Monitoring for Late Effects

Secondary cancers, cardiovascular disease, hypothyroidism, and fertility issues are the most serious late effects in long-term survivors of HL. The incidence of these late effects increases with longer follow-up time. The risk may be less with current treatment programs compared to those used more than 10 years ago.

Secondary Cancers

Solid tumors are the most common secondary cancers and most develop more than 10 years after the completion of treatment. The risk of developing secondary cancers is highest when RT is used as a component of first-line treatment. Meta-analysis by Franklin and colleagues showed that the risk of developing secondary cancers was lower with combined modality treatment than with RT alone as the initial treatment.143 The risk was marginally higher with combined modality treatment when compared with chemotherapy alone as initial treatment. No significant differences in the risk of developing secondary cancers were seen with IFRT versus EFRT, although the risk of developing breast cancer was substantially higher for EFRT. Risks for secondary lung cancer, non-Hodgkin lymphoma (NHL), and leukemia were significantly higher after treatment with chemotherapy alone, whereas combined modality therapy was associated with a higher risk for these and several other cancers.144 Lung cancer and breast cancer are the most common secondary cancers in patients with HL.

Annual breast screening [mammography and MRI] beginning no later than 8 to 10 years after completion of therapy or at age 40 (whichever occurs earlier) is recommended for women who have received chest or axillary irradiation.141 They should also be encouraged to perform monthly breast self-examination and undergo yearly breast examination by a health care professional. In a prospective study that evaluated the sensitivity and specificity of breast MRI with that of mammography in women who

received chest irradiation for HL, the sensitivity of the combined MRI and mammography as a combined screening modality was higher than that of MRI or mammography alone (94% for combined MRI and mammography; 67% and 68%, respectively, for MRI and mammography).145 The guidelines recommend breast MRI in addition to mammography for women who received irradiation to the chest between 10 and 30 years of age, which is consistent with the recommendation of the American Cancer Society Guidelines146 and the NCCN Guidelines for Detection, Prevention, and Risk Reduction.

The guidelines recommend that routine surveillance tests for cervical, colorectal, endometrial, lung, and prostate cancer be performed as per the American Cancer Society Guidelines.

Cardiovascular Disease

Mediastinal irradiation and anthracycline-based chemotherapy are the highest risk factors for developing cardiac disease, which may be asymptomatic.147-149 RT-induced cardiotoxicity is usually observed more than 5 to 10 years after completion of treatment. However, cardiovascular symptoms may emerge at any age. Coronary CT angiography abnormalities have been detected in nearly 15% of the patients within the first 5 years after treatment and their incidence significantly increases 10 years after treatment.150 In a multivariate analysis patient’s age at treatment, hypercholesterolemia, hypertension, and RT dose to the coronary artery origins were identified as independent prognostic factors.

Based on data regarding increased long-term risk of cardiac disease, annual blood pressure monitoring (even in asymptomatic individuals) and aggressive management of cardiovascular risk factors is recommended.141 A baseline stress test or echocardiogram and carotid US (for patients treated with neck RT) should be considered at 10-year intervals after completion of treatment.

Version 3.2021 © 2021 National Comprehensive Cancer Network© (NCCN©), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

MS-19