Table I. Approaches to the diagnosis and treatment of advanced Hodgkin’s disease.

	Diagnosis	Initial therapy	Follow-up during therapy	Follow-up after therapy	Relapse management	Remarks
USA	PET scan, PFTs with DLCO (if using bleomycin) and echo (and fertility preservation); no bone marrow, unless for patients over age of 60– 65 years and with cytopenias	Younger pts ages < 60–65 years: A + AVD for IPS 3-7; RATHL based therapy for IPS 0–2 pts ages> 60–65 years who are fit: sequential BV and AVD; for unfit: brentuximab vedotin ± DTIC	Repeat PET s/p 3 cycles; once negative, then CTs	Office visits q 3 months and re-staging CT scans q 6 months for 2 years (starting counting from diagnosis)	Transplant-eligible: ICE if relapse < 1 year vs. Brentuximab vedotin if relapse> 1 year followed by ASCT; BV maintenance after transplant if> 2 risk factors Transplant-ineligible: BV ± PD1 inhibitor (unless resistant to the former-then PD1 inhibitor alone)	Always advocate participation in a clinical trial
UK	Excision biopsy is the gold standard; however, core biopsies are increasingly used to expedite the diagnostic process	PET-adapted. ABVD. escBEACOPP is used by some centres for high-risk patients	PET2 response: For PET-patients (DS1–3) then AVD × 4 For PET+ patients (DS 4 or 5) some centres in UK escalate to escBEACOPP. Alternatively ifosfamidecontaining salvage for DS5 patients followed by ASCT in those patients who respond	End of treatment PET scan 6 weeks after the last dose chemotherapy	Re-biopsy Ifosfamide-containing salvage followed by ASCT for patients who are PET– (DS 1–3) after salvage For PET+ patients after 2 cycles of salvage, second-line salvage – BV	ABVD is the regimen of choice. DS 5 patients on PET2 are escalated to IGEV. DS 4 patients generally continue on ABVD The preferred salvage at Barts is IGEV
Germany	Histological diagnosis, preferably on excisional biopsy Assessment of disease extent and risk factors by PET Discuss measures to preserve fertility	Within a clinical trial if available (eg GHSG HD21) PET2-guided 4–6 cycles of eBEACOPP outside a clinical trial	Consider in-patient administration of the first escBEACOPP cycle Laboratory safety assessments 2-39/week. Dose delay and/or reduction in case of prolonged haematologic recovery	Consolidative RT with 30 Gy to PET+ (DS ≥ 3) residues Regular follow-up visits at increasing intervals for the first 5 years Focused on treatment-related toxicities and cancer-related fatigue	Salvage chemotherapy with eg 2 cycles DHAP followed by BEAM and ASCT. Consider tandem ASCT and/or consolidation with BV in higher-risk patients
India	Open biopsy wherever feasible, otherwise a trucut biopsy adequate for histopathology and immunohistochemistry Staging with resource constraints: clinical examination, ultrasound abdomen, chest X-ray and bone marrow biopsy Staging – No resource constraints: whole body PET/CT scan	Resource constraints: ABVD 6 cycles regardless of stage No resource constraints: ABVD 9 × 6 with plan for interim PET2	Resource constraints: Interim assessment with clinical examination, ultrasound and chest Xray, depending on site of initial disease No resource constraints: Omit further bleomycin if interim PET2–	Resource constraints: IFRT to sites of initial bulk disease Clinical follow-up every 3 months No resource constraints: IFRT to sites of initial bulk disease or PET + lesions> 1·5 cm Clinical follow-up every 3 months	2–4 cycles of GCD followed by autologous transplant in 2nd remission	Our previously published data (Korula et al. Br J Haem 2019) indicates that in a resource constraint setting, using 6 cycles of ABVD without interim or end-therapy PET assessment is a strategy with acceptable disease-free survival rates (3 yr RFS in early stage and advanced stage 88·1% and 73·9% respectively) comparable to CT/PET re-assessment (3 yr RFS 91·8% and 81·3% in early and advanced stage respectively) - toxicity notwithstanding
Thailand	CT-guided biopsy of the mediastinal mass	Escalated BEACODD regimen followed by ISRT	CT scan with contrast	Complete history, physical examination, CBC and ESR every 3 months for 1 year, then every 6 months until year 3 then annually, annual thyroid-stimulating hormone in patients receiving radiotherapy for neck, annual fasting blood sugar and lipid profile after 5 years post-therapy, annual breast screening initiating 8–10 years post-therapy or at age 40 if patients underwent chest or axillary radiation, stress test/echocardiogram at 10-year interval after treatment is completed and carotid ultrasound at 10-year intervals if neck irradiation was done	ICE, ESHAP or DHAP regimens and subsequently with ASCT	-A PET/CT can be performed in a small percentage of patients who can afford extra charge. Procarbazine is not available in Thailand. Hence, escalated BEACODD regimen has been used instead, replacing procarbazine by dacarbazine and prednisolone by dexamethasone

A + AVD, doxorubicin, vinblastine, dacarbazine plus brentuximab vedotin; ABVD, doxorubicin, bleomycin, vincristine, dacarbazine; ASCT, autologous stem cell transplant; AVD, doxorubicin, vinblastine, dacarbazine; BEACODD, bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, dacarbazine, dexamethasone; BEACOPP, bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procarbazine, prednisone; BEAM, carmustine/, etoposide, cytarabine and melphalan; BV, brentuximab vedotin; CBC, complete blood count; CT, computed tomography; DHAP, dexamethasone, cytarabine, cisplatin; DLCO, diffusing capacity of the lungs for carbon monoxide; DS, Deauville score; DTIC, dacarbazine; ESHAP, etoposide, methylprednisolone; cytarabine, cisplatin; ESR, erythrocyte sedimentation rate; GHSG, German Hodgkin Study Group; ICE, ifosfamide, carboplatin, etoposide; IFRT, involved field radiotherapy; IGEV, ifosfamide, gemcitabine, vinorelbine; IPS, International Prognostic Score; ISRT, involved site radiation therapy; PET, positron emission topography; PFT, pulmonary function test; RATHL, Response-Adapted Therapy in Hodgkin lymphoma; RFS, relapse-free survival; RT, radiotherapy.