The Childhood Cancer Survivor Study: a National Cancer Institute-supported resource for outcome and intervention research

Chronic medical conditions in adult survivors of retinoblastoma: Results of the Retinoblastoma Survivor Study

BACKGROUND

Limited data are available regarding long-term morbidity in adult survivors of retinoblastoma (Rb).

METHODS

The Retinoblastoma Survivor Study is a retrospective cohort of adult survivors of Rb diagnosed between 1932 and 1994. Participants completed a comprehensive questionnaire adapted from the Childhood Cancer Survivor Study surveys. Chronic conditions were classified using the National Cancer Institute's Common Terminology Criteria for Adverse Events (version 4.03). Multivariate Poisson regression was used to compare survivors of Rb with 2377 non-Rb controls, consisting of the Childhood Cancer Survivor Study sibling cohort and survivors with bilateral versus unilateral disease.

RESULTS

Survivors of Rb (53.6% with bilateral disease) and non-Rb controls had a mean age of 43.3 years (standard deviation, 11 years) and 37.6 years (SD, 8.6 years), respectively, at the time of study enrollment. At a median follow-up of 42 years (range, 15-75 years), 86.6% of survivors of Rb had at least 1 condition and 71.1% had a severe/life-threatening (grade 3-4) condition. The adjusted relative risk (RR) of a chronic condition in survivors compared with non-Rb controls was 1.4 (95% confidence interval [95% CI], 1.3-1.4; P<.01); for a grade 3 to 4 condition, the RR was 7.6 (95% CI, 6.4-8.9; P<.01). Survivors were at an excess risk regardless of laterality. After stratifying by laterality and excluding ocular conditions and second malignant neoplasms (SMNs), only those with bilateral disease were found to be at an increased risk of any nonocular, non-SMN condition (RR, 1.2; 95% CI, 1.1-1.2) and for grade 3 to 4 nonocular, non-SMN conditions (RR, 1.7; 95% CI, 1.2-2.5).

CONCLUSIONS

Survivors of Rb have an increased risk of chronic conditions compared with non-Rb controls. After excluding ocular conditions and SMNs, this excess risk was found to persist only for those with bilateral disease. Cancer 2016;122:773-781. © 2016 American Cancer Society.

Breast Cancer Risk in Childhood Cancer Survivors Without a History of Chest Radiotherapy: A Report From the Childhood Cancer Survivor Study

PURPOSE

Little is known about the breast cancer risk among childhood cancer survivors who did not receive chest radiotherapy. We sought to determine the magnitude of risk and associated risk factors for breast cancer among these women.

PATIENTS AND METHODS

We evaluated cumulative breast cancer risk in 3,768 female childhood cancer survivors without a history of chest radiotherapy who were participants in the Childhood Cancer Survivor Study.

RESULTS

With median follow up of 25.5 years (range, 8 to 39 years), 47 women developed breast cancer at a median age of 38.0 years (range, 22 to 47 years) and median of 24.0 years (range, 10 to 34 years) from primary cancer to breast cancer. A four-fold increased breast cancer risk (standardized incidence ratio [SIR] = 4.0; 95% CI, 3.0 to 5.3) was observed when compared with the general population. Risk was highest among sarcoma and leukemia survivors (SIR = 5.3; 95% CI, 3.6 to 7.8 and SIR = 4.1; 95% CI, 2.4 to 6.9, respectively). By the age of 45 years, the cumulative incidence of breast cancer in sarcoma and leukemia survivors was 5.8% (95% CI, 3.7 to 8.4) and 6.3% (95% CI, 3.0 to 11.3), respectively. No other primary cancer diagnosis was associated with an elevated risk. Alkylators and anthracyclines were associated with an increased breast cancer risk in a dose-dependent manner (P values from test for trend were both < .01).

CONCLUSIONS

Women not exposed to chest radiotherapy who survive childhood sarcoma or leukemia have an increased risk of breast cancer at a young age. The data suggest high-dose alkylator and anthracycline chemotherapy increase the risk of breast cancer. This may suggest a possible underlying gene-environment interaction that warrants further study.

Radiation-Related New Primary Solid Cancers in the Childhood Cancer Survivor Study: Comparative Radiation Dose Response and Modification of Treatment Effects

OBJECTIVES

The majority of childhood cancer patients now achieve long-term survival, but the treatments that cured their malignancy often put them at risk of adverse health outcomes years later. New cancers are among the most serious of these late effects. The aims of this review are to compare and contrast radiation dose-response relationships for new solid cancers in a large cohort of childhood cancer survivors and to discuss interactions among treatment and host factors.

METHODS

This review is based on previously published site-specific analyses for subsequent primary cancers of the brain, breast, thyroid gland, bone and soft tissue, salivary glands, and skin among 12,268 5-year childhood cancer survivors in the Childhood Cancer Survivor Study. Analyses included tumor site-specific, individual radiation dose reconstruction based on radiation therapy records. Radiation-related second cancer risks were estimated using conditional logistic or Poisson regression models for excess relative risk (ERR).

RESULTS

Linear dose-response relationships over a wide range of radiation dose (0-50 Gy) were seen for all cancer sites except the thyroid gland. The steepest slopes occurred for sarcoma, meningioma, and nonmelanoma skin cancer (ERR/Gy > 1.00), with glioma and cancers of the breast and salivary glands forming a second group (ERR/Gy = 0.27-0.36). The relative risk for thyroid cancer increased up to 15-20 Gy and then decreased with increasing dose. The risk of thyroid cancer also was positively associated with chemotherapy, but the chemotherapy effect was not seen among those who also received very high doses of radiation to the thyroid. The excess risk of radiation-related breast cancer was sharply reduced among women who received 5 Gy or more to the ovaries.

CONCLUSIONS

The results suggest that the effect of high-dose irradiation is consistent with a linear dose-response for most organs, but they also reveal important organ-specific and host-specific differences in susceptibility and interactions between different aspects of treatment.

The rising incidence of second cancers: patterns of occurrence and identification of risk factors for children and adults

As the population of cancer survivors has increased and continues to age, the occurrence of second cancers has risen dramatically-from 9% of all cancer diagnoses in 1975-1979 to 19% in 2005-2009. The Childhood Cancer Survivor Study, a cohort of more than 14,000 childhood cancer survivors with detailed exposure data and long-term follow-up, has substantially contributed to our understanding of the roles of radiotherapy and chemotherapy in second cancer occurrence. In particular, dose-related risks have been demonstrated for second cancers of the breast, thyroid, central nervous system, gastrointestinal tract, and sarcomas following radiation. Cytotoxic chemotherapy-which has long been known to be leukemogenic-also appears to contribute to risk for a range of other second cancer types. Individuals who develop a second cancer are at particularly high risk for developing additional second cancers. A genome-wide association study of survivors of Hodgkin lymphoma who received radiotherapy identified a locus on chromosome 6q21 as being associated with second cancer risk, demonstrating that recent advances in genomics are likely to prove invaluable for elucidating the contribution of genetic susceptibility to second cancer etiology. Among adults, risk of second cancers varies substantially by type of first and second cancer, patient age, and prevalence of second cancer risk factors, including primary cancer treatments, environmental and lifestyle exposures, and genetic susceptibility. Further research is needed to quantify second cancer risks associated with specific etiologic factors and to identify the patients at highest risk of developing a second cancer to target prevention and screening efforts.

Statistical methods for studying disease subtype heterogeneity

A fundamental goal of epidemiologic research is to investigate the relationship between exposures and disease risk. Cases of the disease are often considered a single outcome and assumed to share a common etiology. However, evidence indicates that many human diseases arise and evolve through a range of heterogeneous molecular pathologic processes, influenced by diverse exposures. Pathogenic heterogeneity has been considered in various neoplasms such as colorectal, lung, prostate, and breast cancers, leukemia and lymphoma, and non-neoplastic diseases, including obesity, type II diabetes, glaucoma, stroke, cardiovascular disease, autism, and autoimmune disease. In this article, we discuss analytic options for studying disease subtype heterogeneity, emphasizing methods for evaluating whether the association of a potential risk factor with disease varies by disease subtype. Methods are described for scenarios where disease subtypes are categorical and ordinal and for cohort studies, matched and unmatched case-control studies, and case-case study designs. For illustration, we apply the methods to a molecular pathological epidemiology study of alcohol intake and colon cancer risk by tumor LINE-1 methylation subtypes. User-friendly software to implement the methods is publicly available.

Secondary cancers after a childhood cancer diagnosis: a nationwide hospital-based retrospective cohort study in Japan

BACKGROUND

The epidemiology of secondary cancers in childhood cancer survivors has been unknown in Asian countries. Our aim is to assess the incidence and risk factors for secondary cancers through a nationwide survey in Japan.

METHODS

A retrospective cohort study comprising 10,069 children who were diagnosed with cancer between 1980 and 2009 was conducted in 15 Japanese hospitals. The cumulative incidence rate was calculated using death as the competing risk and compared by the Gray method. The standardized incidence ratio (SIR) was defined as the ratio of the number of observed cancers divided by the number of expected cancers. The risk factors were analyzed using Cox regression analysis.

RESULTS

One hundred and twenty-eight patients (1.3 %) developed secondary cancers within a median follow-up of 8.4 years. The cumulative incidence rate was 1.1 % (95 % confidence interval [CI] 0.9-1.4) at 10 years and 2.6 % (95 % CI 2.1-3.3) at 20 years after primary cancer diagnosis. Sensitivity analysis, limited to 5-year survivors (n = 5,387), confirmed these low incidence rates. The SIR of secondary cancers was 12.1 (95 % CI 10.1-14.4). In the Cox analysis, the hazard ratios for secondary cancers were 3.81 (95 % CI 1.53-9.47) for retinoblastoma, 2.78 (95 % CI 1.44-5.38) for bone/soft tissue sarcomas, and 1.81 (95 % CI 1.16-2.83) for allogeneic stem cell transplantation.

CONCLUSIONS

The cumulative incidence of secondary cancers in children in Japan was not high; however, the SIR was relatively high. Retinoblastoma or sarcoma in addition to allogeneic stem cell transplantation were significant risk factors for secondary cancers.

Psychosocial Outcomes in Adult Survivors of Retinoblastoma

PURPOSE

Survival rates for individuals diagnosed with retinoblastoma (RB) exceed 95% in the United States; however, little is known about the long-term psychosocial outcomes of these survivors.

PATIENTS AND METHODS

Adult RB survivors, diagnosed from 1932 to 1994 and treated in New York, completed a comprehensive questionnaire adapted from the Childhood Cancer Survivor Study (CCSS), by mail or telephone. Psychosocial outcomes included psychological distress, anxiety, depression, somatization, fear of cancer recurrence, satisfaction with facial appearance, post-traumatic growth, and post-traumatic stress symptoms; noncancer CCSS siblings served as a comparison group.

RESULTS

A total of 470 RB survivors (53.6% with bilateral RB; 52.1% female) and 2,820 CCSS siblings were 43.3 (standard deviation [SD], 11) years and 33.2 (SD, 8.4) years old at the time of study, respectively. After adjusting for sociodemographic factors, RB survivors did not have significantly higher rates of depression, somatization, distress, or anxiety compared with CCSS siblings. Although RB survivors were more likely to report post-traumatic stress symptoms of avoidance and/or hyperarousal (both P < .01), only five (1.1%) of 470 met criteria for post-traumatic stress disorder. Among survivors, having a chronic medical condition did not increase the likelihood of psychological problems. Bilateral RB survivors were more likely than unilateral RB survivors to experience fears of cancer recurrence (P < .01) and worry about their children being diagnosed with RB (P < .01). However, bilateral RB survivors were no more likely to report depression, anxiety, or somatic complaints than unilateral survivors.

CONCLUSION

Most RB survivors do not have poorer psychosocial functioning compared with a noncancer sample. In addition, bilateral and unilateral RB survivors seem similar with respect to their psychological symptoms.

Health care utilization, lifestyle, and emotional factors and mammography practices in the Childhood Cancer Survivor Study

BACKGROUND

Women with a history of chest radiotherapy have an increased risk of breast cancer; however, many do not undergo annual recommended screening mammography. We sought to characterize the relationship between mammography and potentially modifiable factors, with the goal of identifying targets for intervention to improve utilization.

METHODS

Of 625 female participants sampled from the Childhood Cancer Survivor Study, who were treated with chest radiotherapy, 551 responded to a survey about breast cancer screening practices. We used multivariate Poisson regression to assess several lifestyle and emotional factors, health care practices, and perceived breast cancer risk, in relation to reporting a screening mammogram within the last two years.

RESULTS

Women who had a Papanicolaou test [prevalence ratio (PR): 1.77; 95% confidence interval (CI) 1.26-2.49], and who perceived their breast cancer risk as higher than the average woman were more likely to have had a mammogram (PR, 1.26; 95% CI, 1.09-1.46). We detected an attenuated effect of echocardiogram screening [PR, 0.70; 95% CI (0.52-0.95)] on having a mammogram among older women compared with younger women. Smoking, obesity, physical activity, coping, and symptoms of depression and somatization were not associated with mammographic screening.

CONCLUSION

Our findings suggest that compliance with routine and risk-based screening can be an important indicator of mammography in childhood cancer survivors. In addition, there is a need to ensure women understand their increased breast cancer risk, as a means to encouraging them to follow breast surveillance guidelines.

IMPACT

Screening encounters could be used to promote mammography compliance in this population.

Recurrent stroke in childhood cancer survivors

OBJECTIVE

To estimate the rates and predictors of recurrent stroke among survivors of pediatric cancer who have had a first stroke.

METHODS

The Childhood Cancer Survivor Study is a retrospective cohort study with longitudinal follow-up that enrolled 14,358 survivors (<21 years old at diagnosis; diagnosed 1970-1986; survived ≥5 years after cancer diagnosis) and followed them prospectively since 1994. We surveyed 443 survivors who reported a first stroke to identify recurrent stroke, and estimated recurrent stroke rates ≥5 years after cancer diagnosis.

RESULTS

Among 329 respondents (74% response rate), 271 confirmed a first stroke at a median age of 19 years (range 0-53), and 70 reported a second stroke at a median age of 32 years (range 1-56). In a multivariable Cox proportional hazards model, independent predictors of recurrent stroke included cranial radiation therapy (CRT) dose of ≥50 Gy (vs none, hazard ratio [HR] 4.4; 95% confidence interval [CI] 1.4-13.7), hypertension (HR 1.9; 95% CI 1.0-3.5), and older age at first stroke (HR 6.4; 95% CI 1.8-23; for age ≥40 vs age 0-17 years). The 10-year cumulative incidence of late recurrent stroke was 21% (95% CI 16%-27%) overall, and 33% (95% CI 21%-44%) for those treated with ≥50 Gy of CRT.

CONCLUSION

Survivors of childhood cancer, particularly those previously treated with high-dose cranial radiation, have a high risk of recurrent stroke for decades after a first stroke. Although these strokes are mostly occurring in young adulthood, hypertension, an established atherosclerotic risk factor, independently predicts recurrent stroke in this population.

Equivalence Ratio for Daunorubicin to Doxorubicin in Relation to Late Heart Failure in Survivors of Childhood Cancer

PURPOSE

Cumulative anthracycline dose is one of the strongest predictors of heart failure (HF) after cancer treatment. However, the differential risk for cardiotoxicity between daunorubicin and doxorubicin has not been rigorously evaluated among survivors of childhood cancer. These risks, which are based on hematologic toxicity, are currently assumed to be approximately equivalent.

PATIENTS AND METHODS

Data from 15,815 survivors of childhood cancer who survived at least 5 years were used. Survivors were from the Emma Children's Hospital/Academic Medical Center (n = 1,349), the National Wilms Tumor Study (n = 364), the St Jude Lifetime Cohort Study (n = 1,695), and the Childhood Cancer Survivor Study (n = 12,407). The hazard ratio (HR) for clinical HF through age 40 years for doses of daunorubicin and doxorubicin (per 100-mg/m(2) increments) was estimated by using Cox regression adjusted for sex, age at diagnosis, treatment with other anthracycline agents and chest radiation, and cohort membership.

RESULTS

In total, 5,144 (32.5%) patients received doxorubicin as part of their cancer treatment, whereas 2,243 (14.7%) received daunorubicin. On the basis of 271 occurrences of HF during a median follow-up time after cohort entry of 17.3 years (range, 0.0 to 35.0 years), the cumulative incidence of HF at age 40 years was 3.2% (95% CI, 2.8% to 3.7%). The average ratio of HRs for daunorubicin to doxorubicin was 0.45 (95% CI, 0.23 to 0.73). A similar ratio was obtained by using a linear dose-response model, which yielded an HR of 0.49 (95% CI, 0.28 to 0.70).

CONCLUSION

Compared with doxorubicin, daunorubicin was less cardiotoxic among survivors of childhood cancer than most current guidelines suggest. This may have implications for follow-up guidelines. The feasibility of substitution of doxorubicin with daunorubicin in childhood cancer treatment protocols to reduce cardiotoxicity should be additionally investigated.

Longitudinal smoking patterns in survivors of childhood cancer: An update from the Childhood Cancer Survivor Study

BACKGROUND

Survivors of pediatric cancer have elevated risks of mortality and morbidity. Many late adverse effects associated with cancer treatment (eg, second cancers and cardiac and pulmonary disease) are also associated with cigarette smoking, and this suggests that survivors who smoke may be at high risk for these conditions.

METHODS

This study examined the self-reported smoking status for 9397 adult survivors of childhood cancer across 3 questionnaires (median time interval, 13 years). The smoking prevalence among survivors was compared with the smoking prevalence among siblings and the prevalence expected on the basis of age-, sex-, race-, and calendar time-specific rates in the US population. Multivariable regression models examined characteristics associated with longitudinal smoking patterns across all 3 questionnaires.

RESULTS

At the baseline, 19% of survivors were current smokers, whereas 24% of siblings were current smokers, and 29% were expected to be current smokers on the basis of US rates. Current smoking among survivors dropped to 16% and 14% on follow-up questionnaires, with similar decreases in the sibling prevalence and the expected prevalence. Characteristics associated with consistent never-smoking included a higher household income (relative risk [RR], 1.16; 95% confidence interval [CI], 1.08-1.25), higher education (RR, 1.32; 95% CI, 1.22-1.43), and receipt of cranial radiation therapy (RR, 1.08; 95% CI, 1.03-1.14). Psychological distress (RR, 0.86; 95% CI, 0.80-0.92) and heavy alcohol drinking (RR, 0.64; 95% CI, 0.58-0.71) were inversely associated. Among ever-smokers, a higher income (RR, 1.17; 95% CI, 1.04-1.32) and education (RR, 1.23; 95% CI, 1.10-1.38) were associated with quitting, whereas cranial radiation (RR, 0.86; 95% CI, 0.76-0.97) and psychological distress (RR, 0.80; 95% CI, 0.72-0.90) were associated with not having quit. The development of adverse health conditions was not associated with smoking patterns.

CONCLUSIONS

Despite modest declines in smoking prevalence, the substantial number of consistent current smokers reinforces the need for continued development of effective smoking interventions for survivors.

Intestinal Obstruction in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE

For adult survivors of childhood cancer, knowledge about the long-term risk of intestinal obstruction from surgery, chemotherapy, and radiotherapy is limited.

METHODS

Intestinal obstruction requiring surgery (IOS) occurring 5 or more years after cancer diagnosis was evaluated in 12,316 5-year survivors in the Childhood Cancer Survivor Study (2,002 with and 10,314 without abdominopelvic tumors) and 4,023 sibling participants. Cumulative incidence of IOS was calculated with second malignant neoplasm, late recurrence, and death as competing risks. Using piecewise exponential models, we assessed the associations of clinical and demographic factors with rate of IOS.

RESULTS

Late IOS was reported by 165 survivors (median age at IOS, 19 years; range, 5 to 50 years; median time from diagnosis to IOS, 13 years) and 14 siblings. The cumulative incidence of late IOS at 35 years was 5.8% (95% CI, 4.4% to 7.3%) among survivors with abdominopelvic tumors, 1.0% (95% CI, 0.7% to 1.4%) among those without abdominopelvic tumors, and 0.3% (95% CI, 0.1% to 0.5%) among siblings. Among survivors, abdominopelvic tumor (adjusted rate ratio [ARR], 3.6; 95% CI, 1.9 to 6.8; P < .001) and abdominal/pelvic radiotherapy within 5 years of cancer diagnosis (ARR, 2.4; 95% CI, 1.6 to 3.7; P < .001) increased the rate of late IOS, adjusting for diagnosis year; sex; race/ethnicity; age at diagnosis; age during follow-up (as natural cubic spline); cancer type; and chemotherapy, radiotherapy, and surgery within 5 years of cancer diagnosis. Developing late IOS increased subsequent mortality among survivors (ARR, 1.8; 95% CI, 1.1 to 2.9; P = .016), adjusting for the same factors.

CONCLUSION

The long-term risk of IOS and its association with subsequent mortality underscore the need to promote awareness of this complication among patients and providers.

Risk of Subsequent Neoplasms During the Fifth and Sixth Decades of Life in the Childhood Cancer Survivor Study Cohort

PURPOSE

Survivors of childhood cancer have an increased risk for subsequent neoplasms (SNs), but the incidence beyond the age of 40 years and associations with therapeutic exposures have not been well described.

PATIENTS AND METHODS

Among 14,364 survivors of childhood cancer diagnosed between 1970 and 1986, 3,171 had an attained age of 40 years or older at the time of last contact. Cumulative incidence of SNs, standardized incidence ratios (SIRs), excess absolute risk of subsequent malignant neoplasms (SMNs), and relative risks (RRs) for SMNs and nonmelanoma skin cancers were calculated.

RESULTS

In total, 679 SNs were diagnosed in patients age 40 years or older. These included 196 SMNs, 419 nonmelanoma skin cancers, 21 nonmalignant meningiomas, and 43 other benign neoplasms. At age 55 years, the cumulative incidence of new SNs and SMNs occurring after age 40 years was 34.6% (95% CI, 28.7 to 40.6) and 16.3% (95% CI, 11.7 to 20.9), respectively. Survivors were twice as likely as the general population to receive a diagnosis of SMN after age 40 years (SIR, 2.2; 95% CI, 1.9 to 2.5). Among SMNs, risk was increased for breast cancer (SIR, 5.5; 95% CI, 4.5 to 6.7), renal cancer (SIR, 3.9; 95% CI, 2.0 to 7.5), soft tissue sarcoma (SIR, 2.6; 95% CI, 1.5 to 4.4), and thyroid cancer (SIR, 1.9; 95% CI, 1.0 to 3.5). Female sex (RR, 1.9; 95% CI, 1.3 to 2.6; P < .001) and therapeutic radiation exposure (RR, 2.2; 95% CI, 1.4 to 3.3; P < .001) were associated with an increased for risk for SMN in multivariable analysis.

CONCLUSION

Even after age 40 years, survivors of childhood cancer remain at increased risk for treatment-related SNs. These data suggest the need for life-long monitoring and should inform anticipatory guidance provided to survivors of childhood cancer.

Identifying Predictors of Longitudinal Decline in the Level of Medical Care Received by Adult Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study

OBJECTIVES

Characterize longitudinal changes in the use of medical care in adult survivors of childhood cancer.

DATA SOURCES

The Childhood Cancer Survivor Study, a retrospective cohort study of 5+ year survivors of childhood cancer.

STUDY DESIGN

Medical care was assessed at entry into the cohort (baseline) and at most recent questionnaire completion. Care at each time point was classified as no care, general care, or survivor-focused care.

DATA COLLECTION

There were 6,176 eligible survivors. Multivariable models evaluated risk factors for reporting survivor-focused care or general medical care at baseline and no care at follow-up; and survivor-focused care at baseline and general care at follow-up.

PRINCIPAL FINDINGS

Males (RR, 2.3; 95 percent CI 1.8-2.9), earning <$20,000/year (RR, 1.6; 95 percent CI 1.2-2.3) or ≤ high school education (RR, 2.5; 95 percent CI 1.6-3.8 and RR 2.0; 95 percent CI 1.5-2.7 for

CONCLUSIONS

While the incidence of late effects increases over time for survivors, the likelihood of receiving survivor-focused care decreases for vulnerable populations.

Collapse

Key Words

• Childhood cancer survivors
• delivery of health care
• health care access
• health insurance
• survivorship

Collapse

MESH Headings

• Adolescent
• Adult
• Age Factors
• Female
• Health Services/statistics & numerical data
• Health Status
• Humans
• Longitudinal Studies
• Male
• Middle Aged
• Neoplasms/epidemiology
• Neoplasms/therapy
• Retrospective Studies
• Sex Factors
• Socioeconomic Factors
• Survivors/statistics & numerical data
• Young Adult

Collapse

Grants

• U24 CA055727 NCI NIH HHS
• CA21765 NCI NIH HHS
• P30 CA008748 NCI NIH HHS
• P30 CA021765 NCI NIH HHS
• CA55727 NCI NIH HHS

Collapse

Affiliation(s)

Jacqueline Casillas Address correspondence to Jacqueline Casillas, M.D., M.S.H.S., Department of Pediatrics, University of California, 10833 Le Conte Ave. Room A2-312 MDCC, Los Angeles, CA 90095; e-mail:
Kevin C Oeffinger Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Melissa M Hudson Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Mark L Greenberg Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Mark W Yeazel Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Kirsten K Ness Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Tara O Henderson Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Leslie L Robison Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Gregory T Armstrong Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Qi Liu Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Wendy Leisenring Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Yutaka Yasui Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
Paul C Nathan Kevin C. Oeffinger, M.D., is with the Department of Medicine and Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY Melissa M. Hudson, M.D., and Gregory T. Armstrong, M.D., are with the Departments of Oncology and Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Mark L. Greenberg, M.B., Ch.B., F.R.C.P.C., F.A.A.P., and Paul C. Nathan, M.D., M.Sc., are with the Department of Paediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada Mark W. Yeazel, M.D., M.P.H., is with the Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN Kirsten K. Ness, P.T., Ph.D., and Leslie L. Robison, Ph.D., are with the Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN Tara O. Henderson, M.D., is with The University of Chicago Medicine Comer Children's Hospital, Chicago, IL Qi Liu, M.S., and Yutaka Yasui, Ph.D., are with the Department of Public Health Sciences, University of Alberta, Edmonton, AB, Canada Wendy Leisenring, Sc.D., is with the Cancer Prevention and Biostatistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA

Collapse

Chimeric EWSR1-FLI1 regulates the Ewing sarcoma susceptibility gene EGR2 via a GGAA microsatellite

Deciphering the ways in which somatic mutations and germline susceptibility variants cooperate to promote cancer is challenging. Ewing sarcoma is characterized by fusions between EWSR1 and members of the ETS gene family, usually EWSR1-FLI1, leading to the generation of oncogenic transcription factors that bind DNA at GGAA motifs. A recent genome-wide association study identified susceptibility variants near EGR2. Here we found that EGR2 knockdown inhibited proliferation, clonogenicity and spheroidal growth in vitro and induced regression of Ewing sarcoma xenografts. Targeted germline deep sequencing of the EGR2 locus in affected subjects and controls identified 291 Ewing-associated SNPs. At rs79965208, the A risk allele connected adjacent GGAA repeats by converting an interspaced GGAT motif into a GGAA motif, thereby increasing the number of consecutive GGAA motifs and thus the EWSR1-FLI1-dependent enhancer activity of this sequence, with epigenetic characteristics of an active regulatory element. EWSR1-FLI1 preferentially bound to the A risk allele, which increased global and allele-specific EGR2 expression. Collectively, our findings establish cooperation between a dominant oncogene and a susceptibility variant that regulates a major driver of Ewing sarcomagenesis.

Psychosocial and Neurocognitive Outcomes in Adult Survivors of Adolescent and Early Young Adult Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE

To characterize psychological and neurocognitive function in long-term cancer survivors diagnosed during adolescence and early young adulthood (AeYA).

METHODS

Six thousand one hundred ninety-two survivors and 390 siblings in the Childhood Cancer Survivor Study completed the Brief Symptom Inventory-18 and a Neurocognitive Questionnaire. Treatment and demographic predictors were examined, and associations with social attainment (employment, education, and living independently) were evaluated. Logistic regression models were used to compute odds ratios (ORs) and corresponding 95% CIs.

RESULTS

Among survivors, 2,589 were diagnosed when AeYA (11 to 21 years old). Adjusted for current age and sex, these survivors, compared with siblings, self-reported higher rates of depression (11.7% v 8.0%, respectively; OR, 1.55; 95% CI, 1.04 to 2.30) and anxiety (7.4% v 4.4%, respectively; OR, 2.00; 95% CI, 1.17 to 3.43) and more problems with task efficiency (17.2% v 10.8%, respectively; OR, 1.72; 95% CI, 1.21 to 2.43), emotional regulation (19.1% v 14.1%, respectively; OR, 1.74; 95% CI, 1.26 to 2.40), and memory (25.9% v 19.0%, respectively; OR, 1.44; 95% CI, 1.09 to 1.89). Few differences were noted between survivors diagnosed with leukemia or CNS tumor before 11 years old versus during later adolescence, although those diagnosed with lymphoma or sarcoma during AeYA were at reduced risk for self-reported psychosocial and neurocognitive problems. Unemployment was associated with self-reports of impaired task efficiency (OR, 2.93; 95% CI, 2.28 to 3.77), somatization (OR, 2.29; 95% CI, 1.77 to 2.98), and depression (OR, 1.94; 95% CI, 1.43 to 2.63).

CONCLUSION

We demonstrated that risk for poor functional outcome is not limited to survivors' diagnoses in early childhood. AeYA is a critical period of development, and cancer during this period can impact neurocognitive and emotional function and disrupt vocational attainment.

Efficacy of a tobacco quitline among adult survivors of childhood cancer

INTRODUCTION

The purpose of this investigation was to determine the efficacy of two evidence-based tobacco quitlines in adult survivors of childhood cancer who regularly smoke cigarettes.

METHODS

A total of 519 adult survivors of childhood cancer were randomized to either Proactive + 4 weeks of medication (Counselor-initiated intervention, n = 260) or a Reactive + 2 weeks of medication (Participant-initiated intervention, n = 259) condition. Both conditions received telephone counseling to quit smoking as well as nicotine replacement therapy. The primary outcome was biochemically verified (i.e. cotinine) point prevalence smoking cessation at 12 months follow-up.

RESULTS

Participants randomized to the Proactive + 4 weeks of medication condition self-reported a higher rate of cessation than those survivors in the Reactive + 2 weeks of medication condition at 8 weeks (33.2% vs. 17.0%, p < .001), but cessation rates were not significantly different at 12 months (23.0% vs. 18.7%, p = .29). However, 80% of participants claiming abstinence failed biochemical verification, indicating marked falsification of self-reported smoking status. Adjusted cessation rates were less than 2% in both intervention conditions.

CONCLUSIONS

Our results indicate that neither a Proactive + 4 weeks of medication or Reactive + 2 weeks of medication quitline significantly impacted long-term smoking cessation rates. Our results further indicate that self-reports of smoking status are unreliable in survivors of childhood cancer, a population in considerable need of tobacco abstinence. Rates of smoking cessation may be markedly overestimated in studies of childhood cancer survivors that rely on self-reports of tobacco abstinence, and future studies need to include biochemical verification of tobacco status in this population.

Concentration, working speed and memory: cognitive problems in young childhood cancer survivors and their siblings

BACKGROUND

Cognitive problems can have a negative effect on a person's education, but little is known about cognitive problems in young childhood cancer survivors (survivors). This study compared cognitive problems between survivors and their siblings, determined if cognitive problems decreased during recent treatment periods and identified characteristics associated with the presence of a cognitive problem in survivors.

METHODS

As part of the Swiss Childhood Cancer Survivor Study, a questionnaire was sent to all survivors, aged 8-20 years, registered in the Swiss Childhood Cancer Registry, diagnosed at age <16 years, who had survived ≥ 5 years. Parent-reported (aged 8-15 years) and self-reported (aged 16-20 years) cognitive problems (concentration, working speed, memory) were compared between survivors and siblings. Multivariable logistic regression was used to identify characteristics associated with cognitive problems in survivors.

RESULTS

Data from 840 survivors and 247 siblings were analyzed. More often than their siblings, survivors reported problems with concentration (12% vs. 6%; P = 0.020), slow working speed (20% vs. 8%; P = 0.001) or memory (33% vs. 15%; P < 0.001). Survivors from all treatment periods were more likely to report a cognitive problem than were siblings. Survivors of CNS tumors (OR = 2.82 compared to leukemia survivors, P < 0.001) and those who had received cranial irradiation (OR = 2.10, P = 0.010) were most severely affected.

CONCLUSION

Childhood cancer survivors, even those treated recently (2001-2005), remain at risk to develop cognitive problems, suggesting a need to improve therapies. Survivors with cognitive problems should be given the opportunity to enter special education programs.

Visualization of risk of radiogenic second cancer in the organs and tissues of the human body

BACKGROUND

Radiogenic second cancer is a common late effect in long term cancer survivors. Currently there are few methods or tools available to visually evaluate the spatial distribution of risks of radiogenic late effects in the human body. We developed a risk visualization method and demonstrated it for radiogenic second cancers in tissues and organs of one patient treated with photon volumetric modulated arc therapy and one patient treated with proton craniospinal irradiation.

METHODS

Treatment plans were generated using radiotherapy treatment planning systems (TPS) and dose information was obtained from TPS. Linear non-threshold risk coefficients for organs at risk of second cancer incidence were taken from the Biological Effects of Ionization Radiation VII report. Alternative risk models including linear exponential model and linear plateau model were also examined. The predicted absolute lifetime risk distributions were visualized together with images of the patient anatomy.

RESULTS

The risk distributions of second cancer for the two patients were visually presented. The risk distributions varied with tissue, dose, dose-risk model used, and the risk distribution could be similar to or very different from the dose distribution.

CONCLUSIONS

Our method provides a convenient way to directly visualize and evaluate the risks of radiogenic second cancer in organs and tissues of the human body. In the future, visual assessment of risk distribution could be an influential determinant for treatment plan scoring.

Conditional survival in pediatric malignancies: analysis of data from the Childhood Cancer Survivor Study and the Surveillance, Epidemiology, and End Results Program

BACKGROUND

Long-term survivors of pediatric cancer are at risk of life-threatening late effects of their cancer. Previous studies have shown excesses in long-term mortality within high-risk groups defined by demographic and treatment characteristics.

METHODS

To investigate conditional survival in a pediatric cancer population, the authors performed an analysis of conditional survival in the original Childhood Cancer Survivor Study (CCSS) cohort and the Surveillance, Epidemiology, and End Results (SEER) database registry. The overall probability of death for patients at 5 years and 10 years after they survived 5, 10, 15, and 20 years since cancer diagnosis and cause-specific death in 10 years for 5-year survivors were estimated using the cumulative incidence method.

RESULTS

Among patients in the CCSS and SEER cohorts who were alive 5 years after their cancer diagnosis, within each diagnosis group at least 92% were alive in the subsequent 5 years, except for patients with leukemia, of whom only 88% of 5-year survivors remained alive in the subsequent 5 years. The probability of all-cause mortality in the next 10 years among patients who survived at least 5 years after diagnosis was 8.8% in CCSS and 10.6% in SEER, approximately 75% of which was due to neoplasms as the cause of death.

CONCLUSIONS

The risk of death among survivors of pediatric cancer in 10 years can vary between diagnosis groups by at most 12%, even up to 20 years after diagnosis. This information is clinically significant when counseling patients regarding their conditional survival, particularly when survivors are seen in long-term follow-up.

Estimating the burden of recurrent events in the presence of competing risks: the method of mean cumulative count

Cumulative incidence has been widely used to estimate the cumulative probability of developing an event of interest by a given time, in the presence of competing risks. When it is of interest to measure the total burden of recurrent events in a population, however, the cumulative incidence method is not appropriate because it considers only the first occurrence of the event of interest for each individual in the analysis: Subsequent occurrences are not included. Here, we discuss a straightforward and intuitive method termed "mean cumulative count," which reflects a summarization of all events that occur in the population by a given time, not just the first event for each subject. We explore the mathematical relationship between mean cumulative count and cumulative incidence. Detailed calculation of mean cumulative count is described by using a simple hypothetical example, and the computation code with an illustrative example is provided. Using follow-up data from January 1975 to August 2009 collected in the Childhood Cancer Survivor Study, we show applications of mean cumulative count and cumulative incidence for the outcome of subsequent neoplasms to demonstrate different but complementary information obtained from the 2 approaches and the specific utility of the former.

Advancing Survivors' Knowledge (ASK) about skin cancer study: study protocol for a randomized controlled trial

Background

Advances in treatment have increased childhood cancer 5-year survival rates to greater than 80%. However, children previously treated with radiation are at significantly increased risk of developing subsequent neoplasms, the most common of which are skin cancers. The National Cancer Institute and Children’s Oncology Group have issued recommendations for survivors treated with radiation to perform monthly skin self-examinations and receive a physician skin examination at least annually, as early detection has demonstrated markedly improved outcomes in the diagnosis and treatment of skin cancers. The goal of the present study is to increase rates of skin self-examinations and clinical skin examinations among adult survivors of childhood cancer treated with radiation.

Methods/Design

This randomized controlled trial uses a 3-group comparative effectiveness design comparing: (1) Patient Activation and Education (PAE) including text messaging, print and web-based tutorials over 12 months; (2) PAE plus physician activation (PAE + MD) adding physician activation/educational materials about survivors’ increased skin cancer risk and conducting full-body skin exams; and (3) PAE plus physician activation, plus teledermoscopy (PAE + MD + TD) adding participant receipt of a dermatoscope intended to empower them to photograph suspect moles or lesions for review by the study dermatologist.

Discussion

The current study addresses barriers to screening in this population by providing educational and motivational information for both survivors and physicians regarding the value of periodic skin examinations. It also utilizes innovative mobile health technology to encourage and motivate (that is activate) survivors to conduct skin self-examinations, request physician exams, and obtain treatment when worrisome lesions are found. Finally, as a comparative effectiveness trial, this study isolates the effects of adding specific components to the patient activation intervention to test the most effective intervention for enhancing skin examination vigilance among this high-risk group.

Trial registration

Clinicaltrials.gov: NCT02046811; Registration date: 22 January 2014.

Subsequent neoplasms in survivors of childhood central nervous system tumors: risk after modern multimodal therapy

BACKGROUND

Multimodal therapy has improved survival for some childhood CNS tumors. However, whether risk for subsequent neoplasms (SNs) also increases is unknown. We report the cumulative incidence of, and risk factors for, SNs after a childhood primary CNS tumor and determine whether treatment that combines radiation therapy (RT) with chemotherapy increases risk for SNs.

METHODS

Analyses included 2779 patients with a primary CNS tumor treated at St Jude Children's Research Hospital between 1985 and 2012. Cumulative incidence and standardized incidence ratios (SIRs) were estimated for SNs confirmed by pathology report. Cumulative incidence among the 237 five-year medulloblastoma survivors treated with multimodal therapy (RT + chemotherapy) was compared with a historical cohort of 139 five-year survivors treated with RT but no chemotherapy in the Childhood Cancer Survivor Study.

RESULTS

Eighty-one survivors had 97 SNs. The cumulative incidence of first SN was 3.0% (95% CI: 2.3%-3.9%) at 10 years, and 6.0% (95% CI: 4.6%-7.7%) at 20 years from diagnosis. Risks were highest for subsequent glioma, all grades (SIR = 57.2; 95% CI: 36.2-85.8) and acute myeloid leukemia (SIR = 31.8; 95% CI: 10.2-74.1). Compared with RT alone, RT + chemotherapy did not increase risk for SNs (hazard ratio: 0.64; 95% CI: 0.38-1.06). Among five-year survivors of medulloblastoma treated with multimodal therapy, cumulative incidence of SN was 12.0% (95% CI: 6.4%-19.5%) at 20 years, no different than survivors treated with RT alone (11.3%, P = .44).

CONCLUSION

The cumulative incidence of SNs continues to increase with time from treatment with no obvious plateau, but the risk does not appear to be higher after exposure to multimodal therapy compared with RT alone. Continued follow-up of survivors as they age is essential.

Childhood Cancer Survivor Study participants' perceptions and understanding of the Affordable Care Act

PURPOSE

The Patient Protection and Affordable Care Act (ACA) established provisions intended to increase access to affordable health insurance and thus increase access to medical care and long-term surveillance for populations with pre-existing conditions. However, childhood cancer survivors' coverage priorities and familiarity with the ACA are unknown.

METHODS

Between May 2011 and April 2012, we surveyed a randomly selected, age-stratified sample of 698 survivors and 210 siblings from the Childhood Cancer Survivor Study.

RESULTS

Overall, 89.8% of survivors and 92.1% of siblings were insured. Many features of insurance coverage that survivors considered "very important" are addressed by the ACA, including increased availability of primary care (94.6%), no waiting period before coverage initiation (79.0%), and affordable premiums (88.1%). Survivors were more likely than siblings to deem primary care physician coverage and choice, protections from costs due to pre-existing conditions, and no start-up period as "very important" (P < .05 for all). Only 27.3% of survivors and 26.2% of siblings reported familiarity with the ACA (12.1% of uninsured v 29.0% of insured survivors; odds ratio, 2.86; 95% CI, 1.28 to 6.36). Only 21.3% of survivors and 18.9% of siblings believed the ACA would make it more likely that they would get quality coverage. Survivors' and siblings' concerns about the ACA included increased costs, decreased access to and quality of care, and negative impact on employers and employees.

CONCLUSION

Although survivors' coverage preferences match many ACA provisions, survivors, particularly uninsured survivors, were not familiar with the ACA. Education and assistance, perhaps through cancer survivor navigation, are critically needed to ensure that survivors access coverage and benefits.

Individual prediction of heart failure among childhood cancer survivors

PURPOSE

To create clinically useful models that incorporate readily available demographic and cancer treatment characteristics to predict individual risk of heart failure among 5-year survivors of childhood cancer.

PATIENTS AND METHODS

Survivors in the Childhood Cancer Survivor Study (CCSS) free of significant cardiovascular disease 5 years after cancer diagnosis (n = 13,060) were observed through age 40 years for the development of heart failure (ie, requiring medications or heart transplantation or leading to death). Siblings (n = 4,023) established the baseline population risk. An additional 3,421 survivors from Emma Children's Hospital (Amsterdam, the Netherlands), the National Wilms Tumor Study, and the St Jude Lifetime Cohort Study were used to validate the CCSS prediction models.

RESULTS

Heart failure occurred in 285 CCSS participants. Risk scores based on selected exposures (sex, age at cancer diagnosis, and anthracycline and chest radiotherapy doses) achieved an area under the curve of 0.74 and concordance statistic of 0.76 at or through age 40 years. Validation cohort estimates ranged from 0.68 to 0.82. Risk scores were collapsed to form statistically distinct low-, moderate-, and high-risk groups, corresponding to cumulative incidences of heart failure at age 40 years of 0.5% (95% CI, 0.2% to 0.8%), 2.4% (95% CI, 1.8% to 3.0%), and 11.7% (95% CI, 8.8% to 14.5%), respectively. In comparison, siblings had a cumulative incidence of 0.3% (95% CI, 0.1% to 0.5%).

CONCLUSION

Using information available to clinicians soon after completion of childhood cancer therapy, individual risk for subsequent heart failure can be predicted with reasonable accuracy and discrimination. These validated models provide a framework on which to base future screening strategies and interventions.

Predictors of colorectal cancer surveillance among survivors of childhood cancer treated with radiation: a report from the Childhood Cancer Survivor Study

BACKGROUND

Childhood cancer survivors treated with radiotherapy to a field including the colon or rectum have an elevated risk of developing radiation-induced colorectal cancer (CRC). The Children's Oncology Group recommends colonoscopy every 5 years beginning at age 35 years for at-risk survivors.

METHODS

Analyses included 702 five-year survivors (Childhood Cancer Survivor Study) aged ≥36 years who received ≥30 gray of abdominal, pelvic, or spinal radiotherapy. Multivariate generalized linear models were used to calculate relative risks (RR) with 95% confidence intervals (95% CI) for adherence to the Children's Oncology Group's CRC surveillance recommendations.

RESULTS

With a median age of 43 years (range, 36-58 years), 29.5% of the survivors (207 of 702 survivors) met surveillance recommendations. In multivariate analyses, age ≥50 years versus age 36 to 49 years (RR, 2.6; 95% CI, 2.0-3.4), reporting a routine cancer follow-up visit within 1 year before the study (RR, 1.5; 95% CI, 1.0-2.2), reporting ≥10 physician visits within the past year versus 0 to 9 visits (RR, 1.4; 95% CI, 1.1-1.7), and discussing future cancer risk with a physician at the time of the most recent follow-up visit (RR, 1.4; 95% CI, 1.1-1.7) were found to be associated with adherence to CRC surveillance recommendations.

CONCLUSIONS

Greater than 70% of survivors at an increased risk of CRC were not screened as recommended. Regular physician contact and discussion of screening were associated with a 60% increase in CRC surveillance. Educational interventions targeted at survivors and their primary care physicians are needed to heighten knowledge of CRC risk after radiotherapy and the importance of appropriate surveillance.

Identifying and addressing the needs of adolescents and young adults with cancer: summary of an Institute of Medicine workshop

Cancer is the leading disease-related cause of death in adolescents and young adults (AYAs). This population faces many short- and long-term health and psychosocial consequences of cancer diagnosis and treatment, but many programs for cancer treatment, survivorship care, and psychosocial support do not focus on the specific needs of AYA cancer patients. Recognizing this health care disparity, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop to examine the needs of AYA patients with cancer. Workshop participants identified many gaps and challenges in the care of AYA cancer patients and discussed potential strategies to address these needs. Suggestions included ways to improve access to care for AYAs, to deliver cancer care that better meets the medical and psychosocial needs of AYAs, to develop educational programs for providers who care for AYA cancer survivors, and to enhance the evidence base for AYAs with cancer by facilitating participation in research.

Challenges of clinical trial design for targeted agents against pediatric leukemias

The past 40 years have seen significant improvements in both event-free and overall survival for children with acute lymphoblastic and acute myeloid leukemia (ALL and AML, respectively). Serial national and international clinical trials have optimized the use of conventional chemotherapeutic drugs and, along with improvements in supportive care that have enabled the delivery of more intensive regimens, have been responsible for the major improvements in patient outcome seen over the past few decades. However, the benefits of dose intensification have likely now been maximized, and over the same period, the identification of new cytotoxic drugs has been limited. Therefore, challenges remain if survival is to be improved further. In pediatric ALL, 5-year-survival rates of over 85% have been achieved with risk-stratified therapy, but a notable minority of patients will still not be cured. In pediatric AML, different challenges remain. A slower improvement in overall survival has taken place in this patient population. Despite the obvious morphological heterogeneity of AML blasts, biological stratification is comparatively limited, and translation into risk-stratified therapeutic approaches has only best characterized by the use of retinoic acid for t(15;17)-positive AML. Even where prognostic markers have been identified, limited therapeutic options or multi-drug resistance of AML blasts has limited the impact on patient benefit. For both, the acute morbidities of current treatment remain significant and may be life-threatening alone. In addition, the Childhood Cancer Survivor Study (CCSS) highlighted many leukemia survivors develop one or more chronic medical conditions attributable to treatment (1, 2). As the biology of leukemogenesis has become better understood, key molecules and intracellular pathways have been identified that offer the possibility of targeting directly the leukemia cells while sparing normal cells. Consequently, there is now a drive to develop novel leukemia-specific or "targeted" therapies. These new classes of drugs will have mechanisms of action, toxicities, and therapeutic indices quite different from conventional cytotoxic drugs previously encountered, thus rendering current clinical trial methodologies inappropriate. Clinical trial methods will need to be adapted to accommodate these features of these new classes of drugs. This review will address the challenges and some of the techniques for developing clinical trials for targeted therapies.

Lifestyle, distress, and pregnancy outcomes in the Childhood Cancer Survivor Study cohort

OBJECTIVE

To evaluate associations between prepregnancy lifestyle factors, psychologic distress and adverse pregnancy outcomes among female survivors of childhood cancer.

STUDY DESIGN

We examined pregnancies of 1192 female participants from the Childhood Cancer Survivor Study. Generalized linear models, adjusted for age at diagnosis, age at pregnancy, parity, and education were used to calculate the odds ratio (OR) and confidence interval (CI) for associations between prepregnancy inactivity, overweight or obese status, smoking status, risky drinking, psychologic distress and pregnancy outcomes. Interactions between lifestyle factors, psychologic distress, type of cancer and cancer treatment were assessed in multivariable models.

RESULTS

The median age of study participants at the beginning of pregnancy was 28 years (range, 14-45). Among 1858 reported pregnancies, there were 1300 singleton live births (310 were preterm), 21 stillbirths, 397 miscarriages, and 140 medical abortions. Prepregnancy physical inactivity, risky drinking, distress, and depression were not associated with any pregnancy outcomes. Compared with those who had never smoked, survivors with >5 pack-years smoking history had a higher risk for miscarriage among those treated with >2.5 Gray (Gy) uterine radiation (OR, 53.9; 95% CI, 2.2-1326.1) than among those treated with ≤2.5 Gy uterine radiation (OR, 1.9; 95% CI, 1.2-3.0). There was a significant interaction between smoking and uterine radiation (Pinteraction = .01).

CONCLUSION

Although most lifestyle factors and psychologic distress were not predictive of adverse pregnancy outcomes, the risk for miscarriage was significantly increased among survivors exposed to >2.5 Gy uterine radiation who had a history of smoking.

Age-dependent changes in health status in the Childhood Cancer Survivor cohort

PURPOSE

To compare age-dependent changes in health status among childhood cancer survivors and a sibling cohort.

METHODS

Adult survivors of childhood cancer and siblings, all participants of the Childhood Cancer Survivor Study, completed three surveys assessing health status. At each of three time points, participants were classified as having poor outcomes in general health, mental health, function, or daily activities if they indicated moderate to extreme impairment. Generalized linear mixed models were used to compare survivors with siblings for each outcome as a function of age and to identify host- and treatment-related factors associated with age-dependent worsening health status.

RESULTS

Adverse health status outcomes were more frequent among survivors than siblings, with evidence of a steeper trajectory of age-dependent change among female survivors with impairment in at least one health status domain (P = .01). In adjusted models, survivors were more likely than siblings to report poor general health (prevalence ratio [PR], 2.37; 95% CI, 2.09 to 2.68), adverse mental health (PR, 1.66; 95% CI, 1.52 to 1.80), functional impairment (PR, 4.53; 95% CI, 3.91 to 5.24), activity limitations (PR, 2.38; 95% CI, 2.12 to 2.67), and an adverse health status outcome in any domain (PR, 2.10; 95% CI, 1.97 to 2.23). Cancer treatment and health behaviors influence the magnitude of differences by age groups. Chronic conditions were associated with adverse health status outcomes across organ systems.

CONCLUSION

The prevalence of poor health status is higher among survivors than siblings, increases rapidly with age, particularly among female participants, and is related to an increasing burden of chronic health conditions.

Increasing cardiomyopathy screening in at-risk adult survivors of pediatric malignancies: a randomized controlled trial

PURPOSE

To determine whether the addition of advanced-practice nurse (APN) telephone counseling to a printed survivorship care plan (SCP) significantly increases the proportion of at-risk survivors who complete cardiomyopathy screening.

PATIENTS AND METHODS

Survivors age ≥ 25 years participating in the Childhood Cancer Survivor Study who received cardiotoxic therapy and reported no history of cardiomyopathy screening in the previous 5 years were eligible for enrollment. The 472 participants (mean age, 40.1 years; range, 25.0 to 59.0; 53.3% women) were randomly assigned to either standard care, consisting of an SCP summarizing cancer treatment and cardiac health screening recommendations (n = 234), or standard care plus two APN telephone counseling sessions (n = 238). The primary outcome-completion of cardiomyopathy screening within 1 year-was validated by medical records and compared between the two arms using adjusted relative risks (RRs) with 95% CIs.

RESULTS

Participants in the standard and APN counseling groups were not statistically different by demographic or clinical characteristics. At the time of 1-year follow-up, 107 (52.2%) of 205 survivors in the APN group completed screening compared with 46 (22.3%) of 206 survivors in the non-APN group (P < .001). With adjustment for sex, age (< 30 v ≥ 30 years), and Children's Oncology Group-recommended screening frequency group (annual, 2 years, or 5 years), survivors in the APN group were > 2× more likely than those in the control group to complete the recommended cardiomyopathy screening (RR, 2.31; 95% CI, 1.74 to 3.07).

CONCLUSION

The addition of telephone counseling to an SCP with cardiac health screening recommendations increases cardiomyopathy screening in at-risk survivors.

Exercise and risk of major cardiovascular events in adult survivors of childhood hodgkin lymphoma: a report from the childhood cancer survivor study

PURPOSE

Survivors of Hodgkin lymphoma (HL) are at increased risk of treatment-related cardiovascular (CV) events; whether exercise modifies this risk is unknown.

METHODS

Survivors of HL (n = 1,187; median age, 31.2 years) completed a questionnaire evaluating vigorous-intensity exercise behavior. CV events were collected in follow-up questionnaires and graded according to Common Terminology Criteria for Adverse Events (version 4.03). The primary end point was incidence of any major (grade 3 to 5) CV event. Poisson regression analyses were used to estimate the association between exercise exposure (metabolic equivalent [MET] hours/week(-1)) and risk of major CV events after adjustment for clinical covariates and cancer treatment.

RESULTS

Median follow-up was 11.9 years (range, 1.7 to 14.3 years). Cumulative incidence of any CV event was 12.2% at 10 years for survivors reporting 0 MET hours/week(-1) compared with 5.2% for those reporting ≥ 9 MET hours/week(-1). In multivariable analyses, the incidence of any CV event decreased across increasing MET categories (Ptrend = .002). Compared with survivors reporting 0 MET hours/week(-1), the adjusted rate ratio for any CV event was 0.87 (95% CI, 0.56 to 1.34) for 3 to 6 MET hours/week(-1), 0.45 (95% CI, 0.26 to 0.80) for 9 to 12 MET hours/week(-1), and 0.47 (95% CI, 0.23 to 0.95) for 15 to 21 MET hours/week(-1). Adherence to national vigorous intensity exercise guidelines (ie, ≥ 9 MET hours/week(-1)) was associated with a 51% reduction in the risk of any CV event in comparison with not meeting the guidelines (P = .002).

CONCLUSION

Vigorous exercise was associated with a lower risk of CV events in a dose-dependent manner independent of CV risk profile and treatment in survivors of HL.

Psychosexual functioning among adult female survivors of childhood cancer: a report from the childhood cancer survivor study

PURPOSE

Childhood cancer survivors may be at risk for impaired psychosexual functioning as a direct result of their cancer or its treatments, psychosocial difficulties, and/or diminished quality of life.

PATIENTS AND METHODS

Two thousand one hundred seventy-eight female adult survivors of childhood cancer and 408 female siblings from the Childhood Cancer Survivor Study (CCSS) completed a self-report questionnaire about their psychosexual functioning and quality of life. On average, participants were age 29 years (range, 18 to 51 years) at the time of the survey, had been diagnosed with cancer at a median age of 8.5 years (range, 0 to 20) and were most commonly diagnosed with leukemia (33.2%) and Hodgkin lymphoma (15.4%).

RESULTS

Multivariable analyses suggested that after controlling for sociodemographic differences, survivors reported significantly lower sexual functioning (mean difference [MnD], -0.2; P = .01), lower sexual interest (MnD, -0.2; P < .01), lower sexual desire (MnD, -0.3; P < .01), lower sexual arousal (MnD, -0.3; P < .01), lower sexual satisfaction (MnD, -0.2; P = .01), and lower sexual activity (MnD, -0.1; P = .02) compared with siblings. Risk factors for poorer psychosexual functioning among survivors included older age at assessment, ovarian failure at a younger age, treatment with cranial radiation, and cancer diagnosis during adolescence.

CONCLUSION

Decreased sexual functioning among female survivors of childhood cancers seems to be unrelated to emotional factors and is likely to be an underaddressed issue. Several risk factors among survivors have been identified that assist in defining high-risk subgroups who may benefit from targeted screening and interventions.

Factors associated with recruiting adult survivors of childhood cancer into clinic-based research

BACKGROUND

A high proportion of pediatric cancer patients are now surviving into adulthood, but are at increased risk for late morbidity and premature mortality related to their diagnosis and therapeutic exposures. Little is known about the potential success of recruiting adult survivors of childhood cancer into research projects that would require a risk-based health evaluation within a clinical setting.

PROCEDURES

Pediatric cancer survivors and siblings eligible for the current study were Childhood Cancer Survivor Study participants who lived within 100 miles of one of five Consortium for Pediatric Intervention Research institutions, regardless of where they were initially diagnosed and treated. A short survey was mailed to 829 survivors and 373 siblings to identify factors that predict interest, potential barriers, and motivators, to participation in research including a risk-based clinical evaluation.

RESULTS

Overall, 92% of survivors responding to the survey were very interested/interested in participating in a research study requiring a visit to a local hospital clinic. Siblings of survivors were less interested than survivors in participating in such a study, with only 78% indicating that they were very interested/interested. Potential motivators to participation included visiting their treating hospital and receiving health information. The primary barrier to participation was related to taking time off from work.

CONCLUSIONS

This study demonstrates that a subgroup of survivors would be willing to return to a long-term follow-up center to participate in intervention-based research. Identified motivating factors and perceived barriers need to be considered in determining the feasibility, design and execution of future research.

Predictors of future health-related quality of life in survivors of adolescent cancer

The purpose of this study was to identify characteristics associated with health-related quality of life (HRQOL) among long-term survivors of adolescent cancer enrolled in the Childhood Cancer Survivor Study. Thirty percent of survivors reported poor physical and/or mental HRQOL. Race/ethnicity, education, and head/neck disfigurement were significantly associated with poor mental HRQOL, while sex, age, household income, obesity, alkylating agents, pelvic radiation, head/neck or limb disfigurement, and walking with a limp were associated with poor physical HRQOL. Identification of high-risk adolescent cancer patients may facilitate timely intervention to attempt to minimize the impact of cancer and treatment on subsequent quality of life.

Proton radiotherapy for pediatric tumors: review of first clinical results

Radiation therapy is a part of multidisciplinary management of several childhood cancers. Proton therapy is a new method of irradiation, which uses protons instead of photons. Proton radiation has been used safely and effectively for medulloblastoma, primitive neuro-ectodermal tumors, craniopharyngioma, ependymoma, germ cell intracranial tumors, low-grade glioma, retinoblastoma, rhabdomyosarcoma and other soft tissue sarcomas, Ewing’s sarcoma and other bone sarcomas. Moreover, other possible applications are emerging, in particular for lymphoma and neuroblastoma. Although both photon and proton techniques allow similar target volume coverage, the main advantage of proton radiation therapy is to sparing of intermediate-to-low-dose to healthy tissues. This characteristic could translate into clinical reduction of side effects, including a lower risk for secondary cancers. The following review presents the state of the art of proton therapy in the treatment of pediatric malignancies.

Late Cardiotoxicity in Aging Adult Survivors of Childhood Cancer

The survival rate for childhood cancer is steadily improving, and the current estimate for the prevalence of childhood cancer survivors in the United States is 420,000. With this encouraging trend and the aging of this population, there is an ever-increasing responsibility to identify adult survivors of childhood cancer with adverse health outcomes related to cancer treatment across the span of their lives. To accomplish this, large cohort studies have been developed to follow survivors longitudinally. Compared to siblings, survivors have a higher cumulative incidence of morbidity and mortality, and this gap in incidence only widens with age. One of the most significant late toxicities in survivors is late onset cardiotoxicity, largely due to anthracycline and chest-directed radiation exposure. Survivors also have an increased prevalence of traditional cardiovascular risk factors as they age, which potentiates the risk for major cardiac events. Prevention is essential. Minimizing anthracycline dose exposure in pediatric cancer patients is a primary method of cardioprotection. Dexrazoxane and enalapril have also been studied as primary (pre-exposure) and secondary (post-exposure) cardioprotecant agents, respectively. Additionally, the Children's Oncology Group has published exposure-driven, risk-based screening guidelines for long-term follow-up, which may be a cost-effective way to identify subclinical cardiac disease before progression to clinical presentation. Ongoing research is needed to determine the most effective diagnostic modality for screening (e.g. echocardiography), and the most effective intervention strategies to improve long-term outcomes.

Efficacy of cabazitaxel in mouse models of pediatric brain tumors

BACKGROUND

There is an unmet need in the treatment of pediatric brain tumors for chemotherapy that is efficacious, avoids damage to the developing brain, and crosses the blood-brain barrier. These experiments evaluated the efficacy of cabazitaxel in mouse models of pediatric brain tumors.

METHODS

The antitumor activity of cabazitaxel and docetaxel were compared in flank and orthotopic xenograft models of patient-derived atypical teratoid rhabdoid tumor (ATRT), medulloblastoma, and central nervous system primitive neuroectodermal tumor (CNS-PNET). Efficacy of cabazitaxel and docetaxel were also assessed in the Smo/Smo spontaneous mouse medulloblastoma tumor model.

RESULTS

This study observed significant tumor growth inhibition in pediatric patient-derived flank xenograft tumor models of ATRT, medulloblastoma, and CNS-PNET after treatment with either cabazitaxel or docetaxel. Cabazitaxel, but not docetaxel, treatment resulted in sustained tumor growth inhibition in the ATRT and medulloblastoma flank xenograft models. Patient-derived orthotopic xenograft models of ATRT, medulloblastoma, and CNS-PNET showed significantly improved survival with treatment of cabazitaxel.

CONCLUSION

These data support further testing of cabazitaxel as a therapy for treating human pediatric brain tumors.

Anonymization of DICOM electronic medical records for radiation therapy

Electronic medical records (EMR) and treatment plans are used in research on patient outcomes and radiation effects. In many situations researchers must remove protected health information (PHI) from EMRs. The literature contains several studies describing the anonymization of generic Digital Imaging and Communication in Medicine (DICOM) files and DICOM image sets but no publications were found that discuss the anonymization of DICOM radiation therapy plans, a key component of an EMR in a cancer clinic. In addition to this we were unable to find a commercial software tool that met the minimum requirements for anonymization and preservation of data integrity for radiation therapy research. The purpose of this study was to develop a prototype software code to meet the requirements for the anonymization of radiation therapy treatment plans and to develop a way to validate that code and demonstrate that it properly anonymized treatment plans and preserved data integrity. We extended an open-source code to process all relevant PHI and to allow for the automatic anonymization of multiple EMRs. The prototype code successfully anonymized multiple treatment plans in less than 1min/patient. We also tested commercial optical character recognition (OCR) algorithms for the detection of burned-in text on the images, but they were unable to reliably recognize text. In addition, we developed and tested an image filtering algorithm that allowed us to isolate and redact alpha-numeric text from a test radiograph. Validation tests verified that PHI was anonymized and data integrity, such as the relationship between DICOM unique identifiers (UID) was preserved.