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Comparison of chemotherapy including escalated BEACOPP versus chemotherapy including ABVD for patients with early unfavourable or advanced stage Hodgkin lymphoma

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Abstract

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Background

There are two different international standards for the treatment of early unfavourable and advanced stage Hodgkin lymphoma (HL): chemotherapy with escalated BEACOPP (bleomycin/etoposide/doxorubicin/cyclophosphamide/vincristine/procarbazine/prednisone) regimen and chemotherapy with ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine) regimen.

Objectives

To provide an evidence‐based answer regarding the advantages and disadvantages of chemotherapy including escalated BEACOPP compared to chemotherapy including ABVD.

Search methods

We searched for randomised controlled trials in MEDLINE, CENTRAL and conference proceedings (January 1985 to November 2010) and EMBASE (1985 to November 2008).

Selection criteria

We included randomised controlled trials examining chemotherapy including at least two cycles of escalated BEACOPP regimens compared to chemotherapy including at least four cycles of ABVD regimens as first‐line treatment for patients with early unfavourable stage or advanced stage HL.

Data collection and analysis

Effect measures used were hazard ratios (HR) for overall survival (OS), progression‐free survival (PFS) and freedom from first progression. Relative risks were used to analyse complete response rate, treatment‐related mortality and adverse events. Two independent review authors extracted data and assessed quality of trials.

Main results

A total of 790 records were screened. Five eligible trials (four published, one ongoing), were identified. These trials included only adult patients (16 to 60 years of age). Four trials with 2868 patients were included in the meta‐analyses: the HD9 and HD14 trials from Germany, the HD2000 and GSM‐HD trials from Italy. All trials reported results for PFS and OS. PFS was statistically significantly longer for escalated BEACOPP: HR was 0.53 (95% confidence interval (CI) 0.44 to 0.64, I2 = 0%). There was no statistically significant difference in OS between the comparators: HR was 0.80 (95% CI 0.59 to 1.09, I2 = 0%). Three trials reported adverse events: the escalated BEACOPP regimens caused statistically significantly more haematological toxicities WHO grade III or IV (anaemia P < 0.00001, neutropenia P = 0.007, thrombocytopenia P < 0.00001), infections (P < 0.00001)) and occurrence of myeloid dysplastic syndrome (MDS) or acute myeloid leukemia (AML) (P = 0.05). There were no differences between both regimens for secondary malignancies, treatment‐related mortality or infertility.

Authors' conclusions

This meta‐analysis showed that adult patients between 16 and 60 years of age with early unfavourable or advanced stage HL benefited from chemotherapy including escalated BEACOPP regarding PFS, but there was no significant difference in OS. Longer follow‐up and the inclusion of the EORTC 20012 trial will lead to a more definitive answer with respect to OS.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

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Comparison of the two international standards of chemotherapy for patients with early unfavourable or advanced stage Hodgkin lymphoma

Hodgkin lymphoma is a malignancy of the lymphatic system. It is one of the most common cancers in young adults, particularly in their third decade of life, but it occurs also in children and elderly people. Within the last fifty years it has become one of the most curable forms of cancer. To find the best treatment with the greatest efficacy and least toxicity is the most important challenge in treating Hodgkin lymphoma. There are two international standards for the treatment of early unfavourable or advanced stage Hodgkin lymphoma: chemotherapy with escalated BEACOPP (bleomycin/etoposide/doxorubicin/cyclophosphamide/vincristine/procarbazine/prednisone) regimen initiated by the German Hodgkin Study Group (GHSG) and chemotherapy with ABVD (doxorubicin/ bleomycin/ vinblastine/ dacarbazine) regimen, which is widely used because it has been proven to be effective, well tolerated and easy to administer. We aimed to clarify the advantages and disadvantages of both treatments by comparing the chance of survival (overall survival), the chance of recurrence of the tumour and the frequencies of adverse events after treatment in patients with early unfavourable stage or advanced stage Hodgkin lymphoma.

We found five eligible trials but one was unpublished. These trials included only adult patients (16 to 60 years of age). We included 2868 patients in our review. The analysis shows a better chance of avoiding recurrence of the tumour in patients who received chemotherapy including escalated BEACOPP. In those with early unfavourable disease, 22 patients (95% confidence interval (CI) 18 to 29) had to be treated to prevent one tumour recurring within 3.5 years; in patients with advanced disease, 7 patients (95% CI 6 to 10) had to be treated to prevent such an event within 10 years. Treatment with escalated BEACOPP caused a higher risk of adverse events such as anaemia (10 times higher) and thrombocytopenia (19 times higher). However, this did not lead to an increased treatment‐related mortality. In addition, there was an eight times higher risk of secondary acute myeloid leukaemia or myelodysplastic syndromes in patients receiving escalated BEACOPP, but the total number of secondary malignancies did not differ statistically within both treatment groups. Differences regarding overall survival could not be shown, which might be caused by the short follow‐up time (less than five years) of three trials included. Since more than 70% of HL patients survived the first five years due to chemotherapy, the differentiation between regimens might needs more time to become apparent. Thus, a longer follow‐up and the inclusion of the recently closed EORTC 20012 trial will allow a more definitive answer with respect to OS.

Nevertheless, these results can only be extrapolated to adult patients (16 to 60 years of age) with early unfavourable or advanced staged HL. Older patients experience more severe treatment‐related toxicity and a higher mortality during treatment than younger patients, which leads to poorer survival outcome in the elderly. The randomised HD9elderly trial examined BEACOPP baseline compared to COPP/ABVD in patients older than 65 years and showed no statistically significant difference for overall survival (50% overall survival rate at five years in both arms), but an important higher rate of toxic deaths, 21% compared to 8%, after treatment with BEACOPP baseline. Therefore, treatment approaches for elderly patients are different from these for the adults ≤ 60 years and the results of this review are only relevant for adult patients younger than 60 years of age.