Hodgkin Lymphoma (HL) is one of the most common malignancies in young adults and has become curable for the majority of patients even in advanced stage. Nowadays, the main challenges are to develop strategies that decrease secondary malignancies and mortality, as well as to retain fertility after treatment. So far, there is no national or international evidence-based guideline giving recommendations for clinical practice in the treatment of HL patients. For this reason, various medical societies, clinical experts from the German Hodgkin Study Group (GHSG) and methodological experts from the Cochrane Haematological Malignancies Group (CHMG) have developed and consented a clinical practice guideline to improve and standardize diagnosis, treatment and follow-up for HL patients. This project was funded by the German Program for Guidelines in Oncology Implementation.
To emphasize the clinically most relevant guideline recommendations related to diagnostics, treatment and follow-up of adult HL patients.
Randomized controlled trials, systeamtic reviews, cohort studies and specific sensitive data included from systematic literature searches in CENTRAL and MEDLINE were appraised for quality and summarized in evidence tables. Based on these tables and trials, guideline authors generated high quality clinical recommendation in an intensive collaboration with the methodological experts clinical experts from different multi-interdisciplinary working-groups. During the final consensus conference, a total of 160 evidence-based recommendations were consented.
There is a strong consensus that all patients should be treated within a clinical trial. Chemotherapy is the mainstay of treatment for all stages of HL. The histological diagnosis should be confirmed by a reference pathologist. For early favorable stages, two cycles of ABVD followed by involved-field radiotherapy (IF-RT) at 20 Gy are strongly recommended; early unfavorable stages should be treated with 2 cycles of BEACOPP escalated followed by 2 cycles of ABVD and IF-RT of 30 Gy; for advanced stages six cycles of BEACOPP escalated followed by 30 Gy radiotherapy on PET-positive residual mass ≥ 2cm is strongly recommended. It is also recommended that patients with relapses or refractory disease, and without severe co-morbidities, receive autologous stem cell transplantation, but not myeloablative allogeneic stem cell transplantation. Additionally, treatment options of subgroups, such as nodular lymphocyte predominant HL, elderly patients or those with co-morbidities such as HIV, are specified in this guideline. The additional benefit of PET remains uncertain as of the lack of high-quality evidence, therefore different recommendations have been provided for staging, interim and follow-up evaluations. It is highly important that health care professionals discuss aspects of fertility protection with female and male patients before starting any treatment. Options for preserving fertility in women have to be adopted to treatment intensity. For male patients, it is recommended to cyropreserve sperm cells before starting the therapy, independently of treatment intensity. There is strong consensus that patients have to prevent to conceive a child during treatment. Health-care professionals should encourage patients to exercise and should discuss potential harms of complementary medicine with the patient. Due to their immunomudulating effect, it is not recommended to take mistletoes at any time. It is strongly recommended to motivate patients to give up smoking, due to the strong associated increased risk of secondary tumors, especially bronchial carcinoma. Structured follow-up care should be provided and should in particular detect relapses, long-term organ toxicities and secondary malignancies.
The first evidence-based guideline on the treatment of patients with HL translates scientific evidence and expert knowledge into precise recommendations for these patients into clinical practice. In addition to this clinical value, the guideline will enable healthcare professionals to improve patient information and quality management.
Engert:Takeda, Millennium: Honoraria, Research Funding. Borchmann:Millenium The Takeda Oncology Company: Research Funding, Travel Grants Other. von Tresckow:Millenium The Takeda Oncology Company: Honoraria, Travel Grants Other.
Asterisk with author names denotes non-ASH members.