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Female Hodgkin survivors need breast cancer screening, study confirms

Dr. Hodgson is seen in this undated handout photo. THE CANADIAN PRESS/ HO-University Health Network

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Dr. Hodgson is seen in this undated handout photo. THE CANADIAN PRESS/ HO-University Health Network

TORONTO - Women who survived Hodgkin lymphoma in childhood and who underwent radiation therapy for the cancer should be screened for breast cancer starting at an early age, a new study reaffirms.

The work, by researchers at Toronto's Princess Margaret Cancer Centre and Dana Farber Cancer Institute in Boston, shows that screening with MRI — magnetic resonance imaging — detects breast cancers in these women at a very early stage, when the prognosis for a cure is good.

The study was published Wednesday in the journal Cancer.

Hodgkin lymphoma — a cancer of the lymphatic system — has a high cure rate, over 90 per cent. But in the past the treatment traditionally involved heavy doses of radiation to the chest, neck and armpit areas, a therapy that raises the risk of developing breast cancer in female survivors.

Previously established recommendations suggest these women should begin breast cancer screening at an earlier-than-normal age, which is 50 in many jurisdictions and 40 in some others.

Senior author Dr. David Hodgson, a radiation oncologist at Princess Margaret, said for survivors of childhood Hodgkin lymphomas, breast cancer screening should begin at age 25 or eight years after treatment, whichever comes later.

An earlier study Hodgson helped to write suggested in Ontario only about a quarter of Hodgkin survivors were being screened on an ongoing basis. The design of the study — which drew data from medical records and did not involve interviews with the women — did not allow the researchers to try to answer the question of why women are disregarding this advice.

Hodgson speculated, though, that some women might not want to think about the possibility of another bout of cancer. In other cases, however, the problem is likely that these women do not know of their increased breast cancer risk and the recommendation that they be screened for the disease. And he said every year he sees survivors who asked to be screened early for breast cancer but were told by their family physicians they didn't need the test.

Nina Pandolfo is one of the women who simply did not know.

Pandolfo, from Innisfil, Ont., was diagnosed with Hodgkin lymphoma in 1992 when she was 19. She recalls it as a frightening time, learning she had to fight cancer when she would have preferred to be partying with friends.

Chemotherapy and 30 radiation sessions that targeted her chest cured Pandolfo of her cancer. She had no idea, however, that it left her with a greater risk of developing another type, breast cancer, down the road.

She was 37 when she discovered a lump in her armpit. Testing led to a biopsy and the breast cancer diagnosis. She remembers being flabbergasted when, on her first consultation appointment at Princess Margaret, she read in a pamphlet that a risk factor for breast cancer was having survived Hodgkin lymphoma.

"And I thought to myself: 'Wow, I can't believe it. The thing that cured me 19 years ago came back as breast cancer. And I still can't believe it today," Pandolfo said.

Pandolfo was advised to have surgery to remove her right breast. She later opted to have the left breast removed as well, because her risk of developing breast cancer in the opposite breast was higher because of her Hodgkin history.

Hodgson's study is the largest to date to evaluate breast cancer screening in women like Pandolfo.

The researchers performed 274 MRI screens on 96 women from 2005 to 2012. Ten breast cancers were discovered in nine women during that period, with those women ranging in age from 24 years old to 43 years old. The median age was 39 — younger than the age at which provincial programs invite women to participate in breast cancer screening programs.

MRIs were more sensitive and picked up more of the cancers early when compared to mammography, Hodgson noted. But they also led to a number of situations where women were called back for further exploration that turned out not to be cancers.

"The downside is that a substantial number of patients get called back for additional tests. Because the MRI is so sensitive that it sees all kinds of things that look like they could be abnormal that need additional investigation to figure out if they're a true cancer or not," Hodgson said.

Women should be warned about this risk because of the anxiety call-backs generate, he said.

Hodgson said he recommends that the Hodgkin lymphoma survivors he sees have both mammograms and breast MRIs annually. But he noted that some of the survivors are reluctant to undergo mammography, because they don't want the additional dose of radiation the test delivers.

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