Chemotherapy and Drug Therapy

Chemotherapy is the mainstay of treatment for HL. A combination chemotherapy regimen consists of two or more chemotherapy drugs. Generally, the drugs are dissolved in fluid and usually administered via a peripheral intravenous (IV) line. If finding an accessible vein is problematic, a central line (a port, or a peripherally inserted central venous catheter (a PICC or PIC line) may be used for some HL patients. 

Chemotherapy is given in cycles of treatment that are separated by periods of rest. Chemotherapy drugs can have strong side effects so the body needs time to recover in between treatment cycles. Typically, the cycles are between 3 and 4 weeks long but they vary in length, depending on the drugs employed, stage and subtype of HL, and how well your disease responds to treatment. 

Some Chemotherapy Combinations

Early-Stage Classical Hodgkin Lymphoma (cHL): Chemotherapy combinations (administered with or without radiation therapy) 

  • ABVD: Adriamycin® (doxorubicin), bleomycin, vinblastine, dacarbazine 
  • Escalated BEACOPP: Bleomycin, etoposide, Adriamycin® (doxorubicin), cyclophosphamide, vincristine, procarbazine, prednisone 
  • AVD: Adriamycin® (doxorubicin), vinblastine, dacarbazine 

Advanced-Stage cHL: Chemotherapy combinations (occasionally, chemotherapy is followed by involved-site radiation therapy (ISRT) 

  • A+AVD: (Adcetris® ([brentuximab vedotin)], Adriamycin® ([doxorubicin)], vinblastine, dacarbazine) 
  • ABVD 
  • ABVD followed by escalated BEACOPP 
  • BrECADD: brentuximab vedotin, etoposide, cyclophosphamide, doxorubicin, dacarbazine, dexamethasone 
  • Escalated BEACOPP 
  • N+AVD: nivolumab + AVD 

Immunotherapy

Monoclonal Antibody Therapy

Monoclonal antibody therapy is a type of targeted therapy. When the body’s immune system identifies something harmful, such as bacteria or a virus, it produces antibodies. Antibodies are proteins that help fight infection. Monoclonal antibodies are a type of protein made in the laboratory that can bind to only one substance. By design, they can only attack a specific target, typically a substance on cancer cells (though sometimes they are designed to bind to a substance on immune cells, in order to improve their function). This targeting can reduce damage to normal, healthy cells. 

Brentuximab vedotin (Adcetris®) is approved for the treatment of adult Hodgkin lymphoma patients. 

Immune Checkpoint Inhibitors  

Checkpoints are molecules found on T cells, a type of white blood cell. T cells circulate throughout the body looking for signs of infection and diseases, including cancer. When a T cell comes near any type of cell, it probes (looks for) certain proteins on the cell’s surface. If the T cell determines that it is a normal, healthy cell, it moves on to check other cells. If the proteins indicate that the cell is foreign or cancerous, the T cell attacks it. But cancer cells can sometimes send misleading signals to these checkpoints, telling the T cells that they are not harmful. Checkpoint inhibitors work by blocking the signals that cancer cells send to T cells. When the signals are blocked, it is more likely the T cells will distinguish the cancer cells from healthy cells and begin an attack. 

Nivolumab (Opdivo®) and pembrolizumab (Keytruda®) can be used for some patients with HL that has become refractory (come back or spread during treatment), or that has relapsed (returned) after the patient has completed other treatments.  

Nivolumab plus chemotherapy may soon be FDA approved for pediatric and adult patients with previously untreated advanced stage HL. 

Chimeric Antigen Receptor (CAR) T-Cell Therapy  

This is a type of immunotherapy that uses a patient’s own T cells (a type of white blood cell) to identify and attack cancer cells. Blood is taken from the patient, and the T cells 

are separated out from the patient’s blood and sent to a laboratory, where they are genetically modified so they will attack cancer cells. The engineered T cells are then multiplied and later reinfused into the patient’s bloodstream. CAR T-cell therapy is currently under study in clinical trials for relapsed and refractory HL. 

Learn more about CAR T-Cell Therapy.  

For information about the drugs listed on this page, visit Drug Listings.

Treatment by Stage

Treatment options for classical Hodgkin lymphoma (cHL) vary depending on the stage of the disease. 

Treatment of Early-Stage (Stage I-II) Favorable HL. The cure rate for patients in this category exceeds 90 percent. The current treatment approach is to administer chemotherapy alone or chemotherapy followed by radiation therapy to areas of the body where lymphoma was found.

For many years, ABVD has been the most commonly used chemotherapy regimen for these patients. ABVD poses less of a risk for later development of leukemia or infertility than many other chemotherapy combinations used for adults. 

Treatment of Early-Stage (Stage I-II) Unfavorable HL. For patients in this category, the disease is considered to be high risk yet potentially curable. Initial treatment usually consists of either a chemotherapy and radiation or chemotherapy alone. Treatment is generally more intense for these patients than for those in the favorable category. Some drug combinations used for treatment of these patients include: ABVD or ABVD followed by escalated BEACOPP.

Treatment of Advanced-Stage (Stage III-IV) HL. Even in advanced stages, HL is curable. In general, patients with advanced-stage HL are treated with more intense regimens of combination chemotherapy. Some drug combinations used for treatment of these patients include:

  • Brentuximab vedotin + AVD
  • ABVD
  • ABVD followed by escalated BEACOPP
  • Escalated BEACOPP
  • BrECADD
  • Nivolumab + AVD

Dose-escalated BEACOPP results in a good cure rate, but it puts patients at a slightly higher risk of developing leukemia or other second cancers. Patients are also at a much higher risk of infertility, and it is less commonly used for this reason.

Use of radiation therapy is limited to a small number of patients, those who have areas of bulky disease (large masses) at diagnosis or evidence of residual disease observed on PET-CT scans after treatment. Even in these cases, the role of radiation therapy for advanced-stage HL varies.

Treatment Response Monitoring

During treatment, patients need to be monitored to check their response to therapy. Response to treatment is important in predicting long-term outcomes. Patients who do not reach complete remission with first-line treatment have a worse prognosis, so there is great value in identifying these patients early in the course of their disease.

Imaging tests are used to distinguish between tumor and fibrous (scar) tissue. PET-CT scans help doctors determine if the disease is responding to treatment. PET-CT has become the standard method for assessment of treatment response in most types of lymphoma.

The Deauville score, based on a five-point scale is the internationally recognized way of using PET-CT to assess treatment response. This scale determines the “FDG uptake” (the absorption of this radioactive material by tissues) in the involved sites. The Deauville score is then used to determine if any treatment modifications are needed.

Minimal/measurable residual disease (MRD) refers to cancer cells that may remain in the body after treatment ends. Besides the use of PET-CT scans to identify residual disease, there are other methods that are under study which may be used to complement these imaging techniques.

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