Current treatment for advanced classical Hodgkin lymphoma

This review summarizes current treatment options of advanced classical Hodgkin lymphoma. It found that PET-scan based treatment minimizes long-term side effects and that both ABVD and eBEACOPP are useful chemotherapy regimens.

Classical Hodgkin lymphoma (cHL) is a cancer of white blood cells. If cancerous lymphoma cells have spread to both the upper and lower half of the body, it is known as advanced cHL. Around 80% of new cHL patients have advanced cHL. Advanced cHL is typically treated with chemotherapy. If the cancer relapses (returns), then second-line treatments such as stem cell transplant are used.

This review summarizes historical and current treatment for advanced cHL.

During WWII, it was discovered that nitrogen mustard can reduce lymphoma cells. This led to the multi-drug regimen MOPP (mechlorethamine hydrochloride, vincristine, procarbazine, prednisone) in the 1960s, which was the first effective treatment for cHL. In the 1970s, ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) replaced MOPP as the standard of care due to being more effective with fewer side effects.

In the 1990s, escalated BEACOPP was developed (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone). Escalated BEACOPP combines drugs from both MOPP and ABVD at higher doses. eBEACOPP is very effective, but also has high rates of side effects. eBEACOPP can cause secondary cancers and cause infertility.

Analyses have compared ABVD to eBEACOPP. Patients taking eBEACOPP are less likely to have their disease worsen within 7 years (85% vs. 73%). However, relapsed cancer responded better to further (second-line) treatment if it had originally been treated with ABVD. Thus the overall 7-year survival rate is similar for both eBEACOPP and ABVD (89% vs. 84%).

Currently, many doctors use PET imaging to monitor advanced cHL. Patients with a positive PET scan take eBEACOPP, while patients with a negative scan switch to the gentler ABVD regimen. For patients with a negative scan, AVD (ABVD without bleomycin) can be used. AVD has similar 5-year results to ABVD while reducing side effects such as lung damage.

Brentuximab vedotin (BV; Adcetris) is a targeted therapy. One study compared BV plus AVD to ABVD alone in patients with advanced cHL. Patients treated with BV-AVD were more likely to survive two years without the cancer progressing (81.0% vs. 74.4%). However, survival over two years was the same for both treatments. Because it is less well studied, initial treatment with BV-AVD is not the current standard of care. Also, it prevents BV from being used as a further (second-line) treatment if the cancer relapses.

This review concluded that treatment for advanced cHL is effective and has improved over time. The current standard of care is either the gentler ABVD or more aggressive eBEACOPP chemotherapy. The use of PET scans to monitor treatment is becoming more common.

The best treatment depends on the particular patient. For example, due to the more serious side effects, eBEACOPP is not typically used for older patients or those with both cHL and another disease.