Understanding Treatment Decisions for Hodgkin Lymphoma: A Qualitative Study

Introduction: Understanding how oncologists use available data to make initial treatment decisions in Hodgkin Lymphoma (HL) is critical to improving the quality of care in HL. We performed a qualitative study to learn about physicians’ decision-making processes for patients with newly diagnosed HL.

Methods: For our semi-structured interviews, we recruited community- and academic-based oncologists between June-December 2021, using purposive and snowball sampling to ensure representation of community oncologists. Our interview guide focused on how oncologists make initial and serial treatments decisions, probing specifically about decisions for older patients.

Results: In our 22 interviews prior to thematic saturation, physicians self-identified as 55% female, 23% Black or Asian, 36% in community-based practices, and 55% in their first decade of oncology practice. We grouped our findings into contextual factors, patient characteristics, and physician preferences.

1) Contextual Factors: Providers described a paternalistic model of care, where most patients deferred to their oncologists for decisions. Some providers made decisions alone, while many community oncologists collaborated with academic providers informally or formally. Community providers endorsed high patient retention in their practices as well as patient reluctance to travel, citing distance as a clinical trial barrier. Only one physician overall utilized a geriatric assessment (GA) with the remainder reporting use of "gut feelings” or abbreviated surrogates of GA to assess fitness. Time and lack of clarity on result implementation were cited as barriers to formal assessment.

2) Patient Characteristics: Physicians cited age, comorbidity, and disease stage as important for initial decisions. Most physicians did not routinely use the International Prognostic Score (IPS), though some used high IPS as an indication for Brentuximab vedotin (Bv) upfront. One physician noted avoiding Bv for patients requiring dexterity for their job. All physicians assessed comorbidity, with pulmonary comorbidity as the most commonly noted to influence initial therapy. Physicians felt that patients <70 were better characterized by comorbidity and fitness than age, but patients age ≥70 were nearly always categorized as "older” regardless of fitness due to risks of toxicity. For older adults, physicians employed serial decision making based on patients’ treatment tolerance, most commonly with the Bv regimen tailored for older adults.

3) Physician Preferences: We identified heterogeneity in perspectives about initial Bv-AVD (doxorubicin, vinblastine, dacarbazine) versus the historical standard of care ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) that was not associated with practice setting or years in practice. Prior experience was a common decision-making factor, with one physician avoiding ABVD in all older adults after witnessing bleomycin toxicity, while others preferred ABVD due to more experience with the regimen. While some physicians felt that Bv-AVD toxicity was acceptable for better event-free survival, others felt the toxicity of fatigue and neuropathy outweighed the benefits of event-free survival and preferred ABVD with de-escalation when indicated.

Oncologists prioritized avoiding dose modifications by treating through medical complications such as neutropenia, although infectious complications were cited as the most common cause of delayed therapy. Though all reported use of interim imaging to de-escalate intensity of therapy when indicated, a few noted that interim imaging in community radiology sites could be difficult to access and interpret. Lastly, several physicians stated that they would not escalate therapy despite inadequate response on interim imaging.

Conclusions: Through qualitative work, we learned how oncologists make treatment decisions for patients with newly diagnosed HL in the modern era. Oncologists’ incorporation of new therapies depends not only on calculators and algorithms but also on their personal experiences, resulting in heterogeneity in clinical decision making. To improve clinical care of patients with HL, our study suggests increasing availability of clinical trials in community sites, disseminating geriatric assessment tools across practice types, and incorporating assessment of uptake of novel therapeutics within clinical trial design.

No relevant conflicts of interest to declare.