Epidemiology of cancer in adolescents

MilCanEpi: Increased Capability for Cancer Care Research in the Department of Defense

The Military Health System (MHS) of the US Department of Defense (DoD) provides comprehensive medical care to over nine million beneficiaries, including active-duty members, reservists, activated National Guard, military retirees, and their family members. The MHS generates an extensive database containing administrative claims and medical encounter data, while the DoD also maintains a cancer registry that collects information about the occurrence of cancer among its beneficiaries who receive care at military treatment facilities. Collating data from the two sources diminishes the limitations of using registry or medical claims data alone for cancer research and extends their usage. To facilitate cancer research using the unique military health resources, a computer interface linking the two databases has been developed, called Military Cancer Epidemiology, or MilCanEpi. The intent of this article is to provide an overview of the MilCanEpi data system, describing its components, structure, potential uses, and limitations.

Exposure to wildfire-related PM2.5 and site-specific cancer mortality in Brazil from 2010 to 2016: A retrospective study

BACKGROUND

Long-term exposure to fine particles ≤2.5 μm in diameter (PM2.5) has been linked to cancer mortality. However, the effect of wildfire-related PM2.5 exposure on cancer mortality risk is unknown. This study evaluates the association between wildfire-related PM2.5 and site-specific cancer mortality in Brazil, from 2010 to 2016.

METHODS AND FINDINGS

Nationwide cancer death records were collected during 2010-2016 from the Brazilian Mortality Information System. Death records were linked with municipal-level wildfire- and non-wildfire-related PM2.5 concentrations, at a resolution of 2.0° latitude by 2.5° longitude. We applied a variant difference-in-differences approach with quasi-Poisson regression, adjusting for seasonal temperature and gross domestic product (GDP) per capita. Relative risks (RRs) and 95% confidence intervals (CIs) for the exposure for specific cancer sites were estimated. Attributable fractions and cancer deaths were also calculated. In total, 1,332,526 adult cancer deaths (age ≥ 20 years), from 5,565 Brazilian municipalities, covering 136 million adults were included. The mean annual wildfire-related PM2.5 concentration was 2.38 μg/m3, and the annual non-wildfire-related PM2.5 concentration was 8.20 μg/m3. The RR for mortality from all cancers was 1.02 (95% CI 1.01-1.03, p < 0.001) per 1-μg/m3 increase of wildfire-related PM2.5 concentration, which was higher than the RR per 1-μg/m3 increase of non-wildfire-related PM2.5 (1.01 [95% CI 1.00-1.01], p = 0.007, with p for difference = 0.003). Wildfire-related PM2.5 was associated with mortality from cancers of the nasopharynx (1.10 [95% CI 1.04-1.16], p = 0.002), esophagus (1.05 [95% CI 1.01-1.08], p = 0.012), stomach (1.03 [95% CI 1.01-1.06], p = 0.017), colon/rectum (1.08 [95% CI 1.05-1.11], p < 0.001), larynx (1.06 [95% CI 1.02-1.11], p = 0.003), skin (1.06 [95% CI 1.00-1.12], p = 0.003), breast (1.04 [95% CI 1.01-1.06], p = 0.007), prostate (1.03 [95% CI 1.01-1.06], p = 0.019), and testis (1.10 [95% CI 1.03-1.17], p = 0.002). For all cancers combined, the attributable deaths were 37 per 100,000 population and ranged from 18/100,000 in the Northeast Region of Brazil to 71/100,000 in the Central-West Region. Study limitations included a potential lack of assessment of the joint effects of gaseous pollutants, an inability to capture the migration of residents, and an inability to adjust for some potential confounders.

CONCLUSIONS

Exposure to wildfire-related PM2.5 can increase the risks of cancer mortality for many cancer sites, and the effect for wildfire-related PM2.5 was higher than for PM2.5 from non-wildfire sources.

Associations between long-term exposure to PM2.5 and site-specific cancer mortality: A nationwide study in Brazil between 2010 and 2018

Long-term exposure to PM_2.5 has been linked to lung cancer incidence and mortality, but limited evidence existed for other cancers. This study aimed to assess the association between PM_2.5 on cancer specific mortality. An ecological study based on the cancer mortality data collected from 5,565 Brazilian cities during 2010-2018 using a difference-in-differences approach with quasi-Poisson regression, was applied to examine PM_2.5-cancer mortality associations. Globally gridded annual average surface PM_2.5 concentration was extracted and linked with the residential municipality of participants in this study. Sex, age stratified and exposure-response estimations were also conducted. Totalling 1,768,668 adult cancer deaths records of about 208 million population living across 5,565 municipalities were included in this study. The average PM_2.5 concentration was 7.63 μg/m³ (standard deviation 3.32) with range from 2.95 μg/m³ to 28.5 μg/m³. With each 10 μg/m³ increase in three-year-average (current year and previous two years) concentrations of PM_2.5, the relative risks (RR) of cancer mortality were 1.16 (95% confidence interval [CI]: 1.11-1.20) for all-site cancers. The PM_2.5 exposure was significantly associated with several cancer-specific mortalities including oral, nasopharynx, oesophagus, and stomach, colon rectum, liver, gallbladder, larynx, lung, bone, skin, female breast, cervix, prostate, brain and leukaemia. No safe level of PM_2.5 exposure was observed in the exposure-response curve for all types of cancer. In conclusion, with nationwide cancer death records in Brazil, we found that long-term exposure to ambient PM_2.5 increased risks of mortality for many cancer types. Even low level PM_2.5 concentrations had significant impacts on cancer mortality.

The Effectiveness of Interventional Cancer Education Programs for School Students Aged 8-19 Years: a Systematic Review

The implementation of effective interventional cancer education programs in schools could help to reduce delays in diagnosis and improve cancer survival by increasing awareness of risk factors and symptoms among students. The aim of this review was to determine the effectiveness of interventional cancer education programs delivered to school students aged 8-19 years. Various databases were searched to identify controlled and uncontrolled studies published in English language articles between January 2000 and January 2020. Selected publications were then critically appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews. A total of 12 studies meeting these criteria were identified. Of these, eight were randomized, and five included control groups. All of the studies conducted the intervention over the course of 1, 3, or 4 days, and there was no follow-up phase in seven studies. Various modes and materials were used in the delivery of the interventions, including children's books and booklets, expert talks or presentations, videos, discussions, role-playing exercises, hands-on activities, group work, quizzes, and homework. There was some evidence to indicate that the interventions enhanced short-term knowledge, attitudes, self-efficacy, and behavioral intentions; however, there was less evidence regarding their long-term effectiveness, particularly in terms of help-seeking barriers. Interventional education programs are important to increase knowledge of cancer among school students aged 8-19 years. Decision-makers should consider including relevant topics within the educational curricula. Both healthcare providers and non-educational organizations should work together to support effective cancer interventional education programs for school students as part of their long-term cancer prevention efforts.

Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families

Children and youth with special health care needs (CYSHCN) and their families may experience a variety of internal (ie, emotional and behavioral) and external (ie, interpersonal, financial, housing, and educational) psychosocial factors that can influence their health and wellness. Many CYSHCN and their families are resilient and thrive. Medical home teams can partner with CYSHCN and their families to screen for, evaluate, and promote psychosocial health to increase protective factors and ameliorate risk factors. Medical home teams can promote protective psychosocial factors as part of coordinated, comprehensive chronic care for CYSHCN and their families. A team-based care approach may entail collaboration across the care spectrum, including youth, families, behavioral health providers, specialists, child care providers, schools, social services, and other community agencies. The purpose of this clinical report is to raise awareness of the impact of psychosocial factors on the health and wellness of CYSHCN and their families. This clinical report provides guidance for pediatric providers to facilitate and coordinate care that can have a positive influence on the overall health, wellness, and quality of life of CYSHCN and their families.

Parental Age and Risk of Pediatric Cancer in the Offspring: A Population-Based Record-Linkage Study in California

Linking birth records and cancer registry data from California, we conducted a population-based study with 23,419 cases and 87,593 matched controls born during 1978-2009 to investigate the relationship of parental age to risk of pediatric cancer. Compared with children born to mothers aged 20-24 years, those born to mothers in older age groups had a 13%-36% higher risk of pediatric cancer; the odds ratio for each 5-year increase in maternal age was 1.06 (95% confidence interval (CI): 1.04, 1.09). For cancer diagnosed in children in age groups 0-14 years and 15-19 years, the odds ratios for each 5-year increase in maternal age were 1.05 (95% CI: 1.02, 1.07) and 1.14 (95% CI: 1.09, 1.19), respectively. Having an older father also conferred an increased risk, with an odds ratio for each 5-year increase of 1.03 (95% CI: 1.02, 1.05) for cancer diagnosed at ages 0-19 years and 1.03 (95% CI: 1.02, 1.05) for cancer diagnosed at ages 0-14 years. While advancing maternal age increased risk of leukemia and central nervous system tumors, older paternal age was not associated with risk of either type. Both maternal and paternal older ages were associated with risk of lymphoma. In this large, population-based record-linkage study, advancing parental age, especially advancing maternal age, was associated with higher pediatric cancer risk, with variations across types of cancer.

Cancer in adolescents: Incidences and trends during 1995-2009 in Taiwan

This study aimed to describe cancer incidence rates and trends specifically for adolescents aged 15-19 years during 1995-2009 in Taiwan. The incidence counts and census data were obtained from the population-based Taiwan Cancer Registry. During the 15-year study period, 4122 adolescents were diagnosed with cancer. The overall incidence rate was 155.2 per million person-years. Other epithelial tumors were the most frequently diagnosed cancer group (23.7%), followed by leukemias (18.0%) and lymphomas (13.9%). When compared to rates in Western countries, a significantly low rate of lymphomas was found. Moreover, rates of the subtypes of melanomas and nasopharyngeal carcinomas being 1/10- and 4-times rates in Western countries were the most striking variations. During 1995-2009, the overall rate of adolescent cancer did not significantly change. However, the most significant upward and declining trends in incidence rates were found for male germ cell neoplasms (annual percent change, APC, 6.4%) and hepatic tumors (APC, -11.1%), respectively. Further investigation and enhancement of the public discourse of possible lifestyle and environmental risk factors associated with increasing trends of certain adolescent cancers should be carried out in Taiwan.

Childhood cancer in Gondar University Hospital, Northwest Ethiopia

Background

Childhood cancer becomes a public health problem in developing countries which aggravates the burden of childhood mortality by infectious diseases and malnutrition. In poor countries, the death rate for most pediatric cancers is almost 100 %. This study attempts to determine the magnitude, patterns and trends of pediatric malignancies in the study area which is important in re-evaluating existing services and in improving facilities and patient care.

Methods

A retrospective study of 3 year period were carried out among all children aged below 15 years old admitted into the pediatric wards of Gondar University Hospital, Northwest Ethiopia. The charts of all children aged below 15 years old admitted in the pediatric wards due to cancer were reviewed by using the data collection format. Data were entered and analyzed using SPSS version 20 statistical package.

Result

A total of 71 cancer cases were diagnosed and admitted to the pediatrics ward during the study period. More than two-third of the study subjects 50 (70.4 %) were males. The mean age of study subjects was 7 ± 4 year where majority 26 (36.6 %) of the study subjects were ≥10 years. Of all, 43 (60.6 %) were hematological malignancy followed by Wilms tumor 13 (18.3 %), Neuroblastoma 5 (7 %), Rhabdomyosarcoma 3 (4.2 %), Brain tumor 3 (4.2 %), Hepatoblastoma 2 (2.8 %). More than two-third of cases were found to be concomitantly malnourished being stunted, wasted and under weight. Nearly half of patients had not received chemotherapy and majority of those started chemotherapy did not complete all the treatment cycles. Shortage and absence of safe and affordable chemotherapy drugs were the major reasons for therapy interruption.

Conclusion

The study shows increasing childhood cancer cases over the years. Hematological malignancy takes the leading prevalence followed by Wilms tumor and Neuroblastoma. The majority of cases were also discharged without any clinical change that had the only death option. Therefore, the government and the hospital should give emphasis to establish cancer therapy centers and insure accessibility and affordability of chemotherapy drugs.

[Management of febrile neutropenias in adolescents and young adults: Differences of practice between adult and pediatric units]

INTRODUCTION

Adolescents and young adults (AYA, 15-25years old) with cancer are treated either in adult or pediatric units. Management of febrile neutropenia (FN) is different between these units. Monitoring rules and indications of hospitalization are often stricter in pediatrics. This study evaluates if these differences influence the occurrence of complications.

METHODS

The medical records of AYA patients treated in our institution in the Euro-E-W-I-N-G99 protocol between 01/09/2000 and 31/05/2013 were retrospectively analyzed. We studied febrile neutropenias occurring after VIDE courses, during the induction period.

RESULTS

Forty-four patients were included (18 from adult units, 26 from pediatrics). Median age at inclusion was 19.6. After 260 courses of VIDE, we observed a median of 2 FN per adult and 3 per pediatric patient (P=0.2). Hospitalization occurred in median 1.5 time per adult and 3 per pediatric patient (P=0.008). Median cumulated length of stay was 4.5days for adults versus 16 days for pediatric patients (P=0.008). There was no significant difference for survival, number of documented infections, transfusions, dose modifications, chemotherapy delay, need for intensive care, infection after post-induction surgery.

CONCLUSION

AYA treated in adult services are less frequently hospitalized for FN with no difference in morbi-mortality. Homogeneous recommendations could be made for these patients, whatever the units they are treated in.

Survival analysis after diagnosis with malignancy of Egyptian adolescent patients: a single-center experience

BACKGROUND

Adolescents with malignancy represent a unique population in oncology, receiving care in pediatric or adult oncology institutions. Previously, adolescents and young adults (AYAs) had good survival rates; yet in the last few decades, AYAs have shown inferior survival rates compared with children due to the increasingly reported AYA-specific malignancies with poor survival rates. This study evaluates the clinicoepidemiological aspects of adolescent cancer diagnosed in a Pediatric Oncology Unit over a 10-year period, the associated risk factors, and the survival rate.

METHODS

Retrospective data analysis of patients aged 10 to 19 years diagnosed in the Pediatric Oncology Unit, Children's Hospital Ain Shams University, Cairo, Egypt, during the period from January 1, 2000 to January 1, 2010.

RESULTS

There were 158 patients (20% of total number of patients diagnosed during the same period), 84 male (53.2%) and 74 female (46.8%). Hematological malignancies were the most common (91.8%), with acute lymphoblastic leukemia being the most prevalent malignancy (61.5%), and solid tumors represented 8.2% of the total number of patients. The 5- and 10-year overall survival rates were 45.2% and 40.2%, respectively. The 5- and 10-year event-free survival rates for hematological malignancies were 39.9% and 37.3%, and for solid tumors it was 36.4%. Infection was the main cause of death (50%).

CONCLUSIONS

Age-related survival gap exists for adolescent cancer patients compared with children. Further studies are needed to provide evidence about optimal treatment regimens in this age group.

Cancer incidence and survival among adolescents in Israel during the years 1998 to 2009

PURPOSE

Our goal was to describe adolescent cancer incidence and survival in Israel, and to identify demographic and epidemiologic variations among adolescents with cancer.

PATIENTS AND METHODS

We used data from the Israel National Cancer Registry in order to examine the incidence and survival of adolescent cancer in Israeli adolescents aged 15-19 years, diagnosed during the years 1998-2009. Cases were analyzed according to sex, ethnicity and geographical region, as well as comparison to other countries in the region and other western countries.

RESULTS

Among the 1,532 new cases of adolescent cancer, there was a total incidence rate of 226 cases per million. The incidence rate for males was higher than for females (230 and 222, respectively) and higher for Jewish adolescents than for Arab adolescents (235 and 194, respectively). The largest groups were Lymphomas (69 per million), Malignant Epithelial Neoplasms (49 per million), and Leukemias (21 per million). We estimated the survival probability updated to December 2009, and calculated the 5-year survival for new cases until the end of 2004. The overall survival at 5 years was 78%, with 62% for the Arabic population and 81% for the Jewish population, dependent on the diagnosis.

CONCLUSIONS

The results of this study show little difference in the predominance of some adolescent cancers in comparison with other developed countries. This study may add more information for further investigation of the genetic and environmental factors that cause adolescent cancer in Israel. As well as delineate the genetic basis for ethnic origin disparities in survival.

The relationships between fatigue, quality of life, and family impact among children with special health care needs

OBJECTIVE

To examine the relationships among pediatric fatigue, health-related quality of life (HRQOL), and family impact among children with special health care needs (CSHCNs), specifically whether HRQOL mediates the influence of fatigue on family impact.

METHODS

266 caregivers of CSHCNs were studied. The Pediatric Quality of Life Inventory Multidimensional Fatigue Scale, Pediatric Quality of Life Inventory Generic Scale, and Impact on Family Scale were used to measure fatigue, HRQOL, and family impact, respectively. Linear regressions were used to analyze the designated relationships; path analyses were performed to quantify the mediating effects of HRQOL on fatigue-family impact relationship.

RESULTS

Although greater fatigue was associated with family impact (p < .05), the association was not significant after accounting for HRQOL. Path analyses indicated the direct effect of fatigue on family impact was not significant (p > .05), whereas physical and emotional functioning significantly mediated the fatigue-family impact relationship (p < .001).

CONCLUSION

Fatigue is related to family impact among CSHCNs, acting through the impairment in HRQOL.

Progression from first symptom to diagnosis in childhood brain tumours

This study was undertaken to investigate the evolution of clinical features between onset of symptoms and diagnosis in children with brain tumours and to identify ways of shortening the time to diagnosis. One hundred and thirty-nine children with a brain tumour were recruited from four UK paediatric neuro-oncology centres. Children had a median of one symptom or sign at symptom onset and six by diagnosis. The symptoms and/or signs experienced at symptom onset and at diagnosis were as follows: headache in 55 and 81 children, nausea and vomiting in 39 and 88 children, motor system abnormalities in 31 and 93 children, cranial nerve palsies in 24 and 75 children, visual system abnormalities in 23 and 96 children, endocrine or growth abnormalities in 10 and 35 children and behavioural change in 4 and 55 children. The median time between symptom onset and diagnosis (symptom interval) was 3.3 months. A longer symptom interval was associated with head tilt, cranial nerve palsies, endocrine and growth abnormalities and reduced visual acuity. More than half of children with brain tumours developed problems with vision and more than a third developed motor problems, cranial nerve palsies, behavioural change, or nausea and vomiting between symptom onset and diagnosis.

Adolescents and young adults with cancer: An orphaned population

Adolescents and young adults (AYAs [15 to 29 years of age]) with cancer have a distinct cancer epidemiology, evolving hormonal milieu, maturing development, transitions in autonomy, increasing demands in education, entry into the workplace and family responsibilities. The prevalence of epithelial cancers in AYA patients represents a major shift from the embryonal cancers that predominate in early childhood. Thus, one would expect a specialized expertise to be required in caring for these patients, who typically fall between paediatric and oncology spheres of practice. Complex issues contribute to the lower survival rates noted for AYAs compared with those of younger patients, even with the same cancer. Cooperative group clinical trial participation has been crucial in advancing the excellent outcomes accomplished in paediatric oncology, yet participation by adolescents in clinical trials (either adult or paediatric) is typically low. There is increasing evidence that both appropriate location of care and access to specialists in paediatric or adult oncology contribute to favourable outcomes. Issues specific to AYA patients should be studied rigorously so that evidence-based approaches may be used to reduce waiting times, ensure prompt referral to appropriate centres, increase accrual to clinical trials, foster compliance, provide comprehensive supportive care and promote programs designed to enhance survivorship.

Epidemiology and cost analysis for patients with oral cancer in a university hospital in China

BACKGROUND

Although several studies have reported the direct cost of oral cancer (OC), little research has invested the factors that could influence the costs of OC patient. This study analyzes the epidemiological characteristics and the direct cost of OC. More specifically, the study examines the relationship between patients' medical costs and influencing factors of epidemiology.

METHODS

All patients encountered from January 2007 to December 2007 at the School of Stomatology of the Fourth Military Medical University (FMMU) in China with diagnosis of oral cancer have been selected. Medical hospitalization days (MHD) and cost per patient (CPP) of the samples have been calculated for different patient groups, and the results have been compared using statistical methods.

RESULTS

A total of 456 oral cancer patients have been selected in this study. The epidemical characteristics are as follows: female/male 176/280; squamous cell carcinoma (SCC)/adenocarcinoma/sarcoma/lymphoma/other types 246/127/40/27/16; stage I/II/III/IV 90/148/103/115; smoker/non-smoker 136/320; rural/urban patients 82/374. Of all the patients, 82.24% were over 40 years of age. Rural patients were significantly younger than urban patients. SCC was the majority histology in older patients, while sarcoma was more common in younger patients. 372 of the patients received treatment and 84 gave up any treatment after diagnosis. Treatment cost accounted for majority of the payment. The CPP and MHD of patients in late clinical stage were higher than that of patient in early stage.

CONCLUSION

Gender, smoking habit and age older than 40 years are the epidemiological risk factors for oral cancer. Lack of medicare, smoking habit, late clinical stage and SCC are the high economic factors for patient medical cost.

Imaging 'the lost tribe': a review of adolescent cancer imaging. Part 1

Although a small proportion of all cancer registrations, malignancy in adolescence and young adulthood remains the most common natural cause of death in this age group. Advances in the management and outcomes of childhood cancer have not been matched within the adolescent population, with increasing incidence and poorer survival seen amongst teenagers with cancer compared with other populations. There have been increasing moves towards specific adolescent oncology centres, with the aim of centralising expertise, however, ‘adolescent imaging’ does not exist as a speciality in the same way that paediatric imaging does, with responsibility for imaging adolescent patients sometimes falling to paediatric radiologists and sometimes to ‘adult’ radiologists, usually with a specific interest in a tumour type or body system. In this article, imaging of the more common malignancies, encountered in adolescent patients is reviewed. Complications of treatment are reviewed in another article to give an overview of adolescent oncology imaging practice.

Trends in cancer mortality in Japanese adolescents and young adults aged 15-29 years, 1970-2006

OBJECTIVE

The primary objective of this study is to describe cancer mortality rates and trends among Japanese adolescents and young adults aged 15-29 years for the period 1970-2006.

MATERIALS AND METHODS

Age-standardized mortality rates were calculated by the direct method using age-specific mortality rates at 5-year age intervals and weights based on the age distribution of the standard world population. The joinpoint regression model was used to describe changes in trends.

RESULTS

For all cancers combined, the mortality rate at age 15-29 years during 2000-2006 was 4.41 (per 100,000 population) for males and 3.81 (per 100,000) for females. Trends of mortality from cancer in Japan were similar to that in other developed countries. A notable exception was cervical cancer, for which Japanese young women showed a significant increase, on average 4.0% per year throughout the period.

CONCLUSION

This report presents updated figures and trends in cancer mortality among adolescents and young adults aged 15-29 years in Japan and other developed countries. We hope this study will raise public awareness on cancer in this age group and provide the impetus for further research to improve the survival and quality of life of the young people in Japan.

The cancer incidence temporality index: An index to show temporal changes in the age of onset of overall and specific cancer (England and Wales, 1971–1999)

The theory that increasing cancer incidence rates in developed countries are primarily the consequence of an expanding ageing population and improved diagnostic testing is widely held. In the United Kingdom the proportion of people aged 50 and over has increased by 45% since 1951 and this proportion is set to increase by a further 36% by the year 2031, so the United Kingdom does indeed have an expanding ageing population. However, the increase in cancer incidence affects people across the whole age spectrum. To test the hypothesis that the age of onset of cancer (overall and specific) in England and Wales is decreasing over time we have developed The Cancer Incidence Temporality Index (CITI), which gives a crude measurement of the portion of the population, in which cancer incidence is rising fastest over time: I=(SigmaO(a)/ SigmaE(a))/(SigmaO(a)/SigmaE(a)), where I is the CITI value, O is the observed number of cases and E is the expected number of cases; 'a' and 'b' refer to separate summation ranges for younger and older age groups. Population data and cancer incidence data in England and Wales, 1971-1999 were obtained from the UK Office for National Statistics. The trends in CITI values have been shown graphically for cancer overall and for specific tumour sites. The impact of diagnostic testing is also addressed. The results of this study suggest that the average age of onset of prostate, breast and cervical cancer is temporally decreasing. The study also suggests that for cancer overall the trend for the age of onset of cancer in males has stabilised since 1990 and has started to reverse in females from 1995 despite the expanding ageing population. A similar trend is observed for leukaemias. The CITI analysis for colon cancer shows that the age of onset in both males and females is increasing over time. The trend for ovarian cancer is similar to that for colon cancer. The CITI analysis for NHL in males is similar to that for colon cancer, however, in females the trend stabilised after 1990. The CITI may aid prediction of changes in the age of onset of cancer and thus aid targeted aetiological research. In addition, we suggest the need for a mathematical model, which may measure the changes in the age of onset of cancer in units of time.

International patterns of cancer incidence in adolescents

International patterns of childhood cancer incidence are well documented but equivalent information relating to adolescence is scarce. This article synthesizes international data on cancer in adolescents from population based cancer registries. Total incidence ranged from 95 to 255 per million person years in the series studied. The highest rates were in Australia and among Jews in Israel and the lowest in India and Japan. Lymphomas were the most frequent cancers in western industrialised countries of the northern hemisphere and in the Middle East, and occurred in substantial numbers in all other regions. Hodgkin lymphoma outnumbered non-Hodgkin in western industrialised countries but was relatively rare in most developing countries and in Japan. Leukaemias were the most frequent diagnostic group in India, East Asia and Latin America. Melanoma was the commonest cancer of adolescents in Australia and New Zealand and moderately frequent in many other predominantly white populations but rarely seen elsewhere. Kaposi sarcoma was the most frequent cancer in both sub-Saharan African series studied. The highest rates for nasopharyngeal carcinoma were in Algeria and Hong Kong and for liver carcinoma in Hong Kong and sub-Saharan Africa. Testicular germ cell tumours were relatively frequent in predominantly white populations. Central nervous system tumours and thyroid carcinoma were most often registered in countries with higher standard of living. Osteosarcoma was moderately frequent almost everywhere. Characteristic embryonal tumours of childhood and the most common carcinomas of adulthood were rarely seen. Only osteosarcoma, ovarian germ cell tumours and, in some populations, nasopharyngeal carcinoma have their highest incidence at age 15-19 years. Total cancer incidence was higher in adolescent males than females, but there was often a female excess in melanoma and thyroid carcinoma, and Hodgkin lymphoma was at least as frequent among females as males in several countries with relatively high incidence. More complete delineation of worldwide patterns of cancer in adolescence would be facilitated by availability of more data classified in a standard way to take account of morphology.

Cancer adolescent pathway in France between 1988 and 1997

We report an adolescent cancer pathway from referral, through diagnosis and treatment, to follow-up in France. All cases of cancer among 15-19 years, diagnosed from 1988 to 1997, recorded by nine French population-based cancer registries (10% of French population) were included. The management of adolescent cancer by paediatricians was rare. An adolescents' pathway through cancer care can be summarized as first visit to general practitioner, referral to adult oncologist for haematological malignancy and medical or surgical specialists for solid tumours, treatment in adult unit, and follow-up by adult oncologist, adult medical or surgical specialist, or general practitioner. Only 9% of the 15-19 years are entered into a clinical trial (respectively 6% and 3% into adult and paediatric clinical trial). The inclusion rate changes according to the diagnosis, higher for acute lymphoblastic leukaemia (39%), non-Hodgkin's lymphomas (NHL) (27%), and acute non-lymphoblastic leukaemia (20%). Only 4% of adolescent cancers were managed on shared adult/paediatric departments, especially for soft-tissue sarcomas (14.9%), malignant bone tumours (13.4), central nervous system tumours (6.2%), and NHL (4.4%). Whatever the reasons for lack of participation in clinical trials, an ideal model requiring communication and cooperation between all adult and paediatric specialists involved in adolescent cancer treatment should reduce the large gap in access to cooperative groups.

Hodgkin's disease incidence and survival in European children and adolescents (1978-1997): report from the Automated Cancer Information System project

This paper reports the geographical patterns and time trends of incidence and survival of Hodgkin's disease (HD) in children and adolescents in Europe over the period 1978-1997. Data on 4230 HD cases were gathered from 62 paediatric or general cancer registries in 19 European countries by the Automated Cancer Information System (ACCIS). European annual incidence rates in 1988-1997 were estimated at 5.8 per million in children (world age-standardised) and at 29.7 per million in adolescents, with higher rates in the East and South. Incidence rates increased steeply with age, while the male predominance, marked for the youngest children, vanished in the highest age groups. Over the period 1978-1997 incidence rates increased in age groups 10-14 years (+1% per year) and 15-19 years (+3.5% per year), mainly due to the nodular sclerosis subtype. Age and sex distribution of cases remained unchanged with time. The overall 5-year survival rate was higher in children (93%, 95% confidence interval (CI) 92-94) than in adolescents (89% (95% CI 87-91)) for the period 1988-1997. Five-year survival increased significantly in all regions from 87% to 93% in children and from 80% to 88% in adolescents between 1978-1982 and 1993-1997. In future, detailed documentation of cases in the cancer registries with respect to standardised diagnostic subtypes, stage of extension, and treatments, will help to refine interpretation of international and temporal variations in incidence and survival.

Changes in body image experienced by adolescents with cancer

Cancer and its treatments affect adolescents' body image. However, it is not known what factors impinge on adolescents' perception of their body image. This multiple case study explored how 5 adolescents with cancer perceived their body image and the impact of this perception on their daily life. Adolescents described their body image as "I don't look normal," a theme that comprised 2 dimensions: "I look ugly" and "I look sick." For the adolescent with cancer, these 2 dimensions evoked feelings of being vulnerably exposed: "People look at me." Consequently, adolescents adopted a new set of coping strategies to help them manage their physical appearance and social interactions: "avoiding," "maintaining normality," "testing the waters," and "peer-shield" themes. Although the adolescents perceived their body image as altered, coping mechanisms enabled adolescents to think of themselves as normal and re-establish their social lives. The results of this small study suggest 2 potential nursing approaches to facilitate adolescents' adaptation to their new body image.

Cancer in adolescents and young adults aged 15-24 years: a report from the North of England young person's malignant disease registry, UK

BACKGROUND

Descriptions of population-based data have rarely been published specifically for adolescents and young adults with cancer.

PROCEDURE

Data on young adults (15-24 years) diagnosed with cancer in the North of England from 1968 to 1997 were obtained from the Northern Region Young Person's Malignant Disease Registry. Temporal changes in incidence and survival rates were investigated.

RESULTS

There were 2,329 first cancers diagnosed over the study period (M:F 1.22:1). Overall age standardized incidence was 174 cases per million 15-24 years old, per year, 190 for males and 157 for females. The most common cancers in young adults were Hodgkin disease (19%), carcinomas (15%), central nervous system tumors (14%), germ cell tumors (13%), and leukemia (11%). Comparing incidence for 1968-1977 with 1988-1997 there were significant increases in the incidence of bone tumors (rate ratio 1.72, 95% CI 1.10-2.68), testicular tumors (rate ratio 1.64, 95% CI 1.16-2.32), thyroid cancer (rate ratio 2.63, 95% CI 1.37-5.02), and malignant melanoma (rate ratio 2.04, 95% CI 1.36-3.08). Survival rates improved significantly (P < 0.001) over the study period; 5-year survival rates over the three time periods 1968-1977, 1978-1987, 1988-1997 for all cancers were 45% (95% CI 41%-49%), 62% (95% CI 58%-65%), and 74% (95% CI 71%-77%) respectively.

CONCLUSIONS

Survival rates improved and there were significant increases in incidence for specific cancers in young adults in the North of England. Further research is required to identify the reasons for changing incidence and to investigate the late effects of treatment among survivors.

Juvenile cancer: improving care for adolescents and young adults within the frame of medical oncology

Despite unique tumour epidemiology, a higher cancer incidence and modest survival improvement compared to paediatric patients, adolescents and young adults aged 15-30 have not been considered as a separate, "special" group of patients in the frame of medical oncology. In an effort to emphasise this need, we review the particular characteristics of diagnosed tumours, a aetiologic associations, nosologic classification, management, outcome and late toxic effects. Adolescents and young adults are in need of specialised care for intensive treatment of curable malignancies, skilled nursing care, interaction with peers, family and physicians as well as continuous psychosocial support. Enrollment in clinical research trials and close follow-up via the development of a cooperative infrastructure are imperative for the optimisation of management and avoidance of late effects. Similar to geriatric and paediatric oncology, we call for the intensification of treatment, support and research multidisciplinary efforts in order to better fulfil the pressing demands of this patient group.

A phenomenologic study of fatigue in adolescents receiving treatment for cancer

PURPOSE/OBJECTIVES

To generate a detailed description of how adolescents with cancer manage their daily lives and the way in which fatigue affects this.

DESIGN

Phenomenologic.

SETTING

A pediatric oncology unit at a regional cancer center in the United Kingdom.

SAMPLE

A convenience sample of adolescents (N = 8), aged 16-19 years and with hematologic or solid tumors, who currently were undergoing primary treatment.

METHODS

Semistructured interviews were conducted using 11 open-ended questions.

MAIN RESEARCH VARIABLES

Adolescents' perceptions of fatigue, well-being, and ability to maintain normal activities.

FINDINGS

Adolescents reported fatigue as overwhelming and embedded in a syndrome of symptoms and emotions associated with the illness itself and with treatment. Fatigue had a significant effect on physical, psychological, and social well-being, placing an extra burden on adolescents who were striving for normality.

CONCLUSIONS

Equipped with a rich description of fatigue, clinicians will be better prepared to initiate strategies congruent with their own work settings and particular patients.

IMPLICATIONS FOR NURSING

The findings should enable healthcare professionals to construct a more accurate and perceptive picture of the needs of particular individuals, highlighting those that may be amenable to intervention.

Evidence in action: fostering growth of research-based practice in children's cancer nursing

It is an honour to be the first children's nurse to be asked to deliver the Robert Tiffany Lecture. However, the invite also provoked some anxiety: the responsibility weighs heavy. An opportunity to both celebrate the success of the speciality and explore the challenges that still face children's cancer nurses could not be missed. Two themes provide the focus for this paper, that of growth and evidence in action. Firstly, I will spend some time reflecting on how far we have come, describing stages of growth, development, maturation and differentiation in children's cancer nursing that defines nurses, and the speciality, as both similar and different to other nurses and other specialities. Secondly, I want to explore the notion of evidence and action and share some of the challenges we face in developing research for practice. The challenges themselves are of interest to all cancer nurses, as the solutions described have the potential for translation to other areas within cancer care. Children's cancer nursing is a relatively new speciality, and in terms of research in nursing this has only become integrated into our work in more recent years. Like many areas in nursing we continue to evolve, by anticipating and responding to changes in cancer treatments and thus influence healthcare delivery. This paper represents a point in time in the United Kingdom. Children's cancer nursing has unique qualities that attract nurses to work in the speciality, the essence of which is knowing about children and young people.

Cancer incidence among adolescents in France

BACKGROUND

In France, cancer ranks third as the most significant cause of mortality in young people. However, the incidence, the survival, and the management of adolescent cancers have never been studied. The aim of this study is to investigate incidence rate (IR) of adolescents with cancer from data recorded in French Cancer Registries covering eight administrative areas, representing 10% of the French population, over a 10-year period (from 1988 to 1997).

PROCEDURE

Data from the FRANCIM network of French population-based Cancer Registries were used to analyze cancer incidence among adolescents aged from 15 to 19 years, excluding basal cell carcinomas of skin.

RESULTS

In total, 699 cases were recorded. Of these, 22.9% were lymphomas, 12.7% germ-cell tumors, 11.9% leukemias, 10.6% central-nervous-system tumors, 10.0% bone neoplasms, 7.6% soft-tissue sarcomas, and 19.5% tumors of adulthood (thyroid carcinomas 4.9%, melanomas 9.0%, and other carcinomas 5.6%). The overall IR was 172.9 per million adolescents (M/F: 1.2) with an annual increase of 3% (P = 0.58). Over the two 5-year periods (1988-1992 and 1993-1997) the IR increases significantly for malignant melanomas (respectively 10.4 and 21.2; P = 0.04).

CONCLUSIONS

Our findings are similar to that reported by previous studies performed in European and North-American countries. Future studies need to focus on the etiology explaining the increase in incidence, the management and the impact of the type of care on outcomes.

Epidemiology of central nervous system tumors in children and young adults (0-29 years), Yorkshire, United Kingdom

The authors describe the incidence and survival of 480 patients diagnosed under 30 years with a CNS tumor in Yorkshire, UK, between 1990 and 2001. The effect on survival from deprivation and other prognostic factors was examined. Young adults (aged 15-29) were significantly less likely to develop CNS tumors than children (p = .001), largely because of an excess of medulloblastoma and ependymoma in the pediatric age range. No significant temporal trends in incidence were present apart from young adults with "other CNS" tumors showing an average annual increase of 10.7% (95% CI 1.3-21.0%; p = .03). Young adults had significantly lower survival rates than children (hazard ratio = 1.52, 95% CI 1.10-2.10). The highest risk of death was observed for patients from the most affluent areas. The overall burden of CNS tumors appears to be relatively constant, but the significantly poorer survival for young people needs further rapid investigation.

The management of cancer in the older adolescent

Cancer in adolescents 15-19 years of age occurs at nearly twice the rate observed in 5- to 14-year-olds, but as of yet they have no explicit organisation for research and care, such as that structured for younger paediatric patients. Adolescents with cancer must be recognised as a subgroup of oncology patients with specific characteristics and needs requiring dedicated interest and management. The need is made most evident as outcome data indicates that adolescents are lagging behind in survival gains made in recent decades by both children and adults with cancer. Improvements in the overall survival, quality of care and quality of survival of adolescents with cancer will only occur by surmounting the challenges, discussed in this review, unique to this group of patients.

Cancer survival in European adolescents and young adults

Survival of patients aged 15-24 years, diagnosed with cancer during the period of 1990-1994, is described within Europe. Data on 15101 patients, extracted from the files of the 56 adult cancer registries included in the EUROCARE-3 database, representing 20 European countries, were analysed and compared. Five-year survival for 'all cancers combined' was 75% in males (ranging from 59% in Estonia to 89% in Iceland), and 78% in females (ranging from 59% in Estonia to 89% in Norway). The Northern European countries (except Denmark) and Austria had the highest survival figures, while survival in the Eastern European countries was lower than the European average. Denmark, UK, and the pool of the central European countries, had intermediate survival figures. Haemopoietic tumours were the most common malignancies: 5-year survival was high for Hodgkin's disease (89%), intermediate for non-Hodgkin's lymphoma (68%) and lower for acute lymphoblastic leukaemia (ALL) (47%) and acute myeloblastic leukaemia (AML) (39%). Five-year survival for gonadal germ cell cancers, the second most common malignancy in young adults, was 90%. Five-year survival for the other cancers under consideration was as follows: 89% for skin melanoma, 66% for all Central Nervous System (CNS) tumours, 57% for bone tumours, 58% for osteosarcoma, 42% for Ewing's sarcoma, 57% for soft-tissue sarcomas, 99% for thyroid carcinoma, 82% for uterine cervical carcinoma, and 83% for ovarian carcinoma. For more 'adult-specific tumours', 5-year survival was good for colon (77%) and lung (60%) cancers, and less favourable, compared with adults, for breast cancer (68%). Adolescents (15-19 years) had significantly worse survival than young adults (20-24 years) for all malignancies combined. Survival for Hodgkin's lymphoma, CNS tumours, melanoma and colon cancer showed marked regional variability. Since many of the tumours occurring in young adults are curable, these results should encourage, without delay, efforts to identify obstacles to improving outcome and reducing geographical inequalities in survival for this group of patients.

Central nervous system tumours in adolescents

Adolescents with brain tumours have been, and in most cases still are, haphazardly assigned, on referral, to either 'paediatric' or 'adult'-based treatment centres. In this age group, there is therefore a history of inconsistent treatment, delivery of inappropriate 'maturity-related' care and a reduced chance of gathering vital biological, clinical and treatment-related information germane to this group of patients and their tumours. These days, adolescents with brain tumours should be actively targeted for recruitment into clinical trials and admission into dedicated neuro-oncology centres or programmes that can deliver the necessary and age appropriate multidisciplinary management.

Melanoma in children and adolescents

Childhood and adolescent melanoma is rare, accounting for only 1.3% for all cases of cancer in patients under the age of 20 years. However, in 15-19 year olds, melanoma accounts for up to 7% of all cancers. Review of reported cases in this age group reveals that predisposing 'paediatric' conditions such as a giant congenital melanocytic naevi or xeroderma pigmentosum are rarely present. Furthermore, inactivating germ-line mutations of the gene CDKN2A have only been reported in 1.5% of cases of early onset melanoma. Epidemiological studies suggest that interactions between solar exposure, development of naevi, pigmentary traits, and a family history of melanoma are the main determinants of melanoma development during the first 20 years of life. As yet, there are no available staging or treatment strategies for this group of patients so treatment recommendations are based on the adult experience. To improve our understanding of the natural history of melanoma and to identify the most appropriate therapies for young patients with this disease, practising physicians are encouraged to enroll their patients, especially those with advanced stage disease, in cooperative group trials which incorporate newer staging systems and promising therapies.