Q&A: Better Treatments for Hodgkin's Disease

Treatments for Hodgkin's disease are very effective in the majority of patients. However, serious side effects, although rare, can be dangerous and difficult for some. This fact continues to motivate doctors to find better treatments.

Answering questions about the disease and current treatments is Fredrick Hagemeister, M.D., professor in the Department of Lymphoma and Myeloma at M. D. Anderson.

What is Hodgkin's disease?

Hodgkin's disease is a lymphoma, a cancer of the lymphatic system, the tissues and organs that produce, store and carry special white blood cells called lymphocytes. (Hodgkin's disease contains the Reed-Sternberg cell, a type of lymphocyte. Non-Hodgkin's lymphomas are different diseases under the microscope and are treated differently.)

What is the standard treatment for Hodgkin's disease?

Early stage(having one or two cancerous lymph nodes above or below the diaphragm) - treated with chemotherapy with or without radiation.

Advanced stage- treated with chemotherapy.

Recurrent disease(the return of the disease) - involves high-dose chemotherapy with stem cell rescue. A patient's stem cells are removed and frozen to protect the cells from being destroyed by the high-dose chemotherapy, which is administered next. After chemotherapy, the stem cells are injected back into the body.

What is the survival rate for Hodgkin's disease?

Hodgkin's disease is expected to be diagnosed in 7,880 people in the United States in 2004, according to the American Cancer Society (ACS). Approximately 84% of patients survive beyond 5 years, and 76% live beyond 10 years, the ACS says.

The risk of relapse is greatest within the first three years. This is why we follow patients closely during that time. The risk of relapse is very, very low after five years.

The survival rate for people who relapse depends on the stage of the disease, type of symptoms and response to chemotherapy.

What are the greatest treatment concerns?

We are looking for answers to the following questions:

• Is there anything better than ABVD [Adriamycin (doxorubicin), bleomycin, vinblastine and dacarbazine], one of the standard chemotherapy regimens commonly used to treat Hodgkin's disease?
• Can we eliminate radiation treatment?
• What are the best treatments for patients who relapse?

Why is a better treatment than ABVD needed?

Of the popular chemotherapy regimens used to treat Hodgkin's disease, we are most concerned about ABVD because it contains bleomycin. In one study, bleomycin caused more than one-fifth of the patients to have pulmonary symptoms. Pulmonary function has to be monitored very carefully. That's why there are many studies looking for better chemotherapy combinations.

Why do you want to eliminate radiation therapy?

Some patients who undergo radiation and survive Hodgkin's disease later have second malignancies and problems with cardiac dysfunction. (Chemotherapy may also contribute.) This can even happen for early stage patients. If we can eliminate the need for radiation, we may reduce the likelihood of secondary primary cancers, including breast, lung, skin and other cancers.

What are issues for relapsed patients?

There are five or six popular standard-dose chemotherapy regimens for Hodgkin's disease; however, the best one is not known because no trials have compared them. Stem cell transplants have been shown to be better than standardized care (chemotherapy and radiation without the transplant), but we still need to know the best combination of chemotherapy.

What M. D. Anderson studies are being conducted for relapsed disease?

A variety of new drugs are being used to treat Hodgkin's disease. SGN30 is a monoclonal antibody we are using as a single agent in a multi-institutional study. It could be added to a chemotherapy regimen, probably ABVD.

We also are heading a national study involving Velcade (bortezomib), a very active agent in myeloma. We hope it would be effective for Hodgkin's disease.

There is also a multi-center trial that intends to answer the question of whether a shorter course of intensive chemotherapy and radiation is better than ABVD standard chemotherapy plus radiation.

What is the hope for the future?

After treatment, 90% of patients with early stage disease have no sign of disease. For later stages of disease we don't have the same results, but we're improving results by:

• Catching the disease early in relapse so we can conduct stem cell rescue
• Controlling complications
• Conducting studies that look at how Hodgkin's disease cells are resistant to chemotherapy

The exciting thing is that cancer centers are all beginning to work together in developing new treatments for Hodgkin's disease through joint clinical trials. That is very helpful because the number of people with Hodgkin's disease is relatively low.