To improve survival in young women treated for Hodgkin's disease with radiation therapy...  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 and early detection depends primarily on the increased use of mammography rather than patient or physician breast examination.  Additional 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 1993; 72:1809-1812)

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.

The most 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 facts..."
"First, the increased risk of breast cancer is undoubtedly associated with the use of radiation...
"Second, the 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 thereafter..."  and
"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 HD."

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 could be eliminated completely.

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.  [1] Involved-Field Radiotherapy for Advanced Hodgkin's Lymphoma by Aleman, et al. and [2] 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 statement that "... 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: 3765-3771)

CONCLUSION: Low-Dose-Involved-Field 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.

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