Search for Effective Regimens in Elderly Patients With Hodgkin Lymphoma
As the U.S. population continues to age, oncologists will be faced with a growing number of elderly patients with Hodgkin lymphoma, but there is currently no consensus on how to treat this population. Regimens used to treat younger patients have too much toxicity for most older patients, and thus it is necessary to identify effective alternative treatments, explained Jane Winter, MD, of Feinberg School of Medicine, Northwestern University, Chicago, at the National Comprehensive Cancer Network (NCCN) 9th Annual Congress on Hematologic Malignancies in New York. Potential options for elderly patients who have good performance status include VEPEMB (vinblastine, cyclophosphamide, procarbazine [Matulane], etoposide, mitoxantrone, and bleomycin), brentuxumab vedotin (Adcetris)–including regimens, and clinical trials.
Lower, but Persistent, Responses in Elderly Population
Hodgkin lymphoma most commonly affects younger and middle-aged people. However, about 20% of cases occur over age 65, and males over 80 have twice the incidence of middle-aged people, Dr. Winter noted.
“As the population ages, we will be seeing more and more elderly people with Hodgkin lymphoma. Deaths from Hodgkin disease occur disproportionately in the elderly, and response rates are generally lower. However, once an elderly person achieves complete response, it usually persists. Studies suggest that 3-year survival is 60% in elderly patients who achieve complete remission,” Dr. Winter continued.
“Complete remission is the most important predictor of survival,” she emphasized.
“Patients who relapse do not do very well. Those with indolent disease do better,” she stated.
The clinical presentation is different in the elderly, with more mixed cellularity, Epstein Barr-Virus positivity, B symptoms, higher erythrocyte sedimentation rate, and poor performance status compared with younger counterparts. The elderly also have less nodular sclerosis, large mediastinal masses, and bulky disease. The stage distribution is similar between the elderly and younger patients.
How to Treat the Elderly?
ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) is the standard of care in the United States and Canada, while Europeans prefer escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone); both regimens contain bleomycin. Patients over age 65 years don’t do as well as middle-aged or younger patients on these toxic regimens, Dr. Winter told listeners. In particular, bleomycin-related pulmonary toxicity is problematic. Thus, researchers are studying other options.
In the SHIELD study, investigators looked at the VEPEMB regimen in patients aged 60 and older. This non–anthracycline-containing regimen utilizes half the dose of bleomycin as ABVD. Patients who achieved complete remission on VEPEMB did very well, and the regimen was reasonably tolerated. In early-stage patients, complete remission was 74%, 3-year overall survival was 81%, and 3-year progression-free survival was 74%. In advanced stage patients, complete remission was 61%, 3-year overall survival was 66%, and 3-year progression-free survival was 58%.
“VEPEMB is an interesting option,” Dr. Winter said. “This shows us what can happen when patients who can tolerate these regimens get them.”
The non–bleomycin-containing PVAG (prednisone, vinblastine, doxorubicin, and gemcitabine) regimen was tested in elderly patients with Hodgkin lymphoma in a phase II study, but it proved too toxic. Grade 4 toxicity was reported in 33% of patients, and thus PVAG is not recommended for this population, she said.
Another option under study in the elderly is induction with two cycles of brentuximab vedotin, followed by six cycles of ABVD. Several trials of brentuximab vedotin are underway and can be accessed at www.clinicaltrials.gov
“Of course, enrolling patients on clinical trials is always a good idea,” Dr. Winter concluded.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
