What is the preferred regimen between BEACOPP (Bleomycin, Etoposide, Adriamycin, Cyclophosphamide, Vincristine, Procarbazine, and Prednisone) and ABVD (Adriamycin, Bleomycin, Vinblastine, and Dacarbazine) for the treatment of Hodgkin lymphoma?

BEACOPP vs ABVD in Hodgkin Lymphoma

For advanced-stage Hodgkin lymphoma in patients ≤60 years old, escalated BEACOPP is superior to ABVD with a 10% overall survival advantage at 5 years, though with increased toxicity. 1, 2

Patient Selection Criteria

BEACOPP is preferred for:

• Patients with advanced-stage (III-IV) Hodgkin lymphoma 1, 2
• Patients ≤60 years of age 1
• Patients with intermediate-stage disease with unfavorable risk factors 2
• Patients with positive interim PET after 2 cycles of ABVD 1, 2

ABVD is preferred for:

• Patients >60 years (BEACOPP contraindicated due to increased treatment-related mortality) 1
• Patients with significant comorbidities or poor performance status 1
• Patients prioritizing fertility preservation or concerned about acute toxicity 2

Efficacy Comparison

BEACOPP advantages:

• Superior tumor control with 85% complete metabolic remission rate vs 76% with ABVD 3
• Better freedom from first progression (85% vs 73% at 7 years) 4
• Lower relapse rate (9% vs 16.6%) in patients achieving complete metabolic remission 3
• 10% overall survival advantage at 5 years in multiple studies 1, 5

ABVD considerations:

• Less toxic but still effective therapeutic option 3
• Similar overall survival when high-dose salvage therapy is planned for relapse 4
• Standard treatment for patients >60 years 1

Treatment Protocols

Escalated BEACOPP regimen:

• Bleomycin: 10 mg/m² IV on day 8
• Etoposide: 200 mg/m² IV on days 1-3
• Adriamycin (doxorubicin): 35 mg/m² IV on day 1
• Cyclophosphamide: 1250 mg/m² IV on day 1
• Vincristine: 1.4 mg/m² (max 2 mg) IV on day 8
• Procarbazine: 100 mg/m² PO on days 1-7
• Prednisone: 40 mg/m² PO on days 1-14
• G-CSF support from day 8
• Recycle every 21 days 1

Treatment duration:

• 6 cycles of escalated BEACOPP followed by localized RT to PET-positive residual lymphoma >2.5 cm 1
• Alternative: 4 cycles of escalated BEACOPP followed by 4 cycles of standard BEACOPP 2

Toxicity Considerations

BEACOPP toxicities:

• Significant hematologic toxicity requiring G-CSF support 2
• Higher risk of infections 3
• Fertility concerns (high risk of infertility) 2
• Increased risk of secondary malignancies 1

Risk management:

• Fertility preservation counseling before treatment 2
• Appropriate surveillance and supportive care 1, 2
• Regular monitoring of complete blood counts 2
• Long-term follow-up for late effects 2

Response Assessment

• Interim PET assessment after 2 cycles to guide treatment decisions 2
• PET-CT at completion of chemotherapy 1
• Consider RT to residual PET-positive masses >2.5 cm after BEACOPP 1

Real-world Considerations

Despite the theoretical survival advantage of BEACOPP in clinical trials, real-world data shows that while BEACOPP results in better initial tumor control, long-term outcomes may be similar between the two regimens when effective salvage therapy is available 3, 4.

Common Pitfalls to Avoid

• Using BEACOPP in patients >60 years (increased treatment-related mortality) 1
• Underestimating the need for supportive care with BEACOPP 2
• Failing to discuss fertility preservation before BEACOPP 2
• Not using G-CSF support with BEACOPP (high risk of severe neutropenia) 2
• Overlooking the importance of interim PET assessment to guide therapy 1, 2

The decision between BEACOPP and ABVD should be based on patient age, disease stage, risk factors, and the availability of appropriate supportive care, with BEACOPP offering superior disease control but requiring careful management of increased toxicity.