Classical Hodgkin lymphoma

Dr Sharlene Parasnath explains the treatment landscape and patient journey of classical Hodgkin lymphoma.

Classical Hodgkin lymphoma (cHL) is a cancer of the lymphatic system and one of the great success stories of modern oncology. It’s highly curable, even when diagnosed at advanced stages.²

Yet, in South Africa (SA), many patients still present late, with Stage 3 or 4 disease, often after weeks or months of unexplained fevers, weight loss, night sweats, and lymph node swelling.³ 

Epidemiology and disease biology

Hodgkin lymphoma has a bimodal age distribution, affecting young adults and again those over 60.¹ In younger patients, the disease often arises in individuals who are otherwise healthy. At the same time, in older adults, co-existing illnesses can complicate treatment.

The hallmark of cHL is the Reed–Sternberg cell, which originates from B-lymphocytes but loses many normal immune functions.¹

These abnormal cells are surrounded by a microenvironment of inflammatory cells that both fuel and hide the tumour, a key reason immunotherapy has become such an exciting area of progress.⁴

Diagnostic journey

Diagnosis relies on excisional lymph node biopsy and immunohistochemistry to confirm classical subtypes, such as nodular sclerosis, mixed cellularity, and lymphocyte-depleted HL.⁵

Staging with computed tomography (CT) or positron emission tomography (PET)-CT scans determines the extent of disease and guides therapy.⁵

In SA, limited access to PET imaging often means that decisions depend on CT findings and clinical risk factors.⁶

Treatment landscape for Stage 3 and 4 cHL

In the state sector, treatment is guided by drugs on the national Essential Medicines List. The mainstays remain doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) chemotherapy protocol and, in selected younger and fit patients, bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, prednisolone, dacarbazine (BEACOPDac) protocol.⁷

For most young patients with good organ function, chemotherapy is well tolerated, and 70–80% achieve long-term remission.¹⁹ However, older patients face unique challenges, which include increased risk of toxicity, particularly from bleomycin and anthracyclines.²⁰

Adjustments to regimens and careful monitoring are crucial for maintaining safety while achieving disease control.

Unfortunately, a proportion of patients with advanced disease remain refractory or relapse after initial therapy.⁸ For these patients, salvage chemotherapy, such as ifosfamide, carboplatin, etoposide (ICE) or gemcitabine, dexamethasone, cisplatin (GDP), is used to re-induce remission,

followed by autologous stem cell transplantation (ASCT), available at several tertiary centres across SA.⁹

ASCT offers the best chance of durable remission, with success rates of 50–60% in eligible patients.¹⁰

Patient journey and quality of life

Living with Hodgkin lymphoma is not only about surviving but about maintaining dignity and hope through treatment. Younger patients may face disruptions in studies, work, or fertility planning. Older adults often contend with frailty, comorbidities, and reduced social support.

The side effects of chemotherapy (fatigue, nausea, hair loss, and infections) are temporary but emotionally taxing.¹¹

Multi-disciplinary support, including counselling, physiotherapy, and nutritional care, plays an essential role.

Outcomes and prognosis

With access to chemotherapy and transplant services, more than two-thirds of patients with Stage 3 and 4 Hodgkin lymphoma can be cured.¹² Those who relapse after transplant face poorer outcomes, but global advances are transforming this space.

New drugs, such as CD30-targeted antibody–drug conjugates and checkpoint inhibitors, can restore remission even in heavily pre-treated patients.¹³

Unfortunately, these therapies aren’t yet included in South Africa’s Essential Medicines List and remain inaccessible to most patients in the public sector.¹⁴

Earlier use of such agents has been shown to improve response rates and quality of life, underscoring the need for advocacy and policy evolution.

Future directions

The future of Hodgkin lymphoma care lies in personalised therapy, tailoring treatment based on individual biology, biomarkers, and early response.¹⁵

PET-adapted strategies already allow clinicians to de-escalate or intensify therapy according to early metabolic response, minimising toxicity while preserving cure rates.¹⁶

Integration of novel agents earlier in therapy, particularly for high-risk or older patients, holds great promise.¹⁷Additionally, supportive care interventions (infection prophylaxis and fertility preservation) are enhancing quality of life during and after treatment.¹⁸

Looking ahead

With early diagnosis, access to chemotherapy and referral for stem cell transplantation when needed, most patients can look forward to recovery. As new therapies become more accessible, outcomes for patients will continue to improve.

Dr Sharlene Parasnath is Head of Clinical Haematology and Haematopoietic Stem Cell Transplantation at Inkosi Albert Luthuli Central Hospital and UKZN in KwaZulu-Natal. She is passionate about teaching haematology and making haematology services available
to all South Africans.

Header image by Freepik

References

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C-ANPROM/ZA/ADCE/0064 JANUARY 2026