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Lammers EMJ, Nijdam A, Zijlstra JM, Janus CPM, de Weijer RJ, Appelman Y, Manintveld OC, Teske AJ, van Leeuwen FE, Aleman BMP. Cardiovascular screening outcomes in the Dutch survivorship care program for Hodgkin lymphoma survivors. J Cancer Surviv 2024:10.1007/s11764-024-01561-y. [PMID: 38649650 DOI: 10.1007/s11764-024-01561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 03/02/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Hodgkin lymphoma (HL) survivors are at increased risk of cardiovascular disease (CVD) due to former lymphoma treatment. In 2013, cardiovascular screening for 5-year HL survivors according to national guidelines was implemented in Dutch survivorship clinics. We aim to assess the following: (1) adherence to screening guidelines and (2) the yield of (risk factors for) CVD in the screening program. METHODS The study population consisted of 5-year HL survivors who received survivorship care at three University Medical Centers from 2013 to 2016 through 2021. Patient characteristics, cardiovascular screening procedures, and outcomes were collected from the medical records. RESULTS In 186 survivors eligible for cardiovascular screening (mean age 47.8 years, 60.8% female), the following diagnostics were performed: complete blood tests (81.0%, median frequency: yearly instead of advised 5-yearly evaluation), electrocardiogram (93.0%), echocardiography (94.6%). Fifty-five percent of survivors had at least one modifiable cardiovascular risk factor (i.e., current smoking, overweight, new/insufficiently controlled hypertension, dyslipidemia, or diabetes). Screening detected ≥ 1 CVD in 31.1% of survivors. Among survivors with available echocardiography report (n = 106), screening detected new aortic and/or mitral valve dysfunction(s) in 51.0% (with grades 3-4 in 4.9%) and impaired left ventricular ejection fraction in 10.3%. CONCLUSIONS Adherence to the screening guidelines in the Dutch HL survivorship care program was reasonable to good and a substantial number of actionable (risk factors for) CVD were diagnosed. IMPLICATIONS FOR CANCER SURVIVORS Our findings inform HL survivors at high risk of late cardiotoxicity about cardiovascular screening findings and demonstrate appropriate therapeutic actions after diagnosis of (risk factors for) CVD.
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Affiliation(s)
- Eline M J Lammers
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annelies Nijdam
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC Location Vrije Universiteit, Cancer Centre Amsterdam, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Roel J de Weijer
- Department of Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Arco J Teske
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Neppelenbroek SIM, Geurts YM, Aleman BMP, Lugtenburg PJ, Rademakers SE, de Weijer RJ, Schippers MGA, Ta BDP, Plattel WJ, Zijlstra JM, van der Maazen RWM, Nijziel MR, Ong F, Schimmel EC, Posthuma EFM, Kersten MJ, Böhmer LH, Muller K, Koene HR, Te Boome LCJ, Bilgin YM, de Jongh E, Janus CPM, van Leeuwen FE, Schaapveld M. Doxorubicin Exposure and Breast Cancer Risk in Survivors of Adolescent and Adult Hodgkin Lymphoma. J Clin Oncol 2024:JCO2301386. [PMID: 38359378 DOI: 10.1200/jco.23.01386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/17/2023] [Accepted: 12/13/2023] [Indexed: 02/17/2024] Open
Abstract
PURPOSE Female Hodgkin lymphoma (HL) survivors treated with chest radiotherapy (RT) at a young age have a strongly increased risk of breast cancer (BC). Studies in childhood cancer survivors have shown that doxorubicin exposure may also increase BC risk. Although doxorubicin is the cornerstone of HL chemotherapy, the association between doxorubicin and BC risk has not been examined in HL survivors treated at adult ages. METHODS We assessed BC risk in a cohort of 1,964 female 5-year HL survivors, treated at age 15-50 years in 20 Dutch hospitals between 1975 and 2008. We calculated standardized incidence ratios, absolute excess risks, and cumulative incidences. Doxorubicin exposure was analyzed using multivariable Cox regression analyses. RESULTS After a median follow-up of 21.6 years (IQR, 15.8-27.1 years), 252 women had developed invasive BC or ductal carcinoma in situ. The 30-year cumulative incidence was 20.8% (95% CI, 18.2 to 23.4). Survivors treated with a cumulative doxorubicin dose of >200 mg/m2 had a 1.5-fold increased BC risk (95% CI, 1.08 to 2.1), compared with survivors not treated with doxorubicin. BC risk increased 1.18-fold (95% CI, 1.05 to 1.32) per additional 100 mg/m2 doxorubicin (Ptrend = .004). The risk increase associated with doxorubicin (yes v no) was not modified by age at first treatment (hazard ratio [HR]age <21 years, 1.5 [95% CI, 0.9 to 2.6]; HRage ≥21 years, 1.3 [95% CI, 0.9 to 1.9) or chest RT (HRwithout mantle/axillary field RT, 1.9 [95% CI, 1.06 to 3.3]; HRwith mantle/axillary field RT, 1.2 [95% CI, 0.8 to 1.8]). CONCLUSION This study shows that treatment with doxorubicin is associated with increased BC risk in both adolescent and adult HL survivors. Our results have implications for BC surveillance guidelines for HL survivors and treatment strategies for patients with newly diagnosed HL.
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Affiliation(s)
| | - Yvonne M Geurts
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Pieternella J Lugtenburg
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Saskia E Rademakers
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roel J de Weijer
- Department of Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Bastiaan D P Ta
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Wouter J Plattel
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC, Location Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Marten R Nijziel
- Catharina Cancer Institute, Department of Hemato-Oncology, Catharina Hospital, Eindhoven, the Netherlands
| | - Francisca Ong
- Department of Radiotherapy, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Erik C Schimmel
- Department of Radiotherapy, Radiotherapiegroep, Arnhem, the Netherlands
| | | | - Marie José Kersten
- Department of Hematology, Amsterdam University Medical Centers, Location University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Lara H Böhmer
- Department of Hematology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Karin Muller
- Department of Radiotherapy, Radiotherapiegroep, Deventer, the Netherlands
| | - Harry R Koene
- Department of Hematology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Liane C J Te Boome
- Department of Hematology, Haaglanden Medical Center, Den Haag, the Netherlands
| | - Yavuz M Bilgin
- Department of Internal Medicine, Admiraal De Ruyter Hospital, Goes, the Netherlands
| | - Eva de Jongh
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Cécile P M Janus
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Michael Schaapveld
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
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3
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Geurts YM, Neppelenbroek SIM, Aleman BMP, Janus CPM, Krol ADG, van Spronsen DJ, Plattel WJ, Roesink JM, Verschueren KMS, Zijlstra JM, Koene HR, Nijziel MR, Schimmel EC, de Jongh E, Ong F, Te Boome LCJ, van Rijn RS, Böhmer LH, Ta BDP, Visser HPJ, Posthuma EFM, Bilgin YM, Muller K, van Kampen D, So-Osman C, Vermaat JSP, de Weijer RJ, Kersten MJ, van Leeuwen FE, Schaapveld M. Treatment-specific risk of subsequent malignant neoplasms in five-year survivors of diffuse large B-cell lymphoma. ESMO Open 2024; 9:102248. [PMID: 38350338 PMCID: PMC10937196 DOI: 10.1016/j.esmoop.2024.102248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/10/2024] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The introduction of rituximab significantly improved the prognosis of diffuse large B-cell lymphoma (DLBCL), emphasizing the importance of evaluating the long-term consequences of exposure to radiotherapy, alkylating agents and anthracycline-containing (immuno)chemotherapy among DLBCL survivors. METHODS Long-term risk of subsequent malignant neoplasms (SMNs) was examined in a multicenter cohort comprising 2373 5-year DLBCL survivors treated at ages 15-61 years in 1989-2012. Observed SMN numbers were compared with expected cancer incidence to estimate standardized incidence ratios (SIRs) and absolute excess risks (AERs/10 000 person-years). Treatment-specific risks were assessed using multivariable Cox regression. RESULTS After a median follow-up of 13.8 years, 321 survivors developed one or more SMNs (SIR 1.5, 95% CI 1.3-1.8, AER 51.8). SIRs remained increased for at least 20 years after first-line treatment (SIR ≥20-year follow-up 1.5, 95% CI 1.0-2.2, AER 81.8) and were highest among patients ≤40 years at first DLBCL treatment (SIR 2.7, 95% CI 2.0-3.5). Lung (SIR 2.0, 95% CI 1.5-2.7, AER 13.4) and gastrointestinal cancers (SIR 1.5, 95% CI 1.2-2.0, AER 11.8) accounted for the largest excess risks. Treatment with >4500 mg/m2 cyclophosphamide/>300 mg/m2 doxorubicin versus ≤2250 mg/m2/≤150 mg/m2, respectively, was associated with increased solid SMN risk (hazard ratio 1.5, 95% CI 1.0-2.2). Survivors who received rituximab had a lower risk of subdiaphragmatic solid SMNs (hazard ratio 0.5, 95% CI 0.3-1.0) compared with survivors who did not receive rituximab. CONCLUSION Five-year DLBCL survivors have an increased risk of SMNs. Risks were higher for survivors ≤40 years at first treatment and survivors treated with >4500 mg/m2 cyclophosphamide/>300 mg/m2 doxorubicin, and may be lower for survivors treated in the rituximab era, emphasizing the need for studies with longer follow-up for rituximab-treated patients.
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Affiliation(s)
- Y M Geurts
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam
| | | | - B M P Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam
| | - C P M Janus
- Department of Radiotherapy, Erasmus Medical Centre, Rotterdam
| | - A D G Krol
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden
| | - D J van Spronsen
- Department of Hematology, Radboud University Medical Centre, Nijmegen
| | - W J Plattel
- Department of Hematology, University Medical Centre Groningen, Groningen
| | - J M Roesink
- Department of Radiotherapy, University Medical Centre Utrecht, Utrecht
| | | | - J M Zijlstra
- Department of Hematology, Amsterdam UMC location Vrije Universiteit, Cancer Centre Amsterdam, Amsterdam
| | - H R Koene
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein
| | - M R Nijziel
- Catharina Cancer Institute, Department of Hemato-Oncology, Catharina Hospital, Eindhoven
| | | | - E de Jongh
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht
| | - F Ong
- Department of Radiotherapy, Medisch Spectrum Twente, Enschede
| | - L C J Te Boome
- Department of Hematology, Haaglanden Medical Centre, The Hague
| | - R S van Rijn
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden
| | - L H Böhmer
- Department of Hematology, Haga Teaching Hospital, The Hague
| | - B D P Ta
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht
| | - H P J Visser
- Department of Hematology, Noordwest Ziekenhuisgroep Alkmaar, Alkmaar
| | - E F M Posthuma
- Department of Internal Medicine, Reinier de Graaf Hospital, Delft
| | - Y M Bilgin
- Department of Internal Medicine, ADRZ, Goes
| | | | - D van Kampen
- Zuidwest Radiotherapeutisch Instituut, Vlissingen
| | - C So-Osman
- Department of Hematology, Erasmus Medical Centre, Rotterdam; Unit Transfusion Medicine, Sanquin Blood Supply Foundation, Amsterdam
| | - J S P Vermaat
- Department of Hematology, Leiden University Medical Centre, Leiden
| | - R J de Weijer
- Department of Hematology, University Medical Centre Utrecht, Utrecht
| | - M J Kersten
- Department of Hematology, Amsterdam UMC location University of Amsterdam, Cancer Centre Amsterdam and LYMMCARE, Amsterdam, The Netherlands
| | - F E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam
| | - M Schaapveld
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam.
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Aleman BMP, Ricardi U, van der Maazen RWM, Meijnders P, Beijert M, Boros A, Izar F, Janus CPM, Levis M, Martin V, Specht L, Corning C, Clementel E, Raemaekers JM, André MP, Federico M, Fortpied C, Girinsky T. A Quality Control Study on Involved Node Radiation Therapy in the European Organisation for Research and Treatment of Cancer/Lymphoma Study Association/Fondazione Italiana Linfomi H10 Trial on Stages I and II Hodgkin Lymphoma: Lessons Learned. Int J Radiat Oncol Biol Phys 2023; 117:664-674. [PMID: 37179034 DOI: 10.1016/j.ijrobp.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/29/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Involved node radiation therapy (INRT) was introduced in the European Organisation for Research and Treatment of Cancer/Lymphoma Study Association/Fondazione Italiana Linfomi H10 trial, a large multicenter trial in early-stage Hodgkin Lymphoma. The present study aimed to evaluate the quality of INRT in this trial. METHODS AND MATERIALS A retrospective, descriptive study was initiated to evaluate INRT in a representative sample encompassing approximately 10% of all irradiated patients in the H10 trial. Sampling was stratified by academic group, year of treatment, size of the treatment center, and treatment arm, and it was done proportional to the size of the strata. The sample was completed for all patients with known recurrences to enable future research on relapse patterns. Radiation therapy principle, target volume delineation and coverage, and applied technique and dose were evaluated using the EORTC Radiation Therapy Quality Assurance platform. Each case was reviewed by 2 reviewers and, in case of disagreement also by an adjudicator for a consensus evaluation. RESULTS Data were retrieved for 66 of 1294 irradiated patients (5.1%). Data collection and analysis were hampered more than anticipated by changes in archiving of diagnostic imaging and treatment planning systems during the running period of the trial. A review could be performed on 61 patients. The INRT principle was applied in 86.6%. Overall, 88.5% of cases were treated according to protocol. Unacceptable variations were predominately due to geographic misses of the target volume delineations. The rate of unacceptable variations decreased during trial recruitment. CONCLUSIONS The principle of INRT was applied in most of the reviewed patients. Almost 90% of the evaluated patients were treated according to the protocol. The present results should, however, be interpreted with caution because the number of patients evaluated was limited. Individual case reviews should be done in a prospective fashion in future trials. Radiation therapy Quality Assurance tailored to the clinical trial objectives is strongly recommended.
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Affiliation(s)
- Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands.
| | | | | | - Paul Meijnders
- Department of Radiotherapy, Iridium Network, Centre for Oncological Research of the University of Antwerp, Antwerp, Belgium
| | - Max Beijert
- Department of Radiotherapy, University Medical Center Groningen, Groningen, Netherlands
| | - Angela Boros
- Radiation Oncology Department, Center Hospitalier Lyon Sud, Pierre Benite, France
| | - Françoise Izar
- Department of Radiotherapy, Institut universitaire du cancer de Toulouse, Toulouse, France
| | - Cécile P M Janus
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mario Levis
- Department of Oncology, University of Turin, Turin, Italy
| | - Valentine Martin
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Coreen Corning
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Enrico Clementel
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - John M Raemaekers
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, Netherlands
| | - Marc P André
- Department of Hematology, CHU UCL Namur, Yvoir, Belgium
| | - Massimo Federico
- CHIMOMO Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Catherine Fortpied
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Theodore Girinsky
- Department of Radiotherapy, Institut Gustave Roussy, Villejuif, France
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5
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Harmeling JX, Woerdeman LAE, Ozdemir E, Schaapveld M, Oldenburg HSA, Janus CPM, Russell NS, Koppert LB, Krul IM, van Leeuwen FE, Mureau MAM. Surgical outcomes following breast reconstruction in patients with and without a history of chest radiotherapy for Hodgkin lymphoma: a multicentre, matched cohort study. Int J Surg 2023; 109:2896-2905. [PMID: 37037583 PMCID: PMC10583922 DOI: 10.1097/js9.0000000000000063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/12/2022] [Indexed: 04/12/2023]
Abstract
BACKGROUND Breast cancer is the most common treatment-related second malignancy among women with previous chest radiotherapy for Hodgkin lymphoma (HL). Little is known about the effects of this kind of radiotherapy on the outcomes of postmastectomy breast reconstruction (BR). This study compared adverse outcomes of BR after HL-related chest radiotherapy to matched controls. METHODS The authors conducted a retrospective, matched cohort study in two expert cancer centres in the Netherlands. BRs after therapeutic or prophylactic mastectomy in HL survivors who received chest radiotherapy were matched with BRs in nonirradiated patients without HL on age at mastectomy date, date of BR, and type of BR. The primary outcome was complication-related BR failure or conversion and secondary outcomes were complication-related re-operation, capsular contracture, major donor-site complications, and complication-related ICU admission. The authors analyzed all outcomes univariably using Fisher's exact tests and the authors assessed reconstruction failure, complication-related re-operation, and capsular contracture with multivariable Cox regression analysis adjusting for confounding and data clustering. RESULTS Seventy BRs in 41 patients who received chest radiotherapy for HL were matched to 121 BRs in 110 nonirradiated patients. Reconstruction failure did not differ between HL survivors (12.9%) and controls (12.4%). The comparison groups showed no differences in number of reoperations, major donor-site complications, or capsular contractures. BR in HL survivors more often let to ICU admission due to complications compared with controls ( P =0.048). CONCLUSIONS We observed no increased risk of adverse outcomes following BR after previous chest radiotherapy for HL. This is important information for counselling these patients and may improve shared decision-making.
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Affiliation(s)
| | | | - Ezgi Ozdemir
- Departments of Plastic and Reconstructive Surgery
| | - Michael Schaapveld
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Cécile P M Janus
- Radiation Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam
| | | | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC, Rotterdam
| | - Inge M Krul
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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6
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Juul SJ, Kicinski M, Schaapveld M, Rossetti S, Aleman BMP, Liu L, van Leeuwen FE, Meijnders P, Krol ADG, Janus CPM, Hutchings M, Maraldo MV. Comparison of outcomes between Hodgkin's lymphoma patients treated in and outside clinical trials: A study based on the EORTC-Dutch late effects cohort-linked data. Eur J Haematol 2023; 110:243-252. [PMID: 36369842 PMCID: PMC10098896 DOI: 10.1111/ejh.13899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022]
Abstract
Studies have shown higher survival rates for patients with Hodgkin lymphoma (HL) treated within clinical trials compared to patients treated outside clinical trials. However, endpoints are often limited to overall survival (OS). In this retrospective cohort study, we investigated the effect of trial participation on OS, the incidence of relapse, second cancer, and cardiovascular disease (CVD). The study population consisted of patients with HL, aged between 14 and 51 years at diagnosis, who started their treatment between 1962 and 2002 at three Dutch cancer centres. Patients were either included in the EORTC Lymphoma Group trials (H1-H9) or treated according to standard guidelines at the time. After adjusting for differences in baseline characteristics, trial participation was associated with longer OS (median OS: 29.4 years [95%CI: 27.0-31.6] for treatment inside trials versus 27.4 years [95%CI: 26.0-28.5] for treatment outside trials, p = .046), a lower incidence of relapse (HR = 0.79, 95%CI: 0.63-0.98, p = .036) and a higher incidence of CVD (HR = 1.49, 95%CI: 1.23-1.79, p < .001). The trial effect for CVD was present only for patients treated before 1983. No evidence of differences in the incidence of second cancer was found. Consequently, essential results from clinical trials should be implemented into standard practice without undue delay.
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Affiliation(s)
| | | | - Michael Schaapveld
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sára Rossetti
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Flora E van Leeuwen
- Department of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paul Meijnders
- Department of Radiation Oncology, Iridium Network, University of Antwerp, Antwerpen, Belgium
| | - Augustinus D G Krol
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Maja V Maraldo
- Department of Oncology, Rigshospitalet, Copenhagen, Denmark
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7
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Aleman BMP, Krul IM, Janus CPM, van der Maazen RWM, van Leeuwen FE. Reply to "Can we avoid thoracic radiotherapy in young females with Hodgkin lymphoma?". Cancer 2023; 129:1455-1456. [PMID: 36827428 DOI: 10.1002/cncr.34713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 01/23/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Inge M Krul
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus University MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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8
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Geurts YM, Shakir R, Ntentas G, Roberti S, Aznar MC, John KM, Ramroth J, Janus CPM, Krol ADG, Roesink JM, van der Maazen RWM, Zijlstra JM, Darby SC, Aleman BMP, van Leeuwen FE, Cutter DJ, Schaapveld M. Association of Radiation and Procarbazine Dose With Risk of Colorectal Cancer Among Survivors of Hodgkin Lymphoma. JAMA Oncol 2023; 9:481-489. [PMID: 36729438 PMCID: PMC9896374 DOI: 10.1001/jamaoncol.2022.7153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Importance Hodgkin lymphoma (HL) survivors have higher rates of colorectal cancer, which may be associated with subdiaphragmatic radiation therapy and/or alkylating chemotherapy. Although radiation dose-response associations with breast, lung, stomach, pancreatic, and esophageal cancer after HL have been demonstrated, the association of radiation therapy with colorectal cancer remains unclear. Objective To quantify the rate of colorectal cancer according to radiation dose to the large bowel and procarbazine dose among HL survivors. Design, Setting, and Participants A nested case-control study examined 5-year HL survivors at 5 hospital centers in the Netherlands. Participants had been diagnosed with HL in 1964 to 2000, when they were 15 to 50 years of age, and were followed for a median of approximately 26 years. Survivors of HL who developed colorectal cancer and survivors who were selected as controls were individually matched on sex, age at HL diagnosis, and date of HL diagnosis. Data were analyzed from July 2021 to October 2022. Exposures Mean radiation doses to the large bowel were estimated by reconstructing individual radiation therapy treatments on representative computed tomography data sets. Main Outcomes and Measures Excess rate ratios (ERRs) were modeled to evaluate the excess risk associated with each 1-gray increase in radiation dose, and potential effect modification by procarbazine was explored. Results The study population included 316 participants (mean [SD] age at HL diagnosis, 33.0 [9.8] years; 221 [69.9%] men), 78 of whom were HL survivors who developed colorectal cancer (cases) and 238 who did not (controls). The median (IQR) interval between HL and colorectal cancer was 25.7 (18.2-31.6) years. Increased colorectal cancer rates were seen for patients who received subdiaphragmatic radiation therapy (rate ratio [RR], 2.4; 95% CI, 1.4-4.1) and those who received more than 8.4 g/m2 procarbazine (RR, 2.5; 95% CI, 1.3-5.0). Overall, colorectal cancer rate increased linearly with mean radiation dose to the whole large bowel and dose to the affected bowel segment. The association between radiation dose and colorectal cancer rate became stronger with increasing procarbazine dose: the ERR per gray to the whole bowel was 3.5% (95% CI, 0.4%-12.6%) for patients who did not receive procarbazine, and increased 1.2-fold (95% CI, 1.1-1.3) for each 1-g/m2 increase in procarbazine dose. Conclusions and Relevance This nested case-control study of 5-year HL survivors found a dose-response association between radiation therapy and colorectal cancer risk, and modification of this association by procarbazine. These findings may enable individualized colorectal cancer risk estimations, identification of high-risk survivors for subsequent screening, and optimization of treatment strategies.
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Affiliation(s)
- Yvonne M. Geurts
- Department of Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Rebecca Shakir
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, UK,Department of Medical Physics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK,School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Sander Roberti
- Department of Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marianne C. Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine, and Health, University of Manchester, Manchester, UK
| | - Katinka M. John
- Department of Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Johanna Ramroth
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Cécile P. M. Janus
- Department of Radiotherapy, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Augustinus D. G. Krol
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Judith M. Roesink
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Josée M. Zijlstra
- Department of Hematology, Amsterdam University Medical Center, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Sarah C. Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Berthe M. P. Aleman
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Flora E. van Leeuwen
- Department of Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - David J. Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK,Oxford Cancer and Hematology Center, Oxford University Hospitals National Health Service Foundation Trust, Churchill Hospital, Oxford, UK
| | - Michael Schaapveld
- Department of Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands
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9
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Krul IM, Boekel NB, Kramer I, Janus CPM, Krol ADG, Nijziel MR, Zijlstra JM, van der Maazen RWM, Roesink JM, Jacobse JN, Schaapveld M, Schmidt MK, Opstal-van Winden AWJ, Sonke GS, Russell NS, Aleman BMP, van Leeuwen FE. Breast cancer and cardiovascular outcomes after breast cancer in survivors of Hodgkin lymphoma. Cancer 2022; 128:4285-4295. [PMID: 36281718 DOI: 10.1002/cncr.34464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 02/25/2022] [Accepted: 03/24/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hodgkin lymphoma (HL) survivors treated with chest radiotherapy have an increased risk of breast cancer (BC). Prior HL treatment and associated cardiovascular disease (CVD) risk may limit BC treatment options. It is unknown how treatment adaptations affect BC and CVD outcomes. METHODS The authors compared 195 BC patients treated with chest/axillary radiotherapy for HL (BC-HL) with 5988 age- and calendar year-matched patients with first primary BC (BC-1). Analyses included cumulative incidence functions and Cox regression models, accounting for tumor characteristics and BC treatment. RESULTS Compared to BC-1 patients, BC-HL patients received anthracycline-containing chemotherapy (23.7% vs. 43.8%, p < .001) and breast-conserving surgery followed by radiotherapy (7.1% vs. 57.7%, p < .001) less often. BC treatment considerations were reported for 71% of BC-HL patients. BC-HL patients had a significantly higher risk of 15-year overall mortality than BC-1 patients (61% vs. 23%). Furthermore, risks of BC-specific mortality and nonfatal BC events were significantly increased among BC-HL patients, also when accounting for tumor and treatment characteristics (2.2- to 4.5-fold). BC-HL patients with a screen-detected BC had a significantly reduced (61%) BC-specific mortality. One-third of BC-HL patients had CVD at BC-diagnosis, compared to <0.1% of BC-1 patients. Fifteen-year CVD-specific mortality and CVD incidence were significantly higher in BC-HL patients than in BC-1 patients (15.2% vs. 0.4% and 40.4% vs. 6.8%, respectively), which was due to HL treatment rather than BC treatment. CONCLUSIONS BC-HL patients experience a higher burden of CVD and worse BC outcomes than BC-1 patients. Clinicians should be aware of increased CVD risk when selecting BC treatment for HL survivors. LAY SUMMARY Patients with breast cancer after Hodgkin lymphoma (BC-HL) may have limited options for BC treatment, due to earlier HL treatment and an associated increased risk of cardiovascular disease (CVD). BC treatment considerations were reported for 71% of BC-HL patients. We examined whether BC-HL patients have a higher risk of CVD or BC events (recurrences/metastases) compared to patients with breast cancer that had no earlier tumors (BC-1). We observed a higher burden of CVD and worse BC outcomes in HL patients compared to BC-1 patients. Clinicians should be aware of increased CVD risk when selecting BC treatment for HL survivors.
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Affiliation(s)
- Inge M Krul
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Naomi B Boekel
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Iris Kramer
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus University MC Cancer Institute, Rotterdam, The Netherlands
| | - Augustinus D G Krol
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Marten R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Judith M Roesink
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Judy N Jacobse
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michael Schaapveld
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marjanka K Schmidt
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Gabe S Sonke
- Medical Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Nicola S Russell
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
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10
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Roberti S, van Leeuwen FE, Ronckers CM, Krul IM, de Vathaire F, Veres C, Diallo I, Janus CPM, Aleman BMP, Russell NS, Hauptmann M. Radiotherapy-related dose and irradiated volume effects on breast cancer risk among Hodgkin lymphoma survivors. J Natl Cancer Inst 2022; 114:1270-1278. [PMID: 35771630 PMCID: PMC9468297 DOI: 10.1093/jnci/djac125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/05/2022] [Accepted: 06/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Breast cancer (BC) risk is increased among Hodgkin lymphoma (HL) survivors treated with chest radiotherapy. Case-control studies showed a linear radiation dose-response relationship for estimated dose to the breast tumor location. However, these relative risks cannot be used for absolute risk prediction of BC anywhere in the breasts. Furthermore, the independent and joint effects of radiation dose and irradiated volumes are unclear. Therefore, we examined the effects of mean breast dose and various dose-volume parameters on BC risk in HL patients. Methods We conducted a nested case-control study of BC among 5-year HL survivors (173 case patients, 464 matched control patients). Dose-volume histograms were obtained from reconstructed voxel-based 3-dimensional dose distributions. Summary parameters of dose-volume histograms were studied next to mean and median breast dose, Gini index, and the new dose metric mean absolute difference of dose, using categorical and linear excess odds ratio (EOR) models. Interactions between dose-volume parameters and mean dose were also examined. Results Statistically significant linear dose-response relationships were observed for mean breast dose (EOR per Gy = 0.19, 95% confidence interval [CI] = 0.05 to 1.06) and median dose (EOR/Gy = 0.06, 95% CI = 0.02 to 0.19), with no statistically significant curvature. All metrics except Gini and mean absolute difference were positively correlated with each other. These metrics all showed similar patterns of dose-response that were no longer statistically significant when adjusting for mean dose. No statistically significant modification of the effect of mean dose was observed. Conclusion Mean breast dose predicts subsequent BC risk in long-term HL survivors.
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Affiliation(s)
- Sander Roberti
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cécile M Ronckers
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Inge M Krul
- Department of Epidemiology and Biostatistics, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Florent de Vathaire
- Radiation Epidemiology Team, Center for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France.,Research Department, Gustave Roussy, Villejuif, France.,University Paris Saclay, Villejuif, France
| | - Cristina Veres
- University Paris Saclay, Villejuif, France.,Molecular Radiation Therapy and Therapeutic Innovation, INSERM U1030, Villejuif, France.,Radiation Oncology Department, Gustave Roussy, Villejuif, France
| | - Ibrahima Diallo
- University Paris Saclay, Villejuif, France.,Molecular Radiation Therapy and Therapeutic Innovation, INSERM U1030, Villejuif, France.,Radiation Oncology Department, Gustave Roussy, Villejuif, France
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Nicola S Russell
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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11
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Van Der Velde N, Janus CPM, Bowen DJ, Hassing HC, Kardys I, Van Leeuwen FE, So-Osman C, Nout RA, Manintveld OC, Hirsch A. Cardiovascular magnetic resonance for early detection of late cardiotoxicity in asymptomatic survivors of hodgkin and non-hodgkin lymphoma. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Long-term survivors of Hodgkin (HL) and non-Hodgkin (NHL) lymphomas experience late adverse effects of mediastinal radiotherapy and/or anthracycline containing chemotherapy, which lead to premature cardiovascular morbidity and mortality. It is unknown whether early stages of myocardial dysfunction and heart failure in these survivors can be detected by cardiovascular magnetic resonance imaging (CMR).
Purpose
To identify early sensitive markers for the detection of subclinical late cardiotoxicity using CMR in asymptomatic survivors of HL and (primary mediastinal large B-cell lymphoma) NHL.
Methods
For this prospective observational study, we included 80 HL or selected NHL survivors, who have been free of disease for ≥5 years and were treated with mediastinal radiotherapy (RT) with/without chemotherapy. Patients with known cardiac disease were excluded. Included patients were compared to 40 age- and sex matched healthy controls. CMR included 1) cine imaging for assessment of left ventricular (LV) and right ventricular (RV) dimensions, systolic function and strain; 2) 2-dimensional late gadolinium enhancement (LGE) imaging; 3) T2 mapping and 4) pre- and post-contrast T1 mapping (MOLLI) for assessment of native T1 values and extracellular volume (ECV).
Results
Of the 80 patients, 78 (98%) had a history of HL and 2 (2%) of NHL with a mean age of 47 ± 11 years (46% male). All patients were treated with mediastinal RT which was combined with anthracycline containing chemotherapy in 68 (85%) patients. The median interval between diagnosis and CMR was 20 [14 – 26] years. Differences in CMR characteristics between patients and healthy controls are shown in the table. LV end-systolic volume was statistically significantly higher, but LV ejection fraction and mass were significantly lower in patients compared to healthy controls. RV volumes were significantly lower in patients, but RV ejection fraction was preserved. Strain parameters of the LV, i.e. global longitudinal strain, global circumferential strain and global radial strain, were slightly but significantly reduced in patients. No significant differences were found in myocardial T2 times and ECV; however, native myocardial T1 time was significantly higher in patients compared to healthy controls. LGE was detected in 25% of the patients and in the majority of patients with LGE this was classified as hinge point fibrosis.
Conclusion
Asymptomatic survivors of HL and NHL are not exempt of late cardiotoxicity, which can be detected by subtle changes in LV myocardial function, strain and native T1 value with CMR. Furthermore, late gadolinium enhancement was present in 25% of the patients. Further longitudinal studies are needed to assess the implication of these changes in relation to clinical outcome.
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Affiliation(s)
- N Van Der Velde
- Erasmus University Medical Centre, Cardiology and Radiology, Rotterdam, Netherlands (The)
| | - CPM Janus
- Erasmus University Medical Centre, Radiation Oncology, Rotterdam, Netherlands (The)
| | - DJ Bowen
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - HC Hassing
- Erasmus University Medical Centre, Cardiology and Radiology, Rotterdam, Netherlands (The)
| | - I Kardys
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - FE Van Leeuwen
- Netherlands Cancer Institute, Psychosocial Research and Epidemiology, Amsterdam, Netherlands (The)
| | - C So-Osman
- Erasmus University Medical Centre, Hematology, Rotterdam, Netherlands (The)
| | - RA Nout
- Erasmus University Medical Centre, Radiation Oncology, Rotterdam, Netherlands (The)
| | - OC Manintveld
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - A Hirsch
- Erasmus University Medical Centre, Cardiology and Radiology, Rotterdam, Netherlands (The)
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12
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de Vries S, Schaapveld M, Janus CPM, Daniëls LA, Petersen EJ, van der Maazen RWM, Zijlstra JM, Beijert M, Nijziel MR, Verschueren KMS, Kremer LCM, van Eggermond AM, Lugtenburg PJ, Krol ADG, Roesink JM, Plattel WJ, van Spronsen DJ, van Imhoff GW, de Boer JP, Aleman BMP, van Leeuwen FE. Long-Term Cause-Specific Mortality in Hodgkin Lymphoma Patients. J Natl Cancer Inst 2020; 113:760-769. [PMID: 33351090 PMCID: PMC8168246 DOI: 10.1093/jnci/djaa194] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/26/2020] [Accepted: 10/14/2020] [Indexed: 12/28/2022] Open
Abstract
Background Few studies have examined the impact of treatment-related morbidity on long-term, cause-specific mortality in Hodgkin lymphoma (HL) patients. Methods This multicenter cohort included 4919 HL patients, treated before age 51 years between 1965 and 2000, with a median follow-up of 20.2 years. Standardized mortality ratios, absolute excess mortality (AEM) per 10 000 person-years, and cause-specific cumulative mortality by stage and primary treatment, accounting for competing risks, were calculated. Results HL patients experienced a 5.1-fold (AEM = 123 excess deaths per 10 000 person-years) higher risk of death due to causes other than HL. This risk remained increased in 40-year survivors (standardized mortality ratio = 5.2, 95% confidence interval [CI] = 4.2 to 6.5, AEM = 619). At age 54 years, HL survivors experienced similar cumulative mortality (20.0%) from causes other than HL to 71-year-old individuals from the general population. Whereas HL mortality statistically significantly decreased over the calendar period (P < .001), solid tumor mortality did not change in the most recent treatment era. Patients treated in 1989-2000 had lower 25-year cardiovascular disease mortality than patients treated in 1965-1976 (4.3% vs 5.7%; subdistribution hazard ratio = 0.65, 95% CI = 0.46 to 0.93). Infectious disease mortality was not only increased after splenectomy but also after spleen irradiation (hazard ratio = 2.81, 95% CI = 1.55 to 5.07). For stage I-II, primary treatment with chemotherapy (CT) alone was associated with statistically significantly higher HL mortality (P < .001 for CT vs radiotherapy [RT]; P = .04 for CT vs RT+CT) but lower 30-year mortality from causes other than HL (15.8%, 95% CI = 9.7% to 23.3%) compared with RT alone (36.9%, 95% CI = 34.0% to 39.8%, P = .001) and RT and CT combined (29.8%, 95% CI = 26.8% to 32.9%, P = .02). Conclusions Compared with the general population, HL survivors have a substantially reduced life expectancy. Optimal selection of patients for primary CT is crucial, weighing risks of HL relapse and long-term toxicity.
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Affiliation(s)
- Simone de Vries
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Michael Schaapveld
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Laurien A Daniëls
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eefke J Petersen
- Department of Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Josée M Zijlstra
- Department of Hematology, Amsterdam University Medical Centers, Vrije Universiteit, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Max Beijert
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Marten R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Leontien C M Kremer
- Late Effects Research Group, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Anna M van Eggermond
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Augustinus D G Krol
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Judith M Roesink
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wouter J Plattel
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Gustaaf W van Imhoff
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - Jan Paul de Boer
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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13
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Opstal-van Winden AWJ, de Haan HG, Hauptmann M, Schmidt MK, Broeks A, Russell NS, Janus CPM, Krol ADG, van der Baan FH, De Bruin ML, van Eggermond AM, Dennis J, Anton-Culver H, Haiman CA, Sawyer EJ, Cox A, Devilee P, Hooning MJ, Peto J, Couch FJ, Pharoah P, Orr N, Easton DF, Aleman BMP, Strong LC, Bhatia S, Cooke R, Robison LL, Swerdlow AJ, van Leeuwen FE. Genetic susceptibility to radiation-induced breast cancer after Hodgkin lymphoma. Blood 2019; 133:1130-1139. [PMID: 30573632 PMCID: PMC6405334 DOI: 10.1182/blood-2018-07-862607] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022] Open
Abstract
Female Hodgkin lymphoma (HL) patients treated with chest radiotherapy (RT) have a very high risk of breast cancer. The contribution of genetic factors to this risk is unclear. We therefore examined 211 155 germline single-nucleotide polymorphisms (SNPs) for gene-radiation interaction on breast cancer risk in a case-only analysis including 327 breast cancer patients after chest RT for HL and 4671 first primary breast cancer patients. Nine SNPs showed statistically significant interaction with RT on breast cancer risk (false discovery rate, <20%), of which 1 SNP in the PVT1 oncogene attained the Bonferroni threshold for statistical significance. A polygenic risk score (PRS) composed of these SNPs (RT-interaction-PRS) and a previously published breast cancer PRS (BC-PRS) derived in the general population were evaluated in a case-control analysis comprising the 327 chest-irradiated HL patients with breast cancer and 491 chest-irradiated HL patients without breast cancer. Patients in the highest tertile of the RT-interaction-PRS had a 1.6-fold higher breast cancer risk than those in the lowest tertile. Remarkably, we observed a fourfold increased RT-induced breast cancer risk in the highest compared with the lowest decile of the BC-PRS. On a continuous scale, breast cancer risk increased 1.4-fold per standard deviation of the BC-PRS, similar to the effect size found in the general population. This study demonstrates that genetic factors influence breast cancer risk after chest RT for HL. Given the high absolute breast cancer risk in radiation-exposed women, these results can have important implications for the management of current HL survivors and future patients.
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Affiliation(s)
| | | | | | - Marjanka K Schmidt
- Department of Epidemiology and Biostatistics
- Division of Molecular Pathology
| | - Annegien Broeks
- Division of Molecular Pathology, Core Facility Molecular Pathology and Biobanking, and
| | - Nicola S Russell
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Augustinus D G Krol
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marie L De Bruin
- Department of Epidemiology and Biostatistics
- Copenhagen Centre for Regulatory Science (CORS), University of Copenhagen, Copenhagen, Denmark
| | | | - Joe Dennis
- Center for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Hoda Anton-Culver
- Department of Epidemiology, University of California Irvine, Irvine, CA
| | - Christopher A Haiman
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Elinor J Sawyer
- Innovation Hub, Guy's Cancer Centre, King's College London, London, United Kingdom
| | - Angela Cox
- Sheffield Cancer Research, Department of Oncology, University of Sheffield, Sheffield, United Kingdom
| | - Peter Devilee
- Department of Pathology and
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje J Hooning
- Department of Medical Oncology, Family Cancer Clinic, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Julian Peto
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Fergus J Couch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Paul Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Oncology, and
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Nick Orr
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, London, United Kingdom
| | - Douglas F Easton
- Center for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- Centre for Cancer Genetic Epidemiology, Department of Oncology, and
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Rosie Cooke
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN; and
| | - Anthony J Swerdlow
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
- Division of Breast Cancer Research, The Institute of Cancer Research, London, United Kingdom
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14
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Krul IM, Opstal-van Winden AWJ, Aleman BMP, Janus CPM, van Eggermond AM, De Bruin ML, Hauptmann M, Krol ADG, Schaapveld M, Broeks A, Kooijman KR, Fase S, Lybeert ML, Zijlstra JM, van der Maazen RWM, Kesminiene A, Diallo I, de Vathaire F, Russell NS, van Leeuwen FE. Breast Cancer Risk After Radiation Therapy for Hodgkin Lymphoma: Influence of Gonadal Hormone Exposure. Int J Radiat Oncol Biol Phys 2017; 99:843-853. [PMID: 28888722 DOI: 10.1016/j.ijrobp.2017.07.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/09/2017] [Accepted: 07/11/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Young women treated with chest radiation therapy (RT) for Hodgkin lymphoma (HL) experience a strongly increased risk of breast cancer (BC). It is unknown whether endogenous and exogenous gonadal hormones affect RT-associated BC risk. METHODS We conducted a nested case-control study among female 5-year HL survivors treated before age 41. Hormone exposure and HL treatment data were collected through medical records and questionnaires for 174 BC case patients and 466 control patients. Radiation dose to breast tumor location was estimated based on RT charts, simulation films, and mammography reports. RESULTS We observed a linear radiation dose-response curve with an adjusted excess odds ratio (EOR) of 6.1%/Gy (95% confidence interval [CI]: 2.1%-15.4%). Women with menopause <30 years (caused by high-dose procarbazine or pelvic RT) had a lower BC risk (OR, 0.13; 95% CI, 0.03-0.51) than did women with menopause ≥50 years. BC risk increased by 6.4% per additional year of post-RT intact ovarian function (P<.001). Among women with early menopause (<45 years), hormone replacement therapy (HRT) use for ≥2 years did not increase BC risk (OR, 0.86; 95% CI, 0.32-2.32), whereas this risk was nonsignificantly increased among women without early menopause (OR, 3.69; 95% CI, 0.97-14.0; P for interaction: .06). Stratification by duration of post-RT intact ovarian function or HRT use did not statistically significantly modify the radiation dose-response curve. CONCLUSIONS BC risk in female HL survivors increases linearly with radiation dose. HRT does not appear to increase BC risk for HL survivors with therapy-induced early menopause. There are no indications that endogenous and exogenous gonadal hormones affect the radiation dose-response relationship.
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Affiliation(s)
- Inge M Krul
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus University MC Cancer Institute, Rotterdam, The Netherlands
| | - Anna M van Eggermond
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marie L De Bruin
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands and Copenhagen Centre for Regulatory Science, University of Copenhagen, Copenhagen, Denmark
| | - Michael Hauptmann
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Augustinus D G Krol
- Department of Radiotherapy, Leiden University Medical Center, Leiden, The Netherlands
| | - Michael Schaapveld
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Annegien Broeks
- Division of Molecular Pathology, Core Facility Molecular Pathology and Biobanking, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Karen R Kooijman
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sandra Fase
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marnix L Lybeert
- Department of Radiotherapy, Catharina Hospital, Eindhoven, The Netherlands
| | - Josée M Zijlstra
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Ausrele Kesminiene
- Section of Environment and Radiation, International Agency for Research on Cancer, Lyon, France
| | - Ibrahima Diallo
- Cancer and Radiation Team, Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Medicale Unit 1018, Villejuif, France
| | - Florent de Vathaire
- Cancer and Radiation Team, Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Medicale Unit 1018, Villejuif, France
| | - Nicola S Russell
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Krul IM, Opstal - van Winden AWJ, Aleman BMP, Janus CPM, van Eggermond AM, de Bruin ML, Hauptmann M, Krol ADG, Schaapveld M, Broeks A, Kooijman KR, Fase S, Lybeert ML, Zijlstra JM, van der Maazen RWM, Kesminiene A, Diallo I, de Vathaire F, Russell NS, van Leeuwen FE. Abstract P2-06-04: Breast cancer after Hodgkin lymphoma: Influence of endogenous and exogenous gonadal hormones on the radiation dose-response relationship. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p2-06-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
After chest radiotherapy (RT) for Hodgkin lymphoma (HL), women experience a dose-dependent increased breast cancer (BC) risk. It is unknown whether endogenous and exogenous gonadal hormones affect the radiation dose-response relationship.
Methods
We conducted a nested case-control study among female 5-year HL survivors treated before 41 years between 1965-2000. Data were collected through medical records and questionnaires for 174 BC cases and 466 matched controls. RT charts, simulation films and mammography reports were used to estimate the radiation dose to the location of the breast tumor.
Results
The median interval between HL and BC diagnosis was 21.9 years. 98% of BC cases had received chest RT, compared to 92% of controls. We observed a linear radiation dose-response curve with an adjusted excess odd ratio (EOR) of 5.4%/Gray (95%CI:1.8%-13.37%). Women with menopause <30 years (caused by high-dose procarbazine or pelvic RT) had a lower BC risk (OR:0.13, 95%CI:0.03-0.54) than women with menopause ≥50 years. BC risk increased with 7.4% for each additional year of intact ovarian function after RT (P<0.001). Among women with an early menopause (<45 years), the use of hormone replacement therapy (HRT) for ≥2 years did not increase BC risk (OR:0.81, 95%CI:0.30-2.21). Endogenous and exogenous hormones did not statistically significantly modify the slope of the radiation dose-response relationship.
Conclusion
HRT use did not appear to increase BC risk in female HL survivors with a therapy-induced early menopause. Moreover, there was no evidence for interaction between RT dose and years with intact ovarian function or HRT use.
Citation Format: Krul IM, Opstal - van Winden AWJ, Aleman BMP, Janus CPM, van Eggermond AM, de Bruin ML, Hauptmann M, Krol ADG, Schaapveld M, Broeks A, Kooijman KR, Fase S, Lybeert ML, Zijlstra JM, van der Maazen RWM, Kesminiene A, Diallo I, de Vathaire F, Russell NS, van Leeuwen FE. Breast cancer after Hodgkin lymphoma: Influence of endogenous and exogenous gonadal hormones on the radiation dose-response relationship [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-06-04.
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Affiliation(s)
- IM Krul
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - AWJ Opstal - van Winden
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - BMP Aleman
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - CPM Janus
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - AM van Eggermond
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - ML de Bruin
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - M Hauptmann
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - ADG Krol
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - M Schaapveld
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - A Broeks
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - KR Kooijman
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - S Fase
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - ML Lybeert
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - JM Zijlstra
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - RWM van der Maazen
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - A Kesminiene
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - I Diallo
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - F de Vathaire
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - NS Russell
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
| | - FE van Leeuwen
- Netherlands Cancer Institute, Amsterdam, Netherlands; Erasmus University MC Cancer Institute, Rotterdam, Netherlands; Utrecht University, Utrecht, Netherlands; Leiden University Medical Center, Leiden, Netherlands; Catharina Hospital, Eindhoven, Netherlands; VU University Medical Center, Amsterdam, Netherlands; Radboud University Medical Center, Nijmegen, Netherlands; International Agency for Research on Cancer, Lyon, France; Institut Gustave Roussy, Villejuif, France
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Schaapveld M, Aleman BMP, van Eggermond AM, Janus CPM, Krol ADG, van der Maazen RWM, Roesink J, Raemaekers JMM, de Boer JP, Zijlstra JM, van Imhoff GW, Petersen EJ, Poortmans PMP, Beijert M, Lybeert ML, Mulder I, Visser O, Louwman MWJ, Krul IM, Lugtenburg PJ, van Leeuwen FE. Second Cancer Risk Up to 40 Years after Treatment for Hodgkin's Lymphoma. N Engl J Med 2015; 373:2499-511. [PMID: 26699166 DOI: 10.1056/nejmoa1505949] [Citation(s) in RCA: 400] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Survivors of Hodgkin's lymphoma are at increased risk for treatment-related subsequent malignant neoplasms. The effect of less toxic treatments, introduced in the late 1980s, on the long-term risk of a second cancer remains unknown. METHODS We enrolled 3905 persons in the Netherlands who had survived for at least 5 years after the initiation of treatment for Hodgkin's lymphoma. Patients had received treatment between 1965 and 2000, when they were 15 to 50 years of age. We compared the risk of a second cancer among these patients with the risk that was expected on the basis of cancer incidence in the general population. Treatment-specific risks were compared within the cohort. RESULTS With a median follow-up of 19.1 years, 1055 second cancers were diagnosed in 908 patients, resulting in a standardized incidence ratio (SIR) of 4.6 (95% confidence interval [CI], 4.3 to 4.9) in the study cohort as compared with the general population. The risk was still elevated 35 years or more after treatment (SIR, 3.9; 95% CI, 2.8 to 5.4), and the cumulative incidence of a second cancer in the study cohort at 40 years was 48.5% (95% CI, 45.4 to 51.5). The cumulative incidence of second solid cancers did not differ according to study period (1965-1976, 1977-1988, or 1989-2000) (P=0.71 for heterogeneity). Although the risk of breast cancer was lower among patients who were treated with supradiaphragmatic-field radiotherapy not including the axilla than among those who were exposed to mantle-field irradiation (hazard ratio, 0.37; 95% CI, 0.19 to 0.72), the risk of breast cancer was not lower among patients treated in the 1989-2000 study period than among those treated in the two earlier periods. A cumulative procarbazine dose of 4.3 g or more per square meter of body-surface area (which has been associated with premature menopause) was associated with a significantly lower risk of breast cancer (hazard ratio for the comparison with no chemotherapy, 0.57; 95% CI, 0.39 to 0.84) but a higher risk of gastrointestinal cancer (hazard ratio, 2.70; 95% CI, 1.69 to 4.30). CONCLUSIONS The risk of second solid cancers did not appear to be lower among patients treated in the most recent calendar period studied (1989-2000) than among those treated in earlier periods. The awareness of an increased risk of second cancer remains crucial for survivors of Hodgkin's lymphoma. (Funded by the Dutch Cancer Society.).
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Affiliation(s)
- Michael Schaapveld
- From the Departments of Epidemiology (M.S., A.M.E., I.M., I.M.K., F.E.L.), Radiation Oncology (B.M.P.A.), and Hematology (J.P.B.), Netherlands Cancer Institute, and the Department of Hematology, VU University Medical Center Amsterdam (J.M.Z.), Amsterdam, the Netherlands Comprehensive Cancer Organization (M.S., I.M., O.V., M.W.J.L.) and the Departments of Radiation Oncology (J.R.) and Hematology (E.J.P.), University Medical Center Utrecht, Utrecht, the Departments of Radiation Oncology (C.P.M.J.) and Hematology (P.J.L.), Erasmus Medical Center Cancer Institute, Rotterdam, the Department of Radiation Oncology, Leiden University Medical Center, Leiden (A.D.G.K.), the Department of Radiation Oncology, Radboud University Medical Center (R.W.M.M., P.M.P.P.), and the Department of Education and Science, Canisius-Wilhelmina Hospital (I.M.), Nijmegen, the Department of Hematology, Radboud University Medical Center, Nijmegen-Rijnstate, Arnhem (J.M.M.R.), the Departments of Hematology (G.W.I.) and Radiation Oncology (M.B.), University Medical Center Groningen, Groningen, the Department of Radiation Oncology, Dr. Bernard Verbeeten Institute, Tilburg (P.M.P.P.), and the Department of Radiotherapy, Catharina Hospital, Eindhoven (M.L.L.) - all in the Netherlands
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van Nimwegen FA, Schaapveld M, Janus CPM, Krol ADG, Petersen EJ, Raemaekers JMM, Kok WEM, Aleman BMP, van Leeuwen FE. Cardiovascular disease after Hodgkin lymphoma treatment: 40-year disease risk. JAMA Intern Med 2015; 175:1007-17. [PMID: 25915855 DOI: 10.1001/jamainternmed.2015.1180] [Citation(s) in RCA: 312] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Hodgkin lymphoma (HL) survivors are at increased risk of cardiovascular diseases. It is unclear, however, how long the increased risk persists and what the risk factors are for various cardiovascular diseases. OBJECTIVES To examine relative and absolute excess risk up to 40 years since HL treatment compared with cardiovascular disease incidence in the general population and to study treatment-related risk factors for different cardiovascular diseases. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 2524 Dutch patients diagnosed as having HL at younger than 51 years (median age, 27.3 years) who had been treated from January 1, 1965, through December 31, 1995, and had survived for 5 years since their diagnosis. EXPOSURES Treatment for HL, including prescribed mediastinal radiotherapy dose and anthracycline dose. MAIN OUTCOMES AND MEASURES Data were collected from medical records and general practitioners. Cardiovascular events, including coronary heart disease (CHD), valvular heart disease (VHD), and cardiomyopathy and congestive heart failure (HF), were graded according to the Common Terminology Criteria for Adverse Events, version 4.0. RESULTS After a median follow-up of 20 years, we identified 1713 cardiovascular events in 797 patients. After 35 years or more, patients still had a 4- to 6-fold increased standardized incidence ratio of CHD or HF compared with the general population, corresponding to 857 excess events per 10,000 person-years. Highest relative risks were seen in patients treated before 25 years of age, but substantial absolute excess risks were also observed for patients treated at older ages. Within the cohort, the 40-year cumulative incidence of cardiovascular diseases was 50% (95% CI, 47%-52%). Fifty-one percent of patients with a cardiovascular disease developed multiple events. For patients treated before 25 years of age, cumulative incidences at 60 years or older were 20%, 31%, and 11% for CHD, VHD, and HF as first events, respectively. Mediastinal radiotherapy increased the risks of CHD (hazard ratio [HR], 2.7; 95% CI, 2.0-3.7), VHD (HR, 6.6; 95% CI, 4.0-10.8), and HF (HR, 2.7; 95% CI, 1.6-4.8), and anthracycline-containing chemotherapy increased the risks of VHD (HR, 1.5; 95% CI, 1.1-2.1) and HF (HR, 3.0; 95% CI, 1.9-4.7) as first events compared with patients not treated with mediastinal radiotherapy or anthracyclines, respectively. Joint effects of mediastinal radiotherapy, anthracyclines, and smoking appeared to be additive. CONCLUSIONS AND RELEVANCE Throughout their lives, HL survivors treated at adolescence or adulthood are at high risk for various cardiovascular diseases. Physicians and patients should be aware of this persistently increased risk.
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Affiliation(s)
| | - Michael Schaapveld
- Department of Epidemiology, The Netherlands Cancer Institute, Amsterdam2Comprehensive Cancer Centre, the Netherlands, Amsterdam
| | - Cécile P M Janus
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Augustinus D G Krol
- Department of Clinical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eefke J Petersen
- Department of Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - John M M Raemaekers
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wouter E M Kok
- Department of Cardiology, Amsterdam Medical Center, Amsterdam, the Netherlands
| | - Berthe M P Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam
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