Older patients with Hodgkin Lymphoma: Walking the tightrope of efficacy and toxicity

Abstract

Since its initial description, classical Hodgkin lymphoma (cHL) portends a greatly improved prognosis and the goal of treatment in most patients is cure with minimisation of toxicity from treatment. Outcomes in older patients (>60 years old) lag behind those of their younger counterparts however, and cure remains achievable mostly for those who can tolerate full doses of conventional chemotherapy. This review addresses the difference in biology between younger and older patients with cHL and examines the impact of frailty and comorbidities on outcomes. The toxicities of conventional chemotherapy in anthracycline-fit and -unfit patients are examined, with a particular focus on pulmonary toxicity associated with bleomycin in older patients. New advances are discussed, including the possibility of using more targeted therapies such as the anti-CD30 antibody brentuximab vedotin (BV) and checkpoint inhibitors as a method of reducing dependency on conventional chemotherapy for those less well able to tolerate it. Treatment of older patients with cHL remains an area of unmet need in hematological research, and efforts to rectify this knowledge gap should continue.

Treatment approaches for older Hodgkin lymphoma patients

“…When simply considering age-related observation of poorer relative survival, a more appropriate age cut-off in HL would be ≥50 years [13] or even ≥40 years, as recently reported in larger series. With increasing age, a higher proportion of advanced stage disease, more mixed-cellularity or lymphocyte-depleted histologic subtypes and higher rates of EBV-positivity are reported [13,14 ▪ ]. In light of these observations, differences in HL biology are potential contributor to the inferior outcomes observed in older patients in addition to reduced fitness and treatment tolerability [15].…”

‘ACOPP’ chemotherapy for older and less fit patients with Hodgkin lymphoma—A multicentre, retrospective study

“…There is a characteristic bimodal age distribution with one peak in adolescence and a second in older adults. Patients aged >60 years comprise 20%–30% of new cHL diagnoses 2,3 but unfortunately are underrepresented in clinical trials and outcomes for this group have not improved in line with the advances seen in management of younger patients. Older patients with cHL are more likely to present with advanced‐stage disease and infra‐diaphragmatic involvement 4 .…”