Comparing second cancer risk for multiple radiotherapy modalities in survivors of hodgkin lymphoma

OBJECTIVES: To assess if excess absolute risk (EAR) of radiation-induced solid cancer can be used to rank radiotherapy plans for treatment of Hodgkin lymphoma (HL) in a statistically significant way. METHODS: EAR models, calibrated with data from the Life Span Study and HL survivors, have been incorporated into a voxelised risk-calculation software, which is used to compare four treatment modalities planned for five virtual HL patients. Organ-specific parameters are generated repeatedly in a Monte Carlo fashion to model their uncertainties. This in turn enables a quantitative estimation of the EAR uncertainties. RESULTS: Parameter-driven uncertainties on total EAR are around 13%, decreasing to around 2–5% for relative EAR comparisons. Total EAR estimations indicate that intensity modulated proton therapy decreases the average risk by 40% compared to the intensity modulated radiation therapy plan, 28% compared to the volumetric modulated arc therapy plan whereas the three-dimensional conformal radiation therapy plan is equivalent within the uncertainty. CONCLUSION: Relative EAR is a useful metric for distinguishing between radiotherapy plans in terms of second cancer risk. ADVANCES IN KNOWLEDGE: Relative EAR is not dominated by model or parameter uncertainties and can be used to guide the choice of radiotherapy for HL patients.