VEPEMB in elderly Hodgkin’s lymphoma patients. Results from an Intergruppo Italiano Linfomi (IIL) study

Hodgkin disease survival in Europe and the U.S

BACKGROUND

The survival of patients with Hodgkin disease (HD) varies markedly across Europe and generally is shorter than the survival of patients in the U.S. To investigate these differences, the authors compared population-based HD survival in relation to morphologic type among populations in Europe and the U.S.

METHODS

The authors analyzed 6726 patients from 37 cancer registries that participated in EUROCARE-3 and 3442 patients from 9 U.S. Surveillance, Epidemiology, and End Results (SEER) registries. Patients were diagnosed during 1990 to 1994 and were followed for at least 5 years. The European registries were grouped into EUROCARE West, EUROCARE UK, and EUROCARE East. Morphologic groups were nodular sclerosis, mixed cellularity, lymphocyte depletion, lymphocyte predominance, and not otherwise specified (NOS). The influence of morphology on geographic differences in 5-year relative survival was explored by using multiple regression analysis.

RESULTS

In the model that was adjusted by age, gender, and years since diagnosis, the relative excess risk (RER) of death was 0.93 (95% confidence interval [95% CI], 0.81-1.05) in EUROCARE West, 1.15 (95% CI, 1.04-1.28) in EUROCARE UK, and 1.39 (95% CI, 1.21-1.60) in EUROCARE East (compared with the SEER data). When morphology was included, EUROCARE UK and SEER no longer differed (RER, 1.06; 95% CI, 0.95-1.18). Morphology distribution varied markedly across Europe and much less in the U.S., with nodular sclerosis less common in Europe (45.9%) than the U.S. (61.7%). The RER data showed that patients who had lymphocyte depletion, NOS, and mixed cellularity had a significantly worse prognoses compared with patients who had nodular sclerosis, whereas patients who had lymphocyte predominance had the best prognosis.

CONCLUSIONS

The current results provide population-based evidence that morphology strongly influences the prognosis of patients with HD. However differences in the morphologic case mix explains only some of the geographic variations observed in survival.

An international approach to the treatment of Hodgkin's disease in the elderly: launch of the SHIELD study programme

Utilising the Scotland and Newcastle Lymphoma Group population data for Hodgkin's disease (HD), collected over a 20-year period, it is evident that 20% of patients are over the age of 60 yr at diagnosis. Data from 674 patients are available. This group comprised 346 men and 328 women. Median follow-up was 9.5 yr. In total 361 patients had stage I/II disease. In this cohort overall response and complete response (CR) rates were 88% and 79%, respectively, for treated patients. Overall 308 patients had stage III/IV disease. Among treated patients in this cohort, overall and CR rates were 78% and 59%, respectively. Response data were missing for 26 patients with stage I/II disease and 43 patients with stage III/IV disease. The chlorambucil, vinblastine, procarbazine and prednisolone, mechlorethamine, vincristine, probarbazine and prednisolone and doxorubicin, bleomycin, vinblastine and decarbazine were the commonest chemotherapy regimens, in descending order of frequency, used to treat this cohort of patients. Outcome did not vary with these regimens. Thirty-four other chemotherapy combinations were used, some curative others palliative. These data and all other published studies confirm the need for a prospective, age-defined approach to HD in the elderly. Such an approach needs to be closely linked to issues of comorbidity, an assessment of frailness and the tailoring of specific protocols for the elderly to allow full dose delivery. The Study of Hodgkin Lymphoma In the Elderly/Lymphoma Database programme has now been launched and attempts to address these issues (http://www.shieldstudy.co.uk).

A prospectively randomized trial carried out by the German Hodgkin Study Group (GHSG) for elderly patients with advanced Hodgkin's disease comparing BEACOPP baseline and COPP-ABVD (study HD9elderly)

In contrast to younger patients, the prognosis of elderly patients with advanced Hodgkin's disease (HD) has not improved substantially over the last 20 years. We thus carried out a prospectively randomized study (HD9(elderly)) to compare the BEACOPP regimen in this setting against standard COPP-ABVD. Between February 1993 and 1998, 75 patients aged 66-75 years with newly diagnosed HD in advanced stages were recruited into the HD9 trial as a separate stratum (HD9(elderly)). Patients were assigned to eight alternating cycles of COPP and ABVD or eight cycles of BEACOPP in baseline doses. Radiotherapy was given to initial bulky or residual disease. In total, 68 of 75 registered patients were assessable: 26 were treated with COPP-ABVD and 42 with BEACOPP baseline. There were no significant differences between COPP-ABVD and BEACOPP in terms of complete remission (76%), overall survival (50%) and freedom from treatment failure (FFTF) (46%) at 5 years. At a median follow-up of 80 months, a total of 37 patients died: 14/26 patients (54%) treated with COPP-ABVD and 23/42 patients (55%) with BEACOPP. Two patients (8%) treated with COPP-ABVD and nine patients (21%) treated with BEACOPP died of acute toxicity. Hodgkin-specific FFTF at 5 years was 55% after COPP-ABVD and 74% after BEACOPP (P=0.13). Thus, there are no differences in survival between these regimens in elderly patients.