Prognostic factors in Hodgkin's disease: problems and pitfalls.

Abstract

It is likely that the success or failure of cytotoxic therapy in the treatment of malignancies such as Hodgkin’s disease is determined at the cellular or even the molecular level. Unfortunately, cellular- and molecular-level assays of efficacy are not readily available at present, and clinical features of the tumor-host relationship often must be used to provide an estimate of this more basic interaction-and, ultimately, prognosis. However, the utility of such “derived” prognostic factors is limited by varying clinical definitions, heterogeneity (of patient, disease and treatment features) and the small sample sizes often available for analysis. An important objective in the identification of prognostic factors is the ability to better target a specific therapy to a specific group-an especially important consideration in the setting of highly toxic therapies-primarily to avoid overtreatment of patients who may be cured with simpler, safer and less costly therapies. Important differences in morbidity and overall cost are particularly evident with the therapies described below, and are of critical importance in situations in which conventional primary therapy is available that has been shown to be effective for most patients. plest approach to identifying Hodgkin’s disease patients who are candidates for intensive therapy (IT) and hematopoietic stem cell rescue (HSCR).’ Specifically, we regard the first recognition of the presence of persistent or recurrent Hodgkin’s disease following suitable primary chemotherapy (e.g., MOPPIABVD, dD, ABVD, etc.2) to be a simple and reliable indicator of poor prognosis. (We also recognize such to be controversial.3) Nonetheless, due to the limited ability of conventional salvage chemotherapy to rescue such patients, we believe the risks of IT + HSCR clearly are justified for those who fail to enter complete remission (CR), as well as for those who