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Below, week by week, is what OnCo's record of Advanced-stage classical Hodgkin lymphoma (stage III to IV) says about the first two months: the order is typical, the timing is yours to ask about. Advanced-stage classical Hodgkin lymphoma is Hodgkin lymphoma involving nodes on both sides of the diaphragm or organs such as the liver, lungs or bone marrow. It is treated with six cycles of combination chemotherapy, and two trials changed the standard: replacing bleomycin with brentuximab vedotin (ECHELON-1) and then with nivolumab (SWOG S1826), which cured more patients with less toxicity. Sections appear only where the record has something to say. Orientation, not medical advice.
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
FDG-PET/CT with Lugano staging, International Prognostic Score, fertility counselling and cardiac and pulmonary baselines.
Ask which of these were tested and what the results were; see the report reader for what each value means.
Written by hand for this cancer from NHS, Macmillan, Cancer Research UK and charity pages, each item naming the page it came from. The days and weeks are the typical order those pages describe, not a schedule; tick what applies to you.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Response-adapted Children's Oncology Group or EuroNet regimens; brentuximab vedotin with AVD in advanced paediatric disease; radiotherapy for slow responders only.
Nivolumab with AVD for six cycles (SWOG S1826, preferred); brentuximab vedotin with AVD (ECHELON-1) as an alternative; PET-adapted ABVD with bleomycin omission after two cycles (RATHL) where antibodies are unavailable.
BrECADD for four to six cycles guided by interim PET (GHSG HD21), replacing escalated BEACOPP.
AVD with brentuximab vedotin sequenced before and after, or nivolumab-AVD; avoid bleomycin and BEACOPP.
PET-directed consolidation radiotherapy only for residual PET-positive bulky disease; long-term survivorship follow-up.
SWOG S1826 randomised 994 patients aged 12 and over with untreated stage III or IV classical Hodgkin lymphoma to nivolumab with AVD or to brentuximab vedotin with AVD, the regimen that had itself displaced ABVD. Two-year progression-free survival was 92 against 83 per cent (hazard ratio 0.45), and any-grade peripheral neuropathy was 28.1 against 54.2 per cent. It is the first trial in this disease to include adolescents and adults in a single protocol, and the FDA approved nivolumab with doxorubicin, vinblastine and dacarbazine for previously untreated stage III or IV classical Hodgkin lymphoma in adults and children of 12 and over on 20 March 2026, converting the two earlier relapsed-disease accelerated approvals to traditional approval at the same time. It is a genuinely gentler regimen as well as a more effective one: less neuropathy, less growth-factor requirement, and no bleomycin. The subset analysis of the 99 eligible patients aged 60 and over reported two-year progression-free survival of 89 per cent with nivolumab-AVD against 64 per cent with brentuximab-AVD (hazard ratio 0.24) and two-year overall survival of 96 against 85 per cent (hazard ratio 0.16), with non-relapse mortality of 6 against 16 per cent, 55 per cent discontinuing brentuximab vedotin against 14 per cent discontinuing nivolumab, and six cycles delivered without dose reduction in 69 against 26 per cent. That matters, because older patients tolerate brentuximab-AVD badly and are the group in which first-line treatment most often fails. What is not yet known: overall survival has not separated, follow-up is short for a disease measured in decades, and the long-term consequences of PD-1 blockade in a 20-year-old who will live another 60 years are unknown. That last point is the honest counter-argument to adopting it everywhere.
GHSG HD21 randomised about 1,500 patients aged 18 to 60 with untreated advanced-stage classical Hodgkin lymphoma to PET-guided BrECADD or PET-guided escalated BEACOPP. Four-year progression-free survival was 94.3 against 90.9 per cent (hazard ratio 0.66) and treatment-related morbidity, a composite of organ toxicity, infection and haematological toxicity, was 42 against 59 per cent. BrECADD replaces the bleomycin, vincristine and procarbazine of escalated BEACOPP with brentuximab vedotin and dacarbazine, which removes the lung toxicity, most of the neuropathy and much of the infertility risk, and PET guidance means most patients receive four cycles rather than six. This is the highest progression-free survival reported in advanced Hodgkin lymphoma. It is also intensive treatment that requires an experienced unit, hospital admission for febrile neutropenia in a substantial minority, and growth-factor support throughout. The earlier PET-guided BEACOPP trials, HD18 and AHL2011, established the principle: HD18 reduced treatment from eight cycles to four in PET-negative patients, and AHL2011 switched PET-negative patients from escalated BEACOPP to ABVD, in both cases without losing disease control.
The two regimens that the current standards displaced are still used, and still reasonable where the newer ones are not available. ABVD with PET adaptation. RATHL enrolled 1,214 patients and showed that in those whose PET after two cycles was negative, bleomycin could be omitted from cycles 3 to 6 without loss of control: three-year progression-free survival 85.7 per cent for continued ABVD against 84.4 per cent for AVD, with less lung toxicity. This remains common British practice and is a perfectly defensible treatment. Brentuximab vedotin with AVD. ECHELON-1 randomised 1,334 patients with untreated stage III or IV disease to A+AVD or ABVD: two-year modified progression-free survival was 82.1 against 77.2 per cent (hazard ratio 0.77) and, at six years, overall survival was 93.9 against 89.4 per cent (hazard ratio 0.59). It is the only first-line trial in advanced Hodgkin lymphoma to show an overall survival advantage. The cost is peripheral neuropathy, which is commoner and more severe than with ABVD; in SWOG S1826 any-grade peripheral neuropathy was 54.2 per cent with brentuximab-AVD against 28.1 per cent with nivolumab-AVD. Growth-factor support is mandatory. In England, NICE TA1059 recommends brentuximab vedotin with doxorubicin, dacarbazine and vinblastine for untreated stage 3 or 4 CD30-positive Hodgkin lymphoma in adults, so this is the regimen that is funded first line; there is no NICE appraisal of nivolumab with AVD. Older and frail patients tolerate none of these well. Options are ABVD with bleomycin omitted, sequential brentuximab vedotin before and after AVD, or a reduced-intensity regimen, and the choice is made on comorbidity rather than on chronological age.
Written by hand for this cancer. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
Every term links to the glossary.