RT FOR EARLY HODGKIN DISEASE

SAN FRANCISCO — A new study showing a significant survival benefit in patients with early-stage Hodgkin's lymphoma who received consolidation radiation added onto chemotherapy is bound to fuel the ongoing debate about whether the use of any radiation at all in early-stage Hodgkin's disease is worth the potential long-term risks.

The study was presented here during the American Society for Radiation Oncology (ASTRO) 56th Annual Meeting. It showed that the 10-year overall survival rate in patients with stage I and II Hodgkin's disease was 84.4% for those who received consolidation radiation after chemotherapy compared with 76.4% for those treated with chemotherapy alone (P < .00001).

"This is the largest data set in this patient population to demonstrate a survival benefit with the addition of radiation therapy," said lead author Rahul Parikh, MD, director, proton beam therapy, Mount Sinai Health System, and assistant professor of radiation oncology, Icahn School of Medicine at Mount Sinai, New York City.

"Given the survival benefit demonstrated in this study, radiotherapy should be included in the combined modality approach of multiagent chemotherapy followed by consolidation radiation therapy in order to maintain high overall survival rates for this curable disease," Dr. Parikh said in a statement.

Others totally disagree.

"Radiation therapy is really not indicated in all patients in early-stage Hodgkin's disease," Vincent DeVita Jr, MD, Amy and Joseph Perella Professor of Medicine and Epidemiology, Yale School of Public Health, New Haven, Connecticut, told Medscape Medical News.

Only about 12% of patients with early-stage disease are resistant to chemotherapy, he explained, "so what you need to do is treat those 12% with radiation therapy, but not 100% of patients."

The way to identify those patients who are resistant to chemotherapy is to offer everyone chemotherapy first, he said. If patients become positron emission tomography (PET)-negative after an appropriate number of cycles, as about 90% of patients will be, those patients are cured, Dr. DeVita said. "The ones that are PET-positive you irradiate."

When physicians approach all patients with early-stage Hodgkin's disease with the combination of chemotherapy plus radiation, the early relapse rate seen in combined modality studies represents that 12% of patients who do not respond to chemotherapy, he said.

Indeed, this 12% of patients who are chemoresistant are the ones who are going to get into trouble later on anyway and who will require some sort of salvage therapy including potentially a transplant.

"Radiation therapy is the gift that keeps on giving," Dr. DeVita added. If oncologists are required to irradiate the mediastinum, patients can develop cardiac complications, for example.

"Like everything else, radiotherapy has improved a good deal," Dr. DeVita conceded, "but you are still exposing the heart to radiation therapy, and you get a lot of second tumors, especially in the breast if you radiate the breast."