A. J. Kumar, C. R. Chao, A. M. Rodday, N. T. Cannizzaro, R. Rodriguez, J. Feliciano, A. M. Evens, S. K. Parsons
Tufts Medical Center, Boston, MA, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, Department of Hematology and Oncology, Los Angeles Medical Center, Los Angeles, CA, Cancer Institute of New Jersey, New Brunswick, NJ, Seattle Genetics, Bothell, WA
Background: While most patients with newly diagnosed HL will be cured, a subset experience treatment failure (TF). Data are limited on the selection of salvage treatment and associated outcomes, particularly in the community setting, where the majority of cancer patients in the United States receive their care.
Methods: Potential TF cases were identified by receipt of > 1 treatment regimens within 4 years after initial treatment from 473 HL cases with Stage II-IV disease diagnosed from 2007–2012 at Kaiser Permanente Southern California. Medical oncologists and trained study staff reviewed medical charts to confirm TF. Detailed data were extracted including initial treatment, type of TF, salvage treatment, and response.
Results: We identified 75 patients with TF. At diagnosis, median age was 36 years (IQR 23, 52); 65% were male; 63% were Non-White or Hispanic; 49% had Stage III or IV disease; 48% had B-symptoms; 39% had mediastinal bulk; and 32% had > 1 comorbidity. Patients received a median of 2 (range 1–9) salvage treatments.
Initial salvage included ifosfamide-based chemotherapy in 57/75 (76%), other (non-ifosfamide) chemotherapy in 9/75 (12%), brentuximab vedotin (Bv) in 8/75 (11%), and unknown therapy in 1/75 (1%) who briefly left Kaiser Permanente. Among patients salvaged with Ifosfamide-based therapy, 40/57 proceeded directly to autologous stem cell transplant (SCT). Of the 17 patients who did not proceed directly to SCT, 9 received additional therapy and then, went on to SCT. Among Bv patients, 3/8 proceeded directly to autologous SCT. Among patients salvaged with other chemotherapy, 1/9 transitioned to SCT, while almost half died with active disease (Table).
At 4 years post initial therapy, 27/75 (36%) of patients with TF died, 22/27 (81%) from HL (median time to death from TF: 376 days (IQR 194, 813)). Of surviving patients, 34/48 (71%) achieved complete remission, 8/48 (17%) have active disease, and 6/48 (12%) were lost to follow-up.
Conclusions: In a community-oncology setting, salvage treatment for HL is heterogeneous. Further, mortality after TF is prominent. There remains a critical gap to identify patients with high-risk features (i.e., patient, clinical, biologic) early in the disease course that may presage inferior outcomes and warrant alternative treatment paradigms.