Hodgkin lymphoma: improving outcomes, reducing side effects

The ASH (American Society of Hematology) meeting in December is the largest gathering of lymphoma experts worldwide. In January, UK experts met in London to talk about the latest developments presented at ASH and their implications for clinical practice in the UK.

In this, our third summary, we are looking specifically at Hodgkin lymphoma.  

Treatment for Hodgkin lymphoma is generally very successful. Research continues to focus on improving the outcomes for people who don’t respond well to their first treatment and on reducing the side effects of treatment for people who do well. New research findings from the American Society of Hematology’s (ASH) annual meeting were discussed by UK clinicians at a post-ASH meeting held in London in January 2018.

Brentuximab vedotin is a newer drug that can now be used for some people with classical Hodgkin lymphoma that has relapsed (come back) or was refractory (didn’t respond to treatment). Many clinical trials are trying to find out if using it as part of first-line treatment can replace the more toxic drugs in standard treatment as well as increasing the number of people who respond to treatment. Most of these trials replace the bleomycin (B) in the standard ABVD chemotherapy regimen (combination of drugs) with brentuximab vedotin.

In a trial where this approach was used for early-stage Hodgkin lymphoma, together with reducing the amount of radiotherapy given after chemotherapy, all 29 people included had a complete response to treatment, with no relapses. This trial is now testing whether radiotherapy can be omitted completely or a new radiotherapy technique can be used to spare people the long-term effects of radiotherapy. Another trial showed that more people responded well to treatment with the new regimen (82%) compared with standard ABVD (75%) but there were some serious side effects and longer follow-up is needed to see if there is any difference in the risk of relapse.

For advanced-stage Hodgkin lymphoma, the phase 3 ECHELON 1 trial tested the same regimens of brentuximab vedotin with AVD versus standard ABVD. The people in the trial are still being followed-up but initial results suggest the new regimen is slightly more effective than the standard regimen. The side effects of the two regimens differ, with brentuximab causing more peripheral neuropathy (nerve problems) and risk of infection and standard treatment causing more lung problems.

Although many people with advanced-stage Hodgkin lymphoma are treated with ABVD, some have a more intensive (stronger) treatment called escalated BEACOPP. This can be more effective but also causes more side effects, with a greater risk of causing infertility. As many people with Hodgkin lymphoma are young, the risk of infertility is a common concern. A new approach showed that people who respond well to the first 2 cycles of escalated BEACOPP do just as well if they have only 2 more cycles instead of the usual 4 or 6 more cycles. This reduces side effects and makes the treatment course shorter. In general, escalated BEACOPP is often considered for people with a high international prognostic score, which means they have lots of factors that mean their lymphoma might be difficult to treat (‘risk factors’).  

For people with Hodgkin lymphoma who do relapse, there are now more treatment options, including more chemotherapy and a stem cell transplant, brentuximab vedotin, and checkpoint inhibitors, which are drugs that harness the power of your immune system to fight the lymphoma. One study showed that checkpoint inhibitors could even still benefit people whose lymphoma is getting worse while they are on treatment as long as they feel well.

Clinical trials are continuing to advance treatment approaches and improve outcomes for people with Hodgkin lymphoma.

Still to come….

Newer drugs, new treatment goals and new guidelines driving change in chronic lymphocytic leukaemia (CLL)

New approaches show promise for high-grade non-Hodgkin lymphoma