Clinical or survival benefit to routine surveillance imaging for classical Hodgkin lymphoma patients in first complete remission

Reporter: J Taylor Whaley, MD
The Abramson Cancer Center of the University of Pennsylvania
Last Modified: June 3, 2013

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Presenter: Sai Ravi Pingali, MD
Presenter's Affiliation: Medical College of Wisconsin Affiliated Hospitals, Milwaukee, Wisconsin
Abstract #: 8505

Background

  • Hodgkin lymphoma is a fairly uncommon cancer, with ~8,000 cases diagnosed annually in the United States.
  • Approximately 75% of patients presenting with Hodgkin lymphoma will be cured of their disease.
  • Following successful treatment with chemotherapy and/or radiation, the appropriate follow up regimen with imaging, tumor markers, and physical exam remains unclear.
  • Routine surveillance imaging (RSI) for patients in complete remission from classical Hodgkin lymphoma is common practice as routine imaging offers the theoretical benefit of detecting asymptomatic relapse, which may allow for early and more successful second-line therapy. Currently, the NCCN guidelines recommend imaging with CT scans every 6-12 months for the first 2-3 years.
  • Despite this, evidence for a clinical benefit of RSI is lacking.
  • Because the majority of cases discovered on imaging have a clinical finding or presenting symptom, some clinicians question the value of surveillance imaging.
  • Additionally, routine imaging is associated with exposure to radiation, costly procedures, risks associated with false positives, and anxiety for patients.
  • In the current retrospective study, the authors compared outcomes in patients with Hodgkin lymphoma undergoing RSI versus clinical surveillance in which scans are only obtained to evaluate concerning signs or symptoms
  • Additionally, the authors attempted to quantitative the costs associated with routine surveillance imaging.

Materials and Methods

  • Patients with classic HL diagnosed at three tertiary care centers (Medical College of Wisconsin, University of Nebraska, and Washington University) from 2000-2010, who achieved complete remission (CR) following frontline therapy, were analyzed retrospectively.
  • Patients were stratified into two groups based on the surveillance strategy employed.
  • Baseline patient characteristics, prognostic features, treatment records, and outcomes were collected.
  • Patients were >18 years old with a minimum of 2 years follow up.
  • The primary objective was to compare overall survival for patients undergoing RSI versus CS.
  • Secondary objectives included the analysis of success of second-line therapy for relapsed patients in each group as well as the costs associated with RSI (cost of imaging only).

Results

  • 241 patients met eligibility criteria, with 164 RSI patients and 77 clinical surveillance patients.
  • Patient characteristics (age, gender, sex, and race) were similar in each group.
  • Median age was 35 years old
  • Tumor characteristics (stage, sedimentation rate, Hasenclever index, bulky disease and B symptoms) were similar in each group as well.
  • Initial treatment techniques were slightly different for the two groups:
    • Chemotherapy consisted of ABVD in 79% and Stanford V in 15%.
    • Patients in the RSI group more commonly received ABVD (92% vs. 57%) and less often radiation therapy (40% vs. 67%).
  • No difference in OS was noted for ABVD vs Standford V
  • No difference in OS was noted with consolidative radiation
  • With a median follow up of 4 years, the overall survival was similar in both groups, with 5 (3.8%) deaths in the RSI group and 4 (5.3%) in the clinical surveillance group
  • Six (4.6%) relapses occurred in the RSI group (4 of which were detected by RSI), and 5 (6.6%) in the clinical surveillance group.
  • All relapsed patients achieved second CR with second-line therapy.
  • Mean number of scans was 4.25 in RSI and 1.14 in clinical surveillance groups, respectively.
  • Mean number of scans per recurrence was 124 in RSI group and 17 in clinical surveillance groups
  • The mean cost per patient was an additional $19,000 for patients in the RSI group
  • The mean cost per relapse in the RSI group was $590,000.

Author's Conclusions

  • RSI did not yield a survival advantage in classic Hodgkin Lymphoma in this cohort of patients.
  • Although this study is small, it is representative of 3 major tertiary cancer centers.
  • Given the radiation exposure, significant costs, and risk for additional procedures associated with RSI, the authors conclude clinical surveillance is the preferred strategy in classic HL patients in first complete remission.

Clinical Implications

  • The authors presented a retrospective study evaluating the use of routine surveillance imaging for patients with Hodgkin Lymphoma in complete remission following first-line therapy.
  • This retrospective study certainly adds to the current body of literature and highlights a controversial topic of the purpose and timing of surveillance imaging.
  • Although the study is small, it was composed of patients from 3 major cancer centers throughout the United States.
  • The topic of too frequent imaging has emerged within several fields of medicine in recent years. With the rapid influx of CT and PET scans into medicine, routine surveillance imaging has become common practice despite a paucity of data to support its use; however, routine imaging in asymptomatic patients does pose potential risks to patients in the form of radiation exposure, false positives, anxiety, and costs.
  • Of 4 major multi-center clinical trials currently accruing for lymphoma, routine follow-up imaging is recommended with 6-11 scans in the 1st 2 years following completion of therapy.
  • Each CT of the chest, abdomen, and pelvis exposes the patient to 20-40 mSv of radiation. Using the linear, no-threshold model for radiation induced carcinogenesis, there is a risk of secondary cancers due to surveillance imaging.
  • Additionally, as the health care system continues to attempt to become more efficient with the use of resources, the monetary value associated with routine imaging is called into question.
  • Additional research is needed on the value and risks associated with routine imaging in Hodgkin lymphoma following complete remissions.



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