Hospitalization rates among survivors of childhood cancer in the Childhood Cancer Survivor Study cohort

Excess healthcare expenditure in adults treated for solid cancer in childhood: a cohort study in France

BACKGROUND

Due to late effects, childhood cancer survivors (CCS) are more likely to have multiple chronic conditions than the general population. However, little is known about the economic burden of care of CCS in the long term.

OBJECTIVES

To estimate excess healthcare expenditure for long-term CCS in France compared to the general population and to investigate the associated factors.

METHODS

We included 5353 5-year solid CCS diagnosed before the age of 21 years before 2000 from the French CCS cohort and obtained a random reference sample from the general population for each CCS, matched on age, gender and region of residence. We used the French national health data system to estimate annual healthcare expenditure between 2011 and 2018 for CCS and the reference sample, and computed the excess as the net difference between CCS expenditure and the median expenditure of the reference sample. We used repeated-measures linear models to estimate associations between excess healthcare expenditure and CCS characteristics.

RESULTS

Annual mean (95% CI) excess healthcare expenditure was €3920 (3539; 4301), mainly for hospitalization (39.6%) and pharmacy expenses (17%). Higher excess was significantly associated with having been treated before the 1990s and having survived a central nervous system tumor, whereas lower excess was associated with CCS who had not received treatment with radiotherapy.

CONCLUSIONS

Of the variables that influence excess healthcare expenditure, a lever for action is the type of treatment administered. Future research should focus on addressing the long-term cost-effectiveness of new approaches, especially those related to radiotherapy.

Regression analysis of general mixed recurrent event data

In modern biomedical datasets, it is common for recurrent outcomes data to be collected in an incomplete manner. More specifically, information on recurrent events is routinely recorded as a mixture of recurrent event data, panel count data, and panel binary data; we refer to this structure as general mixed recurrent event data. Although the aforementioned data types are individually well-studied, there does not appear to exist an established approach for regression analysis of the three component combination. Often, ad-hoc measures such as imputation or discarding of data are used to homogenize records prior to the analysis, but such measures lead to obvious concerns regarding robustness, loss of efficiency, and other issues. This work proposes a maximum likelihood regression estimation procedure for the combination of general mixed recurrent event data and establishes the asymptotic properties of the proposed estimators. In addition, we generalize the approach to allow for the existence of terminal events, a common complicating feature in recurrent event analysis. Numerical studies and application to the Childhood Cancer Survivor Study suggest that the proposed procedures work well in practical situations.

Health Competence Beliefs and Health-Related Quality of Life Among Adolescent and Young Adult Survivors of Childhood Cancer and Healthy Peers

Purpose: Adolescent and young adult (AYA) survivors of childhood cancer are at risk for late-effects that can impact how one perceives their health and well-being. Understanding beliefs about health competence and well-being among survivors can help identify support needs and increase adherence to long-term follow-up guidelines. This study examined differences in health competence beliefs and health-related quality of life (HRQOL) between AYA survivors of childhood cancer and matched healthy peers. In addition, the relationship between health competence beliefs and HRQOL, as well as the moderating effect of cancer survivorship, was investigated. Methods: Survivors (n = 49) and healthy peers (n = 54) completed measures about health competence beliefs (i.e., Health Perception, Cognitive Competence, Autonomy, and School/Work Functioning) and HRQOL. Multiple group analysis was used to investigate differences in health competence beliefs and HRQOL between survivors and peers. Multivariate multiple regression analyses were used to investigate the relationships between health competence beliefs and HRQOL. Finally, a history of cancer was examined as a possible moderator using additional multivariate multiple regression analyses. Results: Survivors reported significantly lower Health Perception, Cognitive Competence, Autonomy, and School/Work Functioning scores compared to healthy peers. Among both groups, Health Perception and Cognitive Competence scores were associated with multiple domains of HRQOL. These relationships were not moderated by having a history of cancer. Conclusions: Perceptions about one's health and cognitive abilities may impact HRQOL among AYA survivors of childhood cancer and health peers. Identifying those at risk for poor well-being may help to guide interventions aimed at increasing adherence to medical recommendations.

Hospitalizations and Cost of Inpatient Care for Physical Diseases in Survivors of Childhood Cancer in Western Australia: A Longitudinal Matched Cohort Study

BACKGROUND

The long-term effects of childhood cancer are unclear in the Australian context. We examined hospitalization trends for physical diseases and estimated the associated inpatient care costs in all 5-year childhood cancer survivors (CCS) diagnosed in Western Australia (WA) from 1982 to 2014.

METHODS

Hospitalization records for 2,938 CCS and 24,792 comparisons were extracted from 1987 to 2019 (median follow-up = 12 years, min = 1, max = 32). The adjusted hazard ratio (aHR) of hospitalization with 95% confidence intervals (CI) was estimated using the Andersen-Gill model for recurrent events. The cumulative burden of hospitalizations over time was assessed using the mean cumulative count method. The adjusted mean cost of hospitalization was estimated using the generalized linear models.

RESULTS

We identified a higher risk of hospitalization for all-cause (aHR, 2.0; 95% CI, 1.8-2.2) physical disease in CCS than comparisons, with the highest risk for subsequent malignant neoplasms (aHR, 15.0; 95% CI, 11.3-19.8) and blood diseases (aHR, 6.9; 95% CI, 2.6-18.2). Characteristics associated with higher hospitalization rates included female gender, diagnosis with bone tumors, cancer diagnosis age between 5 and 9 years, multiple childhood cancer diagnoses, multiple comorbidities, higher deprivation, increased remoteness, and Indigenous status. The difference in the mean total hospitalization costs for any disease was significantly higher in survivors than comparisons (publicly funded $11,483 United States Dollar, P < 0.05).

CONCLUSIONS

The CCS population faces a significantly higher risk of physical morbidity and higher cost of hospital-based care than the comparisons.

IMPACT

Our study highlights the need for long-term follow-up healthcare services to prevent disease progression and mitigate the burden of physical morbidity on CCS and hospital services.

Disparities in pediatric cancer survivorship care: A systematic review

BACKGROUND

Childhood cancer survivors (CCS) experience many long-term health problems that can be mitigated with recommended survivorship care. However, many CCS do not have access to survivorship care nor receive recommended survivorship care. We reviewed the empirical evidence of disparities in survivorship care for CCS.

METHODS

This systematic review searched PubMed, CINAHL, and PsycINFO for studies on survivorship care for CCS (PROSPERO: CRD42021227965) and abstracted the reported presence or absence of disparities in care. We screened 7945 citations, and of those, we reviewed 2760 publications at full text.

RESULTS

A total of 22 studies reported in 61 publications met inclusion criteria. Potential disparities by cancer treatment (N = 14), diagnosis (N = 13), sex (N = 13), and current age (N = 13) were frequently studied. There was high quality of evidence (QOE) of survivorship care disparities associated with non-White race, Hispanic ethnicity, and being uninsured. Moderate QOE demonstrated disparities among CCS who were unemployed and older. Lower QOE was found for disparities based on cancer diagnosis, cancer treatment, age at diagnosis, time since diagnosis, sex, insurance type, income, educational attainment, and geographic area.

CONCLUSIONS

We found strong empirical evidence of disparities in survivorship care for CCS associated with race, ethnicity, and insurance status. Multiple other disparate groups, such as those by employment, income, insurance type, education, cancer diagnosis, age at diagnosis, time since diagnosis, cancer treatment, geographic area, sex, and self-identified gender warrant further investigation. Prospective, multilevel research is needed to examine the role of other patient characteristics as potential disparities hindering adequate survivorship care in CCS.

Accumulation of Chronic Disease Among Survivors of Childhood Cancer Predicts Early Mortality

PURPOSE

Cancer survivors develop cancer and treatment-related morbidities at younger than normal ages and are at risk for early mortality, suggestive of an aging phenotype. The Cumulative Illness Rating Scale for Geriatrics (CIRS-G) is specifically designed to describe the accumulation of comorbidities over time with estimates of severity such as total score (TS) which is a sum of possible conditions weighted by severity. These severity scores can then be used to predict future mortality.

METHODS

CIRS-G scores were calculated in cancer survivors and their siblings from Childhood Cancer Survivor Study cohort members from two time points 19 years apart and members of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004. CIRS-G metrics were analyzed using Cox proportional hazards regression to determine subsequent mortality risk.

RESULTS

In total, 14,355 survivors with a median age of 24 (IQR, 18-30) years and 4,022 siblings with a median age of 26 (IQR, 19-33) years provided baseline data; 6,138 survivors and 1,801 siblings provided follow-up data. Cancer survivors had higher median baseline TS than siblings at baseline (5.75 v 3.44) and follow-up (7.76 v 4.79), all P < .01. The mean increase in TS from baseline to follow-up was significantly steeper in cancer survivors (2.89 males and 3.18 females) vs. siblings (1.79 males and 1.69 females) and NHANES population (2.0 males and 1.94 females), all P < .01. Every point increase in baseline TS increased hazard for death by 9% (95% CI, 8 to 10) among survivors.

CONCLUSION

Application of a geriatric rating scale to characterize disease supports the hypothesis that morbidity accumulation is accelerated in young adult survivors of childhood cancer when compared with siblings and the general population.

Long-term hospitalisations in survivors of paediatric solid tumours in France

The late effects of treatments for childhood cancers may lead to severe and multiple health conditions requiring hospitalisation. We aimed to estimate the hospitalisation rate among childhood cancer survivors (CCS) in France, to compare them with the general population and to investigate the associated factors. We matched total of 5439 5-year solid CCS diagnosed before the age of 21 between 1945 and 2000 by sex, birth year and region of residence to 386,073 individuals of the French general population. After linkage with the national hospital discharge database, we estimated the relative hospitalisation rate (RHR), the absolute excess risks (AERs) and the relative bed-day ratio (RBDR) during 2006-2018. We used generalised linear models to estimate associations between hospitalisation and survivor characteristics. Overall, the RHR was 2.49 (95% confidence interval [CI] 2.46-2.52) and the RBDR was 3.49 (95% CI 3.46-3.51). We found that neoplasm-related hospitalisations had the highest AER (105.8 per 1000 person-years), followed by genitourinary system diseases (34.4 per 1000 person-years) and cardiovascular diseases (19.2 per 1000 person-years). In adjusted analysis, CCS treated with chemotherapy (risk ratio [RR] 1.62, 95% CI 1.53-1.70), radiotherapy (RR 2.11, 95% CI 1.99-2.24) or both (RR 2.59, 95% CI 2.46-2.73) had a higher risk of hospitalisation than the ones who had not received any of these treatments. CCS treated during the past decades by chemotherapy and/or radiotherapy now had a higher hospitalisation risk for all main categories of diagnosis than the general population. Prevention strategies and medical surveillance programmes may promote a long-term decrease in the hospitalisation rate among CSS.

Long-term diagnosis-specific sickness absence, disability pension, and healthcare use in 1305 young adult childhood cancer survivors and in 6430 references; a Swedish ten-year prospective cohort study

Background

Childhood cancer survivors (CCS) are at high risk of chronic health conditions. We aimed to explore young adult CCS’ and matched references’ future diagnoses-specific healthcare use, sickness absence (SA), and disability pension (DP).

Methods

We performed a prospective cohort study with microdata from seven nationwide Swedish registers. We included 1305 young adult CCS born 1983–1988 and living in Sweden in 2008 and 6430 matched references and followed them for ten years (2009–2018) regarding mean annual specialized outpatient visits, inpatient days, and SA (spells >14 days) and/or DP (SADP) days, overall and by eight diagnostic groups. Risk factors for >90 SADP days in 2018 were explored as odds ratios (OR) with 95% confidence intervals (CI) by adjusted logistic regression.

Results

Approximately 80% of CCS and 90% of references did not have SADP in the ten-year follow-up. Mean SADP days/year was higher among CCS (40–50 days/year), particularly in CNS tumor survivors (76–83 days/year), compared to references (12–18 days/year). Most SADP days were DP days. CCS had more mean outpatient visits (1.6–1.8 visits/year) and inpatient days (0.8–1.7 days/year) than references (0.8–1.2 visits/year and 0.6–0.75 days/year, respectively). The main healthcare use and SADP diagnoses were neoplasms and psychiatric disorders among all CCS, along with nervous system and endocrine conditions among CNS tumor survivors. The risk of SADP >90 days in 2018 was higher among female compared to male CCS (OR = 2.34, 95% CI 1.67–3.32), those with elementary schooling compared to high school/university education (OR = 6.52, 95% CI 4.49–9.49), and survivors of CNS tumors compared to other malignancies (OR hematological versus CNS = 2.88, 95% CI 1.95–4.28; OR hematological versus non-CNS solid tumors = 0.71, 95% CI 0.45–1.09).

Conclusions

Most CCS did not have SADP as young adults; nevertheless, their risk of SADP was higher than among matched references. CNS tumor survivors were at particularly high risk of SADP.

Hospitalization and Mortality Outcomes Among Childhood Cancer Survivors by Race, Ethnicity, and Time Since Diagnosis

IMPORTANCE

Cancer outcomes are relatively poor in adults who belong to minoritized racial and ethnic groups. Survival and long-term outcomes by race and ethnicity in individuals with childhood cancers are less studied.

OBJECTIVE

To evaluate survival and hospitalization among American Indian and Alaska Native, Asian, Black, and Hispanic children compared with non-Hispanic White children with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study evaluated all individuals born in Washington State who were younger than 20 years (hereafter referred to as children) and had been diagnosed with cancer during 1987 to 2012, with follow-up ranging from 1 to 27 years. The data subset was built in 2019, and statistical analyses were completed in January 2022.

EXPOSURES

Race and ethnicity.

MAIN OUTCOMES AND MEASURES

Mortality and hospitalization events for all other racial and ethnic groups relative to non-Hispanic White children estimated by Cox proportional hazards regressions for the first 5 years after diagnosis and among cancer survivors 5 or more years after diagnosis.

RESULTS

A total of 4222 children (mean [SD] age, 8.4 [6.4] years; 2199 [52.1%] male; 113 American Indian and Alaska Native [2.7%], 311 Asian [7.4%], 196 Black [4.6%], 387 Hispanic [9.2%], and 3215 non-Hispanic White [76.1%]) with cancer diagnosed at younger than 20 years during 1987 to 2012 were included. Mortality was similar across all groups. Compared with non-Hispanic White survivors at less than 5 years after diagnosis, there were no greatly increased hazard ratios (HRs) for hospitalization. Among survivors at 5 or more years after diagnosis, hospitalization HRs were 1.7 (95% CI, 1.0-3.0) for American Indian and Alaska Native survivors and 1.5 (95% CI, 0.9-2.4) for Black survivors. Significantly increased HRs among Hispanic children were observed for infection-related (HR, 1.4; 95% CI, 1.2-1.6), endocrine-related (HR, 1.3; 95% CI, 1.1-1.6), hematologic-related (HR, 1.3; 95% CI, 1.1-1.5), respiratory-related (HR, 1.3; 95% CI, 1.0-1.5), and digestive-related (HR, 1.2; 95% CI, 1.0-1.5) conditions. American Indian and Alaskan Native children had increased HRs for infection-related (HR, 2.3; 95% CI, 1.2-4.5), hematologic-related (HR, 3.0; 95% CI, 1.4-6.5), and digestive-related (HR, 2.6; 95% CI, 1.3-5.4) conditions. Both American Indian and Alaska Native (HR, 3.6; 95% CI, 1.4-9.0) and Black (HR, 2.5; 95% CI, 1.2-5.5) children had increased mental health-related hospitalizations and death.

CONCLUSIONS AND RELEVANCE

In this cohort study, disproportionately increased long-term risks of hospitalization for physical and mental conditions may have contributed to worse outcomes by race. A key component to bridging the morbidity gap by race is improved understanding of reasons for greater cause-specific hospitalizations in some groups, with development of culturally appropriate intervention strategies.

SARS-CoV-2 vaccine acceptability among caregivers of childhood cancer survivors

OBJECTIVE

To explore willingness/hesitancy to vaccinate self and children against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among caregivers of childhood cancer survivors (CCS).

METHODS

A 19-question survey was sent to caregivers of CCS and completed between February 25 and April 13, 2021. Logistic regression was used to investigate relationships between willingness/hesitancy to vaccinate (a) self and (b) CCS, and demographic variables, confidence in the government and medical community's responses to coronavirus disease 2019 (COVID-19), and factors specific to the CCS community (e.g., previous participation in an investigational therapeutic trial).

RESULTS

Caregivers (6% male) from 130 unique families completed the survey. Mean CCS age at survey was 15 years (SD 6.4). Mean CCS age at diagnosis was 4.3 years (SD 4.3). Mean time from CCS diagnosis to survey completion was 10 years (SD 6.2). Twenty-one percent of caregivers expressed hesitancy to vaccinate themselves and 29% expressed hesitancy to vaccinate their CCS. Caregivers expressing confidence in the federal government's response to COVID-19 were six-fold likelier to express willingness to self-vaccinate (p < .001) and were three-fold likelier to express willingness to vaccinate their CCS (p = .011). Qualitative analysis of free-text responses revealed three general themes, including (a) confidence in science, medicine, and vaccination as a strategy for health promotion, (b) confidence in SARS-CoV-2 vaccination and belief that CCS are at greater risk of COVID-19 complications, and (c) concerns about the swiftness of COVID-19 vaccine development and insufficient safety/efficacy data in children and CCS.

CONCLUSIONS

Results underscore the need for COVID-19 vaccination education and outreach, even among families highly engaged with the medical community, and emphasize the importance of updating these families as relevant data emerge from vaccine trials and registries.

Health care expenditures among long-term survivors of pediatric solid tumors: Results from the French Childhood Cancer Survivor Study (FCCSS) and the French network of cancer registries (FRANCIM)

Background

Childhood cancer survivors (CCS) may require lifelong medical care due to late effects of cancer treatments. Little is known about of their healthcare utilization and expenditures at long-term especially in publicly funded health care system. We aim to estimate and describe the health care expenditures among long-term CCS in France.

Methods

A total of 5319 five-year solid CCS diagnosed before the age of 21 between 1945 and 2000 in France were identified in the French Childhood Cancer Survivors Study cohort (FCCSS) and the French cancer registry. Information about health care expenditure was taken from the French national health data system between 2011 and 2016, and was described according to survivors’ characteristics. Generalized linear models were used to determine associations between health care expenditures and survivors’ characteristics.

Results

Mean annual amount of healthcare expenditures was € 4,255. Expenditures on hospitalizations and pharmacy represents 60% of total expenditures. Mean annual of healthcare expenditures were higher at increasing age, among women survivors (€ 4,795 vs € 3,814 in men) and in central nervous system (CNS) tumor survivors (€ 7,116 vs € 3,366 in lymphoma and € 3,363 in other solid tumor survivors).

Conclusions

Childhood cancer survivorship is associated with a substantial economic burden in France. We found that female gender and CNS primary cancer were associated with increased healthcare expenditures.

Long-Term Risk of Hospitalization for Somatic Diseases Among Survivors of Childhood Acute Lymphoblastic Leukemia

Background

Survivors of childhood acute lymphoblastic leukemia (ALL) may be at increased long-term risk of hospitalization for somatic diseases. However, large population-based cohort studies with risk estimates for survivors successfully cured without experiencing a relapse or requiring hematopoietic stem cell transplantation (HSCT) are lacking.

Methods

Danish and Swedish patients diagnosed with ALL before age 20 years in 1982-2008 were identified in the national cancer registries. Five-year survivors and matched population comparisons without childhood cancer were followed for hospitalization for 120 somatic disease categories in the national hospital registries from 5 years postdiagnosis until 2017, and disease-specific hospitalization rate ratios (RR) were calculated. The mean cumulative count method was used to estimate the mean number of multiple and recurrent disease-specific hospitalizations per individual.

Results

A total of 2024 5-year survivors and 9797 population comparisons were included. The overall hospitalization rate was more than twice as high compared with comparisons (RR = 2.30, 95% confidence interval [CI] = 2.09 to 2.52). At 30 years postdiagnosis, the mean cumulative hospitalization count was 1.69 (95% CI = 1.47 to 1.90) per survivor and 0.80 (95% CI = 0.73 to 0.86) per comparison. In the subcohort without relapse or HSCT (n = 1709), the RR was 1.41 (95% CI = 1.27 to 1.58).

Conclusions

Survivors of childhood ALL were at increased long-term risk for disease-specific hospitalizations; however, in survivors without relapse or HSCT, the rate was only modestly higher than in population comparisons without a childhood cancer. The absolute mean numbers of multiple and recurrent hospitalizations were generally low.

Adaptación cultural mexicana del programa de intervención CASCAdE para padres de supervivientes de cáncer infantil

Objetivo: Describir el proceso de adaptación cultural del programa CASCAdE en línea para padres de supervivientes de cáncer infantil mexicanos. Método: Se utilizó el Modelo Ecológico de Validación (MEV), en dos fases: la primera consistió en la traducción (inglés-español) y adaptación cultural de los contenidos del programa; la segunda fue la evaluación del contenido e integridad del tratamiento. Resultados: Se realizaron cambios en la redacción del texto, se modificó el uso de la segunda persona del singular por la tercera persona del singular “usted”. Del MEV se eligieron para adaptación de materiales: Lenguaje, Personas, Metáforas o dichos, Narrativa y Conceptos. Entre los cambios más relevantes se encuentran el uso de la tercera persona del singular (aceptabilidad) y la adaptación de metáforas que fueran entendibles en este contexto (relevancia). Para la intervención se adaptaron: Métodos, contexto y objetivos, dando como resultado la aplicación individual, cambios en el diseño gráfico e inclusión de iconografías llamativas y amigables para los padres (aceptabilidad). En la evaluación del contenido por jueces expertos se obtuvieron porcentajes del 50% de acuerdo en redacción de las sesiones de introducción del manual para el facilitador y 75% en redacción de la sesión cuatro del manual para padres. Conclusión: Este estudio muestra el proceso de adaptación cultural desde el MEV a fin de contar con los materiales necesarios para que la aplicación del programa CASCAdE en un contexto mexicano.

Health care utilisation following childhood acute lymphoblastic leukaemia: a population-based matched cohort study

OBJECTIVES

Survival among children diagnosed with acute lymphoblastic leukaemia (ALL) has increased considerably. However, morbidity in survivors constitutes a potential increasing burden not limited to secondary health care. Our objectives were to compare health care utilisation, including both primary and secondary health care, between childhood ALL survivors and matched references up to 15 years after curative treatment. Moreover, to increase knowledge on survivors' health service seeking behaviour as time from treatment elapsed.

DESIGN AND SETTING

A Danish population-based matched cohort study linking multiple nationwide registries.

PARTICIPANTS

675 cases, diagnosed with childhood (1.0-17.9 years) ALL between 1994 and 2015, and 6750 matched references sampled randomly from the source population (matched on age, gender and geographical region).

PRIMARY OUTCOME MEASURES

Repeated consultations in general practice and hospital (outpatient and inpatient) estimated as yearly rates from 2.5 years after diagnosis and onwards. We compared cases and references with yearly incidence rate ratios (IRRs) from negative binomial regression models.

RESULTS

Survivors of childhood ALL had a mean number of yearly daytime contacts in general practice of 4.75 (95% CI 4.41 to 5.11) the first year, corresponding to an IRR of 1.85 (95% CI 1.71 to 2.00); decreasing to 1.16 (1.01 to 1.34) after 15 years, and without significant impact of gender (p=0.894) or age (p=0.399). For hospital contacts, ALL survivors had a mean number of yearly contacts of 14.21 (13.38-15.08) the first year, corresponding to an IRR of 31.50 (28.29-35.07); decreasing to 2.42 (1.59-3.68) after 15 years. No differences were found across calendar time.

CONCLUSIONS

ALL survivors used significantly more health care services across sectors than the reference population. Decreasing use over 15 years illustrated the dynamics of health care needs; this knowledge may inform the future organisation of integrated follow-up programmes.

TRIAL REGISTRATION NUMBER

NCT03985826.

Somatic Disease in Survivors of Childhood Malignant Bone Tumors in the Nordic Countries

Simple Summary

The treatment of osteosarcoma and Ewing sarcoma, the two major types of malignant bone tumors in children, has progressed considerably during the last decades, with more patients becoming long-term survivors. This improvement has resulted in an increasing number of patients with long-term adverse health consequences from the life-saving treatment. The aim of this study was to provide a detailed, comprehensive overview of somatic diseases that require hospitalization in long-term survivors of osteosarcoma and Ewing sarcoma. This study contributes new insights into the risk of somatic late effects in survivors of osteosarcoma and Ewing sarcoma which are urgently requested by pediatric oncologists, researchers, and by survivors and their families. The study provides an essential basis for the development of preventive intervention strategies and for optimal patient counseling and follow-up care, which all contribute to improving the health and quality of life in survivors.

Abstract

Survivors of malignant bone tumors in childhood are at risk of long-term adverse health effects. We comprehensively reviewed cases of somatic diseases that required a hospital contact in survivors of osteosarcoma and Ewing sarcoma. In a population-based cohort study, 620 five-year survivors of osteosarcoma (n = 440) or Ewing sarcoma (n = 180), diagnosed before the age of 20 years in Denmark, Finland, Iceland, and Sweden during 1943–2008, were followed in the national hospital registers. Overall rates of hospital contacts for any somatic disease and for 12 main diagnostic groups and 120 specific disease categories were compared with those in a matched comparison cohort (n = 3049) randomly selected from the national population registers. The rate of hospital contact for any somatic disease was 80% higher in survivors of malignant bone tumors than in comparisons and remained elevated up to 30 years after diagnosis. The rate of hospital contacts was higher after Ewing sarcoma (rate ratio (RR) 2.24; 95% confidence interval (CI) 1.76–2.85) than after osteosarcoma (RR 1.67; 95% CI 1.41–1.98). Elevated rates were observed for 11 main diagnostic groups, including infections, second malignant neoplasms, and diseases of the skin, bones, and circulatory, digestive, endocrine, and urinary systems. Survivors of malignant bone tumors in childhood are at increased risk of somatic diseases many years after diagnosis. This comprehensive study contributes new insight into the risk of late effects in survivors of osteosarcoma and Ewing sarcoma, which is an essential basis for optimal patient counseling and follow-up care.

Cardiovascular disease risks in younger versus older adult B-cell non-Hodgkin's lymphoma survivors

Introduction

Young cancer survivors may be at increased risk of early‐onset chronic health conditions. The aim of this population‐based study is to estimate cardiovascular disease (CVD) risk among younger versus older B‐cell non‐Hodgkin's lymphoma (B‐NHL) survivors compared with their respective general population cohorts.

Methods

B‐NHL survivors diagnosed from 1997 to 2015 in the Utah Cancer Registry were matched with up to five cancer‐free individuals on birth year, sex, and birth state, using the statewide Utah Population Database. Electronic medical records and statewide health care facility data were used to identify disease outcomes ≥5 years after cancer diagnosis. Cox Proportional Hazards models were used to estimate hazard ratios for B‐NHL survivors diagnosed at <65 years and ≥65 years old.

Results

Younger B‐NHL survivors had higher relative risks than older cancer survivors of chronic rheumatic disease of the heart valves (HR = 4.14, 99% CI = 2.17–7.89; P value_{heterogeneity} = 0.004); peri‐, endo‐, and myocarditis (HR = 2.43, 99% CI = 1.38–4.28; P value_{heterogeneity} = 0.016); diseases of the arteries (HR = 1.63, 99% CI = 1.21–2.21; P value_{heterogeneity} = 0.044); and hypotension (HR = 2.44, 99% CI = 1.58–3.75; P value_{heterogeneity} = 0.048). B‐NHL survivors of both age groups had elevated relative risks of heart disease overall and congestive heart failure.

Conclusion

Younger B‐NHL survivors had higher risks than older B‐NHL survivors of specific cardiovascular diseases compared to their respective general population cohorts.

Impacts of COVID-19 on caregivers of childhood cancer survivors

PURPOSE

We sought to assess the impact of disruptions due to coronavirus disease 2019 (COVID-19) on caregivers of childhood cancer survivors.

METHODS

A 13-question survey containing multiple-choice, Likert-type, and free-text questions on experiences, behaviors, and attitudes during the COVID-19 outbreak was sent to childhood cancer caregivers and completed between April 13 and May 17, 2020. Ordered logistic regression was used to investigate relationships between demographics, COVID-related experiences, and caregiver well-being.

RESULTS

Caregivers from 321 unique families completed the survey, including 175 with children under active surveillance/follow-up care and 146 with children no longer receiving oncology care. Overall, caregivers expressed exceptional resiliency, highlighting commonalities between caring for a child with cancer and adopting COVID-19 prophylactic measures. However, respondents reported delayed/canceled appointments (50%) and delayed/canceled imaging (19%). Eleven percent of caregivers reported struggling to pay for basic needs, which was associated with greater disruption to daily life, greater feelings of anxiety, poorer sleep, and less access to social support (p < .05). Caregivers who were self-isolating reported greater feelings of anxiety and poorer sleep (p < .05). Respondents who expressed confidence in the government response to COVID-19 reported less disruption to their daily life, decreased feelings of depression and anxiety, better sleep, and greater hopefulness (p < .001) CONCLUSIONS: Caregivers are experiencing changes to medical care, financial disruptions, and emotional distress due to COVID-19. To better serve caregivers and medically at-risk children, clinicians must evaluate financial toxicity and feelings of isolation in families affected by childhood cancer, and work to provide reliable information on how COVID-19 may differentially impact their children.

Infectious Complications in Paediatric Haematopoetic Cell Transplantation for Acute Lymphoblastic Leukemia: Current Status

Haematopoietic stem cell transplantation (HSCT) in paediatric patients with acute lymphoblastic leukaemia (ALL) is associated with a variety of infectious complications which result in significant morbidity and mortality. These patients are profoundly immunocompromised, and immune reconstitution after HSCT generally occurs in astrictly defined order. During the early phase after HSCT until engraftment, patients are at risk of infections due to presence of neutropenia and mucosal damage, with Gramme-positive and Gramme-negative bacteria and fungi being the predominant pathogens. After neutrophil recovery, the profound impairment of cell-mediated immunity and use of glucocorticosteroids for control of graft-vs.-host disease (GvHD) increases the risk of invasive mould infection and infection or reactivation of various viruses, such as cytomegalovirus, varicella zoster virus, Epstein-Barr virus and human adenovirus. In the late phase, characterised by impaired cellular and humoral immunity, particularly in conjunction with chronic GvHD, invasive infections with encapsulated bacterial infections are observed in addition to fungal and viral infections. HSCT also causes a loss of pretransplant naturally acquired and vaccine-acquired immunity; therefore, complete reimmunization is necessary to maintain long-term health in these patients. During the last two decades, major advances have been made in our understanding of and in the control of infectious complications associated with HSCT. In this article, we review current recommendations for the diagnosis, prophylaxis and treatment of infectious complications following HSCT for ALL in childhood.

Risk of late health effects after soft-tissue sarcomas in childhood - a population-based cohort study within the Adult Life after Childhood Cancer in Scandinavia research programme

BACKGROUND

In the 1960s only 1/3 of children with soft-tissue sarcomas survived, however with improved treatments survival today has reached 70%. Given the previous poor survival and the rarity of soft-tissue sarcomas, the risk of somatic late effects in a large cohort of Nordic soft-tissue sarcoma survivors has not yet been assessed.

METHODS

In this population-based cohort study we identified 985 five-year soft-tissue sarcoma survivors in Nordic nationwide cancer registries and late effects in national hospital registries covering the period 1964-2012. Information on tumour site and radiotherapy was available for Danish and Finnish survivors (N = 531). Using disease-specific rates of first-time hospital contacts for somatic diseases in survivors and in 4,830 matched comparisons we calculated relative rates (RR) and rate differences (RD).

RESULTS

Survivors had a RR of 1.5 (95% CI 1.4-1.7) and an absolute RD of 23.5 (17.7-29.2) for a first hospital contact per 1,000 person-years. The highest risks in both relative and absolute terms were of endocrine disorders (RR = 2.5; RD = 7.6), and diseases of the nervous system (RR = 1.9; RD = 6.6), digestive organs (RR = 1.7; RD = 5.4) and urinary system (RR = 1.7; RD = 5.6). By tumour site, excess risk was lower after extremity tumours. Irradiated survivors had a 2.6 (1.2-5.9) times higher risk than non-irradiated.

CONCLUSIONS

Soft-tissue sarcoma survivors have an increased risk of somatic late effects in 5 out of 10 main diagnostic groups of diseases, and the risk remains increased up to 40 years after cancer diagnosis. Risks were slightly lower for those treated for tumours in the extremities, and radiotherapy increased the risk by more than two-fold.

Long-Term Risk of Hospitalization Among Five-Year Survivors of Childhood Leukemia in the Nordic Countries

BACKGROUND

Adverse effects from childhood leukemia treatment may persist or present years after cure from cancer. We provide a comprehensive evaluation of subsequent hospitalization in five-year survivors of childhood acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), and chronic myeloid leukemia (CML).

METHODS

In the Adult Life after Childhood Cancer in Scandinavia Study, we identified 4003 five-year survivors diagnosed with childhood leukemia 1970-2008 in Denmark, Sweden, Iceland, and Finland. Survivors and 129 828 population comparisons were followed for first-time nonpsychiatric hospitalizations for 120 disease categories in the hospital registries. Standardized hospitalization rate ratios and absolute excess rates were calculated. All statistical tests were two-sided.

RESULTS

Survivors of ALL (n = 3391), AML (n = 389), and CML (n = 92) had an increased overall hospitalization rate compared with population comparisons. The rate ratio for any hospitalization was 1.95 (95% confidence interval [CI] = 1.83 to 2.07) in ALL, 3.09 (95% CI = 2.53 to 3.65) in AML, and 4.51 (95% CI = 3.03 to 6.00) in CML survivors and remained increased even 20 years from leukemia diagnosis. Corresponding absolute excess rates per 1000 person-years were 28.48 (95% CI = 24.96 to 32.00), 62.75 (95% CI = 46.00 to 79.50), and 105.31 (95% CI = 60.90 to 149.72).

CONCLUSION

Leukemia survivors have an increased rate of hospitalization for medical conditions. We provide novel insight into the relative and absolute rate of hospitalization for 120 disease categories in survivors of ALL, AML, and CML, which are likely to be informative for both survivors and healthcare providers.

A detailed insight in the high risks of hospitalizations in long-term childhood cancer survivors-A Dutch LATER linkage study

Background

Insight in hospitalizations in long-term childhood cancer survivors (CCS) is useful to understand the impact of long-term morbidity. We aimed to investigate hospitalization rates and underlying types of diagnoses in CCS compared to matched controls, and to investigate the determinants.

Methods

We linked 5,650 five-year CCS from the Dutch nationwide Dutch LATER cohort and 109,605 age- and sex-matched controls to the Dutch Hospital Discharge register, which contained detailed information on inpatient hospitalizations from 1995–2016. Relative hospitalization rates (RHRs) were calculated using a Poisson regression model. Adjusting for multiple hospitalizations per person via a Poisson model for generalized estimated equations, we investigated determinants for hospitalizations for all types of underlying diagnoses among CCS.

Results

CCS were twice as likely to be hospitalized as reference persons (hospitalization rate 178 and 78 per 1,000 person-years respectively; RHR 2.0, 95% confidence interval (CI) 1.9–2.2). Although CCS had more hospitalizations for 17 types of underlying diagnoses, they were especially more likely to be hospitalized for endocrine conditions (RHR: 6.0, 95% CI 4.6–7.7), subsequent neoplasms (RHR: 5.6, 95% CI 4.6–6.7) and symptoms without underlying diagnoses (RHR: 5.2, 95% CI 4.6–5.8). For those types of underlying diagnoses, female sex and radiotherapy were determinants.

Conclusion

This study provides new insights in the high risk of hospitalizations for many types of underlying diagnoses in CCS and treatment related determinants. CCS are especially at high risk for hospitalizations for endocrine conditions, subsequent neoplasms and symptoms without an underlying diagnosis. This new knowledge is important for survivorship care and to identify possible preventable hospitalizations among CCS.

Neurologic disorders in 4858 survivors of central nervous system tumors in childhood-an Adult Life after Childhood Cancer in Scandinavia (ALiCCS) study

Background

A comprehensive overview of neurologic complications among survivors of central nervous system (CNS) tumors in childhood is lacking. We aimed to investigate the risk for these disorders in a large, population-based study with outcome measures from nationwide hospital registries.

Methods

We identified 4858 five-year survivors with diagnoses of CNS tumor in childhood in Denmark, Iceland, Finland, and Sweden in 1943-2007, and 166658 matched population comparison subjects. Inpatient discharge diagnoses of neurologic disorders were used to calculate relative risks (RRs) and absolute excess risks (AERs).

Results

A neurologic disorder was verified in 1309 survivors, while 92.4 were expected, yielding an overall RR of 14.2 (95% confidence interval [CI]: 13.3-15.1) and an AER of 20 hospitalizations per 1000 persons per year. The risks remained increased more than 20 years after diagnosis (RR: 6.3, 95% CI: 5.6-7.2; AER: 11, 9-12). The most frequent diagnoses were epilepsy (affecting 14.1% of all survivors) followed by hydrocephalus (9.5%) and paralytic syndromes (4.2%), with RRs of 28.7 (95% CI: 26.0-31.6), 243 (95% CI: 190-311), and 40.3 (95% CI: 33.1-49.2), respectively. Of these outcomes, 30%-40% were diagnosed prior to or synchronously with the CNS tumor. The survivors had highly increased RRs for infectious diseases of the CNS, disorders of cranial nerves, and degenerative diseases of the nervous system.

Conclusions

Survivors of childhood CNS tumors are at markedly increased risk for neurologic disorders throughout their lives. Health care professionals must be aware of survivors who might benefit from preventive interventions and intensive follow-up.

Cumulative burden of subsequent neoplasms, cardiovascular and respiratory morbidity in young people surviving cancer

BACKGROUND

Long-term childhood and young adult cancer survivors are at increased risk of the late effects of multiple chronic conditions. In this study we estimate the cumulative burden of subsequent malignant neoplasms (SMN), cardiovascular and respiratory hospitalisations in long-term survivors of childhood and young adult cancers and associated treatment risks.

METHODS

Five-year survivors of cancer diagnosed aged 0-29 years between 1992-2009 in Yorkshire, UK were included. The cumulative count of all hospital admissions (including readmissions) for cardiovascular and respiratory conditions and all SMNs diagnosed up to 2015 was calculated, with death as a competing risk. Associations between treatment exposures and cumulative burden were investigated using multiple-failure time survival models.

RESULTS

A total of 3464 5-year survivors were included with a median follow-up of 8.2 years (IQR 4-13 years). Ten-years post diagnosis, the cumulative incidence for a respiratory admission was 6.0 % (95 %CI 5.2-6.9), a cardiovascular admission was 2.0 % (95 %CI 1.5-2.5), and SMN was 1.0 % (95 % CI 0.7-1.4) with an average of 13 events per 100 survivors observed (95 %CI 11-15). The risk of experiencing multiple events was higher for those treated with chemotherapy drugs with known lung toxicity (HR = 1.35, 95 %CI 1.09-1.68).

DISCUSSION

Survivors of childhood and young adult cancer experience a high burden of morbidity due to respiratory, cardiovascular diseases and SMNs up to 20-years post-diagnosis. Statistical methods that capture multiple morbidities and recurrent events are important when quantifying the burden of late effects in young cancer survivors.

Hospitalization after Adolescent and Young Adult (AYA) Cancer: A Population-Based Study in Utah

BACKGROUND

Adolescents and young adults (AYA, age 15-39 years) with cancer may be at elevated risk for late morbidity following their cancer treatment, but few studies have quantified the excess burden of severe disease in this population. Using population-based data from Utah, we examined the risk of inpatient hospitalizations among AYA cancer survivors compared with their siblings and the general population.

METHODS

Survivors of AYA cancer who were ≥2 years from diagnosis and diagnosed from 1994 to 2015 (N = 6,330), their siblings (N = 12,924), and an age- and sex-matched comparison cohort (N = 18,171) were identified using the Utah Population Database (UPDB). Hospitalizations from 1996 to 2017 were identified from statewide discharge records in the UPDB. We estimated multivariable-adjusted hazard ratios (HR) for first hospitalization and rate ratios (RR) for total hospitalizations for survivors relative to the matched comparison cohort and siblings.

RESULTS

Overall, the risk of a first hospitalization was higher among AYA cancer survivors than the matched population-based cohort [HR = 1.93; 95% confidence interval (CI), 1.81-2.06]. Risk was most elevated for survivors of leukemia (HR = 4.76), central nervous system tumors (HR = 3.45), colorectal cancers (HR = 2.83), non-Hodgkin lymphoma (HR = 2.76), and breast cancer (HR = 2.37). The rate of total hospitalizations was also increased among survivors relative to the comparison cohort (RR = 2.05; 95% CI, 1.95-2.14). Patterns were generally similar in analyses comparing survivors to their siblings.

CONCLUSIONS

AYA cancer survivors have a higher burden of inpatient hospitalization than their siblings and the general population.

IMPACT

Results indicate the importance of long-term, risk-based follow-up care to prevent and treat severe morbidities after cancer treatment.

Treatment for lymphoma and late cardiovascular disease risk: A systematic review and meta-analysis

BACKGROUND AND AIMS

Lymphoma patients are frequently treated with cancer therapies that may increase the risk of adverse health outcomes later in life, including cardiovascular disease (CVD) mortality. We sought to investigate the long-term risk of CVD incidence in this survivor population relative to the general population to quantify this health burden.

METHODS

A systematic review and meta-analysis was conducted using EMBASE, MEDLINE, and CINAHL databases, from date of inception to November 2016, with additional searches completed through June 2018. Included reports were observational studies assessing CVD incidence in patients of either Hodgkin or non-Hodgkin lymphoma (HL, NHL) who survived for at least 5 years from the time of diagnosis or if the study had a median follow-up of 10 years. Meta-analyses were performed using random effects models, and subgroup analyses were conducted to determine the incidence of specific CVD subtypes (coronary heart disease, pericardial disease, valvular heart disease, myocardial disease, cardiac dysrhythmia, and cerebrovascular disease). Heterogeneity was assessed using I 2 statistics and prediction intervals.

RESULTS

Of the 7734 studies identified, 22 studies were included in this review, representing 32 438 HL and NHL survivors. Relative to the general population, lymphoma survivors had statistically significant two to threefold increases in the risk for nearly all subtypes of CVD examined. Lymphoma survivors appeared to be particularly susceptible to pericardial diseases (HL: 10.67, 95% confidence interval (CI), 7.75-14.69; NHL: 4.70, 95% CI, 2.08-10.61) and valvular diseases (HL: 13.10, 95% CI, 7.41-23.16; NHL: 3.76, 95% CI, 2.12-6.66). Although the 95% CIs were suggestive of increased risks, the 95% prediction intervals often included the null, reflecting the high heterogeneity of the estimates.

CONCLUSION

Given the suggested increased risks of cardiovascular outcomes in lymphoma survivor populations relative to the general population, tailored screening and prevention programmes may be warranted to offset the future burden of disease.

Long-Term Risk of Infections After Treatment of Childhood Leukemia: A Population-Based Cohort Study Using Administrative Health Data

PURPOSE

Infections are a frequent complication during childhood leukemia treatment. Little is known about the infectious risk in survivors. We compared the relative rate (RR) of infections after treatment completion between pediatric leukemia survivors and the general population.

METHODS

We performed a retrospective, population-based cohort study of children diagnosed with leukemia between 1992 and 2015 in Ontario, Canada, who were alive and relapse free 30 days after treatment completion (index date). Leukemia survivors were matched 5:1 with the general population by year of birth, sex, and rural status and stratified by initial treatment, including and excluding hematopoietic stem-cell transplantation (HSCT). The primary outcome was time to infections, as identified using validated diagnostic codes from administrative databases. Individuals were censored at the earliest of death, first relapse, loss to follow-up, or end of study.

RESULTS

A total of 2,204 leukemia survivors were included and matched with 11,020 controls. The rate of infections was elevated after treatment completion compared with controls (RR, 1.51; 95% CI, 1.45 to 1.57) and at less than 1 year (RR, 1.77; 95% CI, 1.69 to 1.86); 1 to 4.99 years (RR, 1.66; 95% CI, 1.62 to 1.71), and 5 or more years (RR, 1.29; 95% CI, 1.22 to 1.36) from the index date. Among those whose initial treatment excluded HSCT, the rate remained elevated more than 5 years from the index date (RR, 1.29; 95% CI, 1.23 to 1.35). Infection-related death was significantly increased in leukemia survivors both among the entire cohort (hazard ratio, 149.3; 95% CI, 20.4 to 1,091.9) and among those without HSCT (hazard ratio, 92.7; 95% CI, 12.4 to 690.7).

CONCLUSION

A significant association was found between a history of leukemia therapy and an increased risk of infections. Additional study is needed to establish which exposures in patients with leukemia lead to late infections.

Respiratory morbidity in young people surviving cancer: Population-based study of hospital admissions, treatment-related risk factors and subsequent mortality

Respiratory diseases are a major cause of late morbidity and mortality amongst childhood cancer survivors. This population-based study investigates respiratory hospital admissions in long-term survivors of cancers diagnosed in young people to identify specific respiratory morbidities, treatment-related risks and their relationship to subsequent morbidity and mortality. Population-based cancer registrations in Yorkshire, England, diagnosed between 1990 and 2011 aged 0-29 years, were linked to inpatient Hospital Episode Statistics (HES) for admissions up to 2017. All 5-year survivors were included in analysis (n = 4235). Admission rates were compared to age- and sex- matched general population rates. Competing risk regression models were used to assess associations between treatment exposures and risk of admission. Risk of death after admission was calculated using Cox regression. By age 40, cumulative incidence for an admission for any type of respiratory condition was 49%. Respiratory admission rates were 1.86 times higher in cancer survivors than in the general population (95% Confidence Interval (CI) 1.73-2.01), and varied by respiratory condition and age at diagnosis. Treatment with chemotherapy with known lung toxicity increased the risk of admission for all respiratory conditions (subdistribution Hazard ratio (sHR) = 1.26, 95%CI 1.03-1.53) and pneumonia (sHR = 1.48, 95%CI 1.01-2.17). Subsequent mortality was highest in those admitted for pneumonia compared to other respiratory conditions (28% and 15% respectively). Survivors of childhood and young adult cancer remain at significantly increased risk of respiratory complications several decades after treatment, emphasising the importance for clinical initiatives for prevention, early detection and treatment.

An Additive-Multiplicative Mean Model for Panel Count Data with Dependent Observation and Dropout Processes

This paper discusses regression analysis of panel count data with dependent observation and dropout processes. For the problem, a general mean model is presented that can allow both additive and multiplicative effects of covariates on the underlying point process. In addition, the proportional rates model and the accelerated failure time model are employed to describe possible covariate effects on the observation process and the dropout or follow-up process, respectively. For estimation of regression parameters, some estimating equation-based procedures are developed and the asymptotic properties of the proposed estimators are established. In addition, a resampling approach is proposed for estimating covariance matrix of the proposed estimator and a model checking procedure is also provided. Results from an extensive simulation study indicate that the proposed methodology works well for practical situations and it is applied to a motivating set of real data.

Fine Particulate Matter and Respiratory Healthcare Encounters among Survivors of Childhood Cancers

Some chemotherapies that treat childhood cancers have pulmonary-toxic properties that increase risk for adverse respiratory-health outcomes. PM_2.5 causes similar outcomes but its effect among pulmonary compromised cancer survivors is unknown. This case-crossover study identified the PM_2.5-associated odds for primary-respiratory hospitalizations and emergency department visits among childhood cancer survivors in Utah. We compared risk among chemotherapy-treated survivors to a cancer-free sample. We calculated 3-day-average PM_2.5 by ZIP code and county for event and control days. Conditional logistic regression estimated odds ratios. Models were stratified by cause of admission (infection, respiratory disease, asthma), previous chemotherapy, National Ambient Air Quality Standard (NAAQS), and other variables. Results are presented per 10 µg/m³ of PM_2.5. 90% of events occurred at 3-day PM_2.5 averages <35.4 µg/m³, the NAAQS 24-h standard. For survivors, PM_2.5 was associated with respiratory hospitalizations (OR = 1.84, 95% CI = 1.13⁻3.00) and hospitalizations from respiratory infection (OR = 2.09, 95% CI = 1.06⁻4.14). Among chemotherapy-treated survivors, the PM_2.5-associated odds of respiratory hospitalization (OR = 2.03, 95% CI = 1.14⁻3.61) were significantly higher than the cancer-free sample (OR = 0.84, 95% CI = 0.57⁻1.25). This is the first study to report significant associations between PM_2.5 and respiratory healthcare encounters in childhood cancer survivors. Chemotherapy-treated survivors displayed the highest odds of hospitalization due to PM_2.5 exposure and their risk is significantly higher than a cancer-free sample.

Incidence of infections after therapy completion in children with acute lymphoblastic leukemia or acute myeloid leukemia: a systematic review of the literature

Infections are a common complication of treatment for pediatric acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML). Less is known about infections occurring after treatment. We performed a systematic review of the literature to assess the incidence of infections after therapy completion in children and young adults with ALL or AML. Twenty-eight studies, with 4138 patients, were included. Four studies reported infections in patients who did not undergo hematopoietic stem cell transplant (HSCT). Respiratory tract and urinary tract infections affected 9.9-72.5% and 2.9-19.8% of patients, respectively. Twelve studies reported infections in patients treated with HSCT. Late bacterial, viral and fungal infections affected 3.9-38.5%, 16.1-66.7%, and 0.2-41.7% of patients, respectively. Viral hepatitis affected 0.8-75.4% of patients from 12 studies. Our review suggests that infections are a frequent complication after treatment for leukemia in children, especially after HSCT and identifies several knowledge gaps in the current literature.

Overview of Infections Complicating Pediatric Hematopoietic Cell Transplantation

Hematopoietic cell transplantations (HCT) are increasingly being performed in children for the treatment of malignant and nonmalignant diseases. Infections remain an important cause of morbidity and mortality after HCT, where the type and timing of infection is influenced by host, transplant, and pathogen-related factors. Herein, an overview of the epidemiology of infections is presented and organized by timing before and after HCT, understanding that infection may occur at any time point until there is successful immune reconstitution.

Surviving childhood cancer: a systematic review of studies on risk and determinants of adverse socioeconomic outcomes

Substantial improvements in childhood cancer survival have resulted in a steadily increasing population of childhood cancer survivors. Whereas somatic late effects have been assessed in many studies, less is known about the impact of childhood cancer on socioeconomic outcomes in survivors. The aim of this article was to evaluate and summarise the evidence on the socioeconomic conditions of childhood cancer survivors and to identify survivors at particular risk of adverse socioeconomic outcomes. An extensive literature search of three electronic databases was conducted. Of 419 articles identified, 52 met the inclusion criteria. All the selected articles were appraised for quality, and findings were summarised in a narrative synthesis. Childhood cancer survivors were at higher risk of adverse socioeconomic outcomes with regard to educational achievement, income and social security benefits than the general population or a sibling comparison group. The risks for unemployment and a lower occupational position were significantly increased only for survivors of a central nervous system tumour. Notably, survivors of central nervous system tumours, survivors treated with cranial radiotherapy and those diagnosed at younger age independent of cancer type were determinants of particular adverse socioeconomic outcomes. Given the increasing population of childhood cancer survivors, targeted follow-up interventions and support strategies addressing not only the somatic and psychiatric late effects but also the socioeconomic difficulties that some childhood cancer survivors face is of high importance to reduce social inequity, and ensure a high quality of life after childhood cancer.

Somatic late effects in 5-year survivors of neuroblastoma: a population-based cohort study within the Adult Life after Childhood Cancer in Scandinavia study

Because of the rarity of neuroblastoma and poor survival until the 1990s, information on late effects in neuroblastoma survivors is sparse. We comprehensively reviewed the long-term risk for somatic disease in neuroblastoma survivors. We identified 721 5-year survivors of neuroblastoma in Nordic population-based cancer registries and identified late effects in national hospital registries covering the period 1977-2012. Detailed treatment information was available for 46% of the survivors. The disease-specific rates of hospitalization of survivors and of 152,231 randomly selected population comparisons were used to calculate standardized hospitalization rate ratios (SHRRs) and absolute excess risks (AERs). During 5,500 person-years of follow-up, 501 5-year survivors had a first hospital contact yielding a SHRR of 2.3 (95% CI 2.1-2.6) and a corresponding AER of 52 (95% CI 44-60) per 1,000 person-years. The highest relative risks were for diseases of blood and blood-forming organs (SHRR 3.8; 95% CI 2.7-5.4), endocrine diseases (3.6 [3.1-4.2]), circulatory system diseases (3.1 [2.5-3.8]), and diseases of the nervous system (3.0 [2.6-3.3]). Approximately 60% of the excess new hospitalizations of survivors were for diseases of the nervous system, urinary system, endocrine system, and bone and soft tissue. The relative risks and AERs were highest for the survivors most intensively treated. Survivors of neuroblastoma have a highly increased long-term risk for somatic late effects in all the main disease groups as compared to background levels. Our results are useful for counseling survivors and should contribute to improving health care planning in post-therapy clinics.

Hospitalization and mortality among pediatric cancer survivors: a population-based study

PURPOSE

We examined serious long-term outcomes among childhood cancer survivors using population-based data.

METHODS

We used 1982-2014 Washington State data to compare hospitalization and/or death (including cause-specific) during up to 27 years follow-up among all 5+ year childhood cancer survivors < 20 years at diagnosis (n = 3,152) and a sample of comparison children within birth cohorts, with assessment by cancer type and child/family characteristics.

RESULTS

During follow-up (9 years median), 12% of survivors had hospitalizations; 4% died. Greatest absolute risks/1,000 person-years were for hospitalization/deaths due to cancers (8.1), infection (6.2), injuries (6.0), and endocrine/metabolic disorders (5.8). Hazard ratios (HR) and 95% confidence intervals (CI) for hospitalization (2.7, 95% CI 2.4-3.0) and any-cause death (14.7, 95% CI 11.3-19.1) were increased, and for all cause-specific outcomes examined, most notably cancer- (35.1, 95% CI 23.7-51.9), hematological- (6.7, 95% CI 5.3-8.5), nervous system- (6.4, 95% CI 5.2-7.8), and circulatory- (5.2, 95% CI 4.1-6.5) related outcomes. Hospitalizations occurred more often among females and those receiving radiation, with modest differences by urban/rural birth residence and race/ethnicity. Cause-specific outcomes varied by cancer type.

CONCLUSIONS

This study suggests increased risks for the rarely-studied outcomes of long-term fracture and injury, and confirms increased risks of selected other conditions among survivors. Multi-state pooling of population-based data would increase the ability to evaluate outcomes for uncommon cancer types and by racial/ethnic groups under-represented in many studies.

Late effects in survivors of childhood acute lymphoblastic leukemia in the context of selected gene polymorphisms

BACKGROUND

It has been shown that approximately half of survivors of childhood acute lymphoblastic leukemia (ALL) have symptomatic late effects (LE) that may be severe or life-threatening. The aim of our study was to assess the health status of childhood ALL survivors after over 10 years of follow-up and to assess its relationships with gene polymorphisms, numbers and types of LEs, as well as with intensity of chemotherapy and cranial radiotherapy (CRT).

METHODS

We conducted a telephone survey in 125 ALL survivors (median time from completion of treatment was 12 years) and compared the results with those obtained in our previous study. Most of the patients were followed-up by local providers.

RESULTS

The prevalence of LEs of approximately 50% was similar in both study groups. More than one LE was found in almost 25% of patients. Endocrine LEs were less frequent than in our previous study (44% vs 22%), probably due to underdiagnosis. The prevalence of hepatitis B/C decreased from 30%/50 to 18% (counted together), and prevalence of neurologic LEs decreased from 18 to 6%. The increase in the rate of second malignancies was not significant (2% vs. 3%). Sixty four percent of patients continued their education at the time of the study. Approximately 51% of ALL survivors who have completed their education by the time of the study had no permanent employment, including 4 mothers of infants and 3 persons qualified for a disability living allowance. These employment problems may have been due to cognitive impairment. The offspring of the ALL survivors included 11 children, all of them healthy. Further analysis showed higher prevalence of hepatitis in patients treated with CRT (p = 0.0001). Genetic studies revealed higher prevalence of hepatitis in patients homozygous for the rs9939609A variant of the FTO gene compared with other patients (p = 0.03). Moreover, wild-type rs1137101 polymorphism (Q223R) of the and leptin receptor gene was more frequent in patients with psychological LEs (p = 0.03).

CONCLUSIONS

The prevalence of LEs in ALL survivors is of key importance. The transition of childhood ALL survivors from pediatric to adult care should be urgently improved to maintain continued follow-up provide high-quality care.

TRIAL REGISTRATION

Bioethics Committee of the Jagiellonian University approved the study protocol. Registration number: KBET/113/B/2006.

Financial Hardship and the Economic Effect of Childhood Cancer Survivorship

In addition to the long-term physical and psychological sequelae of cancer therapy, adult survivors of childhood cancer are at an elevated risk for financial hardship. Financial hardship can have material, psychological, and behavioral effects, including high out-of-pocket medical costs, asset depletion and debt, limitations in or inability to work, job lock, elevated stress and worry, and a delaying or forgoing of medical care because of cost. Most financial hardship research has been conducted in survivors of adult cancers. The few studies focused on childhood cancer survivors have shown that these individuals are at elevated risk for having difficulties with affording needed health care and report high out-of-pocket medical expenses, difficulty with paying medical bills, or consideration of filing for bankruptcy. Childhood cancer survivors are more likely to be unable to work or to have missed work because of poor health. They are more likely to report difficulties with obtaining insurance coverage and rely more frequently on government-sponsored insurance. Globally, countries able to provide curative cancer therapies have witnessed a growing population of survivors, which places a burden on their health care systems because survivors are more likely to require hospitalization and experience a higher burden of chronic illness than the general population. Guidelines for surveillance for late effects are intended to reduce the burden of morbidity, but research is needed to determine whether such surveillance is cost effective. Of note, risk-based survivor care should include routine surveillance for financial hardship. Improved measures of financial hardship, enhanced data infrastructure, and research studies to identify survivors and families most vulnerable to financial hardship and adverse health outcomes will inform the development of targeted programs to serve as a safety net for those at greatest risk.

An investigation of survivorship clinic attendance among childhood cancer survivors living in a five-state rural region

PURPOSE

Cancer survivorship clinics manage cancer-related health complications and are available primarily in urban areas. We examine how demographic, clinical, and geographic-based characteristics are associated with attendance at the only pediatric survivorship clinic in a largely rural, multistate region.

METHODS

One thousand eight hundred sixteen cancer survivors were diagnosed at age ≤ 25 from 1986 to 2005 while living in the region. Cox models incorporating death as a competing risk and generalized estimating equations calculated hazards ratios (HR) for characteristics measured at the clinic's opening. Subjects were followed from the clinic opening their first visit, death, emigration from the catchment area, or December 31, 2014.

RESULTS

Five percent of survivors visited the clinic. Attendance is positively associated with a leukemia or lymphoma diagnosis (HR = 3.32, 95% confidence interval [CI] = 1.72-6.78 vs CNS tumors), previous relapse (HR = 1.78, 95% CI = 1.00-3.19), and residing >100 mi from the clinic (HR = 2.05, 95% CI 1.03-4.10). Survivors aged ≥ 31 years at clinic opening (HR = 0.19, 95% CI = 0.07-0.54) are less likely to attend than younger survivors. Residence between 16 and 100 mi had an inverse association with attendance, although not significant.

CONCLUSION

Survivorship clinics are not widely attended by survivors in this catchment region. Efforts should be made to recruit survivors aged ≥ 31 and diagnosed with CNS tumors. Distance has a complex association with attendance, which could be attributed to the limited availability of preventative services in regions > 100 mi from the clinic.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors living in this catchment region may not be receiving care necessary to prevent severe late effects.

Risk of hospitalization among survivors of childhood and adolescent acute lymphoblastic leukemia compared to siblings and a general population sample

BACKGROUND

Acute Lymphoblastic Leukemia (ALL) has a high survival rate, but cancer-related late effects in the early post-treatment years need documentation. Hospitalizations are an indicator of the burden of late effects. We identify rates and risk factors for hospitalization from five to ten years after diagnosis for childhood and adolescent ALL survivors compared to siblings and a matched population sample.

METHODS

176 ALL survivors were diagnosed at ≤22 years between 1998 and 2008 and treated at an Intermountain Healthcare facility. The Utah Population Database identified siblings, an age- and sex-matched sample of the Utah population, and statewide inpatient hospital discharges. Sex- and birth year-adjusted Poisson models with Generalized Estimating Equations and robust standard errors calculated rates and rate ratios. Cox proportional hazards models identified demographic and clinical risk factors for hospitalizations among survivors.

RESULTS

Hospitalization rates for survivors (Rate:3.76, 95% CI=2.22-6.36) were higher than siblings (Rate:2.69, 95% CI=1.01-7.18) and the population sample (Rate:1.87, 95% CI=1.13-3.09). Compared to siblings and population comparisons, rate ratios (RR) were significantly higher for survivors diagnosed between age 6 and 22 years (RR:2.87, 95% CI=1.03-7.97 vs siblings; RR:2.66, 95% CI=1.17-6.04 vs population comparisons). Rate ratios for diagnosis between 2004 and 2008 were significantly higher compared to the population sample (RR:4.29, 95% CI=1.49, 12.32), but not siblings (RR:2.73, 95% CI=0.54, 13.68). Survivors originally diagnosed with high-risk ALL did not have a significantly higher risk than siblings or population comparators. However, high-risk ALL survivors (Hazard ratio [HR]:3.36, 95% CI=1.33-8.45) and survivors diagnosed from 2004 to 2008 (HR:9.48, 95% CI=1.93-46.59) had the highest risk compared to their survivor counterparts.

CONCLUSIONS

Five to ten years after diagnosis is a sensitive time period for hospitalizations in the ALL population. Survivors of childhood ALL require better long-term surveillance.

Young adult survivors of childhood acute lymphoblastic leukemia show evidence of chronic inflammation and cellular aging

BACKGROUND

Large epidemiologic studies have reported the premature onset of age-related conditions, such as ischemic heart disease and diabetes mellitus, in childhood cancer survivors, decades earlier than in their peers. The authors investigated whether young adult survivors of childhood acute lymphoblastic leukemia (ALL) have a biologic phenotype of cellular ageing and chronic inflammation.

METHODS

Plasma inflammatory cytokines were measured using a cytometric bead array in 87 asymptomatic young adult survivors of childhood ALL (median age, 25 years; age range, 18-35 years) who attended annual follow-up clinic and compared with healthy, age-matched and sex-matched controls. Leukocyte telomere length (LTL) was measured using Southern blot analysis.

RESULTS

Survivors had significant elevation of plasma interleukin-2 (IL-2), IL-10, IL-17a, and high-sensitivity C-reactive protein levels (all P < .05). A raised high-sensitivity C-reactive protein level (>0.8 mg/dL) was related to increased odds of having metabolic syndrome (odds ratio, 7.256; 95% confidence interval, 1.501-35.074). Survivors also had significantly shorter LTL compared with controls (median, 9866 vs 10,392 base pairs; P = .021). Compared with published data, LTL in survivors was similar to that in healthy individuals aged 20 years older. Survivors who received cranial irradiation had shorter LTL compared with those who had not (P = .013).

CONCLUSIONS

Asymptomatic young adult survivors of childhood ALL demonstrate a biologic profile of chronic inflammation and telomere attrition, consistent with an early onset of cellular processes that drive accelerated aging. These processes may explain the premature development of age-related chronic conditions in childhood cancer survivors. Understanding their molecular basis may facilitate targeted interventions to disrupt the accelerated aging process and its long-term impact on overall health. Cancer 2017;123:4207-4214. © 2017 American Cancer Society.

Long-term inpatient disease burden in the Adult Life after Childhood Cancer in Scandinavia (ALiCCS) study: A cohort study of 21,297 childhood cancer survivors

BACKGROUND

Survivors of childhood cancer are at increased risk for a wide range of late effects. However, no large population-based studies have included the whole range of somatic diagnoses including subgroup diagnoses and all main types of childhood cancers. Therefore, we aimed to provide the most detailed overview of the long-term risk of hospitalisation in survivors of childhood cancer.

METHODS AND FINDINGS

From the national cancer registers of Denmark, Finland, Iceland, and Sweden, we identified 21,297 5-year survivors of childhood cancer diagnosed with cancer before the age of 20 years in the periods 1943-2008 in Denmark, 1971-2008 in Finland, 1955-2008 in Iceland, and 1958-2008 in Sweden. We randomly selected 152,231 population comparison individuals matched by age, sex, year, and country (or municipality in Sweden) from the national population registers. Using a cohort design, study participants were followed in the national hospital registers in Denmark, 1977-2010; Finland, 1975-2012; Iceland, 1999-2008; and Sweden, 1968-2009. Disease-specific hospitalisation rates in survivors and comparison individuals were used to calculate survivors' standardised hospitalisation rate ratios (RRs), absolute excess risks (AERs), and standardised bed day ratios (SBDRs) based on length of stay in hospital. We adjusted for sex, age, and year by indirect standardisation. During 336,554 person-years of follow-up (mean: 16 years; range: 0-42 years), childhood cancer survivors experienced 21,325 first hospitalisations for diseases in one or more of 120 disease categories (cancer recurrence not included), when 10,999 were expected, yielding an overall RR of 1.94 (95% confidence interval [95% CI] 1.91-1.97). The AER was 3,068 (2,980-3,156) per 100,000 person-years, meaning that for each additional year of follow-up, an average of 3 of 100 survivors were hospitalised for a new excess disease beyond the background rates. Approximately 50% of the excess hospitalisations were for diseases of the nervous system (19.1% of all excess hospitalisations), endocrine system (11.1%), digestive organs (10.5%), and respiratory system (10.0%). Survivors of all types of childhood cancer were at increased, persistent risk for subsequent hospitalisation, the highest risks being those of survivors of neuroblastoma (RR: 2.6 [2.4-2.8]; n = 876), hepatic tumours (RR: 2.5 [2.0-3.1]; n = 92), central nervous system tumours (RR: 2.4 [2.3-2.5]; n = 6,175), and Hodgkin lymphoma (RR: 2.4 [2.3-2.5]; n = 2,027). Survivors spent on average five times as many days in hospital as comparison individuals (SBDR: 4.96 [4.94-4.98]; n = 422,218). The analyses of bed days in hospital included new primary cancers and recurrences. Of the total 422,218 days survivors spent in hospital, 47% (197,596 bed days) were for new primary cancers and recurrences. Our study is likely to underestimate the absolute overall disease burden experienced by survivors, as less severe late effects are missed if they are treated sufficiently in the outpatient setting or in the primary health care system.

CONCLUSIONS

Childhood cancer survivors were at increased long-term risk for diseases requiring inpatient treatment even decades after their initial cancer. Health care providers who do not work in the area of late effects, especially those in primary health care, should be aware of this highly challenged group of patients in order to avoid or postpone hospitalisations by prevention, early detection, and appropriate treatments.

Risk and associated risk factors of hospitalization for specific health problems over time in childhood cancer survivors: a medical record linkage study

Childhood cancer survivors (CCS) experience higher hospitalization rates compared to the general population for neoplasms, circulatory diseases, endocrine/nutritional/metabolic diseases and eye disorders. We studied trends in hospitalization rates and associated patient and treatment‐specific risk factors for diagnosis subgroups among these four diseases. We performed medical record linkage of a ≥5‐year CCS cohort with national registers, and obtained a random reference sample matched on age, gender and calendar year per CCS. For each diagnosis subgroup we compared hospitalization rates and trends over time in CCS and the reference population. Further, we analyzed risk factors for hospitalizations within the four CCS diagnosis groups. We used multivariate Poisson regression for all models. We retrieved hospitalization data from 1382 CCS and 26,583 reference persons. CCS had increased hospitalization rates for almost all diagnosis subgroups examined. Hospitalization rates for endocrine/nutritional/metabolic diseases appeared to increase with longer time since primary cancer diagnosis up to 30 years after primary cancer diagnosis. Survivors initially treated with radiotherapy had increased hospitalization rates for neoplasms (P < 0.001), those initially treated with anthracyclines (2.5 [1.1–5.5]) and radiotherapy to thorax and/or abdomen (9.3 [2.4–36.6]) had increased hospitalization rates for diseases of the circulatory system, and those initially treated with radiotherapy to head and/or neck had increased hospitalization rates for endocrine/nutritional/metabolic diseases (6.7 [3.5–12.7]) and diseases of the eye (3.6 [1.5–8.9]). Our study highlights that long‐term health problems resulting in hospitalizations are still clinically relevant later in life of CCS. The identified treatment‐related risk factors associated with hospitalizations support targeted follow‐up care for these risk groups of CCS.

Temporal Trends in Treatment and Subsequent Neoplasm Risk Among 5-Year Survivors of Childhood Cancer, 1970-2015

IMPORTANCE

Cancer treatments are associated with subsequent neoplasms in survivors of childhood cancer. It is unknown whether temporal changes in therapy are associated with changes in subsequent neoplasm risk.

OBJECTIVE

To quantify the association between temporal changes in treatment dosing and subsequent neoplasm risk.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, multicenter cohort study of 5-year cancer survivors diagnosed before age 21 years from pediatric tertiary hospitals in the United States and Canada between 1970-1999, with follow-up through December 2015.

EXPOSURES

Radiation and chemotherapy dose changes over time.

MAIN OUTCOMES AND MEASURES

Subsequent neoplasm 15-year cumulative incidence, cumulative burden, and standardized incidence ratios for subsequent malignancies, compared by treatment decade. Multivariable models assessed relative rates (RRs) of subsequent neoplasms by 5-year increments, adjusting for demographic and clinical characteristics. Mediation analyses assessed whether changes in rates of subsequent neoplasms over time were mediated by treatment variable modifications.

RESULTS

Among 23 603 survivors of childhood cancer (mean age at diagnosis, 7.7 years; 46% female) the most common initial diagnoses were acute lymphoblastic leukemia, Hodgkin lymphoma, and astrocytoma. During a mean follow-up of 20.5 years (374 638 person-years at risk), 1639 survivors experienced 3115 subsequent neoplasms, including 1026 malignancies, 233 benign meningiomas, and 1856 nonmelanoma skin cancers. The most common subsequent malignancies were breast and thyroid cancers. Proportions of individuals receiving radiation decreased (77% for 1970s vs 33% for 1990s), as did median dose (30 Gy [interquartile range, 24-44] for 1970s vs 26 Gy [interquartile range, 18-45] for 1990s). Fifteen-year cumulative incidence of subsequent malignancies decreased by decade of diagnosis (2.1% [95% CI, 1.7%-2.4%] for 1970s, 1.7% [95% CI, 1.5%-2.0%] for 1980s, 1.3% [95% CI, 1.1%-1.5%] for 1990s). Reference absolute rates per 1000 person-years were 1.12 (95% CI, 0.84-1.57) for subsequent malignancies, 0.16 (95% CI, 0.06-0.41) for meningiomas, and 1.71 (95% CI, 0.88-3.33) for nonmelanoma skin cancers for survivors with reference characteristics (no chemotherapy, splenectomy, or radiation therapy; male; attained age 28 years). Standardized incidence ratios declined for subsequent malignancies over treatment decades, with advancing attained age. Relative rates declined with each 5-year increment for subsequent malignancies (RR, 0.87 [95% CI, 0.82-0.93]; P < .001), meningiomas (RR, 0.85 [95% CI, 0.75-0.97]; P = .03), and nonmelanoma skin cancers (RR, 0.75 [95% CI, 0.67-0.84]; P < .001). Radiation dose changes were associated with reduced risk for subsequent malignancies, meningiomas, and nonmelanoma skin cancers.

CONCLUSIONS AND RELEVANCE

Among survivors of childhood cancer, the risk of subsequent malignancies at 15 years after initial cancer diagnosis remained increased for those diagnosed in the 1990s, although the risk was lower compared with those diagnosed in the 1970s. This lower risk was associated with reduction in therapeutic radiation dose.

Early Posttherapy Hospitalizations Among Survivors of Childhood Leukemia and Lymphoma

Long-term survivors of childhood cancers are at increased risk for hospitalization. To test the hypothesis that many treatment-related morbidities are identifiable in the early posttherapy period, we determined the rates and causes for hospitalization among survivors of leukemia and lymphoma during the first 3 years posttherapy. Using a health plan claims database, we identified patients aged 0 to 21 years old treated for leukemia or lymphoma from 2000 to 2010. Survivors were matched 10:1 with similar children without a history of cancer. Hospitalization rates over 3 years were compared using Cox proportional hazards regression and risks of cause-specific hospitalization were compared using log-binomial models. Nineteen percent of childhood leukemia and lymphoma survivors were hospitalized in the first 3 years off therapy. Leukemia survivors (N=529) experienced over 6 times (hazard ratio=6.3; 95% confidence interval [CI], 4.9-8.0) and lymphoma survivors (N=454) over 3 times the hospitalization rate of controls (hazard ratio=3.2; 95% CI, 2.5-4.2). Compared with children without a cancer history, survivors were at increased risk for hospitalization due to infectious causes (leukemia: relative risk [RR], 60.0; 95% CI, 23.4-154.0; lymphoma: RR, 10.0; 95% CI, 4.4-22.9). In addition, lymphoma survivors were at increased risk for cardiovascular-related (RR, 15.0; 95% CI, 5.4-42.0) and pulmonary-related (RR, 8.1; 95% CI, 3.9-16.8) hospitalizations. These findings highlight the morbidity experienced by survivors and suggest that treatment-associated complications may be emerging soon after therapy completion.

High Hospitalization Rates in Survivors of Childhood Cancer: A Longitudinal Follow-Up Study Using Medical Record Linkage

Hospitalization rates over time of childhood cancer survivors (CCS) provide insight into the burden of unfavorable health conditions on CCS and health care resources. The objective of our study was to examine trends in hospitalizations of CCS and risk factors in comparison with the general population. We performed a medical record linkage study of a cohort of 1564 ≥five-year CCS with national registers. We obtained a random sample of the general population matched on year of birth, gender and calendar year per CCS retrieved. We quantified and compared hospitalization rates of CCS and reference persons from 1995 until 2005, and we analyzed risk factors for hospitalization within the CCS cohort with multivariable Poisson models. We retrieved hospitalization information from 1382 CCS and 25583 reference persons. The overall relative hospitalization rate (RHR) was 2.2 (95%CI:1.9–2.5) for CCS compared to reference persons. CCS with central nervous system and solid tumors had highest RHRs. Hospitalization rates in CCS were increased compared to reference persons up to at least 30 years after primary diagnosis, with highest rates 5–10 and 20–30 years after primary cancer. RHRs were highest for hospitalizations due to neoplasms (10.7; 95%CI:7.1–16.3) and endocrine/nutritional/metabolic disorders (7.3; 95%CI:4.6–11.7). Female gender (P<0.001), radiotherapy to head and/or neck (P<0.001) or thorax and/or abdomen (P = 0.03) and surgery (P = 0.01) were associated with higher hospitalization rates in CCS. In conclusion, CCS have increased hospitalization rates compared to the general population, up to at least 30 years after primary cancer treatment. These findings imply a high and long-term burden of unfavorable health conditions after childhood cancer on survivors and health care resources.

[Prevalence of central nervous system tumours and histological identification in the operated patient: 20 years of experience]

BACKGROUND

Central nervous system tumours comprise a heterogeneous group of neoplasms with great histological diversity. Despite the rising prevalence of these tumours in developing countries, some places like Mexico and Latin America have no representative studies that show the real impact of these tumours in our population.

OBJECTIVE

To describe the characteristics of the primary and secondary tumours of the central nervous system in the last 20 years in a Mexican institution.

MATERIAL AND METHODS

Patients with histopathological diagnosis from 1993 to 2013 in our institution, grouping them according to WHO classification 2007, characterising them by age group, gender, and anatomical location.

RESULTS

There were a total of 511 tumours of the central nervous system. Of those, 292 were women and 219 men, with a ratio 1.3: 1, and a mean age of 49.3 years. Tumours with higher prevalence were: Meningeal tumours, 171 (33%), followed by neuroepithelial, 121 (24%). Astrocytoma had the highest prevalence in paediatric patients, whereas in those older than 20 years it was the meningioma. The supratentorial location was the most involved.

CONCLUSION

This is the first study of a series of cases in Mexico that is performed by taking into account benign and malignant tumours of the central nervous system, with patients of all age groups with a range of 20 years. While this work only represents a retrospective analysis of an institution, it can be a strong indication of the epidemiology of these tumours in our environment.

Survivors of childhood cancer in the United States: prevalence and burden of morbidity

BACKGROUND

No studies have estimated the population-level burden of morbidity in individuals diagnosed with cancer as children (ages 0-19 years). We updated prevalence estimates of childhood cancer survivors as of 2011 and burden of morbidity in this population reflected by chronic conditions, neurocognitive dysfunction, compromised health-related quality of life, and health status (general health, mental health, functional impairment, functional limitations, pain, and fear/anxiety).

METHODS

Surveillance, Epidemiology, and End Results (SEER) Program data from 1975 to 2011 were used to update the prevalence of survivors of childhood cancers in the United States. Childhood Cancer Survivor Study data were used to obtain estimates of morbidity burden indicators, which were then extrapolated to SEER data to obtain population-level estimates.

RESULTS

There were an estimated 388,501 survivors of childhood cancer in the United States as of January 1, 2011, of whom 83.5% are ≥5 years after diagnosis. The prevalence of any chronic condition among ≥5-year survivors ranged from 66% (ages 5-19) to 88% (ages 40-49). Estimates for specific morbidities ranged from 12% (pain) to 35% (neurocognitive dysfunction). Generally, morbidities increased by age. However, mental health and anxiety remained fairly stable, and neurocognitive dysfunction exhibited initial decline and then remained stable by time since diagnosis.

CONCLUSIONS

The estimated prevalence of survivors of childhood cancer is increasing, as is the estimated prevalence of morbidity in those ≥5 years after diagnosis.

IMPACT

Efforts to understand how to effectively decrease morbidity burden and incorporate effective care coordination and rehabilitation models to optimize longevity and well-being in this population should be a priority.

Cervicofacial Rhytidectomy After Radiotherapy for Head and Neck Tumors

IMPORTANCE

Whether undergoing cervicofacial rhytidectomy after radiotherapy for tumors of the head and neck is associated with increased complication rates and therefore should be avoided remains unknown.

OBJECTIVE

To evaluate complication rates in patients who have undergone cervicofacial rhytidectomy after radiotherapy for head and neck tumors and compare these rates with those of patients who have not undergone radiotherapy.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective review of the medical records of 16 patients who underwent cervicofacial rhytidectomy after completing radiotherapy for head and neck tumors and those of 16 age-matched control participants who did not undergo radiotherapy. Patients underwent treatment from July 1, 2006, through February 28, 2014, with final follow-up on February 28, 2014. Complications after surgery were reviewed and data for surgery type, technique, radiation dose and delivery method, and time to surgery after radiotherapy were analyzed. Data were collected from June 1 through December 31, 2013, and analyzed from January 1, 2014, through June 1, 2015.

MAIN OUTCOMES AND MEASURES

Rate of complications after surgery.

RESULTS

The radiotherapy and control group patients were a mean of 62 years old. In the radiotherapy group, 8 of 16 were women; 14 of 16 were women in the control group. Two major complications, 1 hematoma and 1 perioperative stroke, occurred in the 16 patients who composed the study cohort. In the control group, there was 1 case of transient facial nerve weakness and 1 case of cellulitis that was successfully treated with antibiotics. Two patients experienced wound dehiscence, and no incidents of motor or sensory nerve injury occurred. Subcutaneous face-lift (3 of 3 patients [100%] vs 1 of 13 patients [8%] who underwent superficial musculoaponeurotic system and deep-plane face-lifts; P = .02) and the addition of chemotherapy (4 of 9 patients [44%] vs 0 of 7 patients who did not receive chemotherapy; P = .04) were associated with increased complications. Being older and the time from completion of radiotherapy and surgery did not show any correlation to complications.

CONCLUSIONS AND RELEVANCE

Aesthetic facial surgery after radiotherapy has an increased risk for complication compared with facial surgery without radiotherapy. The incidence of wound dehiscence is elevated in the population undergoing radiotherapy but can be managed conservatively in most cases. Patients who undergo radiotherapy must be counseled on the increased risk for complications before proceeding with cervicofacial rhytidectomy.

LEVEL OF EVIDENCE

3.

Hospitalization Rates Among Survivors of Young Adult Malignancies

Purpose

There are limited data on health care use among survivors of young adult cancers. We aimed to describe patterns of hospitalization among a cohort of long-term survivors compared with noncancer controls.

Methods

Persons diagnosed between the ages of 20 and 44 years with malignancies in Ontario, Canada, from 1992 to 1999, who lived at least 5 years recurrence free, were identified using the Ontario Cancer Registry and matched to noncancer controls. Hospitalizations were determined using hospital discharges, and rates were compared between survivors and controls. The absolute excess rate of hospitalizations was determined for each type of malignancy in survivors per 100 person-years of follow-up.

Results

The cohort included 20,275 survivors and 101,344 noncancer controls. During the study period, 6,948 (34.3%) survivors were admitted to the hospital and the adjusted relative rate (ARR) of hospitalizations in survivors compared with controls was 1.51 (95% CI, 1.48 to 1.54). The rate of hospitalization was highest for survivors of upper GI, leukemia, and urologic malignancies. The hospitalization rate (per person) for survivors significantly decreased from 0.22 in the first time period examined (5 to 8 years after diagnosis) to 0.15 in the last time period examined (18 to 20 years after diagnosis, P < .0001). However, at all time periods, survivors were more likely to be hospitalized than controls (ARR at 5 to 8 years, 1.67 [95% CI, 1.57 to 1.81]; ARR at 18 to 20 years, 1.22 [95% CI, 1.08 to 1.37]).

Conclusion

Survivors of young adult cancers have an increased rate of hospitalization compared with controls. The rate of hospitalization for 20-year survivors did not return to baseline, indicating a substantial and persistent burden of late effects among this generally young population.