Hematology Advisor: What is currently being done to address this issue?
Dr Jacobs: In more modern trials [during] the last 15 years or so, there has been a concerted effort among the pediatric oncology community to limit exposure [of pediatric patients] to potentially toxic treatments such as anthracyclines, alkylators, and radiotherapy. In particular, the use of radiation has become much more limited in more modern protocols, both in terms of which patients it is offered to, and in terms of the extent of the fields being treated for those patients who require it. In addition, there is a greater emphasis on recognizing which patients are at greatest risk of developing late effects and on early screening and intervention to prevent serious sequelae.
Dr Gore: There are many initiatives to develop adolescent-specific programs and treatment teams to provide these patients with the kind of care they need in an environment that makes them comfortable. Often something as simple as a separate waiting room and different resources and materials to help them pass time in clinic or an infusion center makes a difference. Similarly, access to more psychologic support services can help them better navigate. Sometimes caregiving and a place to stay are needed. It is very multifactorial.
Hematology Advisor: What are the current treatment implications for clinicians in regard to this topic?
Dr Jacobs: Clinicians need to be particularly thoughtful in designing treatment for pediatric patients with HL. Although the immediate goal is cure, the [long-term] goal is cure without significant long-term sequelae. Therefore, the least amount of treatment that has the potential to bring about cure should be the goal. Additionally, clinicians caring for survivors of pediatric HL need to be aware of the long-term toxicities and recommendations regarding screening and early intervention.
Dr Gore: Comprehensive, multidisciplinary teams are key to helping develop better programs and support for these patients. The therapy doesn’t change much between younger and older kids, but older adolescents and young adults have more toxicity and sometimes tolerate therapy less well. So they often get dose reductions or less intensive therapy. It is also important to note that most [treatment] regimens were developed before brentuximab vedotin, which has absolutely improved outcomes for all patients with HL, became available.
Hematology Advisor: What are remaining needs pertaining to pediatric HL treatment?
Dr Jacobs: Ideally, we would have a treatment decision tool that would allow the clinician to plug in information about a patient’s disease characteristics, including stage, pathology, and molecular characteristics, as well as the patient’s personal characteristics – such as genetic propensity for late effects, socioeconomic challenges, and comorbidities – to develop the ideal treatment plan for each patient. Many pieces of this puzzle are under investigation and still need to be worked out.
Dr Gore: More research is needed to develop regimens that are more effective and better tolerated, and with which patients can be more compliant. And of course, there is a need for greater support and more financial resources to help these patients. For example, they may not be living at home or have consistent support and need someone to get them to clinic, help at home, do chores and errands, and similar things that parents automatically do for young children. They also need support if they are going to school or working because their schedules may be interrupted, which in turn adds to their financial burden.
1. Castellino SM, Parsons SK, Kelly KM. Closing the survivorship gap in children and adolescents with Hodgkin lymphoma [published online September 30, 2019]. Br J Haematol. doi:10.1111/bjh.16197
2. Castellino SM, Geiger AM, Mertens AC, et al. Morbidity and mortality in long-term survivors of Hodgkin lymphoma: a report from the Childhood Cancer Survivor Study. Blood. 2011;117:1806-1816.
3. Hoppe BS, Hill-Kayser CE, Tseng YD, et al. Consolidative proton therapy after chemotherapy for patients with Hodgkin lymphoma. Ann Oncol. 2017;28:2179-2184.
4. Flerlage JE, Kelly KM, Beishuizen A, et al. Staging evaluation and response criteria harmonization (SEARCH) for childhood, adolescent and young adult Hodgkin lymphoma (CAYAHL): methodology statement. Pediatr Blood Cancer. 2017;64:e26421.
5. International Guideline Harmonization Group for Late Effects of Childhood Cancer. Guidelines. http://www.ighg.org/guidelines/topics/. Accessed October 30, 2019.