Combination chemotherapy

• Enter patient in a multicentre randomised clinical trial if possible.

• ABVD (fflp596) is the standard regimen for patients with advanced HL (stage III or IV) not enrolled in a clinical trial.

• In a randomised trial of 361 patients 6-8 cycles of ABVD was equivalent to 12 cycles of MOPP-ABVD alternating regimen (CR 82% vs. 83%; FFS at 5 years 61% vs. 65%) and superior to 6-8 cycles of MOPP (CR 67%; 5 year FFS 50%)2.

• ABVD has a much lower risk of infertility than MOPP regimens and is not associated with increased risk of leukaemia but the anthracycline component may exacerbate the cardiac and pulmonary complications of mediastinal irradiation.

• Often poorly tolerated by elderly patients due to cumulative doses of doxorubicin and bleomycin.

• Alternative: brief duration dose intensified regimens, e.g. Stanford V low cumulative doses of alkylators, doxorubicin and bleomycin over 12 weeks followed by radiotherapy to sites of bulk disease (>5cm); FFS 89%, OS 96% at 6 years in a single institution study; multicentre randomised trials in progress; fertility preserved in a high proportion; very low risk of leukaemia.

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