Multiple primary cancer survivors have poorer health status and well-being than single primary cancer survivors: a study from the population-based PROFILES registry

Risk and prediction of multiple primary malignancies after early gastric cancer

BACKGROUND

Patients with early gastric cancer have increased risk of developing multiple primary malignancies (MPM) due to improved survival rates. The purpose of this study was to evaluate the clinicopathological features of MPM and to generate a useful tool for predicting the development of MPM after early gastric cancer.

METHODS

We selected 1025 early gastric cancer patients with complete medical records for a retrospective analysis. The Cox proportional risk regression model was used to analyze the independent risk factors for the development of MPM in early gastric cancer. RStudio software was used to compare the OS of early gastric cancer patients with and without MPM, and a nomogram was established to predict the probability of MPM 1-, 2-, 3-year after early gastric cancer. The predictive effectiveness of the nomogram was evaluated by the C-index and calibration curve. Decision curve analysis (DCA) measured the applicability of the nomogram to clinical practice.

RESULTS

Of the 1025 patients with early gastric cancer, 66 patients (6.4%) had 69 primary cancers other than early gastric cancer. They had a median follow-up of 41 months, and their cumulative incidence of MPM was 4.9%, 5.4% and 5.9% after 1-, 2-, and 3- year, respectively. Oesophageal cancer was the most frequently detected MPM, followed by lung and colorectal cancers. Male (p=0.038), age ≥65 years (p=0.003), smoking history (p=0.036), and lymph node metastasis (p=0.013) were independent risk factors for MPM in patients with early gastric cancer. Patients with early gastric cancer with MPM had a worse OS prognosis than patients with early gastric cancer without MPM (p<0.001). The internally validated nomogram predicted the probability of developing MPM after early gastric cancer (C index= 0.697). The calibration chart showed that the predicted probability of MPM in early gastric cancer was similar to the observed result, and the DCA showed strong clinical practicability.

CONCLUSION

After the diagnosis and treatment of early gastric cancer, we should be alert to the possibility of MPM and perform regular and careful monitoring.

Common Multiple Primary Cancers Associated With Breast and Gynecologic Cancers and Their Risk Factors, Pathogenesis, Treatment and Prognosis: A Review

The mammary gland is closely related to the female reproductive system in many aspects, affecting the whole gynecological system. Breast cancer (BC) is the most common malignancy in women and associated with considerable negative effects. Due to various factors including co-pathogenic genetic mutations, environment factors, lifestyle, behavioral factors, treatment regimens and in-creased survival of patients with BC, there is an increased probability of developing additional primary gynecologic cancers such as ovarian cancer (OC), endometrial cancer (EC), and cervical cancer (CC). More and more studies have been conducted in recent years. Multiple primary cancers (MPCs), also known as multiple primary malignancies, refers to two or more different primary cancers in the same patient occurring in the same or different organs or tissues. The pathogenesis of multiple primary cancers is complex and has a negative effect on the prognosis and survival of patients. This review discusses the common types of BC-associated MPCs, namely, BC associated with OC, BC associated with EC and BC associated with CC, as well as risk factors, pathogenesis, treatment, and prognosis of MPCs associated with breast and gynecologic cancers. It provides new intervention and treatment ideas for patients with BC-associated MPCs to improve quality of life and prognosis.

Cancer Patient Experience of Uncertainty While Waiting for Genome Sequencing Results

There is limited knowledge about cancer patients' experiences of uncertainty while waiting for genome sequencing results, and whether prolonged uncertainty contributes to psychological factors in this context. To investigate uncertainty in patients with a cancer of likely hereditary origin while waiting for genome sequencing results, we collected questionnaire and interview data at baseline, and at three and 12 months follow up (prior to receiving results). Participants (N = 353) had negative attitudes towards uncertainty (M = 4.03, SD 0.68) at baseline, and low levels of uncertainty at three (M = 8.23, SD 7.37) and 12 months (M = 7.95, SD 7.64). Uncertainty about genome sequencing did not change significantly over time [t(210) = 0.660, p = 0.510]. Greater perceived susceptibility for cancer [r(348) = 0.14, p < 0.01], fear of cancer recurrence [r(348) = 0.19, p < 0.01], perceived importance of genome sequencing [r(350) = 0.24, p < 0.01], intention to change behavior if a gene variant indicating risk is found [r(349) = 0.29, p < 0.01], perceived ability to cope with results [r(349) = 0.36, p < 0.01], and satisfaction with decision to have genome sequencing [r(350) = 0.52, p < 0.01] were significantly correlated with negative attitudes towards uncertainty at baseline. Multiple primary cancer diagnoses [B = -2.364 [-4.238, -0.491], p = 0.014], lower perceived ability to cope with results [B = -0.1.881 [-3.403, -0.359], p = 0.016] at baseline, greater anxiety about genome sequencing (avoidance) [B = 0.347 [0.148, 0.546], p = 0.0012] at 3 months, and greater perceived uncertainty about genome sequencing [B = 0.494 [0.267, 0.721] p = 0.000] at 3 months significantly predicted greater perceived uncertainty about genome sequencing at 12 months. Greater perceived uncertainty about genome sequencing at 3 months significantly predicted greater anxiety (avoidance) about genome sequencing at 12 months [B = 0.291 [0.072, 0.509], p = 0.009]. Semi-structured interviews revealed that while participants were motivated to pursue genome sequencing as a strategy to reduce their illness and risk uncertainty, genome sequencing generated additional practical, scientific and personal uncertainties. Some uncertainties were consistently discussed over the 12 months, while others emerged over time. Similarly, some uncertainty coping strategies were consistent over time, while others emerged while patients waited for their genome sequencing results. This study demonstrates the complexity of uncertainty generated by genome sequencing for cancer patients and provides further support for the inter-relationship between uncertainty and anxiety. Helping patients manage their uncertainty may ameliorate psychological morbidity.

Trends in the proportion of second or later primaries among all newly diagnosed malignant cancers

BACKGROUND

Improvements in cancer survival mean that an increasing number of survivors may live long enough beyond their initial cancer to be diagnosed with additional independent primary cancers. The proportion of newly diagnosed cancers that are second- or higher-order primaries and how this proportion has changed over the past several decades were examined.

METHODS

Data from the Surveillance, Epidemiology, and End Results (SEER) program were used to identify incident malignant primaries diagnosed between 1975 and 2017. Using the SEER sequence number, the authors tabulated the proportion of all cancers in each calendar year that were second- or higher-order primaries. The average annual percent change (AAPC) was then calculated to assess how this proportion has changed over time.

RESULTS

Analyses included nearly 4.9 million incident cancers diagnosed during 1975-2017. The proportion of all cancers that were second- or higher-order increased steadily from 9.77% during 1975-1984 to 21.03% during 2015-2017, reflecting an AAPC of 2.41% (95% CI, 2.16%-2.65%). In 2015-2017, second- or higher-order cancers were most prevalent among cancers of the bladder (28.79%), followed by lung and bronchus (28.07%), melanoma (27.88%), and leukemia (26.10%). The highest AAPCs over the study period were observed for melanoma (4.05%), leukemia (3.51%), and lung and bronchus (3.36%).

CONCLUSIONS

The proportion of newly diagnosed cancers that are second- or higher-order has grown rapidly over the past several decades and currently exceeds 20%. Continued monitoring of second and later primaries will be critical for anticipating the future impact on cancer treatment and survivorship care.

Survival analysis of second primary malignancies after cervical cancer using a competing risk model: implications for prevention and surveillance

Background

Previous studies have reported an increased risk for second primary malignancies (SPMs) after cervical cancer (CC). This study aims to quantify and assess the risk of developing SPMs in long-term survivors of CC.

Methods

A population-based cohort of CC patients aged 20–79 years was obtained from the Surveillance, Epidemiology, and End Results (SEER) database. A competing risk model and corresponding nomogram were constructed to predict the 3-, 5-, and 10-year cumulative risks of SPMs. A Fine-Gray plot was created to validate the model. Finally, we performed decision curve analysis (DCA) to evaluate the clinical usefulness of the model by calculating the net benefit.

Results

A total of 34,295 patients were identified, and approximately 6.3% of the study participants developed SPMs. According to the multivariable competing-risk model, older black CC survivors with localized disease who were treated with radiation therapy were more susceptible to SPMs. The 3-, 5-, and 10-year cumulative incidences of SPMs were 2.5%, 3.6%, and 6.2%, respectively. Calibration curves showed good agreement between the predicted and observed models. The DCA yielded a wide range of risk thresholds at which the net benefits could be obtained from our proposed model.

Conclusions

This study provides physicians with a practical, individualized prognostic estimate to assess the risk of SPMs among CC survivors. CC survivors remain at a high risk of developing SPMs, and further surveillance should focus especially on the patients with black race, older age, localized disease, or those having received radiation therapy.

Life-long follow-up of second primary lung and extra-pulmonary cancer in lung cancer patients is needed

Background: Lung cancer (LC) patients are at high risk of developing second primary cancer (SPC). This study aimed to explore the risk factors associated with SPC and provide an individualized risk prediction model for LC patients. Methods: Initial primary lung cancer (IPLC) patients diagnosed between 1998 and 2011 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. A Fine-Gray multivariate competing-risk model was used to estimate the risk of SPC, and the model was assessed regarding discrimination and calibration. A nomogram was designed for clinical convenience to predict the 3-, 5-, and 10- year probabilities of developing SPCs. Results: A total of 142,491 IPLC patients were considered in this study and 14,374(10.01%) developed SPC within a maximum study period of approximately 19 years. Seven independent prognostic factors were identified according to the competing-risk model, and the SEER summary stage and surgery were the strongest predictors. The model was well calibrated and had good discrimination ability(C-index = 0.746). Conclusions: LC survivors had an increased risk of SPC and factors associated with good prognosis often predicted SPC. Consideration should be given to increasing the duration of routine follow-up even after 10 years of initial diagnosis for those at the highest risk and site-specific follow-up strategy is also required.

Distress and mental health care and medication use among survivors of multiple primary cancer diagnoses: Findings from the 2016 National Health Interview Survey

OBJECTIVE

Over 1 million survivors of multiple primary cancer (MPC) diagnoses reside in the USA. Information regarding their physical and mental health status is limited. This study examined distress and mental health care use among MPC survivors relative to survivors of a single primary cancer (SPC) diagnosis.

METHODS

Using the 2016 National Health Information Survey, MPC survivors (n = 265), SPC survivors (n = 2103), and no cancer controls (NCC; n = 28,320) were identified. The MPC group was compared to the SPC and NCC groups with regard to multiple distress indices and use of mental health care and anxiety and depression medication.

RESULTS

Relative to the SPC group, the MPC group reported more Total Distress (M = 9.59 vs. 8.84; p < .001), and were more likely to report daily or weekly anxiety feelings (OR = 2.07; p < .001), meet criteria for serious psychological distress (OR = 1.49; p = .02) and have talked to a mental health professional (OR = 1.75; p = .01). Comparison of MPC and NweCC groups yielded similar results. The MPC group did not differ from the SPC or NCC groups in severity of anxiety or depression feelings, distress interference, or anxiety and depression medication use.

CONCLUSIONS

MPC survivors reported greater distress relative to SPC survivors. The clinical significance of this greater distress is unclear, however. While MPC survivors were more likely to have talked to a mental health professional, uptake of mental health care appeared to be suboptimal. MPC and SPC survivors might be considered distinct subgroups and increased attention devoted to potentially unique mental and physical health needs of MPC survivors.

Medical conditions and physical function deficits among multiple primary cancer survivors

PURPOSE

Survivors of multiple primary cancers make up a sizable proportion of all cancer survivors, yet little is known about the health of this population. We examined the prevalence of medical conditions and physical function deficits among multiple primary survivors compared with single primary survivors and individuals without a cancer history.

METHODS

Participants were enrolled in the Cancer Prevention Study (CPS)-II Nutrition Cohort in 1992/1993. Prevalent medical conditions (diabetes, heart conditions, cerebrovascular conditions, emphysema/chronic bronchitis, osteoporosis, osteoarthritis), physical function limitations, use of a cane or walker, balance difficulties, and falls within the past year were assessed on a follow-up survey completed in 2011. We estimated age- and sex-adjusted prevalence ratios (PRs), comparing multiple primary survivors (N = 1003) to single primary survivors (N = 12,849) and participants without cancer (N = 63,578).

RESULTS

The prevalence of medical conditions did not differ substantially between multiple primary survivors and either comparison group. However, multiple primary survivors were more likely to report severe limitations in physical function than the single primary (PR = 1.48 (95% CI, 1.28-1.71)) and no-cancer (PR = 1.64 (95% CI, 1.42-1.88)) groups. Using a cane or walker and balance difficulties were also significantly more common among multiple primary survivors.

CONCLUSIONS

Despite a similar prevalence of comorbid medical conditions, severe functional limitations were significantly more common among multiple primary survivors than single primary survivors or individuals without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Assessment of functional status and treatment of physical deficits may be an especially critical component of care for older patients with a history of multiple cancer diagnoses.

Second Primary Malignancies in Patients with Colorectal Cancer: A Population-Based Analysis

Purpose

This study aimed to profile the characteristics of patients with colorectal cancer (CRC) with a second primary malignancy (SPM) and to identify patients with CRC at high risk of developing SPMs.

Methods

We retrospectively reviewed data on patients with CRC aged 20–79 years from the Surveillance, Epidemiology, and End Results (SEER) database. Eligible patients were categorized into only one primary malignancy and SPM cohorts. A competing‐risk model was used to quantify associations between SPM occurrence and the multiple traits of patients. Finally, a decision curve analysis (DCA) was used to evaluate the clinical usefulness of the model by calculating net benefit.

Results

A total of 179,884 patients were identified, 18,285 (10.2%) of whom developed SPMs during a maximum follow‐up of approximately 18 years. The median survival time after the second diagnosis was less than 4 years. The 3‐year, 5‐year, and 10‐year cumulative risks of developing an SPM were 3.9%, 5.9%, and 10.0%, respectively. According to the multivariable competing‐risk model, male colon cancer survivors, older in age, with a well‐differentiated tumor and localized disease, who were treated with surgery were susceptible to SPMs. The DCA yielded a wide range of risk thresholds at which the net benefits would be obtained from our proposed model.

Conclusion

CRC survivors remain at high risk of developing SPMs. Patients with a second diagnosis of cancer showed not only significantly worse survival but also higher cancer‐specific mortality. A web‐based individualized predictive tool was also provided to assist clinicians in identifying patients at high risk of developing SPMs and planning their future care management.

Implications for Practice

Colorectal cancer survivors remain at high risk of developing a second primary malignancy (SPM). This study aimed to profile the characteristics of patients with colorectal cancer with second primary malignancies and to further explore the risk factors related to the development of second primary malignancies, using a large population‐based cohort. A clinically useful competing‐risk nomogram was developed to predict the risk of SPMs based on individual clinical factors. According to the findings, older age, male sex, white or black race, localized disease, and treatment with surgery among patients with colon cancer were associated with an increased risk of developing an SPM. These findings and the proposed tool could be useful to clinicians and caregivers in the clinical counseling of patients with colorectal cancer and the development of long‐term care management.

Little is known about the factors that contribute to the development of a new malignancy among colorectal cancer survivors. This study aimed to comprehensively profile the characteristics of patients with colorectal cancer with a second primary malignancy and, further, to identify patients at high risk for developing a second primary malignancy.

Psychobehavioral risk factors for financial hardship and poor functional outcomes in survivors of multiple primary cancers

OBJECTIVE

Survivors of multiple primary cancers (MPC) are at increased risk for poor health outcomes compared with survivors of single cancers. Using an adapted psychobehavioral stress-response model, the study purpose was to identify pathways and individual risk factors associated with poor health outcomes in adults with MPC.

METHODS

Adult MPC survivors (N = 211) with first cancers (stages I-III) diagnosed within 1 to 10 years were recruited via tumor registry. Employing a cross-sectional design, established questionnaires were used to operationalize patient characteristics and theoretical constructs including perceived stress, psychological and behavioral responses, financial hardship, social role function, and physical health. Disease and treatment data were obtained via registry and medical records. Structural equation modeling (SEM) was performed to fit, test, and modify the hypothesized psychobehavioral model.

RESULTS

Following measurement model refinement, an SEM linking self-management behaviors, distress, financial hardship, and functional health demonstrated a good fit: χ² (200, N = 206) = 332.06, P < .01; Tucker-Lewis index (TLI) = .95, comparative fit index (CFI) = .96, standardized root mean residual (SRMR) = .06, root-mean-square error of approximation (RMSEA) = .06. Less use of self-management behaviors predicted higher distress which, in turn, predicted higher financial hardship; higher distress and financial hardship predicted poorer functional health. Several sociodemographic and personal factors predicted self-management behaviors and distress.

CONCLUSIONS

The hypothesized stress-response model was partially supported. Data supported pathways among self-management behaviors, distress, financial hardship, and functional health. Self-management and distress may represent modifiable intervention targets for MPC survivors. High body mass index (BMI), less education, greater neuroticism, and lower social support were associated with less use of self-management behaviors and higher distress and should be further evaluated as potential markers of vulnerability.

Timing and risk of mood disorders requiring psychotropics in long-term survivors of adult cancers: A nationwide cohort study

BACKGROUND

The increasing number of long-term cancer survivors over the past few decades poses the challenge of mental health care needs. However, little is known about risks of mood disorders in long-term cancer survivors.

METHODS

Long-term survivors (≥5 years) of adult cancers (LSAC) (n = 190,748) newly diagnosed between January 1, 2000 and December 31, 2007 were matched with one control. The primary outcome was diagnosis of mood disorders requiring psychotropics. Cumulative incidences and sub-hazard ratios (SHR) were calculated and multivariate analyses were conducted after accounting for mortality.

RESULTS

The mood disorder risk was significantly higher in the LSAC cohort than in the control cohort (adjusted SHR = 1.16, 95% confidence interval [CI] = 1.13-1.18, P < 0.001). Patients with certain cancer types were at increased risk, particularly in the first 2 years after diagnosis. However, patients with head and neck cancers or esophageal cancers had a higher risk after the 5-year follow-up period. Multivariate analysis indicated that being female, aged 40-59 years, with more than two primary cancers, receiving two or more treatment modalities, having CCI scores higher than 3, a higher urbanization level, and lower monthly income were independently associated with an increased risk of mood disorders.

LIMITATIONS

Some potential confounders such as lifestyle factors were not available in the study.

CONCLUSION

These findings call for increased mental health awareness not only in the early years after the cancer diagnosis, but also during long-term follow-up for certain cancer subtypes.

Quantifying fatigue in (long-term) colorectal cancer survivors: a study from the population-based patient reported outcomes following initial treatment and long term evaluation of survivorship registry

BACKGROUND

Few studies specifically focus on fatigue of (long-term) colorectal cancer (CRC) survivors or compare fatigue levels with a normative population. Association between surviving multiple primary cancers and fatigue is also explored.

METHODS

Survivors diagnosed from 1998 to 2009 were identified from the Eindhoven Cancer Registry. In total, 3739 (79%) respondents and an age- and gender-matched normative population (n=338) completed questionnaires on fatigue and psychological distress.

RESULTS

More survivors reported feeling fatigued than the normative population (39% versus 22%, p<0.0001). Short-term survivors (<5 years post-diagnosis) had the highest mean fatigue scores compared with long-term survivors (≥5 years post-diagnosis) or the normative population (21±7 versus 20±7 versus 18±5, p<0.0001, respectively). Having primary cancers prior to CRC was associated with more fatigue. Surgery+chemoradiation was independently associated with fatigue (odds ratio (OR): 1.63, 95% confidence interval (CI): 1.17-2.29, p=0.004) as were anxiety (OR: 1.16, 95% CI: 1.12-1.19, p<0.0001) and depressive symptoms (OR: 1.38, 95% CI: 1.33-1.43, p<0.0001).

CONCLUSIONS

Fatigue is a significant problem, especially for short-term CRC survivors. The association between chemoradiation and fatigue suggests that patients could benefit from better information on treatment side-effects. When treating fatigue, clinical care should also focus on survivors' psychological needs, especially survivors of multiple primary cancers.