Factors Considered When Choosing a Treatment Plan

Jonathon B. Cohen, MD, MS:This patient received a very appropriate workup: For most of my patients, I typically obtain a PET/CT [positron emission tomography/computed tomography] scan, which provides an accurate reading of their HL [Hodgkin’s lymphoma] stage. It also provides supplemental measurements to identify whether a patient has bulky disease, which is something else we take into account. I typically do not require my patients to have a bone marrow biopsy, unless there was some specific finding in their blood work or an anomaly leading me to suspect an alternative occurrence in the bone marrow. Otherwise, for most of my patients, I recommend an HIV screening if they haven’t been tested prior, in addition to an assessment of their baseline kidney and liver function to help inform whether they can tolerate therapy. Finally, patients for whom we’re considering bleomycin, I require pulmonary function tests—and those applicable for Adriamycin, or other anthracyclines, we’ll typically do a supplemental echocardiogram.

Most patients receive an appropriate workup—at least when they come to see me for an opinion. The only extraneous diagnostic test is perhaps the bone marrow biopsy. This has historically been a standard part of the lymphoma evaluation, but we found that it’s infrequent that the bone marrow biopsy effectively alters your approach to a patient. Furthermore, in Hodgkin’s lymphoma, bone marrow involvement is not particularly common—and so, in most cases, I don’t feel that it is necessary.

There are multiple factors I consider when creating a treatment plan for patients. Needless to say, our goal, generally speaking, is to cure them of their disease state and increase the success rate. [But] in patients [who] have, say, an underlying lung disease, in elderly patients—or those [who] have other comorbidities—we may need to adapt our treatment regardless of a possible slight decrease in the success rate of remission. For most patients we are attempting to cure, [however,] we consider the most aggressive treatments, irrespective of toxicity.

There’s an ongoing challenge when selecting a therapy for any patient with lymphoma [when] you’re trying to balance the efficacy-to-toxicity ratio. In my opinion, as mentioned, when striving for the achievement of remission, it is admissible to compromise a degree of toxicity for increased efficacy. This is my typical rationale when initially considering a patient for treatment. Certainly, there are instances when a patient can’t tolerate the most effective regimen [because of] underlying comorbidities—but that is something we deal with on an individual basis.

Transcript edited for clarity.

A 32-Year-Old Man with Stage IV Hodgkin's Lymphoma

• History & Physical:
  • A 32-year-old man presented to his PCP in January 2017 complaining of abdominal pain, pruritus, fevers of over 101⁰ F, and weight loss
• Imaging
  • PET scan showed avid mediastinal mass
• Labs
  • HgB 12.2 g/dL
  • WBC 7,500 mm²
  • ALC 3,200 mm²
  • Albumin 3.9 mg/dL
  • ANC 4,200/mm³
  • Liver and renal function tests WNL
• Biopsy confirmed mixed cellularity classical Hodgkin’s lymphoma (HL)
• Normal lung and cardiac function
• Final Staging: Stage IVB, cHL, IPS score 2
• ECOG PS 2
• He received 2 cycles of ABVD. PET/CT restaging showed Deauville (1-). He received 4 additional cycles of AVD
• He achieved a CR
• 2 years after completion of therapy, the patient complained of a persistent cough and fatigue
• PET/CT showed bilateral mediastinal masses
• Biopsy confirmed cHL