Published on April 17, 2019
How are novel agents being used in Hodgkin lymphoma care? Does aggressive chemotherapy still have a role? Leading Hodgkin lymphoma experts Dr. Andrew Evens, from Rutgers Cancer Institute of New Jersey, and Dr. Joshua Brody, from Icahn School of Medicine at Mount Sinai, discuss how doctors are integrating more targeted treatments, patient response from new frontline therapies and disease subtypes. Watch now to learn more from the experts.
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Transcript | Understanding Treatment Options: What Is the Course of Care for Hodgkin Lymphoma?
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Traditionally, you’ve done transplant and pretty aggressive therapy if people could withstand it, right?
Well, only for relapsed disease, not front-line. There have been studies looking at that. Before we had novel agents and maybe before Josh and my time, they thought more was better, so they would try to do transplants, and it was trying the best they can, but not for newly diagnosed. Only if it’s come back.
Newly diagnosed, then, has been traditionally pretty aggressive chemotherapy, right?
So, we have—actually, as Andy says, really, a spectrum of aggressiveness. The tried and true chemotherapy over these past 40 years has been an intermediate aggressive chemotherapy we call ABVD, but there have been a lot of trials, more aggressive approaches, more so in Europe than America, a very aggressive approach called BEACOPP or escalated BEACOPP.
That chemotherapy is as tough as an autologous transplant, I would say, and ultimately, ABVD has still been the standard in America and most places in the world, and the question now is can we get a little bit away from the chemotherapy to try to integrate some of these targeted immune therapies into the front-line?
So, what are those new ones?
That’s the brentuximab vedotin (Adcetris).
So, in this big study, the brentuximab vedotin antibody/drug conjugate was the big event. It’s not a new therapy for Hodgkin—it’s seven years of FDA approval for later lines of therapy—but bringing it into the front-line—this is always the way that we discover and implement new drugs. We discover them in later lines of therapy for patients for whom standard things haven’t worked, and then, if they’re very promising, as brentuximab has been, we try to move it from third-line to second-line and first-line therapy.
Okay, but my understanding is with this sort of lymphoma, treatment can be curative.
The high majority of patients—so, that early stage, stage I or II, more than 90 percent of patients will be cured, meaning go away, not come back.
No—well, I would say early stage is less common in the older patients, but probably both groups. And then, for advanced stage, it still is high. It’s not as high as 90 percent, maybe 75 to 80 percent are cured, and that’s where there is some drop-off in the older patient, where historically, it had been quite low—actually 30 to 40 percentage points worse—and that had been a matter of debate. Why is that? Certainly, are you older, is it tolerability? Particularly, the bleomycin can be toxic to older patients in the lungs. But, we also think it might be a different biology—the older patients.
So, there are a few different subtypes of Hodgkin lymphoma. They tend to be a little different—something called mixed cellularity—you tend to see a virus inside the tumor called Epstein-Barr virus. So, it could be a little bit of both of why older patients historically had done not just a little worse, but actually a lot worse, so we think that’s changing too.