ATTENTION YOUNG WOMEN SURVIVORS OF
HODGKIN’S DISEASE AND OTHER LYMPHOMAS
LOOKING DOWN THE ROAD...
WILL YOU BE SAVED OR WILL YOU BE A VICTIM?
To improve survival in young women treated for Hodgkin's disease with
mammographic screening... as early as 5 years after radiation therapy and therefore in many
instances well before the age of 40 has been recommended. It is hoped that all young women in this
category will alert their physicians to this need and review it with them. They
should speak with their family physicians or their oncologists and request that
they monitor their mammographic follow-up studies.
Analyses of modern comprehensive series of Hodgkin’s survivors,
verify that radiation induced second primary solid tumors, especially breast
neoplasms, are increased among patients who have survived after radiation
treatment during childhood, young adulthood or as a mature adult. To counter
this complication of survival and in recognition of this ‘menace’ of treatment
induced breast cancer… early and diligent mammographic screening has been
recommended… as early as 5 years after the initial radiation therapy even
if that occurs long before the age of 40.
Screening mammography at periodic
intervals, despite its limitations, is currently recognized as the primary means
readily available that can reduce the mortality rate from breast cancer
early detection depends primarily on the increased use of mammography rather
than patient or physician breast examination.
examinations using ultra-sound techniques or MRIs may also be very useful.
Although at this point in time we are
beginning to develop methods of improving survival of breast cancer patients
with the use of newly developed chemotherapeutic agents...
early detection must still be considered a primary means to reduce the number
of deaths from breast cancer and Dr. Kopan's commentary ten years ago still
has validity: “Screening
[mammography] is clearly not the ultimate solution to the breast cancer
problem, but until methods to prevent cancer can be devised, or perfect
cures developed, earlier detection offers the only opportunity to reduce
the number of breast cancer deaths for a significant number of women.” (Kopans
D.B. Mammography Screening for Breast Cancer. Editorial. Cancer
DESPITE MORE THAN A DECADE OF
OBSERVATIONS REGARDING THE CLEAR ASSOCIATION BETWEEN RADIATION TREATMENT
FOR HODGKIN'S DISEASE AND THE DEVELOPMENT OF BREAST CANCER ESPECIALLY IN
YOUNG WOMEN... There is still a reluctance 1)
to either eliminate radiation therapy for these young women patients with
Hodgkin's disease or 2) at the very least come to a consensus
about how many years after radiation therapy, in these young women, should mammographic, sonographic or MRI
screening for breast cancer take place.
recent reviews and thoughtful scientific analyses of these matters keep
these 'hot' issues alive but still incompletely resolved:
Dr. Suzanne L.Wolden, et al reporting in the Journal of Clinical
Oncology from the Departments of Radiation Oncology, Medicine, and
Surgery, Stanford University Medical Center, Stanford, CA. stated: "The
risk of breast cancer first becomes significantly elevated in years 5
through 9 of follow-up. Thus, we recommend that screening begin 5 years
after radiotherapy or at age 40, whichever occurs first. Patients
should be instructed how to perform breast self-examination and be
encouraged to do so at follow-up evaluations. Women should also have
annual clinical breast examination and mammography beginning 5 years after
radiation exposure. The median age at diagnosis of breast cancer was
43 years in this series, which is the same as that reported for 37
patients with breast cancer after Hodgkin’s disease at the Memorial
Sloan-Kettering Cancer Center."
Management of Breast Cancer After Hodgkin’s Disease
By Suzanne L. Wolden, Steven L. Hancock, Robert W. Carlson, Don R.
Goffinet, Stefanie S. Jeffrey, and Richard T. Hoppe (Journal of
Clinical Oncology, Vol 18, No 4 (February), 2000: pp 765-772)
Dr. Lois B. Travis, et
al, recognized that 'early' and follow-up mammographic
screening was recommended by 'many investigators' and that more
educational efforts had to be made to alert young women treated for
Hodgkin's disease with regard to this issue. In
Breast Cancer Following Radiotherapy and Chemotherapy Among Young Women
With Hodgkin Disease
they stated: "Although no
consensus recommendations exist with regard to breast cancer screening for
young women treated for HD using radiotherapy, many investigators advocate
a baseline mammogram 5 to 8 years following initial treatment." and that it was "... unsettling that a recent report of women
treated for HD prior to age 30 years found that 40% did not perceive
themselves to be at increased risk of breast cancer suggesting the
continued need for patient education and programs of public awareness." (JAMA Vol. 290 No. 4 pp.465-475 July 23, 2003)
Dr. Joachim Yahalom an outstanding radiation therapy
oncologist who is dedicated to the treatment of patients with Hodgkin's
disease and other lymphomas in his Editorial commentary (JAMA Vol. 290:529-531 July 23,2003.)
in regard to the
report by Travis, et al. noted:
"During the last decade, multiple studies have documented and
characterized the risk of breast cancer after HD, and have established 3
the increased risk of breast cancer is
undoubtedly associated with the use of radiation...
increased risk of breast cancer is age-related, with the highest risk
associated with treatment at ages 10 years to 20 years. The risk remains
significantly increased until age 25 years or 30 years, and disappears
"Third, the increased risk is
manifested late, the median time from HD treatment to breast cancer is 15
years, and only few events have been reported at the first decade after
Dr. Yahalom's advice and conclusion and that of others is
to modify the size and dose of the radiation therapy in this cohort of
young patients but that it is not necessary to eliminate radiation therapy.
Others have suggested that radiation therapy
THE POTENTIAL FOR ELIMINATING RADIATION THERAPY AS A SINGLE OR COMBINED
MODALITY OF TREATMENT WITH CHEMOTHERAPY
In an Editorial in the New England Journal of Medicine Dr. Vincent
DeVita, an expert in the treatment of Hodgkin's disease, former head of the
National Cancer Institute and retired Chief of the Yale Cancer Center, commented on the significant results and observations made in two large
studies that appeared in the same issue of the New England Journal of
Medicine, Volume 348, June 12, 2003
Number 24.  Involved-Field Radiotherapy for
Advanced Hodgkin's Lymphoma by Aleman, et al. and  Standard and
Increased-Dose BEACOPP Chemotherapy Compared with COPP-ABVD for Advanced
Hodgkin's Disease by Volker Diehl, et al.
Dr. DeVita emphasized the
observations noted by Aleman, et al. that
because radiotherapy "by itself increases the risk of late second solid tumors
in the irradiated field and the incidence rises steeply when radiotherapy and
chemotherapy are combined..." and that chemotherapy alone may achieve excellent results
as reported by Diehl, et al, it may be possible to eliminate radiation
therapy as a primary therapeutic modality in the treatment of Hodgkin's disease.
Dr. DeVita concluded in a diplomatic but clearly understandable
"... we have taken too long to pose some of the more obvious
questions, a number of which surfaced many years ago and which might simplify
treatment and reduce the long-term risks — even if it means ultimately excluding
one specialty or another from the management of this disease."
In a pediatric population the Children’s Cancer Group
investigated whether radiation could be omitted in patients achieving a
complete response to initial chemotherapy without jeopardizing the
excellent outcome obtained with combined-modality therapy.
Randomized Comparison of Low-Dose Involved-Field Radiotherapy and No
Radiotherapy for Children With Hodgkin’s Disease Who Achieve a Complete
Response to Chemotherapy By James B. Nachman,
Richard Sposto, Philip Herzog, Gerald S. Gilchrist, Suzanne L. Wolden,
John Thomson, Marshall E. Kadin, Paul Pattengale, P. Charlton Davis,
Raymond J. Hutchinson, Keith White for the Children’s Cancer Group
(Journal of Clinical Oncology, Vol 20, Issue 18 (September), 2002:
Radiotherapy (LD-IFRT) after an initial complete response to risk-adapted
chemotherapy improved Event Free Survival (EFS) but at the time of this
report there was no survival advantage for LD-IFRT, but follow-up
time was short.
CANCER HEART DISEASE
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