Managing Neutropenia During ABVD for Hodgkin Lymphoma

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Managing Neutropenia During ABVD for Hodgkin Lymphoma

In this small study, therapy-induced neutropenia did not substantially affect patient outcomes in patients who did not receive cytokine support.

ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, dacarbazine) chemotherapy is a standard regimen for treating patients with Hodgkin lymphoma (HL); 6 to 8 cycles usually are given for advanced-stage disease, and fewer cycles, in combination with radiotherapy, are prescribed for patients with early-stage disease. During therapy, neutropenia occurs in most patients, necessitating dose reductions or delays in treatment, which can negatively affect dose intensity and lower the expected high cure rate. Although concurrent cytokine therapy with a myeloid growth factor, such as filgrastim, can help maintain neutrophil counts, higher rates of bleomycin pulmonary toxicity in conjunction with growth factor administration have been reported (J Clin Oncol 2005; 23:7614).

To determine whether neutropenia during treatment adversely affects patient outcomes, researchers conducted a single-institution study of 38 HL patients who received ABVD with no growth factor support. Most patients had stage I or II disease and received 3 to 4 cycles of ABVD, followed by radiation therapy. ABVD was administered on days 1 and 15 of each cycle; in about one third of cycles, neutrophil counts were lower than 1000/dL. Although most patients had one or more episodes of grade III/IV neutropenia, only two patients (5%) developed neutropenic fever. Most scheduled chemotherapy cycles (95%) were given as planned. One patient developed bleomycin pulmonary toxicity.

Comment: ABVD regimens yield gratifyingly high cure rates in HL patients. Treatment usually is associated with neutropenia (although risk for febrile neutropenia is classified as <10% by National Comprehensive Cancer Network practice guidelines). In this small single-institution study, ABVD schedule and dose intensity were maintained without growth factor support. Febrile neutropenia occurred in only 2 of 176 treatment cycles, which suggested that this is a safe strategy for patients with early disease who receive 3 to 4 cycles of ABVD. The cost savings of eliminating routine myeloid growth factors are considerable, and bleomycin pulmonary toxicity rates might be lower. Validating and confirming these results in prospective trials that include patients with advanced-stage HL who receive more cycles of therapy will be important.

— Michael E. Williams, MD

Published in Journal Watch Oncology and Hematology March 19, 2007