Journal Information
Vol. 39. Num. 4.October - December 2017
Pages 293-390
Download PDF
More article options
Vol. 39. Num. 4.October - December 2017
Pages 293-390
Scientific Comment
DOI: 10.1016/j.bjhh.2017.08.004
Hodgkin's lymphoma in developing countries: can we go further?
Rafael Dezen Gaiolla
Corresponding author

Correspondence to: Hospital das Clínicas da Faculdade de Medicina de Botucatu da Universidade Estadual “Júlio de Mesquita Filho” (HCFMB-UNESP), Distrito de Rubião Junior S/N, Botucatu, SP, Brazil.
Universidade Estadual “Júlio de Mesquita Filho” (UNESP), Botucatu, SP, Brazil
Related content
Rev Bras Hematol Hemoter 2017;39:325-3010.1016/j.bjhh.2017.08.001
José Carlos Jaime-Pérez, Carmen Magdalena Gamboa-Alonso, José Ramón Padilla-Medina, Raúl Alberto Jiménez-Castillo, Leticia Alejandra Olguín-Ramírez, César Homero Gutiérrez-Aguirre, Olga Graciela Cantú-Rodríguez, David Gómez-Almaguer
This item has received
Article information
Full Text
Download PDF
Full Text

Hodgkin's lymphoma (HL) is a B cell malignancy that affects approximately 8000 new patients in the United States annually.1 This is the most common lymphoma affecting the young population with a higher incidence at ages 15 to 35 years. Because of its particular histological features and biological behavior, HL is highly responsive to chemotherapy and radiation, and therefore is considered a model of successful cancer treatment. In fact, in the last decades, important advances were made regarding HL treatment resulting in unprecedented high cure rates. Elegantly designed clinical trials conducted by important cooperative groups in Europe and North America have set the basis for treatment and established the guidelines for HL management in the modern era. In early-stage disease, treatment based on the ABVD (Doxorubicin, Bleomycin, Vinblastine, Dacarbazine) regimen remains the standard of care. Short-course chemotherapy (2–4 cycles) followed by radiotherapy (20–30Gy) has demonstrated high efficacy and acceptable acute and long-term toxicity, with cure rates that exceed 90%.2 Duration of treatment and doses of radiation depend on the presence of some adverse prognostic factors.3 In advanced-stage HL, the best treatment choice has been a matter of exhaustive debate. In the United States, 6–8 cycles of ABVD remains the standard of care, resulting in 5-year failure-free survival of 60% and 5-year OS of 73%.4,5 In Europe, the German Hodgkin Study Group has developed a more intensive protocol, the escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) regimen, which is widely used in many centers. When compared to ABVD, escalated BEACOPP results in better progression-free and overall survival but with more acute and late toxicities.6–8 Defining which patients really do benefit from more intensive regimens is still a challenge.9 More recently, the concept of response-adapted therapy based on interim positron emission tomography-computed tomography (PET-CT) has proven to be of prognostic importance and seems to improve outcomes by identifying patients who are most likely to benefit from more potent treatment regimens.10

In developing countries, however, the outcomes of HL treatment are not so exciting. Although data is scarce and mostly comes from small population-based and retrospective studies, the reported progression-free survival and overall survival are significantly lower than those observed in developed countries, especially for advanced-stage disease.11,12 In this issue of the Revista Brasileira de Hematologia e Hemoterapia, Jaime-Pérez et al.13 present the data of 128 HL patients retrospectively studied at a university hospital in Monterrey, Mexico. The authors found a high rate of primary refractory disease (43% of the entire cohort) and poor 5-year progression-free survival (PFS) even for the early-stage population (median: 42.7%; 95% confidence interval: 27.5–57.9). Noteworthy, the majority of patients presented with advanced disease and up to 20% experienced chemotherapy dose reductions due to toxicity or did not complete the planed treatment. Some robust data has recently been published by the Brazilian Prospective Hodgkin's Lymphoma Registry,14 similarly showing a high proportion of advanced-stage HL at the moment of diagnosis in Brazil. However, the 3-year PFS and overall survival (OS) were 74% and 90%, respectively, better than those observed in the Mexican study. With small differences, similar findings have been observed in other developing countries.11,12,15,16 Altogether, these data suggest that outcomes of HL treatment are very heterogeneous across different regions of the world. One possible explanation is that in many developing countries patients may not have easy access to public healthcare, which could postpone diagnosis and increase the number of more advanced-stage HL. Once diagnosed, patients not always have full access to adequate staging procedures (even computed tomography), resulting in a considerable number of under staged and, therefore, undertreated cases. Additionally, some hospitals not always have appropriate emergency supportive care to deal with chemotherapy complications, thereby increasing morbidity and mortality rates. Finally, differences in the economic and social environment, pattern of Epstein–Barr virus infection and genetic background may also explain some differences in HL behavior at different geographic locations.17 Indeed, lower economic status has been associated with more aggressive disease and worse outcomes in HL.18

Although Jaime-Pérez et al. described a single institution experience, their work brings into focus a very important concern about the management of HL in countries with limited resources. All the efforts necessary to improve diagnosis and treatment outcomes are of extreme importance and strongly desirable in the context of a highly curable disease.

Conflicts of interest

The author declares no conflict of interest

National Cancer Institute Surveillance
Epidemiology, and End Results (SEER) Program Populations (1969–2015)
DCCPS, Surveillance Research Program, released December, (2016)
Available from:
A. Engert,A. Plütschow,H.T. Eich,A. Lohri,B. Dörken,P. Borchmann
Reduced treatment intensity in patients with early-stage Hodgkin's lymphoma
N Engl J Med, 363 (2010), pp. 640-652
H.T. Eich,V. Diehl,H. Gorgen,T. Pabst,J. Markova,J. Debus
Intensified chemotherapy and dose-reduced involved-field radiotherapy in patients with early unfavorable Hodgkin's lymphoma: final analysis of the German Hodgkin Study Group HD11 trial
J Clin Oncol, 28 (2010), pp. 4199-4206
S. Viviani,G. Bonadonna,A. Santoro,V. Bonfante,M. Zanini,L. Devizzi
Alternating versus hybrid MOPP and ABVD combinations in advanced Hodgkin's disease: ten-year results
J Clin Oncol, 14 (1996), pp. 1421-1430
D.B. Duggan,G.R. Petroni,J.L. Johnson,J.H. Glick,R.I. Fisher,J.M. Connors
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 (2003), pp. 607-614
A. Engert,V. Diehl,J. Franklin,A. Lohri,B. Dörken,W.-D. Ludwig
Escalated-dose BEACOPP in the treatment of patients with advanced-stage Hodgkin's lymphoma: 10 years of follow-up of the GHSG HD9 study
J Clin Oncol, 27 (2009), pp. 4548-4554
A. Engert,H. Haverkamp,C. Kobe,J. Markova,C. Renner,A. Ho
Reduced-intensity chemotherapy and PET-guided radiotherapy in patients with advanced stage Hodgkin's lymphoma (HD15 trial): a randomised, open-label, phase 3 non-inferiority trial
N. Skoetz,A. Will,I. Monsef,C. Brillant,A. Engert,B. von Tresckow
Comparison of first-line chemotherapy including escalated BEACOPP versus chemotherapy including ABVD for people with early unfavourable or advanced stage Hodgkin lymphoma
Cochrane Database of Systematic Reviews [Internet],
Available from: [cited 27.8.17]
T.P. Vassilakopoulos,P.W. Johnson
Treatment of advanced-stage Hodgkin lymphoma
M.C. Moghbel,E. Mittra,A. Gallamini,R. Niederkohr,D.L. Chen,K. Zukotynski
Response assessment criteria and their applications in lymphoma: Part 2
R.N. Maddi,V.G. Linga,K.K. Iyer,J.S. Chowdary,S. Gundeti,R. Digumarti
Clinical profile and outcome of adult Hodgkin lymphoma: experience from a tertiary care institution
Indian J Med Paediatr Oncol, 36 (2015), pp. 255-260
L. Chatenoud,P. Bertuccio,C. Bosetti,T. Rodriguez,F. Levi,E. Negri
Hodgkin's lymphoma mortality in the Americas, 1997–2008: achievements and persistent inadequacies: Hodgkin's lymphoma mortality in the Americas
Int J Cancer, 133 (2013), pp. 687-694
J.C. Jaime-Pérez,C.M. Gamboa-Alonso,J.R. Padilla-Medina,R.A. Jiménez-Castillo,L.A. Olguín-Ramírez,C.H. Gutiérrez-Aguirre
High frequency of primary refractory disease and low progression-free survival rate of Hodgkin lymphoma: a decade of experience in a Latin American center
Rev Bras Hematol Hemoter, 39 (2017), pp. 325-330
I. Biasoli,N. Castro,M. Delamain,T. Silveira,J. Farley,B.P. Simões
Treatment outcomes for Hodgkin lymphoma: first report from the Brazilian Prospective Registry
Hematol Oncol, (2017),
(ahead of print)
B. Andjelic,D. Antic,L. Jakovic,M. Todorovic,A. Bogdanovic,V. Djurasinovic
A single institution experience on 314 newly diagnosed advanced Hodgkin lymphoma patients: the role of ABVD in daily practice
Eur J Haematol, 93 (2014), pp. 392-399
R.G. Shafi,M.M. Al-Mansour,S.S. Kanfar,H. Al Hashmi,A. Alsaeed,M. Al-Foheidi
Hodgkin lymphoma outcome: a retrospective study from 3 tertiary centers in Saudi Arabia
Oncol Res Treat, 40 (2017), pp. 288-292
R.T. Hoppe,P.T. Mauch,J.O. Armitage,V. Diehl,L.M. Weiss
Hodgkin Lymphoma
2nd ed., Philadelphia, (1999)
I. Biasoli,N. Castro,M. Delamain,T. Silveira,J. Farley,B.P. Simões
Lower socioeconomic status is associated with shorter survival in HL patients – an analysis from the Brazilian Hodgkin Lymphoma Registry
Poster presented at: 10th international Symposium on Hodgkin Lymphoma, (2016)

See paper by Jaime-Pérez et al. on pages 325–30.

Copyright © 2017. Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular
Revista Brasileira de Hematologia e Hemoterapia

Subscribe to our Newsletter

Article options
Cookies policy
To improve our services and products, we use cookies (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.

Are you a health professional able to prescribe or dispense drugs?