Resources-Stratified Guidelines for Classical Hodgkin Lymphoma

Physician frontline treatment preferences for stage III/IV classic Hodgkin lymphoma: the real-world US CONNECT study

Aim: To understand US physicians' frontline (1L) treatment preferences/decision-making for stage III/IV classic Hodgkin lymphoma (cHL). Materials & methods: Medical oncologists and/or hematologists (≥2 years' practice experience) who treat adults with stage III/IV cHL were surveyed online (October-November 2020). Results: Participants (n = 301) most commonly considered trial efficacy/safety data and national guidelines when selecting 1L cHL treatments. Most physicians (91%) rated overall survival (OS) as the most essential attribute when selecting 1L treatment. Variability was seen among regimen selection for hypothetical newly diagnosed patients, with OS cited as the most common reason for regimen selection. Conclusion: While treatment selection varied based on patient characteristics, US physicians consistently cited OS as the top factor considered when selecting a 1L treatment for cHL.

Real-World Use of Positron Emission Tomography-Computed Tomography and Reported Deauville Scores in Advanced-Stage Classic Hodgkin Lymphoma: A Community Oncology Practice Perspective

PURPOSE

To evaluate the use of interim positron emission tomography-computed tomography (PET-CT) scans and Deauville 5-point scale (5PS) score reporting for stage III/IV classic Hodgkin lymphoma (cHL) treated frontline (1L) in community oncology settings.

METHODS

This retrospective, observational study included adults with stage III/IV cHL initiating 1L doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD), brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine, or an escalated dosing regimen of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone within the US Oncology Network between January 2017 and October 2019. Data were collected from electronic health records and chart reviews and summarized descriptively.

RESULTS

A total of 262 patients were included; 48.9% were age 39 years or younger. Most were male (57%), White (59%), had an International Prognostic Score <4 (76%), and received 1L ABVD (74%). Forty-nine percent of patients had stage III and 51% had stage IV cHL. Of 258 patients with ≥1 PET-CT scan, 71% (n = 184) had an interim scan and 64% received ≥1 scan at an off-site location. Of patients treated 1L with ABVD who received a baseline and interim scan, Deauville 5PS scores were not documented for 45% of patients; in 90% of these cases, a standardized uptake value (SUV) was reported.

CONCLUSION

In community oncology settings, under-reporting of Deauville 5PS scores for interim PET-CT scans was observed. In the absence of Deauville 5PS scores, SUV results were generally provided. These results highlight educational opportunities that exist for PET-adapted ABVD, including consistency in reporting/utilization of Deauville 5PS scores to de-escalate or escalate treatment.

Survival rates of adult patients with Hodgkin lymphoma who underwent ABVD versus escalated BEACOPP in a resource-limited country: An observational study

BACKGROUND

The survival rate of adult patients with Hodgkin lymphoma (HL) depends on the responses to standard chemotherapy, radiotherapy, or combined therapy. Resource-limited countries face numerous obstacles in supporting patients with HL who undergo chemotherapy, especially in advanced stages.

AIM

To analyze the survival outcomes of adult patients with HL after combined-modality treatment (CMT) with involved-field or non-involved-field radiotherapy.

METHODS AND RESULTS

We retrospectively reviewed the medical records of 90 adult patients with HL who received CMT at Rajavithi Hospital, Bangkok between 2007 and 2021. Patients with stage I-IV disease received different therapies depending on their risk group. The risk groups were evaluated according to initial response, bulky disease, and B symptoms. Patients (n = 90) who underwent CMT were followed up for 34.7 months (range, 1-141 months). The median follow-up periods of early and advanced-stage patients were 53.1 months and 23.5 months, respectively. The estimated 5-year overall survival (OS) and progression-free survival (PFS) rates of patients with advanced-stage diseases were 85% and 62%, respectively. There was a difference in the 3-year overall survival among advance-stage patients who underwent ABVD (94%) compared to those administered BEACOPPesc (50%), and the 3-year PFS (84%) among patients who underwent ABVD was higher than that among those administered BEACOPPesc (66%). Radiotherapy increased toxicity but did not improve the survival rate.

CONCLUSION

Chemotherapy administered to patients with advanced-stage adult HL was more effective than BEACOPPesc when ABVD was administered. Our findings are relevant for hospitals with limited resources.

Observations of Oncologists on Treatment Selection With Interim Positron Emission Tomography-Adapted Approaches in Classic Hodgkin Lymphoma: The Real-World CONNECT Study

PURPOSE

We surveyed oncologists who treat classic Hodgkin lymphoma (cHL) as part of the CONNECT study to understand the treatment decision-making process, including the impact of positron emission tomography/computed tomography (PET/CT) imaging.

METHODS

US physicians self-identifying as oncologists, hematologists, or hematologists/oncologists with ≥2 years of practice experience who treated ≥1 adult with stage III/IV cHL in the frontline setting in the last year were surveyed (October 19-November 16, 2020). Physician demographics, guideline adherence, and PET/CT utilization, interpretation, and access barriers were assessed.

RESULTS

In total, 301 physicians participated in the survey. Eighty-eight percent of physicians gave somewhat-to-significant consideration to NCCN guidelines. Most physicians (94%; n = 284) reported obtaining a PET/CT scan at diagnosis; of these physicians, 97% reported obtaining an interim PET/CT scan for stage III/IV cHL, with 65% typically obtaining an interim PET/CT scan after cycle 2. The Deauville 5-point scale (5PS) was the primary scoring system used to review PET/CT results by 62% of physicians, with a positive score defined as ≥3 by 44%, ≥4 by 37%, and ≥2 by 12% of physicians. Fifty-five percent of physicians reported difficulty in obtaining PET/CT scans.

CONCLUSION

Although most physicians considered NCCN guidelines when treating patients with stage III/IV cHL, interim PET/CT scans after cycle 2 were not universally obtained. When PET/CT scans were obtained, Deauville 5PS scores were not always provided, and variability existed on what defined a positive score. These findings suggest that opportunities exist for education and improved PET-adapted treatment approaches.

Real-World Patient Characteristics, Treatment Patterns, and Outcomes for Patients With Stage III or IV Classic Hodgkin Lymphoma Treated With Frontline ABVD: A Retrospective Database Review in the United States

In newly diagnosed stage III/IV classic Hodgkin lymphoma (cHL), A+AVD (brentuximab vedotin, doxorubicin, vinblastine, dacarbazine) improved overall survival (OS) versus ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine). As clinical trial and real-world populations may differ, real-world treatment characteristics and OS (rwOS) were assessed for patients with stage III/IV cHL treated with frontline ABVD. This retrospective, observational analysis of deidentified electronic health record data (1/1/2011-8/31/2020) evaluated baseline disease and clinical characteristics, treatment patterns, and rwOS in patients with stage III/IV cHL treated with frontline ABVD. Data for 167 patients were analyzed. A median of 6 ABVD cycles were received. Baseline/interim positron emission tomography (PET) scans were obtained for 60.5%/89.8% of patients. Of patients diagnosed in 2016 or later (n = 73), 89% received an interim PET scan; 15/46 patients with no documented Deauville score, 6/15 with a score of 1 to 3, and 3/4 with a score of 4 to 5 de-escalated to AVD. Following frontline ABVD, 55.1% of patients received subsequent systemic therapy and 31.7% stem cell transplantation (SCT). At a median follow-up of 31.8 months, 82.0% of patients were alive (median rwOS, 101.2 months). Patients with stage III/IV cHL treated with frontline ABVD in the real world versus in clinical trials receive more subsequent therapy, including SCTs. Interim PET scans and Deauville scores were not universally obtained after treatment cycle 2, yet treatment de-escalation was observed. Patients with stage III/IV cHL may benefit from frontline A+AVD versus ABVD, as it improves OS and reduces the burden of subsequent therapy, including SCTs.

A multidimensional framework for rating health system performance and sustainability: A nine plus one ranking system

Background

Health Care provision in terms of prevention, detection and treatment is primarily dependent on the quality of the hosting Health System. In its health report 2000, the WHO's attempt to assess and rank health systems’ quality Worldwide was heavily criticized. We propose a novel framework for health system performance and ranking using three indicators for three domains; general health system performance, clinical outcome of treatment applied to the main causes of death and health system sustainability domains.

Methods

Each domain was rated as “A – high”, “B – intermediate” or “C – poor” according to the aggregate score values of its three indicators. Hence the highest rank a health system can achieve is “AAA” and the lowest is “CCC”. If there is a need to define a “numerical rank” to further differentiate health systems with similar rating from one another, the total health expenditure per capita per year was used as an additional “number 10” indicator to achieve that level of differentiation. The framework was applied to Health Systems serving most of the World population including China, India, Brazil, USA, Russia, Germany, Japan, UK, France, Singapore and Switzerland. Data pertinent to each indicator was captured from published reports in peer-reviewed journals and/or from official websites. A Delphi survey was conducted for data not available online.

Results

Among the 11 health systems tested, no one scored AAA, Switzerland, France, Germany and Japan scored AAB, Singapore scored ABB, UK scored BBB, USA, Russia and China scored BBC, Brazil scored BCC while India scored CCC. Total health expenditure per capita per year lead to ranking Switzerland first followed by France, Germany, and Japan.

Conclusion

This novel ranking system is a practical and an applicable tool that test health system performance and sustainability. It can be utilized to guide all organizations, people and actions whose primary intent is to promote, restore or maintain health to achieve their targets. An International Health System Ranking database that will be hosted by the Institute of Global, Health, Faculty of Medicine, University of Geneva, Switzerland.

Hodgkin Reed-Sternberg-Like Cells in Non-Hodgkin Lymphoma

Reed-Sternberg cells (RSCs) are hallmarks of classic Hodgkin lymphoma (cHL). However, cells with a similar morphology and immunophenotype, so-called Reed-Sternberg-like cells (RSLCs), are occasionally seen in both B cell and T cell non-Hodgkin Lymphomas (NHLs). In NHLs, RSLCs are usually present as scattered elements or in small clusters, and the typical background microenviroment of cHL is usually absent. Nevertheless, in NHLs, the phenotype of RSLCs is very similar to typical RSCs, staining positive for CD30 and EBV, and often for B cell lineage markers, and negative for CD45/LCA. Due to different therapeutic approaches and prognostication, it is mandatory to distinguish between cHL and NHLs. Herein, NHL types in which RSLCs can be detected along with clinicopathological correlation are described. Moreover, the main helpful clues in the differential diagnosis with cHL are summarized.

Hodgkin lymphoma

Hodgkin lymphoma (HL) is a B cell lymphoma characterized by few malignant cells and numerous immune effector cells in the tumour microenvironment. The incidence of HL is highest in adolescents and young adults, although HL can affect elderly individuals. Diagnosis is based on histological and immunohistochemical analyses of tissue from a lymph node biopsy; the tissue morphology and antigen expression profile enable classification into one of the four types of classic HL (nodular sclerosis, mixed cellularity, lymphocyte-depleted or lymphocyte-rich HL), which account for the majority of cases, or nodular lymphocyte-predominant HL. Although uncommon, HL remains a crucial test case for progress in cancer treatment. HL was among the first systemic neoplasms shown to be curable with radiation therapy and multiagent chemotherapy. The goal of multimodality therapy is to minimize lifelong residual treatment-associated toxicity while maintaining high levels of effectiveness. Recurrent or refractory disease can be effectively treated or cured with high-dose chemotherapy followed by autologous haematopoietic stem cell transplantation, and prospective trials have demonstrated the potency of immunotherapeutic approaches with antibody-drug conjugates and immune checkpoint inhibitors. This Primer explores the wealth of information that has been assembled to understand HL; these updated observations verify that HL investigation and treatment remain at the leading edge of oncological research.