Chapter 4: Cancer incidence in Canada: trends and projections (1983-2032) – Hodgkin lymphoma - HPCDP: Volume 35, Supplement 1, Spring 2015

Chapter 4: Projections by Cancer Site

20. Hodgkin lymphoma

Hodgkin lymphoma (HL) is a relatively rare cancer. In 2003–2007, the average annual number of new HL cases was 490 for males and 395 for females, constituting 0.6% and 0.5% of all new male and female cancer cases in Canada, respectively (Tables 4.20.1 and 4.20.2).

TABLE 4.20.1
Observed (2003–2007) and projected average annual new cases by age and province/territories combined (TC), Hodgkin lymphoma, males, Canada, 2003–2032
Period Age New cases
CA BC AB SK MB ON QC NB NS PE NL TC

Abbreviations: AB, Alberta; BC, British Columbia; CA, Canada; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PE, Prince Edward Island; QC, Quebec; SK, Saskatchewan; TC, All Territories (Yukon, Northwest Territories and Nunavut).

Note: Totals may not add up due to rounding.

2003–07 <45 300 35 30 10 10 115 80 10 10 0 5 0
45–54 65 5 5 0 0 30 15 0 0 0 0 0
55–64 50 5 5 0 0 20 15 0 0 0 0 0
65–74 40 5 5 0 0 20 10 0 0 0 0 0
75–84 25 5 5 0 0 10 5 0 0 0 0 0
85+ 5 0 0 0 0 0 0 0 0 0 0 0
Total 490 50 50 15 15 195 125 15 15 0 5 0
2008–12 <45 295 30 35 10 10 110 75 5 10 0 5 0
45–54 75 10 10 5 0 30 20 0 0 0 0 0
55–64 60 5 5 0 5 25 15 0 0 0 0 0
65–74 45 5 5 0 0 20 10 0 0 0 0 0
75–84 25 5 5 0 0 10 5 0 0 0 0 0
85+ 5 0 0 0 0 0 0 0 0 0 0 0
Total 505 55 55 15 15 200 125 15 15 0 5 0
2013–17 <45 295 30 35 10 10 115 80 5 10 0 5 0
45–54 75 5 10 0 0 30 15 0 0 0 0 0
55–64 65 5 10 0 5 30 15 0 0 0 0 0
65–74 55 5 5 0 0 25 10 0 0 0 0 0
75–84 25 5 5 0 0 10 5 0 0 0 0 0
85+ 5 0 0 0 0 5 0 0 0 0 0 0
Total 520 55 60 15 20 215 130 15 15 0 5 0
2018–22 <45 300 25 35 10 10 120 80 5 5 0 0 0
45–54 70 10 10 0 0 30 15 0 0 0 0 0
55–64 75 10 10 0 5 35 15 5 0 0 0 0
65–74 60 5 5 0 5 30 15 0 0 0 0 0
75–84 30 5 5 0 0 15 5 0 0 0 0 0
85+ 10 0 0 0 0 5 0 0 0 0 0 0
Total 545 55 60 15 20 235 130 15 15 0 5 0
2023–27 <45 305 25 35 10 10 130 75 5 5 0 0 0
45–54 75 10 10 0 0 30 20 0 0 0 0 0
55–64 75 5 10 0 5 35 15 0 0 0 0 0
65–74 70 5 10 0 5 35 15 5 5 0 0 0
75–84 40 5 5 0 0 20 5 0 0 0 0 0
85+ 10 0 0 0 0 5 0 0 0 0 0 0
Total 580 55 65 20 20 255 135 15 15 0 5 0
2028–32 <45 315 25 35 10 10 135 75 5 5 0 0 0
45–54 85 10 10 5 0 30 25 0 0 0 0 0
55–64 75 10 10 0 5 35 15 0 0 0 0 0
65–74 85 10 10 5 5 45 15 5 5 0 0 0
75–84 50 5 5 0 0 25 10 0 0 0 0 0
85+ 10 0 0 0 0 5 0 0 0 0 0 0
Total 615 60 70 20 20 275 140 15 15 0 5 0
TABLE 4.20.2
Observed (2003–2007) and projected average annual new cases by age and province/territories combined (TC), Hodgkin lymphoma, females, Canada, 2003–2032
Period Age New cases
CA BC AB SK MB ON QC NB NS PE NL TC

Abbreviations: AB, Alberta; BC, British Columbia; CA, Canada; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PE, Prince Edward Island; QC, Quebec; SK, Saskatchewan; TC, All Territories (Yukon, Northwest Territories and Nunavut).

Note: Totals may not add up due to rounding.

2003–07 <45 245 30 30 5 10 95 55 5 10 0 0 0
45–54 40 5 5 0 0 15 10 0 0 0 0 0
55–64 45 5 5 0 0 20 10 0 0 0 0 0
65–74 30 5 0 0 0 10 10 0 0 0 0 0
75–84 30 0 0 0 0 15 10 0 0 0 0 0
85+ 5 0 0 0 0 0 0 0 0 0 0 0
Total 395 45 40 10 15 160 95 10 15 0 5 0
2008–12 <45 260 30 35 5 10 100 65 5 10 0 0 0
45–54 45 5 5 0 0 20 10 0 0 0 0 0
55–64 45 5 5 0 0 20 10 0 0 0 0 0
65–74 35 5 5 0 0 15 10 0 0 0 0 0
75–84 30 5 0 0 0 15 5 0 0 0 0 0
85+ 10 0 0 0 0 5 5 0 0 0 0 0
Total 420 50 50 10 20 170 100 10 15 0 5 0
2013–17 <45 255 30 35 5 10 100 65 5 10 0 0 0
45–54 45 5 5 0 0 20 10 0 0 0 0 0
55–64 50 5 5 0 5 25 10 0 0 0 0 0
65–74 45 5 5 0 0 20 10 0 0 0 0 0
75–84 30 5 5 0 0 15 5 0 0 0 0 0
85+ 10 0 0 0 0 5 5 0 0 0 0 0
Total 440 55 55 10 20 180 105 10 20 0 5 0
2018–22 <45 250 35 35 5 10 95 70 5 10 0 0 0
45–54 50 5 5 0 0 20 10 0 0 0 0 0
55–64 55 5 5 0 5 30 10 0 0 0 0 0
65–74 60 10 5 0 5 25 10 0 5 0 0 0
75–84 35 5 5 0 0 15 5 0 0 0 0 0
85+ 10 0 0 0 0 5 5 0 0 0 0 0
Total 455 55 60 10 20 195 110 10 20 0 5 0
2023–27 <45 240 35 35 5 10 95 70 5 10 0 0 0
45–54 50 5 5 0 0 20 10 0 0 0 0 0
55–64 60 5 10 0 5 35 10 0 0 0 0 0
65–74 65 10 5 0 5 30 10 0 5 0 0 0
75–84 45 5 5 0 0 25 10 0 0 0 0 0
85+ 10 0 0 0 0 5 5 0 0 0 0 0
Total 475 60 65 10 20 215 115 10 20 0 5 0
2028–32 <45 240 35 35 5 10 100 75 5 10 0 0 0
45–54 55 5 5 0 0 20 10 0 0 0 0 0
55–64 65 5 10 0 5 35 10 0 0 0 0 0
65–74 70 10 5 0 5 40 10 0 5 0 0 0
75–84 55 5 5 0 5 35 10 0 5 0 0 0
85+ 15 0 5 0 0 5 5 0 0 0 0 0
Total 500 65 70 10 25 235 120 10 20 0 5 0

HL is classified into 2 main groups: classical HL, the most common type, and nodular lymphocyte-predominant HL, which represents about 1 in 20 cases.Endnote 111, Endnote 267 The 5-year relative survival rates for HL diagnosed between 2006 and 2008 were 83% for males and 87% for females.Endnote 1

HL has a bimodal age distribution, with peaks at age 20 to 24 and 75 to 79 for both sexes in 2003–2007 (Figure 4.20.1). The disease was more common in men than in women beginning in adulthood, although the rates corresponded at ages 10 to 19. Tables 4.20.1 and 4.20.2 show that more than 70% of all HL cases occurred in those younger than 55. The age distribution between males and females was nearly identical (Figure 4.20.1).

FIGURE 4.20.1
Age-specific incidence rates of Hodgkin lymphoma, Canada, 2003–2007 (from average annual counts)

Age-specific incidence rates of Hodgkin lymphoma, Canada, 2003–2007 (from average annual counts)

[Click to enlarge]

[FIGURE 4.20.1, Text Equivalent]

Health Promotion and Chronic Disease Prevention in Canada - Volume 35 · Supplement 1 · Spring 2015

FIGURE 4.20.1
Age-specific incidence rates of Hodgkin lymphoma, Canada, 2003-2007 (from average annual counts)

Hodgkin lymphoma has a bimodal age distribution, with peaks at age 20 to 24 and 75 to 79 for both sexes in 2003-2007. The disease was more common in men than in women beginning in adulthood, although the rates corresponded at ages 10 to 19. The age distributions between males and females were nearly identical.

Figure 4.20.2 indicates that overall ASIRs of HL decreased modestly in both sexes until 1998–2002. During 1998–2007, the ASIRs increased non-significantly in males by 0.4% per year and by 0.9% per year in females (Figures 3.1 and 3.2). Quebec, Ontario, the Atlantic region and the country had similar trends for males, British Columbia showed an opposite pattern from 1988–1992, and the rates in the Prairies seemed to stabilize (Figure 4.20.2). For females, the ASIRs in British Columbia and Quebec were similar to the entire country, and the rates in Ontario have decreased steadily since 1988–1992. The rates for females in the Prairies and the Atlantic region seem random, likely because of the small numbers of annual cases and the unusual age distribution of the cancer occurrence, making it complicated to interpret the trends.

FIGURE 4.20.2
Age-standardized incidence rates (ASIRs) by region, Hodgkin lymphoma, 1983–2032

Age-standardized incidence rates (ASIRs) by region, Hodgkin lymphoma, 1983–2032

[Click to enlarge]

[FIGURE 4.20.2, Text Equivalent]

Health Promotion and Chronic Disease Prevention in Canada - Volume 35 · Supplement 1 · Spring 2015

FIGURE 4.20.2
Age-standardized incidence rates (ASIRs) by region, Hodgkin lymphoma, 1983-2032

The overall incidence rates for Hodgkin lymphoma (HL) in Canada are projected to decrease slightly in both sexes. Rates of HL in British Columbia males are projected to decrease significantly and diverge from those in other regions, where the rates will tend to remain unchanged and consistent. For females, the rates are projected to increase slightly in Quebec, the Atlantic region and the Prairies, and to decrease marginally in Ontario and British Columbia. The projected rates for HL in both sexes will be lowest in British Columbia and highest in Quebec.

The overall incidence rates for HL are projected to decrease slightly in both sexes (Figure 4.20.2), whereas the overall ASIRs are projected to increase steadily in the 45–54 age group and decrease or level off in other age groups (Figure 4.20.3). The ASIRs in males and females are predicted to converge in the age groups older than 54. Rates of HL in British Columbia males are projected to decrease significantly and diverge from those in other regions, where the rates will tend to remain unchanged and consistent (Figure 4.20.2). For females, the rates are projected to increase slightly in Quebec, the Atlantic region and the Prairies, and to decrease marginally in Ontario and British Columbia. The projected rates for HL in both sexes will be lowest in British Columbia and highest in Quebec.

FIGURE 4.20.3
Age-standardized incidence rates (ASIRs) for Hodgkin lymphoma by age group, Canada, 1983–2032 (red lines denote males, blue lines denote females)

Age-standardized incidence rates (ASIRs) for Hodgkin lymphoma by age group (males, females), Canada, 1983–2032

[Click to enlarge]

[FIGURE 4.20.3, Text Equivalent]

Health Promotion and Chronic Disease Prevention in Canada - Volume 35 · Supplement 1 · Spring 2015

FIGURE 4.20.3
Age-standardized incidence rates (ASIRs) for Hodgkin lymphoma by age group, Canada, 1983-2032

Whereas the overall incidence rates for Hodgkin lymphoma are projected to decrease slightly in both sexes, the ASIRs are projected to increase steadily in the 45-54 age group and decrease or level off in other age groups. The ASIRs in males and females are predicted to converge in the age groups older than 54.

From 2003–2007 to 2028–2032, the ASIRs of HL for Canada are expected to decrease by 3% in males, from 3.1 to 3.0 per 100 000, and by 7% in females, from 2.5 to 2.3 per 100 000 (Tables 4.20.3 and 4.20.4).

TABLE 4.20.3
Observed (2003–2007) and projected age-standardized incidence rates (ASIRs) by age and province/territories combined (TC), Hodgkin lymphoma, males, Canada, 2003–2032
Period Age ASIRs
CA BC AB SK MB ON QC NB NS PE NL TC

Abbreviations: AB, Alberta; BC, British Columbia; CA, Canada; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PE, Prince Edward Island; QC, Quebec; SK, Saskatchewan; TC, All Territories (Yukon, Northwest Territories and Nunavut).

2003–07 <45 3.0 2.6 2.7 3.6 2.7 2.9 3.4 3.5 4.0 2.8 2.2 1.1
45–54 2.7 1.9 2.4 2.8 1.6 3.1 2.8 3.5 3.1 1.8 1.0 2.6
55–64 2.9 1.8 3.0 4.5 3.0 3.2 2.9 3.1 2.9 0.0 3.0 0.0
65–74 4.0 3.3 3.3 1.7 4.3 4.4 4.1 5.3 2.3 3.8 4.3 10.9
75–84 4.2 2.9 5.9 1.7 5.3 4.7 4.4 2.8 3.2 7.6 0.0 0.0
85+ 3.1 2.5 3.1 5.3 2.8 3.5 3.8 0.0 0.0 0.0 0.0 0.0
Total 3.1 2.5 2.9 3.4 2.8 3.1 3.4 3.6 3.7 2.7 2.2 1.8
2008–12 <45 2.9 2.3 2.6 3.3 2.6 2.9 3.4 3.1 3.1 2.5 2.1 1.6
45–54 2.8 2.3 2.7 3.6 1.5 3.0 2.8 3.8 3.1 2.5 2.0 1.6
55–64 2.8 2.0 3.4 2.7 3.8 3.3 2.7 4.3 2.7 2.5 2.0 1.5
65–74 3.5 2.4 3.7 3.8 4.3 4.1 3.6 5.1 4.5 3.1 2.5 1.9
75–84 3.8 3.6 5.0 3.8 3.9 4.3 3.2 6.0 4.2 3.3 2.7 2.1
85+ 2.9 4.1 3.5 3.4 4.3 3.0 3.0 1.6 0.9 2.5 2.0 1.6
Total 3.0 2.3 2.9 3.3 2.7 3.1 3.3 3.5 3.2 2.6 2.1 1.6
2013–17 <45 2.9 2.1 2.6 3.2 2.5 2.8 3.4 3.2 3.0 2.5 2.1 1.6
45–54 2.8 2.1 2.7 3.6 1.4 3.0 2.9 3.9 2.9 2.5 2.0 1.6
55–64 2.7 2.0 3.5 2.7 3.8 3.2 2.4 4.3 2.5 2.4 1.9 1.5
65–74 3.4 2.1 3.7 3.8 4.3 4.3 3.2 5.2 4.2 3.0 2.4 1.9
75–84 3.6 3.4 5.1 3.7 3.9 4.2 3.0 6.1 3.9 3.1 2.6 2.0
85+ 2.7 3.0 3.5 3.4 4.2 3.4 2.6 1.7 0.8 2.4 1.9 1.5
Total 2.9 2.2 2.9 3.3 2.7 3.0 3.3 3.6 3.0 2.5 2.1 1.6
2018–22 <45 2.8 1.9 2.6 3.2 2.5 2.9 3.4 3.2 2.9 2.5 2.0 1.6
45–54 2.9 2.3 2.7 3.5 1.4 3.0 3.3 3.9 2.8 2.6 2.1 1.6
55–64 2.9 2.1 3.5 2.6 3.8 3.5 2.4 4.4 2.4 2.5 2.0 1.6
65–74 3.3 2.3 3.7 3.7 4.2 4.2 3.0 5.2 4.1 2.9 2.4 1.8
75–84 3.3 2.9 5.1 3.7 3.9 4.0 2.7 6.1 3.7 2.9 2.4 1.8
85+ 2.6 3.8 3.5 3.3 4.2 3.1 2.2 1.7 0.7 2.3 1.9 1.4
Total 2.9 2.0 2.9 3.2 2.7 3.1 3.2 3.6 3.0 2.5 2.1 1.6
2023–27 <45 2.9 1.8 2.6 3.2 2.5 3.0 3.4 3.2 2.9 2.5 2.0 1.6
45–54 3.1 2.5 2.7 3.5 1.4 3.0 3.8 3.9 2.8 2.7 2.2 1.7
55–64 3.0 2.1 3.5 2.6 3.8 3.6 2.6 4.4 2.4 2.6 2.1 1.7
65–74 3.3 2.4 3.7 3.7 4.2 4.3 2.8 5.2 4.0 2.9 2.3 1.8
75–84 3.3 2.7 5.1 3.7 3.8 4.5 2.6 6.1 3.7 2.9 2.4 1.8
85+ 2.5 3.2 3.5 3.3 4.2 3.3 2.3 1.7 0.7 2.2 1.8 1.4
Total 2.9 1.9 2.9 3.2 2.7 3.2 3.3 3.6 2.9 2.6 2.1 1.6
2028–32 <45 2.9 1.6 2.6 3.2 2.5 3.1 3.2 3.2 2.8 2.5 2.0 1.6
45–54 3.1 2.3 2.7 3.5 1.4 2.8 4.1 4.0 2.7 2.7 2.2 1.7
55–64 3.1 2.2 3.5 2.6 3.7 3.7 3.0 4.4 2.3 2.7 2.2 1.7
65–74 3.5 2.5 3.7 3.7 4.2 4.7 2.8 5.2 3.9 3.1 2.5 2.0
75–84 3.2 2.9 5.1 3.7 3.8 4.3 2.5 6.1 3.6 2.8 2.3 1.8
85+ 2.3 2.8 3.5 3.3 4.2 3.0 2.0 1.7 0.7 2.0 1.6 1.3
Total 3.0 1.9 2.9 3.2 2.7 3.3 3.2 3.6 2.9 2.6 2.1 1.6
TABLE 4.20.4
Observed (2003–2007) and projected age-standardized incidence rates (ASIRs) by age and province/territories combined (TC), Hodgkin lymphoma, females, Canada, 2003–2032
Period Age ASIRs
CA BC AB SK MB ON QC NB NS PE NL TC

Abbreviations: AB, Alberta; BC, British Columbia; CA, Canada; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario; PE, Prince Edward Island; QC, Quebec; SK, Saskatchewan; TC, All Territories (Yukon, Northwest Territories and Nunavut).

2003–07 <45 2.6 2.4 2.8 2.4 2.6 2.5 2.6 2.3 3.3 1.7 1.5 1.2
45–54 1.6 1.4 1.1 0.8 2.8 1.7 1.8 1.1 1.3 0.0 0.9 0.0
55–64 2.4 1.8 2.1 2.1 2.6 2.8 2.2 2.9 3.2 0.0 0.7 7.1
65–74 2.7 2.6 2.3 2.3 3.4 2.7 2.9 3.5 2.0 0.0 3.0 0.0
75–84 3.5 2.0 3.4 2.9 4.7 4.0 3.7 4.7 2.3 0.0 1.4 0.0
85+ 2.0 1.2 2.2 2.6 2.5 1.8 2.5 2.1 4.8 0.0 0.0 0.0
Total 2.5 2.3 2.5 2.2 2.7 2.5 2.5 2.4 3.0 1.2 1.5 1.4
2008–12 <45 2.6 2.4 2.9 2.1 2.9 2.5 2.9 2.5 3.6 1.3 1.6 1.4
45–54 1.6 1.5 1.6 1.4 1.8 1.7 1.7 1.7 2.1 0.8 0.9 0.9
55–64 2.1 1.5 2.1 1.6 3.2 2.6 1.8 2.2 2.2 1.0 1.2 1.1
65–74 2.7 2.6 2.9 2.8 3.6 2.8 2.6 2.8 3.7 1.3 1.6 1.5
75–84 3.2 2.4 3.3 2.4 4.6 3.8 2.9 3.4 4.4 1.5 1.9 1.7
85+ 2.0 1.3 3.0 1.1 3.1 1.6 2.6 2.1 6.3 1.0 1.2 1.1
Total 2.5 2.2 2.7 2.0 2.9 2.5 2.6 2.4 3.4 1.2 1.5 1.4
2013–17 <45 2.5 2.4 2.9 2.0 3.0 2.4 3.1 2.5 3.9 1.2 1.5 1.4
45–54 1.8 1.5 2.4 1.3 1.9 1.9 1.7 1.7 2.3 0.9 1.1 1.0
55–64 2.1 1.5 2.0 1.5 3.3 2.7 1.7 2.2 2.4 1.0 1.2 1.1
65–74 2.8 2.6 3.0 2.7 3.7 3.2 2.3 2.8 4.0 1.3 1.6 1.5
75–84 3.0 2.4 3.8 2.3 4.7 3.5 2.8 3.3 4.8 1.5 1.8 1.6
85+ 2.2 1.3 3.9 1.0 3.2 1.8 2.3 2.1 6.9 1.0 1.3 1.2
Total 2.4 2.2 2.8 1.9 3.0 2.5 2.7 2.4 3.7 1.2 1.4 1.3
2018–22 <45 2.4 2.4 2.9 2.0 3.0 2.3 3.2 2.4 4.1 1.2 1.4 1.3
45–54 2.0 1.5 2.4 1.3 1.9 2.2 2.0 1.7 2.4 1.0 1.2 1.1
55–64 2.1 1.5 2.6 1.4 3.3 2.8 1.6 2.2 2.6 1.0 1.2 1.1
65–74 2.8 2.6 2.6 2.6 3.7 3.4 2.3 2.8 4.3 1.4 1.7 1.5
75–84 3.1 2.4 4.4 2.2 4.8 4.0 2.4 3.3 5.1 1.5 1.9 1.7
85+ 1.9 1.3 3.2 1.0 3.2 1.7 2.2 2.0 7.2 0.9 1.1 1.0
Total 2.4 2.2 2.9 1.9 3.0 2.5 2.8 2.4 3.9 1.2 1.4 1.3
2023–27 <45 2.3 2.4 2.9 1.9 3.0 2.3 3.3 2.4 4.3 1.1 1.4 1.3
45–54 2.1 1.5 2.2 1.3 1.9 2.1 2.2 1.7 2.5 1.0 1.2 1.1
55–64 2.3 1.5 3.6 1.4 3.4 3.2 1.6 2.1 2.7 1.1 1.4 1.3
65–74 2.8 2.6 2.3 2.6 3.7 3.6 2.2 2.7 4.4 1.4 1.7 1.5
75–84 3.2 2.4 4.3 2.2 4.8 4.6 2.2 3.3 5.2 1.6 1.9 1.8
85+ 1.9 1.3 4.3 1.0 3.2 1.6 2.1 2.0 7.4 0.9 1.1 1.0
Total 2.3 2.2 2.9 1.8 3.0 2.5 2.9 2.4 4.0 1.1 1.4 1.3
2028–32 <45 2.2 2.4 2.9 1.9 3.0 2.3 3.4 2.4 4.4 1.1 1.3 1.2
45–54 2.0 1.5 2.4 1.2 1.9 1.9 2.1 1.7 2.6 1.0 1.2 1.1
55–64 2.6 1.5 3.4 1.4 3.4 3.6 1.9 2.2 2.8 1.3 1.5 1.4
65–74 2.8 2.6 2.9 2.5 3.8 3.8 2.1 2.7 4.5 1.4 1.7 1.5
75–84 3.3 2.4 3.5 2.2 4.8 4.9 2.2 3.3 5.4 1.6 2.0 1.8
85+ 2.0 1.3 4.4 0.9 3.3 2.1 1.7 2.0 7.6 1.0 1.2 1.1
Total 2.3 2.2 2.9 1.8 3.1 2.5 3.0 2.4 4.1 1.1 1.4 1.3

Due to the projected Canada population growth and aging, the annual number of newly diagnosed cases is predicted to increase by roughly 26% in both sexes, from 490 to 615 in males and from 395 to 500 in females (Tables 4.20.1 and 4.20.2).

Comments

The etiology of HL remains incompletely characterized. Known risk factors for HL include infectious agents, a compromised immune system, genetic factors, and social and environmental factors. EBV, a ubiquitous virus infecting 80% to 100% of people worldwide, plays a causative role in the etiology of the neoplasm.Endnote 52, Endnote 268, Endnote 269 The EBV genome is present in approximately 50% of the lymphoma cells of cases.Endnote 86 Patients with immunodeficiences or autoimmune diseases are at elevated risk of HL.Endnote 86 For instance, a systematic review shows an 11-fold increase in risk of HL in people with HIV/AIDS.Endnote 270 Familial aggregation of HL has been observed. Having a parent with the disease increases the risk 3-fold.Endnote 271 The familial risks are higher in males and in siblings.Endnote 271

Recent reviews report that ever smoking is associated with a 10% to 15% increased risk of HL,Endnote 272, Endnote 273 functioning in a dose-dependent manner.Endnote 272 Socioeconomic status in childhood is also linked to the risk. High childhood socioeconomic status, single family housing, small family size and high maternal education increase HL risk.Endnote 274 It has been speculated that these social environments delay exposure to common infections which facilitate immune maturation.Endnote 274

The bimodal age distribution of the incidence is expected to be the same in developed countries.Endnote 275 EBV is more commonly associated with HL cases in older adults or younger children, possibly suggesting an alternate age-dependent pathway. Endnote 268 HIV plays a role in developing HL in young people.Endnote 275

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