The first 60 days: Advanced-stage classical Hodgkin lymphoma (stage III to IV)
Advanced-stage classical Hodgkin lymphoma is Hodgkin lymphoma involving nodes on both sides of the diaphragm or organs such as the liver, lungs or bone marrow. It is treated with six cycles of combination chemotherapy, and two trials changed the standard: replacing bleomycin with brentuximab vedotin (ECHELON-1) and then with nivolumab (SWOG S1826), which cured more patients with less toxicity. Below, week by week, is what OnCo's record of Advanced-stage classical Hodgkin lymphoma (stage III to IV) says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
FDG-PET/CT with Lugano staging, International Prognostic Score, fertility counselling and cardiac and pulmonary baselines.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- PathologistNamed in the standard of care for: Older or frail patients.
- RadiologistNamed in the standard of care for: Staging and risk, First line, adults and adolescents 12 and over, First line, intensive European option, Children and 1 more.
- Medical oncologistNamed in the standard of care for: First line, adults and adolescents 12 and over, First line, intensive European option, Children, Older or frail patients and 1 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Children, End of treatment.
- Palliative and supportive care teamNamed in the standard of care for: Staging and risk, First line, adults and adolescents 12 and over, Older or frail patients.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Response-adapted Children's Oncology Group or EuroNet regimens; brentuximab vedotin with AVD in advanced paediatric disease; radiotherapy for slow responders only.
Nivolumab with AVD for six cycles (SWOG S1826, preferred); brentuximab vedotin with AVD (ECHELON-1) as an alternative; PET-adapted ABVD with bleomycin omission after two cycles (RATHL) where antibodies are unavailable.
BrECADD for four to six cycles guided by interim PET (GHSG HD21), replacing escalated BEACOPP.
AVD with brentuximab vedotin sequenced before and after, or nivolumab-AVD; avoid bleomycin and BEACOPP.
PET-directed consolidation radiotherapy only for residual PET-positive bulky disease; long-term survivorship follow-up.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example International Prognostic Score, Interim FDG-PET after cycle two, Baseline metabolic tumour volume, CD30 expression, 9p24.1 amplification and PD-L1 expression), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Stage III classical Hodgkin lymphoma, Stage IV classical Hodgkin lymphoma, Advanced classical Hodgkin lymphoma with a high International Prognostic Score.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Staging and risk
- For my situation (staging and risk), which of the standard options do you recommend and why?Guideline options include: FDG-PET/CT with Lugano staging, International Prognostic Score, fertility counselling and cardiac and pulmonary baselines.
First line, adults and adolescents 12 and over
- For my situation (first line, adults and adolescents 12 and over), which of the standard options do you recommend and why?Guideline options include: Nivolumab with AVD for six cycles (SWOG S1826, preferred); brentuximab vedotin with AVD (ECHELON-1) as an alternative; PET-adapted ABVD with bleomycin omission after two cycles (RATHL) where antibodies are unavailable.
- Am I a candidate for Nivolumab, Brentuximab vedotin, Doxorubicin or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of SWOG S1826 and ECHELON-1 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
First line, intensive European option
- For my situation (first line, intensive european option), which of the standard options do you recommend and why?Guideline options include: BrECADD for four to six cycles guided by interim PET (GHSG HD21), replacing escalated BEACOPP.
- Am I a candidate for Brentuximab vedotin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of GHSG HD21 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Children
- For my situation (children), which of the standard options do you recommend and why?Guideline options include: Response-adapted Children's Oncology Group or EuroNet regimens; brentuximab vedotin with AVD in advanced paediatric disease; radiotherapy for slow responders only.
- Am I a candidate for Brentuximab vedotin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of A Study of Brentuximab Vedotin + Adriamycin, Vinblastine, and Dacarbazine in Pediatric Participants With Advanced Stage Newly Diagnosed Hodgkin Lymphoma apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Older or frail patients
- For my situation (older or frail patients), which of the standard options do you recommend and why?Guideline options include: AVD with brentuximab vedotin sequenced before and after, or nivolumab-AVD; avoid bleomycin and BEACOPP.
- Am I a candidate for Brentuximab vedotin, Nivolumab, Doxorubicin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
End of treatment
- For my situation (end of treatment), which of the standard options do you recommend and why?Guideline options include: PET-directed consolidation radiotherapy only for residual PET-positive bulky disease; long-term survivorship follow-up.
Any stage
- Are there clinical trials I could join, for example of SWOG S1826, GHSG HD21, A Study of Brentuximab Vedotin + Adriamycin, Vinblastine, and Dacarbazine in Pediatric Participants With Advanced Stage Newly Diagnosed Hodgkin Lymphoma, PD-1 blockade + AVD chemotherapy?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Long-term outcomes of nivolumab-AVD beyond a few years are not yet known”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Nivolumab-AVD and BrECADD have never been compared”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Advanced-stage classical Hodgkin lymphoma (stage III to IV): the full pageAdvanced-stage classical Hodgkin lymphoma is Hodgkin lymphoma involving nodes on both sides of the diaphragm or organs such as the liver, lungs or bone marrow. It is treated with six cycles of combination chemotherapy, and two trials changed the standard: replacing bleomycin with brentuximab vedotin (ECHELON-1) and then with nivolumab (SWOG S1826), which cured more patients with less toxicity.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- ABVD, BEACOPP and BrECADD (Hodgkin lymphoma regimens): The chemotherapy recipes that cure most Hodgkin lymphoma: ABVD (four drugs, the long-standing standard), the more intensive German BEACOPP, and newer versions that replace bleomycin with brentuximab vedotin (A+AVD) or add nivolumab (N-AVD).
- Reed-Sternberg cell: The Reed-Sternberg cell is the giant, often two-nucleus cancer cell of Hodgkin lymphoma; it makes up only about 1% of the tumour, and the rest is immune cells it has recruited.
- Deauville five-point scale: A 1-to-5 score for how bright a lymphoma looks on PET compared with the liver; 1-3 is considered a complete metabolic response.
- Lugano classification / Ann Arbor staging: The Lugano classification is the lymphoma staging system: stage I to IV by how many lymph node regions and organs are involved, with PET-based response criteria.
- Late effects and survivorship toxicity: Health problems appearing months or decades after treatment ends: heart damage, infertility, second cancers, lymphoedema, dry mouth, memory problems, weak bones.
Every term links to the glossary.