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Ykema BL, Gini A, Rigter LS, Spaander MC, Moons LM, Bisseling TM, de Boer JP, Verbeek WH, Lugtenburg PJ, Janus CP, Petersen EJ, Roesink JM, van der Maazen RW, Aleman BM, Meijer GA, van Leeuwen FE, Snaebjornsson P, Carvalho B, van Leerdam ME, Lansdorp-Vogelaar I. Cost-Effectiveness of Colorectal Cancer Surveillance in Hodgkin Lymphoma Survivors Treated with Procarbazine and/or Infradiaphragmatic Radiotherapy. Cancer Epidemiol Biomarkers Prev 2022; 31:2157-2168. [PMID: 36166472 PMCID: PMC9720424 DOI: 10.1158/1055-9965.epi-22-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/19/2022] [Accepted: 09/13/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hodgkin lymphoma survivors treated with infradiaphragmatic radiotherapy (IRT) and/or procarbazine have an increased risk of developing colorectal cancer. We investigated the cost-effectiveness of colorectal cancer surveillance in Dutch Hodgkin lymphoma survivors to determine the optimal surveillance strategy for different Hodgkin lymphoma subgroups. METHODS The Microsimulation Screening Analysis-Colon model was adjusted to reflect colorectal cancer and other-cause mortality risk in Hodgkin lymphoma survivors. Ninety colorectal cancer surveillance strategies were evaluated varying in starting and stopping age, interval, and modality [colonoscopy, fecal immunochemical test (FIT, OC-Sensor; cutoffs: 10/20/47 μg Hb/g feces), and multi-target stool DNA test (Cologuard)]. Analyses were also stratified per primary treatment (IRT and procarbazine or procarbazine without IRT). Colorectal cancer deaths averted (compared with no surveillance) and incremental cost-effectiveness ratios (ICER) were primary outcomes. The optimal surveillance strategy was identified assuming a willingness-to-pay threshold of €20,000 per life-years gained (LYG). RESULTS Overall, the optimal surveillance strategy was annual FIT (47 μg) from age 45 to 70 years, which might avert 70% of colorectal cancer deaths in Hodgkin lymphoma survivors (compared with no surveillance; ICER:€18,000/LYG). The optimal surveillance strategy in Hodgkin lymphoma survivors treated with procarbazine without IRT was biennial FIT (47 μg) from age 45 to 70 years (colorectal cancer mortality averted 56%; ICER:€15,000/LYG), and when treated with IRT and procarbazine, annual FIT (47 μg) surveillance from age 40 to 70 was most cost-effective (colorectal cancer mortality averted 75%; ICER:€13,000/LYG). CONCLUSIONS Colorectal cancer surveillance in Hodgkin lymphoma survivors is cost-effective and should commence earlier than screening occurs in population screening programs. For all subgroups, FIT surveillance was the most cost-effective strategy. IMPACT Colorectal cancer surveillance should be implemented in Hodgkin lymphoma survivors.
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Affiliation(s)
- Berbel L.M. Ykema
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Andrea Gini
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Lisanne S. Rigter
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Manon C.W. Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Leon M.G. Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tanya M. Bisseling
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jan Paul de Boer
- Department of Medical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Wieke H.M. Verbeek
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Cecile P.M. Janus
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eefke J. Petersen
- Department of Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Judith M. Roesink
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | - Berthe M.P. Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Gerrit A. Meijer
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Flora E. van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Petur Snaebjornsson
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Beatriz Carvalho
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Monique E. van Leerdam
- Department of Gastrointestinal Oncology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.,Corresponding Author: Iris Lansdorp-Vogelaar, Dr. Molewaterplein 40, Rotterdam 3015 GD, the Netherlands. Phone: 311-0703-8454; E-mail:
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Neppelenbroek SI, Geurts YM, Aleman BM, Janus CP, Rademakers SE, de Weijer RJ, Van Der Maazen RW, Zijlstra JM, Beijert M, Verschueren KM, Ta B, Nijziel MR, Posthuma EF, Kersten MJ, Muller K, te Boome L, Bilgin Y, de Jongh E, Schaapveld M, Van Leeuwen F. Anthracycline exposure and breast cancer risk in female Hodgkin lymphoma survivors. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12074 Background: Female Hodgkin lymphoma (HL) survivors treated with chest radiotherapy (RT) at a young age have a strongly increased risk of breast cancer (BC). Recently concern has been raised that anthracyclines may also increase BC risk, based on studies in childhood cancer survivors with/without a history of chest RT. So far, the association between anthracyclines and BC risk has not been examined in cancer survivors treated at adolescent/adult ages. Now that RT dose and volumes are decreasing, the potential contribution of anthracyclines to BC risk is an important issue. Methods: We assessed BC risk in a cohort of 2314 female 5-year HL survivors, treated at ages 15-50 years and diagnosed between 1965 and 2008 in 20 Dutch hospitals. Treatment factors were time-dependently included in the analysis, focusing on the effect of anthracycline exposure on BC risk. Results: After a median follow-up of 18.8 years, 258 women developed invasive BC or ductal carcinoma in situ as a subsequent malignancy. The 30-year cumulative incidence was 15.0% (95% Confidence Interval (CI) 12.8-17.4%). Mantle field RT (or other RT involving both axillae) was associated with increased risk of BC (Hazard ratio (HR) 1.9; 95% CI 1.2-2.8) compared to no supradiaphragmatic RT or RT to the neck only (Table 1). Gonadotoxic treatment (>4.2 g/m2 procarbazine or pelvic RT) significantly decreased this risk. In a multivariable analysis, anthracycline exposure was associated with increased BC risk (HR 1.8; 95% CI 1.3-2.5) in patients who received a cumulative dose of >200 mg/m2. Among patients exposed to gonadotoxic treatment, the HR of BC associated with >200mg/m2 anthracyclines was 3.8 (95% CI 2.0-7.2), with a trend for higher risk with higher anthracycline dose (HR 1.58 per 100mg/m2 anthracycline, p<0.001). Conclusions: Our results suggest an association of anthracyclines with BC risk in HL survivors. Also when accounting for the protective effect of gonadotoxic treatment on RT-associated BC risk, anthracyclines significantly contributed to a higher BC risk.[Table: see text]
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Affiliation(s)
| | - Yvonne M. Geurts
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Berthe M.P. Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | - Roel J. de Weijer
- Department of Hematology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Josée M. Zijlstra
- Department of Hematology, Amsterdam UMC location VUmc, Amsterdam, Netherlands
| | - Max Beijert
- University Medical Center Groningen, Groningen, Netherlands
| | | | | | - Marten R. Nijziel
- Catharina Cancer Institute, Department of Hemato-Oncology, Catharina Hospital, Eindhoven, Netherlands
| | | | - Marie José Kersten
- Department of Hematology, Amsterdam UMC location AMC, Amsterdam, Netherlands
| | | | | | - Yavuz Bilgin
- Department of Internal Medicine, Admiraal de Ruyter Hospital, Goes, Netherlands
| | - Eva de Jongh
- Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Michael Schaapveld
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Flora Van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
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Van Leeuwen F, Krul I, Opstal-Van Winden A, Janus CP, Daniels L, Maas A, Van Nimwegen R, de Vries S, Hauptmann M, Józwiak K, Aleman BM. Cardiovascular disease risk after treatment-induced primary ovarian insufficiency in female survivors of Hodgkin lymphoma. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.7_suppl.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
114 Background: Female survivors of Hodgkin lymphoma (HL) treated with alkylating chemotherapy (CT) and/or pelvic radiotherapy (RT) have an increased risk of primary ovarian insufficiency (POI). Among women with a natural menopause, POI has been associated with increased risk of cardiovascular disease (CVD). We examined whether treatment-induced POI increases long-term CVD risk in HL survivors. Methods: From a large Dutch cohort of 5-year HL survivors, we selected 918 women who were treated before 41 years of age between 1965 and 2000. Data on HL treatment, menopausal status and cardiovascular events (ischemic heart disease (IHD), heart failure (HF) and valvular heart disease (VHD)) were obtained from medical records, general practitioners and patient questionnaires. CVD risks were estimated with Cox regression models using time-dependent covariates and attained age as the time scale. Results: After a median follow-up of 24 years, 299 out of 918 women (33%) had developed POI (median menopausal age, 34 years). We identified 463 cardiovascular events in 300 women, of whom 85 developed CVD after POI. POI was not associated with subsequent CVD risk (HR:0.85, 95% CI 0.62-1.16) compared with a menopausal age of ≥40 years. Compared with women who reached menopause at ages ≥50 years, the HRs for menopausal ages of < 30 years, 30-39 and 40-49 years were 0.90 (95% CI 0.52-1.56), 0.87 (95% CI 0.57-1.33) and 0.96 (95% CI 0.64-1.44), respectively. Furthermore, a short duration of intact ovarian function after HL treatment ( < 5 years) did not increase CVD risk compared to a long duration (≥25 years) (HR:0.72, 95% CI 0.44-1.20). 177 women had used HRT, of whom 115 (65%) with POI (median duration of HRT use, 8.3 years). Women who used HRT for ≥5 years did not have a higher CVD risk than non-HRT users (HR 1.02, 95% CI 0.64-1.62). Similar results were found in analyses with IHD, HF and VHD as separate outcomes. Conclusions: POI and duration of post-treatment intact ovarian function did not affect CVD risk in HL survivors, suggesting that an early artificial menopause does not increase CVD risk.
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Affiliation(s)
| | - Inge Krul
- Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | | | | | - Angela Maas
- Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Michael Hauptmann
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Katarzyna Józwiak
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
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Nijdam A, de Weijer RJ, Janus CP, Clevers-Petersen EJ, Roesink JM, Lugtenburg PJ, van 't Veer MB, Aleman BM, Raemaekers JMM, Van Leeuwen F. Attendance to Hodgkin lymphoma survivorship care clinics in the Netherlands. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.5_suppl.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
71 Background: Survivors of Hodgkin lymphoma (HL) are at risk for late adverse effects of treatment. The Dutch BETER consortium, consisting of healthcare providers, researchers and patient representatives, has set up survivorship care clinics where HL survivors are screened for late effects. Methods: In order to assess patient characteristics and clinical attendance rates, descriptive statistics were calculated for data on HL survivors who were invited to attend the BETER clinics in the University Medical Center Utrecht (UMCU) and Erasmus University Medical Center (EMC). Results: Overall 291 survivors were invited to attend one of the two BETER clinics. Median age at invitation was 46 years (interquartile range IQR: 40-55 years), median age at HL diagnosis 29 years (IQR: 22-37 years) and median time since diagnosis 16 years (IQR: 11-22 years). Survivors were referred to the BETER clinic by the general EMC/UMCU outpatient clinics where they were still under surveillance (42%) or invited by phone (37%) or letter (20%). While 79% of survivors responded to the invitation, only 53% of all patients actually visited the BETER clinic. Most common reasons to not attend were: undergoing surveillance or treatment for late effects elsewhere (91%) and unwillingness to attend (8%; e.g. due to financial or emotional burden). Ninety-eight% of survivors who were still under surveillance in EMC/UMCU hospitals attended the BETER clinic, as opposed to only 19% of survivors who were no longer under surveillance. Survivors initially invited by letter were more likely to attend (38%) than those who were first contacted by phone (11%). Age at invitation and age at HL diagnosis were similar in those who did and did not attend. Similar data for another 3 clinics are being collected and will be presented at the ASCO Survivorship Symposium. Conclusions: These preliminary data show that only half of HL survivors who were invited, attended a BETER clinic. Unfortunately, survivors who were no longer under medical surveillance were less likely to attend, especially when first contacted by phone. Future, more detailed, evaluation of (non-)attendance in more BETER clinics may reveal the need for additional implementation measures to improve the BETER survivorship care program.
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Affiliation(s)
- Annelies Nijdam
- Department of Psychosocial Oncology and Epidemiology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Cecile P.M. Janus
- Erasmus Medical Center Cancer Institute, Department of Radiation Oncology, Rotterdam, Netherlands
| | | | - Judith M. Roesink
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Berthe M.P. Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | | | - Flora Van Leeuwen
- Department of Psychosocial Oncology and Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
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Rigter LS, Schaapveld M, Aleman BM, Janus CP, van Eggermond AM, Krol AD, Van Der Maazen R, Roesink JM, Zijlstra JM, Van Imhoff GW, Poortmans PM, Beijert M, Lugtenburg PJ, Visser O, Snaebjornsson P, Van Leeuwen F, van Leerdam ME. Long-term survival of gastrointestinal cancer diagnosed in Hodgkin lymphoma survivors. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
40 Background: The risk of developing gastrointestinal (GI) cancer is increased in Hodgkin lymphoma survivors. This study aims to compare overall survival of GI cancer in Hodgkin lymphoma survivors with survival of first primary GI cancer patients. Methods: This cohort study compared overall survival of GI cancer patients in a Hodgkin lymphoma survivor population (HL-GI (n = 92) including esophageal (n = 25), gastric (n = 31), small intestinal (n = 2), colorectal cancer (n = 34)) with survival of a population-based cohort of first primary GI cancer patients (GI-1, n = 911) which was generated by individual matching of the 92 cases, based on tumor location, gender, age and year at diagnosis. Clinical characteristics were compared by Chi square tests. Cox regression was used for multivariable survival analysis (corrected for age, gender, and clinicopathological characteristics related to the GI tumor). Results: When comparing HL-GI and GI-1 patients, no differences in tumor stage, grade of differentiation or frequency of surgery were found. HL-GI patients were less frequently treated for their GI tumor with radiation therapy (7% vs. 24% in GI-1 patients, p < 0.001) or chemotherapy (28% vs. 41%, p = 0.02). Overall 5-year and 20-year survival of HL-GI patients and GI-1 patients was non-significantly lower (28% vs. 38%, p = 0.13 and 19% vs. 29%, p = 0.06, respectively). This result was confirmed multivariably (5-year survival, p = 0.33, 20-year survival, p = 0.14). Also, for esophageal, gastric and colorectal cancer separately, no differences in overall survival were found between HL-GI patients and GI-1 patients. Conclusions: Long-term overall survival of GI cancer patients is similar in Hodgkin lymphoma survivors and first primary GI cancer patients. HL-GI patients did however receive less treatment with radiation therapy or chemotherapy. These treatments may not have been recommended due to prior Hodgkin lymphoma treatment or comorbidity. As risks of other causes of mortality are also increased in Hodgkin lymphoma survivors, the relatively good survival in this population is remarkable.
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Affiliation(s)
| | - Michael Schaapveld
- Department of Psychosocial Oncology and Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Berthe M.P. Aleman
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Cecile P.M. Janus
- Erasmus Medical Center Cancer Institute, Department of Radiation Oncology, Rotterdam, Netherlands
| | - Anna M. van Eggermond
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Augustinus D.G. Krol
- Leiden University Medical Center, Department of Clinical Oncology, Leiden, Netherlands
| | | | - Judith M. Roesink
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Josee M Zijlstra
- Department of Hematology, VU University Medical Center, Amsterdam, Netherlands
| | | | - Philip M. Poortmans
- Radiation Oncology Department, Radboud University Medical Centre Nijmegen, Nijmegen, Netherlands
| | - Max Beijert
- University Medical Center Groningen, Groningen, Netherlands
| | | | - Otto Visser
- Comprehensive Cancer Centre the Netherlands, Utrecht, Netherlands
| | | | - Flora Van Leeuwen
- Department of Psychosocial Oncology and Epidemiology, The Netherlands Cancer Institute, Amsterdam, Netherlands
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Schaapveld M, van Eggermond AM, Janus CP, Krol AD, Raemaekers JMM, Clevers-Petersen EJ, Lugtenburg PJ, Zijlstra JM, Van Imhoff GW, Van Der Maazen RW, Roesink JM, Beijert ML, Poortmans PM, Kremer LC, Louwman MJ, Lybeert M, De Boer JP, Aleman BM, van Leeuwen FE. Cause-specific mortality among patients with Hodgkin lymphoma (HL) up to 40 years after treatment. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.9517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Michael Schaapveld
- Department of Psychosocial Oncology and Epidemiology,The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Anna M. van Eggermond
- Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Cecile P.M. Janus
- Erasmus Medical Center Cancer Institute, Department of Radiation Oncology, Rotterdam, Netherlands
| | - Augustinus D.G. Krol
- Leiden University Medical Center, Department of Clinical Oncology, Leiden, Netherlands
| | - John M. M. Raemaekers
- Department of Internal Medicine, Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Jose M. Zijlstra
- Department of Hematology, VU University Medical Center, Amsterdam, Netherlands
| | | | | | - Judith M. Roesink
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | - Max L. Beijert
- Department of Radiotherapy, University Medical Center Groningen, Groningen, Netherlands
| | | | - Leontien C.M. Kremer
- Department of Pediatric Oncology, Emma Children’s Hospital/Academic Medical Center, Amsterdam, Netherlands
| | | | - Marnix Lybeert
- Department of Radiotherapy, Catharina Hospital, Eindhoven, Netherlands
| | - J. P. De Boer
- Netherlands Cancer Institute, Antoni Van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Berthe M.P. Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Flora E. van Leeuwen
- Department of Psychosocial Oncology and Epidemiology,The Netherlands Cancer Institute, Amsterdam, Netherlands
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van Nimwegen FA, Schaapveld M, Janus CP, Krol AD, Raemaekers JM, Clevers-Petersen EJ, Aleman BM, van Leeuwen FE. Cardiovascular diseases after Hodgkin lymphoma treatment: 35-year disease risk and sequence of events. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.9505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Frederika A. van Nimwegen
- Department of Psychosocial Oncology and Epidemiology,The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Michael Schaapveld
- Department of Psychosocial Oncology and Epidemiology,The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Cecile P.M. Janus
- Erasmus Medical Center Cancer Institute, Department of Radiation Oncology, Rotterdam, Netherlands
| | - Augustinus D.G. Krol
- Leiden University Medical Center, Department of Clinical Oncology, Leiden, Netherlands
| | - John M.M. Raemaekers
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Berthe M.P. Aleman
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Flora E. van Leeuwen
- Department of Psychosocial Oncology and Epidemiology,The Netherlands Cancer Institute, Amsterdam, Netherlands
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