Progress isn’t free.

Headline: Omitting radiation for all patients with favorable, early stage Hodgkin lymphoma with a negative PET scan after chemotherapy is a bad idea.

The Study: This is a touchy subject. That’s because some (many?) med oncs feel that radiation is an archaic hold-over from the early days of Hodgkin lymphoma (HL). That argument is great if you genuinely believe chemo is harmless. In H10, the EORTC concluded that giving ABVD alone produced a rate of progression-free survival (PFS) that was not non-inferior to standard ABVD + involved nodal radiation (99% with → 87% without radiation at 5 years). In contrast, the authors of RAPID shrugged off their not non-inferior outcome to essentially conclude that disease outcomes were “good enough” sans radiation (PFS 95% → 91% at 3 years). Here we have the final results from the HD16 trial where patients with favorable HL received the German standard of ABVD x 2 cycles followed by, if PET-negative, 20 Gy versus observation. At 5 years, omitting radiation yet again reduced PFS from 93% → 86%, officially not non-inferior. So. Are continued calls for omission based on a founded belief that radiation results in excess non-lymphoma events decades later? Or that radiation should be omitted simply as a final treatment vestige of days gone by? If the former, then it makes sense to carefully select patients for whom the potential long-term effects of radiation balance the consistent 5-10% decrease in disease control. If the latter, these data provide no evidence that radiation should be systematically omitted from the treatment paradigm for early stage HL.

TBL: Among patients meeting GHSD-favorable criteria for Hodgkin lymphoma and a negative PET after 2 cycles of ABVD, the omission of radiation results in a significant decrease in disease control. | Fuchs, J Clin Oncol 2019 as presented by Eich, ASTRO 2019