In a recent edition of the Journal of Clinical Oncology Wolff and colleagues from Johns Hopkins review their experience in following women who had adjuvant chemotherapy and radiation for breast cancer. It had long been suspected that the chemo might have long-term consequences but this article, because of the size of the group and the care with which the analysis was done, nails it down. They found a six-fold increased risk of bone-marrow cancers, mostly myeloid (acute and chronic myelogenous leukemia, myelodysplastic syndrome) but also non-Hodgkin lymphoma to a lesser extent. The type of chemo used did not seem to matter. The risk was still small, less than one percent, but it was much greater than expected for age-matched patients. Adding radiation increased the risk slightly, but using radiation without chemo did not convey increased risk. Dr. Stark comments, “There is no free lunch in Oncology. These data compel physicians to include bone marrow cancer as a long-term risk, albeit small, in their discussion with patients about risks and benefits to adjuvant chemotherapy. The good done by these treatment still outweighs the bad by several orders of magnitude.”