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Mehtap Ö, Toptas T, Dal MS, Karadag FK, Atas U, Özsan GH, Sayınalp N, Saydam G, Uçar MA, Kırkızlar HO, Salim O, Tekinalp A, Özkalemkaş F, Pepedi F, Akay OM, Kılıçaslan E, Paydas S, Bozdağ SC, Yılmaz M, Karakus V, Arikan FG, Darçın T, Erdogan E, Cinar E, Gürsoy V, Durusoy SS, Birtaş Ateşoğlu E, Tombak A, Büyükkurt N, Özcan M, Altuntaş F, Kaygusuz Atagündüz I, Ferhanoglu B. A new scoring system to predict survival in elderly advanced stage Hodgkin lymphoma patients. Leuk Lymphoma 2024:1-9. [PMID: 39269267 DOI: 10.1080/10428194.2024.2395458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 08/01/2024] [Accepted: 08/17/2024] [Indexed: 09/15/2024]
Abstract
Predictive prognostic scoring (PS) systems are not primarily applicable to elderly patients with classical Hodgkin lymphoma (cHL). The objective of this study was to develop a PS system for these patients. The derivation cohort (DC) was utilized for model development, consisting of 97 variables. The resulting algorithm was named as Hodgkin's Lymphoma Early Death in the Elderly within 12 months (HEDEL12). Internal and external validation cohorts (IVC and EVC) were employed for validation. A total of 286 patients were evaluated retrospectively. In DC 38 of 178 patients died within the first 12 months and overall survival (OS) at 12-month was 78.6%. Independent predictors of HEDEL12 were female sex, low albumin levels (<3.5 g/dL), and ECOG scores 2-4. According to HEDEL12 scores 0-1, OS at 12- months were 89.8% and 91.0% for IVC and EVC, respectively. The HEDEL12 scoring is useful in predicting the survival of advanced-stage cHL patients.
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Affiliation(s)
- Özgür Mehtap
- Department of Hematology, Kocaeli University, Kocaeli, Turkiye
| | - Tayfur Toptas
- Department of Hematology, Marmara University, Istanbul, Turkiye
| | - Mehmet S Dal
- Department of Hematology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkiye
| | | | - Unal Atas
- Department of Hematology, Akdeniz University, Antalya, Turkiye
| | - Güner H Özsan
- Department of Hematology, Dokuz Eylul University, Izmir, Turkiye
| | - Nilgün Sayınalp
- Department of Hematology, Hacettepe University, Ankara, Turkiye
| | - Guray Saydam
- Department of Hematology, Ege University, Izmir, Turkiye
| | - Mehmet Ali Uçar
- Department of Hematology, Cukurova University, Adana, Turkiye
| | | | - Ozan Salim
- Department of Hematology, Akdeniz University, Antalya, Turkiye
| | - Atakan Tekinalp
- Department of Hematology, Necmettin Erbakan University Meram, Konya, Turkiye
| | - Fahir Özkalemkaş
- Department of Hematology, Bursa Uludağ University, Bursa, Turkiye
| | - Funda Pepedi
- Department of Hematology, Cukurova University, Adana, Turkiye
| | - Olga M Akay
- Department of Hematology, Koç Universityİstanbul, Turkiye
| | - Emrah Kılıçaslan
- Department of Hematology, Gülhane Training and Research Hospital, İstanbul, Turkiye
| | - Semra Paydas
- Department of Hematology, Cukurova University, Adana, Turkiye
| | | | - Mehmet Yılmaz
- Department of Hematology, SANKO University, Gaziantep, Turkiye
| | - Volkan Karakus
- Department of Hematology, Antalya Education and Research Hospital, Antalya, Turkiye
| | | | - Tahir Darçın
- Department of Hematology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkiye
| | - Elcin Erdogan
- Department of Hematology, Dokuz Eylul University, Izmir, Turkiye
| | - Erkin Cinar
- Department of Hematology, Hacettepe University, Ankara, Turkiye
| | - Vildan Gürsoy
- Department of Hematology, Bursa Uludağ University, Bursa, Turkiye
| | - Salih S Durusoy
- Department of Hematology, SANKO University, Gaziantep, Turkiye
| | | | - Anıl Tombak
- Department of Hematology, Mersin University, Mersin, Turkiye
| | - Nurhilal Büyükkurt
- Department of Hematology, Baskent University Hospital Adana, Adana, Turkiye
| | - Muhit Özcan
- Department of Hematology, Ankara University, Ankara, Turkiye
| | - Fevzi Altuntaş
- Department of Hematology, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkiye
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2
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Bröckelmann PJ. Treatment approaches for older Hodgkin lymphoma patients. Curr Opin Oncol 2024; 36:353-359. [PMID: 39005230 DOI: 10.1097/cco.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
PURPOSE OF REVIEW Hodgkin lymphoma (HL) occurs at two age peaks around 25 and 60 years of age. Due to varying fitness and co-morbidities older patients are a heterogeneous group that has relatively poor treatment outcomes. The evolving therapeutic landscape for older HL is summarized herein. RECENT FINDINGS Due to lack of data from larger trials and approval of novel drugs, first-line treatment of limited-stage HL (i.e. early-stage favourable and unfavourable) remains largely A(B)VD and radiotherapy based. For patients with advanced-stage HL, the anti-CD30 antibody-drug conjugate brentuximab vedotin is approved in combination with AVD chemotherapy (BV-AVD). Due to toxicities such as febrile neutropenia or polyneuropathy and lack of improvement in progression-free and overall survival in the older subgroup, fully concomitant BV-AVD is however not used widely. More recently, promising early data was reported with the combination of nivolumab and AVD (N-AVD) in patients >60 years with advanced-stage HL. Second-line treatment depends on fitness and might include high-dose chemotherapy and autologous stem-cell transplantation for selected patients. For unfit or multiply relapsed patients, anti-PD1 antibodies are the preferred treatment option. SUMMARY The increasing number of older HL patients constitutes a therapeutic challenge despite recent advances and the increased usage of targeted agents.
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Affiliation(s)
- Paul J Bröckelmann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD)
- German Hodgkin Study Group (GHSG)
- Max Planck Research Group Mechanisms of DNA Repair, Max Planck Institute for Biology of Ageing, Cologne, Germany
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McKenna M, Ryu Tiger YK, Rutherford SC, Evens AM. The Management of older patients with Hodgkin lymphoma: implications of S1826. Semin Hematol 2024:S0037-1963(24)00068-4. [PMID: 38945791 DOI: 10.1053/j.seminhematol.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/27/2024] [Indexed: 07/02/2024]
Abstract
Classical Hodgkin lymphoma (cHL) is diagnosed in patients ages 60 and older in approximately 20%-25% of cases in Western populations. Outcomes in this subset of patients have historically been poor, with 5-year progression free survival (PFS) and overall survival rates significantly lower than those seen in younger patients. Challenges to overcome include age-related co-morbidities, and prominent and potentially lethal treatment-related toxicity. There have been increased efforts to study the older cHL patient population, including analysis of geriatric assessments and the integration of newer targeted therapies such as brentuximab vedotin (BV) and nivolumab (N) into treatment paradigms. A recent phase 3 clinical trial (S1826, NCT03907488) led by the North American oncology cooperative groups compared brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine (BV-AVD) with nivolumab, doxorubicin, vinblastine, and dacarbazine (N-AVD). At a median follow-up of 1-year, N-AVD improved PFS vs BV-AVD in patients and few immune adverse events were observed. Moreover, in a pre-planned subset analyses of cHL patients ages ≥60 years, the 1-year PFS for N-AVD was 93% (95% CI, 79%-98%) versus 64% (95% CI, 45%-77%) for BV-AVD. In addition, N-AVD was largely better tolerated particularly in older patients, which included markedly less neuropathy, lower treatment discontinuation, and less nonrelapse mortality. As a result, N-AVD is poised to become a standard of care for older, advanced-stage cHL patients who are fit for full-dose anthracycline-based combination therapy. More studies are needed to continue to improve outcomes for older cHL patients, especially unfit and frail populations.
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Affiliation(s)
- Marshall McKenna
- Division of Blood Disorders, Rutgers Cancer Institute, New Brunswick, NJ
| | | | | | - Andrew M Evens
- Division of Blood Disorders, Rutgers Cancer Institute, New Brunswick, NJ.
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Burton C, Allen P, Herrera AF. Paradigm Shifts in Hodgkin Lymphoma Treatment: From Frontline Therapies to Relapsed Disease. Am Soc Clin Oncol Educ Book 2024; 44:e433502. [PMID: 38728605 DOI: 10.1200/edbk_433502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Combination chemotherapy with or without radiation has served as the primary therapeutic option for classic Hodgkin lymphoma (cHL), leading to durable remission in a majority of patients with early- and advanced-stage cHL. Patients with relapsed/refractory (RR) cHL could still be cured with salvage chemotherapy and autologous stem-cell transplantation. Brentuximab vedotin (BV) and the anti-PD-1-blocking antibodies, nivolumab and pembrolizumab, are highly effective treatments for cHL and have revolutionized the management of the disease. Recent studies incorporating BV and PD-1 blockade into salvage therapy for RR cHL and into frontline treatment regimens have changed the cHL treatment paradigm. The novel agents are also useful in the treatment of older patients who have poor outcomes with traditional therapy. This manuscript will review current strategies for approaching the management of previously untreated, RR, and challenging populations with cHL, including how to incorporate the novel agents.
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Affiliation(s)
- Cathy Burton
- Department of Haematology, St James's University Hospital, Leeds, United Kingdom
| | - Pamela Allen
- Department of Hematology and Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Alex F Herrera
- Division of Lymphoma, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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Upshaw JN, Nelson J, Sweigart B, Rodday AM, Kumar AJ, Konstam MA, Wong JB, Ky B, Karmiy S, Friedberg JW, Evens AM, Kent DM, Parsons SK. Impact of Preexisting Heart Failure on Treatment and Outcomes in Older Patients With Hodgkin Lymphoma. JACC CardioOncol 2024; 6:200-213. [PMID: 38774008 PMCID: PMC11103040 DOI: 10.1016/j.jaccao.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 05/24/2024] Open
Abstract
Background Older patients with Hodgkin lymphoma (HL) often have comorbid cardiovascular disease; however, the impact of pre-existing heart failure (HF) on the management and outcomes of HL is unknown. Objectives The aim of this study was to assess the prevalence of pre-existing HF in older patients with HL and its impact on treatment and outcomes. Methods Linked Surveillance, Epidemiology, and End Results (SEER) and Medicare data from 1999 to 2016 were used to identify patients 65 years and older with newly diagnosed HL. Pre-existing HF, comorbidities, and cancer treatment were ascertained from billing codes and cause-specific mortality from SEER. The associations between pre-existing HF and cancer treatment were estimated using multivariable logistic regression. Cause-specific Cox proportional hazards models adjusted for comorbidities and cancer treatment were used to estimate the association between pre-existing HF and cause-specific mortality. Results Among 3,348 patients (mean age 76 ± 7 years, 48.6% women) with newly diagnosed HL, pre-existing HF was present in 437 (13.1%). Pre-existing HF was associated with a lower likelihood of using anthracycline-based chemotherapy regimens (OR: 0.42; 95% CI: 0.29-0.60) and a higher likelihood of lymphoma mortality (HR: 1.25; 95% CI: 1.06-1.46) and cardiovascular mortality (HR: 2.57; 95% CI: 1.96-3.36) in models adjusted for comorbidities. One-year lymphoma mortality cumulative incidence was 37.4% (95% CI: 35.5%-39.5%) with pre-existing HF and 26.3% (95% CI: 25.0%-27.6%) without pre-existing HF. The cardioprotective medications dexrazoxane and liposomal doxorubicin were used in only 4.2% of patients. Conclusions Pre-existing HF in older patients with newly diagnosed HL is common and associated with higher 1-year mortality. Strategies are needed to improve lymphoma and cardiovascular outcomes in this high-risk population.
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Affiliation(s)
- Jenica N. Upshaw
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jason Nelson
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Benjamin Sweigart
- Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
| | - Angie Mae Rodday
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Anita J. Kumar
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts, USA
| | - Marvin A. Konstam
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | - John B. Wong
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Division of Clinical Decision Making, Tufts Medical Center, Boston, Massachusetts, USA
| | - Bonnie Ky
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samuel Karmiy
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jonathan W. Friedberg
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | | | - David M. Kent
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Susan K. Parsons
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts, USA
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Ghesquières H, Krzisch D, Nicolas-Virelizier E, Kanoun S, Gac AC, Guidez S, Touati M, Laribi K, Morschhauser F, Bonnet C, Waultier-Rascalou A, Orsini-Piocelle F, André M, Fournier M, Morand F, Berriolo-Riedinger A, Burroni B, Damotte D, Traverse-Glehen A, Quittet P, Casasnovas O. The phase 2 LYSA study of prednisone, vinblastine, doxorubicin, and bendamustine for untreated Hodgkin lymphoma in older patients. Blood 2024; 143:983-995. [PMID: 37979133 DOI: 10.1182/blood.2023021564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/10/2023] [Accepted: 10/29/2023] [Indexed: 11/19/2023] Open
Abstract
ABSTRACT Older patients with classical Hodgkin lymphoma (cHL) require more effective and less toxic therapies than younger patients. In this multicenter, prospective, phase 2 study, we investigated a new firstline therapy regimen comprising 6 cycles of prednisone (40 mg/m2, days 1-5), vinblastine (6 mg/m2, day 1), doxorubicin (40 mg/m2, day 1), and bendamustine (120 mg/m2, day 1) (PVAB regimen) every 21 days for patients with newly diagnosed cHL aged ≥61 years with an advanced Ann Arbor stage. A Mini Nutritional Assessment score ≥17 was the cutoff value for patients aged ≥70 years. The primary end point was the complete metabolic response (CMR) rate after 6 cycles. The median age of the 89 included patients was 68 years (range, 61-88 years), with 35 patients (39%) aged ≥70 years. Seventy-eight patients (88%) completed the 6 cycles. The toxicity rate was acceptable, with a 20% rate of related serious adverse events. CMR was achieved by 69 patients (77.5%; 95% confidence interval [CI], 67-86). After a median follow-up of 42 months, 31 patients progressed or relapsed (35%), and 24 died (27%) from HL (n = 11), toxicity during treatment (n = 4), secondary cancers (n = 6), or other causes (n = 3). The 4-year progression-free survival (PFS) and overall survival rates were 50% and 69%, respectively. Multivariate analysis showed that liver involvement (P = .001), lymphopenia (P = .001), CRP (P = .0005), and comedications (P = .003) were independently associated with PFS. The PVAB regimen yielded a high CMR rate with acceptable toxicity. Over long-term follow-up, survival end points were influenced by unrelated lymphoma events. This trial was registered at www.clinicaltrials.gov as #NCT02414568 and at EudraCT as 2014-001002-17.
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Affiliation(s)
- Hervé Ghesquières
- Department of Hematology, Hopital Lyon Sud, Claude Bernard Lyon 1 University, Pierre Benite, France
| | - Daphné Krzisch
- Department of Hematology, Assistance Publique Hopitaux de Paris, Hopital Saint Louis, Paris, France
| | | | - Salim Kanoun
- Department of Hematology, Cancer Research Center of Toulouse, Team 9, INSERM Unité Mixte de Recherche 1037, Toulouse, France
| | - Anne Claire Gac
- Department of Hematology, Institut d'Hematologie de Basse Normandie, Caen, France
| | - Stéphanie Guidez
- Hematology Department, Centre Hospitalier Universitaire, Poitiers, France
| | - Mohamed Touati
- Department of Hematology, Hôpital Dupuytren, Centre Hospitalier Universitaire, Limoges, France
| | - Kamel Laribi
- Hematology Department, Centre Hospitalier, Le Mans, France
| | - Franck Morschhauser
- Department of Hematology, Centre Hospitalier Universitaire Lille, Universite de Lille, ULR 7365 Groupe de Recherche sur les formes Injectables et les Technologies Associées, Lille, France
| | | | | | | | - Marc André
- Department of Hematology, Centre Hospitalier Universitaire, Université Catholique de Louvain Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Marguerite Fournier
- Department of Statistics, Lymphoma Study Association Clinical Research, Hopital Lyon Sud, Pierre Benite, France
| | - Fabienne Morand
- Department of Statistics, Lymphoma Study Association Clinical Research, Hopital Lyon Sud, Pierre Benite, France
| | | | - Barbara Burroni
- Department of Pathology, Université de Paris Cité, Centre de Recherche des Cordeliers UMRS U1138 et GH Paris Centre APHP, Paris, France
| | - Diane Damotte
- Department of Pathology, Université de Paris Cité, Centre de Recherche des Cordeliers UMRS U1138 et GH Paris Centre APHP, Paris, France
| | | | - Philippe Quittet
- Department of Hematology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Olivier Casasnovas
- Department of Hematology, University Hospital F. Mitterrand and INSERM Unité Mixte de Recherche 1231, Dijon, France
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7
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Friedberg JW, Bordoni R, Patel-Donnelly D, Larson T, Goldschmidt J, Boccia R, Cline VJM, Mamidipalli A, Liu J, Akyol A, Yasenchak CA. Brentuximab vedotin with dacarbazine or nivolumab as frontline cHL therapy for older patients ineligible for chemotherapy. Blood 2024; 143:786-795. [PMID: 37946283 DOI: 10.1182/blood.2022019536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/29/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
ABSTRACT Older patients with advanced-stage classical Hodgkin lymphoma (cHL) have inferior outcomes compared with younger patients, potentially due to comorbidities and frailty. This noncomparative phase 2 study enrolled patients aged ≥60 years with cHL unfit for conventional chemotherapy to receive frontline brentuximab vedotin (BV; 1.8 mg/kg) with dacarbazine (DTIC; 375 mg/m2) (part B) or nivolumab (part D; 3 mg/kg). In parts B and D, 50% and 38% of patients, respectively, had ≥3 general comorbidities or ≥1 significant comorbidity. Of the 22 patients treated with BV-DTIC, 95% achieved objective response, and 64% achieved complete response (CR). With a median follow-up of 63.6 months, median duration of response (mDOR) was 46.0 months. Median progression-free survival (mPFS) was 47.2 months; median overall survival (mOS) was not reached. Of 21 patients treated with BV-nivolumab, 86% achieved objective response, and 67% achieved CR. With 51.6 months of median follow-up, mDOR, mPFS, and mOS were not reached. Ten patients (45%) with BV-DTIC and 16 patients (76%) with BV-nivolumab experienced grade ≥3 treatment-emergent adverse events; sensory peripheral neuropathy (PN; 27%) and neutropenia (9%) were most common with BV-DTIC, and increased lipase (24%), motor PN (19%), and sensory PN (19%) were most common with BV-nivolumab. Despite high median age, inclusion of patients aged ≤88 years, and frailty, these results demonstrate safety and promising durable efficacy of BV-DTIC and BV-nivolumab combinations as frontline treatment, suggesting potential alternatives for older patients with cHL unfit for initial conventional chemotherapy. This trial was registered at www.clinicaltrials.gov as #NCT01716806.
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Affiliation(s)
| | | | | | | | | | - Ralph Boccia
- Center for Cancer and Blood Disorders, Bethesda, MD
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8
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Evens AM. Hodgkin lymphoma treatment for older persons in the modern era. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:483-499. [PMID: 38066840 PMCID: PMC10727079 DOI: 10.1182/hematology.2023000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
There has been a renewed effort globally in the study of older Hodgkin lymphoma (HL) patients, generating a multitude of new data. For prognostication, advancing age, comorbidities, altered functional status, Hispanic ethnicity, and lack of dose intensity (especially without anthracycline) portend inferior survival. Geriatric assessments (GA), including activities of daily living (ADL) and comorbidities, should be objectively measured in all patients. In addition, proactive multidisciplinary medical management is recommended (eg, geriatrics, cardiology, primary care), and pre-phase therapy should be considered for most patients. Treatment for fit older HL patients should be given with curative intent, including anthracyclines, and bleomycin should be minimized (or avoided). Brentuximab vedotin given sequentially before and after doxorubicin, vinblastine, dacarbazine (AVD) chemotherapy for untreated patients is tolerable and effective, and frontline checkpoint inhibitor/AVD platforms are rapidly emerging. Therapy for patients who are unfit or frail, whether due to comorbidities and/or ADL loss, is less clear and should be individualized with consideration of attenuated anthracycline-based therapy versus lower-intensity regimens with inclusion of brentuximab vedotin +/- checkpoint inhibitors. For all patients, there should be clinical vigilance with close monitoring for treatment-related toxicities, including neurotoxicity, cardiopulmonary, and infectious complications. Finally, active surveillance for "postacute" complications 1 to 10 years post therapy, especially cardiac disease, is needed for cured patients. Altogether, therapy for older HL patients should include anthracycline-based therapy in most cases, and novel targeted agents should continue to be integrated into treatment paradigms, with more research needed on how best to utilize GAs for treatment decisions.
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Affiliation(s)
- Andrew M. Evens
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
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Wilson MR, Haynes E, Parsons K, Hopkins D, Robertson E, Ferguson G, Quinn D, Murray J, Osborne W, Leach M, McKay P. 'ACOPP' chemotherapy for older and less fit patients with Hodgkin lymphoma-A multicentre, retrospective study. Br J Haematol 2023; 202:796-800. [PMID: 37357380 DOI: 10.1111/bjh.18947] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
Management of classical Hodgkin lymphoma in older patients is challenging due to poor tolerance of the chemotherapy regimens used in younger patients. We modified the BEACOPP regimen (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisolone), whereby bleomycin and etoposide were removed and cyclophosphamide dose was reduced, for older patients with co-morbidities. Here we present data from the first 41 patients treated with 'ACOPP' across 3 centres, demonstrating that it can be delivered, with a favourable toxicity profile (TRM 2%) and promising efficacy (2-year PFS and OS, 73% (95% CI: 52-94) and 93% (95% CI: 80-100) respectively).
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Affiliation(s)
- Matthew R Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Euan Haynes
- Department of Haematology, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Katrina Parsons
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - David Hopkins
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | | | - Graeme Ferguson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Daire Quinn
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Jim Murray
- Department of Haematology, Royal United Hospital Bath NHS Trust, Bath, UK
| | - Wendy Osborne
- Department of Haematology, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mike Leach
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
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10
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Current Treatment Options and the Role of Functional Status Assessment in Classical Hodgkin Lymphoma in Older Adults: A Review. Cancers (Basel) 2023; 15:cancers15051515. [PMID: 36900306 PMCID: PMC10000520 DOI: 10.3390/cancers15051515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Along with the fact that classical Hodgkin lymphoma (cHL) in older adults is frequently considered biologically different from cHL in younger patients, its most distinctive feature is its dismal clinical outcome due to the decreased effectiveness and greater toxicity of therapies. Although strategies to mitigate specific toxicities (e.g., cardiological and pulmonary) have obtained some results, in general, reduced-intensity schemes, proposed as an alternative to ABVD, have proved to be less effective. The addition of brentuximab vedotin (BV) to AVD, especially in a sequential scheme, has demonstrated good efficacy. However, the problem of toxicity persists even with this new therapeutic combination, with comorbidities remaining an important prognostic factor. The adequate stratification of functional status is necessary to distinguish between those patients who will benefit from full treatment and those who will benefit from alternative strategies. A simplified geriatric assessment based on the determination of ADL (activity of daily living), IADL (instrumental ADL), and CIRS-G (Cumulative Illness Rating Scale-Geriatric) scores is an easy-to-use tool that permits adequate patient stratification. Other factors of considerable impact on functional status such as sarcopenia and immunosenescence are currently being studied. A fitness-based treatment choice would also be very useful for relapsed or refractory patients, a more frequent and challenging situation than that is found in young cHL patients.
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Barrett A, Collins GP. Older patients with Hodgkin Lymphoma: Walking the tightrope of efficacy and toxicity. Front Oncol 2023; 12:1017787. [PMID: 36713561 PMCID: PMC9880490 DOI: 10.3389/fonc.2022.1017787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/11/2022] [Indexed: 01/15/2023] Open
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.
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Clinical Dilemmas in the Treatment of Elderly Patients Suffering from Hodgkin Lymphoma: A Review. Biomedicines 2022; 10:biomedicines10112917. [PMID: 36428485 PMCID: PMC9687245 DOI: 10.3390/biomedicines10112917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/02/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Elderly patients make up a significant number of cases of newly diagnosed Hodgkin lymphoma. However, unlike in young patients, the outcomes of elderly patients are poor, and they are under-represented in phase III trials. Prior to treatment initiation, geriatric assessment should ideally be performed to address the patient's fitness and decide whether to pursue a curative or palliative approach. The ABVD regimen is poorly tolerated in unfit patients, with high treatment-related mortality. Alternative chemotherapy approaches have been explored, with mixed results obtained concerning their feasibility and toxicity in phase II trials. The introduction of brentuximab vedotin-based regimens led to a paradigm shift in first- and further-line treatment of elderly Hodgkin lymphoma patients, providing adequate disease control within a broader patient population. As far as checkpoint inhibitors are concerned, we are only just beginning to understand the role in the treatment of this population. In relapsed/refractory settings there are few options, ranging from autologous stem cell transplantation in selected patients to pembrolizumab, but unfortunately, palliative care is the most common modality. Importantly, published studies are frequently burdened with numerous biases (such as low numbers of patients, selection bias and lack of geriatric assessment), leading to low level of evidence. Furthermore, there are few ongoing studies on this topic. Thus, elderly Hodgkin lymphoma patients are hard to treat and represent an unmet need in hematologic oncology. In conclusion, treatment needs to be personalized and tailored on a case-by-case basis. In this article, we outline treatment options for elderly Hodgkin lymphoma patients.
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The outcome of older adults with classic Hodgkin lymphoma in British Columbia. Blood Adv 2022; 6:5924-5932. [PMID: 36075016 PMCID: PMC9701622 DOI: 10.1182/bloodadvances.2022008258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/25/2022] [Indexed: 12/14/2022] Open
Abstract
Outcomes in older adults with classic Hodgkin lymphoma (cHL) have traditionally been poor, in part, related to poor tolerance to standard chemotherapy. Herein, we evaluated the survival of patients with cHL aged ≥60 years in British Columbia in a population-based analysis. From 1961 to 2019, 744 patients with newly diagnosed cHL were identified. With a median follow-up of 9 years, 5-year disease-specific survival (DSS) and overall survival (OS) have improved by decade comparison (both P < .001), remaining stable in the past 20 years (DSS, P = .35; OS, P = .26). In the modern management era (2000-present), 361 of 401 patients (90%) received active therapy for cHL and had a 5-year OS of 60%. For those who received curative-intent therapy (n = 327), the 5-year progression-free survival (PFS), OS, and DSS were 60%, 65%, and 76%, respectively, and estimates were superior in those who were 60 to 69 years of age (72%, 77%, and 83%, respectively) compared with those who were 70 to 79 years of age (54%, 57%, and 70%, respectively) and ≥80 years of age (28%, 39%, and 63%, respectively) (P < .05 for all). Overall, pulmonary toxicity occurred in 58 of 279 patients (21%) treated with bleomycin, with 22 of 58 (38%) occurring after cycles 1 or 2, accounting for 8 of 20 (40%) treatment-related deaths. Outcomes in older adults with cHL have improved in recent decades; however, they remain poor for those aged ≥70 years, even in the modern treatment era. Furthermore, treatment-related toxicity remains a significant concern and use of bleomycin should be avoided in most patients.
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Real-world evidence of ABVD-like regimens compared with ABVD in classical Hodgkin lymphoma: a 10-year study from China. J Cancer Res Clin Oncol 2022:10.1007/s00432-022-04321-6. [DOI: 10.1007/s00432-022-04321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/22/2022] [Indexed: 10/15/2022]
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Zhang Y, Xing Z, Mi L, Li Z, Zhu J, Wei T, Wu W. Novel Agents For Relapsed and Refractory Classical Hodgkin Lymphoma: A Review. Front Oncol 2022; 12:929012. [PMID: 35928877 PMCID: PMC9344040 DOI: 10.3389/fonc.2022.929012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/22/2022] [Indexed: 12/23/2022] Open
Abstract
Classical Hodgkin lymphoma (cHL) is the most common type of HL that occurs mainly in people aged between 15–30 and over 55 years. Although its general prognosis is favorable, 10%–30% of patients with cHL will ultimately develop relapsed or refractory disease (r/r cHL). Improving the cure rate of r/r cHL has proven to be challenging. Some novel agents, such as brentuximab vedotin and immune checkpoint inhibitors, which have been used in conventional regimens for patients with r/r cHL in the past decade, have been shown to have good curative effects. This paper reviews the conventional regimens for patients with r/r cHL and focuses on the newest clinical trials and treatment measures to prolong prognosis and reduce adverse events. The evaluation of prognosis plays a vital role in analyzing the risk of relapse or disease progression; thus, finding new predictive strategies may help treat patients with r/r cHL more efficaciously.
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Affiliation(s)
- Yujie Zhang
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Zhichao Xing
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Li Mi
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Zhihui Li
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Jingqiang Zhu
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Tao Wei
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wenshuang Wu, ; Tao Wei,
| | - Wenshuang Wu
- Department of Thyroid Surgery, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Thyroid and Parathyroid Disease, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wenshuang Wu, ; Tao Wei,
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Lew TE, Seymour JF. Clinical experiences with venetoclax and other pro-apoptotic agents in lymphoid malignancies: lessons from monotherapy and chemotherapy combination. J Hematol Oncol 2022; 15:75. [PMID: 35659041 PMCID: PMC9164485 DOI: 10.1186/s13045-022-01295-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/18/2022] [Indexed: 11/20/2022] Open
Abstract
BH3-mimetics are a novel drug class of small molecule inhibitors of BCL2 family proteins which restore apoptosis in malignant cells. The only currently approved BH3-mimetic, the selective BCL2 inhibitor venetoclax, is highly efficacious in chronic lymphocytic leukemia and has rapidly advanced to an approved standard of care in frontline and relapsed disease in combination with anti-CD20 monoclonal antibodies. In this context, tumour lysis syndrome and myelosuppression are the most commonly encountered toxicities and are readily manageable with established protocols. Venetoclax is active in other lymphoid malignancies including several B cell non-Hodgkin lymphomas, acute lymphoblastic leukemia and multiple myeloma, with the highest intrinsic sensitivity observed in mantle cell lymphoma and Waldenstrom macroglobulinemia. Venetoclax combination with standard regimens in follicular lymphoma, multiple myeloma and aggressive B cell neoplasms has shown some promise, but further studies are required to optimize dose and scheduling to mitigate increased myelosuppression and infection risk, and to find validated biomarkers of venetoclax sensitivity. Future research will focus on overcoming venetoclax resistance, targeting other BCL2 family members and the rational design of synergistic combinations.
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Affiliation(s)
- Thomas E Lew
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia.,Blood Cells and Blood Cancer Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - John F Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and Peter MacCallum Cancer Centre, Melbourne, VIC, 3000, Australia. .,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia.
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Miyazaki K. Management of elderly patients with malignant lymphoma. Jpn J Clin Oncol 2022; 52:690-699. [PMID: 35435235 DOI: 10.1093/jjco/hyac056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 04/02/2022] [Indexed: 11/14/2022] Open
Abstract
More than half of patients with malignant lymphoma are 65 years old or older. The outcome for older patients is poorer than that for younger patients. A poor prognosis is associated with heterogeneity and consists of physical function, performance status, poor nutritional status and various comorbidities. Therefore, attention should be given to serious treatment-related toxicities. Diffuse large B-cell lymphoma is the most frequently diagnosed type of malignant lymphoma. Most patients with diffuse large B-cell lymphoma can be potentially cured with the current standard chemotherapeutic regimen of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone. However, a reduced-dose regimen of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone or alternative treatment options might be suitable for older patients who are frail or unfit and have cardiac comorbidities. A comprehensive geriatric assessment is a potential tool for determining an appropriate therapeutic approach for each older patient. Follicular lymphoma is the second most common type of non-Hodgkin lymphoma, and the disease course is usually characterized by an indolent clinical course. Advanced follicular lymphoma with a high tumor burden has historically been treated with chemoimmunotherapy, but the treatment goal for older patients is relief of symptoms. Incorporating novel targeted agents such as brentuximab vedotin into therapies for older Hodgkin lymphoma patients might be a promising alternative to the anthracycline-containing regimen.
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Affiliation(s)
- Kana Miyazaki
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
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