Cost considerations in the first-line treatment of advanced Hodgkin lymphoma
Cette étude canadienne compare le rapport coût-efficacité de 5 stratégies thérapeutiques de première ligne chez des patients atteints d'un lymphome hodgkinien de stade avancé et éligibles pour une greffe
The choice of first-line treatment for advanced Hodgkin lymphoma must balance disease control with early and late treatment-related effects. For ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine), concerns about long-term toxicities, especially secondary malignancies and infertility, are reduced at the expense of higher relapse rates. Conversely, BEACOPP escalated (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone in escalated doses) provides excellent initial disease control but leads to higher immediate and long-term toxicities. To improve upon these shortcomings, major cooperative groups have modified ABVD and BEACOPP escalated with use of interim PET-adapted augmentations to maintain disease control and reduce toxicities. From the RATHL trial, ABVD is now escalated to BEACOPP escalated in individuals who are at high risk of relapse (Deauville score of 4 or 5 via interim PET scan), or de-escalated to prevent bleomycin pulmonary toxicity (in patients with Deauville score 1–3). For BEACOPP escalated-based strategies, BEACOPP escalated is now either de-escalated to ABVD after two cycles in patients with a Deauville score of 1–3 (as per the AHL2011 trial), or reduced to a total of only four cycles in patients with a Deauville score of 1–2 (as per the HD18 trial ), from the historical eight cycles. In both the AHL2011 and HD18 trials, de-escalating BEACOPP escalated reduced major concerns, including treatment-related mortality and long-term toxicities. Recently, a novel agent (brentuximab vedotin) has replaced bleomycin in ABVD to form A-AVD (brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine), in an attempt to improve disease control and avoid pulmonary toxicity associated with bleomycin (as per the ECHELON-1 trial). However, A-AVD has concerns of its own, including peripheral neuropathy, febrile neutropenia, financial toxicity, and uncertainties with salvageability and long-term outcomes. With many new treatment approaches, the debate surrounding first-line chemotherapy selection for advanced Hodgkin lymphoma has become even more controversial. Unfortunately, randomised controlled trials comparing the modern approaches have not been done, further complicating decision making and leaving clinicians to infer conclusions based on cross-trial comparisons.
The Lancet Haematology , commentaire, 2019