Patient and Physician Preferences for Front-Line Treatment of Advanced Stage Hodgkin Lymphoma in Germany, France and the United Kingdom

Introduction: The standard treatment regimens for advanced-stage Hodgkin lymphoma (HL) are adriamycin/bleomycin/vinblastine/dacarbazine (ABVD) and escalated dose bleomycin/etoposide/ adriamycin/cyclophosphamide/vincristine/procarbazine/prednisone (BEACOPPesc) in patients under age 60. The objective of this study was to understand drivers of treatment preferences among patients and physicians for choice of front-line treatments in advanced stage HL.

Methods: A discrete choice experiment (DCE) was administered to hematologists/oncologists who manage patients with HL and individuals diagnosed with HL in the previous 2 years located in France, Germany and the United Kingdom. The attributes and levels were informed from a targeted literature review, physician interviews, and patient qualitative interviews. A total of six attributes were included: 5-year overall survival (OS; levels: 84%, 89%, 94%); 5-year progression free survival (PFS; levels: 68%, 77%, 85%); risk of side effects resulting in hospitalization (levels: 40%, 60%, 80%); risk of peripheral neuropathy following treatment (levels: low risk, high risk); risk of infertility (levels: low risk, high risk); and risk of permanent pulmonary toxicity (levels: no risk, approximately 20%). Based on patient interviews, the PFS attribute was altered slightly for the patient DCE, described as the risk of HL coming back or getting worse within 5 years (levels: 26%, 15%, 4%). Participants reviewed 12 unique DCE scenarios, developed using a d-efficient design, and selected their preference between two hypothetical unnamed treatments. Patients considered themselves when selecting their preference whereas physicians considered five different advanced HL patient types that differed in gender, age (30 vs 65 years), smoking status, and desire to have children. The DCE data were analyzed using a mixed logit model, using effects coding, which produces coefficients for the mean and standard deviation of each attribute level. Separate models were run for each of the patient types for the physician DCE. The relative importance of each attribute was calculated by dividing the difference between the coefficients of the minimum and maximum of each attribute by the sum of the differences for all the attributes. The least important attribute was assigned a value of 1.00 and the remaining attributes' importance level were reported relative to 1.00.

Results: A total of 281 physicians and 289 patients provided logical responses and were included in the analysis. Physicians were a mean of 47 years of age, 73% were male and they had a mean of 15 years' experience in treating HL. Patients were a mean of 37 years of age (8% > 55 years of age), 63% were male, and nearly half with known disease stage were in advanced stages of disease (43% in stage III, IV, intermediate or advanced stage).

OS was considered the most important attribute to physicians in 3 of 5 patient profiles (Table 1). For smokers (profile 4), physicians ranked pulmonary toxicity as the most important attribute, over 1.5 times as important than OS, over twice as important as PFS and over 5 times as important as short-term side effects. Among older patients (profile 5), short term side effects was most important to physicians' preferences.

From the patients' perspective, PFS was the most important attribute, followed by OS, both of which were over twice as important as short-term side effects. Patients considered long-term side effects (peripheral neuropathy, infertility, and pulmonary toxicity) almost twice as important as short-term side effects. OS was most important to male patients followed by PFS, whereas PFS was most important to female patients and OS was less important than long-term side effects (Table 2). Among older patients, PFS was most and infertility least important. Short-term side effects were the least important attribute to younger patients.

Conclusion: Generally, patients are willing to endure treatments with worse short and long-term effects if the treatment provided better efficacy outcomes. Physicians' treatment preferences are patient-specific, with age and potential comorbidities impacting the importance of pulmonary toxicity and short-term side effect attributes. This study demonstrates the complexity of the decision making process for front-line HL treatments. Novel therapies would provide treatment options to address patient-specific needs.

Table 1

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Table 1

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