A Phase 3 clinical trial has demonstrated that patients with advanced (Stage 3 or 4) classic Hodgkin lymphoma who underwent initial treatment with nivolumab, a PD-1 checkpoint inhibitor, combined with chemotherapy, had significantly better outcomes than patients treated with standard chemotherapy plus brentuximab vedotin, a monoclonal antibody, a year after starting treatment. Significantly, adding nivolumab to chemotherapy may also remove the need for radiation treatment in younger patients.
Ninety-four percent of adolescent and adult patients in the nivolumab group experienced one-year progression-free survival, compared with 86% in the brentuximab vedotin arm. Nivolumab was also well-tolerated, with few serious immune-related side effects. The median follow-up was 12.1 months.
Hodgkin lymphoma, a relatively rare cancer type, affects the lymph nodes. It mostly strikes people between the ages of 20 and 40 and is traditionally treated with chemotherapy and/or radiation therapy.
The findings were presented by City of Hope’s Alex Herrera, M.D., at the American Society of Clinical Oncology's 2023 Plenary Session on June 4 in Chicago.
Lead investigator on the study, Herrera is chief of the Division of Lymphoma at City of Hope and is an investigator with the SWOG Cancer Research Network, a clinical trials group funded by the National Cancer Institute (NCI), part of the National Institutes of Health.
“The results are remarkable. The combination of nivolumab and chemotherapy is potent and safe in patients with Stage 3 or 4 classic Hodgkin lymphoma as an initial treatment,” Herrera said. “The therapy is poised to be a standard for treatment for advanced Hodgkin lymphoma. This is indeed great news for patients with this cancer, as there is another effective and safe treatment option for them.”
Georgie Garabet, 43, of Glendora, California, was one of the patients who participated in the trial. When Garabet began to feel sick in early 2020, he was a 40-year-old father of two children under the age of 3. His symptoms included uncontrollable itching all over his body and severe weight loss.
After a few trips to emergency rooms and to his primary-care doctor, he was eventually diagnosed with Stage 3 Hodgkin lymphoma.
“I panicked when I heard the word cancer,” Garabet said. At the same time, he was relieved to know what was causing his symptoms.
Garabet met Herrera and instantly felt he was in good hands. “He explained everything so well,” he said. Garabet enrolled in the trial. After his first infusion, he felt exhausted, but that was the worst he felt during treatment, he said. After only four infusions, he was in remission. He was advised to continue the treatment in case any cancer lingered, and he did. “Now when people tell me they have cancer, I tell them not to panic. There are a lot of cures now,” he said.
Enrolling nearly 1,000 patients, the S1826 trial, supported by the NCI and led by SWOG, is the largest classic Hodgkin lymphoma study ever conducted in the NCI’s National Clinical Trials Network and is also representative of a diverse patient population. About a quarter of the enrolled patients were Black or Hispanic. A partnership with the Children’s Oncology Group (COG) helped ensure the trial included young adolescents, and a quarter of enrolled patients were younger than 18 years old. Nearly two-thirds of all patients had Stage 4 cancer.
“This study speaks to the power of the National Clinical Trials Network and is an excellent example of the transformative work that the NCI funds,” said Jonathan Friedberg, M.S., M.M.Sc., senior author of the study, chair of the SWOG Cancer Research Network’s lymphoma committee and director of the Wilmot Cancer Institute at the University of Rochester. “Hodgkin lymphoma is not a common disease, and the NCTN enabled a large network of more than 200 pediatric and adult community providers and academic medical centers to work together. Because of that, we were able to get data very quickly and directly impact patient care. This was a critical investment in cancer research and treatment.”
Patients with Stage 3 or 4 classic Hodgkin lymphoma who had not been previously treated and were age 12 or older were eligible for the trial. Of a total of 976 eligible patients, 489 were enrolled in the N-AVD arm (nivolumab plus Adriamycin, vinblastine and dacarbazine), while 487 were part of the BV-AVD group (brentuximab vedotin plus the same chemotherapy drugs). Each group received six infusion cycles of each combination therapy.
No Need for Radiation
As expected with combination chemotherapy, the most common side effects included gastrointestinal and hematologic toxicities, and fatigue. However, less than 1% of patients needed radiation after trial treatment, which is a dramatic reduction in the proportion of patients being initially treated for Hodgkin lymphoma who need radiation, especially among pediatric patients.
“The ability to maintain high rates of relapse-free survival with minimal use of radiation therapy in children with newly diagnosed advanced stage Hodgkin lymphoma will be a paradigm shift,” said Sharon Castellino, M.D., M.Sc., chair of the COG Hodgkin lymphoma committee and director of the Leukemia and Lymphoma Program at the Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Winship Cancer Institute at Emory University. This is significant because radiation treatment carries a higher risk of complications later in life.
Brentuximab vedotin was the first antibody-drug conjugate developed for classic Hodgkin lymphoma. Several studies have demonstrated that incorporating the therapy into frontline treatment improves progression-free survival and overall survival. Despite improved outcomes, there are still serious side effects, and relapses can occur.
“There is definitely a need to improve frontline therapies for Hodgkin lymphoma, particularly because a disproportionate number of patients with this disease are teens and young adults,” Herrera added.
PD-1 checkpoint inhibitors are a powerful and growing form of immunotherapy used to treat melanoma, kidney cancer, head and neck cancers, relapsed or difficult to treat Hodgkin lymphoma and other cancers. The PD-L1 protein is expressed on Hodgkin lymphoma tumor cells and aids the cancer by signaling to immune cells, such as T cells, to stop working against tumors.
Checkpoint inhibitors block the PD-L1 protein to help the immune system and, specifically, T cells, do what they’re designed to do, eradicate cancer. In this study, adding nivolumab to chemotherapy worked so well that some patients experienced remission after only a few treatments.
Next steps for the trial include following patients to measure the durability of progression-free survival, overall survival and other patient outcomes.