[Hodgkin disease: should high-risk patients be selected and chemotherapy be intensified?]

Death still occurs in Hodgkin's disease (HD) patients with advanced stages, but also in early stages. Therefore, the identification of the population of HD patients who would best benefit from an intensification of treatment is a prerequisite in all stages. The best known prognostic factors are bulky mediastinum, B symptoms, and visceral involvement in advanced HD and, in early HD, the number of nodal areas. No satisfactory combination of these factors can clearly identify a group of patients requiring high dose- and potentially risky therapy. Therefore only a very small subgroup of patients with advanced disease (less than 5% of them) calls for intensified regimens, which makes randomized trials very difficult. A large data base, accrued through a cooperative effort and the addition of early stages to advanced stages, would help to clarify the prognostic analysis. In addition, the patient population needs to be selected on the basis of the best therapeutic approach to-date. The analysis parameter should take into account only the failures due to the tumor progression as opposed to those due to a combination of tumor progression and early plus late toxicities. Three successive steps are required to achieve the goal of high-risk patient's treatment optimization. The first is to define, on a well-defined tumor-risk scale, the kind of results that are to be considered as "unacceptable" when up-to-date conventional strategies are applied. The second is to infer the size of the "high-risk" population, in inverse ratio to the severity of the risk accepted for "normal-risk" patients. The third is to tailor the iatrogenic risk, ie the intensity of the high-dose treatment, to the size of the target population and to the anti-tumor benefit that is anticipated. Obviously, the definition of these parameters belongs to the medical decision-makers. Nevertheless, the availability of a quantified tumor-risk scale would allow to elaborate a reliable strategy in patients at risk for failure, lethal toxicity and unbearable health expenses. A collection of adequate recent trial is proposed through the Third International Symposium on Hodgkin's lymphoma in Köln (21-23 September 1995). This effort will be pursued through the International Data Base for Hodgkin's Disease (IDHD). Newer and more efficient strategies may then be designed.