This month, John Sweetenham, MD, advises on treatment options for an elderly patient with Hodgkin lymphoma.
I have a 90-year-old female patient with relatively poor performance status and newly diagnosed bulky, symptomatic Hodgkin lymphoma. What treatment options does she have – chemotherapy with ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, and dacarbazine), gemcitabine as a single agent, brentuximab vedotin, others? I worry that she won’t be able to tolerate ABVD.
EXPERTS MAKE THE CALL
As you know, treatment of Hodgkin lymphoma in elderly patients is challenging – mainly due to the risks of excessive treatment-related toxicity, and the fact that older patients with the disease have a significantly worse prognosis than younger patients. Since your patient is not a candidate for ABVD, I am assuming that her performance status is also poor, which will limit therapeutic options.
I think brentuximab vedotin is worth considering in this scenario. The risk of peripheral neuropathy associated with this treatment, however, can be dose-limiting. Even so, I think this is one of the most active single agents for Hodgkin lymphoma and a reasonable option – especially because the peripheral neuropathy can be managed by dose reduction if it interferes with her activities of daily living.
Since this is a palliative rather than curative situation, oral chlorambucil is another option to consider if the patient does not tolerate brentuximab vedotin. I know it sounds unlikely, but chlorambucil does have single-agent activity in Hodgkin lymphoma and was a component of front-line regimens for Hodgkin lymphoma in younger patients in Europe for many years. It is certainly well tolerated.
Finally, rituximab as a single agent may also be worth considering. It has a 20 to 30 percent response rate in classical Hodgkin lymphoma, and I have had some impressive anecdotal experiences with this approach.
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