General Updates | Current treatment approaches for relapsed Hodgkin lymphoma & challenges that remain

So relapsed Hodgkin is becoming increasingly challenging, partly because it’s becoming increasingly rare. And so our sort of collective experience is diminishing. That’s a good thing, of course. And also as the frontline treatment landscape changes, that’s going to have an impact on how we treat patients with relapsed disease. So currently, you know, any patient I see with relapsed disease is brentuximab and checkpoint inhibitor naive. You know, they’ve not had those in the frontline setting. So, and where I work in England, we can only use targeted agents in a licensed and approved setting. And that means monotherapy third line, which is a bit frustrating because if I could choose anything, I would rather second line go straight for a checkpoint plus chemo combination, something like pembro-GVD or nivolumab plus ICE. The data there shows very high response rates. And what is so exciting about the checkpoint inhibitor data before a transplant is that it does seem to sensitize patients’ disease to a more effective outcome post-transplant. So, you know, there’s quite big data collection reports now showing that if you have a PD-1 inhibitor prior to your autologous transplant, that’s the single most important factor for predicting outcome after a transplant. However, at the moment, second line, I have to use chemotherapy. So, GDP, I typically use. It’s easy to give. There is some randomized data now from the Spanish, showing that introducing brentuximab second line with chemo, they combined it with ESHAP, so-called BRESHAP, that showed an increase in response rates. But as I say, we don’t have that available, so I have to stick with chemo. And then if that doesn’t work, if patients are chemo-refractory, then I tend to switch to a checkpoint inhibitor at that time. So pembrolizumab is the one that is reimbursed in that setting. Again, to try and get them in a better remission before a transplant, but also to get that chemosensitization. So even if it doesn’t work, the pembrolizumab, normally I can then go in with chemo again. And usually it does work in that setting because of this chemosensitization and then take patients to an autologous stem cell transplant. So most people, yes, I do aim for an autologous stem cell transplant. That was based on quite old randomized data. There are, though, there’s an increasing appreciation, I think, that there are some low-risk patients that we may not need to take to an autologous stem cell transplant. And there were two very interesting papers published by the pediatric group in Europe, one using brentuximab and nivolumab combination. That was a commercial study and radiotherapy consolidation to low-risk relapse patients. And that included patients up to the age of 30, showing very high deep remissions, probable cures from that approach. And another was an academic study, again, taking low-risk relapsed patients and giving them chemotherapy, again, with consolidation radiotherapy. So I think you do need to consolidate patients in the relapsed setting. But whether you always need to do an autologous transplant or can you use something else like radiotherapy is more up for debate. There are also people looking at PD-1 inhibitors as a consolidation, trying to avoid a transplant. But I think the jury’s out at the moment on that strategy.

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