Chemo alone trumps chemo plus radiation for early-stage Hodgkin lymphoma
Last Updated: 2011-12-15 15:10:01 -0400 (Reuters Health)
By Fran Lowry
NEW YORK (Reuters Health) - In patients with limited-stage Hodgkin lymphoma, treatment with ABVD chemotherapy alone led to better overall survival than a strategy that includes subtotal nodal radiation therapy, according to new research presented this week at the 53rd annual meeting of the American Society of Hematology.
Patients with limited-stage Hodgkin lymphoma (HL) are often treated with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) plus radiation.
But investigators from the National Cancer Institute of Canada (NCIC) Clinical Trials Group (CTG), together with the Eastern Cooperative Oncology Group (ECOG), believed that dropping radiotherapy might result in equally good outcomes without the long-term toxic effects of radiation.
"We believed that ABVD chemotherapy alone would provide comparable disease control and be associated with fewer deaths due to late treatment effects from extended-field radiation therapy," lead author Dr. Ralph M. Meyer, from Queen's University, Kingston, Ontario, Canada, told Reuters Health.
In what they said was the final analysis of data from a phase III trial, the researchers compared the 12-year outcomes of approximately 400 patients with non-bulky clinical stage I-IIA HL who had been stratified into low and high-risk groups and then randomized to receive ABVD alone, or extended-field radiation therapy with or without ABVD.
Overall survival, the primary endpoint, was 94% with chemotherapy alone and 87% with radiation.
An analysis of the results in the high-risk patients revealed similar findings, with 92% of patients in the ABVD only arm achieving overall survival at 12 years, compared with 81% patients in the ABVD plus radiation arm.
There were 12 deaths in the chemotherapy-alone arm, six due to Hodgkin lymphoma and six due to other causes. In the radiation group, there were 24 deaths, but only four were due to Hodgkin lymphoma. The other 20 were due to other causes, including 10 second cancers.
"This study shows that ABVD alone is associated with a lower risk of second cancers and heart problems," Dr. Meyer said. "Until these results, minority opinion would be to give chemotherapy alone. I think what you'll see now is that swings to become a majority opinion."
He also noted that a major limitation of the study is that radiation protocol is now outdated; by today's standards it would be considered excessive. This means that some of the downside that was seen with the radiation may be exaggerated.
"Nonetheless, our results are very comparable to the best results reported now using less chemo and modern radiation. Even with modern radiation there will be risks of giving radiation to the chest and the heart area. In women the radiation field will include part of the breast, so there is a risk of breast cancer, it will include part of the lung, so there is the risk of lung cancer, and of course the skin is always exposed and so there is the risk of melanoma," he said.
He added: "Patients will need to be told there's a slight risk of the cancer coming back by not giving radiation, but in the long-term, getting chemotherapy alone has advantages of avoiding long-term effects of the radiation."
The study was published online, in the New England Journal of Medicine to coincide with its presentation at the conference.
Dr. Jane N. Winter, from Northwestern University Feinberg School of Medicine in Chicago, who was the ECOG chair of the trial, told Reuters Health she believes that the findings will encourage the "growing trend in the U.S. to use chemotherapy alone in early stage patients."
Early positron emission technology (PET) scanning for patients receiving chemotherapy alone can be used to monitor for signs of recurrence, she added.
"There are ongoing trials incorporating early PET-scanning for early stage patients that do not include radiotherapy, and need the support of the community to provide additional evidence for this strategy."
N Engl J Med 2011.
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