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Adamska M, Kowal-Wiśniewska E, Barańska M, Przybyłowicz-Chalecka A, Łojko-Dankowska A, Joks M, Jarmuż-Szymczak M, Gil L. Acute Myeloid Leukemia Post Cytotoxic Therapy in Breast Cancer Survivors-Over 23 Years of Single Center Analysis. J Clin Med 2024; 13:989. [PMID: 38398301 PMCID: PMC10888691 DOI: 10.3390/jcm13040989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/22/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Acute myeloid leukemia post cytotoxic therapy (AML-pCT) among breast cancer (BC) survivors represents a life-threatening complication. This study aims to assess the clinical outcomes of AML-pCT post BC. Methods: An analysis of all AML patients treated at a single hematology center (2000-2023) was performed to select patients with AML-pCT post BC. We applied the 2022 ELN criteria to define the genetic risk. Results: Among 847 AML patients, 28 were diagnosed with AML-pCT following BC. Complex karyotype (CK) occurred in 23.8% of patients. The median overall survival (OS) was 40 months. The survival outcomes were better after allogenic hematopoietic stem cell transplantation (alloHCT) treatment compared to chemotherapy alone (median OS: 47 versus 7 months, p = 0.008). Patients demonstrating CK showed lower survival compared to those without CK (2-year OS: 25.0% versus 66.2%, p = 0.0048). The multivariable Cox proportional hazards regression model indicated that treatment with alloHCT emerged as a significant factor associated with improved OS. The treatment was associated with superior OS (HR = 0.07, 95% CI = 0.01-0.86, p = 0.04). Conclusions: Patients with AML-pCT following BC were characterized with the highest frequency of adverse genetic risk profiles and demonstrated worse survival rates. AlloHCT should be performed as early as possible in such patients. The growing need for studies on inherited cancer susceptibility underscores the importance of close AML-pCT development monitoring in BC survivors.
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Affiliation(s)
- Monika Adamska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
- Doctoral School, Poznan University of Medical Sciences, 60-812 Poznan, Poland
| | - Ewelina Kowal-Wiśniewska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
- Institute of Human Genetics, Polish Academy of Sciences, 60-479 Poznan, Poland
| | - Marta Barańska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
| | - Anna Przybyłowicz-Chalecka
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
| | - Anna Łojko-Dankowska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
| | - Monika Joks
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
| | - Małgorzata Jarmuż-Szymczak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
- Institute of Human Genetics, Polish Academy of Sciences, 60-479 Poznan, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, 60-569 Poznan, Poland
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Petrone G, Gaulin C, Derkach A, Kishtagari A, Robson ME, Parameswaran R, Stein EM. Routine clinical parameters and laboratory testing predict therapy-related myeloid neoplasms after treatment for breast cancer. Haematologica 2023; 108:161-170. [PMID: 35770528 PMCID: PMC9827166 DOI: 10.3324/haematol.2021.280437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Indexed: 02/05/2023] Open
Abstract
We aim to identify predictors of therapy-related myeloid neoplasms (t-MN) in patients with breast cancer (BC) and cytopenias to determine the timing of bone marrow biopsy (BMBx). Patients with BC and cytopenias who were referred for BMBx between 2002-2018 were identified using the Memorial Sloan Kettering Cancer Center institutional database. Characteristics associated with the risk of t-MN were evaluated by multivariable logistic regression and included in a predictive model. The average area under the receiver operating characteristic curve (AUC) was estimated by 5-fold cross-validation. Of the 206 BC patients who underwent BMBx included in our study, 107 had t-MN. By multivariable analysis, white blood cell count 4-11 K/mcL, absolute neutrophil count (ANC) ≥1.5 K/mcL, hemoglobin ≥12.2 g/dL, red cell distribution width 11.5-14.5%, the presence of bone metastasis and a time from BC diagnosis to BMBx <15 months significantly decreased the likelihood of t-MN. The average AUC was 0.88. We stratified our cohort by bone metastasis and by findings on peripheral smear. In both the subset without bone metastasis (n=159) and in the cohort with no blasts or dysplastic cells on peripheral smear (n=96) our variables had similar effects on the risk of t-MN. Among the 47 patients with bone metastasis, an ANC ≥1.5 K/mcL was the only variable associated with a decreased risk of t-MN. Our findings show that in patients with BC and unexplained cytopenias, clinical and laboratory parameters can predict t-MN and assist clinicians in determining the timing of a BMBx.
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Affiliation(s)
- Giulia Petrone
- Department of Medicine, Mount Sinai Morningside and Mount Sinai West, New York, NY
| | - Charles Gaulin
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix
| | - Andriy Derkach
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ashwin Kishtagari
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark E Robson
- Breast Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rekha Parameswaran
- Division of Hematology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eytan M Stein
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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Kaplan HG, Calip GS, Malmgren JA. Maximizing Breast Cancer Therapy with Awareness of Potential Treatment-Related Blood Disorders. Oncologist 2020; 25:391-397. [PMID: 32073195 PMCID: PMC7216464 DOI: 10.1634/theoncologist.2019-0099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 01/29/2020] [Indexed: 01/18/2023] Open
Abstract
In this review we summarize the impact of the various modalities of breast cancer therapy coupled with intrinsic patient factors on incidence of subsequent treatment-induced myelodysplasia and acute myelogenous leukemia (t-MDS/AML). It is clear that risk is increased for patients treated with radiation and chemotherapy at younger ages. Radiation is associated with modest risk, whereas chemotherapy, particularly the combination of an alkylating agent and an anthracycline, carries higher risk and radiation and chemotherapy combined increase the risk markedly. Recently, treatment with granulocyte colony-stimulating factor (G-CSF), but not pegylated G-CSF, has been identified as a factor associated with increased t-MDS/AML risk. Two newly identified associations may link homologous DNA repair gene deficiency and poly (ADP-ribose) polymerase inhibitor treatment to increased t-MDS/AML risk. When predisposing factors, such as young age, are combined with an increasing number of potentially leukemogenic treatments that may not confer large risk singly, the risk of t-MDS/AML appears to increase. Patient and treatment factors combine to form a biological cascade that can trigger a myelodysplastic event. Patients with breast cancer are often exposed to many of these risk factors in the course of their treatment, and triple-negative patients, who are often younger and/or BRCA positive, are often exposed to all of them. It is important going forward to identify effective therapies without these adverse associated effects and choose existing therapies that minimize the risk of t-MDS/AML without sacrificing therapeutic gain. IMPLICATIONS FOR PRACTICE: Breast cancer is far more curable than in the past but requires multimodality treatment. Great care must be taken to use the least leukemogenic treatment programs that do not sacrifice efficacy. Elimination of radiation and anthracycline/alkylating agent regimens will be helpful where possible, particularly in younger patients and possibly those with homologous repair deficiency (HRD). Use of colony-stimulating factors should be limited to those who truly require them for safe chemotherapy administration. Further study of a possible leukemogenic association with HRD and the various forms of colony-stimulating factors is badly needed.
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Affiliation(s)
| | - Gregory S. Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at ChicagoChicagoIllinoisUSA
| | - Judith A. Malmgren
- Healthstat Consulting Inc.SeattleWashingtonUSA
- Department of Epidemiology, University of WashingtonSeattleWashingtonUSA
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4
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An emerging trend of rapid increase of leukemia but not all cancers in the aging population in the United States. Sci Rep 2019; 9:12070. [PMID: 31427635 PMCID: PMC6700310 DOI: 10.1038/s41598-019-48445-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022] Open
Abstract
The “baby boomers” born in 1946–1964 in the United States (U.S.) started to reach the age of 65 in 2011, rapidly accelerating U.S. population aging. There are great public concerns about its impact on health care with anticipation of rising cancer incidences. We examined the incidences and deaths of leukemia and overall cancer in the U.S. from 1998 to 2018. The acute myeloid leukemia (AML) and chronic myeloid leukemia (CML) incidences remained constant prior to 2011 but have climbed up substantially since then, and the chronic lymphocytic leukemia (CLL) incidence has increased continuously since 1998. The significant increase of myeloid leukemia and CLL incidences was strongly correlated with the U.S. population aging. The incidence of all cancers was increased in correlation with a small increase in aging population prior to 2011, but surprisingly has changed marginally since 2011, which was not significantly correlated with the accelerated population aging. We observed the most substantial decline of deaths with CML, whereas AML deaths continued to rise in the past 20 years. In conclusion, the overall cancer incidence was not increased as fast as previously feared with aging Americans; however, the incidences of myeloid leukemia and CLL significantly outpaced that of all cancers.
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5
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Calip GS, Moran KM, Sweiss K, Patel PR, Wu Z, Adimadhyam S, Lee TA, Ko NY, Quigley JG, Chiu BCH. Myelodysplastic syndrome and acute myeloid leukemia after receipt of granulocyte colony-stimulating factors in older patients with non-Hodgkin lymphoma. Cancer 2019; 125:1143-1154. [PMID: 30548485 PMCID: PMC6420387 DOI: 10.1002/cncr.31914] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Granulocyte colony-stimulating factors (G-CSFs), which are used for the prevention of complications from chemotherapy-related neutropenia, are linked to the risk of developing second primary myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). The objective of this study was to examine the correlation between using a specific G-CSF agent and the risk of MDS/AML among older patients with non-Hodgkin lymphoma (NHL). METHODS This was a retrospective cohort study of adults aged >65 years who were diagnosed with first primary NHL between 2001 and 2011. With data from the Surveillance, Epidemiology, and End Results-Medicare-linked database, adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for the risk of MDS/AML associated with the receipt of G-CSF(filgrastim and pegfilgrastim) in Cox proportional-hazards models, which were stratified according to treatment accounting for confounding by indication. RESULTS Among 18,245 patients with NHL patients who had a median follow-up of 3.5 years, 56% received chemotherapy and/or immunotherapy, and G-CSF was most commonly used in those who received rituximab plus multiple chemotherapy regimens (77%). Subsequent MDS/AML diagnoses were identified in 666 patients (3.7%). A modest increased risk of MDS/AML was observed with the receipt of G-CSF (HR, 1.28; 95% CI, 1.01-1.62) and a trend was observed with increasing doses (Ptrend < .01). When specific agents were analyzed, an increased risk of MDS/AML was consistently observed with filgrastim (≥10 doses: HR, 1.67; 95% CI, 1.25-2.23), but not with pegfilgrastim (≥10 + doses: HR, 1.11; 95% CI, 0.84-1.45). CONCLUSIONS A higher of MDS/AML was observed in patients with NHL risk among those who received G-CSF that was specific to the use of filgrastim (≥10 doses), but not pegfilgrastim. Neutropenia prophylaxis is an essential component of highly effective NHL treatment regimens. The differential risk related to the types of G-CSF agents used warrants further study given their increasing use and newly available, US Food and Drug Administration-approved, biosimilar products.
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Affiliation(s)
- Gregory S. Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kellyn M. Moran
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Karen Sweiss
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL
| | - Pritesh R. Patel
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Zhaoju Wu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Sruthi Adimadhyam
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Todd A. Lee
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL
| | - Naomi Y. Ko
- Section of Hematology Oncology, Boston University School of Medicine, Boston, MA
| | - John G. Quigley
- Division of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL
| | - Brian C.-H. Chiu
- Department of Public Health Sciences, The University of Chicago, Chicago, IL
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6
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Johnson RH, Anders CK, Litton JK, Ruddy KJ, Bleyer A. Breast cancer in adolescents and young adults. Pediatr Blood Cancer 2018; 65:e27397. [PMID: 30156052 PMCID: PMC6192832 DOI: 10.1002/pbc.27397] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 06/22/2018] [Accepted: 06/25/2018] [Indexed: 01/09/2023]
Abstract
Breast cancer is the most common cancer of adolescents and young adult (AYA) women aged 15 to 39 years, accounting for 5.6% of all invasive breast cancer in women. In comparison with older women, AYAs are more likely to have familial cancer predisposition genes, larger breast tumors, unfavorable biological characteristics, distant metastatic disease at diagnosis, and adverse outcome. Endocrine therapy and some chemotherapy recommendations differ between young and older women. AYAs require coordinated multidisciplinary care, treatment regimens that minimize late effects such as premature menopause and osteoporosis, and proactive management of psychological and sexual health during and after cancer treatment.
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Affiliation(s)
| | - Carey K. Anders
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center; Chapel Hill, North Carolina
| | | | | | - Archie Bleyer
- Oregon Health and Science University; Portland, Oregon
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7
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Shieh A, Mohamed AA. A Case of Therapy-Related Acute Myeloid Leukemia in a Patient With Heterozygous Mutations in the Ataxia Telangiectasia Mutated Gene. J Hematol 2017; 6:96-100. [PMID: 32300401 PMCID: PMC7155842 DOI: 10.14740/jh330w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/29/2017] [Indexed: 11/17/2022] Open
Abstract
Use of adjuvant chemotherapy has improved survival for many patients with breast cancer. Unfortunately, such treatment can come at a price, in particular, malignancies. We present a case of a 36-year-old woman with heterozygous mutations in the ataxia telangiectasia mutated (ATM) gene who was admitted to the hospital for fatigue and diffusely scattered bruises. She was diagnosed with invasive ductal carcinoma of the left breast and had bilateral mastectomy with axillary node clearance followed by adjuvant chemotherapy 3 years prior. Her vitals were stable. Lab tests revealed thrombocytopenia, leukocytosis, and anemia. Peripheral blood smear and bone marrow biopsy revealed numerous myeloblasts. After flow cytometry and FISH analysis were performed, a diagnosis of therapy-related acute myeloid leukemia (t-AML) was made. The patient was treated with induction chemotherapy and a bone marrow biopsy revealed residual disease. Re-induction therapy was given and a bone marrow biopsy revealed complete remission. She subsequently received an allogenic stem cell transplant and was cured. Her treatment course was uncomplicated. We raise the question as to whether certain chemotherapy agents should be avoided in patients with mutations in DNA repair genes. Furthermore, it is essential for physicians to educate patients on the risk of secondary malignancies arising from chemotherapeutic treatment.
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Affiliation(s)
- Andrew Shieh
- Penn State Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA
| | - Ali A Mohamed
- Penn State Milton S. Hershey Medical Center, 500 University Dr., Hershey, PA 17033, USA
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8
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Zeidan AM, Long JB, Wang R, Hu X, Yu JB, Huntington SF, Abel GA, Mougalian SS, Podoltsev NA, Gore SD, Gross CP, Ma X, Davidoff AJ. Risk of myeloid neoplasms after radiotherapy among older women with localized breast cancer: A population-based study. PLoS One 2017; 12:e0184747. [PMID: 28902882 PMCID: PMC5597231 DOI: 10.1371/journal.pone.0184747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/30/2017] [Indexed: 01/12/2023] Open
Abstract
Background There are inconsistent and limited data regarding the risk of myeloid neoplasms (MN) among breast cancer survivors who received radiotherapy (RT) in the absence of chemotherapy. Concern about subsequent MN might influence the decision to use adjuvant RT for women with localized disease. As patients with therapy-related MN have generally poor outcomes, the presumption of subsequent MN being therapy-related could affect treatment recommendations. Methods We used the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database to study older women with in-situ or stage 1–3 breast cancer diagnosed 2001–2009 who received surgery. Chemotherapy and RT were ascertained using Medicare claims, and new MN diagnoses were captured using both SEER registry and Medicare claims. We excluded women who received chemotherapy for initial treatment, and censored at receipt of subsequent chemotherapy. Competing-risk survival analysis was used to assess the association between RT and risk of subsequent MN adjusting for relevant characteristics. Results Median follow-up for 60,426 eligible patients was 68 months (interquartile range, 46 to 92 months), with 47.6% receiving RT. In total, 316 patients (0.52%) were diagnosed with MN; the cumulative incidence per 10,000 person-years was 10.6 vs 9.0 among RT-treated vs non-RT-treated women, respectively (p = .004); the increased risk of subsequent MN persisted in the adjusted analysis (hazard ratio = 1.36, 95% confidence interval: 1.03–1.80). The results were consistent in multiple sensitivity analyses. Conclusions Our data suggest that RT is associated with a significant risk of subsequent MN among older breast cancer survivors, though the absolute risk increase is very small. These findings suggest the benefits of RT outweigh the risks of development of subsequent MN.
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Affiliation(s)
- Amer M. Zeidan
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
- * E-mail:
| | - Jessica B. Long
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut, United States of America
| | - Xin Hu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
| | - James B. Yu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut, United States of America
| | - Scott F. Huntington
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
| | - Gregory A. Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Sarah S. Mougalian
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
| | - Nikolai A. Podoltsev
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Steven D. Gore
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Cary P. Gross
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut, United States of America
| | - Amy J. Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut, United States of America
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut, United States of America
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9
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Freedman RA, Seisler DK, Foster JC, Sloan JA, Lafky JM, Kimmick GG, Hurria A, Cohen HJ, Winer EP, Hudis CA, Partridge AH, Carey LA, Jatoi A, Klepin HD, Citron M, Berry DA, Shulman LN, Buzdar AU, Suman VJ, Muss HB. Risk of acute myeloid leukemia and myelodysplastic syndrome among older women receiving anthracycline-based adjuvant chemotherapy for breast cancer on Modern Cooperative Group Trials (Alliance A151511). Breast Cancer Res Treat 2016; 161:363-373. [PMID: 27866278 DOI: 10.1007/s10549-016-4051-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 11/05/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE We examined acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) events among 9679 women treated for breast cancer on four adjuvant Alliance for Clinical Trials in Oncology trials with >90 months of follow-up in order to better characterize the risk for AML/MDS in older patients receiving anthracyclines. METHODS We used multivariable Cox regression to examine factors associated with AML/MDS, adjusting for age (≥65 vs. <65 years; separately for ≥70 vs. <70 years), race/ethnicity, insurance, performance status, and anthracycline receipt. We also examined the effect of cyclophosphamide, the interaction of anthracycline and age, and outcomes for those developing AML/MDS. RESULTS On Cancer and Leukemia Group B (CALGB) 40101, 49907, 9344, and 9741, 7290 received anthracyclines; 15% were in the age ≥65 and 7% were ≥70. Overall, 47 patients developed AML/MDS (30 AML [0.3%], 17 MDS [0.2%]); 83% of events occurred within 5 years of study registration. Among those age ≥65 and ≥70, 0.8 and 1.0% developed AML/MDS (vs. 0.4% for age <65), respectively. In adjusted analyses, older age and anthracycline receipt were significantly associated with AML/MDS (adjusted hazard ratio [HR] for age ≥65 [vs. <65] = 3.13, 95% confidence interval [CI] 1.18-8.33; HR for anthracycline receipt [vs. no anthracycline] = 5.16, 95% CI 1.47-18.19). There was no interaction between age and anthracycline use. Deaths occurred in 70% of those developing AML/MDS. CONCLUSIONS We observed an increased risk for AML/MDS for older patients and those receiving anthracyclines, though these events were rare. Our results help inform discussions surrounding anticipated toxicities of adjuvant chemotherapy in older patients.
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Affiliation(s)
- Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
| | - D K Seisler
- Alliance Statistics and Data Center, Mayo Clinic and Mayo Cancer Center, Rochester, MN, USA
| | - J C Foster
- Alliance Statistics and Data Center, Mayo Clinic and Mayo Cancer Center, Rochester, MN, USA
| | - J A Sloan
- Alliance Statistics and Data Center, Mayo Clinic and Mayo Cancer Center, Rochester, MN, USA
| | - J M Lafky
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | - G G Kimmick
- Duke University School of Medicine, Durham, NC, USA
| | - A Hurria
- Department of Medical Oncology and Therapeutics Research and Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - H J Cohen
- Duke University School of Medicine, Durham, NC, USA
| | - E P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - C A Hudis
- Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - L A Carey
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC, USA
| | - A Jatoi
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | - H D Klepin
- Department of Hematology and Oncology, Wake Forest University, Winston-Salem, NC, USA
| | - M Citron
- ProHEALTH Care Associates, Lake Success, NY, USA
| | - D A Berry
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L N Shulman
- Division of Hematology and Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - A U Buzdar
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - V J Suman
- Alliance Statistics and Data Center, Mayo Clinic and Mayo Cancer Center, Rochester, MN, USA
| | - H B Muss
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC, USA
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10
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Myelodysplastic syndrome after breast cancer. The challenge of late complications in long-term survivors. Leuk Res 2016; 49:88-9. [DOI: 10.1016/j.leukres.2016.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 08/22/2016] [Indexed: 11/21/2022]
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11
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Malmgren JA, Calip GS, Pyott SM, Atwood MK, Kaplan HG. Therapy-related myelodysplastic syndrome following primary breast cancer. Leuk Res 2016; 47:178-84. [PMID: 27414978 DOI: 10.1016/j.leukres.2016.06.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Therapy-related myelodysplastic syndrome (t-MDS) is a serious clinical disease occurring after breast cancer treatment. METHODS A cohort of 11,684 invasive breast cancer (BC) patients from 1990-2014 were followed for incidence of t-MDS through institutional and the Surveillance, Epidemiology and End Results (SEER) Program registries. t-MDS cases were identified using ICD-O SEER registry codes, pathology and chart reports. Treatment, cytogenetics, and time from BC diagnosis to t-MDS and t-MDS diagnosis to last follow up or death were obtained. Incidence rate ratios were calculated using SEER national incidence rates for comparison. RESULTS 27 cases of t-MDS post BC treatment were confirmed. 96% of cases were breast cancer stage I-II at diagnosis. All patients had received radiation treatment and 59% received adjuvant chemotherapy. Two patients were alive with no evidence of disease after treatment with stem cell transplantation (age 33 and 46). t-MDS incidence was 30 times the expected population rate among patients <55 years (RR 31.8, 95% CI 15.0, 60.8) with shorter time from t-MDS diagnosis to death (median survival time: <55: 8 months, 55-74: 26 months, 75+: 23 months). CONCLUSION We found elevated t-MDS risk especially among younger BC patients with stem cell transplantation the only observed curative treatment.
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Affiliation(s)
- Judith A Malmgren
- HealthStat Consulting, Inc., Seattle, WA, United States; University of Washington, Department of Epidemiology, Seattle, WA, United States.
| | - Gregory S Calip
- University of Illinois at Chicago, Center for Pharmacoepidemiology and Pharmacoeconomic Research, Chicago, IL, United States
| | | | - Mary K Atwood
- Swedish Cancer Institute, Department of Oncology, Seattle, WA, United States
| | - Henry G Kaplan
- Swedish Cancer Institute, Department of Oncology, Seattle, WA, United States
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Calip GS, Malmgren JA, Lee WJ, Schwartz SM, Kaplan HG. Myelodysplastic syndrome and acute myeloid leukemia following adjuvant chemotherapy with and without granulocyte colony-stimulating factors for breast cancer. Breast Cancer Res Treat 2015; 154:133-43. [PMID: 26450505 PMCID: PMC4718738 DOI: 10.1007/s10549-015-3590-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 10/03/2015] [Indexed: 10/23/2022]
Abstract
Risk of myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) post-breast cancer treatment with adjuvant chemotherapy and granulocyte colony-stimulating factors (G-CSF) is not fully characterized. Our objective was to estimate MDS/AML risk associated with specific breast cancer treatments. We conducted a retrospective cohort study of women aged ≥66 years with stage I-III breast cancer between 2001 and 2009 using the Surveillance, Epidemiology, and End Results-Medicare database. Women were classified as receiving treatment with radiation, chemotherapy, and/or G-CSF. We used multivariable Cox proportional hazards models to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (CI) for MDS/AML risk. Among 56,251 breast cancer cases, 1.2 % developed MDS/AML during median follow-up of 3.2 years. 47.1 % of women received radiation and 14.3 % received chemotherapy. Compared to breast cancer cases treated with surgery alone, those treated with chemotherapy (HR = 1.38, 95 %-CI 0.98-1.93) and chemotherapy/radiation (HR = 1.77, 95 %-CI 1.25-2.51) had increased risk of MDS/AML, but not radiation alone (HR = 1.08, 95 % CI 0.86-1.36). Among chemotherapy regimens and G-CSF, MDS/AML risk was differentially associated with anthracycline/cyclophosphamide-containing regimens (HR = 1.86, 95 %-CI 1.33-2.61) and filgrastim (HR = 1.47, 95 %-CI 1.05-2.06), but not pegfilgrastim (HR = 1.10, 95 %-CI 0.73-1.66). We observed increased MDS/AML risk among older breast cancer survivors treated with anthracycline/cyclophosphamide chemotherapy that was enhanced by G-CSF. Although small, this risk warrants consideration when determining adjuvant chemotherapy and neutropenia prophylaxis for breast cancer patients.
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Affiliation(s)
- Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 South Wood Street M/C 871, Chicago, IL, 60612-7230, USA.
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Judith A Malmgren
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- HealthStat Consulting, Inc., Seattle, WA, USA
| | - Wan-Ju Lee
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, 833 South Wood Street M/C 871, Chicago, IL, 60612-7230, USA
| | - Stephen M Schwartz
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Racial and ethnic differences in risk of second primary cancers among breast cancer survivors. Breast Cancer Res Treat 2015; 151:687-96. [PMID: 26012645 DOI: 10.1007/s10549-015-3439-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
Disparities exist in breast cancer (BC) outcomes between racial and ethnic groups in the United States. Reasons for these disparities are multifactorial including differences in genetics, stage at presentation, access to care, and socioeconomic factors. Less is documented on racial/ethnic differences in subsequent risk of second primary cancers (SPC). The purpose of this study is to evaluate the risk of SPC among different racial/ethnic groups of women with BC. We conducted a retrospective cohort study of 134,868 Non-Hispanic White, 17,484 Black, 18,034 Hispanic, and 19,802 Asian/Pacific Islander (API) women with stages I-III BC in twelve Surveillance, Epidemiology and End Results Program registries between 2001 and 2010. Standardized incidence ratios (SIR), 95 % confidence intervals (CI), and absolute excess risks were calculated by comparing incidence of SPC in the cohort to incidence in the general population for specific cancer sites by race/ethnicity and stratified by index BC characteristics. All women were at increased risks of second primary BC and acute myeloid leukemia (AML), with higher risk among more advanced stage index BC. Black and API women had higher SIRs for AML [4.86 (95 % CI 3.05-7.36) and 5.00 (95 % CI 3.26-7.32)], respectively] which remained elevated among early-stage (I) BC cases. Women with a history of invasive BC have increased risk of SPC, most notable for second primary BC and AML. These risks for secondary cancers differ by race/ethnicity. Studies evaluating possible genetic and biobehavioral mechanisms underlying these differences are warranted. Strategies for BC adjuvant treatment and survivorship care may require further individualization with consideration given to race/ethnicity.
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