Lymphoid Malignancy Treatment Considerations - Episode 6

Frontline Treatment of Hodgkin Lymphoma

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The three commonly administered frontline chemotherapy regimens for patients with Hodgkin lymphoma include, ABVD (Adriamycin [doxorubicin], bleomycin, vinblastine, and dacarbazine), Stanford V (doxorubicin, vinblastine, mechlorethamine, vincristine, bleomycin, etoposide, and prednisone followed by radiation therapy), and BEACOPP (bleomycin, etoposide, Adriamycin [doxorubicin], cyclophosphamide, Oncovin [vincristine], procarbazine, and prednisone).

Steve M. Horwitz, MD, suggests that ABVD is the standard treatment for most patients with Hodgkin's lymphoma, specifically in the United States. However, for certain high-risk patients, Horwitz considers treatment with BEACOPP. This regimen is more effective but induces more side effects. In patients at high-risk, the greater concern is the disease, rather than toxicity, Horwitz believes.

Outside of clinical trials, Anas Younes, MD, notes that his standard frontline regimen is ABVD. Even in high-risk patients, Younes notes caution regarding the use of BEACOPP. In many scenarios, intensified upfront treatments may prolong progress-free survival without prolonging overall survival, Younes believes.

The phase III ECHELON-1 trial is exploring brentuximab vedotin in combination with AVD (Adriamycin [doxorubicin], vinblastine, and dacarbazine) versus ABVD as a frontline treatment for patients with Hodgkin lymphoma, Younes points out. The primary endpoint of this study is modified progression free survival (NCT01712490). In similar phase II study, the AVD plus brentuximab vedotin combination resulted in a complete remission rate of 96% without inducing pulmonary toxic effects compared with a complete remission rate of 95% with a pulmonary toxic effects rate of 44% with ABVD.

The blanket use of frontline BEACOPP in high-risk patients with Hodgkin lymphoma results in overtreatment and unnecessary toxicity, notes Andrei R. Shustov, MD. If ABVD is utilized, the rate of relapse may be higher, but many of these patients can still be cured by autologous transplant, Shustov states.

Future approaches may look at switches in therapy based on PET scans, suggests Myron S. Czuczman, MD. Trials are exploring the use of imaging to switch from ABVD to BEACOPP or vice versa for patients who do not respond after a set number of cycles. At this point, the main concern with this approach is the accuracy of PET imaging at measuring response, Czuczman concedes.