Role of radiotherapy and chemotherapy in the risk of leukemia after childhood cancer: an international pooled analysis

Rodrigue S Allodji, Margaret A Tucker, Michael M Hawkins, Marie-Cécile Le Deley, Cristina Veres, Rita Weathers, Rebecca Howell, Dave Winter, Nadia Haddy, Carole Rubino, Ibrahima Diallo, Mark P Little, Lindsay M Morton, Florent de Vathaire

Research output: Contribution to journalArticlepeer-review


Childhood cancer survivors are at increased risk for second primary leukemia (SPL), but there is little consensus on the magnitude of some risk factors because of the small size of previous studies. We performed a pooled analysis of all published studies with detailed treatment data, including estimated active bone marrow (ABM) dose received during radiation therapy and doses of specific chemotherapeutic agents for childhood cancer diagnosed from 1930 through 2000, in order to more thoroughly investigate treatment-related risks of SPL. A total of 147 SPL cases (of which 69% were acute myeloid leukemia [AML]) were individually matched to 522 controls, all from four case-control studies including patients from six countries (France, United Kingdom, United States, Canada, Italy and Netherlands). Odds ratios (OR) and corresponding 95% confidence intervals (CIs) were calculated using conditional logistic regression, and the excess OR per Gray (EOR/Gy) was also calculated. After accounting for the other therapies received, topoisomerase II inhibitor was associated with an increased SPL risk (highest tertile vs none: OR = 10.0, 95% CI: 3.7-27.3). Radiation dose to the ABM was also associated with increased SPL risk among those not receiving chemotherapy (EOR/Gy = 1.6, 95% CI: 0.1-14.3), but not among those who received chemotherapy (CT). SPL were most likely to occur in the first decade following cancer treatment. Results were similar when analyses were restricted to AML. The evidence of interaction between radiation and CT has implications for leukemogenic mechanism. The results for topoisomerase II inhibitors are particularly important given their increasing use to treat childhood cancer.

Original languageEnglish
JournalInternational Journal of Cancer
Early online date26 Oct 2020
Publication statusE-pub ahead of print - 26 Oct 2020

Bibliographical note

© 2020 Union for International Cancer Control.


  • alkylating agents
  • chemotherapy
  • childhood cancers survivors
  • radiation dose to active bone marrow
  • radiotherapy
  • secondary leukemia
  • topoisomerase II inhibitors

ASJC Scopus subject areas

  • Oncology
  • Cancer Research


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