Guideline for the first‐line management of Classical Hodgkin Lymphoma — A British Society for Haematology guideline

Abstract

This guideline was compiled according to the British Society for Haematology (BSH) process at BSH Guidelines Process 2016 (b-s-h.org.uk). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) nomenclature was used to evaluate levels of evidence and to assess the strength of recommendations. The GRADE criteria can be found at http://www.grade worki nggro up.org. Recommendations are based on a review of the literature using Medline, PubMed/ Medline and Cochrane searches beginning from 2013 up to January 2021. The following search terms were used: [Hodgkin lymphoma OR Hodgkin disease] NOT non-Hodgkin; AND [chemotherapy OR radiotherapy]; AND [elderly]; AND [teenage OR adolescent OR young adult]; AND [pregnancy]. Filters were applied to include only publications written in English, studies carried out in humans, clinical conferences, congresses, clinical trials, clinical studies, meta-analyses, multicentre studies and randomised controlled trials. References pre-2013 were taken from the previous version of this guideline. 1 Review of the manuscript was performed by the British Society for Haematology (BSH) Guidelines Committee Haematology Oncology Taskforce, the BSH Guidelines Committee and the Haematology Oncology sounding board of BSH.

Minimising the Toxicities of First Line Hodgkin Lymphoma Treatment in the Modern Era

“…Pragmatically, with certain patients where the risk of bleomycin lung toxicity is elevated [ 16 ] (elderly, long-term smokers, renal impairment, cumulative bleomycin dose, etc. ), this potentially fatal risk may exceed the progression free survival (PFS) deficit from bleomycin omission, so treating with AVD will remain appropriate for specific individuals [ 17 ]. Indeed, it is now common practice in the UK to remove bleomycin from ABVD, either initially or after 2 cycles of ABVD, when treating patients over 60 years [ 17 ].…”

“…), this potentially fatal risk may exceed the progression free survival (PFS) deficit from bleomycin omission, so treating with AVD will remain appropriate for specific individuals [ 17 ]. Indeed, it is now common practice in the UK to remove bleomycin from ABVD, either initially or after 2 cycles of ABVD, when treating patients over 60 years [ 17 ].…”

“…For these poorer risk patients, the H10 trial was the first prospective randomised trial to show that intensification of ABVD to eBEACOPP in non-CMR patients reduces the risk of relapse and indeed likely improves OS (5-year OS 89.3% vs. 96.0%, HR = 0.45; [95% CI, 0.19–1.07]; p = 0.062). Finally, the shrinking of radiotherapy fields from extended field to involved field to involved node has significantly reduced the extent of the exposed radiotherapy field and while these changes have not been validated in a prospective randomised trial, there is no evidence to suggest a loss of disease control with these more targeted techniques [ 17 ].…”

“…Many of these patients will then require more intensive chemotherapy, including an autologous stem cell transplant which comes with significant morbidity and an additional set of longer-term risks including infertility and secondary malignancies [ 25 ]. A further difficulty is that if a patient declines radiotherapy, then the optimal number of ABVD cycles to deliver remains unclear, although UK guidelines suggest at least 3 cycles [ 17 ]. For many patients who fail to achieve a CMR after 2 cycles of ABVD the best strategy to reduce the longer-term risks of relapse would be to intensify therapy to 2 cycles of eBEACOPP prior to radiotherapy.…”

Navigating increasingly individualised Hodgkin lymphoma treatments to optimally balance risks and benefits

“…The updated British Society of Haematology (BSH) guideline provides a concise summary of the currently available evidence for the varying approaches in the management of HL patients after first diagnosis. Follows et al 3 provide a framework to successfully navigate the increasingly individualised treatment strategies in both early‐ and advanced‐stage HL.…”