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There is actually more than one 'standard', it kind of depends on your doctor and the hospital or clinic where he/she has privileges or with which certain health care organization they are associated.
However, even the 'standards' at some of the best cancer hospitals in the US are merely guidelines for those physicians. They aren't beholden to them, nor should they be, since every case of cancer is different and should be addressed according to the needs of the patient and the specifics of the disease.
Your therapy regimen of six cycles of ABVD for HL stage I isn't uncommon; in fact, it's very common (number of cycles varies between 2 and 6) and ABVD is considered the best chemo regimen currently known for Hodgkin's.
Thank you for your answer Ross. The reason I ask this question is because after consulting with another doctor, I was told my situation would be 4 cycles of ABVD.
I do trust my current doctor, however, with the uncomfortable feeling of the treatment, it will be glad if I can have even one cycle less.
Tommy:
I'm not surprised that another doc said 4 cycles, and I don't blame you for preferring as few cycles as is necessary. However, for 'standard' treatments I normally start by looking at the guidelines for the National Comprehensive Cancer Network (nccn.org) and looking at theirs for Hodgkin's, for most instances of stage I, their guidelines are for 4 cycles of ABVD with the potential to add 2 more at the end of the first 4 even in the event that the patient shows no evidence of cancer. The reason I tell you that is only because I don't want you to buy into the 4 cycles only to be disappointed to learn that 4 might still turn into 6 later on.
Ross
I too was recently diagnosed with stage 1 HL
I have been to 3 different doctors in 3 different cancer centers. The first insisted that the standard is 6 rounds however he would discuss it with his team. The Doctor at Sloan mentioned a Canadian study showing only 4 rounds for stage 1 but she needed to research if I would fit the protocols of said study. The third and final doctor, and the one I decided to use went with " Lets do 2 rounds, repeat the PET and then discuss our options.
Jberen:
Take a look at this post of mine over at supportgroups.com, and note the link to the abstract at the bottom of the post, it may be something you will want to bring to your doctor.
Ross
Ross
What I can't seem to decide is, is the long term risk associated with mediastinal exposure to radiation worse than extending chemo alone. Radiation as we know causes blood vessel damage at the site along with long term cancer risk. Does it make sense to avoid the radiation and extend the chemo or reduce the chemo and add the radiation?
Josh
I am a cancer survior of Ovarian and Non hodgkins lymphoma, and now my cancer has returned. I am a mother of 5 adult children and 13 grandbabies. My Family and I are very close and I guess you could say they do not handle me being sick in the best of ways. This time two of my sons are away and attending college, so my husband is the only one I have told outside of a few at work that will notice my treatments effect. Otherwise they would put school on hold and come home, and I just can not do that. I cried on my way to work, I feel very scared and alone...... My husband is mad, I just want to be held and able to cry... but i have to be strong for them, so I guess no questions just a comment.
Josh-
this is a powerful question with so many implications.
Keep in mind that you're able to get radiation because your HL is evidently limited to the mediastinum. otherwise you wouldn't be a candidate for radiotherapy. you make an interesting point, and I'm so glad - so so glad - to start seeing HL patients standing up for themselves and not being purely content with the fact that their cancer is so highly treatable because yeah there are serious concerns down the road that everyone neglects in the giddiness over the curability of HL.
anyway, both treatments are inducing 'something' to die; chemo is inhibiting mitosis, radiation is in effect making cells commit suicide. i guess the question is whether HL patients with later stage disease- who did not receive radiation and were cured - are they better off than those with early stage who did get it? you mention blood vessel damage but more to my mind is the cardiopulmonary toxicity you'll (presumably) be at risk for from mediastinum radiation , as well as the exposure to doxorubicin, along with of course, the secondary leukemias.
still, the study i point out at supportgroups.com by the GHSG is compelling- they're concluding that the new standard of care for HL patients with early favorable disease should be HALF of what it is now, on both the radiation and chemo fronts. you can never know where the line is drawn, but cutting treatment in half almost makes your question moot- almost- since it seems to allow you to have your cake and eat it too- radiation and chemo- in lesser doses.
I realize i've taken this discussion nowhere, but you ask such a great question and i wish more HL patients were asking the same question. In the flurry to cure HL we all ignore the 'twenty years from now' but it can't be ignored any longer.
Ross
My HL has a node touching the pericardium. Exposure to radiation might have long term catastrophic effects. Add to that, My father died at age 39 from a heart attack. Now granted. he was a smoker and in those days medical technology was nowhere compared to today for cardiovascular care. But still the concept of radiation even at a lower dose is somewhat scary to me. Am I not better off avoiding it all together? or is radiation allowing or less chemo. and if so, which is worse long term, radiation or more chemo.
The probability of developing impaired myocardial function based on a combined index of signs, symptoms and decline in left ventricular ejection fraction (LVEF) is estimated to be 1 to 2% at a total cumulative dose of 300 mg/m2 of Doxorubicin, 3 to 5% at a dose of 400 mg/m2, 5 to 8% at 450 mg/m2 and 6 to 20% at 500 mg/m2. The risk of developing CHF increases rapidly with increasing total cumulative doses of Doxorubicin in excess of 400 mg/m2. 4 doses of ABVD would be less than 400mg/m2. However even at lower doses, combined with radiation to the mediastinal region there would be an increased risk of developing CHF.
There is my dillema in a nutshell. Of course the absolute worst thing would be a recurrence of the HL. So we need to gurantee no return and still minimize the risk of heart failure.
Any suggestions?
Josh
Unless he began smoking as a pre-teen, I don't see his smoking being a major factor in his heart attack. Although the key wouldn't be medical tech, it would be the standards for cigarettes. For instance in the early 1950s Kent sold about 12 billion cigarettes the filters of which were made of a type of asbestos. Point is, I would think the variables would be there, and not with medical tech. Add to that a somewhat evident heart problem ...
I don't know that anyone can tell you w ith any degree of certainty that one is worse long-term than the other, chief reason being that long-term survival studies are very rare, and even if they weren't rare there could be no telling the actual cause of the CHF or secondary cancer. Either way you seem to be looking for stats, a percentage by which to hedge a bet.
By the way do you have a diagnosed heart condition or are you just being cautious?
At any rate, later stage HL patients don't get radiation, but even stage IV patients have a cure rate that bumps around 85-90%. this isn't to say radiation is pointless, it's to say that radiation is effective in reducing a localized mass, and that combination chemo regimens have proven effective without radiation.
As for suggestions, although they're about NHL, you might try contacting the Intl Lymphoma Epidemiology Consortium, browsing papers at the open access journal Radiation Oncology, or hit up the German Hodgkins Study Group, they're the foremost authorities on HL worldwide, in my humble opinion.
Finally, a few months ago I wrote about a new HL regimen that was geared towards pediatric HL patients, in such a way as to reduce the potential cardiopulmonary toxicity. It was ABVE-PC and you'll note that although it's got the pediatric label, there's no reason to think that it wouldn't be effective for most patients (elderly aside). Check it out.
Josh-
Did you catch this Reuters piece about avoiding radiation in early Hodgkin's?
Ross
Thank you. Just read it. The question now becomes can I get away with 4 rounds. In the article he doesnt specify which subset of the group had the relaps. Wsa it evenly distributed or leanng more towards the group that only had 4 rounds? Also, I turn 49 next month so I am older than the study.
Josh
I don't know Josh, I think the evidence is mounting. The Dana-Farber retrospective cut off at 45, at 49 your age is immaterial in this regard. The only thing standing in the way would be prognostic factors but for all I know you're in good health, better health than many in the study.
Couple this with the German HSG abstract presented at the ASH meeting that saw no statistically meaningful difference in success rates between 2 cycles of ABVD and 4 cycles as well as radiation (HERE).
Put that on top of yesterday's blockbuster news about the molecular markers in HL tumors predicting who will respond to initial treatment and who may not, and I think you can- assuming you're Stage IA and considered favorable, I think you can make the argument for getting away with 2xABVD followed by PET and restaging, which, ideally, would find you cancer-free.