Real-World Adherence to National Comprehensive Cancer Network (NCCN) Guidelines Regarding the Usage of PET/CT and Reported Deauville Scores in Advanced Stage Classical Hodgkin Lymphoma: A Community Oncology Practice Perspective

Introduction: Current National Comprehensive Cancer Network (NCCN) guidelines recommend one of three frontline (1L) regimens to treat stage III or IV classical Hodgkin Lymphoma (cHL): doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD), brentuximab vedotin, doxorubicin, vinblastine, and dacarbazine (A+AVD), or bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (escalated (e) dose-BEACOPP). PET/CT imaging is important at initial staging and in follow up including after two cycles (interim PET2) to assess and adapt treatment based on response for patients who newly start treatment with ABVD (Johnson et al., 2016). Despite NCCN guidelines, physicians in community oncology practices may face challenges optimizing outcomes for ABVD patients utilizing the interim PET2 adaptive approach. This study evaluated interim PET2 utilization and reported Deauville scores (DS) in patients with stage III or IV cHL treated in the 1L setting.

Methods: This retrospective observational study included adult patients diagnosed with stage III or IV cHL and treated with 1L ABVD, A+AVD, or eBEACOPP within the US Oncology Network (USON) between 01 January 2017 and 31 January 2020. Patients enrolled in therapeutic clinical trials or received treatment for another primary cancer diagnosis were excluded. Patient data were sourced from the USON's electronic health records database, iKM™. Demographic, clinical, and treatment characteristics were sourced from structured iKM elements. Interim PET2 details, including Deauville scores, were obtained from manual chart review. Descriptive statistics were generated for all patient characteristics.

Results: 262 patients with cHL were eligible. The majority of the patients were <39 years (48.9%), male (56.9%), Caucasian (58.8%), stage IV cHL (50.8%), had a low (<4) International Prognostic Score (76.0%), completed most treatment cycles (median = 6 [IQR 2,4]) and were treated with 1L ABVD (74.0%). Almost all patients (98.5%) had at least one documented PET-CT of which 87.6% had one at baseline (≤90 days prior to treatment initiation) and 79% had an interim PET-CT (Figure). For patients treated with 1L ABVD with an interim PET-CT, 65% did not report a Deauville score vs. 35% with a documented Deauville score (of which, 29% with score of 1-3 and 5.0% with score of 4-5). 54% of patients treated with 1L A+AVD did not report a Deauville score compared to 42% with scores of 1-3 and 4% with scores of 4-5. The majority of patients (93%) treated with 1L ABVD with or without a reported Deauville score de-escalated to AVD. Results were consistent in the sensitivity analysis of patients with both baseline PET-CT and interim PET-CT.

Conclusions: Findings from this retrospective, observational, community oncology study found that Deauville scores were reported for only 1/3 of interim PET-CT in patients treated with 1L ABVD patients with stage III or IV cHL. Despite this, initial treatment modification of de-escalation from ABVD to AVD was common and escalation to BEACOPP was rarely observed. These results suggest that albeit interim PET-CT is utilized, the Deauville scores to inform escalation or de-escalation of treatment decisions in stage III or IV cHL patients is missing and not universally reported in the community oncology setting. Our findings support a potential opportunity to educate oncologists and radiologists on the importance of consistently reporting PET-CT Deauville scores given the fact that providers may lack the complete information to ensure treatment modifications are optimized for patient outcomes. Additionally, compared with ABVD, A+AVD that does not require treatment adaptation by interim PET/CT Deauville score may be a therapy option.

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