Who Actually Detects Relapse in Hodgkin Lymphoma: Patient or Physician?.
Authors: Foltz Lynda M. , Song Kevin W. , Connors Joseph M. 
Published: April 2020

Abstract
Background: Few studies have objectively assessed the value of routine clinical, laboratory and radiological evaluation to detect recurrence of Hodgkin lymphoma. The optimal follow up of patients (pts) in complete remission following initial therapy has not been defined.
Methods: We identified 99 adult pts with Hodgkin lymphoma, who received treatment and follow up supervised by the British Columbia Cancer Agency and relapsed between Jan 1990 and April 2004. Pts who did not achieve complete remission or had a second hematological malignancy were excluded. Pts were followed with clinical assessment, chest radiograph, CBC and alk phos every 3 m for 2 y, then every 6 m for 3 y, then annually. Routine CT scans were recommended every 6 m for 3 y then annually for 2 y. Relapses were categorized as identified by pt (symptoms, new palpable disease) or by physician (routine physical examination or radiological or laboratory studies in asymptomatic pts).
Results: Median age at original diagnosis was 28 y (range 14–73). 86 pts initally had advanced and 13 limited stage disease. Primary treatment was chemotherapy +/− radiation in 93 pts and radiation alone in 6 pts. 10 pts had autologous SCT for primary refractory disease. Median follow up from diagnosis was 82 months (range 12–241). Median time to first relapse from completion of treatment was 14 months (range 2–142). Of the 99 relapses, 75 (76%) were identified by the pt and 24 (24%) by the physician. Pt systemic symptoms of relapse were: fatigue 13 pts; alcohol induced pain 3; weight loss 11; pruritis 9; night sweats 19; fever 6. Local symptoms were shortness of breath 8; chest pain 8; back pain 9; abd pain 3. 29 pts had more than 1 symptom. 44 pts noted a new lymph node or mass and 1 pt had leg swelling. 24 relapses were detected by physician: 14 on CXR, 7 on CT scan, 1 on lymphangiogram and 2 on physical exam. No asymptomatic relapses were identified by laboratory abnormalities alone. 2 of the 13 relapses in pts with initially limited stage disease (18%) were detected by physician (1 CXR and 1 CT chest), vs 22 of 86 (26%) in advanced disease. 78% of relapses occurred within 36 months of completing initial treatment.
Patient vs Physician Detected Relapses by Follow up Period
Time from therapy completion Patient Detected Relapse Physician Detected Relapse Total # Relapses &lt; 12 months 37 (80%) 9 (20%) 46 12–35 months 19 (61%) 12 (39%) 31 ≥ 36 months 19 (86%) 3 (14%) 22 All Relapses 75 (76%) 24 (24%) 99
80% of relapses within 12 months of therapy completion were detected by pts despite more intensive physician surveillance in this period. The proportion of physician detected relapses was greatest 12–36 months after completion of treatment, possibly due to relapse with more slowly progressive disease amenable to detection on periodic routine testing while it is still being carried on relatively frequently. The 22% of relapses occurring in the period of less frequent surveillance, greater than 3 years after treatment, were primarily detected by pts.
Conclusions: 76% of Hodgkin lymphoma relapses were detected by the pt and 78% of relapses occurred within 3 years of therapy completion. Asymptomatic relapse was detected on physical exam and radiological studies but not laboratory testing. The highest proportion of physician detected relapses occurred 12–35 months after treatment. Annual routine follow up beyond 36 months contributed minimally to relapse detection, identifying only 3% of total relapses.