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Marcotte EL, Pankratz N, Amatruda JF, Frazier AL, Krailo M, Davies S, Starr JR, Lau CC, Roesler M, Langer E, Hallstrom C, Hooten AJ, Poynter JN. Variants in BAK1, SPRY4, and GAB2 are associated with pediatric germ cell tumors: A report from the children's oncology group. Genes Chromosomes Cancer 2017; 56:548-558. [PMID: 28295819 DOI: 10.1002/gcc.22457] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 12/18/2022] Open
Abstract
Germ cell tumors (GCT) are a rare form of childhood cancer that originate from the primordial germ cell. Recent genome-wide association studies (GWAS) have identified susceptibility alleles for adult testicular GCT (TGCT). We test whether these SNPs are associated with GCT in pediatric and adolescent populations. This case-parent triad study includes individuals with GCT diagnosed between ages 0 and 19. We evaluated 26 SNPs from GWAS of adult TGCT and estimated main effects for pediatric GCT within complete trios (N = 366) using the transmission disequilibrium test. We used Estimation of Maternal, Imprinting and interaction effects using Multinomial modelling to evaluate maternal effects in non-Hispanic white trios and dyads (N = 244). We accounted for multiple comparisons using a Bonferroni correction. A variant in SPRY4 (rs4624820) was associated with reduced risk of GCT (OR [95% CI]: 0.70 [0.57, 0.86]). A variant in BAK1 (rs210138) was positively associated with GCT (OR [95% CI]: 1.70 [1.32, 2.18]), with a strong estimated effect for testis tumors (OR [95% CI]: 3.31 [1.89, 5.79]). Finally, a SNP in GAB2 (rs948662) was associated with increased risk for GCT (OR [95% CI]: 1.56 [1.20, 2.03]). Nominal associations (P < 0.05) were noted for eight additional loci. A maternal effect was observed for KITLG SNP rs4474514 (OR [95% CI]: 1.66 [1.21, 2.28]) and a paternal parent-of-origin effect was observed for rs7221274 (P = 0.00007), near TEX14, RAD51C, and PPM1E. We observed associations between SNPs in SPRY4, BAK1, and GAB2 and GCTs. This analysis suggests there may be common genetic risk factors for GCT in all age groups.
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Fuentes-Alabi S, Vasquez RF, Bhakta N, Rodriguez-Galindo C, Frazier AL, Atun R, Gupta S, Horton S. Cost and Cost-Effectiveness of Childhood Cancer Treatment in El Salvador: A Collaborative Budget Model. J Glob Oncol 2017. [DOI: 10.1200/jgo.2017.009191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract 32 Background: Cure rates for childhood cancer in El Salvador (ES) have increased from 5% in 1991 to 68% today as a result of national and international support. Approximately 200 new cases of pediatric cancer are diagnosed annually in ES—all are treated centrally at the National Children’s Hospital Benjamin Bloom. The cost of childhood cancer treatment in low- and middle-income countries (LMICs), such as ES, has not been well investigated. Such data are integral to inform national childhood cancer treatment plans. We undertook this work to determine the cost of operating a national childhood cancer treatment center in ES and to provide an analytic model framework for similar cost analyses in other LMICs. Methods: We conducted a cross-sectional study to evaluate the cost of childhood cancer treatment covered by a collaborative budget model in ES. We calculated costs on the basis of annual cases diagnosed and admitted to National Children’s Hospital Benjamin Bloom, and captured supportive expenses for families that are essential to reducing abandonment. Cost-effective analyses were performed and compared with traditional thresholds. Results: Initial estimates indicate an annual total operating budget of $5.3 million to treat 200 new cases annually. When combined with current survival outcomes, this represents a cost-effective model using WHO-CHOICE thresholds. Conclusion: Providing the first such comprehensive, institution-based estimate for the cost of treatment of childhood cancer in LMICs, we show that a childhood cancer treatment center represents a cost-effective intervention. This baseline information can be used to prioritize future treatments and interventions in ES. This methodology also allows similar studies to be conducted in other LMICs. Together, these data will inform a case for investment in global access to childhood cancer treatment. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST Soad Fuentes-Alabi No relationship to disclose Roberto Franklin Vasquez No relationship to disclose Nickhill Bhakta No relationship to disclose Carlos Rodriguez-Galindo Honoraria: Novimmune A. Lindsay Frazier Consulting or Advisory Role: Decibel Therapeutics Rifat Atun No relationship to disclose Sumit Gupta No relationship to disclose Susan Horton No relationship to disclose
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Shaikh F, Cullen JW, Olson TA, Pashankar F, Malogolowkin MH, Amatruda JF, Villaluna D, Krailo M, Billmire DF, Rescorla FJ, Egler RA, Dicken BJ, Ross JH, Schlatter M, Rodriguez-Galindo C, Frazier AL. Reduced and Compressed Cisplatin-Based Chemotherapy in Children and Adolescents With Intermediate-Risk Extracranial Malignant Germ Cell Tumors: A Report From the Children's Oncology Group. J Clin Oncol 2017; 35:1203-1210. [PMID: 28240974 DOI: 10.1200/jco.2016.67.6544] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Purpose To investigate whether event-free survival (EFS) can be maintained among children and adolescents with intermediate-risk (IR) malignant germ cell tumors (MGCT) if the administration of cisplatin, etoposide, and bleomycin (PEb) is reduced from four to three cycles and compressed from 5 to 3 days per cycle. Patients and Methods In a phase 3, single-arm trial, patients with IR MGCT (stage II-IV testicular, II-III ovarian, I-II extragonadal, or stage I gonadal tumors with subsequent recurrence) received three cycles of PEb. A parametric comparator model specified that the observed EFS rate should not be significantly < 92%. As recommended for trials that test a reduction of therapy, a one-sided P value ≤ .10 was used to indicate statistical significance. In a post hoc analysis, we also compared results to the EFS rate of comparable patients treated with four cycles of PEb in two prior studies. Results Among 210 eligible patients enrolled from 2003 to 2011, 4-year EFS (EFS4) rate was 89% (95% confidence interval, 83% to 92%), which was significantly lower than the 92% threshold of the comparison model ( P = .08). Among 181 newly diagnosed patients, the EFS4 rate was 87%, compared with 92% for 92 comparable children in the historical cohort ( P = .15). The EFS4 rate was significantly associated with stage (stage I, 100%; stage II, 92%; stage III, 85%; and stage IV, 54%; P < .001). Conclusion The EFS rate for children with IR MGCT observed after three cycles of PEb was less than that of a prespecified parametric model, particularly for patients with higher-stage tumors. These data do not support a reduction in the number of cycles of PEb from four to three. However, further investigation of a reduction in the number of cycles for patients with lower-stage tumors is warranted.
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Kamran SC, Seisen T, Markt SC, Preston MA, Frazier AL, Sweeney C, Beard C. Post-orchiectomy adjuvant therapy versus surveillance for stage IS testicular cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.6_suppl.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
406 Background: To assess contemporary treatment patterns and survival for stage IS testicular cancer. Methods: Using the National Cancer Data Base, we identified 1,362 patients with AJCC stage IS testicular cancer (seminoma or non-seminoma) treated between 2004-2012 with either adjuvant therapy (AT) or initial surveillance. AT was defined as the receipt of chemotherapy, radiotherapy (RT), or retroperitoneal lymph node dissection (RPLND) as part of first line treatment after orchiectomy. Annual percent change (APC) in the use of AT was calculated and multivariable logistic regression analysis was performed to identify predictors of receiving AT. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier curves and Cox regression analyses were used to compare overall survival (OS) between AT and initial surveillance groups. All analyses were stratified according to histologic type. Results: Overall, there were 581 (43%) and 781 (57%) men with seminoma and non-seminoma, respectively. Among men with seminoma, 61% received AT (RT = 45%, chemo = 16%) while 39% received initial surveillance. The use of AT decreased over the study period (APC = -2.7; 95%CI: -4.4, 1.1; P = 0.001). Predictors of receiving AT included low income (OR = 1.63; 95%CI: 1.03, 2.56; P = 0.04), while year of diagnosis (OR = 0.89; 95%CI: 0.83, 0.96; P = 0.003) predicted the opposite. The 5-year IPTW-adjusted rates of OS were 99% and 97% in the AT and initial surveillance groups, respectively (HR = 0.36; 95%CI: 0.12, 1.14; P = 0.08). Among men with non-seminoma, 47% received AT (chemo = 38%, RPLND = 9%) while 53% received initial surveillance. The use of AT remained stable over the study period (APC = +0.8; 95%CI: -0.7, +2.2; P = 0.29). Predictors of receiving AT included stage ≥ pT2 (OR = 1.78; 95%CI: 1.06, 3.00; P = 0.03), and lymphovascular invasion (OR = 2.68; 95%CI: 1.88, 3.83; P < 0.001). The 5-year IPTW-adjusted rates of OS were 97% and 95% in the AT and initial surveillance groups, respectively (HR = 0.66; 95%CI: 0.27, 1.61; P = 0.36). Conclusions: Trends in the use of AT for stage IS testicular cancer differed according to histologic type. Nonetheless, we report 5-year OS rates of ≥ 95% for seminoma and non-seminoma without any significant benefit with the use of AT.
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Kamihara J, Ma C, Alabi SLF, Garrido C, Frazier AL, Rodriguez-Galindo C, Orjuela MA. Socioeconomic status and global variations in the incidence of neuroblastoma: call for support of population-based cancer registries in low-middle-income countries. Pediatr Blood Cancer 2017; 64:321-323. [PMID: 27734570 PMCID: PMC5554414 DOI: 10.1002/pbc.26244] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 12/12/2022]
Abstract
Global variations in the incidence of pediatric cancers have been described; however, the causes of such differences are not known. We investigated the relationship between the incidence of embryonal tumors and human development index on a global scale. Increasing incidence of neuroblastoma correlates significantly with an increasing index of human development, with greater incidence among countries with high socioeconomic development, in apparent contrast to the incidence of retinoblastoma. While more data are needed to corroborate this observation, our findings suggest new avenues for etiological research and serve as a call for support of population-based cancer registries in low-middle-income countries.
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Berkey CS, Rosner B, Tamimi RM, Willett WC, Hickey M, Toriola A, Frazier AL, Colditz GA. Body size from birth through adolescence in relation to risk of benign breast disease in young women. Breast Cancer Res Treat 2017; 162:139-149. [PMID: 28062981 PMCID: PMC5290089 DOI: 10.1007/s10549-016-4084-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Body size, from birth throughout adulthood, is associated with breast cancer risk, but few studies have investigated early-life body size and benign breast disease (BBD), a well-established breast cancer risk factor. We consider whether prenatal factors and size at birth, 10, 18 year, and intervening growth, are related to BBD risk. METHODS The Growing Up Today Study includes 9032 females who completed questionnaires annually from 1996 to 2001, then 2003, 2005, 2007, 2010, and 2013. In 1996, their mothers provided pregnancy-related data. From 2005 to 2013, participants (18 year+) reported whether they had ever been diagnosed with biopsy-confirmed BBD (N = 142 cases). RESULTS Girls had greater adiposity (BMI; kg/m2) at 10 year if they were larger at birth, if mother's pre-pregnancy BMI was higher, or if gestational weight gain was greater (all p < .01). Maternal height was (positively) associated (p < .05) with adolescent peak height growth velocity (PHV; in./year). Greater 10 year adiposity was associated with lower PHV and less height growth 10-18 year (both p < .01). Adiposity at 10 year was inversely associated with BBD (OR 0.83/(kg/m2), p < .01) as was increasing adiposity 10-18 year (OR 0.85/(kg/m2), p = .01). In a separate model, 10 year height (OR 1.13/in., p = .02) and height growth 10-18 year (OR 1.19/in.; p < .01) were positively associated. PHV was similarly positively associated (OR 2.58, p = .01, fastest versus slowest growth quartiles). In a multivariable model of BBD risk, gestational weight gain (daughters at highest risk if <20 lb gained), PHV (slowest growing girls at lowest risk), age 10 year height (positive), and BMI (inverse) were the most critical childhood risk factors (each p < .05). CONCLUSIONS Body size factors from pregnancy through adolescence were independently associated with BBD risk in young women.
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Stark D, Rosenberg AR, Johnston D, Knight K, Caperon L, Uleryk E, Frazier AL, Sung L. Patient-Reported Measures of Hearing Loss and Tinnitus in Pediatric Cancer and Hematopoietic Stem Cell Transplantation: A Systematic Review. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2016; 59:1247-1252. [PMID: 27603148 PMCID: PMC5962920 DOI: 10.1044/2016_jslhr-h-15-0363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/04/2015] [Accepted: 01/04/2016] [Indexed: 05/15/2023]
Abstract
Purpose We identified studies that described use of any patient-reported outcome scale for hearing loss or tinnitus among children and adolescents and young adults (AYAs) with cancer or hematopoietic stem cell transplantation (HSCT) recipients. Method In this systematic review, we performed electronic searches of OvidSP MEDLINE, EMBASE, and PsycINFO to August 2015. We included studies if they used any patient-reported scale of hearing loss or tinnitus among children and AYAs with cancer or HSCT recipients. Only English language publications were included. Two reviewers identified studies and abstracted data. Results There were 953 studies screened; 6 met eligibility criteria. All studies administered hearing patient-reported outcomes only once, after therapy completion. None of the studies described the psychometric properties of the hearing-specific component. Three instruments (among 6 studies) were used: Health Utilities Index (Barr et al., 2000; Fu et al., 2006; Kennedy et al., 2014), Hearing Measurement Scales (Einar-Jon et al., 2011; Einarsson et al., 2011), and the Tinnitus Questionnaire for Auditory Brainstem Implant (Soussi & Otto, 1994). All had limitations, precluding routine use for hearing assessment in this population. Conclusions We identified few studies that included hearing patient-reported measures for children and AYA cancer and HSCT patients. None are ideal to take forward into future studies. Future work should focus on the creation of a new psychometrically sound instrument for hearing outcomes in this population.
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Madenci AL, Levine BS, Laufer MR, Boyd TK, Voss SD, Zurakowski D, Frazier AL, Weldon CB. Preoperative risk stratification of children with ovarian tumors. J Pediatr Surg 2016; 51:1507-12. [PMID: 27289417 DOI: 10.1016/j.jpedsurg.2016.05.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/29/2016] [Accepted: 05/08/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The appropriate operative approach to pediatric patients with ovarian tumors must balance real risk of malignancy with maximal preservation of reproductive potential. We evaluate preoperative risk of malignancy in order to more precisely guide treatment, so as to err on the side of ovarian preservation if at all possible. METHODS We retrospectively reviewed the records of all patients undergoing surgical intervention for ovarian tumors at a single institution. The primary endpoint was ovarian malignancy. RESULTS Of 502 patients who underwent surgery for ovarian tumors, 44 (8.8%) had malignancies. Malignancy rate (95% confidence interval) was low for cystic lesions <9cm (0.0%, 0.0-2.9%) and for tumor marker-negative heterogeneous lesions <9cm (2.3%, 0.4-12.1%). High-risk profiles for malignancy included tumor marker-positive heterogeneous lesions (66.7%, 35.4-87.9%) and solid tumors ≥9cm (69.2%, 16.2-40.3%). Intermediate risk tumors included cystic tumors ≥9cm (6.8%, 3.5-20.7%), tumor marker-negative heterogeneous lesions ≥9cm (31.2%, 18.0-48.6%), and solid tumors <9cm (11.1%, 4.4-25.3%). CONCLUSIONS We developed a decision strategy to help determine who may and may not require an ovarian-sparing approach, which warrants prospective application and validation. Ultimately, the decision to pursue an oncologic surgery with oophorectomy and staging (as opposed to fertility-preserving surgery) should be made after individualized discussion involving the surgeon, patient, and family.
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Liao ZW, Rodrigues MC, Poynter JN, Amatruda JF, Rodriguez-Galindo C, Frazier AL. Risk of second gonadal cancers in women and children with germ cell tumors. Cancer 2016; 122:2076-82. [PMID: 27152727 DOI: 10.1002/cncr.30014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/16/2016] [Accepted: 02/22/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Men with testicular cancer have an increased risk of developing cancer in the contralateral testis, but the risks of second gonadal cancers (SGCs) in women and children treated for germ cell tumors (GCTs) have not previously been quantified. METHODS The incidence of SGCs was ascertained in patients who had survived for at least 1 year after GCT diagnosis using data from the Surveillance, Epidemiology, and End Results SEER 9 registries (1980-2012). Relative risks of SGCs were estimated separately for boys, women, and girls compared with men based on Poisson regression analysis. RESULTS The cohort included 21,546 individuals (1116 boys, 827 women, 622 girls, and 18,981 men). A total of 25 SGCs were identified in boys, 1 in women, and 2 in girls compared with 254 in men. The risk of SGC in postpubertal boys (aged ≥10 years) was comparable to that of adult men (boys: standardized incidence ratio, 15.90; 95% confidence interval, 10.29-23.47; men: standardized incidence ratio, 10.88; 95% confidence interval, 9.58-12.30). However, no SGCs were observed in boys who were diagnosed with a testicular GCT before age 10 years (N = 179). An elevated risk of SGC was also not observed for women or girls. CONCLUSIONS The apparent lack of an SGC in prepubertal boys suggests that susceptibility is either age-dependent and/or histology-dependent. The sex differences in the risk of SGC suggest differences in the etiology of ovarian versus testicular GCT. The finding that the risk of SGCs in postpubertal boys is similar to that observed in men indicates that long-term follow-up for SGC is warranted in postpubertal boys. Cancer 2016;122:2076-82. © 2016 American Cancer Society.
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Frazier AL, Krailo M, Poynter J. Can Big Data Shed Light on the Origins of Pediatric Cancer? Pediatrics 2016; 137:peds.2016-0983. [PMID: 27217479 DOI: 10.1542/peds.2016-0983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2016] [Indexed: 11/24/2022] Open
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Shaikh F, Cullen JW, Olson TA, Pashankar F, Malogolowkin MH, Amatruda J, Villaluna D, Krailo MD, Billmire DF, Rescorla FJ, Egler RA, Dicken BJ, Ross JH, Schlatter M, Rodriguez-Galindo C, Frazier AL. Reduced and compressed cisplatin-based chemotherapy in children and adolescents with intermediate-risk extracranial malignant germ cell tumors: A report from the Children’s Oncology Group. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.10512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gupta S, Aitken JF, Bartels U, Brierley J, Dolendo M, Friedrich P, Fuentes-Alabi S, Garrido CP, Gatta G, Gospodarowicz M, Gross T, Howard SC, Molyneux E, Moreno F, Pole JD, Pritchard-Jones K, Ramirez O, Ries LAG, Rodriguez-Galindo C, Shin HY, Steliarova-Foucher E, Sung L, Supriyadi E, Swaminathan R, Torode J, Vora T, Kutluk T, Frazier AL. Paediatric cancer stage in population-based cancer registries: the Toronto consensus principles and guidelines. Lancet Oncol 2016; 17:e163-e172. [PMID: 27300676 DOI: 10.1016/s1470-2045(15)00539-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 11/03/2015] [Accepted: 11/16/2015] [Indexed: 11/16/2022]
Abstract
Population-based cancer registries generate estimates of incidence and survival that are essential for cancer surveillance, research, and control strategies. Although data on cancer stage allow meaningful assessments of changes in cancer incidence and outcomes, stage is not recorded by most population-based cancer registries. The main method of staging adult cancers is the TNM classification. The criteria for staging paediatric cancers, however, vary by diagnosis, have evolved over time, and sometimes vary by cooperative trial group. Consistency in the collection of staging data has therefore been challenging for population-based cancer registries. We assembled key experts and stakeholders (oncologists, cancer registrars, epidemiologists) and used a modified Delphi approach to establish principles for paediatric cancer stage collection. In this Review, we make recommendations on which staging systems should be adopted by population-based cancer registries for the major childhood cancers, including adaptations for low-income countries. Wide adoption of these guidelines in registries will ease international comparative incidence and outcome studies.
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Shaikh F, Murray MJ, Amatruda JF, Coleman N, Nicholson JC, Hale JP, Pashankar F, Stoneham SJ, Poynter JN, Olson TA, Billmire DF, Stark D, Rodriguez-Galindo C, Frazier AL. Paediatric extracranial germ-cell tumours. Lancet Oncol 2016; 17:e149-e162. [PMID: 27300675 DOI: 10.1016/s1470-2045(15)00545-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/10/2015] [Accepted: 11/16/2015] [Indexed: 12/12/2022]
Abstract
Management of paediatric extracranial germ-cell tumours carries a unique set of challenges. Germ-cell tumours are a heterogeneous group of neoplasms that present across a wide age range and vary in site, histology, and clinical behaviour. Patients with germ-cell tumours are managed by a diverse array of specialists. Thus, staging, risk stratification, and treatment approaches for germ-cell tumours have evolved disparately along several trajectories. Paediatric germ-cell tumours differ from the adolescent and adult disease in many ways, leading to complexities in applying age-appropriate, evidence-based care. Suboptimal outcomes remain for several groups of patients, including adolescents, and patients with extragonadal tumours, high tumour markers at diagnosis, or platinum-resistant disease. Survivors have significant long-term toxicities. The challenge moving forward will be to translate new insights from molecular studies and collaborative clinical data into improved patient outcomes. Future trials will be characterised by improved risk-stratification systems, biomarkers for response and toxic effects, rational reduction of therapy for low-risk patients and novel approaches for poor-risk patients, and improved international collaboration across paediatric and adult cooperative research groups.
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Rosario M, Li F, Wypij D, Roberts AL, Corliss HL, Charlton BM, Frazier AL, Austin SB. Disparities by Sexual Orientation in Frequent Engagement in Cancer-Related Risk Behaviors: A 12-Year Follow-Up. Am J Public Health 2016; 106:698-706. [PMID: 26794176 DOI: 10.2105/ajph.2015.302977] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We examined sexual-orientation disparities in frequent engagement in cancer-related risk indicators of tobacco, alcohol, diet and physical activity, ultraviolet radiation, and sexually transmitted infections (STIs). METHODS We used longitudinal data from the national Growing Up Today Study (1999-2010). Of the analytic sample (n = 9958), 1.8% were lesbian or gay (LG), 1.6% bisexual (BI), 12.1% mostly heterosexual (MH), and 84.5% completely heterosexual (CH). RESULTS More sexual minorities (LGs, BIs, and MHs) than CHs frequently engaged in multiple cancer-related risk behaviors (33%, 29%, 28%, and 19%, respectively). Sexual-minority young women, especially BI and MH, more frequently engaged over time in substance use and diet and physical activity risk than CH women. More young gay than CH men frequently engaged over time in vomiting for weight control (odds ratio [OR] = 3.2; 95% confidence interval [CI] = 1.1, 9.4), being physically inactive (OR = 1.7; 95% CI = 1.2, 2.4), and using tanning booths (OR = 4.7; 95% CI = 3.0, 7.4), and had a higher prevalence of ever having an STI (OR = 3.5; 95% CI = 2.0, 6.4). Individual analyses were generally comparable to the group-level analyses. CONCLUSIONS Young sexual minorities are at risk for cancer through frequent exposure to cancer-related risk behaviors over time. Long-term, longitudinal studies and surveillance data are essential and warranted to track frequent engagement in the risk behaviors and cancer-related morbidity and mortality.
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Pashankar F, Hale JP, Dang H, Krailo M, Brady WE, Rodriguez-Galindo C, Nicholson JC, Murray MJ, Bilmire DF, Stoneham S, Arul GS, Olson TA, Stark D, Shaikh F, Amatruda JF, Covens A, Gershenson DM, Frazier AL. Is adjuvant chemotherapy indicated in ovarian immature teratomas? A combined data analysis from the Malignant Germ Cell Tumor International Collaborative. Cancer 2016; 122:230-7. [PMID: 26485622 PMCID: PMC5134834 DOI: 10.1002/cncr.29732] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 08/09/2015] [Accepted: 08/11/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND There is a debate regarding the management of ovarian immature teratomas (ITs). In adult women, postoperative chemotherapy is standard except for stage I, grade 1 disease, whereas surgery alone is standard in pediatric patients. To determine the role of chemotherapy, a pooled analysis of pediatric and adult clinical trials was conducted. METHODS Data from 7 pediatric trials and 2 adult trials were merged in the Malignant Germ Cell International Collaborative data set. Four trials included patients with newly diagnosed pure ovarian ITs and were selected (Pediatric Oncology Group/Children's Cancer Group Intergroup Study (INT 0106), Second UKCCSG Germ Cell Tumor Study (GC2), Gynecologic Oncology Group (GOG 0078 and GOG 0090). Adult and pediatric trials were analyzed separately. The primary outcome measures were event-free survival (EFS) and overall survival (OS). RESULTS One hundred seventy-nine patients were included (98 pediatric patients and 81 adult patients). Ninety pediatric patients were treated with surgery alone, whereas all adult patients received chemotherapy. The 5-year EFS and OS were 91% and 99%, respectively, for the pediatric cohort and 87% and 93%, respectively, for the adults. There were no relapses in grade 1 patients, regardless of the stage or age. Only 1 adult patient with a grade 2 IT relapsed. Among grade 3 patients, the 5-year EFS was 0.92 (0.72-0.98) for stage I/II and 0.52 (0.22-0.75) for stage III in the pediatric cohort (P = .005) and 0.91 (0.69-0.98) for stage I/II and 0.65 (0.39-0.83) for stage III/IV in the adult cohort (P = .01). Postoperative chemotherapy did not decrease relapses in the pediatric cohort. CONCLUSIONS The grade was the most important risk factor for relapse in ovarian ITs. Among grade 3 patients, the stage was significantly associated with relapse. Adjuvant chemotherapy did not decrease relapses in the pediatric cohort; its role in adults remains unresolved. Cancer 2016;122:230-237. © 2015 American Cancer Society.
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Berkey CS, Rosner B, Willett WC, Tamimi RM, Lindsay Frazier A, Colditz GA. Prenatal factors and infant feeding in relation to risk of benign breast disease in young women. Breast Cancer Res Treat 2015; 154:573-82. [PMID: 26582399 DOI: 10.1007/s10549-015-3637-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/07/2015] [Indexed: 11/26/2022]
Abstract
Benign breast disease (BBD) is a well-established risk factor for breast cancer, but little work has considered a girl's early life and her risk for BBD in adulthood. We investigated factors, from pre-conception through infant feeding practices, in relation to subsequent BBD risk in young women. The Growing Up Today Study (GUTS) includes 9032 females, born 1980-1987, who completed questionnaires annually from 1996 through 2001, then 2003, 2005, 2007, 2010, and 2013. In 1996, their mothers provided each participant's birth weight and length, gestational age, biological father's height, and infant feeding factors (e.g., breast-fed, type of formula). In 1999, their mothers reported maternal pre-pregnancy weight and weight gain during index pregnancy. Beginning in 2005, daughters (18 years+) reported whether they had ever been diagnosed with biopsy-confirmed BBD (n = 142 cases, through 2013). Logistic regression estimated associations between early life factors and biopsy-confirmed BBD. Girls whose mother's BMI prior to pregnancy was 20-25 kg/m(2) were at lower risk of BBD as young women (OR = 0.66, p = 0.04, vs. maternal pre-pregnancy BMI < 20). Girls whose mothers gained 20 + pounds (vs. <20 pounds) during pregnancy were at lower risk (among full-term singleton births: OR = 0.48, p = 0.007, if mother gained 20-35 pounds). However, neither birth weight nor BMI at birth were associated with subsequent BBD risk. We found no evidence that infant feeding practices were linked to BBD. A healthy maternal BMI before pregnancy and sufficient weight gain during pregnancy may produce daughters at lower risk for BBD as young women. Further examination of these findings is needed.
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Olson TA, Murray MJ, Rodriguez-Galindo C, Nicholson JC, Billmire DF, Krailo MD, Dang HM, Amatruda JF, Thornton CM, Arul GS, Stoneham SJ, Pashankar F, Stark D, Shaikh F, Gershenson DM, Covens A, Hurteau J, Stenning SP, Feldman DR, Grimison PS, Huddart RA, Sweeney C, Powles T, Lopes LF, dos Santos Agular S, Chinnaswamy G, Khaleel S, Abouelnaga S, Hale JP, Frazier AL. Pediatric and Adolescent Extracranial Germ Cell Tumors: The Road to Collaboration. J Clin Oncol 2015; 33:3018-28. [PMID: 26304902 PMCID: PMC4979195 DOI: 10.1200/jco.2014.60.5337] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
During the past 35 years, survival rates for children with extracranial malignant germ cell tumors (GCTs) have increased significantly. Success has been achieved primarily through the application of platinum-based chemotherapy regimens; however, clinical challenges in GCTs remain. Excellent outcomes are not distributed uniformly across the heterogeneous distribution of age, histologic features, and primary tumor site. Despite good outcomes overall, the likelihood of a cure for certain sites and histologic conditions is less than 50%. In addition, there are considerable long-term treatment-related effects for survivors. Even modest cisplatin dosing can cause significant long-term morbidities. A particular challenge in designing new therapies for GCT is that a variety of specialists use different risk stratifications, staging systems, and treatment approaches for three distinct age groups (childhood, adolescence, and young adulthood). Traditionally, pediatric cancer patients younger than 15 years have been treated by pediatric oncologists in collaboration with their surgical specialty colleagues. Adolescents and young adults with GCTs often are treated by medical oncologists, urologists, or gynecologic oncologists. The therapeutic dilemma for all is how to best define disease risk so that therapy and toxicity can be appropriately reduced for some patients and intensified for others. Further clinical and biologic insights can only be achieved through collaborations that do not set limitations by age, sex, and primary tumor site. Therefore, international collaborations, spanning different cooperative groups and disciplines, have been developed to address these challenges.
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Billmire DF, Rescorla FJ, Ross JH, Schlatter MG, Dicken BJ, Krailo MD, Rodriguez-Galindo C, Olson TA, Cullen JW, Frazier AL. Impact of central surgical review in a study of malignant germ cell tumors. J Pediatr Surg 2015; 50:1502-5. [PMID: 25783295 PMCID: PMC5149399 DOI: 10.1016/j.jpedsurg.2014.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 12/07/2014] [Accepted: 12/13/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Verification of surgical staging has received little attention in clinical oncology trials. Central surgical review was undertaken during a study of malignant pediatric germ cell tumors. METHODS Children's Oncology Group study AGCT0132 included central surgical review during the study. Completeness of submitted data and confirmation of assigned stage were assessed. Review responses were: assigned status confirmed, assignment withheld pending review of additional information requested, or institutional assignment of stage disputed with explanation given. Changes in stage assignment were at the discretion of the enrolling institution. RESULTS A total of 206 patients underwent central review. Failure to submit required data elements or need for clarification was noted in 40%. Disagreement with stage assignment occurred in 10% with 17/21 discordant patients reassigned to stage recommended by central review. Four ovarian tumor patients not meeting review criteria for Stage I remained in that stratum by institutional decision. Two-year event free survival in Stage I ovarian patients was 25% for discordant patients compared to 57% for those meeting Stage I criteria by central review. CONCLUSIONS Central review of stage assignment improved complete data collection and assignment of correct tumor stage at study entry, and allowed for prompt initiation of chemotherapy in patients determined not to have Stage I disease.
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Rosenberg SM, Moskowitz CS, Ford JS, Henderson TO, Frazier AL, Diller LR, Hudson MM, Stanton AL, Chou JF, Smith S, Leisenring WM, Mertens AC, Cox CL, Nathan PC, Krull KR, Robison LL, Oeffinger KC. Health care utilization, lifestyle, and emotional factors and mammography practices in the Childhood Cancer Survivor Study. Cancer Epidemiol Biomarkers Prev 2015; 24:1699-706. [PMID: 26304504 DOI: 10.1158/1055-9965.epi-14-1377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 08/02/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Women with a history of chest radiotherapy have an increased risk of breast cancer; however, many do not undergo annual recommended screening mammography. We sought to characterize the relationship between mammography and potentially modifiable factors, with the goal of identifying targets for intervention to improve utilization. METHODS Of 625 female participants sampled from the Childhood Cancer Survivor Study, who were treated with chest radiotherapy, 551 responded to a survey about breast cancer screening practices. We used multivariate Poisson regression to assess several lifestyle and emotional factors, health care practices, and perceived breast cancer risk, in relation to reporting a screening mammogram within the last two years. RESULTS Women who had a Papanicolaou test [prevalence ratio (PR): 1.77; 95% confidence interval (CI) 1.26-2.49], and who perceived their breast cancer risk as higher than the average woman were more likely to have had a mammogram (PR, 1.26; 95% CI, 1.09-1.46). We detected an attenuated effect of echocardiogram screening [PR, 0.70; 95% CI (0.52-0.95)] on having a mammogram among older women compared with younger women. Smoking, obesity, physical activity, coping, and symptoms of depression and somatization were not associated with mammographic screening. CONCLUSION Our findings suggest that compliance with routine and risk-based screening can be an important indicator of mammography in childhood cancer survivors. In addition, there is a need to ensure women understand their increased breast cancer risk, as a means to encouraging them to follow breast surveillance guidelines. IMPACT Screening encounters could be used to promote mammography compliance in this population.
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Carwile JL, Willett WC, Wang M, Rich-Edwards J, Frazier AL, Michels KB. Milk Consumption after Age 9 Years Does Not Predict Age at Menarche. J Nutr 2015; 145:1900-8. [PMID: 26136590 PMCID: PMC4516774 DOI: 10.3945/jn.115.214270] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/08/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Regular milk consumption during childhood and adolescence is recommended for bone health. However, milk consumption increases circulating insulin-like growth factor I concentrations, and may also accelerate puberty. OBJECTIVE We prospectively investigated the association between milk consumption and age at menarche in the Growing Up Today Study. METHODS Study participants were 5583 US girls who were premenarcheal and ages 9-14 y in 1996. Girls were followed through 2001, at which time 97% of noncensored participants had reported menarche. Frequency of milk and meat consumption was calculated with the use of annual youth/adolescent food frequency questionnaires from 1996-1998. Intake of related nutrients was also measured. Age at menarche was self-reported annually through 2001. RESULTS During follow-up, 5227 girls attained menarche over 10,555 accrued person-years. In models adjusted for dietary and sociodemographic predictors of menarche, frequency of milk consumption did not predict age at onset of menarche (for >3 glasses of milk/d vs. 1.1-4 glasses/wk, HR: 0.93; 95% CI: 0.83, 1.04). After additional adjustment for body size, premenarcheal girls consuming >3 glasses of milk daily were 13% less likely (95% CI: -3%, -23%; P-trend: <0.01) to attain menarche in the next month relative to those consuming 1.1-4 glasses/wk. Neither total meat nor red meat consumption was associated with age at menarche. CONCLUSIONS Our findings suggest that regular consumption of milk in girls aged ≥9 y is unlikely to substantially affect age at onset of menarche. Studies assessing associations between diet in early childhood and pubertal timing may be more illuminating.
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Boeke CE, Tamimi RM, Berkey CS, Colditz GA, Giovannucci E, Malspeis S, Willett WC, Frazier AL. Adolescent dietary vitamin D and sun exposure in relation to benign breast disease. Cancer Causes Control 2015; 26:1181-7. [PMID: 26084210 DOI: 10.1007/s10552-015-0612-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 06/03/2015] [Indexed: 01/22/2023]
Abstract
PURPOSE Vitamin D may reduce cell proliferation and tumor growth in breast tissue, and exposure may be most important during adolescence when breast tissue is developing. In the Nurses' Health Study II, higher recalled adolescent vitamin D intake was associated with a lower risk of benign breast disease (BBD). Our study aimed to assess adolescent vitamin D exposure in relation to BBD in young women. METHODS Vitamin D was assessed in 6,593 adolescent girls (9-15 years of age at baseline) in the prospective Growing Up Today Study cohort using the mean energy-adjusted intakes from food frequency questionnaires in 1996, 1997, and 1998. In 1999, 5,286 girls reported skin color, sunscreen use, tanning bed use, and number of sunburns in the past year, and we used state of residence to assess low versus high ultraviolet index. Biopsy-confirmed BBD was reported on questionnaires in 2005, 2007, and 2010 (n = 122). RESULTS Dietary vitamin D, tanning behaviors, and other sun exposure variables were not significantly associated with BBD in logistic regression models adjusted for age, family history of breast cancer or BBD, age at menarche, nulliparity, alcohol intake, body mass index, and physical activity. The relative risk for the top (>467 IU/day) versus bottom (<243 IU/day) quartile of vitamin D intake was 0.76 (95 % CI 0.47, 1.23). CONCLUSIONS Sun exposure was not significantly associated with BBD in this prospective cohort. However, a suggestive inverse association between dietary vitamin D and BBD was observed that merits further study.
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Alabi SF, Vasquez R, Antillon F, Polanco AC, Orellana E, Perez-Atayde A, Albanti I, Friedrich P, Rodriguez-Galindo C, Ribeiro K, Frazier AL, Garrido C. Implementation of pediatric population-based cancer registries (PBCR) in Central America (CA). J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e12624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Carwile JL, Willett WC, Spiegelman D, Hertzmark E, Rich-Edwards J, Frazier AL, Michels KB. Sugar-sweetened beverage consumption and age at menarche in a prospective study of US girls. Hum Reprod 2015; 30:675-83. [PMID: 25628346 DOI: 10.1093/humrep/deu349] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
STUDY QUESTION Is sugar-sweetened beverage (SSB) consumption associated with age at menarche? SUMMARY ANSWER More frequent SSB consumption was associated with earlier menarche in a population of US girls. WHAT IS KNOWN ALREADY SSB consumption is associated with metabolic changes that could potentially impact menarcheal timing, but direct associations with age at menarche have yet to be investigated. STUDY DESIGN, SIZE, DURATION The Growing up Today Study, a prospective cohort study of 16 875 children of Nurses' Health Study II participants residing in all 50 US states. This analysis followed 5583 girls, aged 9-14 years and premenarcheal at baseline, between 1996 and 2001. During 10 555 person-years of follow-up, 94% (n = 5227) of girls reported their age at menarche, and 3% (n = 159) remained premenarcheal in 2001; 4% (n = 197) of eligible girls were censored, primarily for missing age at menarche. PARTICIPANTS/MATERIALS, SETTING, METHODS Cumulative updated SSB consumption (composed of non-carbonated fruit drinks, sugar-sweetened soda and iced tea) was calculated using annual Youth/Adolescent Food Frequency Questionnaires from 1996 to 1998. Age at menarche was self-reported annually. The association between SSB consumption and age at menarche was assessed using Cox proportional hazards regression. MAIN RESULTS AND THE ROLE OF CHANCE More frequent SSB consumption predicted earlier menarche. At any given age between 9 and 18.5 years, premenarcheal girls who reported consuming >1.5 servings of SSBs per day were, on average, 24% more likely [95% confidence interval (CI): 13, 36%; P-trend: <0.001] to attain menarche in the next month relative to girls consuming ≤2 servings of SSBs weekly, adjusting for potential confounders including height, but not BMI (considered an intermediate). Correspondingly, girls consuming >1.5 SSBs daily had an estimated 2.7-month earlier menarche (95% CI: -4.1, -1.3 months) relative to those consuming ≤2 SSBs weekly. The frequency of non-carbonated fruit drink (P-trend: 0.03) and sugar-sweetened soda (P-trend: 0.001), but not iced tea (P-trend: 0.49), consumption also predicted earlier menarche. The effect of SSB consumption on age at menarche was observed in every tertile of baseline BMI. Diet soda and fruit juice consumption were not associated with age at menarche. LIMITATIONS, REASONS FOR CAUTION Although we adjusted for a variety of suspected confounders, residual confounding is possible. We did not measure SSB consumption during early childhood, which may be an important window of exposure. WIDER IMPLICATIONS OF THE FINDINGS More frequent SSB consumption may predict earlier menarche through mechanisms other than increased BMI. Our findings provide further support for public health efforts to reduce SSB consumption. STUDY FUNDING/COMPETING INTERESTS The Growing up Today Study is supported by grant R03 CA 106238. J.L.C. was supported by the Breast Cancer Research Foundation; Training Grant T32ES007069 in Environmental Epidemiology from the National Institute of Environmental Health Sciences, National Institutes of Health; and Training Grant T32HD060454 in Reproductive, Perinatal and Pediatric Epidemiology from the National Institute of Child Health and Human Development, National Institutes of Health. A.L.F. is supported by the American Cancer Society, Research Scholar Grant in Cancer Control. K.B.M. was supported in part by the National Cancer Institute at the National Institutes of Health (Public Health Service grants R01CA158313 and R03CA170952). There are no conflicts of interest to declare.
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Frazier AL, Hale JP, Rodriguez-Galindo C, Dang H, Olson T, Murray MJ, Amatruda JF, Thornton C, Arul GS, Billmire D, Shaikh F, Pashankar F, Stoneham S, Krailo M, Nicholson JC. Revised risk classification for pediatric extracranial germ cell tumors based on 25 years of clinical trial data from the United Kingdom and United States. J Clin Oncol 2015; 33:195-201. [PMID: 25452439 PMCID: PMC4279239 DOI: 10.1200/jco.2014.58.3369] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To risk stratify malignant extracranial pediatric germ cell tumors (GCTs). PATIENTS AND METHODS Data from seven GCT trials conducted by the Children's Oncology Group (United States) or the Children's Cancer and Leukemia Group (United Kingdom) between 1985 and 2009 were merged to create a data set of patients with stage II to IV disease treated with platinum-based therapy. A parametric cure model was used to evaluate the prognostic importance of age, tumor site, stage, histology, tumor markers, and treatment regimen and estimate the percentage of patients who achieved long-term disease-free (LTDF) survival in each subgroup of the final model. Validation of the model was conducted using the bootstrap method. RESULTS In multivariable analysis of 519 patients with GCTs, stage IV disease (P = .001), age ≥ 11 years (P < .001), and tumor site (P < .001) were significant predictors of worse LTDF survival. Elevated alpha-fetoprotein (AFP) ≥ 10,000 ng/mL was associated with worse outcome, whereas pure yolk sac tumor (YST) was associated with better outcome, although neither met criteria for statistical significance. The analysis identified a group of patients age > 11 years with either stage III to IV extragonadal tumors or stage IV ovarian tumors with predicted LTDF survival < 70%. A bootstrap procedure showed retention of age, tumor site, and stage in > 94%, AFP in 12%, and YST in 27% of the replications. CONCLUSION Clinical trial data from two large national pediatric clinical trial organizations have produced a new evidence-based risk stratification of malignant pediatric GCTs that identifies a poor-risk group warranting intensified therapy.
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Schultz KAP, Harris A, Williams GM, Baldinger S, Doros L, Valusek P, Frazier AL, Dehner LP, Messinger Y, Hill DA. Reply: Serum microRNA screening for DICER1-associated pleuropulmonary blastoma. Pediatr Blood Cancer 2014; 61:2331-2. [PMID: 25251372 PMCID: PMC4205196 DOI: 10.1002/pbc.25233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 11/10/2022]
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