148 A decision analysis on alternative treatment strategies for favorable prognosis, early-stage Hodgkin's disease

PURPOSE: To compare the therapeutic outcomes of various treatment strategies in early-stage, favorable-prognosis Hodgkin's disease (HD) using methods of decision analysis. METHODS: We constructed a decision-analytic model to determine the life expectancy and quality-adjusted life expectancy for a hypothetical cohort of clinically or pathologically staged 25-year-old patients with early-stage, favorable-prognosis HD treated with varying degrees of initial therapy. Markov models were used to simulate the lifetime clinical course of patients, and baseline probability estimates were derived from published study results. RESULTS: Among patients with pathologic stage (PS) I to II, mantle and para-aortic (MPA) radiotherapy was favored over combined-modality therapy (CMT), mantle radiotherapy, and chemotherapy by 1.18, 1.33, and 1.55 years, respectively. For patients with clinical stage (CS) I to II, the treatment options of MPA-splenic radiotherapy, CMT, and chemotherapy yielded similar survival outcomes. Sensitivity analysis showed that the decision between CMT and MPA-splenic radiotherapy was highly influenced by the precise values of the estimates of treatment efficacy and long-term morbidity, the quality-of-life value assigned to the postsplenic irradiation state, and the time discount value used in the model. Probabilistic sensitivity analysis demonstrated that even if future studies doubled the precision of the estimates of the treatment-related variables, it would be impossible to demonstrate the superiority of one treatment over the other. CONCLUSION: Our model predicted that on average, MPA radiotherapy was clearly the preferred treatment for PS I to II patients. For CS I to II patients the treatment decision is a toss-up between MPA-splenic radiotherapy and CMT, emphasizing the importance of patient preference exploration and shared decision making between patient and physician when choosing between treatments.

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Laparotomy Versus No Laparotomy in the Management of Early-Stage, Favorable-Prognosis Hodgkin's Disease: A Decision Analysis

Journal of Clinical Oncology ◽

10.1200/jco.1999.17.1.241 ◽

1999 ◽

Vol 17 (1) ◽

pp. 241-241 ◽

Cited By ~ 18

Author(s):

Andrea K. Ng ◽

Jane C. Weeks ◽

Peter M. Mauch ◽

Karen M. Kuntz

Keyword(s):

Quality Of Life ◽

Life Expectancy ◽

Decision Analysis ◽

Hodgkin's Disease ◽

Early Stage ◽

Hodgkin’S Disease ◽

Staging Laparotomy ◽

Favorable Prognosis ◽

Quality Adjusted Life

PURPOSE: To perform a decision analysis that compared the life expectancy and quality-adjusted life expectancy of early-stage, favorable-prognosis Hodgkin's disease (HD) managed with and without staging laparotomy, incorporating data on treatment outcomes of HD in the modern era. METHODS: We constructed a decision-analytic model to compare laparotomy versus no laparotomy staging for a hypothetical cohort of 25-year-old patients with clinical stages I and II, favorable-prognosis HD. Markov models were used to simulate the lifetime clinical course of patients, whose prognosis depended on the true pathologic stage and initial treatment. The baseline probability estimates used in the model were derived from results of published studies. Quality-of-life adjustments for procedures and treatments, as well as the various long-term health states, were incorporated. RESULTS: The life expectancy was 36.67 years for the laparotomy strategy and 35.92 years for no laparotomy, yielding a net expected benefit of 0.75 years for laparotomy staging. The corresponding quality-adjusted life expectancies for the two strategies were 35.97 and 35.38 quality-adjusted life years (QALYs), respectively, resulting in a net expected benefit of laparotomy staging of 0.59 QALYs. Sensitivity analysis showed that the decision of laparotomy versus no laparotomy was most heavily influenced by the quality-of-life weight assigned to the postlaparotomy state. CONCLUSION: Our model predicted that on average, for a 25-year-old patient, proceeding with staging laparotomy resulted in a gain in life expectancy of 9 months, or 7 quality-adjusted months. These results suggest that a role remains for surgical staging in the management of early-stage HD.

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A decision analysis on the optimal management strategy for favorable prognosis, early-stage Hodgkin's disease

International Journal of Radiation Oncology*Biology*Physics ◽

10.1016/s0360-3016(98)80170-3 ◽

1998 ◽

Vol 42 (1) ◽

pp. 159

Author(s):

Andrea K. Ng ◽

Jane C. Weeks ◽

Peter M. Mauch ◽

Karen M. Kuntz

Keyword(s):

Decision Analysis ◽

Hodgkin's Disease ◽

Management Strategy ◽

Early Stage ◽

Hodgkin’S Disease ◽

Optimal Management ◽

Favorable Prognosis

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Current treatment strategies in early stage hodgkin’s disease

Current Treatment Options in Oncology ◽

10.1007/s11864-003-0005-z ◽

2003 ◽

Vol 4 (4) ◽

pp. 297-305 ◽

Cited By ~ 5

Author(s):

Andreas Josting ◽

Volker Diehl

Keyword(s):

Hodgkin's Disease ◽

Early Stage ◽

Hodgkin’S Disease ◽

Treatment Strategies ◽

Current Treatment

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Long-Term Survival and Competing Causes of Death in Patients With Early-Stage Hodgkin’s Disease Treated at Age 50 or Younger

Journal of Clinical Oncology ◽

10.1200/jco.2002.08.021 ◽

2002 ◽

Vol 20 (8) ◽

pp. 2101-2108 ◽

Cited By ~ 301

Author(s):

Andrea K. Ng ◽

M. Patricia Bernardo ◽

Edie Weller ◽

Kendall H. Backstrand ◽

Barbara Silver ◽

...

Keyword(s):

Relative Risk ◽

Hodgkin's Disease ◽

Excess Mortality ◽

Early Stage ◽

Hodgkin’S Disease ◽

Term Survival ◽

Long Term Survival ◽

Favorable Prognosis

PURPOSE: To analyze the long-term survival and the pattern and timing of excess mortality in patients with early-stage Hodgkin’s disease. PATIENTS AND METHODS: Between 1969 and 1997, 1,080 patients age 50 or younger were treated for clinical stage IA to IIB Hodgkin’s disease. Overall survival was determined, and prognostic factors were assessed. Relative risk and absolute excess risk (AR) of mortality were calculated for the entire cohort and by prognostic groups (on the basis of B symptoms, mediastinal status, and number of sites, modified from the European Organization for Research and Treatment of Cancer). RESULTS: The median follow-up was 12 years. The 15- and 20-year Kaplan-Meier survival estimates were 84% and 78%, respectively. Cox proportional hazards models showed that number of involved sites (P = .006), mediastinal status (P = .02), and histology (P = .02) were independent predictors of death from all causes. The AR of mortality in patients with a favorable prognosis increased over time, whereas for those with an unfavorable prognosis, the AR peaked in the first 5 years, predominantly from Hodgkin’s disease. The relative risk of mortality from all causes, causes other than Hodgkin’s disease, second tumors, and cardiac disease remained significantly elevated more than 20 years after treatment. CONCLUSION: Patients treated for early-stage Hodgkin’s disease have a sustained excess mortality risk despite good control of the disease. Treatment reduction efforts in patients with early-stage, favorable-prognosis disease should continue, but for patients with an unfavorable prognosis, modified treatment may not be advisable. The excess mortality noted beyond two decades underscores the importance of long-term follow-up care in patients treated for Hodgkin’s disease.

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