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Journal of Clinical Oncology, Vol 23, No 1 (January 1), 2005: pp. 245-246 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.99.122
Radiotherapy in Advanced-Stage Hodgkin's LymphomaDepartment of Hematology, University Medical Center, Nijmegen, the Netherlands
Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, the Netherlands
Department of Epidemiology and Biostatistics, Centre François Baclesse, Caen, France On behalf of the EORTC Lymphoma Group To the Editor: We have read with great interest the report of Laskar et al1 and the accompanying editorial of Diehl2 on the role of radiotherapy (RT) after chemotherapy in the treatment of patients with Hodgkin's lymphoma (HL). Recently, we have reported that adult patients with advanced-stage (III and IV) HL in complete remission (CR) after mechlorethamine, vincristine, prednisone, and procarbazine (MOPP)/doxorubicin, bleomycin, and vinblastine (ABV) chemotherapy, do not benefit from additional involved-field RT.3 Laskar et al report a statistically significant improvement of event-free and overall survival in patients in CR after six cycles of ABV and dacarbazine (ABVD) who were given additional RT, as compared with those who did not receive RT.1 The authors mention in their Discussion that our study, in contrast to their study, did not address the question of consolidation radiation in the proper perspective because all patients received consolidation chemotherapy before randomization to no further treatment or involved-field RT. We think that this is an incorrect interpretation of differences in design between the two studies. In general, it is recommended to give eight cycles of modern chemotherapy (ABVD, escalated bleomycin, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone, and gemcitabine [BEACOPP], or MOPP/ABV hybrid) to patients with advanced-stage HL. This recommendation neglects whether the CR is reached rapidly or later during chemotherapy. The European Organization for the Research and Treatment of Cancer Lymphoma Group used a response-adapted approach in such a way that patients who already achieve an early CR (after four cycles) receive only six cycles in total instead of the classical eight.4 Thus, those patients already received two cycles fewer than considered standard. There is little evidence in the literature to support the use of a total of only four cycles of chemotherapy in advanced stages. Withholding further chemotherapy after four cycles for these patients, as Laskar et al suggest through their interpretation, should be considered experimental, and therefore, could not be incorporated as a standard treatment in our study design. Indeed, our study analyzed the role of additional RT versus no further treatment in advanced stages. Furthermore, as pointed out by Diehl in his Editorial, Laskar et al included patients with all stages of HL for whom the number of required chemotherapy cycles may differ. For example, for certain subgroups of early-stage patients, a limited number of cycles (four or even fewer) might well be sufficient, instead of a fixed number of six. Whether RT adds to the clinical outcome in this specific subgroup of patients cannot be answered from the data of Laskar et al since numbers of patients in these subgroups are small, and frequencies of events are low. In addition, results of unplanned cohort analyses should always be regarded with caution. We fully agree with the statement of Diehl that "patients with advanced stages of Hodgkin's lymphoma will only benefit from additional RT when the preceding chemotherapy is inadequate for effective tumor control." In those with less than complete tumor control (eg, the patients with so-called partial remission), additional RT is indeed effective in reaching definite tumor control, as shown by our data. Carefully combining the experience gained in children and adults will help to design individually tailored treatment strategies with minimized early and long-term toxicities, while maintaining maximal cure rates. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Laskar S, Gupta T, Vimal S, et al: Consolidation radiation after complete remission in Hodgkin's disease following six cycles of ABVD chemotherapy: Is there a need? J Clin Oncol 22:62-68, 2004
2. Diehl V: Chemotherapy or combined modality treatment: The optimal treatment for Hodgkin's disease. J Clin Oncol 22:15-18, 2004
3. Aleman B, Raemaekers J, Tirelli U, et al: Involved-field radiotherapy for advanced Hodgkin's lymphoma. N Engl J Med 348:2396-2407, 2003 4. Somers R, Carde P, Henry-Amar M, et al: A randomized study in stage IIIB and IV Hodgkin's disease comparing eight courses of MOPP versus an alternation of MOPP and ABVD. J Clin Oncol 12:279-287, 1994[Abstract] Related Article
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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