Association of Treatment Intensity With Survival in Older Patients With Hodgkin Lymphoma

Abstract

IMPORTANCEHodgkin lymphoma is an aggressive blood cancer that is highly curable in younger patients who receive multiagent chemotherapy. Worse survival in older patients may reflect lessaggressive treatment, competing risks of death, or different disease biological factors. OBJECTIVE To examine the association between treatment intensity and cause-specific mortality among older adults with Hodgkin lymphoma. DESIGN, SETTING, AND PARTICIPANTS This was a population-based cohort study of patients aged 65 years or older with Medicare Part A and B fee-for-service coverage who received a diagnosis of Hodgkin lymphoma from 2000 to 2013. The association between treatment intensity and causespecific mortality was estimated separately for early-stage and advanced-stage disease with Cox proportional hazards models. Multivariable adjustment and propensity score weighting helped control for confounding. Data are from the 1999 to 2016 Surveillance, Epidemiology, and End Results Medicare database. Data analysis was performed from April 2020 to June 2021. EXPOSURES First-line treatment categorized as (1) full chemotherapy regimen, (2) partial chemotherapy regimen, (3) single chemotherapy agent or radiotherapy, or (4) no treatment. MAIN OUTCOMES AND MEASURESThe main outcome was 3-year Hodgkin lymphoma-specific and other-cause mortality. RESULTS Among 2686 patients (mean [SD] age, 75.7 [6.9] years; 1333 men [50%]), 1307 had earlystage disease and 1379 had advanced-stage disease. For Hodgkin lymphoma-specific mortality in patients with early-stage disease, hazard ratios (HRs) were higher for partial regimens (HR, 1.77; 95% CI, 1.22-2.57) or no treatment (HR, 1.91; 95% CI, 1.31-2.79) than for full regimens; there was no difference between single-agent chemotherapy or radiotherapy and full regimens. For other-cause mortality in patients with early-stage disease, HRs were higher for partial regimens (HR, 1.69; 95% CI, 1.18-2.44), single-agent chemotherapy or radiotherapy (HR, 1.62; 95% CI, 1.13-2.33), or no treatment (HR, 2.71; 95% CI, 1.95-3.78) than for full regimens. For Hodgkin lymphoma-specific mortality in patients with advanced-stage disease, HRs were higher for partial regimens (HR, 3.26; 95% CI,, single-agent chemotherapy or radiotherapy (HR, 2.85; 95% CI,, or no treatment (HR, 4.06; 95% CI,) than for full regimens. For other-cause mortality in patients with advanced-stage disease, HRs were higher for partial regimens (HR, 1.76; 95% CI, 1.32-2.33), singleagent chemotherapy or radiotherapy (HR, 1.65; 95% CI, 1.15-2.37), or no treatment (HR, 2.24; 95% CI, 1.71-2.94) than for full regimens. CONCLUSIONS AND RELEVANCEThis cohort study found variability in the magnitude of the association between treatment intensity and mortality by stage and cause-specific mortality, (continued) Key Points Question Is treatment with full, multiagent chemotherapy regimens associated with better survival compared with less-aggressive regimens in older adults with Hodgkin lymphoma? Findings In this population-based cohort study of 2686 patients aged 6...

Impact of Preexisting Heart Failure on Treatment and Outcomes in Older Patients With Hodgkin Lymphoma

“…However, older patients continue to have a poor prognosis but with heterogeneity in outcomes by cancer stage, histology, Epstein-Barr virus positivity, treatment intensity, comorbidities, functionality, and frailty. 6 , 7 , 22 Although competing causes of death from non-lymphoma-related comorbidities are higher among older patients, our findings suggest that even among patients with pre-existing HF, the risk for lymphoma-related mortality is 3- to 4-fold higher than that for cardiovascular-related mortality in the first 5 years after diagnosis. Of note, the association between pre-existing HF and lymphoma mortality was no longer significant after additionally adjusting for cancer treatment as a time-varying covariate.…”

Nivolumab and Doxorubicin, Vinblastine, and Dacarbazine in Early-Stage Unfavorable Hodgkin Lymphoma: Final Analysis of the Randomized German Hodgkin Study Group Phase II NIVAHL Trial

“…60 years to address persisting unmet needs. 19,20 In addition, longer FU of larger trials is needed to capture more rare persisting or late side effects and HL events.…”

“…However, owing to the recent favorable safety data of anti–PD-1 plus chemotherapy, upcoming trials including UK RATIFY trial and an exploratory INDIE elderly cohort will include patients age > 60 years to address persisting unmet needs. 19,20 In addition, longer FU of larger trials is needed to capture more rare persisting or late side effects and HL events.…”

Overall survival and causes of death in elderly patients with Hodgkin lymphoma: a Norwegian population-based case-control study

“… 19 Also, Surveillance Epidemiology and End Result (SEER) data show that CSS is higher in patients treated with more intensive regimens. 24 In the presence of competing risks of death, the cumulative incidence function may prevent the bias seen in the complement of the Kaplan-Meier survival function and may better estimate patients’ prognosis. 25 , 26 In our data, this is reflected in the lower competing risk of dying of HL compared to DSS in all groups, but with greater differences compared to DSS for those not treated with curative intent ( Table 1 and Online Supplementary Table S3 ).…”