Treatment of advanced stage classical Hodgkin lymphoma: a pathway through the maze

Abstract

The wealth of trial data, complex trial design, and variation in treatment standards in advanced stage classical Hodgkin lymphoma can be difficult to navigate when deciding on the best treatment for patients. In this review, we appraise and synthesise this evidence, in order to explain our suggested treatment approach.Since the 1960s, cures have been achieved in advanced stage classical Hodgkin lymphoma (cHL) through the use of multi-agent chemotherapy regimens often with addition of radiotherapy. Since then, treatment has been improved through a process of rigorous testing in clinical trials, such that progression free survival (PFS) and overall survival rates (OS) are now excellent, especially in younger patients. More recently there has been a shift in focus towards minimizing toxicity (both short and long term) without compromising efficacy. Recent trials have tried to achieve this by risk-stratifying patients, both at baseline and according to response to treatment, so as to guide escalation or de-escalation of therapy. Uncertainty as to where this equipoise between efficacy and toxicity lies has also led to two international standards for treatment of cHL: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) and escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone). It has also influenced decisions on combined modality treatment with radiotherapy.The wealth of trial data, complex trial design, and variation in treatment standards can be difficult to navigate when deciding on the best treatment for our patients. In this article, we aim to provide a possible pathway through this maze.