Wednesday, September 19, 2012

Breast cancer risk after supradiaphragmatic radiotherapy persists beyond 40 years

Everything...and I mean EVERYTHING comes with a price tag.

I came upon this, and my breath caught. This has nothing to do with my personal health journey. It has everything, however, to do with dear sweet 16 year old Hannah...just another potential battle you may have to face down the road. Hannah was diagnosed with Hodgkin's Lymphoma this past spring when she was 15, and has been undergoing very aggressive treatment since. Her last round is scheduled for erev Rosh Hashanah. Her mother (Andrea), whom I got to shared a hug with this past Thursday, was looking at the poetic and positive portend associated with this timing.  Andrea has always been a 1/2 glass full lady.

I, on the other hand, have been trained to be the consummate cynic (4.5 years of law school and nearly two decades practicing law). I listen to the treatment regimen Hannah's young body has had to endure these past six months; I recall my own fears of cumulative radiation exposure;  I stumble across the following abstract; and I viscerally cringe.

And, again, I ask the question constantly on my lips - why must anyone sacrifice their long term health as the cost of being "cured" today?  ####

1:35 | Jun29, 2012 | Oncology, Reuters Health • TheDoctor's Channel Daily Newscast, Women’s Health

NEW YORK (Reuters Health) – The increased risk of breastcancer in women who received radiotherapy above the diaphragm for treatment ofHodgkin’s lymphoma (HL) persists for at least 40 years after treatment,according to a national cohort study from the United Kingdom.
These women need to be followed for at least 40 years, perhaps withmore-intensive screening regimens, say the investigators from the England andWales Hodgkin Lymphoma Follow-Up Group in a report online June 25 in theJournal of Clinical Oncology.

“Supradiaphragmatic radiotherapy is still widely used although techniquesand doses keep changing,” first author Dr. Anthony J. Swerdlow, from theInstitute of Cancer Research, Sutton, Surrey, England, commented in an email toReuters Health.

He and his colleagues documented the clinical characteristics, treatment,and subsequent outcomes of 5,002 women with HL treated with supradiaphragmaticradiation (mantle-field in two thirds of the population) in England and Walesfrom 1956 to 2003. The women were younger than 36 at the time of treatment andwere followed through the end of 2008.

The researchers used modeling to describe specific, cumulative breast cancerrisk at given time points during follow-up according to age at diagnosis,treatment type (inclusion of alkylating agents or pelvic radiation), radiationdose, and time from first treatment.

A total of 373 women developed breast cancer or ductal carcinoma in situduring follow up, yielding a standardized incidence ratio (SIR) of 5.0.

SIRs were greatest for those treated at age 14 years (47.2) and “continuedto remain high for at least 40 years. The maximum absolute excess risk was atattained ages 50 to 59 years,” the investigators report. Alkylatingchemotherapy or pelvic radiotherapy diminished the risk, but only for womentreated at age 20 or older, not for those treated when younger.

The authors tabulated “in detail” cumulative risks of breast cancer based onvarious factors. For example, the cumulative risk of breast cancer in a woman20 to 24 years old at the time of treatment with supradiaphragmatic radiationis 3.5% at 20 years and 29.2% at 40 years. For those treated withsupradiaphragmatic radiation plus alkylating chemo and/or pelvic radiotherapy,the corresponding risks are 3.6% and 11.5%.

“I think the clinical implications (of the article) are in the provision ofrisk statistics to use to advise patients,” Dr. Swerdlow said.

In an accompanying commentary, Dr. Michael Crump, from Princess MargaretHospital and University of Toronto in Canada says, “The legacy of curativeextended-field radiation for HL is a large survivor population that is at anincreased lifetime risk of second cancer, in particular breast, lung and GIcancer. The article by Swerdlow et al … offers additional information toaddress the challenge of individual risk assessment.”

This is largest cohort of survivors of HL yet evaluated for breast cancerrisk, Dr. Crump notes, and the results confirm those of others. Namely, thatbreast cancer risk is “highest in women treated with mantle radiotherapy aroundpuberty, decreases with increasing age at treatment (although still elevatedfor women treated in their thirties, the median age at diagnosis of HL in mostcountries), and decreases with smaller radiation field sizes and lowerradiation doses. Gonadotoxic therapy (alkylating agents or radiation) reducedsubsequent breast cancer risk but only for women treated after age 20 years.”

Dr. Swerdlow and colleagues say the “large cumulative risks of breast cancerwe found 20 to 39 years after supradiaphragmatic radiotherapy, especially inpatients treated at age 20 years, are similar to or higher than the risks bythe same ages in BRCA1 and BRCA2 carriers. They suggest that intensive breastscreening programs for such women may need to continue for 40 years and longerafter initial radiotherapy.”

They also say their data showing maximum absolute excess risk at ages 50 to59 years suggest that “more-intensive screening (eg, annual screening withmagnetic resonance imaging) may be needed.”

In his editorial, Dr. Crump points out that “Both the American CancerSociety and the United Kingdom Notification Risk Assessment and ScreeningProgramme recommend magnetic resonance imaging (MRI) as an adjunct to annualmammography for women who have received thoracic irradiation younger than age36 years, starting 8 years after treatment. Available data suggest that effortsto enroll high-risk women onto screening programs are falling short, and lessthan half of women treated during adolescence or as young adults currentlyreceive annual mammography.”

Continuing, Dr. Crump says, “The United Kingdom guideline recommendscommencing screening at age 25 years but returns women to standard mammographyonce every three years once they have reached age 50 years. The report bySwerdlow et al suggests that this upper age limit should be reconsidered inlight of the very high cumulative risk faced by women even beyond 30 years offollow-up,” he concludes.


TowardRisk-Based Breast Cancer Screening and
Prevention Strategies for Survivors of Hodgkin’s
Lymphoma: One Step Closer?

BreastCancer Risk After Supradiaphragmatic Radiotherapy for Hodgkin’s Lymphoma inEngland and Wales: A National Cohort Study

J Clin Oncol. 2012.


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