Treatment options for advanced Hodgkin lymphoma

This review discussed the current and future treatment options for advanced Hodgkin lymphoma (stage III or IV).

While early-stage Hodgkin lymphoma has very high remission rates, rates for advanced disease are generally lower. The standard treatment option for advanced Hodgkin lymphoma is ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, and dacarbazine). In some cases ABVD is followed by radiation. This has been associated with tumor control rates of 65% to 75%. Newer chemotherapy options include escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone). This combination has had some positive effects on survival, but also increased negative side effects.

The current review discussed recent treatment advances in advanced Hodgkin lymphoma.

One analysis found that escalated BEACOPP had a 10% benefit on 5-year overall survival (time from treatment until death from any cause) compared to ABVD. It is still not clear which patients should be treated with BEACOPP and who can be successfully treated with ABVD. This is important to understand due to the long-term negative effects associated with escalated BEACOPP (such as fatigue and infertility). Current methods of predicting response to treatment may not be sensitive enough to predict who will respond to ABVD and who will not.

A PET scan following the first two ABVD treatment cycles may be able to predict treatment outcomes. A PET scan uses a radioactive substance to image the organs and tissues of the body. It can also highlight areas of cancer activity. One study reported 5-year progression-free survival (PFS; time from treatment until disease progression) of 95% in patients who did not show cancer activity after two ABVD cycles. In patients who did show cancer activity after two cycles, 5-year PFS was 13%.

Recent studies have examined whether PET scans can be used to determine treatment options. This can be useful in deciding whether treatment needs to be escalated. When there is cancer activity on a PET scan after 2 cycles of ABVD, a different treament might be tried. In one study, 182 of 1,119 patients showed cancer activity after two ABVD cycles. These patients were switched to either 3 cycles of escalated BEACOPP or 4 cycles of BEACOPP. The 3-year PFS for these patients was 68%. 74% had no cancer activity on a PET scan after treatment. Future studies are needed to determine whether these patients will relapse in the longer-term.

It is also not clear whether no cancer activity after 2 cycles of ABVD predicts long-term survival. One study noted 3-year PFS of 97% for patients with stage III disease. 3-year PFS was 73% for patients with stage IV.

Studies are also examining the use of new treatment options, including increasing the dose of doxorubicin in ABVD. Brentuximab vedotin (Adcetris) is a chemotherapy combined with an antibody (a protein) that blocks cancer cell growth. This can be combined with some of the agents used in ABVD. Early studies have shown it to be safe and effective.

This review concluded that research on treatments for advanced Hodgkin lymphoma is looking at effectiveness, long-term survival and side effects.