Patients with early-stage nonbulky classic Hodgkin lymphoma (HL) receive intensive radiologic surveillance after treatment, despite a low risk for relapse. A study from Memorial Sloan-Kettering Cancer Center (MSKCC) concluded that routine imaging is unnecessary.
The study evaluated the risk for relapse and value of imaging in a subset of patients who achieved complete remission (by positron-emission tomography [PET]) after 6 cycles of standard chemotherapy with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine).
“We asked whether achieving a PET-negative complete remission would obviate the need for radiologic surveillance,” said Sidonie Hartridge-Lambert, MBBS. “We found that omitting radiologic surveillance would reduce healthcare costs and also radiation exposure, which is important in guarding against second malignancies.”
Dr Hartridge-Lambert said that interim and end-of-therapy PET scanning can provide prognostic information in predicting relapse in HL, but practice and surveillance patterns vary considerably. The pretest probability for relapse in patients with nonbulky classic HL is low, and the incidence of relapse in early-stage patients after a negative posttreatment PET is extremely low.
“Research suggests that most relapses are identified without imaging,” she said, “and relapse patterns suggest that imaging may be of limited benefit 2 years after therapy.”
The study included 47 patients who were treated at MSKCC with initial staging by PET and interim and/or posttreatment PET, plus adequate follow-up. All patients achieved complete remission. Interim restaging included 39 PET and 8 computed tomography (CT) scans, identifying 1 positive result. Posttreatment restaging involved 33 PET and 14 CT scans, with 1 positive.
The 2 patients with positive PET scans were biopsy-proven sarcoid. Two patients relapsed at 7 and 24 months: the first relapse was identified by surveillance scan, the second occurred simultaneously with the resumption of disease symptoms. The 2 relapsed patients are currently in complete remission after stem-cell transplant.
The other 45 patients had a durable complete remission, of whom 21 had additional unscheduled imaging or work-up during surveillance for various reasons; 5 patients had further PET scans to confirm complete remission.
Financial Implications of Surveillance
The costs per scan for each patient during the posttreatment surveillance were based on standard, national Medicare reimbursements of $770 per CT and $1181 per PET.
Multiplied by the number of scans per patient, and excluding relapses, the cost of follow-up was $181,720 for CT (median, $3850), rising 16% to $210,064 including PET (median, $4620).
Extrapolating to the US population of patients with early-stage classic HL, the national cost over the 5 years of the study reaches $13 million, she said.
“Our results, in conjunction with the growing concerns about radiation dose from medical imaging studies, suggest that surveillance imaging in this subset of patients treated with 6 cycles of ABVD alone could be ceased altogether,” she said.
Instead, patients should be closely monitored with history, physical examination, and routine blood work.