The caucus race: Regionalism in the treatment of Hodgkin's disease

Abstract

Patient and physician expectation is that Hodgkin’s disease is not only consistently curable but consistently treated. Unfortunately, neither hope is true. National, state, metropolitan, and institutional variations exist for the treatment of lymphoma, and there is no greater regionalism than in the radiotherapy of difficult subsets of Hodgkin’s disease. In fact, the main reason for confusion and controversy in the management of Hodgkin’s disease is precisely the fact that there are several alternatives, none of which is overwhelmingly superior. The comparison of results from different centers, with different treatment traditions, different historical results, different relations with medical and surgical colleagues, and different ancillary facilities, makes dictation of a “one and only” right way to treat Hodgkin’s disease presumptuous if not impossible. Two articles in this issue of the Journal highlight this issue. In a large series followed for more than a decade, Drs. Lee et al. confirm and extend earlier data from Stanford suggesting that more extensive irradiation is more effective for more aggressive disease (2). TN1 with liver irradiation in Stage IIIA and whole-lung irradiation in cases involving hila or large mediastinal disease appeared to improve relapse-free survival and ablate the need for chemotherapy up front. In a much smaller series, Drs. Hartsell et al. show results consistent with other centers of similar practice: that III Al disease can be frequently well-handled with mantle para-aortic therapy alone (1). Perhaps more specifically, for those who choose to subset by histology and splenic nodule number, patients with favorable histology“minimal” splenic disease-tend to have excellent diseasefree survival with radiotherapy alone. A logic for such treatment has been that more aggressive radiotherapy has conferred greater toxicity in some centers, especially when salvage chemotherapy has been required. Unstated in such regimens is that more advanced Stage III cases have not fared as well with radiation alone. Chemotherapy has been increasingly utilized. Although there are differences in the intensity and ingredients of chemotherapy regimens, these pale before the subtleties of schools of thought for Hodgkin’s disease radiotherapy. This should not be confused with inequities in training, but differing experience with outcome over several decades in differing institutions. We resemble a surgical more than a medical subspeciality. Uniformity of methodology presumes all science and no individuality; why should we ask it of our art? The long-term experience of Lee et al. is well documented but it also raises critical questions for those centers that plan on attempting treatment with irradiation alone in disease advanced by nature of stage or thoracic bulk. The Minnesota experience represents a large mature series in which the superiority of the more recent cohort (“radical radiotherapy”) may in part represent a number of confounding variables, including better imaging with CT and in turn better parenchymal, hilar. and mediastinal staging. In these later years in many centers, increasing numbers of patients with obvious massive mediastinal disease are pre-selected before radiotherapeutic consultation for combined modality therapy. Also, the complications in the later group may have yet to be fully ex-