Protons: moving therapy for hodgkin lymphoma in a positive direction.

Dr. Hoppe and colleagues present a strong case supporting the use of proton therapy (PT) for the treatment of patients with Hodgkin lymphoma (HL). They point out a major quandary of modern therapy for HL, which requires that oncologists navigate between the Scylla of relapse due to inadequate therapy and the Charybdis of severe late toxicities that result from over-exuberant treatment. This was highlighted in the recent study by Meyer et al[1] that compared treatment of nonbulky HL with ABVD (Adriamycin [doxorubicin], bleomycin, vinblastine, dacarbazine) alone vs subtotal nodal radiation (alone or in combination with ABVD); the study demonstrated improved freedom from progression in irradiated patients, but this was more than compensated for by an increase in mortality from late toxicity in that same group. The most common cause of death in the radiated group was secondary malignancies, and the rate was more than double that in the patients treated with chemotherapy only. Additional studies also strongly implicate mediastinal radiation as a significant risk factor for cardiac disease, particularly in younger patients.[2] Unfortunately, similar long-term toxicities might be induced if chemotherapy doses were increased to offset the need for radiation; thus, it is generally accepted that radiation is a critically important aspect of multimodality treatment for many patients with HL.