- Age remains a dominant driver: SPC incidence increased steadily with older age at index cancer diagnosis, with higher rates in men than women after age 20.
- Overall declines mask subgroup increases: SPC incidence decreased modestly over time overall, but increased among survivors diagnosed at older ages and in specific cancers, notably female lung and male bladder cancer.
- Strong cohort effects observed: SPC risk peaked in patients born around 1925–1945 and declined in later cohorts, likely reflecting generational exposures such as tobacco use.
- Cancer-specific patterns differ: Breast cancer survivors showed relatively stable SPC risk across age, whereas melanoma and lung cancer survivors had higher or increasing risks in certain groups.
- Implications for survivorship care: Findings support risk-stratified surveillance strategies based on age, cancer type, and cohort, although causal mechanisms could not be determined due to data limitations.
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