When would you use AVD + brentuximab instead of ABVD for newly diagnosed stage 3 or 4 Hodgkin lymphoma?

By reducing the risk of primary treatment failure from 23% to 18%, the ECHELON-1 study demonstrated that compared to ABVD, AVD + brentuximab vedotin reduces the risk of primary treatment failure by about 25% for patients with advanced-stage classic Hodgkin lymphoma. If given with prophylactic G-CSF, AVD + brentuximab vedotin is less toxic than ABVD primarily because it eliminates bleomycin toxicity. I would use AVD + brentuximab vedotin for all patients with advanced-stage classic Hodgkin lympho...

As of this writing, NCCN guidelines prefer starting patients with stage 3/4 disease with 2 cycles of ABVD following by PET/CT. If there is a favorable response, AVD can be resumed removing any possibly of bleomycin toxicity. Until more experience is gained with BV, this guideline will likely not change.