Which Hodgkin's patients in the Unites States should be treated with BEACOPP?

The majority of patients with advanced Hodgkin lymphoma are cured with current standard therapy such as Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). However, almost 20% of patients fail to achieve complete remission, and depending upon risk group, 20-30% experience relapse with prolonged follow-up. BEACOPP (bleomycin, etoposide, Adriamycin, cyclophosphamide, prednisone, procarbazine) was developed by the German Hodgkin Study Group (GHSG) to improve upon standard therapy by intensifying treatment and substituting etoposide and procarbazine for vinblastine and dacarbazine, respectively. In the HD9 trial, escalated BEACOPP was shown to be superior to COPP/ABVD with regard to time to treatment failure, but was associated with increased risk of secondary malignancies. Modifications of BEACOPP were developed to maintain efficacy while reducing the adverse effects. While several randomized trials have confirmed prolongation of progression-free survival with BEACOPP compared to ABVD, a survival advantage has been difficult to demonstrate. Given the comparable survival between BEACOPP and ABVD, as well as the greater toxicities of the former, including infertility, myelosuppression, and secondary malignancies, ABVD should remain the standard regimen for patients in the U.S. Newer regimens incorporating novel agents such as brentuximab vedotin may further improve the efficacy of current regimens.