Since our original analysis 7 years ago,13 the number of SMNs has increased 2.3 fold, from 314 SMNs in 298 individuals to 802 SMNs in 730 individuals. We can now estimate a 30-year cumulative incidence of 9.3% compared with the 20-year incidence of 3.2%. Although the cohort has aged over this period, the SIRs might be expected to decrease with increased likelihood of cancer in the general age-matched population. However, this has not come to pass. SIRs remain elevated in the CCSS cohort. These data highlight the increasing incidence of SNs with continued follow-up of the CCSS cohort and the need for ongoing surveillance of survivors. The lifetime risk and the period of excess risk for SNs is still not known.