What are the treatment options for patients with Hodgkin lymphoma who are 60 or older?

This article reviewed treatment options for patients with Hodgkin lymphoma (HL), aged 60 or older.

Approximately 20% of patients with HL are aged 60 or older. Treatment options for older patients with HL differ from patients under 60. This is because older patients are more often diagnosed with advanced HL and are more likely to have other health conditions and develop side effects to treatments. 

Recent advances in therapies for HL have improved results for older patients. Treatment for older patients with early HL (stage I or II) differs from patients with advanced HL (stage III or IV). Patients who do not respond to treatment (refractory) or who see a return of HL (relapse) also need different treatment options. It is important to understand the most suitable treatments for older patients depending on the stage of HL.

Older patients with early-stage HL may be given chemotherapy combinations ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) or VEPEMB (vinblastine, cyclophosphamide, procarbazine, etoposide, mitoxantrone, bleomycin). 

ABVD can be used for 2 or 4 cycles with or without radiotherapy. Patients who have unfavorable HL are recommended to receive 4 cycles. However, the risk of serious side effects increases with more ABVD cycles and older ager. This includes lung side effects and patients who have weaker lungs or kidneys should either receive 2 cycles of ABVD or another treatment. 

VEPEMB may be an alternative chemotherapy for older patients with early HL. However, there is very little evidence to suggest it is as effective or safe as ABVD. CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) and brentuximab vedotin (BV; Adcetris) may also be effective for older patients with early HL.

Older patients with advanced HL have significantly poorer treatment results from ABVD compared to younger patients. ABVD is more likely to cause serious side effects in older patients. Studies have shown that PVAG (prednisone, vinblastine, doxorubicin, gemcitabine) and PVAB (prednisone, vinblastine, doxorubicin, bendamustine) were effective and safer for older patients with advanced HL. 

VEPEMB, CHOP, and ChlVPP (chlorambucil, vinblastine, procarbazine, prednisone) are other options.  However, more information on PVAG, PVAB, VEPEMB, CHOP, and ChlVPP for older patients with advanced HL is needed. BV has shown promise for older patients. Studies have combined it with dacarbazine, bendamustine, ABVD, AVD, or CAP (cyclophosphamide, doxorubicin, and prednisolone). BV + dacarbazine and BV + AVD particularly showed promising results, however, these need to be confirmed.

Few clinical trials have focused on older patients with relapsed or refractory HL. Patients who are able to undergo stem cell transplantation (SCT) with chemotherapy have seen good results. However, SCT often causes side effects. BV alone has shown promising results in older patients with relapsed or refractory HL. Biological therapy with nivolumab (Opdivo) or pembrolizumab (Keytruda) is also being investigated. While early results are promising, older patients are more likely to develop infections and be admitted to hospital than younger patients.

The authors concluded that treatments should be offered to older patients with HL depending on the stage of HL and other health conditions present.