Classical Hodgkin lymphoma (cHL) is a curable malignancy, but outcomes vary by stage, prognostic factors, and access to timely treatment. In Brazil, the public healthcare system (SUS) assists most of the population (∼80%) and although first-line therapy is standardized in most centers, data on salvage therapy in refractory/relapsed (R/R) cases are scarce, hindering efforts to improve care. This study analyzes data from the Instituto do Câncer do Estado de São Paulo (ICESP) to provide real-world insights into cHL management within the public healthcare setting.

To describe demographics, clinical and prognostic factors, treatment patterns and R/R rates after first-line therapy in adults diagnosed with cHL between July 2014 to December 2021. Secondary objectives include progression-free survival (PFS) and overall survival (OS) estimates. Exploratory objectives aimed to assess salvage therapy response, R/R rates after each line of therapy and number of therapy lines needed to achieve best response before consolidation with autologous stem cell transplantation (ASCT).

This - retrospective, single-center study used the d Hodgkin's Lymphoma database as data source (to obtain clinical, laboratory and imaging data. Eligible patients were ≥18 years old at cHL diagnosis, which was confirmed by histopathology and immunohistochemistry, and with ≥6 months of follow-up. Patients enrolled in clinical trials or treated with anti–PD1 agents were excluded. Descriptive analysis was used to assess baseline population characteristics (relative and absolute frequencies for categorical variables and measures of central tendency, dispersion, and position for numerical variables). Survival analysis (Kaplan-Meier curves and survival and event-free time estimates reported with 95% CI).

Among 417 patients included the median age was 33 years (IQR: 25–49), 52% were male. At diagnosis, 133 (32%) had limited [Clinical Stages (CS) I/II] and 284 (68%) advanced stages (CS III/IV). Most patients had high-risk prognostic scores (85%). ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) was given in first-line therapy (LOT1) (98%). Primary refractory disease occurred in 15% of the patients and relapsed disease in 11%. In R/R disease, 91% of the patients received LOT2 GIV (gemcitabine, ifosfamide, vinorelbine) and 56% underwent ASCT. In LOT3, 30 patients (63%) were treated with DHAP (dexamethasone, cytarabine, cisplatin) and 14 (54%) underwent ASCT. In LOT4, 6 patients (25%) received ICE (ifosfamide, carboplatin, etoposide) and 3 (33%) underwent ASCT. In LOT 4 and 5, 10 patients (9%) received brentuximab, of whom 2 underwent ASCT. The main reason for ASCT ineligibility was progressive disease (59%). Of the 63 patients who underwent ASCT, 15 (24%) needed more than one line of salvage therapy. The 5-year PFS and OS were 66% and 81%, respectively.

This real-world analysis highlights a high prevalence of advanced-stage cHL at diagnosis and suboptimal response rates to ABVD as first-line therapy within Brazil’s public healthcare system. While ASCT remains a cornerstone for R/R cases, many patients are ineligible due to disease progression after conventional salvage chemotherapy. These findings emphasize the urgent need for earlier diagnosis and broader access to novel therapies, including immunotherapy in the second-line setting, to improve patient outcomes in the Brazilian public healthcare setting.