Subsequent Cancers: After Treatment, They Are All Too Common
Watch for Symptoms, and Stay on Top of Appointments and Screenings
Individuals who are diagnosed with Hodgkin lymphoma and then have treatment will most likely be cured. It is also true that they are approximately twice as likely as the rest of the population to develop a subsequent cancer.
A subsequent cancer is unrelated to the original diagnosis, but results because of treatment--radiation, chemotherapy or a combination of the two. Hodgkin survivors who received radiation to the neck, chest or abdominal area are especially vulnerable for solid tumors. Those who received chemotherapy that included alkylating agents (for example, MOPP regimens that included mechlorethamine, procarbazine or those with cyclophosphomide), typically are at greater risk for blood cancers, such as leukemia and myelodysplastic syndrome, which has symptoms that may include shortness of breath, fatigue and easy bruising. These are most likely to occur within the first decade after treatment. Such agents may also increase the risk of solid cancers, especially if patients were also treated with radiation. Solid tumors are comprised of a solid mass of cancer cells that grow in organ systems, such as the breasts.
“The development of a subsequent cancer depends on one’s treatment exposure.”
- Larissa Nekhlyudov, MD
“The development of a subsequent cancer depends on one’s treatment exposure,” notes Larissa Nekhlyudov, MD, MPH, Clinical Director, Internal Medicine for Cancer Survivors at Dana-Farber Cancer Institute in Boston. In addition to the type and amount of treatment, the area treated and the age when treated, other risk factors such as one’s family history and lifestyle behaviors also play a role in the development of subsequent cancer.
“Treatments have changed. People who are diagnosed today are not likely to pay the price down the road compared with Hodgkin survivors who were treated in the 1970s and 1980s,” says Dr. Nekhlyudov. “This is largely because, with each decade, less radiation was used, and the radiation techniques improved. Today, when we radiate one area, we radiate one area - not all the nearby areas. However, I still see people who were treated in the 1990s who received a lot of radiation, so patients and their clinicians must remain on alert.”
Staying connected, either with a survivor/late effects clinic or a physician who looks broadly at one’s health--and specifically at the impact of Hodgkins treatment--is important. Dr. Nekhlyudov endorses a holistic approach to care that falls into four buckets. “First, what is your risk of recurrence? Luckily for Hodgkin lymphoma, most patients do well, but there are still those who may experience a recurrence. Second, what about monitoring of late effects? For a long-term Hodgkins survivor, that’s a big bucket that needs to be addressed. This includes risk of subsequent cancer and non-cancer conditions that may be related to treatment. Third, psychosocial health, including depression, anxiety, fear of recurrence, as well as the financial and interpersonal impact.
“Finally, and not to be dismissed, is general health promotion, specifically managing blood pressure, cholesterol and sugar - all of which increase the risk of heart disease, still the most common cause of death among cancer survivors. It is important to make sure all appropriate screenings are scheduled.”
"I still see people who were treated in the 1990s who received a lot of radiation, so patients and their clinicians must remain on alert.”
- Larissa Nekhlyudov, MD
The following is Dr. Nekhlyudov’s overview of secondary cancers, in order of their importance for Hodgkin lymphoma survivors:
Breast cancer: “People who were treated for Hodgkins were most likely given radiation in the mantle or chest area and are therefore at risk for breast cancer. They need to be sure they’re receiving the necessary screenings: annual mammography, and now there’s more and more evidence that a breast MRI should also be performed. If you develop breast cancer--even early-stage, such as DCIS (ductal carcinoma in situ)--treatment options will be more limited because radiation therapy is typically not again used as a potential treatment.
“Someone who had Hodgkins might receive advice from a surgeon who may not be aware that you’re going to be at risk for another breast cancer. But it is important to know that, after a lumpectomy, you are still going to be at a high risk for a recurrence or a new cancer in that breast or the other breast. Clearly, it is an individual decision, but women who had Hodgkins, were treated with radiation and have breast cancer need to consider a mastectomy or bilateral mastectomy as an option.” Some women choose to have a prophylactic (preventive) mastectomy to reduce their risk of developing breast cancer.
“Someone who had Hodgkin’s might receive advice from a surgeon who may not be aware that you’re going to be at risk for another breast cancer."
- Larissa Nekhlyudov, MD
Thyroid cancer: “It’s important to perform a clinical examination of the neck. Patients occasionally come into the office and say ‘I have a lump here.’ The next step is to obtain imaging. Thyroid cancer tends to be slow-growing; it’s important for patients to examine their own necks--feeling for lumps or bumps--and then have their doctor also check them.
“The role of screening ultrasound, when there are no lumps on clinical examination, is controversial because nodules are quite common in those who were treated for Hodgkins. It’s not clear that ultrasound adds any value or not. A good neck exam is preferable. But if not possible, then do have an ultrasound.”
Skin cancer: “Hodgkins survivors develop more basal-cell carcinoma, which is not as serious than melanoma. Melanomas in general are less common, but these may occur in areas exposed to radiation. So patients need to be more vigilant than the average person. I tell my Hodgkins patients: you got a whole lot of sunshine--that is, radiation--on this area. Please keep a close eye on your skin, and get regular skin examinations.”
Lung cancer: “Screening with a CT scan, which is recommended today for certain individuals with a history of smoking, is controversial for patients with chest radiation. Even low-dose CT scanning has radiation associated with it. We don’t want to expose our patients to additional radiation. If the person is a smoker, the risk of lung cancer goes up substantially. We ask patients to pay attention to any new or unusual symptoms; there’s a low threshold for evaluation for lung cancer. Hodgkins survivors who do smoke need urgent counseling to stop smoking. Paying attention to secondhand smoke is also important.”
Gastrointestinal cancer: “People who had radiation near their abdominal area, especially people who were treated in the 1970s and 1980s and had mantle radiation or para-aortic radiation, are at risk for colorectal cancer. Because of abdominal radiation, our patients have a higher rate of polyps--often many polyps--which can transform over time into cancer. For the general public, the current recommendation is to have a colonoscopy at age 50, but that’s about to change to 45. Hodgkins survivors with abdominal radiation are encouraged to have a colonoscopy ten years post-treatment, and those who were treated as children should have a colonoscopy starting at age 30. More frequent colonoscopies may also be indicated.
Leukemia and non-Hodgkin lymphoma: “Leukemia develops in some individuals during the first ten years or so after treatment. It tends to be related to chemotherapy--specifically the alkylating agents. Generally, the risk goes down after ten years. We also do see some cases of non-Hodgkin lymphoma, but that is rare.”