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Lang et al

hereditary/familial cancer syndromes, genetic test- ing for specific mutations, such as the CHEK2, PTEN, MLH1, and MSH2 genes, along with the consideration of other lifestyle factors, such as smoking, physical activity, and diet, would have been useful. 22,23 Because 15 of 64 (23.4%) of the NSPMs were diagnosed in the first 5 years after DTC, the authors could not exclude the possibility that some might have been present at or shortly af- ter DTC and might have not been a result of the radiation effect of RAI (ie, surveillance bias). From these data, after adjusting for potential risk factors in the multivariable analysis, such as age, gender, period of DTC diagnosis, and DTC stage, cumulative RAI activity of 3 to 8.9 GBq was the only independent risk factor for NSPM in radiation-na € ıve DTC survivors. The risk of devel- oping NSPM in the female RAI + group was signifi- cantly higher than that of the general population, but this increased risk was not observed in the RAI group. Therefore, the authors concluded that female DTC survivors treated by RAI appeared to be at elevated risk of developing NSPM when compared to the general population and an excess risk was not apparent in those survivors not previ- ously treated by RAI. REFERENCES 1. Cancer incidence and mortality in Hong Kong 1983–2006. Hong Kong Cancer Registry, Hong Kong. Available from: http://www3.ha.org.hk/cancereg/e_stat.asp . 2. Lang BH, Lo CY, Chan WF, Lam KY, Wan KY. Prognostic fac- tors in papillary and follicular thyroid carcinoma: implica- tions for cancer staging. Ann Surg Oncol 2007;14:730-8. 3. Hay ID, Gonzalez-Losada T, Reinalda MS, Honetschlager JA, Richards ML, Thompson GB. Long-term outcome in 215 children and adolescents with papillary thyroid cancer treated during 1940 through 2008. World J Surg 2010;34: 1192-202. 4. Lang BH, Lo CY, Wong IO, Cowling BJ. Impact of second primary malignancy on outcomes of differentiated thyroid carcinoma. Surgery 2010;148:1191-6. 5. Rubino C, de Vathaire F, Dottorini ME, Hall P, Schvartz C, Couette JE, et al. Second primary malignancies in thyroid cancer patients. Br J Cancer 2003;89:1638-44. 6. Brown AP, Chen J, Hitchcock YJ, Szabo A, Shrieve DC, Tward JD. The risk of second primary malignancies up to three decades after the treatment of differentiated thyroid cancer. J Clin Endocrinol Metab 2008;93:504-15.

7. Sandeep TC, Strachan MW, Reynolds RM, Brewster DH, Scelo G, Pukkala E, et al. Second primary cancers in thyroid cancer patients: a multinational record linkage study. J Clin Endocrinol Metab 2006;91:1819-25. 8. Berthe E, Henry-Amar M, Michels JJ, et al. Risk of second primary cancer following differentiated thyroid cancer. Eur J Nucl Med Mol Imaging 2004;31:685-91. 9. Sawka AM, Thabane L, Parlea L, et al. Second primary ma- lignancy risk after radioactive iodine treatment for thyroid cancer: a systematic review and meta-analysis. Thyroid 2009;19:451-7. 10. Verkooijen RB, Smit JW, Romijn JA, Stokkel MP. The inci- dence of second primary tumors in thyroid cancer patients is increased, but not related to treatment of thyroid cancer. Eur J Endocrinol 2006;155:801-6. 11. Canchola AJ, Horn-Ross PL, Purdie DM. Risk of second pri- mary malignancies in women with papillary thyroid cancer. Am J Epidemiol 2006;15:521-7. 12. Lang BH, Lo CY, Chan WF, Lam KY, Wan KY. Staging sys- tems for papillary thyroid carcinoma: a review and compar- ison. Ann Surg 2007;245:266-78. 13. Wong IO, Chan WS, Choi S, Lo SV, Leung GM. Moral haz- ard or realised access to care? Empirical observation in Hong Kong. Health Policy 2006;75:251-61. 14. Subramanian S, Goldstein DP, Parlea L, et al. Second pri- mary malignancy risk in thyroid cancer survivors: a system- atic review and meta-analysis. Thyroid 2007;17:1277-88. 15. Ronckers CM, McCarron P, Ron E. Thyroid cancer and mul- tiple primary tumors in the SEER cancer registries. Int J Cancer 2005;117:281-8. 16. Lang BH, Wong KP. Risk factors for nonsynchronous sec- ond primary malignancy and related death in patients with differentiated thyroid carcinoma. Ann Surg Oncol 2011;18:3559-65. 17. Chuang SC, Hashibe M, Yu GP, et al. Radiotherapy for pri- mary thyroid cancer as a risk factor for second primary can- cers. Cancer Lett 2006;238:42-52. 18. Cooper DS, Doherty GM, Hauger BR, Kloos RT, Lee SL, Man- del SJ, et al. Revised American Thyroid Association manage- ment guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19:1167-214. 19. Kogai T, Taki K, Brent GA. Enhancement of sodium/iodide symporter expression in thyroid and breast cancer. Endocr Relat Cancer 2006;13:797-826. 20. Bhattacharyya N, Chien W. Risk of second primary malig- nancy after radioactive iodine treatment for differentiated thyroid carcinoma. Ann Otol Rhinol Laryngol 2006;115: 607-10. 21. Presentation by Shane Solomon, the Chief Executive of Hospital Authority. Available from http://www.ha.org.hk/ upload/presentation/47.pdf . 22. Cybulski C, Gorski B, Huzarski T, et al. CHEK2 is a multior- gan cancer susceptibility gene. Am J Hum Genet 2004;75: 1131-5. 23. Wei EK, Wolin KY, Colditz GA. Time course of risk factors in cancer etiology and progression. J ClinOncol 2010;28:4052-7.

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