Correspondence

Radiotherapy for Advanced Hodgkin's Disease

N Engl J Med 2003; 349:1187-1188September 18, 2003

Article

To the Editor:

We disagree with Aleman et al. (June 12 issue)1 that involved-field radiotherapy does not improve the outcome after a complete response to chemotherapy in patients with advanced Hodgkin's lymphoma. The authors used two additional cycles of mechlorethamine, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, and vinblastine (MOPP-ABV) as consolidation chemotherapy after a complete response had been achieved. Not surprisingly, involved-field radiotherapy failed to improve the outcome. Had they performed randomization immediately after the achievement of a complete response, the benefit of radiation might have been evident.

The Children's Cancer Group (CCG) trial,2 in which 501 patients with a complete response were randomly assigned to involved-field radiotherapy or to observation, was closed early because there were significantly more relapses in the group assigned to chemotherapy alone (three-year event-free survival of 93 percent, vs. 85 percent with involved-field radiotherapy; P=0.002, according to an “as-treated” analysis). Our own randomized trial (unpublished data) comparing consolidation radiotherapy with observation in 179 patients in whom a complete response was achieved with six cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) shows an improvement in the rates of event-free survival and overall survival at eight years in the radiotherapy group.

In major studies such as those conducted at Stanford University and the National Cancer Institute in Milan, Italy, radiotherapy has been part of the standard protocol treatment for advanced Hodgkin's disease. To quote Prosnitz, “Consolidation radiation for advanced Hodgkin's lymphoma is thus still alive.”3

Tejpal Gupta, M.D.
Vimal Sanghavi, M.D.
Siddhartha Laskar, M.D.
Tata Memorial Hospital, Mumbai 400 012, India
tejpalgupta@rediffmail.com

3 References

1. 1

   Aleman BMP, Raemaekers JMM, Tirelli U, et al. Involved-field radiotherapy for advanced Hodgkin's lymphoma. N Engl J Med 2003;348:2396-2406
   Full Text | Web of Science | Medline

2. 2

   Nachman JB, Sposto R, Herzog P, et al. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol 2002;20:3765-3771
   CrossRef | Web of Science | Medline

3. 3

   Prosnitz LR. Consolidation radiotherapy in the treatment of advanced Hodgkin's disease: is it dead? Int J Radiat Oncol Biol Phys 2003;56:605-608
   CrossRef | Web of Science | Medline

Author/Editor Response

We agree with Dr. Gupta and colleagues that consolidation radiation is not dead; however, the challenge is to select the patients who require radiotherapy. The European Organization for Research and Treatment of Cancer Lymphoma (EORTC) trial was designed to evaluate radiotherapy in patients with advanced Hodgkin's lymphoma who had well-consolidated complete remission after chemotherapy — not to compare radiotherapy with chemotherapy in the securing of a complete response. It is not correct to assert that if patients had undergone randomization immediately after the achievement of a complete response, the benefit of radiation would have been demonstrated. Our results should be weighed against studies with similar populations and treatments. It is not appropriate to refer to the CCG trial, since it involved children with disease at all stages (28 percent of the randomized patients had advanced disease).1 Moreover, the benefit of radiotherapy was limited to event-free survival (among patients with disease of any stage) in the “as-treated” analysis. We would like to emphasize the excellent prognosis for patients who had a partial response to six cycles of MOPP-ABV and then received involved-field radiotherapy, which suggests that consolidation radiotherapy might benefit this selected population of patients.

Berthe M.P. Aleman, M.D.
Netherlands Cancer Institute, 1066 CX Amsterdam, the Netherlands

John M.M. Raemaekers, M.D., Ph.D.
University Medical Center Nijmegen, 6500 HB Nijmegen, the Netherlands

Michel Henry-Amar, M.D., Ph.D.
Centre François Baclesse, F-14076 Caen, France

1 References

1. 1

   Nachman JB, Sposto R, Herzog P, et al. Randomized comparison of low-dose involved-field radiotherapy and no radiotherapy for children with Hodgkin's disease who achieve a complete response to chemotherapy. J Clin Oncol 2002;20:3765-3771
   CrossRef | Web of Science | Medline