Consensus paper stresses ‘less is better’ in treatment of NLPHL

Treatment approaches for nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) should be focused on ‘quality of survival’, given almost all will be long-term survivors who may suffer harms from intensive treatment approaches, a new consensus paper has concluded.

It comes after a paradigm shift in the management of children with early-stage disease towards treatment de-escalation in the past 15 years, according to the position paper published in the British Journal of Haematology

A similar approach to the treatment of adult patients has occurred in some countries and centres, although published data are sparse, the paper from the Hodgkin lymphoma subgroup of the UK National Cancer Research Institute noted.

Yet in some countries a very aggressive treatment approach is still favoured for all patients which is not necessary, said lead author Dr Ananth Shankar, Consultant Paediatric and Adolescent Oncologist at University College London Hospitals and Honorary Associate Professor at UCL.

The consensus paper concludes that the role of active surveillance in all risk groups especially in adults with comorbidities, may be considered appropriate in certain clinical settings as this does not have an adverse impact on survival.

Speaking with the limbic he said it was now known that NLPH is a very indolent disease and very treatable, but in the UK most patients are treated very aggressively.

“The critical point in our paper is that less is better. We want to achieve maximum treatment efficacy with minimal toxicity,” he said.

“The second thing is that the disease is quite similar whether you are a child or an adult,” he says pointing to the fact their guidance covers all stages and all ages.

A global NLPHL working group, of which Dr Shankar is a member, recently published an international survey in Leukaemia & Lymphoma showing considerable variability in the use of radiotherapy and various chemoimmunotherapy regimens between physicians treating adults versus children versus both age groups, as well as among different regions of the world.

He added that there was very clear consensus about the approach to take in these patients which was apparent when developing the paper.

“We have always advocated for a low intensity approach, these patients can be cured they don’t need high intensity treatment. We feel high intensity treatment is wrong.”

One of the things that is forgotten is that some of the children are 10 or 12 when they are diagnosed and giving powerful chemotherapy at that age can impact their reproductive life, he added.

Data shows that even in those who do see late recurrence, a cure is possible with lower or intermediate treatment, he said.

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