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Of nearly 4,000 Dutch people cured of Hodgkin lymphoma, almost half developed another cancer within forty years, and the gentler treatments introduced in the late 1980s had not reduced that risk.
This is the cohort that defines the cost of curing Hodgkin lymphoma. 3,905 people in the Netherlands who had survived at least five years after starting treatment between 1965 and 2000, aged 15 to 50 at the time, were followed and compared with cancer incidence in the general population.
At a median follow-up of 19.1 years, 1,055 second cancers were diagnosed in 908 patients, a standardised incidence ratio of 4.6 (95 per cent confidence interval 4.3 to 4.9). The risk was still raised 35 years or more after treatment (3.9, 2.8 to 5.4), and the cumulative incidence of a second cancer at 40 years was 48.5 per cent (45.4 to 51.5).
The finding that mattered most was the one the authors did not expect. The cumulative incidence of second solid cancers did not differ between the 1965 to 1976, 1977 to 1988 and 1989 to 2000 treatment periods (p = 0.71 for heterogeneity), despite the less toxic protocols introduced in the late 1980s. Breast cancer risk was lower in patients treated with supradiaphragmatic radiotherapy that spared the axilla than with mantle-field irradiation (hazard ratio 0.37, 0.19 to 0.72), but not lower in the most recent period. A cumulative procarbazine dose of 4.3 grams per square metre or more, which is associated with premature menopause, was associated with lower breast cancer risk (hazard ratio 0.57, 0.39 to 0.84) and higher gastrointestinal cancer risk (2.70, 1.69 to 4.30).
The reason every current Hodgkin lymphoma trial is a de-escalation trial, and the reason survivors need lifelong surveillance rather than discharge at five years. It is also a warning about assuming that a gentler protocol is a safer one until a cohort has been followed long enough to say.
Radiotherapy cannot be omitted in early-stage favourable Hodgkin lymphoma on the basis of a negative interim scan without a clinically relevant loss of tumour control. The scan is better at identifying who needs more than at identifying who needs less.
The reason cardiac surveillance belongs in Hodgkin lymphoma survivorship care, the reason smoking cessation is a specific intervention for this group rather than general advice, and part of the reason modern protocols try to limit both mediastinal radiation and cumulative anthracycline dose.
The dose-response curve behind breast surveillance programmes for women irradiated for Hodgkin lymphoma as teenagers or young adults, which in several countries start at 25 or eight years after radiotherapy and use magnetic resonance imaging as well as mammography.
Shares GHSG HD10, GHSG HD16, A radiotherapy-free cure for early Hodgkin lymphoma that actually holds, RADAR and the tag lymphoma-evidence.
Shares GHSG HD16, A radiotherapy-free cure for early Hodgkin lymphoma that actually holds, RADAR, Procarbazine and the tag lymphoma-evidence.
Shares Procarbazine, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Survivorship and late effects are neglected, Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting and the tag lymphoma-evidence.
Shares Procarbazine, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Survivorship and late effects are neglected, Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting and the tag lymphoma-evidence.
Shares Procarbazine, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Survivorship and late effects are neglected, Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting and the tag lymphoma-evidence.
Shares Procarbazine, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Survivorship and late effects are neglected, Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting and the tag lymphoma-evidence.
Shares Positron emission tomography-guided treatment in early-stage favorable Hodgkin lymphoma: final results of the international, randomized phase III HD16 trial by the German Hodgkin Study Group, Early-stage classical Hodgkin lymphoma (stage I to II), Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting, Hodgkin lymphoma and the tag lymphoma-evidence.
Shares Survivorship and late effects are neglected, Lymphoma roadmap: from a jaw tumour in Uganda and the first human cancer virus to gene-expression subtypes, PET-adapted chemotherapy, CAR-T cells, bispecific antibodies and the genetics-directed trials now recruiting, Toxicity and quality of life are undervalued and the tag lymphoma-evidence.