The Management of older patients with Hodgkin lymphoma: implications of S1826.

Classical Hodgkin lymphoma (cHL) is diagnosed in patients ages 60 and older in approximately 20%-25% of cases in Western populations. Outcomes in this subset of patients have historically been poor, with 5-year progression free survival (PFS) and overall survival rates significantly lower than those seen in younger patients. Challenges to overcome include age-related co-morbidities, and prominent and potentially lethal treatment-related toxicity. There have been increased efforts to study the older cHL patient population, including analysis of geriatric assessments and the integration of newer targeted therapies such as brentuximab vedotin (BV) and nivolumab (N) into treatment paradigms. A recent phase 3 clinical trial (S1826, NCT03907488) led by the North American oncology cooperative groups compared brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine (BV-AVD) with nivolumab, doxorubicin, vinblastine, and dacarbazine (N-AVD). At a median follow-up of 1-year, N-AVD improved PFS vs BV-AVD in patients and few immune adverse events were observed. Moreover, in a pre-planned subset analyses of cHL patients ages ≥60 years, the 1-year PFS for N-AVD was 93% (95% CI, 79%-98%) versus 64% (95% CI, 45%-77%) for BV-AVD. In addition, N-AVD was largely better tolerated particularly in older patients, which included markedly less neuropathy, lower treatment discontinuation, and less nonrelapse mortality. As a result, N-AVD is poised to become a standard of care for older, advanced-stage cHL patients who are fit for full-dose anthracycline-based combination therapy. More studies are needed to continue to improve outcomes for older cHL patients, especially unfit and frail populations.