The adolescent and young adult gap in cancer care and outcome

Lymphoma in adolescents and young adults

Non-Hodgkin (NHL) and Hodgkin (HL) lymphomas are represented prominently in the adolescent and young adult (AYA) population. These diseases represent 11% of total cancer diagnoses in children, 4% in those 40 years of age and older, and 13% in AYA (aged 15-39 years). Although age-adjusted incidence rates of NHL increase with age, the more aggressive lymphomas are seen more commonly in the younger population with a transition to low-grade, indolent subtypes as the population ages. Burkitt lymphoma, diffuse large B-cell lymphoma, lymphoblastic lymphoma, and anaplastic large cell lymphoma make up the most common subtypes in the AYA population, although within the subgroup age 30-39 years, follicular lymphoma becomes more prominent. As a result, much of the armamentarium in the treatment of aggressive NHL and HL in adults is based on data from pediatric clinical trials. There are obvious limitations to this approach. It is vital that we gain a more thorough understanding of the biology and therapeutic responsiveness of NHL and HL in the AYA population. Thus, we must leverage the large prospective and retrospective trials that have been completed to date and redirect our approaches to cancer care in this unique population. We review the epidemiological data on NHL and HL from the Surveillance, Epidemiology and End Results registries as a cornerstone for a comparative analysis of therapeutic outcomes available in this population.

Relative lack of conditional survival improvement in young adults with cancer

Cancer prognosis is usually reported in terms of survival from time of diagnosis. For patients surviving a period of time after diagnosis, conditional survival (CS) accounts for changing risk over time. This report provides information on how CS in cancer patients changes as a function of age at diagnosis. Using data from the US Surveillance, Epidemiology and End Results database, we examined survival for patients diagnosed between 1973 and 2002. The average annual percent change (AAPC) in CS during the first 5 years after diagnosis was evaluated for the 14 most common cancers occurring in young adults, defined as 15- to 39-year-olds, and how they compared with cancers that are more common in older and younger patients. For all cancers, young adult patients had less CS improvement over time than younger or older patients, and this difference was most pronounced in those aged 20 to 29 years (45% below the mean). Eleven of the 14 most common cancers in 15- to 39-year-olds either had a lower CS improvement after diagnosis than either younger or older patients, or than just the older patients. Young adults with leukemia had the greatest improvement in CS over time. In conclusion, young adults with cancer have not enjoyed the same improvement in CS over time compared with other age groups. Explanations for this deficit include the biologic nature of the type of cancers in young adults and less effective therapies for patients in the age group. Regardless of the reasons, the deficit is yet another challenge faced by young adult patients that merits further study.

Psychosocial outcomes and service use among young adults with cancer

At the crossroads between pediatric and older adult groups, young adults with cancer may be underserved or inadequately or inappropriately served by existing support services. Empirical evidence has not established well the extent to which utilization of psychosocial support services delivered throughout a continuum of care results in desired outcomes. If self-efficacy is demonstrated to play a significant role in promoting quality of life and psychological well-being in young adult cancer patients, then a cancer-specific self-efficacy model can serve as an evidence-based framework for developing, implementing, and testing new interventions. A focus on self-efficacy has the potential to promote young adults' abilities to remain active and independent, seek and understand medical information, manage stress, cope with treatment-related side effects, maintain a "positive attitude," regulate emotions, and seek social support. Future research should aim to identify which patients represent at-risk targets for intervention, as well as the most appropriate time points along the continuum of care at which patients/survivors are most likely to benefit from delivery/utilization of psychosocial support services.

End-of-life experiences in adolescents dying with cancer

PURPOSE

This study explores the experiences of individuals in early, middle, and late adolescence dying from cancer. Place of death, medications used at end of life (EOL), and discussions prior to death are examined.

METHODS

Data were obtained from a retrospective review of medical charts from 103 adolescents who died of cancer between 2000 and 2005.

RESULTS

Adolescents with leukemia/lymphoma were relatively more likely to die in an intensive care unit (p = 0.028) where cause of death was more likely to be treatment-related (p < 0.001), and EOL discussions more likely to occur in the last 7 days of life (p = 0.002). Anxiolytic use was significantly higher during late adolescence (p = 0.037).

CONCLUSIONS

Adolescents have unique developmental needs that should be considered at EOL. Timing of EOL discussions occurred very close to death for a significant number of adolescents, allowing very little time to psychologically prepare for death.

Indications for hematopoietic cell transplantation in acute leukemia

Based on available data, all adults with AML under age 60 years with matched siblings should be considered for allogeneic transplantation in first remission, except for those with favorable risk cytogenetics and possibly those whose disease has normal cytogenetics and is FLT3/ITD negative and NPM1 positive. Patients with matched siblings not transplanted in first remission should be followed closely so that transplantation in early first relapse can be considered. Those without matched siblings should receive a MUD transplant in first CR if they have higher risk disease. All others should receive standard chemotherapy and consider a matched unrelated transplant or autologous transplant, should they relapse. RIC allogeneic transplantation using either a matched family member or a MUD can be considered for patients age 60 years or greater with AML in second or subsequent remission, or AML in first remission with intermediate or high risk disease.

Young people in the United Kingdom and Ireland with perinatally acquired HIV: the pediatric legacy for adult services

Children with perinatally acquired HIV-1 infection are surviving into adolescence and increasingly transitioning toward adult services. Planning appropriate services in adult life requires an understanding of their progress through pediatric care. We describe the demographic features, disease progression, antiretroviral therapy (ART), and resistance in young people aged 10 years or more living in the United Kingdom and Ireland reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) with prospective annual follow-up in the Collaborative HIV Paediatric Study (CHIPS) between 1996 and September 2007. Six hundred fifty-four perinatally infected young people were identified; 76% black African, 57% born abroad. Median age at presentation and duration of follow-up was 1 and 11 years, respectively, if born in the United Kingdom/Ireland, and 8 and 5 years if born elsewhere. One hundred sixty-nine (26%) ever had an AIDS-defining illness. Ten died during adolescence. At last follow-up, 64% were on ART, 18% off treatment having previously received ART and 18% were ART naive. Of 518 who had received highly active antiretroviral therapy (HAART), 47% were triple class experienced. At last follow-up 77 (12%) had CD4 counts less than 200 per microliter; of those on HAART, 78% had HIV-1 RNA </=400 copies per milliliter, median CD4 count 554 (interquartile range [IQR] 324-802). Among 166 with resistance assays on HAART, 52% and 12% had dual- and triple-class HIV-1-associated resistance mutations, respectively. One hundred three (16%) young people had transferred to adult services. Young adults with perinatally acquired HIV-1 infection require coordinated multidisciplinary transitional care services and careful long-term follow-up in adult life.

Transplants in Adult ALL--? Allo for everyone

The large MRC/ECOG adult acute lymphoblastic leukemia (ALL) study establishes the value of sibling donor allogeneic transplant in standard-risk patients demonstrating superior outcome to conventional chemotherapy. The small but significant number of patients having matched unrelated donor (MUD) transplants on this study protocol appear to do well, and may establish the value of such an approach for those without a sibling. Reduced-intensity conditioning (RIC) conditioning might begin to address the transplant-related mortality problems of the older patients. The youngest adults may not need a transplant at all. If they are now treated on pediatric chemotherapy protocols, their outcome appears to improve significantly. The MRC/ECOG study, the emerging MUD and RIC data all help establish allogeneic transplant more widely in this disease.

Assessing cancer symptoms in adolescents with cancer using the Taiwanese version of the M. D. Anderson Symptom Inventory

The purpose of this study was to evaluate the validity and reliability of the Taiwanese version of the M. D. Anderson Symptom Inventory (MDASI-T) in Taiwanese adolescent cancer patients. One hundred eight adolescent cancer patients were interviewed using the MDASI-T, and the results were then used to establish the psychometric properties of this instrument. Data were analyzed by factor analysis, cluster analysis, Pearson correlation, Mann-Whitney U test, and descriptive statistics. The construct validity was determined using a confirmatory factor analysis with oblimin rotation. The concurrent validity demonstrated moderate correlations between the MADSI-T subscale scores and the Medical Outcome Study 36-Item Short-Form Health Survey. Known-group validity was established by comparing MDASI-T scores between adolescent cancer patients with a low functional status and those with a high functional status (Karnofsky Performance Status scores <or= 80 and >80, respectively). The alpha coefficient of the symptoms severity and interference subscales demonstrated good internal consistency. There was acceptable test-retest stability of the MDASI-T in 35 adolescents during a 3-day interval. This study provides evidence that the MDASI-T is a reliable and valid instrument for measuring cancer-related symptoms in Taiwanese adolescents with cancer.

Challenges in the recruitment of adolescents and young adults to cancer clinical trials

The adolescent and young adult (AYA) oncology population has seen inferior progress in cancer survival compared with younger children and older adults over the past 25 years. Previously, AYAs had the best survival rates due to the prevalence of highly curable diseases including Hodgkin lymphoma and germ cell tumors, yet today AYAs have inferior survival rates to children and some adult cohorts. Survival rates are particularly poor for AYA-specific diseases such as sarcomas. Research involving children and adults diagnosed with common malignancies such as acute lymphoblastic leukemia has resulted in improved survival rates. However, AYAs have not directly benefited from such research due to low rates of access to and accrual on clinical trials. AYAs are less likely to have insurance or access to healthcare, are more likely to see providers who are not part of research institutions, and are less likely to be referred to or to join clinical trials, all of which may contribute to worse outcomes. Few clinical trials target AYA-specific diseases, leading to little information regarding how these diseases behave and what role the host plays. Tumor samples for this population are underrepresented in national tumor banks. Coupled with the need for more clinical trials that focus on AYA-specific cancers, better collaboration between adult and pediatric cooperative groups as well as increased education among community oncologists and primary care providers will be needed to enhance participation in clinical trials with the goal to increase survival and improve quality of that survival.

Survival from adolescent cancer

BACKGROUND

Adolescent cancer is the leading cause of non-accidental mortality in young people. The tumour types occurring most commonly in this age group are distinctive and differ markedly from those developing in younger children and older adults.

OBJECTIVE

The aim is to present survival data for the major types of cancer and for all malignancies combined in adolescents aged from 15 to 19 years, highlighting intercountry differences, temporal trends, and age/treatment regimen comparisons of survival rates.

RESULTS

Results from European and American data show that 5-year overall survival among adolescents with cancer is approximately 73-78%, close to that observed among children. As in paediatric series, there are geographical differences, with lower survival rates in Eastern European countries. Adolescents have substantially lower survival than children for acute lymphoid leukaemia, malignant non-Hodgkin lymphoma, Ewing's tumour, osteosarcoma, soft-tissue sarcoma. Temporal improvement in survival from children cancer is twice higher than survival from adolescents malignancies.

CONCLUSION

Several reasons could explain these geographical differences, such as better referral, greater availability of complex and expensive treatment regimens, reflecting variations in health care systems and resources. Age-group variations could be explained by differences in biology and in treatment regimen, and lack of participation in clinical trials. Some are inherent in the psychosocial characteristics of these patients, such as delays in seeking medical attention, poor compliance with treatment. It is necessary to focus on cancer in adolescence, as the new frontier in oncology, and adolescents with cancer must be now the subject of specific survival analyses.

How I treat acute lymphocytic leukemia in adults

The treatment of newly diagnosed acute lymphocytic leukemia (ALL) in adults remains unsatisfactory. Not withstanding the outstanding progress in curing childhood ALL, only approximately one third of adults younger than 60 years can be cured, and the overall published survival curves have not changed significantly during the past 15 years. Recent therapeutic advances in allogeneic transplantation through the conduct of large collaborative studies, better understanding of the relevance of cytogenetics, improved molecular techniques for the detection of minimal residual disease, and clinical research into novel biologic and targeted therapies have all combined to offer potentially a better hope for an improved outcome in this disease. The current approach in 2007 to the management of this disease is presented by way of a discussion of illustrative cases. In this uncommon and difficult disease, well-structured intergroup studies will remain vital for future progress.

Hope and spiritual well-being in adolescents with cancer

This study examines the relationships of hope and spiritual well-being (SWB)--and its dimensions, religious well-being (RWB) and existential well-being (EWB)--to time since diagnosis among adolescents with cancer. A descriptive cross-sectional design was used. The sample of 78 adolescents diagnosed with cancer was recruited from two pediatric oncology clinics. Adolescents in the first two time periods reported significantly higher levels of SWB, RWB, and EWB than those in subsequent time periods. Hope did not significantly vary over time. Hence, time since diagnosis may influence adolescents' levels of SWB and its dimensions during the cancer experience. Adolescents' use of SWB, RWB, and EWB as coping resources should be examined in longitudinal studies from diagnosis through survivorship.

Adolescent and young adult (AYA) oncology: the first A

Whereas adolescents with cancer as a group used to have a better prognosis than children with malignant disease, trends suggest that the overall survival of 15- to 19-year-olds is now worse than in younger patients. Also, the incidence of cancer is higher in 15- to 19-year age span than during the first 15 years of life. In 2006, the U.S. National Cancer Institute (NCI) and the Lance Armstrong Foundation conducted a Program Review Group (PRG) of the Adolescent and young Adult (AYA) problem. Recommendations covered awareness, prevention/cancer control/epidemiology/risk, biology, access, health insurance, clinical care models, clinical trials/research, special populations, psychosocial/behavioral factors, health-related quality of life, and long-term effects. This Commentary reviews each of the primary executive recommendations of the PRG report with respect to their adolescent oncology perspective and application. Primary implementation of the recommendations is responsibility of a new consortium of organizations devoted to assisting adolescents and young adults with cancer, the LiveStrong Young Adult Alliance, a program of the Lance Armstrong Foundation. Prior programs included the Children's Oncology Group AYA Committee and two disease-specific initiatives: the Intergroup Consortium Against Sarcoma and a clinical trial in young adults with acute lymphoblastic leukemia that will be conducted by Cancer and Leukemia Group B, the Southwest Oncology Group, and Eastern Cooperative Oncology Group. Preliminary evidence indicates that these efforts have already had measurable success.

Where do teenagers and young adults receive treatment for cancer?

BACKGROUND

Little is known about where teenagers and young adults receive their first cancer treatment.

METHOD

We extracted data on 2260 residents of southeast England diagnosed with a malignant neoplasm aged 10-24 between 1998 and 2002 from the Thames Cancer Registry database. We identified 11 cancer network areas of residence, and the hospital and network where each patient received their first chemotherapy treatment. We classified hospitals as those including paediatric oncology centres, cancer centres with a teenage cancer unit or adult cancer centres or units. We examined how many patients in each of the age groups 10-14, 15-19 and 20-24 travelled outside their network of residence for chemotherapy.

RESULTS

Overall 45% (1018) received chemotherapy. Three networks had paediatric oncology centres, and one also had a teenage cancer unit. Most 10-14-year-olds were referred from their network of residence to networks with these services. However, there was an increasing tendency for patients aged 15-19 and 20-24 to be treated within their network of residence and to be referred less commonly.

CONCLUSIONS

Many young people with cancer are not referred to services providing care tailored to the needs of their age group. The absence of any pattern to referral, despite the presence of a teenage cancer unit in the area, suggests a lack of coordinated referral practice within and between cancer networks.

Relationships of age and gender to hope and spiritual well-being among adolescents with cancer

The purpose of this study was to examine hope and spiritual well-being, with its 2 dimensions of religious well-being and existential well-being, as they relate to age and gender among adolescents with cancer. A cross-sectional design was guided by the conceptual framework, Adolescent Psychosocial Adaptation to the Cancer Experience. A total of 78 adolescents with a diagnosis of cancer were enrolled from 2 pediatric oncology clinics. Middle adolescents (15-17 years of age) reported higher religious well-being than late adolescents (18-20 years of age). Middle-adolescent boys were more hopeful than were early adolescent boys (13- 14 years of age). Also, girls were more hopeful and reported higher spiritual well-being than age the boys. Developmental phase and/or gender may influence adolescents' levels of hope, spiritual well-being, religious well-being, and existential well-being as they cope during the cancer experience. The nurse should consider developmental phase and gender when planning interventions to foster hope and spiritual well-being in adolescents' adaptations to the cancer experience.

Myths and Lessons from the Adult/Pediatric Interface in Acute Lymphoblastic Leukemia

The development of effective therapy for children with acute lymphoblastic leukemia (ALL) is one of the great successes of clinical oncology, with long-term survival achieved in over 80% of patients. However, cure rates for adults with ALL remain relatively low, with only 40% of patients cured. With an age-unrestricted, biology-based approach, we anticipate a better understanding about why these outcome differences exist, and think that by extending successful pediatric clinical programs to include adult patients with ALL, we can directly compare uniformly treated adults and children in terms of response to therapy, toxicity and underlying biology.

The treatment of adolescents and young adults with acute lymphoblastic leukemia

Intensive chemotherapy regimens for children with acute lymphoblastic leukemia (ALL) have greatly improved, and the majority of children with precursor B-cell ALL are able to achieve a complete remission (CR), with an induction rate approaching 98% and a 5-year estimated event-free survival rate (EFS) of approximately 80%. Although there have been dramatic improvements over the last several decades in both the EFS and overall survival (OS) rates in young children with ALL, the results in adult clinical trials have not kept pace. Current adult treatment regimens result in CR rates in the 80% range, with EFS at 5 years of only 30%-40%. Adolescents and young adults represent a minority of patients enrolled onto either adult or pediatric clinical trials. As a result, little information is available regarding CR, EFS, and OS rates for this age group, and the appropriate treatment regimen for this group of patients remains elusive. Recent studies suggest that young adult patients have far superior outcomes when treated on more intensive pediatric regimens. In addition, new insights into the molecular pathogenesis of T cell ALL have led to new therapeutic strategies.