What options do I have for an elderly patient with Hodgkin lymphoma who cannot tolerate ABVD?

Senior Director of Clinical Affairs, Executive Medical Director, Huntsman Cancer Institute, Salt Lake City, Utah

This month, John Sweetenham, MD, advises on treatment options for an elderly patient with Hodgkin lymphoma.

CLINICAL DILEMMA

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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