ABVD remains standard of care for advanced Hodgkin's lymphoma
Last Updated: 2012-11-26 17:45:20 -0400 (Reuters Health)
By Will Boggs, MD
NEW YORK (Reuters Health) - Stanford V, a combined modality approach for patients with advanced Hodgkin's lymphoma, does not improve outcomes over the established combination of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD).
"There have not been major differences among regimens for Hodgkin's lymphoma in randomized trials recently, so I think our major thrust now should be to identify molecular or immunologic markers that predict outcome (gene expression profiles, macrophage markers, EBV, etc.) and introduction of new agents (e.g., brentuximab vedotin)," said Dr. Leo I. Gordon from Northwestern University in Chicago, in an email to Reuters Health.
Dr. Gordon and colleagues in the Eastern Cooperative Oncology Group, the Cancer and Leukemia Group B, the Southwest Oncology Group, and the Canadian NCIC Clinical Trials Group compared 12 weeks of Stanford V and six to eight cycles of ABVD, with or without radiation therapy, in 794 patients with advanced or locally extensive Hodgkin's lymphoma.
All patients received radiotherapy for bulky mediastinal adenopathy beginning 2 to 3 weeks after completion of chemotherapy. In addition, in the Stanford V group, 36 Gy was delivered to any pretreatment site larger than 5 cm and for macroscopic splenic disease.
Overall response rates did not differ between treatments, with complete and clinical complete remission rates of 72.7% for ABVD and 68.7% for Stanford V, the researchers reported today online in the Journal of Clinical Oncology.
After a median 6.4 years of follow-up, there was no significant difference in five-year failure-free survival for ABVD vs Stanford V (74% vs 71%) or in five-year overall survival (88% in each group).
Patients with locally advanced disease fared better than those with stages III and IV disease, and patients with high-risk disease had better failure-free survival with Stanford V than with ABVD (67% vs 57%; p=0.02).
Although toxicity was similar in the two arms, the Stanford V patients experienced significantly more grade 3 lymphopenia, grade 3 or 4 leukocytopenia, grade 3 and 4 sensory neuropathy, and grade 3 or 4 motor neuropathy.
Second cancers occurred with equal frequency after ABVD (15 instances) and Stanford V (19 instances).
"While there are options for treatment of advanced Hodgkin's lymphoma, ABVD remains the standard of care," Dr. Gordon concluded. "That said, we have not compared the BEACOPP regimens with ABVD in a large randomized trial. The current intergroup trial is looking at the value of early imaging (PET scan) as a predictor of outcome, and while not a randomized study, this trial should provide some useful information on early imaging with PET."
Dr. Dan L. Longo from Harvard Medical School in Boston wrote an editorial that accompanied this report. He told Reuters Health, "Standard ABVD is the regimen of choice for patients with advanced stage Hodgkin's lymphoma. The main decision is whether radiation therapy should be added following six cycles of chemotherapy."
"The optimal usage of radiation therapy has not been well defined," Dr. Longo said. "In general, most people should not receive any radiotherapy. If the patient had a large mediastinal mass at initial presentation, they may benefit from added radiation therapy, but they are put at risk of second cancers and premature coronary artery disease."
"New active agents are coming along, e.g. brentuximab vedotin, that may further improve the outcome of treatment when their optimal use is defined," Dr. Longo concluded. "In the meantime, ABVD is the treatment of choice and radiation therapy should be avoided if at all possible."
In his editorial, he wrote, "There is reason to hope that the next group of changes incorporated into the management of Hodgkin lymphoma will both enhance the fraction of patients cured from between 85% and 90% to between 95% and 100% and decrease the risk of late treatment-related toxicities that can interfere with and shorten the lives of patients who are cured."
J Clin Oncol 2012.
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