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Cost-effectiveness of first-line treatment options for patients with advanced-stage Hodgkin lymphoma: a modelling study. LANCET HAEMATOLOGY 2020; 7:e146-e156. [PMID: 31948928 DOI: 10.1016/s2352-3026(19)30218-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/28/2019] [Accepted: 09/11/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Several strategies are available for the initial treatment of advanced-stage Hodgkin lymphoma, but the optimal strategy in terms of cost-effectiveness is unclear. The aim of this study was to compare the quality-adjusted effectiveness and costs of five modern treatment options for transplantation-eligible patients with newly diagnosed advanced-stage Hodgkin lymphoma. METHODS A Markov decision-analytic model was developed using a 20-year time horizon. Five of the most common treatment approaches were selected based on clinical experience and expert opinion: (1) six cycles of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD), including data from the HD2000 trial, Viviani and colleagues, and EORTC trial; (2) six cycles of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP; from the HD15 trial or PET-adapted as in the HD18 trial, two initial cycles of BEACOPP followed by four additional cycles for patients with a positive PET and either two or four additional cycles of BEACOPP for patients with a negative PET); (3) PET-adapted escalation (as in the RATHL trial, two cycles of standard ABVD chemotherapy followed by an additional four cycles of ABVD or AVD in PET-negative patients and four cycles of BEACOPP in PET-positive patients); (4) six cycles of brentuximab vedotin, doxorubicin, vinblastine, dacarbazine (A-AVD) or ABVD as in the Echelon-1 trial; and (5) PET-adapted de-escalation (as in the AHL2011 trial, two cycles of BEACOPP followed by PET2 scan; PET-positive patients received two additional BEACOPP cycles and PET-negative patients received two cycles of ABVD; at PET4, PET-negative patients completed two further cycles of either ABVD or BEACOPP depending on what they received after PET2, and PET-positive patients received salvage therapy). Note that all uses of BEACOPP in these strategies were BEACOPPescalated. The randomised groups of interest from these studies comprised 4255 patients enrolled between April, 2000, and January, 2016. Baseline probability estimates and utilities were derived from the included trials in addition to a systematic review of published studies. A Canadian public health payer's perspective was considered (CAN$1=US$0·74) and adjusted for inflation for 2018. All costs and benefits were discounted by 1·5% per year because life-years now are more valuable than future potential life-years. FINDINGS Probabilistic analyses (10 000 simulations) showed that, for a willingness-to-pay threshold of CAN$50 000, a PET-adapted de-escalation strategy based on AHL2011 was more cost-effective 87% of the time. This strategy had the highest number of life-years (14·6 years [95% CI 13·7-15·1]) and quality-adjusted life years (13·2 years [95% CI 10·2-14·4]), and the lowest direct costs ($53 129 [95% CI 31 914-94 446]) compared with the other treatment regimens. Sensitivity analyses showed that the model was robust to key variables, including probability of treatment-related mortality, relapse, frequency of secondary malignancy, death from secondary malignancy, and probability of infertility after BEACOPP. INTERPRETATION Our results suggest that, when considering cost, effectiveness, and short and long-term toxicities, the preferred treatment strategy for patients with newly diagnosed advanced-stage Hodgkin lymphoma is the PET-adapted de-escalation regimen starting with BEACOPP and de-escalating to ABVD as appropriate. Although our findings do not provide an absolute best treatment approach for clinicians to follow for all patients, they can contribute to shared decision making between patients and treating physicians. FUNDING None.
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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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Carde PP, Grynberg M, Poirot C, Glimelius B, Mounier N. Reply to C.F. Hess et al. J Clin Oncol 2017; 35:374. [DOI: 10.1200/jco.2016.69.7995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Patrice P. Carde
- Patrice P. Carde, Gustave Roussy Cancer Campus, Villejuif, France; Michael Grynberg, Hôpital Jean Verdier, Bondy, France; Catherine Poirot, Hôpital Saint Louis, Paris, France; Bengt Glimelius, Uppsala University Hospital, Uppsala, Sweden; and Nicolas Mounier, L’Archet Hospital, Nice, France
| | - Michael Grynberg
- Patrice P. Carde, Gustave Roussy Cancer Campus, Villejuif, France; Michael Grynberg, Hôpital Jean Verdier, Bondy, France; Catherine Poirot, Hôpital Saint Louis, Paris, France; Bengt Glimelius, Uppsala University Hospital, Uppsala, Sweden; and Nicolas Mounier, L’Archet Hospital, Nice, France
| | - Catherine Poirot
- Patrice P. Carde, Gustave Roussy Cancer Campus, Villejuif, France; Michael Grynberg, Hôpital Jean Verdier, Bondy, France; Catherine Poirot, Hôpital Saint Louis, Paris, France; Bengt Glimelius, Uppsala University Hospital, Uppsala, Sweden; and Nicolas Mounier, L’Archet Hospital, Nice, France
| | - Bengt Glimelius
- Patrice P. Carde, Gustave Roussy Cancer Campus, Villejuif, France; Michael Grynberg, Hôpital Jean Verdier, Bondy, France; Catherine Poirot, Hôpital Saint Louis, Paris, France; Bengt Glimelius, Uppsala University Hospital, Uppsala, Sweden; and Nicolas Mounier, L’Archet Hospital, Nice, France
| | - Nicolas Mounier
- Patrice P. Carde, Gustave Roussy Cancer Campus, Villejuif, France; Michael Grynberg, Hôpital Jean Verdier, Bondy, France; Catherine Poirot, Hôpital Saint Louis, Paris, France; Bengt Glimelius, Uppsala University Hospital, Uppsala, Sweden; and Nicolas Mounier, L’Archet Hospital, Nice, France
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Merli F, Luminari S, Gobbi PG, Cascavilla N, Mammi C, Ilariucci F, Stelitano C, Musso M, Baldini L, Galimberti S, Angrilli F, Polimeno G, Scalzulli PR, Ferrari A, Marcheselli L, Federico M. Long-Term Results of the HD2000 Trial Comparing ABVD Versus BEACOPP Versus COPP-EBV-CAD in Untreated Patients With Advanced Hodgkin Lymphoma: A Study by Fondazione Italiana Linfomi. J Clin Oncol 2016; 34:1175-81. [DOI: 10.1200/jco.2015.62.4817] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The randomized HD2000 trial compared six cycles of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), four escalated plus two standard cycles of BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone), and six cycles of COPP-EBV-CAD (cyclophosphamide, lomustine, vindesine, melphalan, prednisone, epidoxorubicin, vincristine, procarbazine, vinblastine, and bleomycin; CEC) in patients with advanced-stage Hodgkin lymphoma. After a median follow-up of 42 months, patients who received BEACOPP were reported to have experienced better progression-free survival (PFS) but not better overall survival (OS) results than those receiving ABVD. We here report a post hoc analysis of this trial after a median follow-up of 10 years. Patients and Methods Three hundred seven patients were enrolled, 295 of whom were evaluable. At the time of our analysis, the median follow-up for the entire group was 120 months (range, 4 to 169 months). Results The 10-year PFS results for the ABVD, BEACOPP, and CEC arms were 69%, 75%, and 76%, respectively; corresponding OS results were 85%, 84%, and 86%. Overall, 13 second malignancies were reported: one in the ABVD arm and six each in the BEACOPP and CEC arms. The cumulative risk of developing second malignancies at 10 years was 0.9%, 6.6%, and 6% with ABVD, BEACOPP, and CEC, respectively; the risk with either BEACOPP or CEC was significantly higher than that reported with ABVD (P = .027 and .02, respectively). Conclusion With these mature results, we confirm that patients with advanced Hodgkin lymphoma have similar OS results when treated with ABVD, BEACOPP, or CEC. However, with longer follow-up, we were not able to confirm the superiority of BEACOPP over ABVD in terms of PFS, mainly because of higher mortality rates resulting from second malignancies observed after treatment with BEACOPP and CEC.
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Affiliation(s)
- Francesco Merli
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Stefano Luminari
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Paolo G. Gobbi
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Nicola Cascavilla
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Caterina Mammi
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Fiorella Ilariucci
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Caterina Stelitano
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Maurizio Musso
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Luca Baldini
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Sara Galimberti
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Francesco Angrilli
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Giuseppe Polimeno
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Potito Rosario Scalzulli
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Angela Ferrari
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Luigi Marcheselli
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
| | - Massimo Federico
- Francesco Merli, Caterina Mammi, Fiorella Ilariucci, and Angela Ferrari, Azienda Ospedaliera Arcispedale S. Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS); Reggio Emilia; Stefano Luminari, Luigi Marcheselli, and Massimo Federico, University of Modena and Reggio Emilia, Modena; Paolo G. Gobbi, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia; Nicola Cascavilla and Potito Rosario Scalzulli, IRCCS “Casa Sollievo della Sofferenza” Hospital, San Giovanni Rotondo
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Behringer K, Goergen H, Hitz F, Zijlstra JM, Greil R, Markova J, Sasse S, Fuchs M, Topp MS, Soekler M, Mathas S, Meissner J, Wilhelm M, Koch P, Lindemann HW, Schalk E, Semrau R, Kriz J, Vieler T, Bentz M, Lange E, Mahlberg R, Hassler A, Vogelhuber M, Hahn D, Mezger J, Krause SW, Skoetz N, Böll B, von Tresckow B, Diehl V, Hallek M, Borchmann P, Stein H, Eich H, Engert A. Omission of dacarbazine or bleomycin, or both, from the ABVD regimen in treatment of early-stage favourable Hodgkin's lymphoma (GHSG HD13): an open-label, randomised, non-inferiority trial. Lancet 2015; 385:1418-27. [PMID: 25539730 DOI: 10.1016/s0140-6736(14)61469-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The role of bleomycin and dacarbazine in the ABVD regimen (ie, doxorubicin, bleomycin, vinblastine, and dacarbazine) has been questioned, especially for treatment of early-stage favourable Hodgkin's lymphoma, because of the drugs' toxicity. We aimed to investigate whether omission of either bleomycin or dacarbazine, or both, from ABVD reduced the efficacy of this regimen in treatment of Hodgkin's lymphoma. METHODS In this open-label, randomised, multicentre trial (HD13) we compared two cycles of ABVD with two cycles of the reduced-intensity regimen variants ABV (doxorubicin, bleomycin, and vinblastine), AVD (doxorubicin, vinblastine, and dacarbazine), and AV (doxorubicin and vinblastine), in patients with newly diagnosed, histologically proven, classic or nodular, lymphocyte predominant Hodgkin's lymphoma. In each treatment group, 30 Gy involved-field radiotherapy (IFRT) was given after both cycles of chemotherapy were completed. From Jan 28, 2003, patients were centrally randomly assigned (1:1:1:1) with a minimisation method to the four groups. Because of high event rates, assignment to the AV and ABV groups stopped early, on Sept 30, 2005, and Feb 10, 2006; assignment to ABVD and AVD continued (1:1) until Sept 30, 2009. Our primary objective was to show non-inferiority of the experimental variants compared with ABVD in terms of freedom from treatment failure (FFTF), by excluding a difference of 6% after 5 years corresponding to a hazard ratio (HR) of 1.72, via a 95% CI. Analyses reported here include qualified patients only, and between-group comparisons include only patients recruited during the same period. The trial was registered, number ISRCTN63474366. FINDINGS Of 1502 qualified patients, 566, 198, 571, and 167 were randomly assigned to receive ABVD, ABV, AVD, or AV, respectively. 5 year FFTF was 93.1%, 81.4%, 89.2%, and 77.1% with ABVD, ABV, AVD, and AV, respectively. Compared with ABVD, inferiority of the dacarbazine-deleted variants was detected with 5 year differences of -11.5% (95% CI -18.3 to -4.7; HR 2.06 [1.21 to 3.52]) for ABV and -15.2% (-23.0 to -7.4; HR 2.57 [1.51 to 4.40]) for AV. Non-inferiority of AVD compared with ABVD could also not be detected (5 year difference -3.9%, -7.7 to -0·1; HR 1.50, 1.00 to 2.26). 178 (33%) of 544 patients given ABVD had WHO grade III or IV toxicity, compared with 53 (28%) of 187 given ABV, 142 (26%) of 539 given AVD, and 40 (26%) of 151 given AV. Leucopenia was the most common event, and highest in the groups given bleomycin. INTERPRETATION Dacarbazine cannot be omitted from ABVD without a substantial loss of efficacy. With respect to our predefined non-inferiority margin, bleomycin cannot be safely omitted either, and the standard of care for patients with early-stage favourable Hodgkin's lymphoma should remain ABVD followed by IFRT. FUNDING Deutsche Krebshilfe and Swiss State Secretariat for Education and Research.
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Affiliation(s)
- Karolin Behringer
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Helen Goergen
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Felicitas Hitz
- Cantonal Hospital of St Gallen, St Gallen, Switzerland and SAKK Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | | | - Richard Greil
- Third Medical Department, Paracelcus Medical University, Salzburg, Austria
| | - Jana Markova
- University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stephanie Sasse
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Michael Fuchs
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Max S Topp
- University Hospital Würzburg, Würzburg, Germany
| | | | - Stephan Mathas
- Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | | | | | - Peter Koch
- University Hospital Münster, Münster, Germany
| | | | - Enrico Schalk
- Department of Haematology and Oncology, Medical Centre, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Robert Semrau
- Department of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - Jan Kriz
- University Hospital Münster, Münster, Germany
| | - Tom Vieler
- Medizinische Klinik, Universitätsklinik Schleswig-Holstein, Kiel, Germany
| | - Martin Bentz
- Medizinische Klinik, Städtisches Klinikum Karlsruhe, Germany
| | - Elisabeth Lange
- Medizinische Klinik, Hämatologie/Onkologie, Evangelisches Krankenhaus, Hamm, Germany
| | - Rolf Mahlberg
- Medizinische Klinik, Krankenanstalt Mutterhaus d. Borromäerinnen, Trier, Germany
| | - Andre Hassler
- Zentrum für Innere Medizin, Hämatologie/Onkologie, Charité Campus Mitte, Berlin, Germany
| | - Martin Vogelhuber
- Medizinische Klinik, Universitätsklinik Regensburg, Regensburg, Germany
| | - Dennis Hahn
- Klinik für Onkologie, Katharinenhospital, Stuttgart, Germany
| | - Jörg Mezger
- Medizinische Klinik-Hämatologie, Onkologie, Immunologie, Palliativmedizin, St. Vincentius-Kliniken gAG, Karlsruhe, Germany
| | - Stefan W Krause
- Department of Internal Medicine 5, Haematology/Oncology, University of Erlangen, Germany
| | - Nicole Skoetz
- Cochrane Haematological Malignancies Group, Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Bastian von Tresckow
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany
| | - Harald Stein
- Berlin Reference Center for Lymphoma and Haematopathology, Berlin, Germany
| | - Hans Eich
- University Hospital Münster, Münster, Germany
| | - Andreas Engert
- German Hodgkin Study Group (GHSG), Department of Internal Medicine 1, University Hospital of Cologne, Cologne, Germany.
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Mounier N, Nicolas M, Gisselbrecht C, Christian G. Decision-making in the management of adult classical Hodgkin's lymphoma: determining the optimal treatment. Expert Rev Hematol 2015; 8:205-16. [PMID: 25634543 DOI: 10.1586/17474086.2015.995622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This review discusses promising new approaches in classical Hodgkin's lymphoma that have been recently evaluated. There is a focus on the fluorodeoxyglucose PET scanning that is now considered crucial for staging and treatment evaluation, including interim evaluation after two cycles. An up-front treatment strategy is discussed, with the place of radiation therapy and the difficult choice of chemotherapy intensity emphasized. Indications for frail patients are also reviewed, particularly elderly or HIV-positive patients. Emerging data on the antibody drug conjugate brentuximab vedotin and its future potential in the transplantation framework for relapsed/refractory Hodgkin's lymphoma is also discussed.
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Mounier N, Brice P, Bologna S, Briere J, Gaillard I, Heczko M, Gabarre J, Casasnovas O, Jaubert J, Colin P, Delmer A, Devidas A, Bachy E, Nicolas-Virelizier E, Aoudjhane A, Humbrecht C, Andre M, Carde P. ABVD (8 cycles) versus BEACOPP (4 escalated cycles ≥4 baseline): final results in stage III–IV low-risk Hodgkin lymphoma (IPS 0–2) of the LYSA H34 randomized trial. Ann Oncol 2014; 25:1622-8. [DOI: 10.1093/annonc/mdu189] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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9
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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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10
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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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11
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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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12
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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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13
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[News in hodgkin lymphoma therapy]. Bull Cancer 2014; 101:68-74. [PMID: 24445772 DOI: 10.1684/bdc.2013.1877] [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: 11/17/2022]
Abstract
Hodgkin lymphoma is a well-known clinico-pathological entity with a stable incidence among time accounting for 1200 new cases each year in France. The disease is one of the most curable cancer and occurs often in young patients with a median age at 33 years, the major clinical symptoms are lymph nodes mostly above the diaphragm (mediastinal and supra-clavicular). The diagnosis should be suggested with non-specific symptoms such as fever, night sweats, pruritus, weight-loss, lymph node, cough.. leading to prescribe routine exams like blood test with leucocyte count, erythrocyte sedimentation rate and chest Xray. Treatments always include chemotherapy and radiotherapy in localized disease and at a low dose only in involved fields. The usually good prognostic of Hodgkin lymphoma may not let us forget that there are still deaths in patients with refractory or early relapse of the disease. There is still an unmet need is these patients and the search for new drugs is essential.
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14
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Skoetz N, Trelle S, Rancea M, Haverkamp H, Diehl V, Engert A, Borchmann P. Effect of initial treatment strategy on survival of patients with advanced-stage Hodgkin's lymphoma: a systematic review and network meta-analysis. Lancet Oncol 2013; 14:943-52. [DOI: 10.1016/s1470-2045(13)70341-3] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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15
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Borchmann P, Kreissl S, Diehl V, Engert A. Treatment of Advanced-Stage Hodgkin Lymphoma: Let Us Face the Facts. J Clin Oncol 2013; 31:3045-6. [DOI: 10.1200/jco.2013.49.1811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Wongso D, Fuchs M, Plütschow A, Klimm B, Sasse S, Hertenstein B, Maschmeyer G, Vieler T, Dührsen U, Lindemann W, Aulitzky W, Diehl V, Borchmann P, Engert A. Treatment-related mortality in patients with advanced-stage hodgkin lymphoma: an analysis of the german hodgkin study group. J Clin Oncol 2013; 31:2819-24. [PMID: 23796987 DOI: 10.1200/jco.2012.47.9774] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The introduction of BEACOPP(escalated) (escalated-dose bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) has significantly improved tumor control and overall survival in patients with advanced-stage Hodgkin lymphoma. However, this regimen has also been associated with higher treatment-related mortality (TRM). Thus, we analyzed clinical course and risk factors associated with TRM during treatment with BEACOPP(escalated). PATIENTS AND METHODS In this retrospective analysis, we investigated incidence, clinical features, and risk factors for BEACOPP(escalated)-associated TRM in the German Hodgkin Study Group trials HD9, HD12, and HD15. RESULTS Among a total of 3,402 patients, TRM of 1.9% (64 of 3,402) was mainly related to neutropenic infections (n = 56; 87.5%). Twenty of 64 events occurred during the first course of BEACOPP(escalated) (31.3%). Higher risk of TRM was seen in patients age ≥ 40 years with poor performance status (PS) and in patients age ≥ 50 years. PS and age were then used to construct a new risk score; those with a score ≥ 2 had TRM of 7.1%, whereas patients who scored 0 or 1 had TRM of 0.9%. CONCLUSION The individual risk of TRM associated with BEACOPP(escalated) can be predicted by a simple algorithm based on age and PS. High-risk patients should receive special clinical attention.
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Affiliation(s)
- Diana Wongso
- University Hospital of Cologne, Cologne, Germany
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17
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Les données incontournables de l’American Society of Clinical Oncology (Asco) 2012 : le point de vue du comité de rédaction du Bulletin du Cancer. Bull Cancer 2012; 99:1209-17. [DOI: 10.1684/bdc.2012.1670] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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