Hodgkin's disease management and follow-up revisited

Modern therapy of Hodgkin's disease (HD) has contributed to improve long term survival for most patients. However, the problem of HD therapy cannot be considered as solved, since in large scale studies the proportion of individuals who after a period of complete remission die from intercurrent causes yields evidence of an increased mortality rate. In 1989, the establishment of an international data base on HD comprising more than 14,000 cases allowed analysis of survival and causes of death in these patients. Overall, the 10-year, 15-year and 20-year survival rates were 68%, 60% and 51% respectively. Compared with the general population, the increase in mortality was 31% at 15 years, giving a standardized mortality ratio of 7.68 (p < 0.001). Death was related to disease progression in 67.1% of subjects. Among patients who died from causes unrelated to HD or its treatment, second cancer deaths represented the first cause with 38%, followed by infections with 21% and acute myocardial infarction with 13%. This picture justifies the current increasing concern to refine the treatment of HD in order to minimize complications without reducing the overall chance of survival. Treatment choice should take into account the short and long term consequences of each available strategy and Hodgkin's disease patients should be submitted to routine follow-up for the rest of their lives.