Chemotherapy is the mainstay of treatment for HL. A combination chemotherapy regimen consists of two or more chemotherapy drugs. Generally, the drugs are dissolved in fluid and usually administered via a peripheral intravenous (IV) line. If finding an accessible vein is problematic, a central line (a port, or a percutaneously inserted central venous catheter (a PICC or PIC line) may be used for some HL patients. Percutaneous means “through the skin.”
Chemotherapy is given in cycles of treatment that are separated by periods of rest. Chemotherapy drugs can have strong side effects so the body needs time to recover in between treatment cycles. Typically, the cycles are between 3 and 4 weeks long but they vary in length, depending on the drugs employed.
Some chemotherapy combinations for Hodgkin lymphoma include:
Early-stage classical Hodgkin lymphoma (cHL)
- Chemotherapy combinations
- ABVD (Adriamycin® [doxorubicin], bleomycin, vinblastine, dacarbazine)
- Dose-escalated BEACOPP (bleomycin, etoposide, Adriamycin [doxorubicin], cyclophosphamide, Oncovin® [vincristine], procarbazine, prednisone), for early-stage unfavorable cHL
- Combination chemotherapy is administered with or without radiation therapy
- Chemotherapy combinations
- A+AVD (Adcetris® [brentuximab vedotin], Adriamycin [doxorubicin], vinblastine, dacarbazine)
- Dose-escalated BEACOPP, in selected younger patients
- Occasionally, chemotherapy is followed by involved-site radiation therapy (ISRT)
For information about the drugs listed on this page, visit Drug Listings.
Early-Stage Favorable Hodgkin Lymphoma Treatment. The cure rate for patients diagnosed in early-stage favorable HL (either stage I or stage II with no unfavorable risk factors) exceeds 90 percent. The current treatment approach is to administer combined modality therapy (combination chemotherapy either alone or with reduced amounts of radiation). This approach has resulted in less toxicity and improved outcome. To date, ABVD (Adriamycin® [doxorubicin], bleomycin, vinblastine, dacarbazine) is the most effective and least toxic regimen available. It poses less of a risk for later development of leukemia or infertility than many other adult chemotherapy combinations.
Current practice guidelines for treatment of early-stage favorable HL suggest that at least 90 percent of patients can be cured with as few as two courses of ABVD, followed by a reduced dose of radiation.
Other treatment regimens omit radiation therapy altogether and treat with chemotherapy alone. Rarely, the use of PET-CT scan results, either during or after treatment, can guide the treatment team about whether or not radiation therapy should be included; however, most patients do not receive radiation. Concerns about the late effects of radiation therapy (especially an increased risk of developing secondary cancers) have led some oncology groups to recommend chemotherapy alone for some patients, particularly when the risk of developing a secondary cancer is considered to be high. Patients who are at higher risk of a secondary cancer include women younger than 35 years and those with a family history of breast cancer, or for whom the radiation therapy would involve breast tissue.
Early-Stage Unfavorable Hodgkin Lymphoma Treatment. Patients in this category (stages I and II with unfavorable risk factors) are considered to have a higher-risk disease. These patients are also treated with chemotherapy, either alone or with radiation therapy. Treatment generally requires at least four to six cycles of combination chemotherapy, sometimes followed by radiation therapy. Again, PET-CT scan results, both during and after therapy, may affect the nature and length of chemotherapy and the use of radiation. Drug combinations used for treatment include
- Dose-escalated BEACOPP.
Advanced-Stage Hodgkin Lymphoma. Hodgkin lymphoma is potentially curable, even in late stages. In general, patients with advanced-stage HL (stage III or IV disease) are treated with six cycles of combination chemotherapy. Drug combinations used for treatment include
- A+AVD (Adcetris [brentuximab vedotin], Adriamycin [doxorubicin], vinblastine, dacarbazine)
- Dose-escalated BEACOPP, sometimes used.
Dose-escalated BEACOPP results in a good cure rate but patients carry a small risk of developing leukemia or other secondary cancers. Patients are also at a much higher risk of infertility, and for this reason, it is less commonly used. It may be used for patients who have advanced HL. Radiation therapy is reserved for the few patients with initial sites of bulky disease (large masses) or residual cancer observed on PET-CT scans. Even in these situations, the role of radiation therapy for advanced disease is variable.
Treatment Response Monitoring. During treatment, patients need to be monitored to check their response to therapy. Response to treatment is important in predicting long-term outcomes. Patients who fail to reach complete remission with first-line treatment have a worse prognosis, so there is great value in identifying these patients early in the course of their disease.
Imaging tests are used to distinguish between tumor and fibrous (scar) tissue. The PET scan is typically better than a CT scan in determining that difference and the combination PET-CT scan has become the standard for assessment of treatment response in most types of lymphoma.
A five-point scale called the “Deauville criteria,” developed in 2009, is now an internationally recognized way of using PET-CT in the initial staging and assessment of treatment response. This scale determines the FDG uptake (the absorption of, in this case radioactive material, by tissues) in the involved sites. These scans need to be carefully evaluated in order to assess response and decide if any treatment modifications are appropriate.