Chemotherapy only in early stage Hodgkin lymphoma: more relapses but the same survival--what to do?

Limited-stage Hodgkin lymphoma can almost always be cured with combined-modality chemotherapy plus involved-field or involved-nodal radiation, at the cost of exposing all patients--many unnecessarily--to radiation. Large prospective randomized clinical trials, including a total of over 1,200 patients, indicate that at least 95% of patients with limited-extent Hodgkin lymphoma are cured. The data also demonstrate that more than 80% of patients treated with two to three cycles of ABVD chemotherapy reach a positron emission tomography (PET)-negative state. Such patients need only one to two additional cycles of ABVD to reach an anticipated 95% cure rate. The remaining 20% of patients, with a positive PET, should be given radiation to reach the same 95% cure rate. The above approach leads to the same overall cure rate as one comprising combined chemotherapy and radiation, but avoids radiation for 80% of patients. Treatment outcome for limited-stage Hodgkin lymphoma is best optimized--considering cost, inconvenience, toxicity, and efficacy--using interim PET assessment to minimize exposure to radiation.