NCCN Updates Hodgkin’s Disease Treatment Guidelines

HOLLYWOOD, Florida- There were several significant changes to the National Comprehensive Cancer Network (NCCN) Hodgkin's disease guidelines announced at the Seventh Annual NCCN Conference (see Table for NCCN member institutions). According to Richard T. Hoppe, MD, of Stanford Hospital and Clinics and chair of the NCCN Hodgkin's disease panel, the most recent version excludes laparotomy from the initial evaluation guidelines. Laparotomy had been in previous guidelines as an option for patients as part of the staging evaluation. "With respect to the initial staging evaluation of patients, none of the NCCN institutions any longer are performing staging laparotomy and splenectomy," he said. The new guidelines recommend combined modality therapy for all patients with early-stage disease. "For the management of patients with localized disease that is stage I and II, in every scenario, we now indicate that the preferred treatment is combined modality therapy, which is generally going to be abbreviated chemotherapy plus involved- field radiation therapy," Dr. Hoppe said. "There are still yet some scenarios where we consider radiation therapy alone to be acceptable, but that's not necessarily the treatment of choice." Combined modality therapy had been listed previously as an option, but this year it was listed as the preferred option. This change, according to Dr. Hoppe, was based on clinical trials, mainly in Europe, looking at long-term outcome of treatment with combined modality therapy vs radiation therapy alone. "In addition, for early-stage disease, we have mentioned treatment with chemotherapy alone; however, we advise that chemotherapy alone should really be done only in the setting of a prospective randomized clinical trial," he said. The new guidelines also reflect a deletion of the recommendation of consolidative radiation therapy for patients with nonbulky stage III or IV disease. The change is based on a recent European Organization for Research and Treatment of Cancer (EORTC) trial that was reported last year at the American Society of Therapeutic Radiation Oncology (ASTRO) and American Society of Hematology (ASH) annual meetings. "However, we continue to recommend consolidative radiation therapy for virtually all stages of disease where there is a large mass, whether it is early disease or advanced disease," he commented. Dr. Hoppe and his co-presenter, Jane N. Winter, MD, of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, made a strong point to encourage United States clinicians to enter patients into Hodgkin's disease clinical trials. Currently in the United States, there is a trial for advanced disease comparing conventional treatment ONI with ABVD (doxorubicin, bleomycin(Drug information on bleomycin), vinblastine(Drug information on vinblastine), and dacarbazine(Drug information on dacarbazine)) to treatment with Stanford V (doxorubicin, vinblastine, mechlorethamine, vincristine, bleomycin, etoposide, and prednisone(Drug information on prednisone)) chemotherapy. This always includes consolidative radiation therapy to bulky sites of disease, defined as greater than 5 cm, Dr. Hoppe said. Large cooperative group trials in Europe are looking at issues related to the management of early disease. "Those are important-they are testing the question of how many cycles of chemotherapy are appropriate and what dose of radiation is necessary for patients with stage IA or IIA disease. Those trials have variations in the numbers of cycles of chemotherapy, from 2 to 4 to even 6, and in the dose of radiation from 20 Gy to 30 Gy and 36 Gy," Dr. Hoppe said. In addition, he said, there are trials in Europe and North America testing the concept of chemotherapy alone for patients with early-stage disease, "and we encourage participation in those trials."