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Most people treated for Hodgkin lymphoma are cured, and the long follow-up cohorts show that the treatment leaves a raised risk of heart disease, of a second cancer and of an underactive thyroid for decades. Several of those risks have a screening programme attached, and the commonest failure is not being enrolled in it.
**Why this is the best documented survivorship literature in oncology.** Hodgkin lymphoma mostly affects people in their twenties and thirties and most of them are cured, so two Dutch cohorts have been able to follow survivors for forty years.
**Second cancers.** Among 3,905 people who survived at least five years after treatment given between 1965 and 2000 at ages 15 to 50, 1,055 second cancers were diagnosed in 908 people over a median follow-up of 19.1 years, a standardised incidence ratio of 4.6 against the general population. The rate was still 3.9 times higher 35 or more years after treatment, and the cumulative incidence of a second cancer at 40 years in that cohort was 48.5 per cent. The authors' own conclusion was that the risk of second solid cancers was not lower among those treated in the most recent period they studied, 1989 to 2000, than in the two earlier ones. Those patients were treated with the radiotherapy fields of their era; modern fields are much smaller, and what that is worth over forty years is not yet known, because the cohort that would measure it has not been followed for forty years.
**Breast cancer after chest radiotherapy, and the screening that answers it.** The NHS Breast Screening Programme places women who received radiotherapy to breast tissue during treatment for Hodgkin or non-Hodgkin lymphoma between the ages of 10 and under 36 into its very high risk group, alongside proven gene carriers, and screens them annually, usually with magnetic resonance imaging. Lymphoma Action says screening usually begins 8 to 15 years after treatment, which is when the raised risk emerges. In the Dutch cohort, the risk of breast cancer was lower after supradiaphragmatic radiotherapy that did not include the axilla than after the older mantle field, with a hazard ratio of 0.37.
**That this can go wrong, and has.** NHS England contacted 1,487 women in England who should have been referred for annual breast screening and may not have been: women who received radiotherapy above the waist for Hodgkin lymphoma between the ages of 10 and 35 inclusive in the years 1962 to 2003. Everyone treated after 2003 would have been enrolled automatically. If you were treated above the waist as a young woman and have never been invited, that is a reason to ask rather than to assume.
**The heart.** Among 2,524 Dutch patients treated before the age of 51 between 1965 and 1995, 1,713 cardiovascular events occurred in 797 people over a median 20 years. Thirty-five or more years on, coronary heart disease and heart failure were still 4 to 6 times more common than in the general population. The 40-year cumulative incidence of cardiovascular disease in that cohort was 50 per cent, and 51 per cent of those affected had more than one event. Mediastinal radiotherapy raised the risk of coronary disease, valve disease and heart failure; anthracycline chemotherapy raised the risk of valve disease and heart failure. The effects of radiotherapy, anthracyclines and smoking appeared to add together, which is the strongest argument for stopping smoking that this literature contains.
**The thyroid, the lungs and the bones.** Lymphoma Action says radiotherapy to the neck or upper chest, some chemotherapy drugs and some targeted treatments can cause an underactive thyroid, that the risk is highest in the first five years and stays raised after that, that it is found on a blood test and treated with thyroxine tablets, and that a yearly thyroid blood test follows neck radiotherapy. Lung scarring can follow chest radiotherapy, bleomycin or rituximab. High-dose steroids, some chemotherapy and radiotherapy to the treated area can thin the bones.
**The practical answer.** Lymphoma Action says the team should give you and your general practitioner a written treatment summary listing the treatment you had, the side effects and late effects to expect, the symptoms that could mean the lymphoma has returned, who to contact at any hour, and any lifestyle recommendations. Asking for that document, keeping it, and showing it to any health professional who treats you afterwards is what converts this literature into something a person can act on.
Showing the technology this term belongs to: Survivorship care and late-effects surveillance.
Shares Escalated chemotherapy or ABVD in advanced Hodgkin lymphoma: more cures, more late harm, and what the interim scan changed, Early-stage classical Hodgkin lymphoma (stage I to II), Late effects and survivorship toxicity, Advanced-stage classical Hodgkin lymphoma (stage III to IV).
Shares Secondary malignancy (therapy-related cancer), Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma), Early-stage classical Hodgkin lymphoma (stage I to II), Late effects and survivorship toxicity.
Shares Early-stage classical Hodgkin lymphoma (stage I to II), Late effects and survivorship toxicity, Relapsed and refractory classical Hodgkin lymphoma, Survivorship care and late-effects surveillance.
Shares Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Hodgkin lymphoma.
Shares Late effects of Hodgkin lymphoma treatment, and the follow-up that answers them, Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV).
Shares Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma), Early-stage classical Hodgkin lymphoma (stage I to II), Advanced-stage classical Hodgkin lymphoma (stage III to IV), Hodgkin lymphoma.
Shares Escalated chemotherapy or ABVD in advanced Hodgkin lymphoma: more cures, more late harm, and what the interim scan changed, The surveillance schedule, and the evidence that routine scans do not find relapse first, Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma.
Shares Early-stage classical Hodgkin lymphoma (stage I to II), Relapsed and refractory classical Hodgkin lymphoma, Advanced-stage classical Hodgkin lymphoma (stage III to IV), Hodgkin lymphoma.