Second Cancers Caused by Cancer Treatment

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Hodgkin disease

Survivors of Hodgkin disease (HD) have a risk of developing another cancer that is 2 to 3 times that of people who didn't have HD (the general population). Overall, the risk of a second cancer is more than 20% (1 in 5) in the first 20 years after treatment.

Risk of leukemia

Survivors of HD have an increased risk of acute leukemia and myelodysplastic syndrome (MDS) that is mainly linked to treatment with chemotherapy (chemo). The risk with chemo is highest if an alkylating agent was used, particularly when the combination of drugs known as MOPP (mechlorethamine, vincristine/Oncovin, prednisone, and procarbazine) was used as the main chemo regimen. Leukemia and MDS are much less common in people treated with regimens that include the combination known as ABVD (doxorubicin/Adriamycin, bleomycin, vinblastine, and dacarbazine).

Some patients with HD are treated with stem cell transplant. Most often, this is used for HD that has come back after treatment (or never went away in the first place). Patients with HD treated with stem cell transplant have a higher risk of leukemia and MDS that seems to be related to the additional chemo that is given prior to transplant.

Treating HD with radiation alone has little effect on leukemia risk, but adding radiation to chemo may increase the risk from the chemo even further.

The chance of getting leukemia after HD is related to the patient's age when they were treated, with the highest risk seen in those who were 35 or older during treatment. The risk also seems to go up as the amount of chemo used increases.

Risk of non-Hodgkin lymphoma

The risk of non-Hodgkin lymphoma (NHL) is also higher in those who survive HD. Because this risk does not seem to change based on the type of treatment used, many experts do not think that NHL seen after HD is caused by cancer treatments.

Risk of solid tumors

Radiation therapy for HD has been linked to an increased risk of developing solid tumor cancers. The risk is highest in the parts of the body that were in the path of the radiation beam.

The most common second cancer in female survivors of HD is breast cancer. The risk is highest in those who had radiation to an area in the center of the chest between the lungs before age 30. In the past, many patients got radiation to this area as a part of mantle field radiation. (Mantle field radiation covers the area of the neck, chest, and armpits.) The risk of breast cancer from radiation can be affected by chemo and its side effects. Alkylating agent chemotherapy causes some women to go through menopause early. In women who went through menopause before age 35 because of HD treatment, the risk of breast cancer isn’t increased – it’s actually lower than expected.

Lung cancer risk is also higher after treatment for HD. This higher risk is related to chest radiation treatments as well as chemotherapy with alkylating agents. Patients who have both chemo and radiation are even more likely to develop lung cancer. Smoking further increases the risk. The risk of lung cancer goes up if the patient smoked before treatment, but the risk gets even higher if the patient keeps on smoking after treatment.

The risk of thyroid cancer is also increased in HD patients who were treated with radiation to the neck. Other cancers that are seen after radiation include gastrointestinal (stomach) cancer and sarcoma.

Over time, treatment for HD has changed. Chemotherapy with alkylating agents has become much less common. Radiation is given in lower doses, and often only the areas directly affected by HD are treated (known as involved-field radiation). These changes seem to have helped lower the cancer risks after treatment, but long-term follow-up studies are still needed.

Follow-up care

Since there is an increased risk for a second cancer following treatment for Hodgkin disease, survivors of HD should be carefully followed up. Your doctors should watch for the development of solid tumors, leukemia, and non-Hodgkin lymphoma along with recurrence of Hodgkin disease.

All patients should be encouraged to reduce their risk of lung cancer by avoiding tobacco smoke.

Women who were treated with radiation to the chest (such as mantle field radiation therapy) before age 35 should start breast cancer screening early. The Children’s Oncology Group’s guidelines recommend that patients treated with this type of radiation (as a child, teen, or young adult) start screening 5 to 8 years after finishing their HD treatment or at age 25, whichever is later. This screening should include regular breast exams, mammograms, and breast MRI. The American Cancer Society’s guidelines recommend yearly breast MRIs in addition to mammograms for women who were treated with chest radiation while they were aged 10 to 30.

Patients who had radiation to their abdomen (belly) should pay special attention to any abdominal problems and report them to the doctor right away. Problems like unplanned weight loss, ongoing diarrhea, or other bowel problems could be a sign of a serious condition.

Last Medical Review: 01/30/2012
Last Revised: 01/30/2012