First-line management of classical Hodgkin lymphoma

This study summarized key guidelines for the diagnosis, treatment, and follow-up of classical Hodgkin lymphoma.

Hodgkin lymphoma (HL) is a cancer of the lymph system. Classical HL is the most common form and considered very treatable. It mostly occurs in young adults aged 20 to 34 years, but is also seen in adults over the age of 70. The standard treatment for classical HL is often a combination of chemotherapy and radiation therapy. The British Journal of Haematology has recently updated key guidelines on the management of patients with classical HL.

Before treatment, it is important that patients are classified as having favorable or unfavorable disease. Unfavorable disease would include larger tumors or symptoms such as weight loss, fever, or night sweats. To stage the disease, patients should undergo a CT scan, preferably combined with a PET scan. Blood tests should screen for HIV before treatment. Patients should be offered a review of options for fertility preservation.

The standard treatment for favorable early-stage HL includes 2 cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, and dacarbazine) followed by radiation (at a dose of 20 Gy). The standard treatment for unfavorable patients is 4 cycles of ABVD followed by radiation (at a dose of 30 Gy). Two cycles of another chemotherapy, escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone), followed by 2 cycles of ABVD and 30 Gy of radiation is also possible.

Chemotherapy alone increased the risk of relapse by 3 to 7% compared to when combined with radiation. Early stage patients treated without radiation should therefore receive at least 3 cycles of ABVD. Radiation should not be omitted in patients with larger tumors.

Treatment options are different for advanced classical HL. 6 to 8 cycles of ABVD are recommended for patients under the age of 60. 5-year overall survival rates (proportion who have not died from any cause since treatment) with ABVD have ranged from 82 to 90%. An alternative option is 6 cycles of escalated BEACOPP. One study involving 2,182 patients reported a 5-year overall survival rate of 95% with 6 cycles of escalated BEACOPP. Escalated BEACOPP may be particularly suited for patients with higher risk disease. Patients who are positive for cancer on a PET scan after chemotherapy may be treated with radiation. Patients who do not respond to treatment may consider a stem cell transplant.

Patients over the age of 60 should be assessed for fitness and classified as frail or non-frail before treatment. Curative chemotherapy and radiation is recommended in non-frail elderly patients. Patients considered frail should not be offered standard chemotherapy. Elderly patients treated with bleomycin need to be closely monitored for signs of lung damage.

Delaying chemotherapy in pregnant women with classical Hodgkin lymphoma is generally not recommended. High-quality evidence recommends ABVD chemotherapy for pregnant patients. It has been used in all 3 trimesters of pregnancy. However, the risk of abnormal fetal development from chemotherapy is likely to be higher in the first trimester. Radiation should be delayed until after delivery.

Patients are usually followed for 2 to 5 years after first-line treatment. HL treatment increases the long-term risk of developing secondary cancers, thyroid problems, and heart or lung problems. Complete avoidance of smoking and careful screening of risk factors is recommended. These include high blood pressure, diabetes, and high cholesterol levels. Routine CT or PET/CT scanning for otherwise well patients is not normally required.

This study outlined the British Journal of Haematology treatment recommendations for classical Hodgkin lymphoma.