New York, NY—In a presentation at the 2016 National Comprehensive Cancer Network (NCCN) Congress on Hematologic Malignancies, Ranjana H. Advani, MD, Saul Rosenberg Professor of Lymphoma, Stanford University Medical Center, CA, and Vice Chair of the NCCN’s non-Hodgkin and Hodgkin lymphoma guidelines panel questioned the necessity of using radiotherapy in patients with stage I or stage II Hodgkin lymphoma.
“The cure rate for early-stage I or II Hodgkin lymphoma that is categorized as favorable disease is 90%, which is very high, so one of our objectives should be to reduce toxicity,” said Dr Advani.
Although the NCCN, the European Organisation for the Research and Treatment of Cancer (EORTC), and the German Hodgkin Study Group vary slightly in their definition of favorable disease, some of the variables are similar, and include mediastinal mass ratio, erythrocyte sedimentation rate, B symptoms, and the number of lymph node sites involved.
A 2012 study analyzed the 12-year survival rate of patients with Hodgkin lymphoma who received doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD); the ABVD regimen plus radiotherapy; or radiotherapy alone (Meyer RM, et al. N Engl J Med. 2012;366:399-408), Dr Advani said. At 12 years follow-up, disease-free progression rate was 87% in the ABVD-only arm and 92% in the combined radiotherapy groups, but the overall survival rate was 94% with ABVD alone versus 87% with radiotherapy alone.
“The Meyer et al study was performed with an outdated mode of radiotherapy—subtotal lymphoid radiation therapy—and without the benefit of PET [positron emission tomography] scans and Deauville criteria scoring. Nonetheless, the study did suggest that patients with Hodgkin lymphoma have excellent longer-term survival with chemotherapy alone,” Dr Advani said.
She discussed studies showing that excluding radiotherapy is not necessarily inferior for favorable outcomes in patients with PET-negative scans after 2 to 3 cycles of the ABVD regimen in selected patients.
A study by Radford and colleagues included 571 patients with newly diagnosed stage IA or stage IIA Hodgkin lymphoma who received 3 cycles of the ABVD regimen and then had PET scans (Radford J, et al. N Engl J Med. 2015;372:1598-1607). Patients whose PET scans were negative, defined as Deauville score 1-2, were randomized to radiotherapy or to no further treatment. The 3-year progression-free survival (PFS) rate was 94.6% in the radiotherapy group versus 90.8% in the group that received no further therapy. Radford and colleagues calculated a noninferiority margin of 7%, and concluded that their results did not demonstrate the noninferiority of excluding radiotherapy from patients’ treatment.
The EORTC study by Raemaekers and colleagues investigated the necessity of radiotherapy for various patient populations with Hodgkin lymphoma. In the standard treatment arm, 221 patients with favorable disease received 2 cycles of ABVD and underwent an additional cycle of ABVD and radiotherapy, regardless of whether they had PET-negative or PET-positive scans after 2 cycles of ABVD.
Patients with favorable disease received 2 cycles of ABVD, and if they had a PET-negative scan (defined as a Deauville score 1-2), they received 2 additional cycles of ABVD. If they had a PET-positive scan, they received 2 cycles of BEACOPP escalated (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone), as well as involved nodal radiotherapy. The 1-year PFS rate was 94.9% in patients who received ABVD only, and 100% in patients who received chemotherapy and radiotherapy.
“The use of risk-adapted chemotherapy strategies with interim PET scanning improved risk stratification at diagnosis, and emerging novel treatments may allow for high cure rates while minimizing exposure to toxicity from chemotherapy and radiotherapy. Important current clinical trials will help to further define optimal management for these patients,” said Dr Advani.
