Risk-adapted therapy for advanced-stage Hodgkin lymphoma

Abstract

More than 80% of patients with advanced-stage Hodgkin lymphoma are now cured with contemporary treatment approaches. The ongoing challenge is how to further improve outcomes by identifying both high-risk patients who may benefit from more intensive frontline therapy to reduce the risk of relapse as well as lower-risk patients who may do just as well with less intensive therapy. Numerous trials have used an interim positron emission tomography (PET) response-adapted approach to evaluate early escalation or deescalation of therapy for patients with a positive or negative interim PET scan, respectively. Recent trials have incorporated novel agents, including brentuximab vedotin (BV) and the immune checkpoint inhibitors, in the frontline setting. Based on results of the ECHELON-1 trial, the Food and Drug Administration approved BV in combination with adriamycin, vinblastine, and dacarbazine chemotherapy for stage III to IV Hodgkin lymphoma. Improved methods to assess higher risk at diagnosis using quantitative PET metrics, such as metabolic tumor volume and total lesion glycolysis, and incorporation of emerging biomarkers may further refine patient selection for more intensive upfront therapy. The ultimate goal is to achieve the highest level of efficacy for an individual patient while minimizing the short- and long-term toxicities.

Figure 1.

Therapy options for advanced-stage HL. The flowchart shows therapy options for patients with advanced-stage HL based on IPS risk and response on interim PET scan. Percentages of patients with a positive or negative interim PET scan and PFS percentages are based on the RATHL, the AHL 2011 LYSA, and the ECHELON-1 trials, assuming that AVD is equivalent to ABVD for interim PET-negative patients. *mPFS values are for patients who had a negative or positive interim PET scan after 2 cycles of BV-AVD. Adapted with permission from Lim and Johnson.