Journal of the National Cancer Institute Advance Access published online on December 9, 2008
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djn394
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© The Author 2008. Published by Oxford University Press.
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Risk of Second Malignancies in Survivors of Retinoblastoma: More Than 40 Years of Follow-up
Affiliations of authors: Department of Ophthalmology (TM, ACM, SMI, PJR) and EMGO Institute (FEvL), VU University Medical Center, Amsterdam, the Netherlands; Department of Health Sciences, VU University, Amsterdam, the Netherlands (MRdB); Department of Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands (FEvL)
Correspondence to: Tamara Marees, MSc, Department of Ophthalmology, VU University Medical Center, de Boelelaan 1117, 1007 MB Amsterdam, the Netherlands (e-mail: t.marees{at}vumc.nl).
Background: Survivors of hereditary retinoblastoma have an elevated risk of developing second malignancies, but data on the risk in middle-aged retinoblastoma survivors (ie, those with more than 40 years of follow-up) are scarce.
Methods: Data from the Dutch retinoblastoma registry were used to analyze risks of second malignancies in 668 retinoblastoma survivors, diagnosed from 1945 to 2005 (median age = 24.9 years) and classified as having had hereditary or nonhereditary disease based on the presence of family history, bilateral disease, or a germline RB1 mutation. Standardized incidence ratios (SIRs) and absolute excess risks (AERs) of subsequent cancers in patients with hereditary and nonhereditary disease were estimated by comparison with Dutch sex-, age-, and calendar year–specific rates. Multivariable Cox regression and competing risk analyses were used to determine associations of treatment with risks of second malignancies. All statistical tests were two-sided.
Results: After a median follow-up of 21.9 years, the risk of second malignancies in survivors of hereditary retinoblastoma (SIR = 20.4, 95% confidence interval [CI] = 15.6 to 26.1) far exceeded the risk of survivors of nonhereditary retinoblastoma (SIR = 1.86, 95% CI = 0.96 to 3.24). Among patients with hereditary disease, treatment with radiotherapy was associated with a further increase in the risk of a subsequent cancer (hazard ratio = 2.81, 95% CI = 1.28 to 6.19). After 30 years of follow-up, elevated risks of epithelial cancers (lung, bladder, and breast) were observed among survivors of hereditary retinoblastoma. After 40 years of follow-up, the AER of a second malignancy among survivors of hereditary retinoblastoma had increased to 26.1 excess cases per 1000 person-years. The cumulative incidence of any second malignancy 40 years after retinoblastoma diagnosis was 28.0% (95% CI = 21.0% to 35.0%) for patients with hereditary disease.
Conclusion: Our analysis of middle-aged hereditary retinoblastoma survivors suggests that these individuals have an excess risk of epithelial cancer. Lifelong follow-up studies are needed to evaluate the full spectrum of subsequent cancer risk in hereditary retinoblastoma survivors.
| Context and Caveats Prior knowledge Survivors of hereditary retinoblastoma are at increased risk of second malignancies, in part due to radiation. Because few patients have been followed for more than 40 years after diagnosis, the long-term risks of subsequent epithelial malignancies were not known. Study design Cancer registry data and population data were used to calculate standardized incidence ratios and absolute excess risks for various second malignances. Cox regression models were used to determine the associations of treatment type with risk for subsequent cancers. Contribution This study demonstrated that survivors of hereditary retinoblastoma are at increased risk for epithelial cancers that develop 30–40 years after diagnosis, including bladder, lung, and breast cancers. Implications Lifelong follow-up studies are needed to evaluate the full spectrum of excess malignancies in retinoblastoma survivors. Limitations The relative rarity of hereditary retinoblastoma makes precise quantifications of risks of various second malignancies and identification of treatments (eg, chemotherapy) associated with increased risk difficult. From the Editors
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Manuscript received February 1, 2008; revised September 4, 2008; accepted October 6, 2008.
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J Natl Cancer Inst 2008 100: 1741.
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