Assessing the efficacy and tolerability of PET-guided BrECADD versus eBEACOPP in advanced-stage, classical Hodgkin lymphoma (HD21): a randomised, multicentre, parallel, open-label, phase 3 trial.

Alexander Fosså, Carsten Kobe, Michael Fuchs, Richard Greil, Bernd Hertenstein, Sebastian Scholl, Josée M Zijlstra, Felix Keil, Andreas Rosenwald, Justin Ferdinandus, Andreas Hüttmann, Bastian von Tresckow, Markus Dietlein, Peter Borchmann, Roland Schroers, Gundolf Schneider, Valdete Schaub, Wolfram Jung, Benjamin Unger, Andreas Rank, Christian Meyer Zum Büschenfelde, Peter Kamper, Daniel Molin, Sven Borchmann, Athanasios Zomas, Michael Hallek, Vladan Vucinic, Alden Moccia, Andreas Zimmermann, Urban Novak, Stephan Mathas, Karolin Behringer, Wolfram Klapper, Maike de Wit, Judith Dierlamm, Hans-Joachim Beck, Sonja Martin, Helen Kaul, Pratyush Giri, Hans-Theodor Eich, Andreas Viardot, Max S Topp, Mark Hertzberg, Stefanie Kreissl, Volker Diehl, Mathias Hänel, Christian Baues, Julia Meissner, Karolin Trautmann-Grill, Andrea Kerkhoff

Journal: Lancet (London, England) 2024;404(10450):341-352

PMID: 38971175

Abstract

BACKGROUND

Intensified systemic chemotherapy has the highest primary cure rate for advanced-stage, classical Hodgkin lymphoma but this comes with a cost of severe and potentially life long, persisting toxicities. With the new regimen of brentuximab vedotin, etoposide, cyclophosphamide, doxorubicin, dacarbazine, and dexamethasone (BrECADD), we aimed to improve the risk-to-benefit ratio of treatment of advanced-stage, classical Hodgkin lymphoma guided by PET after two cycles.

METHODS

This randomised, multicentre, parallel, open-label, phase 3 trial was done in 233 trial sites across nine countries. Eligible patients were adults (aged ≤60 years) with newly diagnosed, advanced-stage, classical Hodgkin lymphoma (ie, Ann Arbor stage III/IV, stage II with B symptoms, and either one or both risk factors of large mediastinal mass and extranodal lesions). Patients were randomly assigned (1:1) to four or six cycles (21-day intervals) of escalated doses of etoposide (200 mg/m intravenously on days 1-3), doxorubicin (35 mg/m intravenously on day 1), and cyclophosphamide (1250 mg/m intravenously on day 1), and standard doses of bleomycin (10 mg/m intravenously on day 8), vincristine (1·4 mg/m intravenously on day 8), procarbazine (100 mg/m orally on days 1-7), and prednisone (40 mg/m orally on days 1-14; eBEACOPP) or BrECADD, guided by PET after two cycles. Patients and investigators were not masked to treatment assignment. Hierarchical coprimary objectives were to show (1) improved tolerability defined by treatment-related morbidity and (2) non-inferior efficacy defined by progression-free survival with an absolute non-inferiority margin of 6 percentage points of BrECADD compared with eBEACOPP. An additional test of superiority of progression-free survival was to be done if non-inferiority had been established. Analyses were done by intention to treat; the treatment-related morbidity assessment required documentation of at least one chemotherapy cycle. This trial was registered at ClinicalTrials.gov (NCT02661503).

FINDINGS

Between July 22, 2016, and Aug 27, 2020, 1500 patients were enrolled, of whom 749 were randomly assigned to BrECADD and 751 to eBEACOPP. 1482 patients were included in the intention-to-treat analysis. The median age of patients was 31 years (IQR 24-42). 838 (56%) of 1482 patients were male and 644 (44%) were female. Most patients were White (1352 [91%] of 1482). Treatment-related morbidity was significantly lower with BrECADD (312 [42%] of 738 patients) than with eBEACOPP (430 [59%] of 732 patients; relative risk 0·72 [95% CI 0·65-0·80]; p<0·0001). At a median follow-up of 48 months, BrECADD improved progression-free survival with a hazard ratio of 0·66 (0·45-0·97; p=0·035); 4-year progression-free survival estimates were 94·3% (95% CI 92·6-96·1) for BrECADD and 90·9% (88·7-93·1) for eBEACOPP. 4-year overall survival rates were 98·6% (97·7-99·5) and 98·2% (97·2-99·3), respectively.

INTERPRETATION

BrECADD guided by PET after two cycles is better tolerated and more effective than eBEACOPP in first-line treatment of adult patients with advanced-stage, classical Hodgkin lymphoma.

FUNDING

Takeda Oncology.

Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Address: Faculty of Medicine, University of Cologne, Cologne, Germany; Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University Hospital, Düsseldorf, Germany; German Hodgkin Study Group, Cologne, Germany. Electronic address: [email protected].; Faculty of Medicine, University of Cologne, Cologne, Germany; Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University Hospital, Düsseldorf, Germany; German Hodgkin Study Group, Cologne, Germany.; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Oncology Institute of Southern Switzerland, EOC, Medical Oncology, Bellinzona, Switzerland.; 3rd Medical Department, Paracelcus Medical University, Salzburg, Austria; Salzburg Cancer Research Institute, Cancer Cluster Salzburg, Salzburg, Austria; Arbeitsgemeinschaft Medikamentöse Tumortherapie, Salzburg, Austria.; Prince of Wales Hospital Department of Haematology and University NSW, Sydney, NSW, Australia; Australasian Leukaemia & Lymphoma Group, Melbourne, VIC, Australia.; University of Tübingen, Tübingen, Germany.; Department of Haematology, University Hospital, University Duisburg-Essen, Essen, Germany.; Department of Haematology, Hanusch Krankenhaus, Vienna, Austria.; University Hospital Hamburg-Eppendorf, Hamburg, Germany.; Department III of Internal Medicine, Klinikum Chemnitz, Chemnitz, Germany.; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Department of Medical Oncology, University Hospital Bern, Bern, Switzerland.; Department of Hematology and Oncology, University of Heidelberg, Heidelberg, Germany.; Department of Hematology and Oncology, Klinikum Leverkusen, Leverkusen, Germany.; Department of Hematology, Oncology, and Cancer Immunology, Charité-Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Berlin, Germany; Humboldt University of Berlin, Berlin Institute of Health, Berlin, Germany; Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Biology of Malignant Lymphomas, Berlin, Germany; Experimental and Clinical Research Center (ECRC), a joint cooperation between Charité and MDC, Berlin, Germany.; Department of Hematology, Amsterdam UMC, Vrije Universiteit, Cancer Center, Amsterdam, Netherlands.; Department of Oncology, Oslo University Hospital, Oslo, Norway; Nordic Lymphoma Group, University Hospital of Ulm, Ulm, Germany.; Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany.; Department of Internal Medicine I, Klinikum Bremen Mitte, Bremen, Germany.; Department of Haematology and Oncology, Robert Bosch Hospital, Stuttgart, Germany.; Department of Haematology and Bone Marrow Transplant, Royal-Adelaide-Hospital, Adelaide, SA, Australia.; Klinik für Innere Medizin II, Jena University Hospital, Jena, Germany.; Department of Internal Medicine II, Hematology and Oncology, University Hospital Wuerzburg, Wuerzburg, Germany.; Department of Haematology and Oncology, Göttingen, Germany.; Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University of Leipzig, Leipzig, Germany.; Department of Medicine III, Universitätsmedizin Mainz, Mainz, Germany.; Department for Medicine A, Hematology, Oncology, Hemostaseology and Pneumology, University Hospital Muenster, Muenster, Germany.; Hämatologie, Onkologie und Tumorimmunologie, HELIOS Klinikum Berlin-Buch, Berlin, Germany.; Department of Internal Medicine II, University Hospital Augsburg, Augsburg, Germany.; Department of Hematology and Oncology, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Germany.; Clinic for Hematology, Oncology, Immunology and Palliative Medicine, Vincentius-Deaconry Clinics gAG, Karslruhe, Germany.; Clinic for Hematology, Oncology and Palliative Medicine, Vivantes Klinikum Neukölln, Berlin, Germany.; Medical Clinic I, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany.; Nordic Lymphoma Group, University Hospital of Ulm, Ulm, Germany; Department of Hematology, University Hospital of Aarhus, Aarhus, Denmark.; Nordic Lymphoma Group, University Hospital of Ulm, Ulm, Germany; Department of Immunology, Genetics and Pathology, Cancer Immunotherapy, Uppsala University, Uppsala, Sweden.; Ordensklinikum Linz Elisabethinen, Linz, Austria.; Faculty of Medicine, University of Cologne, Cologne, Germany; Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University Hospital, Düsseldorf, Germany; German Hodgkin Study Group, Cologne, Germany; Department of Haematology, University Hospital, University Duisburg-Essen, Essen, Germany.; Institute for Pathology, University Hospital Würzburg, Würzburg, Germany.; Karl Lennert Cancer Center, University Hospital Schleswig-Holstein, Kiel, Germany.; Department of Radiotherapy, University Hospital of Muenster, Muenster, Germany.; Department of Radiation Oncology, University Hospital of Ruhr-Universität Bochum, Marien Hospital Herne, Herne, Germany.; Global Medical Lead for Lymphoma & Leukemia at Takeda Oncology, Cambridge, MA, USA.; Faculty of Medicine, University of Cologne, Cologne, Germany; Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, University Hospital, Düsseldorf, Germany.; Department of Nuclear Medicine, University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Cologne, Germany.
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