Quality indicators for early stage Hodgkin's lymphoma

INTRODUCTION

The purpose of this project was to devise simple, practicable quality indicators (QIs) for the treatment of early stage (I-II) Hodgkin's lymphoma (ESHL), and to test their applicability retrospectively at a single large teaching hospital.

METHODS

Of the available treatment guidelines, we chose the two eviQ (evidence and Quality, Cancer Institute New South Wales) documents first published in early 2012 (updated in 2015) for ESHL favourable and ESHL unfavourable (based upon German Hodgkin Study Group practice) as being most relevant to the Australian setting, and selected nine QIs from them viz. baseline staging investigations, discussion in a multi-disciplinary meeting, chemotherapy type and number of cycles, radiotherapy (RT) planning technique, use of dose volume histograms, dose, treatment volume and timing. We identified all patients with ESHL treated radically with chemotherapy and/or RT at the Royal Adelaide Hospital between July 2009 and July 2014, and extracted relevant data from hospital records. QI score for each item was defined as the percentage of patients who received care as recommended in the eviQ guidelines, and improvement potential as an indicator score <90%.

RESULTS

Raw QI scores varied between 74-100%. When corrected for clinical circumstances legitimising deviation from the guidelines, the range was 83-100%. Only number of chemotherapy cycles (87% corrected) and RT dose (83% corrected) had improvement potential. However, compliance after publication of the eviQ guidelines was virtually perfect for each item.

CONCLUSIONS

The chosen QIs for ESHL proved to be practicable to apply in this single centre review where overall compliance was high, and excellent in the latter half of the study period. We would encourage reporting of raw and corrected QI scores.

Involved field radiation therapy following high dose chemotherapy and autologous stem cell transplant benefits local control and survival in refractory or recurrent Hodgkin lymphoma

BACKGROUND AND PURPOSE

Patients with recurrent or primary refractory Hodgkin lymphoma (HL) treated with high dose chemotherapy (HDT) and autologous stem cell transplant (ASCT) commonly relapse post-ASCT in previous disease sites. We sought to evaluate involved field radiation therapy (IFRT) following ASCT and patterns of recurrence, overall survival (OS), and disease specific survival (DSS).

METHODS AND MATERIALS

Between May 1993 and October 2003, 62 (n=66) evaluable patients with refractory/relapsed HL underwent HDT followed by ASCT. Thirty-two (52%) patients received IFRT following transplant. Survival was calculated from the day of hematopoietic stem cell infusion.

RESULTS

Median follow-up was 2.3 years (range 0.03-11.56). Estimated 3-year OS (p=0.05) and DSS (p=0.08) were 69.6% and 82.1% with IFRT and 40% and 57.6% without IFRT on univariate analysis. B-symptoms were adverse on univariate (p=0.007) and multivariate (p=0.01) analysis. HL patients who received IFRT following ASCT had improved local control in areas of previously recurrent disease (p=0.03).

CONCLUSION

OS and DSS showed marginal benefit at 3 years. Given the retrospective nature of our study and attendant selection bias that can be both positive and negative, a future prospective study is warranted to better understand the value of IFRT in the transplant setting.

Reduced versus full doses of irradiation after 3 cycles of combined doxorubicin, bleomycin, vinblastine, and dacarbazine in early stage Hodgkin lymphomas: results of a randomized trial

BACKGROUND

The combination of 3 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and a tailored, extended irradiation schedule has been used to treat patients with early Hodgkin lymphoma (HL) in the authors' group since 1981. The randomized H97-E trial (1997-2004) was designed to assess the impact of a slightly reduced irradiation dose on the freedom from treatment failure (FFTF) rate.

METHODS

Patients with supradiaphragmatic HL at clinical stages I and II who had </=2 affected lymph node areas and a mediastinal mass ratio <0.33 were randomized into an experimental arm (EA) and a control arm (CA). Patients in the EA received 3 cycles of ABVD followed by irradiation at 36 grays (Gy) to initially involved sites and 24 Gy to adjacent sites, the upper infradiaphragmatic area, and the spleen. Patients in the CA received the same chemotherapy regimen and the same irradiation given at doses of 40 Gy and 30 Gy, respectively. Two hundred two patients who had received the CA treatment in 2 previous trials served as a historic control group (HCG).

RESULTS

The 10-year FFTF and overall survival rates were similar for the 89 patients in the EA (88.6% and 97.8%, respectively), for the 99 patients in the CA (92.6% and 95%, respectively), and for the 202 patients in the HCG (91.9% and 92.9%, respectively). Surprisingly, the 10-year incidence of severe or fatal complications was nil in the EA but reached 15.5% in the CA (P < .003) and 11.1% in the HCG.

CONCLUSIONS

Slightly lowering the radiation dose did not have an impact on the excellent cure rate among patients with early HL but significantly reduced the rate of long-term, radiation-induced complications.

Role of chemotherapy in Hodgkin's lymphoma

The development of curative chemotherapy regimens for the treatment of Hodgkin's lymphoma (HL) is one of the true success stories in oncology. Most patients diagnosed with HL today can be cured. The major task remaining before us is curing as many patients as possible with their initial therapeutic approach while minimizing the acute toxicities and limiting the lifetime risks of important secondary events such as cardiovascular complications and secondary malignancies. In the 40 years since DeVita et al. developed the mechlorethamine, vincristine, procarbazine, and prednisone chemotherapy regimen, we have learned a great deal about risk stratification to minimize treatment-related toxicity. Positron emission tomography may further assist us in reducing radiation treatment without compromising cures. This review will discuss the development of the chemotherapy regimens used in the management of early and advanced stage HL and the advantages and disadvantages of their use in combination with radiation therapy.

New Strategies for the Treatment of Early Stages of Hodgkin's Lymphoma

The treatment of early or limited-stage Hodgkin's lymphoma continues to evolve. With the likelihood of cure of the lymphoma approaching 95% it has become increasingly necessary to balance improved effectiveness of treatment with minimization of troublesome late toxicity. Carefully crafted treatment strategies based on optimal combinations of brief chemotherapy and involved-field radiation or even reliance on brief chemotherapy alone for carefully selected patients have emerged as the most attractive approaches to achieve this important balance.

Are We Improving the Long-Term Burden of Hodgkin's Lymphoma Patients with Modern Treatment?

The cure rate of patients who have Hodgkin's lymphoma (HL) amounts to 80% or more because of risk-adapted treatment using modern chemotherapy and radiotherapy schedules. In this article we describe important late effects after treatment of HL and how we expect the long-term burden of patients who have HL to change applying modern treatments. Because treatment always has side effects to some extent, awareness of possible late effects after treatment remains important for patients and treating physicians.

Radiotherapy of hodgkin lymphoma: indications, new fields, and techniques

In recent years, radiotherapy in patients with Hodgkin lymphoma has evolved considerably because of sophisticated imaging technologies and radiation delivery techniques. Even more recently, a new radiation field concept has emerged to ensure better normal tissue protection while preserving an excellent clinical outcome. The role of radiation therapy is also rapidly changing because the concept of a risk-adapted treatment strategy, in which combined-modality treatments were the order of the day, is now expanding into a concept of response-adapted treatments.

Patterns of disease progression and outcomes in a randomized trial testing ABVD alone for patients with limited-stage Hodgkin lymphoma

BACKGROUND

In the National Cancer Institute of Canada Clinical Trials Group/Eastern Cooperative Oncology Group HD.6 trial, progression-free survival was better in patients randomized to therapy that included radiation, compared to doxorubicin (Adriamycin), bleomycin, vinblastine and dacarbazine (ABVD) alone. We now evaluate patterns of progression and subsequent outcomes of patients with progression.

PATIENTS AND METHODS

After a median of 4.2 years, 33 patients have progressed. Two radiation oncologists determined whether sites of progression were confined within radiation fields. Freedom from second progression (FF2P) and freedom from second progression or death (FF2P/D) were compared.

RESULTS

Reviewers agreed for the extended (kappa = 0.87) and involved field (kappa = 1.0) analyses. Progression after ABVD alone was more frequently confined within both the extended (20/23 vs. 3/10; P = 0.002) and involved fields (16/23 vs. 2/10; P = 0.02). There was no difference in FF2P between groups [5-year estimate 99% (radiation) versus 96% (ABVD alone)] [hazard ratio (HR) = 3.14, 95% confidence interval (CI) 0.63-15.6; P = 0.14]; the 5-year estimates of FF2P/D were 94% in each group (HR = 1.04, 95% CI 0.41-2.63; P = 0.93).

CONCLUSION

Treatment that includes radiation reduces the risk of progressive Hodgkin lymphoma in sites that receive this therapy, but we are unable to detect differences in FF2P or FF2P/D.

Hodgkin's lymphoma: molecular targets and novel treatment strategies

The WHO classification of Hodgkin's lymphoma (HL) distinguishes between two major subtypes, classical and nodular lymphocyte predominant HL. Approximately 95% of patients with HL will have the classical HL histology, which is characterized by the presence of rare malignant Hodgkin's and Reed-Sternberg cells among an overwhelming number of benign reactive cells. In recent years, new studies have shed more light on the biological and molecular features of Hodgkin's and Reed-Sternberg cells, providing hope that new targeted therapy may be developed to enhance the cure rate and to reduce treatment-related toxicity. In this review, the current understanding of the pathology and biology of HL will be discussed, as well as the current treatment approaches for patients with classical HL. Future treatment strategies will also be discussed based on our understanding of HL biology.

Long-term Events in Adult Patients with Clinical Stage IA-IIA Nonbulky Hodgkin's Lymphoma Treated with Four Cycles of Doxorubicin, Bleomycin, Vinblastine, and Dacarbazine and Adjuvant Radiotherapy: A Single-Institution 15-Year Follow-up

PURPOSE

To report on long-term events after short doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy and adjuvant radiotherapy in favorable early-stage Hodgkin's lymphoma.

EXPERIMENTAL DESIGN

We monitored late events and causes of death over 15 years (median follow-up, 120 months) in 120 patients with nonbulky stage IA-IIA Hodgkin's lymphoma, treated with four cycles of ABVD and limited radiotherapy. Pulmonary and cardiac function tests were done throughout the follow-up. Outcome measures included cause-specific mortality, standardized mortality ratio, and standardized incidence ratio for secondary neoplasia.

RESULTS

Projected 15-year event-free and overall survival were 78% and 86%, and tumor mortality was 3%. Standardized mortality ratio was significantly higher than 1 for both males (2.8; P=0.029) and females (9.4; P=0.003). The risk of cardiovascular events at 5 and 12 years was 5.5% and 14%, with a median latent time of 67 months (range: 23-179 months) from the end of radiotherapy. Pulmonary toxicity developed in 8% of patients; all had received mediastinal irradiation and the median time from radiotherapy to pulmonary sequelae was 76 weeks (range: 50-123 weeks). The risk of secondary neoplasia at 5 and 12 years was 4% and 8%, respectively, with no cases of leukemia. Fertility was preserved.

CONCLUSIONS

Long-term events were mostly related to radiotherapy; the role of short ABVD chemotherapy was very limited, as documented by fertility preservation and lack of secondary myelodysplasia/leukemia. A proportion of patients died from causes unrelated to disease progression and the excess mortality risk was mostly due to the occurrence of secondary neoplasms and cardiovascular diseases. A moderate dose reduction of radiotherapy from 40-44 Gy to 30-36 Gy did not decrease the risk of late complications; abolishing radiotherapy in nonbulky early-stage Hodgkin's lymphoma is being evaluated.

Evolving role of radiation therapy for hematologic malignancies

Radiation therapy continues to play a paramount role in the therapy of hematologic malignancies, whether as definitive therapy, as consolidation after chemotherapy, as part of bone marrow transplantation protocols, or in palliation. During the past 2 decades, significant advances in radiation therapy have occurred, including the evolution of involved-field irradiation and the adoption of conformal radiation administration. It is hoped that modern techniques will reduce the long-term sequelae associated with radiation-based treatments.

Involved-node radiotherapy (INRT) in patients with early Hodgkin lymphoma: Concepts and guidelines

BACKGROUND AND PURPOSE

To describe new concepts for radiation fields in patients with early stage Hodgkin lymphoma treated with a combined modality.

PATIENTS AND MATERIALS

Patients receiving combined modality therapy with at least 2 or 3 cycles of chemotherapy prior to radiotherapy. Pre- and postchemotherapy cervical and thoracic CT scans are mandatory and should be performed, whenever possible, in the treatment position with the use of image fusion capabilities. A pre-chemotherapy PET scan is strongly recommended to increase the detection of involved lymph nodes.

RESULTS

Radiation fields are designed to irradiate the initially involved lymph nodes exclusively and to encompass their initial volume. In some cases, radiation fields are slightly modified to avoid unnecessary irradiation of muscles or organs at risk.

CONCLUSIONS

The concept of involved-node radiotherapy (INRT) described here is the first attempt to reduce the size of radiation fields compared to the classic involved fields used in adult patients. Proper implementation of INRT requires adequate training and an efficient prospective or early retrospective quality assurance program.

The Management of Patients with Limited-Stage Classical Hodgkin Lymphoma

The term limited-stage Hodgkin lymphoma refers to those patients with stage I–II disease and an absence of bulky disease. Among those patients with classical Hodgkin lymphoma, approximately one-third of patients will fall into this category. As long-term disease control can now be anticipated in more than 90% of these patients, management strategies must increasingly address the need to reduce the long-term treatment-related risks. Current treatment options include use of combined modality therapy that includes an abbreviated course of chemotherapy and involved-field radiation or treatment with chemotherapy, currently consisting of ABVD, as a single modality. The choice of treatment between these two options involves specific trade-offs that must balance issues of disease control against long-term risk of late effects.