Follow up of Hodgkin’s lymphoma after treatment

Prof. Ahmed ZeeneldinProf Medical Oncology

NCI, CU

HL

• High cure rates ≥ 80%– 20% relapse

• Long-term complications• Heart & Lungs• Thyroid & Breast • Fertility• Other secondary malignancies

Follow-up After CR and end of TX

• Aims:– Detect relapse earlier treatment ? Better outcome – Follow acute and chronic toxicities

• Myelospuression, Immunesupression• Heart• Lungs• Thyroid • Breast • Fertility• Other secondary malignancies

Characteristics of an ideal FU

• Patient– Positive impact on patients

• Survival• Quality of life

– Minimal bothering to patients• Less invasive• Acceptable cost

• Health care system– Cost/effective– Acceptable burden on care-givers

FU triad• Regular• Purposeful (to check for)– Disease recurrence (local and metastasis), – Complications of therapy (short- and long-term)– Other malignancies and precancerous lesions,

• Individualized (frequency & procedures): – Type of Cancer (and its stage)– Treatment, – Possible treatment related problems,– Person’s overall health,

How frequent

• General rule– Q 3-4 MONTHS in the first 2-3 YEARS– Q 6-12 MONTHS after that– Is there a stopping time?

5-y Freedom from progression:early stages

• 20% recurrence/progression• 15% in the first 5 years• 10% thereafter with plateau at year 8

10-y Freedom from progressionadvanced stages

Late therapy effects

• What:– Secondary cancers, – cardiovascular disease, – hypothyroidism, and – fertility issues

• When:– increases with longer follow-up time

• Regimens– Less with current treatment programs (ABVD, Stanford V)

compared to those used more than 10 years ago (MOPP, COPP)

Risk of 2nd malignancies in HL

Thus, follow up should be long-term

Frequency in HL

• Q3-6 months in first 1-2 years• Q6-12 months in next 3 years• Q 12 months annually

Year 1 Year 2 Year 3 Year 4 Year 5 Years ≥ 6 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 X (X) X (X) X (X) X (X) X X X X X X X

Procedures

• Clinical: H&P• Lab:

– Simple: CBC, biochemistry, serum markers– Complex/invasive:

• Imaging– Simple: CXR, US– Complex: CT, MRI, PET/CT

• Special procedure– Biopsies– BMA– Endoscopies

Procedures in HL

• Clinical (H& P) : every visit• Lab:

– CBC and plateletes + ESR and LDH every visit– Thyroid function tests: at least annulaly

• Imaging:– Initially positive imaging– CT chest and abdomen– Breast mammo/MRI

• Vaccination:– Influenza: annually– Pneumococcal, meningococcal, and H-flu: in splenectomy or splenic

RT every 5 years

Role of PET (PET/CT)

• Recommended: – Initial staging (before therapy)– Interim assessment of response (during TX)– at the end of TX to assess residual masses

• Controversial in post-therapy surveillance – False positive

Frequency and procedures in HL

• Q3-6 months in first 1-2 years• Q6-12 months in next 3 years• Q 12 months annually

Year 1 Year 2 Year 3 Year 4 Year 5 Years ≥ 6 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 3 6 9 12 H&P X (X) X (X) X (X) X (X) X X X X X X X LAB X (X) X (X) X (X) X (X) X X X X X X X Imag X X X X X X X X

Who

• Oncologist– Surgical– Medical/pediatric/hematologist– Radiation– Others

• Specialized clinics• Primary care• Patient

Who

Outcome CostOncologist

SurgicalMedical/pediatric/hematologistRadiationOthers

Best++++

Highest++++

Specialized clinics +++ +++Primary care ++ ++Patient Least

+Least

+

Who in HL

• Oncologists:– Medical – Pediatric– Radiation

– Due to the long-term risks of therapies (including secondary cancers and cardiovascular diseases)

– Need for some one aware– Especially in first 5 years then annually

Follow-up After CR and end of TX

• Aims:– Detect relapse earlier treatment ? Better

outcome – Follow acute and chronic toxicities• Heart• Lungs• Thyroid • Breast • Fertility• Other secondary malignancies

Follow-up After CR and end of TX

• Aims:– Detect relapse earlier treatment ? Better

outcome [H&P, ESR, CT (PET?CT), biopsy]– Follow acute and chronic toxicities• Heart [H&P, BP, echo]• Lungs [H&P, PFT, CT Chest]• Thyroid [H&P, T3, T4, TSH, Neck US, thyroid scan]• Breast [H&P, mammogram, US, MRI]• Fertility [serum hormones, semen analysis, US ovaries]• Other secondary malignancies: breast and lungd

Secondary Cancers• Solid tumors are the most common especially breast and lung• Mostly >10 years after the completion of treatment. • Highest risk when RT is used as a component of first-line treatment.

– lower risk with combined modality treatment than with RT alone as – marginally higher risk with combined modality treatment when compared

with chemotherapy alone. – No significant differences in the risk with IFRT vs. EFRT,

• Risk of breast cancer was substantially higher for EFRT. • Risks for secondary lung cancer, non-Hodgkin’s lymphoma (NHL),

and leukemia were significantly higher after treatment with chemotherapy alone, whereas combined modality therapy was associated with a higher risk for these and several other cancers.

Screening

• Breast cancer:– High risk patients: women who received chest or axillary

irradiation – Procedures

• Monthly self-breast examination• Annual breast examination by a health care professional• Annual breast screening [mammography ± MRI]

– MRI women who received irradiation to the chest between 10 and 30 years of age,

– When:• Age of 40 or 8-10 years after therapy completion(whichever first)

Screening

• Lung cancer– High risk patients: chest irradiation or alkylating

agent chemotherapy, and those with a smoking history

– Procedure: Chest imaging (low-dose spiral CT)– Frequency: Q 6 months – Stop after 5 years when there is no increased risk

Cardiovascular Disease

• Risk factors: Mediastinal irradiation and anthracycline-based chemotherapy

• May develop years after therapy• Procedures– annual blood pressure monitoring (even in

asymptomatic individuals) and – Echo 10 years after therapy w prior chest irradiation– Carotid ultrasound (for patients treated with neck RT– Aggressive management of cardiovascular risk factors is

recommended

Hypothyroidism

• 50% of long-term survivors who received neck or upper mediastinal irradiation

• Procedure:– Thyroid examination with every visit– Thyroid function tests at least annualy

Pulmonary Toxicity

• Risk:– Bleomycin-induced pulmonary toxicity (BPT)• Other risk factors : older age, cumulative bleomycin

dose, pulmonary irradiation, and prior history of lung disease, growth factors

Myelosuppression

• uncommon to continue for very long beyond completion of the primary treatment program

• Mostly with HDT/SCT• Increase risk for infections• Pneumococcal, meningococcal, and H-flu

revaccination is recommended every 5 years for patients treated with splenic RT or splenectomy