Risk of Second Cancer in Hodgkin Lymphoma Survivors and Influence of Family History

Latent class analysis-derived classification improves the cancer-specific death stratification of lymphomas: A large retrospective cohort study

Lymphomas have diverse etiologies, treatment approaches, and prognoses. Accurate survival estimation is challenging for lymphoma patients due to their heightened susceptibility to non-lymphoma-related mortality. To overcome this challenge, we propose a novel lymphoma classification system that utilizes latent class analysis (LCA) and incorporates demographic and clinicopathological factors as indicators. We conducted LCA using data from 221,812 primary lymphoma patients in the Surveillance, Epidemiology, and End Results (SEER) database and identified four distinct LCA-derived classes. The LCA-derived classification efficiently stratified patients, thereby adjusting the bias induced by competing risk events such as non-lymphoma-related death. This remains effective even in cases of limited availability of cause-of-death information, leading to an enhancement in the accuracy of lymphoma prognosis assessment. Additionally, we validated the LCA-derived classification model in an external cohort and observed its improved prognostic stratification of molecular subtypes. We further explored the molecular characteristics of the LCA subgroups and identified potential driver genes specific to each subgroup. In conclusion, our study introduces a novel LCA-based lymphoma classification system that provides improved prognostic prediction by accounting for competing risk events. The proposed classification system enhances the clinical relevance of molecular subtypes and offers insights into potential therapeutic targets.

Incidence rate and risk factors of second primary neoplasms among older patients with hematological malignancies: Insights from a Chinese single-center experience (1997-2021)

Background

Patients with hematological malignancies face an increased risk of developing second primary neoplasms due to various factors, including immune system compromise and chemotherapy-related effects. However, the incidence and associated risk factors in older patients remain poorly understood. This study aimed to assess the incidence, identify risk factors, and evaluate their impact on survival outcomes among older patients with hematological malignancies.

Methods

This retrospective single-center study analyzed data from 163 patients, focusing on the occurrence of second primary neoplasms. Cumulative incidence rates were calculated, and risk factor analysis was conducted using a competing risk model.

Results

Among 124 eligible patients with a total follow-up duration of 572.57 person-years, the incidence rate of second primary neoplasms was 15.72/1000 person-years. The standardized incidence ratio (SIR) was 0.81 (95% confidence interval [CI] [0.39-1.48], P = 0.518). History of radiotherapy emerged as a significant risk factor (sub-distribution hazard ratio [SHR] = 21.61 [2.81-166.14], P = 0.003), whereas regular natural killer (NK) cell infusion was associated with reduced risk (SHR = 3.25 e-8 [9.81 e-9-1.08 e-7], P ＜ 0.001).

Conclusions

These findings underscore the importance of informing older patients with hematological malignancies about the long-term risks of second primary neoplasms. Healthcare providers should carefully weigh risk factors when formulating treatment strategies. The results are valuable for investigating the fundamental principles underlying the occurrence and progression of second primary neoplasms.

Effect of family history of cancer on postoperative survival in patients with non-small cell lung cancer

Background

Family history of cancer (FHC) has been reported to increase mortality of non-small cell lung cancer, mainly comprised of lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC). However, the impact of FHC on long-term survival remains controversial. This study aims to identify the impact of FHC on postoperative survival in LUAD and LUSC.

Methods

Patients underwent lung resection for LUAD or LUSC in West China Hospital from 2009 to 2021 were enrolled. The 5-year overall survival (OS), lung cancer-specific survival (LCSS) and progression-free survival (PFS) were compared between the patients with and without FHC. Multivariable Cox regression was also performed.

Results

A total of 6,253 patients were enrolled, including 5,685 LUAD and 568 LUSC. Altogether 18.9% (1,077/5,685) patients had FHC in LUAD, and 12.7% (72/568) patients had FHC in LUSC. In LUAD, the patients with FHC showed comparable survival compared with the patients without FHC regarding 5-year OS (87.9% vs. 86.5%, P=0.49), 5-year PFS (84.8% vs. 80.9%, P=0.06), and 5-year LCSS (89.2% vs. 88.0%, P=0.96). In LUSC, the patients with FHC had poorer survival compared with the patients without FHC according to 5-year OS (40.9% vs. 68.2%, P=0.007), 5-year PFS (42.3% vs. 66.2%, P=0.003), and 5-year LCSS (45.8% vs. 72.7%, P=0.003). Multivariate analyses indicated that FHC was an independent prognostic factor of OS, PFS, and LCSS in the patients with LUSC.

Conclusions

FHC was associated with a poor survival after lung resection in LUSC not LUAD patients. More attention should be paid in postoperative monitoring and treatment in LUSC patients with FHC.

Melanoma as Subsequent Primary Malignancy in Hematologic Cancer Survivors-A Literature Review

The occurrence of second primary malignancies is becoming increasingly important among cancer survivors. Melanoma, an aggressive neoplasm originating from the melanocytes, is responsible for most skin cancer-related deaths. This review aims to explore the risk of melanoma occurrence as a second primary cancer after the most common subtypes of hematologic neoplasia, a malignant disease originating from myeloid or lymphocytic cell lineages. Chronic lymphocytic leukemia (CLL) and non-Hodgkin lymphoma (NHL) are among the most associated subtypes with melanoma development. We also discuss the underlying hypotheses that may explain the associations between these malignancies and the impact of melanoma on survival. The review emphasizes the importance of increasing awareness of melanoma risk in hematologic cancer survivors, as it can lead to prompt recognition, improved skin surveillance, and better survival outcomes.

The Art of Bioimmunogenomics (BIGs) 5.0 in CAR-T Cell Therapy for Lymphoma Management

Purpose

Lymphoma, the most predominant neoplastic disorder, is divided into Hodgkin and Non-Hodgkin Lymphoma classifications. Immunotherapeutic modalities have emerged as essential methodologies in combating lymphoid malignancies. Chimeric Antigen Receptor (CAR) T cells exhibit promising responses in chemotherapy-resistant B-cell non-Hodgkin lymphoma cases.

Methods

This comprehensive review delineates the advancement of CAR-T cell therapy as an immunotherapeutic instrument, the selection of lymphoma antigens for CAR-T cell targeting, and the conceptualization, synthesis, and deployment of CAR-T cells. Furthermore, it encompasses the advantages and disadvantages of CAR-T cell therapy and the prospective horizons of CAR-T cells from a computational research perspective. In order to improve the design and functionality of artificial CARs, there is a need for TCR recognition investigation, followed by the implementation of a quality surveillance methodology.

Results

Various lymphoma antigens are amenable to CAR-T cell targeting, such as CD19, CD20, CD22, CD30, the kappa light chain, and ROR1. A notable merit of CAR-T cell therapy is the augmentation of the immune system's capacity to generate tumoricidal activity in patients exhibiting chemotherapy-resistant lymphoma. Nevertheless, it also introduces manufacturing impediments that are laborious, technologically demanding, and financially burdensome. Physical, physicochemical, and physiological limitations further exacerbate the challenge of treating solid neoplasms with CAR-T cells.

Conclusion

While the efficacy and safety of CAR-T cell immunotherapy remain subjects of fervent investigation, the promise of this cutting-edge technology offers valuable insights for the future evolution of lymphoma treatment management approaches. Moreover, CAR-T cell therapies potentially benefit patients, motivating regulatory bodies to foster international collaboration.

Bone damage and health-related quality of life in Hodgkin lymphoma survivors: closing the gaps

In the recent decades, remarkable successes have been recorded in the treatment of Hodgkin's lymphoma to the point that today it represents one of the neoplasms with the highest rates of cure and with the highest life expectancy. Nonetheless, this raises the concern for the health of long- term survivors. Late side effects of treatments in synergy with other risk factors expose survivors to increased morbidity and impaired quality of life. In the complexity of the topics concerning these last aspects, an area of growing interest is that of bone damage that follows Hodgkin Lymphoma and its treatments. In this narrative review, we conducted our work through assessment of available evidence focusing on several aspects linking bone damage and quality of life with Hodgkin lymphoma and its treatments. At present, the problem of osteopenia and osteoporosis in Hodgkin lymphoma survivors is a theme for which awareness and knowledge need to be implemented.

Lifetime risks of second primary malignancies after pediatric Hodgkin lymphoma and non-Hodgkin lymphoma

OBJECTIVES

Survivors after pediatric Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are with lifetime risk for second primary malignancy (SPM). This necessitates a thorough analysis to better understand the potential long-term health implications for these individuals.

METHODS

We used a US-wide population-based cancer registry data to quantify the SPM risk and identify its incidence patterns among pediatric lymphoma patients.

RESULTS

We observed 4.74-fold (95% CI 4.27-5.25) and 3.40-fold (95% CI 2.78-4.10) increased risks of SPM in survivors after pediatric HL and NHL, respectively. Through over 40 years' follow-up, the cumulative incidence of SPM for pediatric lymphoma was persistently increasing, and here we firstly report the high 40-year cumulative incidence rates of SPM, 22.2% for HL and 12.6% for NHL, suggesting that SPM accounts for a great proportion of deaths among survivors. Of 6805 pediatric lymphomas, 462 (6.36%) developed a SPM, especially second breast and thyroid cancer, followed by hematologic neoplasms including leukemia and NHL. The competing risk analysis demonstrated gender, lymphoma subtype and radiotherapy were significantly associated with SPM. Different risk patterns of SPM were identified between pediatric HL and NHL. Chemotherapy accelerated SPM development but did not increase its incidence risk.

CONCLUSION

Overall, patients after pediatric lymphoma can be with high lifetime risk of SPM, and more attention should be paid to SPM-related signs for early detection and intervention.

Breast Cancer and Mediastinal Hodgkin's Lymphomas: Multidisciplinary Discussion

Treatment for Hodgkin's lymphoma (HL) has evolved, with modern treatments combining less toxic chemotherapy and radiation, leading to improved long-term disease-free survival. However, there is a higher chance of second cancer, especially breast cancer, following effective HL treatment. The impact of reduced radiation doses and volumes, as well as the use of advanced irradiation techniques, on the risk of second malignancy is not clear. According to medical organizations, the history of chest irradiation is a relative contraindication to breast preservation therapy for women with initial breast cancer, leading to a paradigm of mastectomy. This article proposes a discussion between radiation oncologists and surgeons to review major trials and recent developments on the prevalence of breast cancer following HL therapy, the risk of contralateral cancer, the feasibility of breast conserving surgery (BCS), as well as breast reconstruction modalities.

Long-Term Periodic and Conditional Survival Trends in Prostate, Testicular, and Penile Cancers in the Nordic Countries, Marking Timing of Improvements

Survival studies are important tools for cancer control, but long-term survival data on high-quality cancer registries are lacking for all cancers, including prostate (PC), testicular (TC), and penile cancers. Using generalized additive models and data from the NORDCAN database, we analyzed 1- and 5-year relative survival for these cancers in Denmark (DK), Finland (FI), Norway (NO), and Sweden (SE) over a 50-year period (1971-2020). We additionally estimated conditional 5/1-year survival for patients who survived the 1st year after diagnosis. Survival improved early for TC, and 5-year survival reached 90% between 1985 (SE) and 2000 (FI). Towards the end of the follow-up, the TC patients who had survived the 1st year survived the next 4 years with comparable probability to the background population. For PC, the 90% landmark was reached between 2000 (FI) and after 2010 (DK). For penile cancer, 5-year survival never reached the 90% landmark, and the improvements in survival were modest at best. For TC, early mortality requires attention, whereas late mortality should be tackled for PC. For penile cancer, the relatively high early mortality may suggest delays in diagnosis and would require more public awareness and encouragement of patients to seek medical opinion. In FI, TC and penile cancer patients showed roughly double risk of dying compared to the other Nordic countries, which warrants further study and clinical attention.

Long-term outcomes in Hodgkin lymphoma survivors. Temporary trends and comparison with general population

The high cure rates of Hodgkin lymphoma (HL) make this oncological disease among those with the greatest number of long-term survivors. This single-institution study including 383 HL patients with up to 45 years of follow-up, analyses the morbidity and mortality of this population after treatments in comparison with the overall Spanish population, and investigates whether it has changed over time stratifying by periods of time, as a consequence of therapeutic optimization. The median age was 34.8 years (range 15-87) with median overall survival of 30 years, significantly higher in women (HR 0.58, 95% CI 0.42-0.79) (p = 0.0002). 185 late-stage diseases were noted (35% patients), cardiovascular disease (CVD) being the most frequent (23.2%). 30% of patients developed at least one second malignant neoplasm (SMN) to give a total of 174 SMNs. 20.9% of the patients died from HL and 67.0% died from non-HL causes (32.2% from SMN, 17% from CVD). The overall standardized mortality ratio (SMR) was 3.57 (95% CI: 3.0-4.2), with striking values of 7.73 (95% CI: 5.02-8.69) and of 14.75 (95% CI: 11.38-19.12) for women and patients <30 years at diagnosis, respectively. Excluding HL as the cause of death, the SMRs of those diagnosed before 2000 and from 2000 were proved to be similar (3.88 vs 2.73), maintaining in this last period an unacceptable excess of mortality due to secondary toxicity in patients cured of HL. Our study confirm that HL treatment substantially reduces the life expectancy of patients cured of HL. In recent periods, despite therapeutic optimization, deaths from toxicity continue to occur, mainly from CVD and SMN. Risk-factor monitoring should be intensified, prevention programs developed, and therapeutic optimization of LH investigated, especially in two vulnerable groups: those aged <30 years at diagnosis, and women.

BeEAM Conditioning including High-Dose Bendamustine before Autologous Stem Cell Transplantation Is Safe and Effective in Patients with Waldenstrom's Macroglobulinemia

High-dose chemotherapy (HDCT) with autologous stem cell transplantation (ASCT) is an option to consolidate remission in Waldenstrom's macroglobulinemia (WM), particularly in selected younger patients with chemosensitive disease. BEAM, consisting of BCNU, etoposide, cytarabine, and melphalan, is often used as a conditioning regimen. However, problems with BCNU, including pneumotoxicity, tolerance, and availability, necessitate the search for alternatives. In this pilot study, we investigated high-dose chemotherapy with BeEAM, in which BCNU is replaced with high-dose bendamustine as an alternative conditioning regimen in six subsequent patients with WM. Bendamustine treatment was well tolerated without unexpected toxicities. The overall response rate was 6/6 patients (2 very good partial responses (VGPR) and 4 PR). After a median follow-up of 72 months, two (33%) patients relapsed. Median progression-free and overall survivals were not reached, and no severe late-onset toxicities were observed so far. In this pilot study, BeEAM conditioning before ASCT seems feasible, safe, and effective in patients with WM.

The characteristics and survival of second primary lung cancer after Hodgkin's lymphoma: A comparison with first primary lung cancer using the SEER database

OBJECTIVE

The study aimed to compare the characteristics and prognosis between patients with second primary lung cancer following Hodgkin's lymphoma and those with primary lung cancer.

MATERIALS AND METHODS

Using the SEER 18 database, the characteristics and prognosis were compared between the second primary non-small cell lung cancer following Hodgkin's lymphoma (HL-NSCLC) (n = 466) and the first primary non-small cell lung cancer (n = 469,851)(NSCLC-1), as well as between the second primary small cell lung cancer following Hodgkin's lymphoma (n = 93) (HL-SCLC) and the first primary small cell lung cancer (n = 94,168) (SCLC-1). Comparisons of categorical variables were performed using Chi-square or Fisher's test. Continuous variables were compared using the Mann-Whitney U test. Overall survival (OS) was estimated using the Kaplan-Meier method, and the difference between groups was analyzed by log-rank test.

RESULTS

HL-NSCLC group had more males than NSCLC-1 group, and the median age of HL-NSCLC group was younger than that of NSCLC-1 group. Patients with HL-NSCLC showed inferior OS than those with NSCLC-1 (median: 10 months vs. 11 months, P = 0.006). Both HL-SCLC and SCLC-1 groups had poor prognosis, with median OS of 7 months (P = 0.4). The 3-year cumulative risks of death from any cause for patients with the latencies from HL to NSCLC of 0 to 5 years, >5 to 10 years, >10 to 15 years, >15 to 20 years, and>20 years were 71.8%, 82.6%, 86.8%, 85.7% and 78.5%, respectively(P = 0.020).

CONCLUSION

HL-NSCLC patients had worse prognosis than NSCLC-1 patients, while HL-SCLC patients shared similar characteristics and survival with SCLC-1 patients.

Second primary malignancies in cervical cancer and endometrial cancer survivors: a population-based analysis

Background: We evaluated the relative attribution and interactions of treatment and patient-related risk factors for second primary malignancies (SPMs) in cervical and endometrial cancer survivors.

Methods: Stage I–III cervical and endometrial cancer survivors’ data from the Surveillance, Epidemiology, and End Results (SEER) registry between January 1988 and December 2015 were analyzed. The standardized incidence ratio (SIR), excess absolute risk (EAR), and corresponding 95% confidence interval (95% CI) values were calculated. Analyses were classified based on proxies of human papillomavirus (HPV), smoking, hormone, and radiotherapy (RT) status. Additive and multiplicative interactions were assessed.

Results: Cervical cancer survivors had a higher risk for developing potentially HPV and smoking-related SPMs, especially in the RT group (SIR_HPV = 3.7, 95% CI: 2.9–4.6; SIR_smoking = 3.2, 95% CI: 2.8–3.6). Second vaginal cancer patients had the highest SIR (23.8, 95% CI: 14.9–36.0). There were strong synergistic interactions between RT and the proxy of smoking (P_interaction < 0.001), accounting for 36% of potentially smoking-related SPMs in cervical cancer survivors.

Conclusions: RT, HPV, and smoking promote SPMs in cervical cancer to different extents. The SPM burden in cervical cancer survivors could be mostly attributed to smoking and RT and their interactions.

The development of a decision aid to support Hodgkin lymphoma survivors considering lung cancer screening

BACKGROUND

Decisions aids (DA) can support patients to make informed decisions about screening tests. This study describes the development and initial evaluation of a lung cancer screening (LCS) DA targeted towards survivors of Hodgkin lymphoma (HL).

METHODS

A prototype decision aid booklet was developed and subsequently reviewed by a steering group who provided feedback. Revisions were made to produce the DA tested in this study. HL survivors were recruited to an online survey and/or focus groups. Lymphoma practitioners were invited to an interview study. In the online survey, decisional conflict scales and knowledge scales were completed before and after accessing the DA. The focus groups and interviews explored acceptability and comprehensibility and the decisional needs of stakeholders. Focus groups and interviews were audio recorded. The framework method was used to analyse qualitative data.

RESULTS

38 HL survivors completed the online survey. Following exposure to the DA, knowledge of LCS and risk factors and decisional conflict scores (total score and subscale scores) improved significantly. 11 HL survivors took part in two focus groups (n = 5 and n = 6) and 11 practitioners were interviewed. Focus group and interview results: The language, format and length were considered acceptable. Both groups felt the DA was balanced and presented a choice. Icon arrays were felt to aid comprehension of absolute risk values and for some survivors, they reduced affective risk perceptions. Among survivors, the impact of radiation risk on decision making varied according to gender and screening interval, whilst practitioners did not anticipate it to be a major concern for patients. Both groups expressed that a screening offer could mitigate anxiety about lung cancer risk. As anticipated by practitioners, survivors expressed a desire to seek advice from their clinical team. Practitioners thought the DA would meet their informational needs regarding LCS  when supporting survivors.

CONCLUSIONS

The DA is considered acceptable by HL survivors and practitioners. The DA reduces decisional conflict and improves knowledge in HL survivors, suggesting that it would support HL survivors to make informed decisions when considering LCS in a future clinical trial.

Racial/Ethnic Disparities on the Risk of Second Malignant Neoplasm Among Hodgkin Lymphoma Survivors

Background

Hodgkin lymphoma survivors are at risk for second malignant neoplasm (SMN). How race/ethnicity affects the risk remains unclear.

Methods

This retrospective cohort study included 22,415 patients diagnosed with primary Hodgkin lymphoma from January 1992 to December 2015 in 13 Surveillance, Epidemiology, and End Results-based registries and divided patients into four groups: non-Hispanic whites, non-Hispanic blacks, Hispanics, and Asian/others. Taking non-Hispanic whites as a reference, both the proportional subdistribution hazard (PSH) and the cause-specific hazard (CSH) methods were used to calculate the SMN hazard ratio for other racial/ethnic groups with and without considering the competing mortality risk.

Results

1,778 patients developed SMN with a median follow-up of 11.63 years. In the adjusted PSH model, Hispanic, Asian/others, and non-Hispanic black patients had 26% (PSH, 0.74; 95% CI, 0.63–0.87), 20% (PSH, 0.80; 95% CI, 0.64–1.01), and 12% (PSH, 0.88; 95% CI, 0.75–1.03) decreased overall SMN hazard, respectively. Moreover, the PSH method revealed the racial/ethnic difference in the SMN risk in the skin, the respiratory system, and the endocrine system. These hazards were slightly higher and different with the use of the CSH approach. In addition to the aforementioned overall SMN and subtypes, adjusted CSH analysis also revealed the racial/ethnic disparities in the risk of subsequent female breast cancer, digestive cancer, and non-Hodgkin lymphoma.

Conclusions

The subtype and SMN risk among Hodgkin lymphoma survivors varied by race/ethnicity. The use of CSH and PSH provides a dynamic view of racial/ethnic effects on SMN risk in Hodgkin lymphoma survivors.

Second primary malignancy risk after Hodgkin lymphoma treatment among HIV-uninfected and HIV-infected survivors

We compared secondary primary malignancy risk (SPM) in HIV-uninfected and HIV-infected Hodgkin lymphoma (HL) survivors. We used data from the California Cancer Registry on patients diagnosed with HL from 1990 to 2015 (all ages included), and standardized incidence ratios (SIRs) and multivariable competing risk models for analyses. Of 19,667 survivors, 735 were HIV-infected. Compared with the general population, the risk of SPM was increased by 2.66-fold in HIV-infected and 1.92-fold in HIV-uninfected survivors. Among HIV-infected survivors, median time to development of SPM was shorter (5.4 years) than in HIV-uninfected patients (8.1 years). Additionally, the highest risk of SPM was observed <2 years after diagnosis in HIV-infected survivors (SIR = 4.47), whereas risk was highest ≥20 years after diagnosis (SIR = 2.39) in HIV-uninfected survivors. The risk of SPMs persisted for decades and was higher among HIV-infected survivors, suggesting that these patients should benefit from long-term surveillance and cancer prevention practices.

Selection of Mediastinal Lymphoma Patients for Proton Therapy Within the Proton Collaborative Group Registry: Concordance With the ILROG Guidelines

PURPOSE

As patients with mediastinal lymphoma are typically young with curable disease, advanced radiation techniques such as proton therapy are often considered to minimize subacute and late toxicity. However, it is unclear which mediastinal lymphoma patients are treated with proton therapy. Within a prospective, multi-institutional proton registry, we characterized mediastinal lymphoma patients treated with proton therapy and assessed concordance with consensus recommendations published in 2018 by the International Lymphoma Radiation Oncology Group (ILROG).

METHODS

Eligible patients included those with lymphoma of the mediastinum treated exclusively with proton therapy for whom digital imaging and communications in medicine (DICOM) treatment data were available for review. Given the challenge with reliably visualizing the left mainstem coronary artery, the inferior-most aspect of the left pulmonary artery (PA) was used as a surrogate. Extent of disease was characterized as upper mediastinum (above level of left PA), middle mediastinum (below left PA but at or above level of T8), or low mediastinum (below T8).

RESULTS

Between November 2012 and April 2019, 56 patients were treated and met inclusion criteria. Patients treated with proton therapy were young (median, 24 y; range: 12 to 88), with over half being female (55%). Patients were most commonly treated at initial diagnosis (86%) and had Hodgkin lymphoma (79%). Most patients (96%) had mediastinal disease that extended down to the level of the heart: 48% had middle and 48% had low mediastinal involvement. Nearly all patients (96%) met the ILROG consensus recommendations: 95% had lower mediastinal disease, 46% were young females, and 9% were heavily pretreated. Heart (mean) and lung dose (mean, V5, V20) were significantly associated with lowest extent of mediastinal disease.

CONCLUSIONS

Mediastinal lymphoma patients treated with proton therapy are typically young with lower mediastinal involvement. Within a prospective, multi-institutional proton registry, nearly all treated patients fit the ILROG consensus recommendations regarding which mediastinal lymphoma patients may most benefit from proton therapy.

The Incidence of Mental Disorders Increases over Time in Patients with Cancer Pain: Data from a Retrospective Cohort Study

Background

It is well known that cancer patients more seldom have a psychiatric disorder than noncancer patients with chronic pain. Conversely, earlier studies have suggested that, at the psychiatric level, long-term cancer survivors (LCSs) have more in common with noncancer patients affected by chronic pain.

Materials and Methods

We investigated 89 cancer patients with acute pain (Acute Cancer Pain Patients, ACPPs) treated at a university outpatient chemotherapy department and compared these with 61 LCSs (living >5 yr after the first diagnosis) admitted by general practitioners for the treatment of noncancer pain. Upon administration, each patient was psychiatrically assessed by a liaison-psychiatrist conducting a semistructured interview. In a second step, we compared the LCS patients with hitherto treated noncancer patients suffering from chronic pain and ACPPs with data published by Derogatis in 1983.

Results

In a comparison of LCSs with ACPPs, LCSs have more patients with brain organic disorders and more addictions. The largest cancer group within the LCSs is patients with urogenital (Uro) cancer (44.3%), while within the ACPPs, these are patients with cancer of the gastrointestinal (GI) tract (ACPP-GI, 57.2%). As far as the distribution of mental disorders is concerned, long-term cancer survivors show some similarities to noncancer patients. The data of ACPPs are similar to those of cancer patients, published by Derogatis. Discussion. The higher values of addiction and brain organic disorders, in particular, and the slight differences for psychic disorders in general of LCSs vs. ACPPs may result from the different cancer types and a longer survival time for urogenital tract cancer compared to GI cancer. In an additional examination, we compared patients with acute cancer of the GI tract (ACPP-GI, n = 50) with those of the urogenital tract (ACPP-Uro, n = 43). ACPP-Uro had the lowest percentage of patients with psychiatric disorders in general (ACPP-Uro 37.2%, ACPP-GI 50.0%, all LCSs 65.6%, and LCS-Uro 74.1%) and addiction, in particular (ACPP-Uro 2.3%, ACPP-GI 4.0%, and LCSs 13.1%).

Conclusion

Cancer patients can develop a process of chronification with an increase in the prevalence of mental disorders. For urogenital cancer, an increase in the probability to develop mental disorders is a function of time.

A Review of Modifiable Risk Factors in Young Women for the Prevention of Breast Cancer

Breast cancer is the most common cancer diagnosis in women aged less than 40 years and the second most common cause of cancer death in this age group. Global rates of young onset breast cancer have risen steadily over the last twenty years. Although young women with breast cancer have a higher frequency of underlying pathogenic mutations in high penetrance breast cancer susceptibility genes (CSG) than older women, the vast majority of young breast cancer patients are not found to have a germline CSG mutation. There is therefore a need to inform young women regarding non-genetic breast cancer risk factors which have the potential to be influenced by changes in individual behaviour. A Pubmed search was performed using the search terms “young” or “early onset”, and “breast cancer” and “modifiable risk”. Titles and abstracts from peer-reviewed publications were screened for relevance. This review presents evidence for potentially modifiable risk factors of breast cancer risk in young women, including lifestyle factors (physical activity, body habitus, alcohol use, smoking, shift work and socioeconomic factors), reproductive and hormonal factors and iatrogenic risks. The extent to which these factors are truly modifiable is discussed and interactions between genetic and non-genetic risk factors are also addressed. Health care professionals have an opportunity to inform young women about breast health and risk when presenting at a “teachable moment”, including the benefits of physical activity and alcohol habits as risk factor. More focussed discussions regarding individual personal risk and benefit should accompany conversations regarding reproductive health and take into consideration both non-modifiable and iatrogenic BC risk factors.

Deciphering the Risk of Developing Second Primary Thyroid Cancer Following a Primary Malignancy-Who Is at the Greatest Risk?

Simple Summary

Associations between thyroid cancer and breast cancer have been elucidated, in that patients with breast cancer have a greater risk of developing subsequent thyroid cancer. However, not much is known about the relationship other primary cancers and subsequent thyroid cancer. In this review, we completed a thorough review of the existing literature to understand the relationship between primary cancers and second primary thyroid cancer (SPTC). Our findings suggest that surveillance protocols should be considered for patients at a higher risk of SPTC, including those with primary breast, renal cell, basal cell, and ovarian cancers who are female and/or Caucasian.

Abstract

Background: It is critical to understand factors that may contribute to an increased risk of SPTC in order to develop surveillance protocols in high-risk individuals. This systematic review and meta-analysis will assess the association between primary malignancy and SPTC. Methods: A search of PubMed and Embase databases was completed in April 2020. Inclusion criteria included studies that reported the incidence or standardized incidence ratio of any primary malignancy and SPTC, published between 1980–2020. The PRISMA guidelines were followed and the Newcastle–Ottawa Scale was used to assess quality of studies. Results: 40 studies were included, which were comprised of 1,613,945 patients and 15 distinct types of primary cancers. In addition, 4196 (0.26%) patients developed SPTC following a mean duration of 8.07 ± 4.39 years. Greater risk of developing SPTC was found following primary breast (56.6%, 95%CI, 44.3–68.9, p < 0.001), renal cell (12.2%, 95%CI, 7.68–16.8, p < 0.001), basal cell (7.79%, 95%CI, 1.79–13.7, p = 0.011), and ovarian cancer (11.4%, 95%CI, 3.4–19.5, p = 0.005). SPTC patients were more likely to be females (RR = 1.58, 95%CI, 1.2–2.01, p < 0.001) and Caucasians (p < 0.001). Conclusions: Surveillance protocols should be considered for patients at a higher risk of SPTC, including those with primary breast, renal cell, basal cell and ovarian cancers who are female and/or Caucasian.

Current overview and special considerations for second breast cancer in Hodgkin lymphoma survivors

Second breast cancer (SBC) is the most common solid cancer among Hodgkin Lymphoma (HL) female survivors. We reviewed the related modifying risk factors, radiation-induced carcinogenesis, tumors characteristics, management specificities, prevention and surveillance modalities based on current evidence. The risk of developing SBC may be influenced essentially by the age at HL treatment, follow-up latency, dose of irradiation received and the extent of irradiated field. SBCs generally develop at younger age, they are often bilateral, and exhibit more aggressive biological features and worse prognosis. No firm answer about the benefits of breast surveillance is provided by literature, but compelling evidence tends toward a clinical benefit in early detection. Increasing awareness among health providers' care and current survivors as well as the implementation of screening measures is crucial. Great efforts are ongoing in individualizing treatment strategies for future HL patients and response-adapted approaches are holding promise in prevention of these second malignancies.

Risk and Prognosis of Secondary Rectal Cancer After Radiation Therapy for Pelvic Cancer

Background

The relationship between pelvic radiation therapy (RT) and second primary rectal cancer (SPRC) is unclear. The aim of this study was to assess the risk and prognosis of SPRC after pelvic RT.

Materials and Methods

Data for patients who had primary pelvic cancer (PPC) between 1973 and 2016 were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Multiple primary standardized incidence ratios (SIRs) were used to assess the risk of SPRC. Five-year overall survival (OS) and rectal cancer-specific survival (RCSS) were calculated using Kaplan–Meier curves.

Results

A total of 573,306 PPC patients were included, 141,225 of whom had been treated with RT. Primary cancers were located in the prostate (50.83%), bladder (24.18%), corpus uterus (16.26%), cervix (5.83%), and ovary (2.91%). A total of 1,491 patients developed SPRC. Overall, the patients who received RT were at increased risk of developing SPRC (SIR = 1.39, 95% confidence interval [CI]: 1.27–1.52). The risk of SPRC decreased in patients who did not undergo RT (SIR = 0.85, 95% CI: 0.80–0.91). The SIR for SPRC in patients who underwent external beam radiation therapy (EBRT) was 1.22 (95% CI: 1.09–1.36). The SIR for SPRC in patients who underwent a combination of EBRT and brachytherapy (EBRT–BRT) was 1.85 (95% CI: 1.60–2.14). For patients who received RT, the SIR for SPRC increased with time after a 5-year latency period from PPC diagnosis. The survival of RT-treated SPRC patients was significantly worse than that of patients with primary rectal cancer only (PRCO).

Conclusions

Patients receiving pelvic RT were at an increased risk of developing SPRC. Different pelvic RT treatment modalities had different effects on the risk of SPRC. We suggest that long-term surveillance of SPRC risk is required for patients who have undergone pelvic RT, especially young patients.

Life-long follow-up of second primary lung and extra-pulmonary cancer in lung cancer patients is needed

Background: Lung cancer (LC) patients are at high risk of developing second primary cancer (SPC). This study aimed to explore the risk factors associated with SPC and provide an individualized risk prediction model for LC patients. Methods: Initial primary lung cancer (IPLC) patients diagnosed between 1998 and 2011 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. A Fine-Gray multivariate competing-risk model was used to estimate the risk of SPC, and the model was assessed regarding discrimination and calibration. A nomogram was designed for clinical convenience to predict the 3-, 5-, and 10- year probabilities of developing SPCs. Results: A total of 142,491 IPLC patients were considered in this study and 14,374(10.01%) developed SPC within a maximum study period of approximately 19 years. Seven independent prognostic factors were identified according to the competing-risk model, and the SEER summary stage and surgery were the strongest predictors. The model was well calibrated and had good discrimination ability(C-index = 0.746). Conclusions: LC survivors had an increased risk of SPC and factors associated with good prognosis often predicted SPC. Consideration should be given to increasing the duration of routine follow-up even after 10 years of initial diagnosis for those at the highest risk and site-specific follow-up strategy is also required.

Compliance with cancer screening and influenza vaccination guidelines in non-Hodgkin lymphoma survivors

PURPOSE

Compliance with US Preventive Services Task Force (USPSTF) age-appropriate cancer screening and immunization guidelines in lymphoma survivors is not known. We sought to measure compliance in non-Hodgkin lymphoma (NHL) survivors and identify any differences based on patient, disease, and treatment characteristics.

METHODS

Eligible NHL survivors were identified from the Molecular Epidemiology Resource (MER) prospective cohort study. Survivors self-reported colorectal, breast, and prostate cancer screening and influenza immunization in a questionnaire 3 years post-diagnosis (FU3). The USPSTF guidelines were used to define compliance. Chi-square tests were used to compare characteristics of compliant versus non-compliant survivors.

RESULTS

A total of 1833 MER participants from 2005 to 2012 completed a FU3. Rates of breast and prostate cancer screening were 96% and 72%, respectively. No differences in compliance based on patient or disease characteristics or treatment were observed. Ninety-two percent of survivors were compliant with colorectal cancer screening. Older age, indolent lymphoma histology, and 2008-2012 year of diagnosis were associated with higher compliance. Eighty-two percent of survivors were compliant with influenza vaccination and older age was associated with higher compliance.

CONCLUSION

NHL survivors have high compliance with USPSTF recommendations for cancer screening and immunization. Survivors who are younger or have aggressive lymphomas are less likely to meet the colorectal cancer screening guidelines. Older survivors are more likely to receive influenza vaccination.

IMPLICATIONS FOR CANCER SURVIVORS

Measures to further improve preventive care for NHL survivors, especially those younger in age, are necessary.

Long-term Hodgkin Lymphoma Survivors: A Glimpse of What Happens 10 Years After Treatment

INTRODUCTION

This retrospective study was focused on 96 patients (median age at diagnosis, 35 years) with newly diagnosed Hodgkin lymphoma (HL) treated at the University Hospital of Bari (Italy) between 2005 and 2008, to evaluate the outcome and the long-term toxicity.

PATIENTS AND METHODS

First-line chemotherapy was ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) in all patients; 49 (51%) patients had undergone radiotherapy. At the end of treatment, 75 (78%) patients were in complete remission (CR); 18 (24%) of 75 patients relapsed after first-line treatment; 20 (21%) underwent autologous hematopoietic stem cell transplantation, and 3 (3%) underwent allogeneic stem cell transplantation.

RESULTS

After a median follow-up of 12 years, 85 (88%) patients are alive in CR, and 11 (14%) have died (2 of a second neoplasia, 1 of infection, and 8 of the disease). The 140-month Kaplan-Meier survival estimates were 86%. Three women became pregnant and each gave birth to a healthy child. The most prevalent chronic conditions at last follow-up were: a reduction in lung transfer factor for carbon monoxide (40%), fatigue (31%), hypothyroidism (30%), and infertility (16%).

CONCLUSIONS

Results of this study offer indications about how long after the initial treatment excess deaths from causes other than HL begin to occur. However, challenges remain, namely establishing the optimal time to begin screening for potential late complications and developing better surveillance guidelines. Further work is needed to identify risk factors that may predict specific late effects.

Long-Term Outcomes in 10-Year Survivors of Early-Stage Hodgkin Lymphoma

PURPOSE

Although radiation therapy improves progression-free survival in early-stage Hodgkin lymphoma (HL), substantial concerns remain regarding the impact of delayed normal tissue effects on quality of life and survival. We hypothesized that treatment with combined-modality therapy (CMT; chemotherapy and radiation therapy) improves overall survival among 10-year survivors compared with treatment with radiation therapy or chemotherapy alone.

METHODS AND MATERIALS

We compared patients in the Surveillance, Epidemiology, and End Results database who received a diagnosis of stage I/II HL between 1983 and 2006 who received chemotherapy and/or external beam radiation and survived at least 10 years. Our primary study outcome was overall survival; we also analyzed cause-specific and other-cause-specific survival.

RESULTS

Of 10,443 ten-year survivors of stage I/II classical HL, 33.6% received chemotherapy alone, 23.8% radiation therapy alone, and 42.6% CMT. Median follow-up was 16.1 years. On multivariate analysis including race, stage, sex, age, and "modern" treatment in 1995 and later, 10-year survivors who received CMT had improved overall survival relative to survivors who received RT alone (hazard ratio, 1.41; 95% confidence interval, 1.21-1.64; P < .01) or chemotherapy alone (hazard ratio, 1.35; 95% confidence interval, 1.16-1.57; P < .01).

CONCLUSIONS

This survival difference was driven by an increase in death from both HL and non-HL causes in those treated with chemotherapy alone. Our analysis suggests that CMT offers optimal survivorship for patients with stage I/II HL.

Influence of family history on risk of second primary cancers and survival in patients with squamous cell skin cancer

BACKGROUND

Patients with squamous cell skin cancer (SCC) have an excellent prognosis but second primary cancers (SPCs) weaken survival prospects. Family history is a known risk factor for cancer but whether it is a risk factor for SPC in patients with SCC is not known.

OBJECTIVES

To quantify the risk of family history on SPCs in patients with SCC and estimate survival probabilities of patients with SPCs depending on family history.

METHODS

With 13 945 histologically verified SCCs, relative risks (RRs) were estimated for family history using a generalized regression model. For survival analysis, hazard ratios (HRs) were assessed using a multivariable Cox proportional-hazards model.

RESULTS

Family history of invasive SCC increased risk of second invasive SCC [RR = 42·92, 95% confidence interval (CI) 33·69-50·32] compared with risk without family history (RR 19·12, 95% CI 17·88-21·08). Family history of any nonskin cancer in invasive SCC increased risk of the same cancers to be diagnosed as SPC (RRF_H = 1·48, 95% CI 1·35-1·61 vs. RR_{no FH} = 1·40, 95% CI 1·32-1·48); significant increases were observed for seven different nonskin cancers. Most results were replicated for in situ SCC. SPC was deleterious for survival irrespective of family history; HR for patients with SPC was 4·28 (95% CI 3·83-4·72) vs. those without SPC (1·04).

CONCLUSIONS

Family history of nonskin cancer was associated with approximately a doubling of risk for SPCs in patients with SCC. SPC increases the death rate in patients with SCC 3-4 times, irrespective of family history. Taking family history into account at SCC diagnosis may help prevention or early detection of SPCs. What's already known about this topic? Second primary cancers (SPCs) are frequently diagnosed in patients with invasive and in situ squamous cell carcinoma (SCC); some epidemiological studies suggest a link to immune dysfunction. Family history of cancer is a risk factor for practically all first primary cancers but whether it also influences risk of SPCs in patients with SCC is not known. The possible influence of family history on survival in patients with SCC remains to be established. Linked Comment: Youlden and Baade. Br J Dermatol 2020; 183:414-415.

The relative risk of second primary cancers in Switzerland: a population-based retrospective cohort study

BACKGROUND

More people than ever before are currently living with a diagnosis of cancer and the number of people concerned is likely to continue to rise. Cancer survivors are at risk of developing a second primary cancer (SPC). This study aims to investigate the risk of SPC in Switzerland.

METHODS

The study cohort included all patients with a first primary cancer recorded in 9 Swiss population-based cancer registries 1981-2009 who had a minimum survival of 6 months, and a potential follow-up until the end of 2014. We calculated standardized incidence ratios (SIR) to estimate relative risks (RR) of SPC in cancer survivors compared with the cancer risk of the general population. SIR were stratified by type of first cancer, sex, age and period of first diagnosis, survival period and site of SPC.

RESULTS

A total of 33,793 SPC were observed in 310,113 cancer patients. Both male (SIR 1.18, 95%CI 1.16-1.19) and female (SIR 1.20, 95%CI 1.18-1.22) cancer survivors had an elevated risk of developing a SPC. Risk estimates varied substantially according to type of first cancer and were highest in patients initially diagnosed with cancer of the oral cavity and pharynx, Hodgkin lymphoma, laryngeal, oesophageal, or lung cancer. Age-stratified analyses revealed a tendency towards higher RR in patients first diagnosed at younger ages. Stratified by survival period, risk estimates showed a rising trend with increasing time from the initial diagnosis. We observed strong associations between particular types of first and SPC, i.e. cancer types sharing common risk factors such as smoking or alcohol consumption (e.g. repeated cancer of the oral cavity and pharynx (SIRmales 20.12, 95%CI 17.91-22.33; SIRfemales 37.87, 95%CI 30.27-45.48).

CONCLUSION

Swiss cancer survivors have an increased risk of developing a SPC compared to the general population, particularly patients first diagnosed before age 50 and those surviving more than 10 years. Cancer patients should remain under continued surveillance not only for recurrent cancers but also for new cancers. Some first and SPCs share lifestyle associated risk factors making it important to promote healthier lifestyles in both the general population and cancer survivors.

Survival of Patients With Second Primary Hodgkin Lymphoma

INTRODUCTION

The increased risk for second malignancies after Hodgkin lymphoma (HL) diagnosis is well known. However, to our knowledge, no study has investigated the outcomes of patients diagnosed with HL after an antecedent malignancy (HL-2). We aimed to investigate overall survival (OS), disease-specific survival (DSS), and correlates of survival in HL-2 using the Surveillance, Epidemiology and End Results (SEER) database.

PATIENTS AND METHODS

HL-2 patients (n = 821) identified from the 2000-2014 SEER-18 registries were compared to first primary HL patients (HL-1, n = 31,355) from the same registries. Multivariable, propensity score-matched (PSM), and competing risks regression analyses were conducted to assess the effect of antecedent malignancy on survival.

RESULTS

Hematologic (n = 309, 37.6%), prostate (n = 169, 20.6%), and breast (n = 76, 9.3%) malignancies were common antecedent malignancies in HL-2. Median latency between antecedent malignancy and HL diagnosis was 39 months. Median ages at HL diagnosis for HL-1 and HL-2 were 36 and 66 years, respectively (P < .001). The 5-year OS and HL-DSS rates for HL-2 versus HL-1 were 53.2% versus 82.7% and 79.1% versus 90.9%, respectively (P < .001). On multivariable analysis, antecedent malignancy was associated with decreased OS (hazard ratio [HR] = 1.27; 95% confidence interval [CI], 1.13-1.42; P < .001). With PSM balancing across covariables, antecedent malignancy was associated with decrements in HL-DSS (HR = 1.46; 95% CI, 1.12-1.92; P = .006) and OS (HR = 2.09; 95% CI, 1.74-2.51; P < .001).

CONCLUSION

The decrement in DSS in HL-2 relative to HL-1 may be related to biological differences in HL, age, and/or other unanalyzed factors. Further study of HL-2 patients is warranted.

Comparative photon and proton dosimetry for patients with mediastinal lymphoma in the era of Monte Carlo treatment planning and variable relative biological effectiveness

Background

Existing pencil beam analytical (PBA) algorithms for proton therapy treatment planning are not ideal for sites with heterogeneous tissue density and do not account for the spatial variations in proton relative biological effectiveness (vRBE). Using a commercially available Monte Carlo (MC) treatment planning system, we compared various dosimetric endpoints between proton PBA, proton MC, and photon treatment plans among patients with mediastinal lymphoma.

Methods

Eight mediastinal lymphoma patients with both free breathing (FB) and deep inspiration breath hold (DIBH) CT simulation scans were analyzed. The original PBA plans were re-calculated with MC. New proton plans that used MC for both optimization and dose calculation with equivalent CTV/ITV coverage were also created. A vRBE model, which uses a published model for DNA double strand break (DSB) induction, was applied on MC plans to study the potential impact of vRBE on cardiac doses. Comparative photon plans were generated on the DIBH scan.

Results

Re-calculation of FB PBA plans with MC demonstrated significant under coverage of the ITV V99 and V95. Target coverage was recovered by re-optimizing the PT plan with MC with minimal change to OAR doses. Compared to photons with DIBH, MC-optimized FB and DIBH proton plans had significantly lower dose to the mean lung, lung V5, breast tissue, and spinal cord for similar target coverage. Even with application of vRBE in the proton plans, the putative increase in RBE at the end of range did not decrease the dosimetric advantages of proton therapy in cardiac substructures.

Conclusions

MC should be used for PT treatment planning of mediastinal lymphoma to ensure adequate coverage of target volumes. Our preliminary data suggests that MC-optimized PT plans have better sparing of the lung and breast tissue compared to photons. Also, the potential for end of range RBE effects are unlikely to be large enough to offset the dosimetric advantages of proton therapy in cardiac substructures for mediastinal targets, although these dosimetric findings require validation with late toxicity data.

Patients with Non-Hodgkin's Lymphoma Are at Risk of Adenomatous Colon Polyps

BACKGROUND

Patients with non-Hodgkin's lymphoma (NHL) are frequently referred for colonoscopy to evaluate gastrointestinal symptoms during their treatment course. Here, we described the rate of colonic adenomas in patients with NHL.

METHODS

This was a retrospective study of patients with NHL who underwent colonoscopy after being diagnosed with NHL between January 2000 and December 2017.

RESULTS

Of the 17,938 patients who had been diagnosed with NHL in the study period, 2176 met the inclusion criteria. The mean age at the time of colonoscopy was 61 years. Most patients were male (61%). Overall, 1273 polyps were detected in 811 patients (37%). Sessile serrated adenomas were detected in 102 (5%) patients. The overall ADR was 12% in patients younger than 40 years of age (n = 103), 26% in patients aged 40-50 (n = 251), 34% in patients aged 51-60 (n = 630), and 43% in patients older than 60 (n = 1212). Most polyps were located in the right colon (63%), and 101 (8%) were larger than 1 cm. Villous adenomatous features were present in 1% of polyps, while high-grade dysplasia was detected in 22%. Invasive adenocarcinoma was identified in 4%. The median interval from lymphoma diagnosis to adenoma detection was 1.4 years (interquartile range 0.5-3.8 years). A repeat colonoscopy was performed in 343 patients. The overall ADR on repeat colonoscopy was 30%. Cox regression analysis revealed that age (hazards ratio 1.04; 95% confidence interval 1.03-1.05; P < 0.001) and male sex (hazards ratio 1.35; 95% confidence interval 1.13-1.60; P = 0.001) were independent factors associated with worse overall survival. By contrast, screening colonoscopy was associated with longer survival duration (hazards ratio 0.48; 95% confidence interval 0.36-0.63; P < 0.001).

CONCLUSION

The ADR in NHL patients aged 40-50 years was equivalent to that reported in the literature in non-cancer patients aged 50-70 years. Early screening colonoscopy may be warranted in NHL patients younger than 50 years. Screening colonoscopy significantly improved the overall survival of patients with NHL.

Novel Biomarker Approaches in Classic Hodgkin Lymphoma

Classic Hodgkin lymphoma (cHL) is one of the most common lymphomas in the Western world. Advances in the management of cHL have led to high cure rates exceeding 80%. Nevertheless, relapse or refractory disease in a subset of patients and treatment-related toxicity still represents unsolved clinical problems. The introduction of targeted treatments such as PD-1 blockade and the CD30 antibody drug conjugate, brentuximab vedotin, has broadened treatment options in cHL, emphasizing the critical need to identify biomarkers with the goal to provide rationales for treatment selection, increase effective drug utilization, and minimize toxicity. The unique biology of cHL featuring low abundant tumor cells and numerous nonmalignant immune cells in the tumor microenvironment can provide various types of promising biomarkers related to the tumor cells directly, tumor microenvironment cross-talk, and host immune response. Here, we comprehensively review novel biomarkers including circulating tumor DNA and gene expression-based prognostic models that might guide the ideal management of cHL in the future.

Risk of subsequent primary leukaemias among 69,460 five-year survivors of childhood cancer diagnosed from 1940 to 2008 in Europe: A cohort study within PanCareSurFup

BACKGROUND

Survivors of childhood cancers are at risk of developing subsequent primary leukaemias (SPLs), but the long-term risks beyond 20 years of treatment are still unclear. We investigated the risk of SPLs in five-year childhood cancer survivors using a large-scale pan-European (PanCareSurFup) cohort and evaluated variations in the risk by cancer and demographic factors.

METHODS

This largest-ever assembled cohort comprises 69,460 five-year childhood cancer survivors from 12 European countries. Standardised incidence ratios (SIRs) and absolute excess risks (AERs) were calculated.

RESULTS

One hundred fifteen survivors developed an SPL including 86 myeloid leukaemias (subsequent primary myeloid leukaemias [SPMLs]), 17 lymphoid leukaemias and 12 other types of leukaemias; of these SPLs, 31 (27%) occurred beyond 20 years from the first childhood cancer diagnosis. Compared with the general population, childhood cancer survivors had a fourfold increased risk (SIR = 3.7, 95% confidence interval [CI]: 3.1 to 4.5) of developing leukaemia, and eight leukaemias per 100,000 person-years (AER = 7.5, 95% CI: 6.0 to 9.2) occurred in excess of that expected. The risks remained significantly elevated beyond 20 years from the first primary malignancy (SIR = 2.4, 95% CI: 1.6 to 3.4). Overall, the risk ratio for SPML (SIR = 5.8, 95% CI: 4.6 to 7.1) was higher than that for other SPLs.

CONCLUSIONS

We demonstrate that beyond 20 years after childhood cancer diagnosis, survivors experience an increased risk for SPLs compared with that expected from the general population. Our findings highlight the need for awareness by survivors and their healthcare providers for potential risk related to SPL.

Second primary cancers in non-Hodgkin lymphoma: Family history and survival

Second primary cancers (SPCs) account for an increasing proportion of all cancer diagnoses and family history of cancer may be a risk factor for SPCs. Using the Swedish Family-Cancer Database on non-Hodgkin lymphoma (NHL), we assessed the influence of family history on risk of SPCs and of SPCs on survival. NHL patients were identified from the years 1958 to 2015 and generalized Poisson models were used to calculate relative risks (RRs) for SPCs and familial SPCs. Among 14,393 NHL patients, a total of 1,866 (13.0%) were diagnosed with SPC. Familial risk of nine particular cancers was associated with risks of these cancers as SPCs, with twofold to fivefold increase in RRs. At the end of a 25-year follow-up period, the survival probability for persons with SPC was only 20% of that for patients without SPC; the hazard ratio for SPC was 1.59 (95% CI: 1.46-1.72). Survival could be predicted by the prognostic groups based on first cancers and HRs increase systematically with worse prognosis yielding a trend of p = 4.6 × 10^-5 . SPCs had deleterious consequences for survival in NHL patients. Family history was associated with increasing numbers of SPCs. Prevention of SPCs and their early detection is an important target in the overall strategy to improve survival in NHL patients. Counseling for avoidance of risk factors and targeted screening based on family history are feasible steps in risk reduction.

CD163 is a predictive biomarker for prognosis of classical Hodgkin's lymphoma in Saudi patients

Hodgkin's lymphoma (HL) is a hematological malignancy characterized by a minority of neoplastic cells outnumbered by tumor-associated macrophages (TAMs). The overexpression of the CD163 antigen by TAMs is considered to be a significant predictive biomarker for risk stratification. This is likely caused by a genetic single-nucleotide polymorphism (SNP) at the gene promoter. The aim of the present retrospective case-control study was to establish a gene expression profile of a specific biomarker for classical HL (CHL) in order to predict the outcome and survival of CHL patients in Saudi Arabia. The protein expression of CD163 on TAMs was studied using immunohistochemistry (IHC). A prognosis index was calculated for the CD163 protein to assess the risk stratification of CHL. Genotyping of selected SNPs of this antigen was performed for 100 CHL cases and controls. The analysis revealed that the CD163 protein expression level was significantly correlated with disease relapse (DR) and overall survival (OS). In addition, the CD163 index threshold (15.0) was found to be significantly correlated with the relapse rate. Among the studied CD163 SNPs, rs75608120 exhibited a significant correlation with the DR rate of CHL patients, but not with OS. The findings of the present study confirmed that CD163 is a specific marker for TAMs, and its overexpression by TAMs is significantly associated with relapse and reduced survival post-therapy. In addition, a new methodology of indexing CD163 protein expression for HL risk stratification was proposed. Thus, the present study identified a specific predictive molecular and antigenic biomarker for CHL prognosis.

Second cancers and causes of death in patients with testicular cancer in Sweden

While treatment for testicular cancer (TC) has become standardized after the 1980s with an associated significant improvement in patient survival, this has been accompanied by an increased risk of second primary cancers (SPCs). Patients were identified from the Swedish Cancer Registry spanning the years from 1980 to 2015, including 8788 individuals with primary TC and their SPCs. Relative risks (RRs) for SPC were calculated using the generalized Poisson regression model. SPCs were diagnosed in 9.4% of patients with TC and half of them were late onset cancers not common in the population in their 40s. Overall RR of SPCs (excluding second TC) was 1.30 (95%CI: 1.20–1.40), including high risks for seven solid cancers, non-Hodgkin lymphoma and leukemia. Second TC was the most common SPC and the RR of 17.19 (95%CI: 14.89–19.85) was the highest recorded. Cancers known to be fatal as first primary cancers were also fatal as SPC in TC patients. Survival at 30 years of follow-up was approximately 80% for TC patients without SPC but it decreased to 40% for patients with SPC. The unexpected finding that half of the identified SPCs were typical late onset cancers in the middle-aged population raises concerns that therapy may facilitate premature aging. The risks of SPC are clinically important for the long-term management of TC patients and the high-mortality calls for a future management strategy.

Family History of Breast Cancer Associated with Breast Cancer in Survivors of Hodgkin Lymphoma

Introduction

Advances in treatments for Hodgkin Lymphoma (HL) have significantly increased survival of childhood and adult patients; however, the leading cause of death in HL survivors is due to secondary malignancy following HL treatment [1,2]. Among women treated for HL, breast cancer (BC) is the most common secondary malignancy [3]. We explored if an association exists between HL and BC exists within families.

Methods

Utilizing the Utah Population Database and the Utah Cancer Registry, we identified 988 women with HL, and no history of BC prior to HL, diagnosed in Utah from 1966-2014. We examined if women with HL were at greater risk of developing BC based on the presence or absence of family history of BC. We also examined the familial recurrence risk of BC among female FDRs of women with HL and BC using Cox regression methods.

Result

Among 988 female HL patients, 42 (4.3%) were diagnosed with subsequent BC while among 9,876 matched controls, 280 controls (2.8%) were diagnosed with BC from 1966-2014 (P < 0.05). We observed a significant 3-fold increased risk of BC in the first-degree relatives (parent, full sibling, or child of patient) of female HL patients with subsequent BC, compared to FDR in controls (HR = 2.8, 95%CI 1.4-5.6; P = 0.005). Female HL patients who had a family history of BC were significantly more likely to develop BC, compared to HL patients with no history of BC among relatives (HR = 3.3, 95%CI 1.6-7.1; P = 0.002).

Conclusion

Women with HL and a family history of BC are at even higher than anticipated risk of BC, as are their female relatives. Obtaining a thorough family history for a woman preparing to undergo therapy for HL is important for treatment decisions for HL and maintaining an up to date family history over time is also important for the management of a woman's ongoing cancer risks and her surveillance strategy following survival of HL.

Humanized anti-CD123 antibody facilitates NK cell antibody-dependent cell-mediated cytotoxicity (ADCC) of Hodgkin lymphoma targets via ARF6/PLD-1

CD123 (IL-3Rα) is frequently expressed by malignant Hodgkin lymphoma (HL) cells. Naked monoclonal antibodies (mAb) against HL lack clinical benefit, partially due to absence of natural killer (NK) cells in the tumor microenvironment. Here we show that the combination of a fully humanized anti-CD123 mAb (CSL362) and high-affinity Fcγ-receptor NK-92 cells (haNK) effectively target and kill HL cells in vitro. First, we confirmed high expression of CD123 in 2 of the 3 HL cell lines (KM-H2 and L-428), and its absence in NK cells. Cytotoxicity of haNK cells against CD123-positive HL cells was significantly higher in the presence of CSL362. This was also shown with IL-15-activated primary NK cells, although haNK cells showed a 10.87-fold lower estimated half-maximal stimulatory effective concentration (EC₅₀). CSL362 facilitated a significant increase in the expression of CD107a, intracellular IFN-γ and TNF-α and enhanced expression of c-JUN, PLD-1, and ARF6 by NK cells. Inhibition of the ARF6–PLD-1 axis (NAV2729), but not of the MAPK pathway (U0126), completely abrogated CSL362-facilitated antibody-dependent cell-mediated cytotoxicity (ADCC) in haNK and activated primary NK cells. Our results support CD123 as an immunotherapeutic target for HL and the combination of NK cells and CSL362 as a treatment strategy for HL.

Familial Risks and Mortality in Second Primary Cancers in Melanoma

Background

Malignant melanoma (MM) patients are at increasing risk of developing second primary cancers (SPCs). We assessed mortality and risk of SPCs in MM patients with siblings or parents affected with same cancer compared with that of the general population.

Methods

We used the Swedish Family-Cancer Database to assess relative risks (RRs) and causes of death in SPCs until 2015 in patients with a MM diagnosis between 1958 and 2015. We identified 35 451patients with MM among whom 3212 received a subsequent diagnosis of SPC. RRs of SPCs after MM diagnosis were calculated stratifying over concordant family history of cancer in first-degree relatives.

Results

Familial RRs were increased for second melanoma (RR = 19.28, 95% CI = 16.71 to 22.25), squamous cell skin cancer (RR = 7.58, 95% CI = 5.57 to 10.29), leukemia (RR = 5.69, 95% CI = 2.96 to 10.94), bladder (RR = 4.15, 95% CI = 2.50 to 6.89), ovarian (RR = 3.89, 95% CI = 1.46 to 10.37), kidney cancer (RR = 3.77, 95% CI = 1.57 to 9.06), cancer of unknown primary (RR = 3.67, 95% CI = 1.65 to 8.16), nervous system (RR = 2.88, 95% CI = 1.20 to 6.93), breast (RR = 2.34, 95% CI = 1.92 to 2.84), lung (RR = 2.24, 95% CI = 1.50 to 3.35), and prostate cancer (RR = 2.22, 95% CI = 1.89 to 2.61) with statistical significance. For all cancers, familial RR was in excess (2.09, 95% CI = 2.02 to 2.16 vs 1.78, 95% CI = 1.69 to 1.87; P_trend < .0001). Cause of death in MM patients with SPC is shown to be dependent on the cancer site though SPCs contributed to majority of deaths.

Conclusions

SPCs appear higher with prior family history of cancer and contribute to mortality. SPC was the most common cause of death in patients with SPC and is almost uniformly the major contributing cause of death for all cancer sites. For improved survival in MM patients, prevention and early detection of SPCs would be important.

Familial risks of second primary cancers and mortality in ovarian cancer patients

Background

With improving survival in ovarian cancer, second primary cancers (SPCs) and their etiological foundations are becoming an issue. The ways in which family history may influence the occurrence of SPCs and the related mortality are not well known.

Methods

Based on the Swedish Family-Cancer Database, we identified 11,300 ovarian cancer patients and followed them for diagnoses of SPCs until the end of 2015. Relative risks (RRs) of SPC in patients who had parents or siblings diagnosed with the same cancer (positive family history) were compared to those in patients without a family history (negative family history). Causes of death were compared between patients with and without SPC.

Results

A total of 1,111 (9.8%) ovarian cancer patients developed SPC with a median follow-up of 8 years. The impact of a family history of cancer on the risk of the same cancer as SPC was significant for colon (RR_{positive family history} [95% CI] vs RR_{negative family history} [95% CI]: 4.95 [3.03–8.09] vs 2.00 [1.63–2.47]), lung (3.32 [1.88–5.84] vs 1.45 [1.16–1.83]), and breast (2.08 [1.58–2.73] vs 1.01 [0.88–1.15]) cancers. With a family history of any cancer, the RR for non-ovarian SPCs was 1.66 (1.54–1.74), in contrast to 1.38 (1.24–1.54) for SPCs without any family history (P-trend <0.001). Accounting for 42.1% of all deaths, SPC was found to be the main cause of death for patients with SPC.

Conclusion

A family history of a particular cancer contributed to an increased risk of SPC at the same site. Therefore, considering family history at the time of diagnosis of ovarian cancer may alert physicians to a syndromic background, management of which may help the patient and her family members.

Impact of family history of cancer on risk and mortality of second cancers in patients with prostate cancer

BACKGROUND

Survival rates are increasing in patients with prostate cancer, and second primary cancers (SPCs) are becoming more common in these patients. However, the etiology and clinical consequences of SPCs are not well-known. We define the impact of family history on SPC and causes of mortality in these patients.

PATIENTS AND METHODS

A nation-wide cohort study based on the Swedish Family-Cancer Database covering 4.4 million men and 80,449 prostate cancers diagnosed between 1990 and 2015. Relative risks (RRs) and cumulative incidence for SPCs and for familial SPC were calculated for prostate cancer patients.

RESULTS

SPC was diagnosed in 6,396 men and more than a third of these patients had a first-degree family history of any cancer; the familial risk was 1.37 (95% CI: 1.27-1.40), compared to 1.10 (1.08-1.16), without a family history. Cumulative incidence by the age of 83 years reached 21% for prostate cancer alone, 28% in those with SPC, and 35% in patients with SPC and family history. Family history was associated with the risk of seven specific SPCs, including colorectal, lung, kidney, bladder and skin (both melanoma and squamous cell) cancers, and leukemia. Colorectal and lung cancers were common SPCs, and family history doubled the risk of these SPCs. In patients with SPC, half of all causes of death were due to SPC and only 12.77% were due to prostate cancer. Most deaths in SPC were caused by lung and colorectal cancers.

CONCLUSIONS

SPCs were an important cause of death in patients with prostate cancer and family history was an important risk factor for SPCs. Prevention of SPC should be essential when prostate cancer survival rates are being improved and this could start by conducting a thorough assessment of family history at the time of prostate cancer diagnosis.

Targeting Immune System Alterations in Hodgkin Lymphoma

PURPOSE OF REVIEW

This review discusses novel immunotherapeutic approaches to treat Hodgkin lymphoma (HL), specifically PD-1 inhibitors and cellular immunotherapy.

RECENT FINDINGS

PD-1 inhibitors have shown promising results in the treatment of relapsed or refractory HL, leading to FDA approval of nivolumab and pembrolizumab, although complete remissions are rare. Chimeric antigen receptor T cells directed against CD30 have been investigated with preliminary clinical trials showing minimal toxicities and some responses in heavily pre-treated patients with HL. HL is unique as it consists of a small percentage of malignant cells (Hodgkin Reed Sternberg cells) surrounded by an inflammatory microenvironment which promotes tumor growth and suppresses immune responses, making it an ideal target for immunotherapeutic approaches, such as PD-1 inhibitors and cellular immunotherapy. Current research is focused on overcoming barriers to efficacy via rational combinations that overcome resistance to therapy.

Survivors at risk: Hodgkin lymphoma survivors at high risk of second cancers

Amit Sud speaks to Sebastian Dennis-Beron, Commissioning Editor: Amit Sud is a clinical research fellow in Hematology at the Institute of Cancer Research, UK. He undertook his undergraduate medical training at the University of Manchester, gaining an honors degree. He completed his Masters in Medical Research at Manchester University, gaining a distinction. He continued his medical training in Manchester and London and started his specialization in Hematology in South West London. He was successful in obtaining a Cancer Research UK funded clinical research fellowship in Hematology under the supervision of Professor Richard Houlston at the Institute of Cancer Research. His current research focus is that of genetic susceptibility to Hodgkin lymphoma. He is a trainee member of the NCRI Lymphoma Clinical Studies Group.

Trends in the Risks of Secondary Cancers in Patients With Hodgkin Lymphoma

INTRODUCTION

The present study analyzed the trends in secondary cancer (SC) risks among Hodgkin lymphoma (HL) patients in the United States.

MATERIALS AND METHODS

Patients with HL diagnosed from 1973 to 2014 were identified from the Surveillance, Epidemiology, and End Results database. We compared the risk of SCs in HL patients relative to the risk in the US general population across 3 periods: 1973 to 1986, 1987 to 2000, and 2001 to 2014 to study the effect of treatment practices on the development of SCs.

RESULTS

In a follow-up study of 23,864 HL survivors for 284,730 person-years, 3260 SCs were diagnosed with a standardized incidence ratio (SIR) of 1.97 (95% confidence interval [CI], 1.9-2.04). A statistically significant decrease was found in the overall SIRs of SCs diagnosed in HL patients from 1987 to 2000 (SIR, 1.82; 95% CI, 1.72-1.93) and from 2001 to 2014 (SIR, 1.66; 95% CI, 1.51-1.82) relative to patients with SCs diagnosed from 1973 to 1986 (SIR, 2.24; 95% CI, 2.13-2.35). The decline in the overall SIR mostly resulted from declines in digestive tract and breast cancers. The SIRs of most other solid tumors and hematologic malignancies did not decrease. After adjusting for age, gender, and race, patients with a diagnosis from 1973 to 1986 had a 12% greater risk of developing SCs (hazard ratio, 1.12; 95% CI, 1.03-1.23; P = .01) compared with the patients with a diagnosis from 1987 to 2000.

CONCLUSION

Although the overall risk of SCs in patients with HL declined after modifications in HL treatment, the risk did not change significantly at most individual sites. Thus, close follow-up with active surveillance for SCs is crucial for long-term survivors of HL.

End-of-treatment and serial PET imaging in primary mediastinal B-cell lymphoma following dose-adjusted EPOCH-R: a paradigm shift in clinical decision making

Dose-adjusted-EPOCH-R obviates the need for radiotherapy in most patients with primary mediastinal B-cell lymphoma. End-of-treatment PET, however, does not accurately identify patients at risk of treatment failure, thereby confounding clinical decision making. To define the role of PET in primary mediastinal B-cell lymphoma following dose-adjusted-EPOCH-R, we extended enrollment and follow up on our published phase II trial and independent series. Ninety-three patients received dose-adjusted-EPOCH-R without radiotherapy. End-of-treatment PET was performed in 80 patients, of whom 57 received 144 serial scans. One nuclear medicine physician from each institution blindly reviewed all scans from their respective institution. End-of-treatment PET was negative (Deauville 1-3) in 55 (69%) patients with one treatment failure (8-year event-free and overall survival of 96.0% and 97.7%). Among 25 (31%) patients with a positive (Deauville 4-5) end-of-treatment PET, there were 5 (20%) treatment failures (8-year event-free and overall survival of 71.1% and 84.3%). Linear regression analysis of serial scans showed a significant decrease in SUV_max in positive end-of-treatment PET non-progressors compared to an increase in treatment failures. Among 6 treatment failures, the median end-of-treatment SUV_max was 15.4 (range, 1.9-21.3), and 4 achieved long-term remission with salvage therapy. Virtually all patients with a negative end-of-treatment PET following dose-adjusted-EPOCH-R achieved durable remissions and should not receive radiotherapy. Among patients with a positive end-of-treatment PET, only 5/25 (20%) had treatment-failure. Serial PET imaging distinguished end-of-treatment PET positive patients without treatment failure, thereby reducing unnecessary radiotherapy by 80%, and should be considered in all patients with an initial positive PET following dose-adjusted-EPOCH-R (clinicaltrials.gov identifier 00001337).

Early-stage Hodgkin lymphoma in the modern era: simulation modelling to delineate long-term patient outcomes

We developed a novel simulation model integrating multiple data sets to project long-term outcomes with contemporary therapy for early-stage Hodgkin lymphoma (ESHL), namely combined modality therapy (CMT) versus chemotherapy alone (CA) via ¹⁸ F-fluorodeoxyglucose positron emission tomography response-adaption. The model incorporated 3-year progression-free survival (PFS), probability of cure with/without relapse, frequency of severe late effects (LEs), and 35-year probability of LEs. Furthermore, we generated estimates for quality-adjusted life years (QALYs) and unadjusted survival (life years, LY) and used model projections to compare outcomes for CMTversusCA for two index patients. Patient 1: a 25-year-old male with favourable ESHL (stage IA); Patient 2: a 25-year-old female with unfavourable ESHL (stage IIB). Sensitivity analyses assessed the impact of alternative assumptions for LE probabilities. For Patient 1, CMT was superior to CA (CMT incremental gain = 0·11 QALYs, 0·21 LYs). For Patient 2, CA was superior to CMT (CA incremental gain = 0·37 QALYs, 0·92 LYs). For Patient 1, the advantage of CMT changed minimally when the proportion of severe LEs was reduced from 20% to 5% (0·15 QALYs, 0·43 LYs), whereas increasing the severity proportion for Patient 2's LEs from 20% to 80% enhanced the advantage of CA (1·1 QALYs, 6·5 LYs). Collectively, this detailed simulation model quantified the long-term impact that varied host factors and alternative contemporary treatments have in ESHL.

Long-term follow up of Hodgkin lymphoma

BACKGROUND

Hodgkin lymphoma (HL) is the paradigm of curable disease. This study analyzed the overall survival (OS) of patients with HL and compared their survival between decades and with the expected survival of a general population.

RESULTS

The median follow-up was 22 years. The median OS was 33 years. The incidence mortality rate for all causes is 2 per every 100 patients per year. The OS of our cohort at 10 years from diagnosis was 76% (95% CI: 72-79) and 52% at 30 years (95% CI: 48-57). Overall SMR (1980-2013) was 2,943 (95% CI: 2,518-3,439). Excluding the primary tumor as the cause of death, the SMR obtained is 2,266 (95% CI: 1,895-2,710). The SMR for those patients diagnosed before the year 2000 was 2,097 (95% CI: 1,732-2,539); and for those diagnosed after 2000 was 5,218 (95% CI: 8,655). The group of patients diagnosed after 2000 had statistically significant more advanced stages, were older and less responsive to treatment.

CONCLUSIONS

Despite the advances achieved, the risk of death remains higher than in the general population, mainly for those patients diagnosed after year 2000, even after almost 40 years of follow-up. This data might suggest a shift to more aggressive forms of disease in recent years.

PATIENTS AND METHODS

A total of 595 patients diagnosed with HL were included between January 1966 and February 2014. The standardized mortality ratio (SMR) was analyzed using the annual rate of mortality in the general Spanish population, adjusted for age, sex and time period.