Rev. Bras. Hematol. Hemoter. vol.39 número4

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rev bras hematol hemoter. 2017;39(4):299–300

w w w . r b h h . o r g

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

Scientific

Comment

Hodgkin’s

lymphoma

in

developing

countries:

can

we

go

further?

夽

Rafael

Dezen

Gaiolla

∗

UniversidadeEstadual“JúliodeMesquitaFilho”(UNESP),Botucatu,SP,Brazil

Hodgkin’slymphoma(HL)isaBcellmalignancythataffects approximately 8000 new patients in the United States annually.1 _This _is _the _most _common _lymphoma _affecting

theyoungpopulationwithahigherincidenceatages15to 35years.Becauseofitsparticularhistologicalfeaturesand biologicalbehavior,HLishighlyresponsivetochemotherapy andradiation,andthereforeisconsideredamodelof success-fulcancertreatment.Infact,inthelastdecades,important advances were made regarding HL treatment resulting in unprecedented high cure rates. Elegantly designed clinical trialsconductedbyimportantcooperativegroupsinEurope andNorthAmericahavesetthebasisfortreatmentand estab-lishedtheguidelinesforHLmanagementinthemodernera. Inearly-stagedisease,treatmentbasedontheABVD (Doxoru-bicin,Bleomycin,Vinblastine,Dacarbazine)regimenremains thestandardofcare.Short-coursechemotherapy(2–4cycles) followedbyradiotherapy (20–30Gy) hasdemonstrated high efficacy and acceptable acute and long-term toxicity, with cureratesthatexceed90%.2_Duration_of_treatment_and_doses

ofradiationdependonthepresenceofsomeadverse prognos-ticfactors.3_In_{advanced-stage}_HL,_the_best_treatment_choice

hasbeenamatterofexhaustivedebate.IntheUnitedStates, 6–8cyclesofABVDremainsthestandardofcare,resultingin 5-yearfailure-freesurvivalof60%and5-yearOSof73%.4,5_In

Europe,theGerman HodgkinStudyGrouphas developeda moreintensiveprotocol,theescalatedBEACOPP(bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine,

DOIoforiginalarticle:http://dx.doi.org/10.1016/j.bjhh.2017.08.001.

夽

SeepaperbyJaime-Pérezetal.onpages325–30.

∗ _{Correspondence}_to:_Hospital_das_Clínicas_da_Faculdade_de_Medicina_de_Botucatu_da_Universidade_Estadual_“Júlio_de_Mesquita_Filho”

(HCFMB-UNESP),DistritodeRubiãoJuniorS/N,Botucatu,SP,Brazil. E-mailaddress:[email protected]

procarbazine,andprednisone)regimen,whichiswidelyused inmany centers.When comparedtoABVD,escalated BEA-COPP resultsinbetterprogression-freeand overallsurvival but withmore acute and late toxicities.6–8 _Defining _which

patientsreallydobenefitfrommoreintensiveregimensisstill achallenge.9_More_recently,_the_concept_of_{response-adapted}

therapy based on interim positron emission tomography-computedtomography(PET-CT)hasproventobeofprognostic importanceand seemstoimprove outcomesbyidentifying patients who are most likelyto benefit from morepotent treatmentregimens.10

In developing countries, however, the outcomes of HL treatment are notsoexciting. Althoughdataisscarce and mostly comes from small population-based and retrospec-tivestudies,thereportedprogression-freesurvivalandoverall survivalaresignificantlylowerthanthoseobservedin devel-opedcountries,especiallyforadvanced-stagedisease.11,12_In

this issue of the Revista Brasileira de Hematologia e Hemoter-apia,Jaime-Pérezetal.13_present_the_data_of₁₂₈_HL_patients

retrospectivelystudiedatauniversityhospitalinMonterrey, Mexico.Theauthorsfoundahighrateofprimaryrefractory disease(43%oftheentirecohort)andpoor5-year progression-freesurvival(PFS)evenfortheearly-stagepopulation(median: 42.7%; 95% confidence interval: 27.5–57.9).Noteworthy, the majorityofpatientspresentedwithadvanceddiseaseandup to20%experiencedchemotherapydosereductionsdueto tox-icityordidnotcompletetheplanedtreatment.Somerobust

http://dx.doi.org/10.1016/j.bjhh.2017.08.004

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revbrashematolhemoter.2017;39(4):299–300

datahasrecentlybeen publishedbythe Brazilian Prospec-tiveHodgkin’sLymphomaRegistry,14_similarly_showing_a_high

proportionofadvanced-stageHLatthemomentof diagno-sisinBrazil.However,the3-yearPFSandoverallsurvival(OS) were74%and90%,respectively,betterthan thoseobserved intheMexicanstudy.Withsmalldifferences,similarfindings have been observed inother developing countries.11,12,15,16

Altogether,thesedatasuggestthatoutcomesofHLtreatment areveryheterogeneousacrossdifferentregionsoftheworld. Onepossibleexplanationisthatinmanydevelopingcountries patients may not have easy access to public healthcare, whichcouldpostponediagnosisandincreasethenumberof moreadvanced-stageHL.Oncediagnosed,patientsnotalways havefullaccesstoadequatestagingprocedures(even com-puted tomography), resulting in a considerable number of under staged and,therefore, undertreated cases. Addition-ally,somehospitalsnotalwayshaveappropriateemergency supportive careto deal with chemotherapy complications, therebyincreasingmorbidityandmortalityrates.Finally, dif-ferences in the economic and social environment, pattern ofEpstein–Barrvirusinfectionandgeneticbackgroundmay alsoexplainsomedifferencesinHLbehavioratdifferent geo-graphiclocations.17_Indeed,_lower_economic_status_has_been

associatedwithmoreaggressivediseaseandworseoutcomes inHL.18

AlthoughJaime-Pérezetal.describedasingleinstitution experience,theirworkbringsintofocusaveryimportant con-cernaboutthemanagementofHLincountrieswithlimited resources.Alltheeffortsnecessarytoimprovediagnosisand treatmentoutcomesareofextremeimportanceandstrongly desirableinthecontextofahighlycurabledisease.

Conflicts

of

interest

Theauthordeclaresnoconflictofinterest

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