Elderly patients make up a significant number of cases of newly diagnosed Hodgkin lymphoma. However, unlike in young patients, the outcomes of elderly patients are poor, and they are under-represented in phase III trials. Prior to treatment initiation, geriatric assessment should ideally be performed to address the patient’s fitness and decide whether to pursue a curative or palliative approach. The ABVD regimen is poorly tolerated in unfit patients, with high treatment-related mortality. Alternative chemotherapy approaches have been explored, with mixed results obtained concerning their feasibility and toxicity in phase II trials. The introduction of brentuximab vedotin-based regimens led to a paradigm shift in first- and further-line treatment of elderly Hodgkin lymphoma patients, providing adequate disease control within a broader patient population. As far as checkpoint inhibitors are concerned, rwesearchers are only just beginning to understand the role in the treatment of this population. In relapsed/refractory settings there are few options, ranging from autologous stem cell transplantation in selected patients to pembrolizumab, but unfortunately, palliative care is the most common modality. Importantly, published studies are frequently burdened with numerous biases (such as low numbers of patients, selection bias and lack of geriatric assessment), leading to low level of evidence.
Domain | Explanation | Tools Used in Aggressive Lymphomas and Proposed by ASCO |
---|---|---|
Non-cancer life expectancy | Comorbidities predicting the non-cancer-related mortality | CIRS-G [5][6][7][5,6,7] * HCT-CI [8][9][8,9] |
Geriatric syndrome | The aggregate of “symptoms and signs associated with any morbid process, and constituting together the picture of the disease” [10] | GA [11] ** and G8 [12][13][12,13] *** |
Function | Loss of activities of daily life (ADL) and instrumental activities of daily life (IADL) | Katz index for ADL [14][15][16][14,15,16] Schonberg index for IADL [17] ****; other indexes [16][18][19][20][16,18,19,20] |
Falls | Number of falls in the last 6 months [4] | Single-item question |
Cognition | Cognitive impairment is associated with worse outcomes [4] | Various indexes [21][22][23][21,22,23] ***** |
Depression | Depression in cancer patients is related to multiple variables, ranging from treatment feasibility and mortality to functional decline [4] ****** | GDS [24] |
Nutrition | Unintentional weight loss and BMI are associated with mortality [4] | SMM, CT and PET-CT [25] ******* |
Toxicity | Risk factors for treatment-related toxicity | GA [11], G8 [12], GRI [22], nutrition [25] and CARG toxicity tool [26] |
Study | n | Disease Stage | Regimen | CR | Outcome Rate * | p ** | AE Rate N (Rate) *** |
CVD-Related Death N (Rate) |
Respiratory AE N (Rate) *** |
Infection AE N (Rate) *** |
TRM Due to AEs |
---|---|---|---|---|---|---|---|---|---|---|---|
Boll et al. [39] | 117 | early | ABVD 4x | 89% | 5-year PFS = 74.8% 5-year OS = 81.2% |
p < 0.001 | 79 (68%) | 8 (7%) | 6 (5%) | 11(10%) | 5% |
Boll et al. [41] **** | 287 | early | AVD 2x (HD13, N = 82) | 98% | 5-year PFS = 79% 5-year OS = 91% |
p = NR | 31(40%) | NR | NR | 2(3%) | 1% |
ABVD 2x (HD13, N = 67) |
99% | 5-year PFS = 78% 5-year OS = 86% |
26 (42%) | 3 (4%) | 1 (2%) | 4 (6%) | NR | ||||
ABVD 2x (HD10, N = 70) | 96% | 5-year PFS = 79% 5-year OS = 84% |
24 (37%) | NR | 1(2%) | 5 (8%) | 3% | ||||
ABVD 4x (HD10, N = 68) | 88% | 5-year PFS = 79% 5-year OS = 87% |
45(65%) | 5 (7%) | 7 (10%) | (8) 12% | 6% | ||||
Evens et al. [43] ***** |
24 | advanced | ABVD x6 |
65% | 5-year FFS = 53% 5-year OS = 64% |
p = 0.002 p < 0.0001 |
22 (92%) | NR | Grade 3 = 5 (20%) Grade 4 = 7 (27%) |
Grade 3 = 10 (4%) Grade 4 = 10 (4%) |
9% |