Two major areas of dispute in Hodgkin lymphoma are treatment of advanced stages and of elderly patients. For advanced stages the debate is whether BEACOPPesc/14 or ABVD is to be considered standard. ABVD is standard in many countries, especially for those with IPS 0-2. There is no golden standard for therapy in elderly patients. In Sweden CHOP has been the standard treatment in patients >70 years during the study period. Outcome is also inferior in elderly compared with younger patients.
We have analysed data from all 2345 Hodgkin lymphoma patients (1257 men and 1088 women, median age 42, range 16-99) diagnosed from 2000 through 2014 in the Swedish Lymphoma Registry. Median follow-up was 6.7 years. Overall survival (OS) at 3 and 5 years were 83% and 79%, without any differences between calendar periods (2000-2004, 2005-2009, and 2010-2014). In the most recent calendar period (2010-2014), longer survival was observed among patients ≥61 years (P = 0.027), but not among those <61 (P = 0.49). This improvement was restricted to women with advanced stage disease (P = 0.005). Stage IV disease was more common in the most recent calendar period (2010-2014) compared to the first (2000-2004), both in women (22% vs 15%, P = 0.003) and in men (28% vs 21%; P = 0.006), likely explained by the increasing use of PET-CT. In multivariate analysis, adjusted for all factors significant in univariate analysis, of patients ≥61 years, CHOP (compared with ABVD) was an independent adverse factor for OS (HR 1.7; 95% CI, 1.1-2.7; P = 0.027). Patients <61 with advanced stages treated with BEACOPPesc/14 and ABVD showed identical OS in univariate and multivariate analysis (P = 0.51).
In conclusion, outcome was not improved over time except in elderly women. The implementation of FDG-PET/CT has resulted in a stage migration with an increased proportion of patients with stage IV disease. ABVD seems superior to CHOP for elderly who tolerate this regimen. BEACOPP and ABVD show equal OS in younger patients with advanced stage disease, supporting the use of PET/CT-adapted ABVD as initial therapy.