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How Important Is Bleomycin in the Adriamycin + Bleomycin + Vinblastine + Dacarbazine Regimen?

SUNY, Syracuse, NY
Dana-Farber Cancer Institute, Boston, MA
Duke University, Durham, NC

To the Editor:

Adriamycin + bleomycin + vinblastine + dacarbazine (ABVD) remains the major standard chemotherapy regimen for the treatment of Hodgkin's disease. It has been shown in prospective randomized trials to be superior or equivalent to mechlorethamine + vincristine + procarbazine + prednisone (MOPP), MOPP alternating with ABVD, or MOPP–adriamycin + bleomycin + vinblastine (-ABV) hybrid, but with less acute toxicity.^1,2 The absence of myelodysplasia, leukemia, or permanent sterilization offers an advantage over nitrogen mustard–containing programs. Bleomycin, however, does increase the risk of pulmonary complications and often necessitates the frequent assessment of pulmonary function during the course of therapy.³ Pulmonary symptoms or abnormal thoracic radiographics generally warrants the cessation of bleomycin. In that circumstance, it has been our practice to continue the regimen but without bleomycin. To assess the impact of this policy, we reviewed the outcome of patients with advanced Hodgkin's disease treated with ABVD, without radiation therapy, in whom the bleomycin was discontinued. The database is two randomized trials—the Cancer and Leukemia Group B 8251 trial¹ and the Cancer and Leukemia Group B 8952 trial.²

Of 363 patients with complete drug dosing information for at least six cycles of ABVD, 40 had bleomycin discontinued. The distribution of the number of patients discontinuing bleomycin by cycle of treatment is as follows: five (12.5%) in the first two cycles, nine (22.5%) in the third cycle, 12 (30%) during the fourth cycle, 11 (27.5%) during the fifth cycle, and three (7.5%) following the fifth cycle. Their outcome is comparable to that of the larger group who received at least six cycles without cessation of bleomycin dosing. The complete response rate was 91% compared with 90% in the bleomycin-modified group. A competing-risks analysis of relapse (controlling for death from other causes) showed no difference in time to relapse (P = .65; Fig 1; Table 1).

View larger version (14K): [in this window] [in a new window]   Fig 1. Cancer and Leukemia Group B 8251 and 8952: cumulative incidence of recurrent Hodgkin's disease (HD) by treatment. ABVD, adriamycin + bleomycin + vinblastine + dacarbazine; Bleo, bleomycin.

Authors' Disclosures of Potential Conflicts of Interest

The following authors or their immediate family members have indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. Acted as a consultant within the last 2 years: George P. Canellos, Bristol-Myers Squibb Co.

REFERENCES

1. Canellos GP, Anderson JR, Propert KJ, et al: Chemotherapy of advanced Hodgkin's disease with MOPP, ABVD, or MOPP alternating with ABVD. N Engl J Med 327:1478-1484, 1992[Abstract]

2. Duggan DB, Petroni GR, Johnson JL, et al: Randomized comparison of ABVD and MOPP/ABV hybrid for the treatment of advanced Hodgkin's disease: Report of an intergroup trial. J Clin Oncol 21:607-614, 2003[Abstract/Free Full Text]

3. Horning SJ, Adhikari A, Rizk N, et al: Effect of treatment for Hodgkin's disease on pulmonary function: Results of a prospective study. J Clin Oncol 12:297-305, 1994[Abstract]

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