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This Week in NEJM: Feb 2, 2012

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In NEJM this week, researchers in the US and Canada compare combinations of radiation and chemotherapy treatments for patients with limited-stage Hodgkin's lymphoma. The team randomly assigned 405 patients with previously untreated stage IA or IIA nonbulky Hodgkin's lymphoma to receive either doxorubicin, bleomycin, vinblastine, and dacarbazine combination chemotherapy alone or subtotal nodal radiation therapy with or without ABVD. At 12 years, the researchers found that the rate of overall survival was 94 percent in the ABVD group, compared to 87 percent in the radiation group, with or without ABVD. In addition, the rates of freedom from disease progression were 87 percent in the ABVD group and 92 percent in the radiation group, and the rates of event-free survival were 85 percent in the ABVD group and 80 percent in the radiation group. "Among patients with Hodgkin's lymphoma, ABVD therapy alone, as compared with treatment that included subtotal nodal radiation therapy, was associated with a higher rate of overall survival owing to a lower rate of death from other causes" including secondary cancers and cardiovascular events, the authors write.

In a related editorial, Memorial Sloan-Kettering Cancer Center's David Straus says the 17 years spent on the ABVD versus radiation trial were "well worth the wait" as the study supports the view that the relapse rate for Hodgkin's lymphoma patients is not a reliable measure of long-term survival. "With the availability of effective salvage treatment for relapses on the one hand and the accumulation of late fatal treatment-related deaths on the other, long-term outcomes are probably more important than is the low early relapse rate," Straus says. So although radiation therapy remains useful for some patients, there is now a need to define a subgroup of Hodgkin's lymphoma patients for whom radiation would be more harmful than useful in the long run, he says, adding "limiting the use of radiation therapy to the fraction of patients who require it should make an important contribution to the ultimate goal of maximizing the long-term cure rate while minimizing late morbidity and mortality."

Finally in NEJM this week, researchers at University Hospital Zurich in Switzerland submit a letter on ultraviolet A and photosensitivity that some patients experience during vemurafenib therapy. It is important to advise patients about the most appropriate measures for photoprotection, the authors write. The researchers also determine the ultraviolet emission spectrum responsible for side effects like erythema. "On the basis of the nature and the evolution of the skin lesions, we conclude that vemurafenib causes UVA-dependent phototoxicity," the team adds. "This information and other UVA-specific properties such as constant intensity regardless of daylight and season should be communicated to patients who are beginning to receive therapy with vemurafenib."

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