and relative survival (RS) during 1989-2017. We included 9,985 patients with cHL. Radiotherapy alone was virtually not applied as from 2000 among patients aged 18-69 years with stage I/II disease, following the broader application of chemotherapy combined with radiotherapy. Chemotherapy only was the preferred treatment for patients with stage III/IV disease. Throughout the entire study period, around 20% of patients aged ≥70 years across all disease stages received no anti-neoplastic therapy. The most considerable improvements in 5-year RS were confined to patients aged 18-59 years. Five-year RS for patients with stage I/II disease diagnosed during 2010-2017 was 99%, 98%, 100%, 93%, 84%, and 61% for patients aged 18-29, 30-39, 40-49, 50-59, 60-69, and ≥70 years, respectively. The corresponding estimates for stage III/IV disease were 96%, 92%, 90%, 80%, 58%, and 46%. Collectively, the improvements in survival likely relate to advances in cHL management. These achievements, however, do not seem to translate into significant benefits for patients ≥60 years. Therefore, novel therapies are urgently needed to reduce excess mortality in elderly cHL patients.
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Affiliation(s)
- Julia Driessen
- Department of Hematology, Amsterdam UMC, University of Amsterdam, LYMMCARE (Lymphoma and Myeloma Center Amsterdam), Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Otto Visser
- Department of Registration, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Wouter J Plattel
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marie José Kersten
- Department of Hematology, Amsterdam UMC, University of Amsterdam, LYMMCARE (Lymphoma and Myeloma Center Amsterdam), Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Avinash G Dinmohamed
- Department of Hematology, Amsterdam UMC, University of Amsterdam, LYMMCARE (Lymphoma and Myeloma Center Amsterdam), Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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