Specht L, Gray R G, Clarke M J, Peto R
Department of Oncology, Herlev Hospital/University of Copenhagen, Denmark.
J Clin Oncol. 1998 Mar;16(3):830-43. doi: 10.1200/JCO.1998.16.3.830.
To assess the effect of more extensive radiotherapy and of adjuvant combination chemotherapy on long-term outcome of early-stage Hodgkin's disease.
In a collaborative worldwide systematic overview, individual patient data were centrally reviewed on 1,974 patients in eight randomized trials of more versus less extensive radiotherapy and on 1,688 patients in 13 trials of radiotherapy plus chemotherapy versus radiotherapy alone. Crude mortality data on 226 patients in two other trials of chemotherapy were also reviewed.
More extensive radiotherapy reduced the risk of treatment failure (resistant or recurrent disease) at 10 years by more than one third (31.3% v 43.4% failures; P < .00001), but there was no apparent improvement in overall 10-year survival (77.1 % v 77.0% alive). The addition of chemotherapy to radiotherapy halved the 10-year risk of failure (15.8% v 32.7%; P < .00001), with a small, nonsignificant improvement in survival (79.4% v 76.5% alive). This involved a reduction of borderline significance for deaths from Hodgkin's disease (12.3% v 15.4% dead at 10 years; P = .07), which was partly counterbalanced by a nonsignificant excess of deaths from other causes (12.4% v 10.0% 10-year risk).
More extensive radiotherapy fields or the addition of chemotherapy to radiotherapy in the initial treatment of early-stage Hodgkin's disease had a large effect on disease control, but only a small effect on overall survival. Recurrences could be prevented by more extensive radiotherapy or by additional chemotherapy. However, if chemotherapy had not been given initially, recurrences were generally salvageable by re-treatment with chemotherapy. Hence, less intensive primary treatment--particularly a reduction in radiotherapy fields--appears to achieve similar survival rates as more intensive treatment, although more randomized evidence is needed to confirm this.
评估更广泛的放射治疗及辅助联合化疗对早期霍奇金病长期预后的影响。
在一项全球协作的系统性综述中，对八项比较更广泛与较不广泛放射治疗的随机试验中的1974例患者以及十三项放射治疗加化疗与单纯放射治疗的试验中的1688例患者的个体患者数据进行了集中审查。还审查了另外两项化疗试验中226例患者的粗死亡率数据。
更广泛的放射治疗使10年时治疗失败（耐药或复发疾病）的风险降低了三分之一以上（失败率分别为31.3%和43.4%；P<.00001），但10年总生存率无明显改善（生存率分别为77.1%和77.0%）。放射治疗联合化疗使10年失败风险减半（分别为15.8%和32.7%；P<.00001），生存率有小幅但无显著意义的提高（生存率分别为79.4%和76.5%）。这包括霍奇金病死亡的临界显著性降低（10年时死亡率分别为12.3%和15.4%；P = 0.07），部分被其他原因导致的死亡无显著增加所抵消（10年风险分别为12.4%和10.0%）。
在早期霍奇金病的初始治疗中，更广泛的放射治疗野或放射治疗联合化疗对疾病控制有很大影响，但对总生存率影响较小。更广泛的放射治疗或额外的化疗可预防复发。然而，如果最初未给予化疗，复发通常可通过化疗再治疗挽救。因此，强度较低的初始治疗——特别是放射治疗野的减少——似乎能达到与强度较高治疗相似的生存率，尽管需要更多随机证据来证实这一点。
