Perspectives Risk assessment in the management of newly diagnosed classical Hodgkin lymphoma

Over the past 60 years, continuous improvement in the management of Hodgkin lymphoma has brought clinicians and patients to an era in which the large majority of patients are cured, regardless of disease presentation. This improvement in outcome has brought a new obligation to those who wish to optimally manage this previously lethal malignancy: an obligation to maintain very high cure rates while simultaneously minimizing toxicity, especially persistent late toxicity, which may permanently reduce the quality of life of survivors or even cause their death. A fine balance must be maintained in which maximal effectiveness of treatment, which presently is built around multiagent chemotherapy and judicious use of radiation, is maintained while minimizing exposure to interventions associated with major late toxicity. In brief, clinicians must recommend just enough treatment to achieve the greatest efficacy and yet induce the least harm. Careful assessment of risk is an essential part of achieving this balance. Such risk assessment must, in turn, address multiple factors, of which some are intrinsic to the host, others are related to tumor burden and tumor biology, and lastly, several are evaluable at diagnosis and determinable as the treatment course unfolds (Figure 1). Full appreciation of important factors that increase the risk of treatment failure or the likelihood of undesirable, potentially avoidable acute or late toxicity and how these risks can be minimized is essential to optimal management of Hodgkin lymphoma today. This review examines these risk factors and identifies strategies that minimize their impact on our patients. It is necessary to acknowledge, however, that important risk-altering biological characteristics may remain undescribed at present but be identified and become important with further research. Risk factors intrinsic to the patient