Hodgkins - update on treatment strategies in children and adolescents
Prof Christine Mauz-Körholz - University of Giessen, Giessen, Germany
I gave an update, actually, to the treatment of paediatric Hodgkin’s lymphoma and I tried to summarise previous objectives and actual and contemporaneous objectives for the treatment in paediatric Hodgkin’s lymphoma. It is a highly curable disease in children and adults and the focus lies now more in efficacy of those treatments but also on the reduction of late effects, namely radiotherapy induced second cancers and also cardiovascular disease. This is late effects that those survivors are going to suffer from so our aim as paediatric doctors lies in these fields, to find cures for children without giving them late effects in their later life.
What are some of the current treatments?
Currently most of the trials are still relying on combined modality treatment, namely chemotherapy plus radiotherapy, but there has always been an effort to reduce or to probably completely eliminate radiotherapy. This has been focussed on in several large collaborative groups, like in the North American groups, also in the Latin and South American groups as well as in the European groups. Only very recently I must say, about ten years ago, a European network had been formed among the European national groups for treating Hodgkin’s disease in children and adolescents and this was the aim to focus on radiotherapy elimination and to find dose dense chemotherapy regimens for always better defining cures for those populations.
What new strategies are being implemented?
One of the new strategies is to perform response adaptation according to metabolic response, that is not very new in Hodgkin’s lymphoma but it entered the paediatric trials quite late because with the high efficacy large numbers of patients are needed to show the proof of principle, to show that these results can be used for a large population of children with Hodgkin’s lymphoma. The response assessment after two cycles, that’s now been mainly a mainstay in most of the collaborative trials, namely the European Network of Paediatric Hodgkin’s Lymphoma now saved radiotherapy upon this concept for 50% of all children whereas in the previous trials the majority of the patients, about 85% or more, had been irradiated. So the hope is that with refinement of these techniques ever more patients can be treated without radiotherapy. But, in the end, it will probably need more intensive and more dose dense chemotherapy cycles to compensate for the loss of treatment burden of radiotherapy.
What developments would you like to see in the near future?
It would be really an achievement to eliminate also the late effects of chemotherapy. But, if you will, we have to balance the high cure rate with lowering the radiotherapy rates but then we have also to give more treatment burden. The hope will lie in new agents that are less toxic and equally effective so that by the time these drugs, the old-fashioned, let’s say, chemotherapy drugs can probably be exchanged by new agents. Our hope is lying in cancer immunotherapy which has recently emerged and has produced exciting results, especially on Hodgkin’s lymphoma. For instance, the PD-1 receptor is highly distributed and so this needs to be studied. But it will take time because the paediatric population is, of course, lower and it has to be studied in relapsed cohorts first. So it will take time but this is a great hope.
What is your take-home message?
Our focus, like in many other cancer treatments, is we have to spend more effort on finding individualised risk factors, then finding individualised treatments and to harmonise our risk stratification criteria, that will be the future for treating children and adolescents with Hodgkin’s lymphoma.