Chief, Lymphoma Service, Memorial Sloan Kettering Cancer Center
How do you typically treat a newly diagnosed Hodgkin lymphoma patient?
Treatment depends on their clinical state. If they are early on in the disease and, the lymphocytes are non-bulky, then I treat with chemotherapy and radiation. Recently, we have been looking at potentially being able to treat some patients with chemotherapy, generally ABVD (Adriamycin, Bleomycin, Vinblastine and Dacarbazine), alone. If the disease has progressed further and they are at stage III or stage IV, we also follow the chemotherapy and radiation treatment but will increase the number of cycles a patient will go through.
What are the goals for future treatments?
Although there is already a tremendously high cure rate of over 80 percent for patients with early stage disease, we still want to improve cure rates and also focus on reducing treatment-related toxicity. We can reduce toxicity by reducing the amount of chemotherapy by incorporating an antibody drug like brentuximab vedotin (Adcetris).
In more advanced stages of Hodgkin lymphoma, we can combine brentuximab vedotin as a frontline regimen along with AVD, removing the need for the B in the chemotherapy equation.
How do you typically treat relapsed or refractory patients?
With patients who are either refractory to treatment or who have relapsed, generally we treat with second line therapies, which are platinum-based therapies such as Ifosfamide Carboplatin Etoposide (ICE) and Cannabidiol (CBD) to name a couple. This is followed by an autologous stem cell transplant. We can also utilize platinum-based regimens as well as gensadabine regimens. If the disease continues to progress the standard of care is to treat with more brentuximab vedotin.
What are the treatment options or recommendations post-transplant?
While this is not standard care patients, we have seen success in randomized trials using brentuximab vedotin.
Are there any special concerns for HL patients?
Since the majority of HL patients are younger, in their late 20's to early 30's range, these treatments do pose some risks other than the traditional side effects of therapy. Namely in this age range fertility is often a concern. ABVD has a very low rate for affecting fertility and the younger you are the less likely you will have any complications. Given that the need for second line therapy in relapsed or refractory patients does present more of a substantial risk, we always discuss precautionary measures with patients like sperm banking for males and egg collection and freezing for females. It is important for young adults with lymphoma to discuss fertility concerns and options with their healthcare team.
Do you suggest clinical trials for HL patients?
Yes, clinical trials are designed so that we expect to see positive responses in patients. For example, some people do not respond to brentuximab but clinical trials are showing that some other new agents like BD1 antibodies are inducing very good responses. Information like that and the potential for better treatments can really only happen through patients' involvement in clinical trials. Clinical trials provide an opportunity for patients to receive the latest therapies in a setting that is designed to receive better positive outcomes for patients. Specifically, Phase I and II trials regarding immune checkpoint inhibitors are showing major promise.