What would be the preferred chemotherapy regimen in elderly patients with advanced stage classical Hodgkin Lymphoma and contraindication to doxorubicin and bleomycin?

First, I’d seek clarification as to what contraindications were present. Contraindications to either can be absolute or more relative. A Hgb-adj DLCO of less than 50% in the presence of known lung disease is an absolute contraindication to bleo, whereas a DLCO of 65 perhaps contributed to by HL itself is more relative. An LVEF if less than 30, confirmed by cardiac MR, is an absolute contraindication to doxorubicin, whereas an EF of 40-50 is more relative.

Next, I’d want to clarify goals of care. Is the patient a candidate for curative chemotherapy or is their overall frailty prohibitive of any consideration of multi agent chemotherapy?

in the setting of relative contraindication to doxorubicin, consideration could be given to using a non-dox containing program, proceeding with dox with caution, or substituting liposomal doxorubicin. Similarly with a relative contraindication to bleo, one could consider either excluding bleo from cycle 1a or both 1a and 1b, and repeating PFTs; or proceeding with bleo with caution and the intention of dropping after 2b in the setting of PET2 negative response (Deauville 1-3 as per RATHL); or using a non-bleo containing regimen.

Taking the hypothetical of a patient who is a candidate for curative therapy but has absolute contraindication to both dox and bleo, I would routinely consider CMOPP (cyclophosphamide 650mg/m2 substituted for nitrogen mustard); the ChlVPP regimen is also a consideration in elderly frail patients. 

I do not believe that the data for BV monotherapy establish it as an appropriate consideration as first-line therapy, nor BV+Benda. And I would not favor a “DIY” approach incorporating BV into a non-anthracycline based program such as CMOPP or ChlVPP as an N=1 experiment.