51
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Acute lymphoblastic leukemia in adolescent and young adults: treat as adults or as children? Blood 2018; 132:351-361. [DOI: 10.1182/blood-2018-02-778530] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 04/08/2018] [Indexed: 12/21/2022] Open
Abstract
Abstract
Adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) are recognized as a unique population with specific characteristics and needs. In adolescents age 15 to 20 years, the use of fully pediatric protocols is supported by many comparative studies of pediatric and adult cooperative groups. In young adults, growing evidence suggests that pediatric-inspired or even fully pediatric approaches may also dramatically improve outcomes, leading to long-term survival rates of almost 70%, despite diminishing indications of hematopoietic stem-cell transplantation. In the last decade, better knowledge of the ALL oncogenic landscape according to age distribution and minimal residual disease assessments has improved risk stratification. New targets have emerged, mostly in the heterogeneous B-other group, particularly in the Philadelphia-like ALL subgroup, which requires both in-depth molecular investigations and specific evaluations of targeted treatments. The remaining gap in the excellent results reported in children has many other contributing factors that should not be underestimated, including late or difficult access to care and/or trials, increased acute toxicities, and poor adherence to treatment. Specific programs should be designed to take into account those factors and finally ameliorate survival and quality of life for AYAs with ALL.
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52
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Sano H, Kobayashi R, Suzuki D, Kishimoto K, Hori D, Matsushima S, Yoshida M, Sarashina T, Toriumi N, Kobayashi K. Differential efficacy of empirical antibiotic therapy for febrile neutropenia in adolescent/young adult (AYA) and child patients. Int J Hematol 2018; 108:543-549. [DOI: 10.1007/s12185-018-2503-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/04/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
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53
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Martins HTG, Balmant NV, de Paula Silva N, Santos MDO, Reis RDS, de Camargo B. Who cares for adolescents and young adults with cancer in Brazil? J Pediatr (Rio J) 2018; 94:440-445. [PMID: 28888615 DOI: 10.1016/j.jped.2017.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/29/2017] [Accepted: 06/14/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Approximately 6% of all cancers arise in adolescents and young adults. Currently, the ward type best placed to treat this patient group remains controversial. The aim of this study was to evaluate exactly where adolescents and young adults with cancer are treated in Brazil. METHODS Data were extracted from 271 Brazilian hospital-based cancer registries (2007-2011), including all five national regions (North, Northeast, Midwest, South, and Southeast). Variables included gender, age, ethnicity, National Code of Health Establishment, hospital unit state, and region. Tumors were classified according to the World Health Organization classification for adolescents and young adults with cancer. Odds ratios with 95% confidence intervals were computed by unconditional logistic regression. RESULTS Most patients were managed on medical oncology wards, followed by pediatric oncology and then by non-specialist wards. Of patients aged 15-19 years, 49% were managed on pediatric wards; most of the older patients (96%; aged 20-24) were managed on adult wards. Patients were more likely to be seen in medical oncology wards as their age increased (OR=2.03 [1.98-2.09]), or if they were based in the South (OR=1.50 [1.29-1.73]). Conversely, bone tumors were less likely to be treated (decreased OR) on medical oncology wards, regardless of age, gender, and region. CONCLUSION An elevated risk of treatment on medical oncology wards was observed for older patients and those treated in the South. Bone tumors were generally treated in pediatric oncology wards, while skin cancers were treated in medical oncology wards, regardless of age, gender, and region.
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Affiliation(s)
- Helena T G Martins
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brazil; Instituto Nacional de Câncer, Centro de Pesquisa, Programa de Hematologia Pediátrica e Oncologia, Rio de Janeiro, RJ, Brazil
| | - Nathalie V Balmant
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brazil; Instituto Nacional de Câncer, Centro de Pesquisa, Programa de Hematologia Pediátrica e Oncologia, Rio de Janeiro, RJ, Brazil
| | - Neimar de Paula Silva
- Instituto Nacional de Câncer, Rio de Janeiro, RJ, Brazil; Instituto Nacional de Câncer, Centro de Pesquisa, Programa de Hematologia Pediátrica e Oncologia, Rio de Janeiro, RJ, Brazil
| | - Marceli de O Santos
- Instituto Nacional do Câncer, Divisão de Vigilância e Análise de Situação Coordenação de Prevenção e Vigilância, Rio de Janeiro, RJ, Brazil
| | | | - Beatriz de Camargo
- Instituto Nacional de Câncer, Centro de Pesquisa, Programa de Hematologia Pediátrica e Oncologia, Rio de Janeiro, RJ, Brazil.
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54
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Who cares for adolescents and young adults with cancer in Brazil? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2018. [DOI: 10.1016/j.jpedp.2017.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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55
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McNeer JL, Bleyer A. Acute lymphoblastic leukemia and lymphoblastic lymphoma in adolescents and young adults. Pediatr Blood Cancer 2018; 65:e26989. [PMID: 29418064 DOI: 10.1002/pbc.26989] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 12/29/2017] [Accepted: 01/02/2018] [Indexed: 01/22/2023]
Abstract
Compared to younger and older age groups, the incidence of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) has increased more in the adolescent and young adult (AYA) population, the cause of which is unknown. As of the last decade, only half of the AYA patients with these diseases were surviving 10 years. Strong evidence exists that favors "pediatric" treatment regimens for AYAs compared to "adult" treatment regimens in terms of survival rates, hospitalization time, toxicities, late effects, and quality of life both during and after treatment. Targeted agents are clinically accessible for certain subsets of patients with Philadelphia-like ALL, the incidence of which peaks in AYAs. Treatment teams must appreciate the complex psychosocial underpinnings in these patients in order to maximize compliance with the prolonged and complex treatment plans during the AYA years.
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Affiliation(s)
- Jennifer L McNeer
- Section of Pediatric Hematology/Oncology/Stem Cell Transplant, Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Archie Bleyer
- Department of Radiation Medicine, Oregon Health & Science University, Bend, Oregon
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, Texas
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56
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Hughes N, Stark D. The management of adolescents and young adults with cancer. Cancer Treat Rev 2018; 67:45-53. [PMID: 29753962 DOI: 10.1016/j.ctrv.2018.05.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 12/11/2022]
Abstract
Adolescents and Young Adults (AYA) with cancer are young people developing serious illness when at the interface between the responsibilities of paediatric and adult cancer services. Personally, they are in a period of transition both biologically and in major social roles (Sawyer et al., 2018) [1]. For these and other reasons they present a unique set of clinical challenges in their management. Over the last 20 years the requirement for specific services to address their needs has been identified and this has become a growing field of research. Despite this survival rates still lag behind those of children and older adults with cancer (Gatta et al., 2009) [2]. Why do AYA patients have worse outcomes? The observation is that the reason is multifactorial with path to diagnosis, unique cancer biology, uncertainty of treatment protocol, compliance issues and poor recruitment to clinical trials all playing a part. In this review we will discuss the unique challenges faced by healthcare professionals when managing AYA patients who are commonly and accurately described as being in an 'interface' position.
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Affiliation(s)
- Nicola Hughes
- Leeds Institute of Cardiovascular and Molecular Medicine, University of Leeds, UK.
| | - Dan Stark
- Leeds Institute of Cancer and Pathology, St James's Institute of Oncology, Beckett Street, Leeds, UK
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57
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Muffly L, Alvarez E, Lichtensztajn D, Abrahão R, Gomez SL, Keegan T. Patterns of care and outcomes in adolescent and young adult acute lymphoblastic leukemia: a population-based study. Blood Adv 2018; 2:895-903. [PMID: 29669756 PMCID: PMC5916002 DOI: 10.1182/bloodadvances.2017014944] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 02/13/2018] [Indexed: 01/07/2023] Open
Abstract
Adolescents and young adults (AYAs, 15-39 years) with acute lymphoblastic leukemia (ALL) represent a heterogeneous population who receive care in pediatric or adult cancer settings. Using the California Cancer Registry, we describe AYA ALL patterns of care and outcomes over the past decade. Sociodemographics, treatment location, and front-line therapies administered to AYAs diagnosed with ALL between 2004 and 2014 were obtained. Cox regression models evaluated associations between ALL setting and regimen and overall survival (OS) and leukemia-specific survival (LSS) for the entire cohort, younger AYA (<25 years), and AYAs treated in the adult cancer setting only. Of 1473 cases, 67.7% were treated in an adult setting; of these, 24.8% received a pediatric ALL regimen and 40.7% were treated at a National Cancer Institute (NCI)-designated center. In multivariable analyses, front-line treatment in a pediatric (vs adult) setting (OS HR = 0.53, 95% confidence interval [CI], 0.37-0.76; LSS HR = 0.51, 95% CI, 0.35-0.74) and at an NCI/Children's Oncology Group (COG) center (OS HR = 0.80, 95% CI, 0.66-0.96; LSS HR = 0.80, 95% CI, 0.65-0.97) were associated with significantly superior survival. Results were similar when analyses were limited to younger AYAs. Outcomes for AYAs treated in an adult setting did not differ following front-line pediatric or adult ALL regimens. Our population-level findings demonstrate that two-thirds of AYAs with newly diagnosed ALL are treated in an adult cancer setting, with the majority receiving care in community settings. Given the potential survival benefits, front-line treatment of AYA ALL at pediatric and/or NCI/COG-designated cancer centers should be considered.
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Affiliation(s)
- Lori Muffly
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University, Stanford, CA
| | - Elysia Alvarez
- Division of Hematology/Oncology, Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA
| | | | | | - Scarlett Lin Gomez
- Cancer Prevention Institute of California, Fremont, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA; and
| | - Theresa Keegan
- Division of Hematology/Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA
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58
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Sellar RS, Rowntree C, Vora AJ, Furness CL, Goulden N, Mitchell C, Moorman AV, Hough R. Relapse in teenage and young adult patients treated on a paediatric minimal residual disease stratified ALL treatment protocol is associated with a poor outcome: results from UKALL2003. Br J Haematol 2018; 181:515-522. [PMID: 29687881 DOI: 10.1111/bjh.15208] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/21/2018] [Indexed: 11/29/2022]
Abstract
Outcomes for teenage and young adult (TYA) patients with acute lymphoblastic leukaemia (ALL) who relapse on contemporary risk-adapted paediatric protocols are largely unknown and there is no consensus on optimal salvage strategies. We assessed the treatment and outcome of TYA patients (aged 16-24 years) recruited to the UKALL2003 trial, who relapsed following attainment of complete morphological remission. Forty-two of 223 patients (18·8%) relapsed, the majority (n = 26, 62%) on treatment. Thirty-eight (90%) patients received salvage treatment, with 22 (58%) achieving second remission (CR2) and 21 patients receiving an allogeneic haematopoietic cell transplant (alloHSCT). Post-relapse outcomes were poor with a 5-year overall survival (OS) of 23% (95% confidence interval; 11-37%). Outcomes for patients relapsing on active treatment were inferior to those relapsing after completing treatment (5-year OS 9% vs. 52%, log-rank P = 0·001). No patient with B cell ALL relapsing on treatment was alive at the end of the study period. TYA patients with ALL who relapse on the UK paediatric protocol, UKALL2003, are largely unsalvageable with conventional approaches aimed at achieving CR2 followed by alloHSCT. Future efforts should be aimed at identifying those patients who are destined to relapse and exploring novel treatment approaches for this high-risk group and for those who do relapse.
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Affiliation(s)
- Rob S Sellar
- Cancer Institute, University College London, London, United Kingdom.,Department of Haematology, University College London Hospitals, London, United Kingdom
| | | | - Ajay J Vora
- Department of Paediatric Haematology, The Children's Hospital, Sheffield, United Kingdom
| | - Caroline L Furness
- Haemato-Oncology, Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Nicholas Goulden
- Department of Haematology, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Anthony V Moorman
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rachael Hough
- Cancer Institute, University College London, London, United Kingdom.,Department of Haematology, University College London Hospitals, London, United Kingdom
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59
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Friend BD, Schiller GJ. Closing the gap: Novel therapies in treating acute lymphoblastic leukemia in adolescents and young adults. Blood Rev 2018; 32:122-129. [DOI: 10.1016/j.blre.2017.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 08/28/2017] [Accepted: 09/19/2017] [Indexed: 12/13/2022]
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60
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Burke PW, Aldoss I, Lunning MA, Devlin SM, Tallman MS, Pullarkat V, Mohrbacher AM, Douer D. Pegaspargase-related high-grade hepatotoxicity in a pediatric-inspired adult acute lymphoblastic leukemia regimen does not predict recurrent hepatotoxicity with subsequent doses. Leuk Res 2018; 66:49-56. [DOI: 10.1016/j.leukres.2017.12.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 12/02/2017] [Accepted: 12/31/2017] [Indexed: 01/27/2023]
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61
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Zhu MY, Wang H, Huang CY, Xia ZJ, Chen XQ, Geng QR, Wang WD, Wang L, Lu Y. A childhood chemotherapy protocol improves overall survival among adults with T-lymphoblastic lymphoma. Oncotarget 2018; 7:38884-38891. [PMID: 27150061 PMCID: PMC5122438 DOI: 10.18632/oncotarget.9144] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 04/16/2016] [Indexed: 11/26/2022] Open
Abstract
A broadly accepted standard treatment for adult T-lymphoblastic lymphoma (T-LBL) has not yet been defined. To address that issue, we retrospectively compared three chemotherapy regimens used to treat 110 adult patients with newly diagnosed T-LBL. These included two adult regimens (ECOG2993 and hyper-CVAD) and a childhood regimen (BFM-90). These intensive drug regimens are mainly used to treat childhood and adult acute lymphoblastic leukemia. They included induction, consolidation, and maintenance chemotherapy protocols and were administered over the course of 2 years. Seventy-five patients (80%) achieved a complete remission (CR). Within a median follow-up time of 31 months (range: 5–152 months), the 5-year overall survival (OS) and progression-free survival (PFS) rates were 47.7% (95% CI, 35.0–69.8%) and 45.7% (95% CI, 27.6–56.6%), respectively. Shorter survival was associated with age > 40 years, poor ECOG PS and bone marrow involvement. Elevated lactic dehydrogenase (LDH) level, Ann Arbor stage and International Prognostic Index (IPI) score had no prognostic value. The childhood chemotherapy regimen improved CR and the overall survival rate more than the adult regimen in patients aged < 40 years.
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Affiliation(s)
- Meng-Yuan Zhu
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Hua Wang
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Chun-Yu Huang
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Endoscopy, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Zhong-Jun Xia
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Xiao-Qin Chen
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Qi-Rong Geng
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Wei-da Wang
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Liang Wang
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
| | - Yue Lu
- State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Department of Hematological Oncology, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China.,Collaborative Innovation Center of Cancer Medicine, Sun Yat-Sen University Cancer Center, 510060 Guangzhou, Guangdong, P.R. China
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62
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Leonard J, Stock W. Progress in adult ALL: incorporation of new agents to frontline treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:28-36. [PMID: 29222234 PMCID: PMC6142560 DOI: 10.1182/asheducation-2017.1.28] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Treatment of acute lymphoblastic leukemia (ALL) in adults remains a challenge, as the delivery of intensive chemotherapeutic regimens in this population is less feasible than it is in the pediatric population. This has led to higher rates of treatment-related toxicity as well as lower overall survival in the adult population. Over the past several years, a host of novel therapies (eg, immunotherapy and targeted therapies) with better tolerability than traditional chemotherapy are now being introduced into the relapsed/refractory population with very encouraging results. Additionally, insights into how to choose effective therapies for patients while minimizing drug toxicity through pharmacogenomics and the use of minimal residual disease (MRD) monitoring to escalate/de-escalate therapy have enhanced our ability to reduce treatment-related toxicity. This has led to the design of a number of clinical trials which incorporate both novel therapeutics as well as MRD-directed treatment pathways into the frontline setting. The use of increasingly personalized treatment strategies for specific disease subsets combined with standardized and rapid molecular diagnostic testing in the initial diagnosis and frontline treatment of ALL will hopefully lead to further improvements in survival for our adult patients.
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Affiliation(s)
- Jessica Leonard
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR; and
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63
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Hough R, Vora A. Crisis management in the treatment of childhood acute lymphoblastic leukemia: putting right what can go wrong (emergency complications of disease and treatment). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:251-258. [PMID: 29222263 PMCID: PMC6142611 DOI: 10.1182/asheducation-2017.1.251] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The improvement in overall survival in children with acute lymphoblastic leukemia (ALL) over the last 5 decades has been considerable, with around 90% now surviving long term. The risk of relapse has been reduced to such an extent that the risk of treatment-related mortality is now approaching that of mortality caused by relapse. Toxicities may also lead to the suboptimal delivery of chemotherapy (treatment delays, dose reductions, dose omissions), potentially increasing relapse risk, and short- and long-term morbidity, adding to the "burden of therapy" in an increasing number of survivors. Thus, the need to reduce toxicity in pediatric ALL is becoming increasingly important. This work focuses on the risk factors, pathogenesis, clinical features, and emergency management of the life-threatening complications of ALL at presentation and during subsequent chemotherapy, including leucostasis, tumor lysis syndrome, infection, methotrexate encephalopathy, thrombosis, and pancreatitis. Potential strategies to abrogate these toxicities in the future are also discussed.
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Affiliation(s)
- Rachael Hough
- Department of Adolescent Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom; and
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children, London, United Kingdom
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64
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Kansagra A, Litzow M. Treatment of Young Adults with Acute Lymphoblastic Leukemia. Curr Hematol Malig Rep 2017; 12:187-196. [PMID: 28353017 DOI: 10.1007/s11899-017-0377-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Young adults with acute lymphoblastic leukemia are a distinctive category of patients, with substantial difference in disease biology and response to therapy; hence, they pose unique challenges and issues beyond those faced by children and older adults. Despite inferior survival compared to children, there is growing evidence to suggest that young adults have improved outcomes when treated with pediatric-based approaches. With better supportive care and toxicity management and multidisciplinary team and approach, we have made great improvement in outcomes of young adults with ALL. However, despite significant progress, patients with persistence of minimal residual disease have a poor prognosis. This review discusses current controversies in the management of young adults with ALL, outcomes following pediatric and adult protocols, and the role of allogeneic stem cell transplantation. We also explore recent advances in disease monitoring and highlight our approach to incorporation of novel therapies in the management of young adults with ALL.
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Affiliation(s)
- Ankit Kansagra
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Mark Litzow
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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65
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Salzer W, Bostrom B, Messinger Y, Perissinotti AJ, Marini B. Asparaginase activity levels and monitoring in patients with acute lymphoblastic leukemia. Leuk Lymphoma 2017; 59:1797-1806. [DOI: 10.1080/10428194.2017.1386305] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Wanda Salzer
- U.S. Army, Medical Research and Materiel Command, Fort Detrick, MD, USA
| | | | | | | | - Bernard Marini
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
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66
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Results of NOPHO ALL2008 treatment for patients aged 1-45 years with acute lymphoblastic leukemia. Leukemia 2017; 32:606-615. [PMID: 28819280 DOI: 10.1038/leu.2017.265] [Citation(s) in RCA: 261] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/06/2017] [Accepted: 08/09/2017] [Indexed: 12/31/2022]
Abstract
Adults with acute lymphoblastic leukemia (ALL) do worse than children. From 7/2008 to 12/2014, Nordic and Baltic centers treated 1509 consecutive patients aged 1-45 years with Philadelphia chromosome-negative ALL according to the NOPHO ALL2008 without cranial irradiation. Overall, 1022 patients were of age 1-9 years (A), 266 were 10-17 years (B) and 221 were 18-45 years (C). Sixteen patients (three adults) died during induction. All others achieved remission after induction or 1-3 intensive blocks. Subsequently, 45 patients (12 adults) died, 122 patients relapsed (32 adults) with a median time to relapse of 1.6 years and 13 (no adult) developed a second malignancy. Median follow-up time was 4.6 years. Among the three age groups, older patients more often had higher risk ALL due to T-ALL (32%/25%/9%, P<0.001), KMT2A rearrangements (6%/5%/3%, P<0.001) and higher day 29 residual leukemia for B-lineage (P<0.001), but not T-ALL (P=0.53). Event-free survival rates (pEFS5y) were 89±1% (A), 80±3% (B) and 74±4% (C) with significant differences only for non-high risk groups. Except for thrombosis, pancreatitis and osteonecrosis, the risk of 19 specified toxicities was not enhanced by age above 10 years. In conclusion, a pediatric-based protocol is tolerable and effective for young adults, despite their increased frequency of higher risk features.
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67
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Boissel N. How should we treat the AYA patient with newly diagnosed ALL? Best Pract Res Clin Haematol 2017; 30:175-183. [PMID: 29050690 DOI: 10.1016/j.beha.2017.07.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/31/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023]
Abstract
Adolescent and young adult (AYA) patients with acute lymphoblastic leukaemia (ALL) are recognized as a unique population with specific characteristics and needs. In adolescents aged 15-20 years old, the use of full paediatric protocols is supported by many comparative studies of paediatric and adult cooperative groups. In young adults, growing evidence suggests that paediatric-inspired approaches may also improve outcomes and lead to long-term survival rates of almost 70%. In the last decade, better knowledge of ALL oncogenic landscape, age distribution, and minimal residual disease prognostic impact have improved risk stratification. New targets have emerged mostly in the heterogeneous subgroup of Philadelphia-like ALL and will require both in-depth molecular investigations and specific evaluations in rare subgroups of ALL. The remaining gap with the excellent results reported in children has many other contributing factors that should not be underestimated including late or difficult access to care, or poor adherence to treatment.
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Affiliation(s)
- Nicolas Boissel
- Adolescent & Young Adult Hematology Unit, Saint-Louis Hospital, EA-3518, Paris 7 University, 1 avenue Claude Vellefaux, 75010, Paris, France.
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Affiliation(s)
- Ibrahim Aldoss
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA, USA
| | - Anthony S. Stein
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA, USA
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69
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Kansagra A, Dahiya S, Litzow M. Continuing challenges and current issues in acute lymphoblastic leukemia. Leuk Lymphoma 2017; 59:526-541. [PMID: 28604239 DOI: 10.1080/10428194.2017.1335397] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Conventional cytotoxic chemotherapy used to treat acute lymphoblastic leukemia (ALL) has resulted into high cure rates for pediatric patients, however outcomes for adult patients remain suboptimal. The 5-year overall survival is only 30-40% in adults and elderly patients with ALL compared to 90% in children. We have seen major advances in our understanding and management of ALL related to identification of new cytogenetic and molecular abnormalities and development of novel targeted agents for the treatment of ALL. The addition of tyrosine kinase inhibitors, monoclonal antibodies and novel immune therapies (e.g. bispecific T cell engager [BiTE] and chimeric antigen receptor [CAR] T cells) has resulted in improved outcomes. These new developments are changing the treatment paradigm of adults ALL from a 'one size fits all' approach to a more individualized treatment approach based on immunophenotypic, cytogenetic and molecular features. In this article we review recent diagnostic and therapeutic advances along with the challenges in the treatment of patients with ALL.
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Affiliation(s)
- Ankit Kansagra
- a Division of Hematology and Bone Marrow Transplant , Mayo Clinic , Rochester , MN , USA
| | - Saurabh Dahiya
- b Division of Blood and Marrow Transplant , Stanford University , Stanford , CA , USA
| | - Mark Litzow
- a Division of Hematology and Bone Marrow Transplant , Mayo Clinic , Rochester , MN , USA
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Boissel N, Ducassou S. [Adolescents and young adults with acute lymphoblastic leukemia. A specific management]. Bull Cancer 2017; 104:683-689. [PMID: 28576259 DOI: 10.1016/j.bulcan.2017.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 01/05/2023]
Abstract
The acute lymphoblastic leukemia (ALL) is one of the first cancer for which emerged the particularity of the adolescent and young adult population. After decades of poorly concerted approaches, adult and pediatric haematologists found out that adolescents treated according to pediatric approaches had a better outcome than those treated in adult protocols. Therefore, pediatric-inspired therapies have been successfully implemented in the young adult population, leading to decreased criteria for allogeneic stem cell transplantation. More recently, a high prevalence of Philadelphia-like ALL has been identified in the AYA population, which opens the door to the combination of target therapy similar to Philadelphia-positive ALL. AYA patients require specific care programs including fertility counselling, adhesion evaluation, and long-term survivor follow-up. They are to be optimally treated by multidisciplinary teams, exploring their personal needs and determining the best management of the "whole patient".
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Affiliation(s)
- Nicolas Boissel
- Hôpital Saint-Louis, unité d'hématologie adolescents et jeunes adultes, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Stéphane Ducassou
- Hôpital des enfants, unité d'hématologie et oncologie pédiatrique, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
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71
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Tomizawa D, Tanaka S, Kondo T, Hashii Y, Arai Y, Kudo K, Taga T, Fukuda T, Goto H, Inagaki J, Koh K, Ohashi K, Ozawa Y, Inoue M, Kato K, Tanaka J, Atsuta Y, Adachi S, Ishida H. Allogeneic Hematopoietic Stem Cell Transplantation for Adolescents and Young Adults with Acute Myeloid Leukemia. Biol Blood Marrow Transplant 2017; 23:1515-1522. [PMID: 28501543 DOI: 10.1016/j.bbmt.2017.05.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/09/2017] [Indexed: 12/11/2022]
Abstract
Few reports have focused on adolescent and young adult (AYA) patients with acute myeloid leukemia (AML) treated with hematopoietic stem cell transplantation (HSCT). We performed a retrospective analysis based on data obtained from a Japanese nationwide registration database to compare HSCT outcomes in AYA patients with AML with those in children with AML. An analysis of the 2973 patients with de novo AML who received allogeneic HSCT from 1990 to 2013 showed inferior 5-year overall survival (OS) (54% versus 58%, P <.01) and increased treatment-related mortality (TRM) (16% versus 13%, P = .02) in AYA patients. Multivariate analysis for both OS and TRM showed a significant negative impact on AYAs. However, the negative impact of older age lost its significance in an additional analysis focusing on 1407 recent transplant recipients with high-resolution HLA typing (2000 to 2013). Finally, we analyzed the impact of transplantation center type on HSCT outcomes in 317 adolescent patients (15 to 18 years old) and found no difference in outcomes between patients treated at a pediatric or an adult hospital. Higher age was a strong predictive factor for inferior OS resulting from increased TRM, which can be eliminated with better donor selection using high-resolution HLA typing.
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Affiliation(s)
- Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan.
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Kyoto University, Kyoto, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University, Suita, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Kyoto University, Kyoto, Japan
| | - Kazuko Kudo
- Department of Pediatrics, Fujita Health University, Toyoake, Japan
| | - Takashi Taga
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Goto
- Division of Hemato-Oncology/Regenerative Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Jiro Inagaki
- Department of Pediatrics, National Kyushu Cancer Center, Fukuoka, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Masami Inoue
- Department of Hematology/Oncology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - Koji Kato
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan; Department of Healthcare Administration, Nagoya University, Nagoya, Japan
| | - Souichi Adachi
- Department of Human Health Sciences, Kyoto University, Kyoto, Japan
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Desandes E, Brugieres L, Laurence V, Berger C, Kanold J, Tron I, Clavel J, Lacour B. Survival of adolescents with cancer treated at pediatric versus adult oncology treatment centers in France. Pediatr Blood Cancer 2017; 64. [PMID: 27860291 DOI: 10.1002/pbc.26326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND In France, although children aged less than 15 years with cancer are usually referred to pediatric oncology centers, adolescents may be treated at pediatric or adult oncology centers. The objective was to compare survival according to their site of treatment. PROCEDURE Using population-based registration, 15- to 19-year-old patients diagnosed with cancer in 2006 or 2007 and living in six French regions (accounting for 41% of the French population) were included. RESULTS Of the 594 patients included, 33% of the French adolescents were treated at a pediatric oncology center. Compared with those treated at a pediatric center, adolescents treated at an adult center were older, were more likely to have carcinoma and germ-cell tumor, had a longer time to diagnosis, and were less likely to be enrolled in a clinical trial. In addition, the decisions for their management were less likely to be taken in the context of multidisciplinary team meetings. In multivariate analysis, adolescent patients treated at a pediatric center did not have significantly different overall survival (OS) compared with those treated at an adult center (5-year OS: 84.1% [95% confidence interval: 78.6-90.0] versus 87.7% [95% confidence interval: 84.2-91.3]; P = 0.25). CONCLUSIONS The outcomes of French adolescents with cancer have begun to improve, with 81.2% survival in 2006-2007, with no difference between the types of treatment center. However, for this unique group of diseases, survival is not the unique endpoint. In order to ensure good quality of life after cancer, management of those patients requires specific approaches, designed to reduce the late effects of cancer treatment and improve supportive care.
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Affiliation(s)
- Emmanuel Desandes
- French National Registry of Childhood Cancer-French National Registry of Childhood Solid Tumors, University Hospital Centre of Nancy, Vandoeuvre-lès-Nancy, France.,Inserm UMRS-1153, CRESS team 7, University of Paris-Sorbonne, Paris, France
| | - Laurence Brugieres
- Department of Pediatric and Adolescent Oncology, Gustave Roussy, Villejuif, France
| | | | - Claire Berger
- Rhône-Alpes Childhood Cancer Registry, University Hospital Centre of St-Etienne, St-Etienne, France
| | - Justyna Kanold
- Childhood Cancer Registry of Auvergne/Limousin, Inserm CIC 501, University Hospital Centre of Clermont-Ferrand, Clermont-Ferrand, France
| | - Isabelle Tron
- Childhood Cancer Registry of Bretagne, ORS Rennes, Rennes, France
| | - Jacqueline Clavel
- Inserm UMRS-1153, CRESS team 7, University of Paris-Sorbonne, Paris, France.,French National Registry of Childhood Cancer-French National Registry of Childhood Hematological Malignancies, Villejuif, France
| | - Brigitte Lacour
- French National Registry of Childhood Cancer-French National Registry of Childhood Solid Tumors, University Hospital Centre of Nancy, Vandoeuvre-lès-Nancy, France.,Inserm UMRS-1153, CRESS team 7, University of Paris-Sorbonne, Paris, France
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73
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Rytting ME, Jabbour EJ, O'Brien SM, Kantarjian HM. Acute lymphoblastic leukemia in adolescents and young adults. Cancer 2017; 123:2398-2403. [DOI: 10.1002/cncr.30624] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Michael E. Rytting
- Department of Pediatrics-Patient Care, Children's Cancer Hospital; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Elias J. Jabbour
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Susan M. O'Brien
- Chao Family Comprehensive Cancer Center; University of California at Irvine; Orange California
| | - Hagop M. Kantarjian
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
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74
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Management of adults with T-cell lymphoblastic leukemia. Blood 2017; 129:1134-1142. [DOI: 10.1182/blood-2016-07-692608] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 09/27/2016] [Indexed: 12/17/2022] Open
Abstract
Abstract
T-cell acute lymphoblastic leukemia (ALL) is a rare disease in adults with inferior survival outcomes compared with those seen in pediatric patients. Although potentially curable with ∼50% survival at 5 years, adult patients with relapsed disease have dismal outcomes with <10% of patients surviving long term. This review will discuss the diagnosis and management of adult patients with newly diagnosed T-cell ALL with an emphasis on the immunophenotypic and genetic analyses required to assign prognosis, risk stratify, and guide post-remission therapy. The evidence for the main components of complex T-cell ALL treatment regimens is described. The importance of monitoring minimal residual disease is emphasized, with a discussion of the different methods used. The results of hematopoietic cell transplantation are analyzed, and recommendations made about which patients should be considered for this intervention. The treatment of the adolescent and young adult group is delineated, and the role of using “pediatric-inspired” regimens in older adults considered. We also describe the current data and potential future options for the use of novel therapies, including nelarabine and γ-secretase inhibitors, in adult patients with T-cell ALL.
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75
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Wolfson J, Sun CL, Wyatt L, Stock W, Bhatia S. Adolescents and Young Adults with Acute Lymphoblastic Leukemia and Acute Myeloid Leukemia: Impact of Care at Specialized Cancer Centers on Survival Outcome. Cancer Epidemiol Biomarkers Prev 2017; 26:312-320. [PMID: 28209594 DOI: 10.1158/1055-9965.epi-16-0722] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/02/2016] [Accepted: 11/17/2016] [Indexed: 02/06/2023] Open
Abstract
Background: Adolescents and young adults (AYA; 15-39 years) with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) experience inferior survival when compared with children. Impact of care at NCI-designated Comprehensive Cancer Centers (CCC) or Children's Oncology Group sites (COG) on survival disparities remains unstudied.Methods: Using the Los Angeles cancer registry, we identified 1,870 ALL or AML patients between 1 and 39 years at diagnosis. Cox regression analyses assessed risk of mortality; younger age + CCC/COG served as the referent group. Logistic regression was used to determine odds of care at CCC/COG, adjusting for variables above.Results: ALL outcome: AYAs at non-CCC/COG experienced inferior survival (15-21 years: HR = 1.9, P = 0.005; 22-29 years: HR = 2.6, P < 0.001; 30-39 years: HR = 3.0, P < 0.001). Outcome at CCC/COG was comparable between children and young AYAs (15-21 years: HR = 1.3, P = 0.3; 22-29 years: HR = 1.2, P = 0.2) but was inferior for 30- to 39-year-olds (HR = 3.4, P < 0.001). AML outcome: AYAs at non-CCC/COG experienced inferior outcome (15-21 years: HR = 1.8, P = 0.02; 22-39 years: HR = 1.4, P = 0.06). Outcome at CCC/COG was comparable between children and 15- to 21-year-olds (HR = 1.3, P = 0.4) but was inferior for 22- to 39-year-olds (HR = 1.7, P = 0.05). Access: 15- to 21-year-olds were less likely to use CCC/COG than children (P < 0.001). In 22- to 39-year-olds, public/uninsured (ALL: P = 0.004; AML<0.001), African American/Hispanics (ALL: P = 0.03), and 30- to 39-year-olds (ALL: P = 0.03) were less likely to use CCC/COG.Conclusions: Poor survival in AYAs with ALL and AML is mitigated by care at CCC/COG. Barriers to CCC/COG care include public/uninsured, and African American/Hispanic race/ethnicity.Impact: Care at CCC/COG explains, in part, inferior outcomes in AYAs with ALL and AML. Key sociodemographic factors serve as barriers to care at specialized centers. Cancer Epidemiol Biomarkers Prev; 26(3); 312-20. ©2017 AACR.
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Affiliation(s)
- Julie Wolfson
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama. .,Department of Population Sciences, City of Hope, Duarte, California
| | - Can-Lan Sun
- Department of Population Sciences, City of Hope, Duarte, California
| | - Laura Wyatt
- Department of Population Sciences, City of Hope, Duarte, California
| | - Wendy Stock
- Section of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Population Sciences, City of Hope, Duarte, California
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76
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McNeer JL, Bleyer A, Conter V, Stock W. Acute Lymphoblastic Leukemia. CANCER IN ADOLESCENTS AND YOUNG ADULTS 2017. [DOI: 10.1007/978-3-319-33679-4_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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77
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Muffly L, Lichtensztajn D, Shiraz P, Abrahão R, McNeer J, Stock W, Keegan T, Gomez SL. Adoption of pediatric-inspired acute lymphoblastic leukemia regimens by adult oncologists treating adolescents and young adults: A population-based study. Cancer 2017; 123:122-130. [PMID: 27622953 PMCID: PMC5161602 DOI: 10.1002/cncr.30322] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/14/2016] [Accepted: 08/11/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Studies have demonstrated superior outcomes for adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) who are treated using pediatric versus adult therapeutic regimens. To the best of our knowledge, whether adult oncologists in the United States have adopted this approach to ALL in AYA patients is currently unknown. The objective of the current study was to provide a population-based description of ALL treatment patterns in AYA individuals over the past decade. METHODS Data regarding AYA patients aged 15 to 39 years and diagnosed with ALL between 2004 and 2014 while living in the Greater Bay Area were obtained from the Greater Bay Area Cancer Registry (GBACR). Treating facilities were designated as pediatric or adult centers; induction treatment regimens were abstracted from registry text data fields. RESULTS Of 304 patients diagnosed in the GBACR catchment region, complete treatment data were available for 229 (75%). The location of care was identified for 296 patients (97%) treated at 31 unique centers. Approximately 70% of AYA patients received induction therapy at an adult treatment center. All AYA patients who were treated at pediatric centers received pediatric ALL regimens. Among AYA patients treated by adult oncologists with complete treatment data, none received a pediatric regimen before 2008. Between 2008 and 2012, while the US Adult Intergroup C10403 pediatric-inspired ALL protocol was open to accrual, 31% of AYA patients treated by adult oncologists received pediatric regimens. This rate fell to 21% from 2013 through 2014. Adult facilities treating ≥ 2 AYA patients with ALL per year captured in the GBACR were more likely to administer pediatric regimens than lower volume centers (P = .03). CONCLUSIONS As of 2014, only a minority of AYA patients with ALL received pediatric ALL regimens at adult cancer centers. Cancer 2017;122-130. © 2016 American Cancer Society.
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Affiliation(s)
- Lori Muffly
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University, Stanford, California
- Stanford Cancer Institute, Stanford University, Stanford, California
| | | | - Parveen Shiraz
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University, Stanford, California
| | - Renata Abrahão
- Cancer Prevention Institute of California, Freemont, California
| | - Jennifer McNeer
- Section of Hematology/Oncology, Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Theresa Keegan
- Division of Hematology and Oncology, Department of Medicine, University of California at Davis School of Medicine, Sacramento, California
| | - Scarlett Lin Gomez
- Stanford Cancer Institute, Stanford University, Stanford, California
- Cancer Prevention Institute of California, Freemont, California
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Patel B, Kirkwood AA, Dey A, Marks DI, McMillan AK, Menne TF, Micklewright L, Patrick P, Purnell S, Rowntree CJ, Smith P, Fielding AK. Pegylated-asparaginase during induction therapy for adult acute lymphoblastic leukaemia: toxicity data from the UKALL14 trial. Leukemia 2017; 31:58-64. [PMID: 27480385 PMCID: PMC5154375 DOI: 10.1038/leu.2016.219] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 11/23/2022]
Abstract
Safety and efficacy data on pegylated asparaginase (PEG-ASP) in adult acute lymphoblastic leukaemia (ALL) induction regimens are limited. The UK National Cancer Research Institute UKALL14 trial NCT01085617 prospectively evaluated the tolerability of 1000 IU/m2 PEG-ASP administered on days 4 and 18 as part of a five-drug induction regimen in adults aged 25-65 years with de novo ALL. Median age was 46.5 years. Sixteen of the 90 patients (median age 56 years) suffered treatment-related mortality during initial induction therapy. Eight of the 16 died of sepsis in combination with hepatotoxicity. Age and Philadelphia (Ph) status were independent variables predicting induction death >40 versus ⩽40 years, odds ratio (OR) 18.5 (2.02-169.0), P=0.01; Ph- versus Ph+ disease, OR 13.60 (3.52-52.36), P<0.001. Of the 74 patients who did not die, 37 (50.0%) experienced at least one grade 3/4 PEG-ASP-related adverse event, most commonly hepatotoxicity (36.5%, n=27). A single dose of PEG-ASP achieved trough therapeutic enzyme levels in 42/49 (86%) of the patients tested. Although PEG-ASP delivered prolonged asparaginase activity in adults, it was difficult to administer safely as part of the UKALL14 intensive multiagent regimen to those aged >40 years. It proved extremely toxic in patients with Ph+ ALL, possibly owing to interaction with imatinib.
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Affiliation(s)
- B Patel
- Barts Cancer Institute, The London School of Medicine, Queen Mary University of London, London, UK
| | | | - A Dey
- Cancer Institute, University College London, London, UK
| | - D I Marks
- Centre for Clinical Haematology, Nottingham City Hospital, Nottingham, UK
| | | | - T F Menne
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - P Patrick
- CR UK and UCL Cancer Trials Centre, London, UK
| | - S Purnell
- CR UK and UCL Cancer Trials Centre, London, UK
| | | | - P Smith
- CR UK and UCL Cancer Trials Centre, London, UK
| | - A K Fielding
- Cancer Institute, University College London, London, UK
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El-Cheikh J, El Dika I, Massoud R, Charafeddine M, Mahfouz R, Kharfan-Dabaja MA, Bazarbachi A. Hyper-CVAD Compared With BFM-like Chemotherapy for the Treatment of Adult Acute Lymphoblastic Leukemia. A Retrospective Single-Center Analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 17:179-185. [PMID: 27988194 DOI: 10.1016/j.clml.2016.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/16/2016] [Accepted: 11/07/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several induction regimens have been developed for treatment of adult patients with acute lymphoblastic leukemia (ALL). However, only a few prospective randomized trials have directly compared these regimens. PATIENTS AND METHODS In this report, we retrospectively evaluated the outcome of 62 adult ALL patients treated with either hyper-CVAD (hyper fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone; n = 38) or a BFM (Berlin-Frankfurt-Munster)-like regimen (n = 24) between November 2000 and January 2016 at the American university of Beirut Medical Center in Lebanon. The feasibility of allogeneic stem cell transplantation (allo-SCT) for those patients was also evaluated. RESULTS The median follow-up time was 29 (range, 1-129) months. Fifteen (39%) and 10 (42%) patients underwent allo-SCT in the hyper-CVAD and BFM-like group, respectively. At the time of the last follow-up, 28 patients (74%) were in complete remission in the hyper-CVAD group versus 18 patients (75%) in the BFM-like group. Of those, 20 patients (53%) versus 11 patients (46%) were minimal residual disease-negative at the last follow-up, respectively. The 3-year overall survival rate (71.9% vs. 76.9%; P = .808) and 3-year disease-free survival (54.7% vs. 76.4%; P = .435) were similar in hyper-CVAD group compared with the BFM-like group, respectively. Both chemotherapies were relatively well tolerated. CONCLUSION Overall, despite the older age and a greater number of patients with high-risk category (including Philadelphia chromosome-positive) in the hyper-CVAD group, this did not translate into a difference in survival outcome between the 2 groups. The hyper-CVAD regimen appears to be feasible for adult patients with ALL in terms of tolerability and efficacy.
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Affiliation(s)
- Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Imane El Dika
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Radwan Massoud
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maya Charafeddine
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Kumar AJ, Gimotty PA, Gelfand J, Buck G, Rowe JM, Goldstone AH, Fielding A, Marks DI, Litzow M, Paietta E, Lazarus HM, Tallman MS, Luger SM, Loren AW. Delays in postremission chemotherapy for Philadelphia chromosome negative acute lymphoblastic leukemia are associated with inferior outcomes in patients who undergo allogeneic transplant: An analysis from ECOG 2993/MRC UK ALLXII. Am J Hematol 2016; 91:1107-1112. [PMID: 27468137 DOI: 10.1002/ajh.24497] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 07/24/2016] [Accepted: 07/26/2016] [Indexed: 11/08/2022]
Abstract
Adults with acute lymphoblastic leukemia (ALL) have a poorer prognosis than children due to a high risk of relapse. One explanation may be variable adherence to dose-intense chemotherapy. However, little is known about risk factors for delays in therapy and their impact on survival. We conducted an analysis of ECOG 2993/UKALLXII trial to study delays in postremission chemotherapy in adults with newly diagnosed ALL. Logistic regression was used to identify risk factors for a very long delay (VLD, >4 weeks) in start of intensification therapy. Cox regression was used to evaluate the impact of delays on overall survival (OS) and event-free survival (EFS). We evaluated 1076 Philadelphia chromosome negative (Ph-) patients who completed induction chemotherapy, achieved complete remission, and started intensification. Factors independently associated with VLD included duration of hospitalization (odds ratio [OR] = 1.2, P < 0.001) during Phase I; thrombocytopenia during Phase I (OR = 1.16, P = 0.004) or Phase II (OR 1.13, P = 0.001); chemotherapy dose reductions during Induction Phase I (OR = 1.72, P < 0.014); female sex (OR = 1.53, P = 0.010); Black (OR = 3.24, P = 0.003) and Asian (OR = 2.26, P = 0.021) race; and increasing age (OR = 1.31, P < 0.001). In multivariate Cox regression, patients who underwent allogeneic stem cell transplant (alloHCT) had significantly worse OS (HR 1.4, P = 0.03) and EFS (HR 1.4, P = 0.02) after experiencing a VLD compared to alloHCT patients who experienced ≤4 weeks delay. Specific populations (female, older, Black, and Asian patients) were more likely to experience delays in chemotherapy, as were those with significant toxicity during induction. VLDs in therapy negatively affected outcomes in patients undergoing allografting. Am. J. Hematol. 91:1107-1112, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Anita J. Kumar
- Division of Hematology/Oncology; Tufts University Medical Center; Boston MA
| | - Phyllis A. Gimotty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
| | - Joel Gelfand
- Department of Dermatology; University of Pennsylvania; Philadelphia PA
| | | | - Jacob M. Rowe
- Rambam Medical Center; Haifa Israel
- Eastern Cooperative Oncology Group; Brookline MA
| | - Anthony H. Goldstone
- North London Cancer Network, University College London Hospitals; London United Kingdom
| | - Adele Fielding
- Haematology; University College London; London United Kingdom
| | - David I. Marks
- University Hospitals NHS Foundation Trust; Bristol United Kingdom
| | | | - Elisabeth Paietta
- Cancer Center, The North Division of Montefiore Medical Center; Bronx NY
| | - Hillard M. Lazarus
- Case Comprehensive Cancer Center, Case Western Reserve University; Cleveland OH
| | - Martin S. Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center; New York NY
| | - Selina M. Luger
- Abramson Cancer Center, University of Pennsylvania; Philadelphia PA
| | - Alison W. Loren
- Abramson Cancer Center, University of Pennsylvania; Philadelphia PA
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81
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Guzauskas GF, Villa KF, Vanhove GF, Fisher VL, Veenstra DL. Risk-Benefit Analysis of Pediatric-Inspired Versus Hyperfractionated Cyclophosphamide, Vincristine, Doxorubicin, and Dexamethasone Protocols for Acute Lymphoblastic Leukemia in Adolescents and Young Adults. J Adolesc Young Adult Oncol 2016; 6:53-61. [PMID: 27779442 PMCID: PMC5346961 DOI: 10.1089/jayao.2016.0049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Purpose: To estimate the risk–benefit trade-off of a pediatric-inspired regimen versus hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (hyper-CVAD) for first-line treatment of adolescents/young adult (AYA; ages 16–39 years) patients with Philadelphia-negative acute lymphoblastic leukemia. Methods: Patient outcomes were simulated using a 6-state Markov model, including complete response (CR), no CR, first relapse, second CR, second relapse, and death. A Weibull distribution was fit to the progression-free survival curve of hyper-CVAD–treated AYA patients from a single-center study, and comparable patient data from a retrospective study of pediatric regimen–treated AYA patients were utilized to estimate a relative progression difference (hazard ratio = 0.51) and model survival differences. Health-state utilities were estimated based on treatment stage, with an assumption that the pediatric protocol had 0.10 disutility compared with hyper-CVAD before the maintenance phase of treatment. Total life-years and quality-adjusted life-years (QALYs) were compared between treatment protocols at 1, 5, and 10 years, with additional probabilistic sensitivity analyses. Results: Treatment with the pediatric-inspired protocol was associated with a 0.04 increase in life-years, but a 0.01 decrease in QALYs at 1 year. By years 5 and 10, the pediatric-inspired protocol resulted in 0.18 and 0.24 increase in life-years and 0.25 and 0.32 increase in QALYs, respectively, relative to hyper-CVAD. The lower quality of life associated with the induction and intensification phases of pediatric treatment was offset by more favorable progression-free survival and overall survival relative to hyper-CVAD. Conclusions: Our exploratory analysis suggests that, compared with hyper-CVAD, pediatric-inspired protocols may increase life-years throughout treatment stages and QALYs in the long term.
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Affiliation(s)
- Gregory F Guzauskas
- 1 Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington , Seattle, Washington
| | | | | | | | - David L Veenstra
- 1 Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington , Seattle, Washington
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82
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Schindler M, Belle FN, Grotzer MA, von der Weid NX, Kuehni CE. Childhood cancer survival in Switzerland (1976-2013): Time-trends and predictors. Int J Cancer 2016; 140:62-74. [PMID: 27632765 DOI: 10.1002/ijc.30434] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/05/2016] [Indexed: 01/08/2023]
Abstract
Population-based studies on childhood cancer survival are key to monitor progress against cancer and to detect potential differences between regions and other subgroups in the population. We investigated time trends and factors associated with childhood cancer survival on a national level in Switzerland, from 1976 to 2013. We extracted data from the population-based Swiss Childhood Cancer Registry of 5,776 children (age 0-14 years) diagnosed with cancer from 1985 to 2014 in Switzerland. We calculated age-adjusted 5-year survival, defined the annual reduction in risk of death (ARR), and explored associations of survival with clinical and demographic factors. Overall, 5-year survival improved significantly, from 64% in 1976-1983 to 88% in 2004-2013. ARR over the whole period was 4% for all diagnostic groups, greatest for Hodgkin lymphomas (8%), ependymomas (6%), Burkitt's lymphomas (6%) and germ cell tumours (6%). Children treated in hospitals without specialised paediatric cancer centre for leukaemia (HR 12.9), lymphoma (HR 5.0) and neuroblastoma (HR 3.7) were at higher risk of death. In French-speaking Switzerland, risk of death was lower for lymphoma (HR 0.6), CNS tumours (HR 0.7) and neuroblastoma (HR 0.5). Children with migration background had a higher risk of death from all tumours except bone tumours. Childhood cancer survival significantly improved from 1976 to 2013, but there is room for further improvement. Survival rates varied by type of clinical treatment, language region and nationality. All paediatric cancer patients should be referred to a specialised paediatric cancer centre. Further research is needed to intervene and completely eliminate inequalities in survival.
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Affiliation(s)
- Matthias Schindler
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland
| | - Fabiën N Belle
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland
| | - Michael A Grotzer
- Department of Oncology, University Children's Hospital of Zürich, Steinwiesstrasse 75, CH-8032 Züerich, Switzerland
| | - Nicolas X von der Weid
- Department of Paediatric Oncology and Haematology, University Children's Hospital Basel UKKB, Spitalstrasse 33, CH-4056 Basel, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland
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83
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Vrooman LM, Silverman LB. Treatment of Childhood Acute Lymphoblastic Leukemia: Prognostic Factors and Clinical Advances. Curr Hematol Malig Rep 2016; 11:385-94. [DOI: 10.1007/s11899-016-0337-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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84
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Rytting ME, Jabbour EJ, Jorgensen JL, Ravandi F, Franklin AR, Kadia TM, Pemmaraju N, Daver NG, Ferrajoli A, Garcia-Manero G, Konopleva MY, Borthakur G, Garris R, Wang S, Pierce S, Schroeder K, Kornblau SM, Thomas DA, Cortes JE, O'Brien SM, Kantarjian HM. Final results of a single institution experience with a pediatric-based regimen, the augmented Berlin-Frankfurt-Münster, in adolescents and young adults with acute lymphoblastic leukemia, and comparison to the hyper-CVAD regimen. Am J Hematol 2016; 91:819-23. [PMID: 27178680 DOI: 10.1002/ajh.24419] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 05/09/2016] [Accepted: 05/11/2016] [Indexed: 12/13/2022]
Abstract
Several studies reported improved outcomes of adolescents and young adults (AYA) with acute lymphoblastic leukemia (ALL) treated with pediatric-based ALL regimens. This prompted the prospective investigation of a pediatric Augmented Berlin-Frankfurt-Münster (ABFM) regimen, and its comparison with hyper-fractionated cyclophosphamide, vincristine, Adriamycin, and dexamethasone (hyper-CVAD) in AYA patients. One hundred and six AYA patients (median age 22 years) with Philadelphia chromosome- (Ph) negative ALL received ABFM from October 2006 through March 2014. Their outcome was compared to 102 AYA patients (median age 27 years), treated with hyper-CVAD at our institution. The complete remission (CR) rate was 93% with ABFM and 98% with hyper-CVAD. The 5-year complete remission duration (CRD) were 53 and 55%, respectively (P = 0.98). The 5-year overall survival (OS) rates were 60 and 60%, respectively. The MRD status on Day 29 and Day 84 of therapy was predictive of long-term outcomes on both ABFM and hyper-CVAD. Severe regimen toxicities with ABFM included hepatotoxicity in 41%, pancreatitis in 11%, osteonecrosis in 9%, and thrombosis in 19%. Myelosuppression-associated complications were most significant with hyper-CVAD. In summary, ABFM and hyper-CVAD resulted in similar efficacy outcomes, but were associated with different toxicity profiles, asparaginase-related with ABFM and myelosuppression-related with hyper-CVAD. Am. J. Hematol. 91:819-823, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Michael E. Rytting
- Pediatrics-Patient Care; the University of Texas MD Anderson Cancer Center, Texas
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Elias J. Jabbour
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Jeffrey L. Jorgensen
- Department of Hematopathology; the University of Texas MD Anderson Cancer Center, Texas
| | - Farhad Ravandi
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Anna R. Franklin
- Pediatrics-Patient Care; the University of Texas MD Anderson Cancer Center, Texas
| | - Tapan M. Kadia
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Naveen Pemmaraju
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Naval G. Daver
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Alessandra Ferrajoli
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | | | - Marina Y. Konopleva
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Gautam Borthakur
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Rebecca Garris
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Sa Wang
- Department of Hematopathology; the University of Texas MD Anderson Cancer Center, Texas
| | - Sherry Pierce
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Kurt Schroeder
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Steven M. Kornblau
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Deborah A. Thomas
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Jorge E. Cortes
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Susan M. O'Brien
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
| | - Hagop M. Kantarjian
- Department of Leukemia; the University of Texas MD Anderson Cancer Center, Texas
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85
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Egler RA, Ahuja SP, Matloub Y. L-asparaginase in the treatment of patients with acute lymphoblastic leukemia. J Pharmacol Pharmacother 2016; 7:62-71. [PMID: 27440950 PMCID: PMC4936081 DOI: 10.4103/0976-500x.184769] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a hematologic malignancy that predominantly occurs in children between 2 and 10 years of age. L-asparaginase is an integral component of treatment for patients with ALL and since its introduction into pediatric treatment protocols in the 1960s, survival rates in children have progressively risen to nearly 90%. Outcomes for adolescent and young adult (AYA) patients, aged 15-39 years and diagnosed with ALL, have historically been less favorable. However, recent reports suggest substantially increased survival in AYA patients treated on pediatric-inspired protocols that include a greater cumulative dose of asparaginase. All currently available asparaginases share the same mechanism of action - the deamination and depletion of serum asparagine levels - yet each displays a markedly different pharmacokinetic profile. Pegylated asparaginase derived from the bacterium Escherichia coli is used as first-line therapy; however, up to 30% of patients develop a treatment-limiting hypersensitivity reaction. Patients who experience a hypersensitivity reaction to an E. coli-derived asparaginase can continue treatment with Erwinia chrysanthemi asparaginase. Erwinia asparaginase is immunologically distinct from E. coli-derived asparaginases and exhibits no cross-reactivity. Studies have shown that with adequate dosing, therapeutic levels of Erwinia asparaginase activity can be achieved, and patients switched to Erwinia asparaginase due to hypersensitivity can obtain outcomes similar to patients who do not experience a hypersensitivity reaction. Therapeutic drug monitoring may be required to ensure that therapeutic levels of asparaginase activity are maintained.
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Affiliation(s)
- Rachel A Egler
- Department of Pediatric Hematology/Oncology, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Sanjay P Ahuja
- Department of Pediatric Hematology/Oncology, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Yousif Matloub
- Department of Pediatric Hematology/Oncology, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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86
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Trama A, Botta L, Foschi R, Ferrari A, Stiller C, Desandes E, Maule MM, Merletti F, Gatta G. Survival of European adolescents and young adults diagnosed with cancer in 2000-07: population-based data from EUROCARE-5. Lancet Oncol 2016; 17:896-906. [PMID: 27237614 DOI: 10.1016/s1470-2045(16)00162-5] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Data from EUROCARE have consistently shown lower survival for adolescents and young adults (AYAs; aged 15-24 years) than for children (0-14 years) for most cancers that affect both groups, and modest survival improvements up to 2000-02. AYAs have longer survival than that of adults for most cancers. We used the latest definition of AYAs (aged 15-39 years) and provided estimates of 5-year relative survival for European AYAs with cancer diagnosed in 2000-07, compared with children and adults (40-69 years) with cancer, and assessed survival improvements over time. METHODS We analysed data from population-based cancer registries of 27 European countries participating in EUROCARE-5. We used the so-called complete method to estimate 5-year, population-weighted relative survival for 19 cancers affecting AYAs and children, and for 27 cancers affecting AYAs and adults. We assessed relative-survival differences between children versus AYAs, and between AYAs versus adults, using the Z test. We used the period approach to estimate 5-year relative survival over time for children and AYAs, and used a generalised linear model to model survival time trends (1999-2007) and to assess the significance of changes over time. FINDINGS We analysed 56 505 cancer diagnoses in children, 312 483 in AYAs, and 3 567 383 in adults. For all cancers combined, survival improved over time for AYAs (from 79% [95% CI 78·1-80·5] in 1999-2002 to 82% [81·1-83·3] in 2005-07; p<0·0001) and children (from 76% [74·7-77·1] to 79% [77·2-79·4]; p<0·0001). Survival improved significantly in children and AYAs for acute lymphoid leukaemia (p<0·0001) and non-Hodgkin lymphoma (p<0·0001 in AYAs and p=0·023 in children). Survival improved significantly in AYAs only for CNS tumours (p=0·0046), astrocytomas (p=0·040), and malignant melanomas (p<0·0001). Survival remained significantly worse in AYAs than in children for eight important cancers: acute lymphoid leukaemias, acute myeloid leukaemias, Hodgkin's lymphomas, non-Hodgkin lymphomas, astrocytomas, Ewing's sarcomas, and rhabdomyosarcomas (p<0·0001 in all cases), and osteosarcomas (p=0·011). INTERPRETATION Notwithstanding the encouraging results for some cancers, and overall, we showed poorer survival in AYAs than in children for the eight important cancers. Recent European initiatives to improve outcomes in AYAs might reduce the survival gap between children and AYAs, but this reduction can only be verified by future population-based studies. FUNDING Italian Ministry of Health, European Commission.
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Affiliation(s)
- Annalisa Trama
- Evaluative Epidemiology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
| | - Laura Botta
- Evaluative Epidemiology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Roberto Foschi
- Evaluative Epidemiology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Andrea Ferrari
- Paediatric Oncology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Charles Stiller
- Childhood Cancer Research Group, University of Oxford, Oxford, UK
| | - Emmanuel Desandes
- CHU Nancy, Registre National des Tumeurs Solides de l'Enfant, Vandoeuvre-lès-Nancy, France; Université Paris-Sorbonne, CRESS équipe 7, INSERM UMRS-1153, Paris, France
| | - Milena Maria Maule
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Franco Merletti
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Gemma Gatta
- Evaluative Epidemiology Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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87
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Seftel MD, Neuberg D, Zhang MJ, Wang HL, Ballen KK, Bergeron J, Couban S, Freytes CO, Hamadani M, Kharfan-Dabaja MA, Lazarus HM, Nishihori T, Paulson K, Saber W, Sallan SE, Soiffer R, Tallman MS, Woolfrey AE, DeAngelo DJ, Weisdorf DJ. Pediatric-inspired therapy compared to allografting for Philadelphia chromosome-negative adult ALL in first complete remission. Am J Hematol 2016; 91:322-9. [PMID: 26701142 PMCID: PMC4764423 DOI: 10.1002/ajh.24285] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 12/15/2015] [Accepted: 12/17/2015] [Indexed: 12/17/2022]
Abstract
For adults with Philadelphia chromosome-negative (Ph-) acute lymphoblastic leukemia (ALL) in first complete remission (CR1), allogeneic hematopoietic cell transplantation (HCT) is an established curative strategy. However, pediatric-inspired chemotherapy may also offer durable leukemia-free survival in the absence of HCT. We compared 422 HCT recipients aged 18-50 years with Ph-ALL in CR1 reported to the CIBMTR with an age-matched concurrent cohort of 108 Ph- ALL CR1 patients who received a Dana-Farber Consortium pediatric-inspired non-HCT regimen. At 4 years of follow-up, incidence of relapse after HCT was 24% (95% CI 19-28) versus 23% (95% CI 15-32) for the non-HCT (chemo) cohort (P=0.97). Treatment-related mortality (TRM) was higher in the HCT cohort [HCT 37% (95% CI 31-42) versus chemo 6% (95% CI 3-12), P<0.0001]. DFS in the HCT cohort was 40% (95% CI 35-45) versus 71% (95% CI 60-79) for chemo, P<0.0001. Similarly, OS favored chemo [HCT 45% (95% CI 40-50)] versus chemo 73% [(95% CI 63-81), P<0.0001]. In multivariable analysis, the sole factor predictive of shorter OS was the administration of HCT [hazard ratio 3.12 (1.99-4.90), P<0.0001]. For younger adults with Ph- ALL, pediatric-inspired chemotherapy had lower TRM, no increase in relapse, and superior overall survival compared to HCT. Am. J. Hematol. 91:322-329, 2016. © 2015 Wiley Periodicals, Inc.
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MESH Headings
- Adolescent
- Adult
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow Transplantation/methods
- Disease-Free Survival
- Dose-Response Relationship, Drug
- Female
- Hematopoietic Stem Cell Transplantation/methods
- Humans
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/drug therapy
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/mortality
- Leukemia, Myeloid, Chronic, Atypical, BCR-ABL Negative/therapy
- Male
- Middle Aged
- Multivariate Analysis
- Remission Induction/methods
- Transplantation, Homologous
- Young Adult
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Affiliation(s)
- Matthew D. Seftel
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Donna Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research (CIBMTR®), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Divsion of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI
| | - Hai-Lin Wang
- Center for International Blood and Marrow Transplant Research (CIBMTR®), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Karen Kuhn Ballen
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Julie Bergeron
- Department of Hematology, Hôpital Maisonneuve-Rosemont, Montréal, Quebec, Canada
| | - Stephen Couban
- Division of Haematology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Canada
| | - César O. Freytes
- South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Mehdi Hamadani
- Center for International Blood and Marrow Transplant Research (CIBMTR®), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mohamed A. Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Hillard M. Lazarus
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Kristjan Paulson
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research (CIBMTR®), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Stephen E. Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Robert Soiffer
- Department of Medical Oncology/Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - Martin S. Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ann E. Woolfrey
- Department of Pediatric Hematopoietic Cell Transplant, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Daniel J. DeAngelo
- Department of Medical Oncology/Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - for the Acute Leukemia Committee of the CIBMTR and the Dana Farber ALL Consortium
- Gorgun Akpek: Stem Cell Transplantation and Cellular Therapy Program, Banner MD Anderson Cancer Center, Gilbert, AZ; Veronika Bachanova; Bone and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, MN; Ulrike Bacher: Department of Hematology/Oncology, University Medicine Goettingen, Goettingen, Germany; Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg, Hamburg, Germany; Frederic Baron: Centre Hospitalier Universitaire de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium; Asad Bashey: Department of Medicine, The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA; Jean-Yves Cahn: Department of Hematology, University Hospital, Grenoble, France; Bruce M. Camitta: Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI; Edward A. Copelan: Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC; Marcos de Lima: Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH; Abhinav Deol: Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI; Robert Peter Gale: Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom; Usama Gergis: Hematolgic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY; William J. Hogan: Division of Hematology and Transplant Center, Mayo Clinic, Rochester, MN; Partow Kebriaei: Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX; Mark R. Litzow: Division of Hematology and Transplant Center, Mayo Clinic, Rochester, MN; Alison W. Loren: Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Alan M. Miller: Department of Medical Oncology, Baylor University Medical Center, Dallas, TX; Maxim Norkin: Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL; Richard F. Olsson: Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden, Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden; Ran Reshef: Blood and Marrow Transplantation Program and Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY; Mitchell Sabloff: Division of Hematology, Department of Medicine, University of Ottawa and Ottawa Research Institute, Ottawa, Ontario, Canada; Brenda M. Sandmaier: Division of Medical Oncology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Bipin N. Savani: Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Harry C. Schouten: Department of Hematology, Academische Ziekenhuis, Maastricht, Netherlands; Ravi Vij: Division of Hematology and Oncology, Washington University Medical School, St. Louis, MO; Peter H. Wiernik: Our Lady of Mercy Medical Center, New York Medical College, John Cardinal O'Connor Campus, Bronx, NY; Baldeep Wirk: Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA; William Allen Wood: Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill, NC
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88
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Figueiredo L, Cole PD, Drachtman RA. Asparaginase Erwinia chrysanthemi as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia who have developed hypersensitivity to E. coli-derived asparaginase. Expert Rev Hematol 2016; 9:227-34. [PMID: 26765930 DOI: 10.1586/17474086.2016.1142370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase has been a mainstay of therapy in the treatment of acute lymphoblastic leukemia since the 1970s. There are two major preparations available and FDA approved in the United States today, one derived from Escherichia coli and the other from Erwinia chrysanthemi. Erwinia asparaginase is antigenically distinct from and has a considerably shorter biological half-life than E coli asparaginase. Erwinia asparaginase has been used in cases of hypersensitivity to E. coli-derived asparaginases, which has been reported in up to 30% of patients. While PEG asparaginase is increasingly used in front-line therapy for ALL, hypersensitivity still occurs with this preparation, and a change to a non-cross-reactive preparation may be necessary.
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Affiliation(s)
- Lisa Figueiredo
- a Pediatric Hematology/Oncology , Children's Hospital at Montefiore, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Peter D Cole
- a Pediatric Hematology/Oncology , Children's Hospital at Montefiore, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Richard A Drachtman
- b Pediatic Hematology/Oncology , Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
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89
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Nakata-Yamada K, Inoue M, Ioka A, Ito Y, Tabuchi T, Miyashiro I, Masaie H, Ishikawa J, Hino M, Tsukuma H. Comparison of survival of adolescents and young adults with hematologic malignancies in Osaka, Japan. Leuk Lymphoma 2015; 57:1342-8. [PMID: 26695739 DOI: 10.3109/10428194.2015.1083562] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The survival gap between adolescents and young adults (AYAs) with hematological malignancies persists in many countries. To determine to what extent it does in Japan, we investigated survival and treatment regimens in 211 Japanese AYAs (15-29 years) in the Osaka Cancer Registry diagnosed during 2001-2005 with hematological malignancies, and compared adolescents (15-19 years) with young adults (20-29 years). AYAs with acute lymphoblastic leukemia (ALL) had a poor 5-year survival (44%), particularly young adults (29% vs. 64% in adolescents, p = 0.01). Additional investigation for patients with ALL revealed that only 19% of young adults were treated with pediatric treatment regimens compared with 45% of adolescents (p = 0.05). Our data indicate that we need to focus on young adults with ALL and to consider establishing appropriate cancer care system and guidelines for them in Japan.
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Affiliation(s)
- Kayo Nakata-Yamada
- a Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Masami Inoue
- b Department of Hematology/Oncology , Osaka Medical Center and Research Institute for Maternal and Child Health , Osaka , Japan
| | - Akiko Ioka
- a Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Yuri Ito
- a Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Takahiro Tabuchi
- a Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Isao Miyashiro
- a Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Hiroaki Masaie
- c Department of Hematology/Oncology , Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Jun Ishikawa
- c Department of Hematology/Oncology , Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
| | - Masayuki Hino
- d Department of Hematology , Graduate School of Medicine, Osaka City University , Osaka , Japan
| | - Hideaki Tsukuma
- a Center for Cancer Control and Statistics, Osaka Medical Center for Cancer and Cardiovascular Diseases , Osaka , Japan
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90
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Hough R, Rowntree C, Goulden N, Mitchell C, Moorman A, Wade R, Vora A. Efficacy and toxicity of a paediatric protocol in teenagers and young adults with Philadelphia chromosome negative acute lymphoblastic leukaemia: results from UKALL 2003. Br J Haematol 2015; 172:439-51. [DOI: 10.1111/bjh.13847] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/14/2015] [Indexed: 12/31/2022]
Affiliation(s)
| | | | | | | | - Anthony Moorman
- Leukaemia Research Cytogenetics Group; Northern Institute for Cancer Research; Newcastle University; Newcastle upon Tyne UK
| | - Rachel Wade
- Clinical Trial Service Unit; University of Oxford; Oxford UK
| | - Ajay Vora
- Sheffield Children's Hospital; Sheffield UK
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91
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Hijiya N, van der Sluis IM. Asparaginase-associated toxicity in children with acute lymphoblastic leukemia. Leuk Lymphoma 2015; 57:748-57. [PMID: 26457414 PMCID: PMC4819847 DOI: 10.3109/10428194.2015.1101098] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase is an integral component of multiagent chemotherapy regimens for the treatment of children with acute lymphoblastic leukemia. Positive outcomes are seen in patients who are able to complete their entire prescribed course of asparaginase therapy. Toxicities associated with asparaginase use include hypersensitivity (clinical and subclinical), pancreatitis, thrombosis, encephalopathy, and liver dysfunction. Depending on the nature and severity of the toxicity, asparaginase therapy may be altered or discontinued in some patients. Clinical hypersensitivity is the most common asparaginase-associated toxicity requiring treatment discontinuation, occurring in up to 30% of patients receiving Escherichia coli-derived asparaginase. The ability to rapidly identify and manage asparaginase-associated toxicity will help ensure patients receive the maximal benefit from asparaginase therapy. This review will provide an overview of the common toxicities associated with asparaginase use and recommendations for treatment management.
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Affiliation(s)
- Nobuko Hijiya
- a Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Inge M van der Sluis
- b Department of Pediatric Oncology/Hematology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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92
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Boissel N, Sender LS. Best Practices in Adolescent and Young Adult Patients with Acute Lymphoblastic Leukemia: A Focus on Asparaginase. J Adolesc Young Adult Oncol 2015; 4:118-28. [PMID: 26421220 PMCID: PMC4575545 DOI: 10.1089/jayao.2015.0014] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The inclusion of asparaginase in chemotherapy regimens to treat acute lymphoblastic leukemia (ALL) has had a positive impact on survival in pediatric patients. Historically, asparaginase has been excluded from most treatment protocols for adolescent and young adult (AYA) patients because of perceived toxicity in this population, and this is believed to have contributed to poorer outcomes in these patients. However, retrospective analyses over the past 12 years have shown that 2-, 5-, and 7-year overall survival of AYA patients is significantly improved with pediatric versus adult protocols. The addition of asparaginase to adult protocols yielded high rates of first remission and improved survival. However, long-term survival remains lower compared with what has been seen in pediatrics. The notion that asparaginase is poorly tolerated by AYA patients has been challenged in multiple studies. In some, but not all, studies, the incidences of hepatic and pancreatic toxicities were higher in AYA patients, whereas the rates of hypersensitivity reactions did not appear to differ with age. There is an increased risk of venous thromboembolic events, and management with anti-coagulation therapy is recommended. Overall, the risk of therapy-related mortality is low. Together, this suggests that high-intensity pediatric protocols offer an effective and tolerable approach to treating ALL in the AYA population.
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Affiliation(s)
- Nicolas Boissel
- Department of Adult Hematology, Saint-Louis Hospital, University of Paris, Paris, France
| | - Leonard S. Sender
- Department of Epidemiology, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
- Hyundai Cancer Institute, CHOC Children's Hospital, Orange, California
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93
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Improved survival in adult patients with acute lymphoblastic leukemia in the Netherlands: a population-based study on treatment, trial participation and survival. Leukemia 2015; 30:310-7. [PMID: 26286115 DOI: 10.1038/leu.2015.230] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/05/2015] [Accepted: 08/05/2015] [Indexed: 12/11/2022]
Abstract
This nationwide population-based study assessed trends in treatment, trial participation and survival among 1833 adult patients diagnosed with acute lymphoblastic leukemia (ALL) in the Netherlands between 1989 and 2012 reported to the Netherlands Cancer Registry. Patients were categorized into four periods and five age groups (18-24, 25-39, 40-59, 60-69 and ⩾70 years). The application of allogeneic stem cell transplantation (alloSCT), particularly reduced-intensity conditioning (RIC) alloSCT, increased over time up to age 70 years. The inclusion rate in the trials was 67, 66, 55, 58 and 0% for the five age groups. Survival improved over time for patients below 70 years. Five-year relative survival in the period 2007-2012 was 75, 57, 37, 22 and 5% for the five age groups. In that same period, 5-year overall survival among patients aged 18-39 years was 68% for the chemotherapy-alone group and 66% for the alloSCT group. For patients aged 40-69 years, the corresponding estimates were 24 and 41%. Pronounced survival improvement observed among patients aged 18-39 years might mainly be explained by implementation of pediatric-based regimens since 2005, whereas among patients aged 40-69 years, increased application of RIC-alloSCT has contributed significantly to the observed improvement. Outcome of patients aged ⩾70 remains unsatisfactory, indicating a need for specific trials for the elderly.
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94
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Kawedia JD, Rytting ME. Asparaginase in acute lymphoblastic leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 14 Suppl:S14-7. [PMID: 25486949 DOI: 10.1016/j.clml.2014.06.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 06/04/2014] [Indexed: 01/19/2023]
Abstract
Cure rates in pediatric acute lymphoblastic leukemia have significantly improved over the past decades. Now, almost 90% of children will survive the disease. The cure rates in adolescents, young adults, and adults have not kept pace with the improvements in younger patients, even though almost an equal proportion of adult patients achieve complete remission as their pediatric counterparts. Differences in treatment regimens might be important. Intensive use of asparaginase has been a key component of successful pediatric therapy. In this review, we focus on the use of asparaginase and the potential of optimizing asparaginase use via monitoring to minimize adverse drug events and improve efficacy of the drug.
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Affiliation(s)
- Jitesh D Kawedia
- Department of Pharmacy Research, The University of Texas M.D. Anderson Cancer Center, Houston, TX.
| | - Michael E Rytting
- Division of Pediatrics, The University of Texas M.D. Anderson Cancer Center, Houston, TX
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95
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Curran E, Stock W. How I treat acute lymphoblastic leukemia in older adolescents and young adults. Blood 2015; 125:3702-10. [PMID: 25805810 PMCID: PMC4463735 DOI: 10.1182/blood-2014-11-551481] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 03/11/2015] [Indexed: 12/22/2022] Open
Abstract
At the intersection between children and older adults, the care of adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) poses unique challenges and issues beyond those faced by other age groups. Although the survival of AYA patients is inferior to younger children, growing evidence suggests that AYA patients have improved outcomes, with disease-free survival rates of 60% to 70%, when treated with pediatric-based approaches. A holistic approach, incorporating a multidisciplinary team, is a key component of successful treatment of these AYA patients. With the appropriate support and management of toxicities during and following treatment, these regimens are well tolerated in the AYA population. Even with the significant progress that has been made during the last decade, patients with persistence of minimal residual disease (MRD) during intensive therapy still have a poor prognosis. With new insights into disease pathogenesis in AYA ALL and the availability of disease-specific kinase inhibitors and novel targeted antibodies, future studies will focus on individualized therapy to eradicate MRD and result in further improvements in survival. This case-based review will discuss the biology, pharmacology, and psychosocial aspects of AYA patients with ALL, highlighting our current approach to the management of these unique patients.
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Affiliation(s)
- Emily Curran
- University of Chicago Medicine and University of Chicago Comprehensive Cancer Center, Chicago, IL
| | - Wendy Stock
- University of Chicago Medicine and University of Chicago Comprehensive Cancer Center, Chicago, IL
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96
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Abstract
Adolescent and young adult (AYA) patients with cancer are a unique category of patients who, depending on age at time of diagnosis, might receive treatment from oncologists specializing either in the treatment of children or adults. In the USA, AYA oncology generally encompasses patients 15-39 years of age. AYA patients with cancer typically present with diseases that span the spectrum from 'paediatric' cancers (such as acute lymphoblastic leukaemia [ALL] and brain tumours) to 'adult' tumours (such as breast cancer and melanoma), as well as cancers that are largely unique to their age group (such as testicular cancer and bone tumours). Research indicates that outcomes of AYA patients with cancer are influenced not only by the treatment provided, but also by factors related to 'host' biology. In addition to the potential biological and cancer-specific differences between AYAs and other patients with cancer, AYA patients also often have disparate access to clinical trials and suffer from a lack of age-appropriate psychosocial support services and health services, which might influence survival as well as overall quality of life. In this Review, these issues are discussed, with a focus on two types of AYA cancer--ALL and melanoma--highlighting findings arising from the use of emerging technologies, such as whole-genome sequencing.
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97
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Abstract
OBJECTIVES To identify treatment-related toxicities that are either more frequent or more severe in the adolescent and young adult (AYA) oncology population. To explore differences in drug pharmacology and patient physiology that contribute to toxicities in the AYA population and to describe the impact of treatment-related toxicities on outcomes for AYA patients. DATA SOURCES A PubMed search was undertaken using the key words Adolescent Young Adult Oncology, AYA, toxicity, bone marrow transplant, late effects, and chemotherapy. Additional toxicity information was also obtained from recent publications from cancer cooperative groups treating AYA patients. CONCLUSION AYA patients often experience more severe toxicities than children when treated with identical chemotherapy regimens, which can interfere with successful administration of planned treatment, as well as have profound effects on quality of life. AYA patients with cancer face the dual challenge of disease biology associated with inferior response to treatment, thus necessitating treatment intensification, while at the same time suffering higher rates of specific toxicities such as vincristine-induced neuropathy, osteonecrosis, and treatment-related mortality caused by infection. IMPLICATIONS FOR NURSING PRACTICE AYA patients are at a higher risk for toxicities from regimens that may be tolerated by younger patients. Staff should be aware of toxicities facing this population so that appropriate supportive care measures can be utilized. Future research on the pharmacology of drugs in adolescence, hormonal effects on drug-metabolizing enzymes, cumulative exposure to different drugs in combination, and risk and severity of specific toxicities will be critical to improving the treatment of AYA patients.
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98
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Toft N, Birgens H, Abrahamsson J, Griškevičius L, Hallböök H, Heyman M, Klausen TW, Jónsson ÓG, Palk K, Pruunsild K, Quist-Paulsen P, Vaitkeviciene G, Vettenranta K, Asberg A, Helt LR, Frandsen T, Schmiegelow K. Toxicity profile and treatment delays in NOPHO ALL2008-comparing adults and children with Philadelphia chromosome-negative acute lymphoblastic leukemia. Eur J Haematol 2015; 96:160-9. [PMID: 25867866 DOI: 10.1111/ejh.12562] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2015] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Cure rates improve when adolescents and young adults with acute lymphoblastic leukemia (ALL) are treated according to pediatric protocols. Assumed risks of toxicities and associated delays in treatment have played a role in setting upper age limits. The aim of this study was to examine the toxicity profile and treatment delays in NOPHO ALL2008 comparing children and adults. METHODS We collected information on 19 treatment-related toxicities, systematically captured at 3-month intervals throughout therapy, and time intervals between 12 consecutive treatment phases for 1076 patients aged 1-45 yrs treated according to the Nordic/Baltic ALL2008 protocol. RESULTS No adults died during induction. The duration of induction therapy and postinduction treatment phases did not differ between children and adults, except for patients 18-45 yrs being significantly delayed during two of nine high-risk blocks (median number of days for patients 1-9, 10-17, and 18-45 yrs; the glucocorticosteroid/antimetabolite-based block B1: 24, 26, and 29 d, respectively, P = 0.001, and Block 5 (in most cases also a B block): 29, 29, and 37 d, respectively, P = 0.02). A higher incidence of thrombosis with increasing age was found; highest odds ratio 5.4 (95% CI: (2.6;11.0)) for patients 15-17 yrs compared with children 1-9 yrs (P < 0.0001). Risk of avascular osteonecrosis was related to age with the highest OR for patients 10-14 yrs (OR = 10.4 (95% CI: (4.4;24.9)), P < 0.0001). CONCLUSION Adults followed and tolerated the NOPHO ALL2008 protocol virtually as well as children, although thrombosis and avascular osteonecrosis was most common among adolescents.
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Affiliation(s)
- Nina Toft
- Department of Hematology, Herlev University Hospital, University of Copenhagen, Herlev, Denmark
| | - Henrik Birgens
- Department of Hematology, Herlev University Hospital, University of Copenhagen, Herlev, Denmark
| | - Jonas Abrahamsson
- Department of Clinical Sciences, Queen Silvia's Children's Hospital, Gothenburg, Sweden
| | - Laimonas Griškevičius
- Hematology, Oncology and Transfusion Medicine Center Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Helene Hallböök
- Department of Hematology, Uppsala University Hospital, Uppsala, Sweden
| | - Mats Heyman
- Childhood Cancer Research Unit, Karolinska Institute, Astrid Lindgren's Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Katrin Palk
- Department of Hematology, North Estonia Medical Centre, Tallinn, Estonia
| | - Kaie Pruunsild
- Kaie Pruunsild, Tallinn Children's Hospital, Tallinn, Estonia
| | - Petter Quist-Paulsen
- Department of Hematology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Goda Vaitkeviciene
- Centre for Pediatric Oncology and Hematology, Children's Hospital, Affiliate of Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Kim Vettenranta
- Division of Hematology-Oncology and Stem Cell Transplantation, Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland
| | - Ann Asberg
- Department of Pediatrics, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Louise Rold Helt
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Frandsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Gynecology, Obstetrics and Pediatrics, Faculty of Medicine. University of Copenhagen, Copenhagen, Denmark
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99
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Shaw PH, Reed DR, Yeager N, Zebrack B, Castellino SM, Bleyer A. Adolescent and Young Adult (AYA) Oncology in the United States: A Specialty in Its Late Adolescence. J Pediatr Hematol Oncol 2015; 37:161-9. [PMID: 25757020 DOI: 10.1097/mph.0000000000000318] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Over the last 30 years, it has become apparent that oncology patients ages 15 to 39 have not reaped the same rewards of improved survival that we have seen in younger and older patients. As a result, in 2006 the Adolescent and Young Adult (AYA) Oncology Progress Review Group convened and examined the factors that impact the care of the 70,000 new cases per year (approximately 7% of all new cases) in the United States and published their findings. The reasons for inferior survival gains are of course multiple and include the settings in which patients are cared for, clinical trial enrollment, insurance coverage, varied treatment of sarcomas, varied treatment of acute lymphoblastic leukemia, the psychosocial impact of cancer and cancer survivorship. A new area of a yet-to-be completely defined subspecialty was born out of this meeting: AYA oncology. As a medical community we realized that these patients do not fit neatly into the pediatric nor adult world and, therefore, require a unique approach which many individuals, oncology centers, advocacy groups, and cooperative trial groups have started to address. This group of dedicated providers and advocates has made strides but there is still much work to be done on the local, national, and international level to make up for shortcomings in the medical system and improve outcomes. We review key components of AYA cancer care in 2015 that all providers should be aware of, how far we have come, where this movement is headed, and the obstacles that continue to stand in the way of better cure rates and quality of life after cure for this unique group of patients. Like an adolescent maturing into adulthood, this movement has learned from the past and is focused on moving into the future to achieve its goals.
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Affiliation(s)
- Peter H Shaw
- *Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA †Sarcoma Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL ‡Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH §University of Michigan School of Social Work, Ann Arbor, MI ∥Department of Pediatrics, Section on Hematology and Oncology, Wake Forest School of Medicine, Winston-Salem, NC ¶Quality Department, St Charles Health System, Bend, OR
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100
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Abstract
Asparaginase is widely used in chemotherapeutic regimens for the treatment of acute lymphoblastic leukemia (ALL) and has led to a substantial improvement in cure rates, especially in children. Optimal therapeutic effects depend on a complete and sustained depletion of serum asparagine. However, pronounced interpatient variability, differences in pharmacokinetic properties between asparaginases and the formation of asparaginase antibodies make it difficult to predict the degree of asparagine depletion that will result from a given dose of asparaginase. The pharmacological principles underlying asparaginase therapy in the treatment of ALL are summarized in this article. A better understanding of the many factors that influence asparaginase activity and subsequent asparagine depletion may allow physicians to tailor treatment to the individual, maximizing therapeutic effect and minimizing treatment-related toxicity. Therapeutic drug monitoring provides a means of assessing a patient's current depletion status and can be used to better evaluate the potential benefit of treatment adjustments.
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Affiliation(s)
- Barbara Asselin
- a Department of Pediatrics , Golisano Children's Hospital, University of Rochester School of Medicine , Rochester , NY , USA
| | - Carmelo Rizzari
- b Department of Pediatrics , Pediatric Hematology-Oncology Unit, University of Milano-Bicocca, MBBM Foundation, San Gerardo Hospital , Monza , Italy
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