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In this exclusive with i3 Health, Craig H. Moskowitz, MD, Professor of Medicine at the University of Miami and Physician-in-Chief at the Sylvester Comprehensive Cancer Center, and Kami Maddocks, MD, Associate Professor of Clinical Internal Medicine and Lymphoma Program Director at The James Cancer Hospital at The Ohio State University, share their perspectives on the management of relapsed/refractory classical Hodgkin lymphoma (HL) and the advances brought to the treatment of this disease by developments in immune checkpoint inhibitor therapy.
How do you treat your patients with relapsed/refractory Hodgkin lymphoma?
Dr. Moskowitz: Nearly everyone with relapsed/refractory disease is transplant eligible unless the patient is quite elderly. We usually give the patients salvage therapy. The goal is a positron emission tomography (PET)-negative response. Those patients who are PET negative have up to a 70% cure rate. Those patients who have a lack of response—either transplant failures or failed salvage regimens—and need additional therapy are getting checkpoint inhibitors these days.
Not all relapsed and refractory HL patients are created equal; there are risk factors that predict how folks will do. These have been born out of multiple studies. The most important factors are having remission duration of less than a year, having disease outside of the lymph node system, having these symptoms at the time of salvage therapy, or requiring a number of treatments to get to transplant. Obviously, as you accumulate risk factors, the likelihood of being cured is reduced. As I said before, the goal of salvage treatment is a complete response, but for those patients who have multiple risk factors, the end of therapy is to get maintenance brentuximab posttransplant per the AETHERA study.
What is the role of checkpoint inhibitors in Hodgkin lymphoma?
Dr. Moskowitz: Hodgkin lymphoma is set up to respond to checkpoint inhibition because PD-L1 is almost universally expressed. It is amplified at the locus of 9p24 in the majority of patients, so we are set up for a positive response.
The results with both pembrolizumab and nivolumab are basically superimposable as far as palliation is concerned. About 20% to 25% of the patients can have a complete response. Complete responders have a much longer progression-free survival. It has not been reached, but those patients with partial response and stable disease can have prolonged palliation.
Dr. Maddocks: One thing that has been reported with the checkpoint inhibitors is that sometimes the computed tomography (CT) and PET scans aren't indicative of what's going on. This means that if patients have a slight increase in lymph node size but their hemoglobin has remained higher, if before starting they feel great and they haven't had return of B symptoms, then I'll typically continue on for a little bit longer before repeating imaging. If patients are feeling well on the drug, then I just continue it.
About Dr. Moskowitz & Dr. Maddocks
Craig H. Moskowitz, MD, is a Professor of Medicine at the University of Miami Miller School of Medicine and Physician-in-Chief at the University of Miami's Sylvester Comprehensive Cancer Center. Formerly, he served as the Stephen A. Greenberg Chair of Lymphoma Research at Memorial Sloan Kettering Cancer Center. Kami Maddocks, MD, is an Associate Professor of Clinical Internal Medicine and the Lymphoma Program Director at The James Cancer Hospital of The Ohio State University. She is also on the committees for the Lymphoma Research Foundation Lymphoma Clinical Research Mentoring Program and the American Society of Hematology Clinical Research Training Institute. Both Dr. Moskowitz and Dr. Maddocks have authored and co-authored numerous peer-reviewed publications on lymphoma.
For More Information
Moskowitz AJ, Schöder H, Yahalom J, et al (2015). PET-adapted sequential salvage therapy with brentuximab vedotin followed by augmented ifosamide, carboplatin, and etoposide for patients with relapsed and refractory Hodgkin's lymphoma: a non-randomised, open-label, single-centre, phase 2 study. Lancet Oncol, 16(3):284-292. DOI:10.1016/S1470-2045(15)70013-6
Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of i3 Health.