DR EVENS: So this was a patient from practice about 3 months ago. She was an 87-year-old female, came up from Connecticut. Has actually had a second opinion at Memorial, and then came out to U-Mass where I was at the time. And so it was complex in that she had advanced-stage, mixed-cellularity Hodgkin lymphoma. It was EBV-positive. But the difficulty is there was a significant delay in the diagnosis. Someone along the way in primary care had started steroids. They thought it was an inflammatory issue. She had had some pruritus and other symptoms, fever, that maybe not surprisingly got better. But frankly, went almost 6 months before the point where she received just any oncologic opinion.

She was an 87-year-old that was incredibly active, would go to her house on the Cape every other weekend. But after this, I think, 6 months of really protracted diagnosis, by the time we had met her she was almost wheelchair bound, and it was presumed likely due to disease. She had some comorbidities, coronary artery disease, but no recent angina, diabetes, hypertension. Had a prior history of squamous cell carcinoma that was resected and currently was NED from that standpoint.

So we were somewhat vexed, just in general, an over 80-year-old with Hodgkin lymphoma, prior vibrant, now fairly debilitated.

DR LOVE: So Chris, this lady shows up in your clinic. What are you thinking?

DR FLOWERS: Yes. So I think any time you’re facing older patients and patients that have significant comorbidities, you need to take those comorbidities into concern and determine whether or not she’s an appropriate candidate for chemotherapy. It sounds like, in your opinion, that she’s right on the borderline of being an appropriate candidate but probably would benefit from some chemotherapy-based approach. It can be very difficult to give ABVD in many of these older patients. CHOP has been explored in this situation. That’s something that I’ve used in older patients. Given her cardiovascular comorbidities, that may or may not be an option for her. And so I would explore that a little bit further, either in consultation with cardiology or just by doing an echo alone.

The other regimen I’ve used in these older patients is a regimen called ChlVPP, which is an oral agent of chemotherapy, and that can be used in some of these older patients.

DR LOVE: We were talking before, putting aside reimbursement issues, about B-vedotin up front. What about that in this lady?

DR FLOWERS: I’m still a little bit less inclined to use it in the up-front setting. If she failed an up-front regimen, then I’d very quickly use it as a second-line therapy.

DR LOVE: So Jon, what would you be thinking about with this lady?

DR FRIEDBERG: I think a similar list. I think I’ve often thought about CHOP chemotherapy. But I think in the brentuximab vedotin era, I don’t think I’ve ever seen somebody who’s 87 with Hodgkin’s. I mean, I think a lot of the elderly patients I’ve been confronted with are patients in their earlier seventies, where chemotherapy probably could be tolerated. It’s just a question of which regimen.

And I think at age 87, one would have to think a little bit about trying brentuximab vedotin as a single agent. I mean, it’s true there isn’t a lot of data yet.

Fortunately, we have this trial open, which she would be a perfect candidate for.

DR LOVE: So what were you thinking, Andy?

DR EVENS: So further, fortunately, we also have a clinical trial for front-line elderly Hodgkin lymphoma that looks at a little different strategy. A group of us across the US were looking about — it wasn’t really framed for an 87-year-old, any patient over age 60. And we were looking at, instead of the concurrent brentuximab vedotin, we were looking to try to bring that front line. We’re giving it as a sequential strategy. And so, interestingly, phasing it a window study, where we’re giving 2 doses of brentuximab vedotin, then restaging. And we decided on, although there’s a lot of debate and disagreement, that AVD — in other words, ABVD without the bleomycin — for 6 cycles was the standard, and then followed by 4 doses of consolidation brentuximab vedotin. So that study is ongoing.

And obviously, we weren’t super enthusiastic regarding the AVD, but at least it gave us an option to get to brentuximab vedotin. And we thankfully built into the study if patients at PI’s discretion had to come off chemotherapy they could still go on to receive the 4 consolidative doses. So she went on study. And she did okay with the brentuximab vedotin, had a little neuropathy, I wouldn’t call it urosepsis, but had a UTI.

DR LOVE: Neuropathy after 2 doses?

DR EVENS: She had some preexisting diabetic neuropathy. I think that was part of the issue there. It was mild. It wasn’t dose limiting in any fashion.

Went onto the AVD and, maybe not surprisingly, had an incredibly hard time, had borderline sepsis with cycle 1, day 1, delayed it 4 weeks until day 15, cycle 1. And then had cardiomyopathy, where she had not a huge drop but dropped from 60 to 45%, had some slight heart failure. So she has come off chemotherapy. And I saw her last 2 weeks ago. She received her second of the consolidation doses. And I can tell you her PET scan, it got a little off. She was supposed to have a PET scan after the 2 cycles, but she was coming back and forth from Connecticut, had an admission. But at least after the 2 brentuximab and the chemotherapy, she was in a CR.

DR LOVE: CR?

DR EVENS: CR. And she’s much more mobile. Not back where she was 6 to 8 months ago, but markedly improved performance status.

DR LOVE: How much chemo did she actually get?

DR EVENS: So just 2 doses. Basically a day 1 and a day 15 of cycle 1.

Hodgkin lymphoma (HL)

Chronic lymphocytic leukemia (CLL)

Follicular lymphoma (FL)

Mantle-cell lymphoma (MCL)

Diffuse large B-cell lymphoma (DLBCL)

T-cell lymphoma (TCL)