Second Cancer Risk Up to 40 Years after Treatment for Hodgkin's Lymphoma

Schaapveld, M., Aleman, B. M. P., van Eggermond, A. M., Janus, C. P. M., Krol, A. D. G., van der Maazen, R. W. M., Roesink, J., Raemaekers, J. M. M., de Boer, J. P., Zijlstra, J. M., van Imhoff, G. W., Petersen, E. J., Poortmans, P. M. P., Beijert, M., Lybeert, M. L., Mulder, I., Visser, O., Louwman, M. W. J., Krul, I. M., Lugtenburg, P. J. & van Leeuwen, F. E., 24-Dec-2015, In : New England Journal of Medicine. 373, 26, p. 2499-2511 13 p.

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  • Second Cancer Risk Up to 40 Years after Treatment for Hodgkin's Lymphoma

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  • Michael Schaapveld
  • Berthe M. P. Aleman
  • Anna M. van Eggermond
  • Cecile P. M. Janus
  • Augustinus D. G. Krol
  • Richard W. M. van der Maazen
  • Judith Roesink
  • John M. M. Raemaekers
  • Jan Paul de Boer
  • Josee M. Zijlstra
  • Gustaaf W. van Imhoff
  • Eefke J. Petersen
  • Philip M. P. Poortmans
  • Max Beijert
  • Marnix L. Lybeert
  • Ina Mulder
  • Otto Visser
  • Marieke W. J. Louwman
  • Inge M. Krul
  • Pieternella J. Lugtenburg
  • Flora E. van Leeuwen


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.


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.


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).


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.)

Original languageEnglish
Pages (from-to)2499-2511
Number of pages13
JournalNew England Journal of Medicine
Issue number26
Publication statusPublished - 24-Dec-2015



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