SOHO 2023 | Elderly patients with HL: unmet needs and promising strategies
Jonathan Friedberg, MD, MMSc, University of Rochester, Rochester, NY, comments on the inferior outcomes of elderly patients with Hodgkin lymphoma (HL) compared to younger populations, often due to lower treatment tolerability and variations in disease biology. Prof. Friedberg suggests some appealing approaches, such as sequential treatment with rituximab then ABVD chemotherapy, or the use of checkpoint inhibitors. This interview took place at the Eleventh Annual Meeting of the Society of Hematologic Oncology (SOHO 2023) held in Houston, TX.
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Transcript (edited for clarity)
Hodgkin lymphoma, as the audience knows, is a highly curable malignancy. More than 80% of patients diagnosed with Hodgkin lymphoma are ultimately cured. Outcomes have improved dramatically such that in many situations, we are trying to minimize treatment rather than continue to work to improve efficacy. The one group of patients that has been left behind in this success are the older patients. If you just look at patients over the age of 60, that constitutes up to 20% of patients with Hodgkin lymphoma, and those patients have a markedly inferior outcome...
Hodgkin lymphoma, as the audience knows, is a highly curable malignancy. More than 80% of patients diagnosed with Hodgkin lymphoma are ultimately cured. Outcomes have improved dramatically such that in many situations, we are trying to minimize treatment rather than continue to work to improve efficacy. The one group of patients that has been left behind in this success are the older patients. If you just look at patients over the age of 60, that constitutes up to 20% of patients with Hodgkin lymphoma, and those patients have a markedly inferior outcome. As the age goes up, the outcome even gets worse, such that for patients over the age of 70, the survival curve looks much more like a solid tumor survival curve than what you would normally expect with Hodgkin lymphoma. The reasons for this are likely several. In addition to tolerability of treatment, which is a major issue, for example, using the ABVD regimen, up to 10% of patients in some of the studies over the age of 60 had mortality related to bleomycin lung toxicity, and that’s not something that we generally see very frequently in younger patients. Tolerability of treatment is an issue, but so is likely biology of disease. We know that there are some differences, there is an increased incidence of mixed-cellularity subtype, there may be more EBV positivity. Likely, as we get enhanced understanding of genetic changes, there are differences there. So, the approach to treatment relies to some degree on the fitness of the patient. I think for fit patients, what we’ve learned is that rather than giving AVD and brentuximab altogether, a sequential approach of giving brentuximab first, then AVD chemotherapy and then some brentuximab at the end is better tolerated and has at least equal efficacy. However, for the more common scenarios where patients may be unfit or frail as they get older, combination chemotherapy is less likely to be effective or tolerated, and in those scenarios, there is increased evidence, although preliminary, that early incorporation of either single agent brentuximab, doublet combinations, or most recently, the use of checkpoint blockade- either alone or with brentuximab- are very appealing options.
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