Patterns of care and survival for adolescents and young adults with acute leukaemia--a population-based study

The association between hospital volume and overall survival in adult AML patients treated with intensive chemotherapy

BACKGROUND

Acute myeloid leukemia (AML) requires specialized care, particularly when administrating intensive remission induction chemotherapy (ICT). High-volume hospitals are presumed more adept at delivering this complex treatment, resulting in better overall survival (OS) rates. Despite its potential implications for quality improvement, research on the volume-outcome relationship in ICT administration for AML is scarce. This nationwide, population-based study in the Netherlands explored the volume-outcome relationship in AML.

MATERIALS AND METHODS

Data from the Netherlands Cancer Registry on adult (≥18 years of age) ICT-treated AML patients, diagnosed between 2014 and 2018, were analyzed. Hospital volume was assessed against OS using mixed-effects Cox regression, adjusting for patient and disease characteristics (i.e. case mix), with hospital as a random effect.

RESULTS

Our study population consisted of a total of 1761 patients (57% male), with a median age of 61 years. The average annual number of ICT-treated patients varied across the 24 hospitals (range 1-56, median 13, and interquartile range 8-20 patients per hospital per year). Overall, an increase of 10 ICT-treated patients annually was associated with an 8% lower mortality risk [hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.87-0.98, P = 0.01]. This association was not significant at 30-day (HR 1.02, 95% CI 0.89-1.17, P = 0.75) and 42-day (HR 0.96, 95% CI 0.85-1.08, P = 0.54) OS but became apparent after 100-day OS (HR 0.91, 95% CI 0.83-0.99, P = 0.05).

CONCLUSIONS

There is a volume-outcome association within AML care. This finding could support hospital volume as a metric in AML care. However, it should be acknowledged that centralizing care is a complex process with implications for health care providers and patients. Therefore, any move toward centralization must be judiciously balanced.

European Society of Gynaecological Oncology quality indicators for the surgical treatment of endometrial carcinoma

BACKGROUND

Quality of surgical care as a crucial component of a comprehensive multi-disciplinary management improves outcomes in patients with endometrial carcinoma, notably helping to avoid suboptimal surgical treatment. Quality indicators (QIs) enable healthcare professionals to measure their clinical management with regard to ideal standards of care.

OBJECTIVE

In order to complete its set of QIs for the surgical management of gynecological cancers, the European Society of Gynaecological Oncology (ESGO) initiated the development of QIs for the surgical treatment of endometrial carcinoma.

METHODS

QIs were based on scientific evidence and/or expert consensus. The development process included a systematic literature search for the identification of potential QIs and documentation of the scientific evidence, two consensus meetings of a group of international experts, an internal validation process, and external review by a large international panel of clinicians and patient representatives. QIs were defined using a structured format comprising metrics specifications, and targets. A scoring system was then developed to ensure applicability and feasibility of a future ESGO accreditation process based on these QIs for endometrial carcinoma surgery and support any institutional or governmental quality assurance programs.

RESULTS

Twenty-nine structural, process and outcome indicators were defined. QIs 1-5 are general indicators related to center case load, training, experience of the surgeon, structured multi-disciplinarity of the team and active participation in clinical research. QIs 6 and 7 are related to the adequate pre-operative investigations. QIs 8-22 are related to peri-operative standards of care. QI 23 is related to molecular markers for endometrial carcinoma diagnosis and as determinants for treatment decisions. QI 24 addresses the compliance of management of patients after primary surgical treatment with the standards of care. QIs 25-29 highlight the need for a systematic assessment of surgical morbidity and oncologic outcome as well as standardized and comprehensive documentation of surgical and pathological elements. Each QI was associated with a score. An assessment form including a scoring system was built as basis for ESGO accreditation of centers for endometrial cancer surgery.

[DKG certification of paediatric cancer centres - a wide field …]

Die Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH) und die Deutsche Krebsgesellschaft (DKG) haben Kriterien für die DKG-Zertifizierung der Kinderonkologie erarbeitet, nach denen 2017 in Deutschland erstmals pädiatrisch-onkologische Abteilungen zertifiziert wurden. Das Ziel der DKG-Zertifizierung ist „die Vereinheitlichung und die transparente Darstellung der Versorgungsqualität für pädiatrische Patientinnen und Patienten mit hämato-onkologischen Erkrankungen“, wie 2018 in einer Veröffentlichung von Mensah et al. dargestellt. Die Auswahl der Zertifizierungskriterien hat innerhalb der GPOH zu einer intensiven Diskussion darüber geführt, inwieweit die Kriterien für sich genommen einer wissenschaftlichen Überprüfbarkeit standhalten und damit valide Parameter für die Bestimmung der Versorgungsqualität in der Kinderonkologie in Deutschland darstellen.

Wir haben untersucht, ob aus der Arbeit von Mensah et al. valide Folgerungen für das deutsche Gesundheitssystem ableitbar sind. Dabei zeigt sich, dass die momentan definierten DKG-Zertifizierungskriterien für die Kinderonkologie in Deutschland in kritischen Bereichen einer fundierten wissenschaftlichen Grundlage entbehren.

Diese Arbeit stellt Fallzahlen als Maß für Qualität in der Kinderonkologie infrage und regt die Entwicklung alternativer Kriterien für die Überprüfbarkeit von Qualität in der deutschen Kinderonkologie an.

Development and validation of a nomogram to individually predict survival of young patients with nonmetastatic gastric cancer: A retrospective cohort study

BACKGROUND/AIMS

Evidence regarding gastric cancer (GC) patients <40 years old is limited. The aim of the study was to identify risk factors affecting overall survival (OS) of young patients with nonmetastatic GC and to establish a nomogram for prognostic prediction using data from the Surveillance, Epidemiology and End Results (SEER) database. Furthermore, this study sought to externally validate this nomogram in an independent patient cohort.

PATIENTS AND METHODS

In this retrospective cohort study, the records of patients aged <40 years with nonmetastatic GC (n = 559), from the SEER database, between 2006 and 2015, were examined. The nomogram was established based on the Cox proportional hazards regression model using the SEER dataset. Patients with nonmetastatic GC (n = 201) in our department between 2009 and 2015 were selected as an external validation set. Discrimination and calibration were performed in both cohorts.

RESULTS

The multivariate Cox model identified race, tumor subsites, tumor size, depth of invasion, lymph node metastasis, number of examined lymph nodes, and surgery as independent covariates associated with OS. The nomogram exhibited superior discriminative power than the eighth tumor, node, metastasis (TNM) staging system in both the training set [Harrell's concordance index (C index): 0.762 vs. 0.635,P < 0.001] and validation set (C index: 0.805 vs. 0.712,P= 0.176). Calibration of the nomogram was good in both cohorts.

CONCLUSIONS

We developed a nomogram predicting 3- and 5-year OS rates in young patients with nonmetastatic GC. Both the training set and validation set showed good discrimination and calibration, suggesting good clinical applicability.

Long-term complications in adolescent and young adult leukemia survivors

Adolescents and young adults (AYAs) with cancer, defined by the National Cancer Institute as having been diagnosed between the ages of 15 and 39 years old, have not benefited from the same improvements in quality of outcomes and survival that have been seen for individuals diagnosed in childhood or as older adults. Although is leukemia composed of a diverse group of diagnoses, leukemia AYA survivors share unique vulnerabilities with other AYA diagnostic groups. They will spend the majority of their lives as survivors, with clear evidence of adverse medical conditions, health care requirements, and social and psychological needs that differ not only from their peers but also, from the needs of other cancer survivor populations. Furthermore, they share a developmental stage of life in which careers, finances, and family concerns are uniquely impacted by the cancer diagnosis and treatment. Leukemia in AYAs typically presents with higher-risk biologic features, and treatment requires multiagent chemotherapy, including alkylating agents, anthracyclines, high-dose steroids, frequently intrathecal chemotherapy, and sometimes, cranial radiation. Thus, AYAs have significant risks for long-term complications, subsequent malignancies, and accelerated development of usual age-related comorbid conditions, such as cardiovascular disease and dyslipidemias. AYAs require specialized health care monitoring, surveillance for late effects, and periodic evaluation of psychosocial, health behavior, and life goal outcomes.

Acute myelogenous leukemia in adolescents and young adults

The incidence of acute myelogenous leukemia (AML) increases progressively with age. Favorable genetic mutations are most prevalent in children, and unfavorable profiles increase proportionately in adolescents and young adults (AYA) and into later adulthood. Survival rates of AYA have improved over recent decades to 50-60%, but their accrual to clinical trials remains poor. In contrast to AYA with acute lymphoblastic leukemia, the prognostic benefit for AYA with AML enrolled in pediatric compared with adult trials is minor and only seen when different protocols are used. The distinctive needs of AYA, including intensive psychological services, call for their treatment within specialized centers that offer complex supportive care.

Surgical Management of Adolescents and Young Adults With Gastrointestinal Stromal Tumors: A US Population-Based Analysis

Importance

There is a dearth of population-based evidence regarding outcomes of the adolescent and young adult (AYA) population with gastrointestinal stromal tumors (GISTs).

Objectives

To describe a large cohort of AYA patients with GISTs and investigate the effect of surgery on GIST-specific survival (GSS) and overall survival (OS).

Design, Setting, and Participants

This retrospective cohort study of 392 AYA patients and 5373 older adult (OA) patients in the Surveillance, Epidemiology, and End Results (SEER) database with GISTs histologically diagnosed from January 1, 2001, through December 31, 2013, with follow-up through December 31, 2015, compared the baseline characteristics of AYA (13-39 years old) and OA (≥40 years old) patients and among AYA patients stratified by operative management. Kaplan-Meier estimates were used for OS analyses. Cumulative incidence functions were used for GSS analysis. The effect of surgery on survival was evaluated with a multivariable Fine-Gray regression model.

Exposure

Tumor resection.

Main Outcomes and Measures

GIST-specific survival and OS.

Results

This study included 392 AYA and 5373 OA patients diagnosed with GISTs (207 [52.8%] male AYA patients, 2767 [51.5%] male OA patients, 277 [70.7%] white AYA patients, and 3661 [68.1%] white OA patients). Compared with the OA patients, more AYA patients had small-intestine GISTs (139 [35.5%] vs 1465 [27.3%], P = .008) and were managed operatively (332 [84.7%] vs 4212 [78.4%], P = .003). Multivariable analysis of AYA patients found that nonoperative management was associated with a more than 2-fold increased risk of death from GISTs (subdistribution hazard ratio, 2.27; 95% CI, 1.21-2.25; P = .01). On subset analysis of 349 AYA patients with tumors of the stomach and small intestine, small-intestine location was associated with improved survival (OS: 91.1% vs 77.2%, P = .01; GSS: 91.8% vs 78.0%, P = .008). On subset analysis of 91 AYA patients with metastatic disease, operative management was associated with improved survival (OS: 69.5% vs 53.7%, P = .04; GSS: 71.5% vs 56.7%, P = .03).

Conclusions and Relevance

This study found that AYA patients are more likely to undergo surgical management than OA patients. Operative management is associated with improved OS and GSS in AYA patients, including those with metastatic disease.

Survival of adolescents with cancer treated at pediatric versus adult oncology treatment centers in France

BACKGROUND

In France, although children aged less than 15 years with cancer are usually referred to pediatric oncology centers, adolescents may be treated at pediatric or adult oncology centers. The objective was to compare survival according to their site of treatment.

PROCEDURE

Using population-based registration, 15- to 19-year-old patients diagnosed with cancer in 2006 or 2007 and living in six French regions (accounting for 41% of the French population) were included.

RESULTS

Of the 594 patients included, 33% of the French adolescents were treated at a pediatric oncology center. Compared with those treated at a pediatric center, adolescents treated at an adult center were older, were more likely to have carcinoma and germ-cell tumor, had a longer time to diagnosis, and were less likely to be enrolled in a clinical trial. In addition, the decisions for their management were less likely to be taken in the context of multidisciplinary team meetings. In multivariate analysis, adolescent patients treated at a pediatric center did not have significantly different overall survival (OS) compared with those treated at an adult center (5-year OS: 84.1% [95% confidence interval: 78.6-90.0] versus 87.7% [95% confidence interval: 84.2-91.3]; P = 0.25).

CONCLUSIONS

The outcomes of French adolescents with cancer have begun to improve, with 81.2% survival in 2006-2007, with no difference between the types of treatment center. However, for this unique group of diseases, survival is not the unique endpoint. In order to ensure good quality of life after cancer, management of those patients requires specific approaches, designed to reduce the late effects of cancer treatment and improve supportive care.

Access to principal treatment centres and survival rates for children and young people with cancer in Yorkshire, UK

Background

Principal Treatment Centres (PTC) were established to provide age-appropriate care as well as clinical expertise for children and young people with cancer. However, little is known about the effects of specialist treatment centres on survival outcomes especially for teenagers and young adults. This population-based study aimed to describe access to PTC and the associated trends in survival for 0–24 year olds accounting for stage of disease at presentation and treatment.

Methods

Patients diagnosed from 1998–2009 aged 0–24 years were extracted from the Yorkshire Specialist Register of Cancer in Children and Young People, including information on all treating hospitals, followed-up until 31st December 2014. The six commonest cancer types were included: leukaemia (n = 684), lymphoma (n = 558), CNS tumours (n = 547), germ cell tumours (n = 364), soft tissue sarcomas (n = 171) and bone tumours (n = 163). Treatment was categorised into three groups: ‘all’, ‘some’ or ‘no’ treatment received at a PTC. Treatment at PTC was examined by diagnostic group and patient characteristics. Overall survival was modelled using Cox regression adjusting for case-mix including stage, treatment and other socio-demographic and clinical characteristics.

Results

Overall 72% of patients received all their treatment at PTC whilst 13% had no treatment at PTC. This differed by diagnostic group and age at diagnosis. Leukaemia patients who received no treatment at PTC had an increased risk of death which was partially explained by differences in patient case-mix (adjusted Hazard Ratio (HR) = 1.73 (95%CI 0.98–3.04)). Soft tissue sarcoma patients who had some or no treatment at PTC had better survival outcomes, which remained after adjustment for patient case-mix (adjusted HR = 0.48 (95%CI 0.23–0.99)). There were no significant differences in outcomes for other diagnostic groups (lymphoma, CNS tumours, bone tumours and germ cell tumours). For leukaemia patients survival outcomes for low risk patients receiving no treatment at PTC were similar to high risk patients who received all treatment at PTC, implying a benefit for care at the PTC.

Conclusion

This study demonstrates that for leukaemia patients receiving treatment at a PTC is associated with improved survival that may compensate for a poorer prognosis presentation. However, further information on risk factors is needed for all diagnostic groups in order to fully account for differences in patient case-mix.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3160-5) contains supplementary material, which is available to authorized users.

Outcome of Adolescents and Young Adults Compared With Pediatric Patients With Acute Myeloid and Promyelocytic Leukemia

BACKGROUND

Studies on the outcome of adolescents and young adults (AYAs) with acute myeloid leukemia (AML) and acute promyelocytic leukemia (APL) are limited.

METHODS

We compared the outcome of AYA (19-30 years) patients with AML and PML and pediatric (0-18 years) patients with AML (pAMLs) and APL (pAPLs) utilizing the Surveillance Epidemiology and End Results-18 registry. Early mortality rate (EMR), defined as mortality within 1 month of diagnosis, was used as a surrogate for treatment-related mortality. Survival statistics were computed using the Kaplan-Meier method. Multivariate analysis was done using logistic regression and the Cox proportional hazard regression model.

RESULTS

A total of 6343 patients with AML were identified; 44.7% were AYAs. pAMLs had lower EMR (6.2% vs. 9.2%; P < .01) and higher overall survival (OS) (1-year, 70.3% vs. 62.1%; 5-year, 48.2% vs. 36.4%; P < .01). Nine hundred twenty patients with APL were also identified; 59.5% were AYAs. No statistically significant difference was found between AYAs with APL and pAPLs in EMR (11.4% vs. 14.1%; P = .23) and OS (1-year, 83.8% vs. 81.2%; P = .31 and 5-year, 68.2% vs. 73.1%; P = .11]. Comparing all patients with AML and APL, AYAs with APL and pAPLs had higher EMR (11.4% and 14.1% vs. 6.2% and 9.2%; P ≤ .01) but better OS than AYAs with AML and pAMLs (5-year OS, 68.2% and 73.1% vs. 48.2% and 36.4%; P ≤ .01).

CONCLUSION

Our analysis shows AYAs with AML have worse EMR and OS compared with pAMLs. AYAs with APL and pAPLs have similar outcomes. To our knowledge, this is the first study reporting outcomes of AYAs with APL and pAPLs using a large population-based registry and their comparison with same age patients with AML.

Barriers and facilitators for clinical trial participation among diverse Asian patients with breast cancer: a qualitative study

Background

Recruitment rates for cancer trials are low for racial/ethnic minorities. Little is known about factors influencing trial recruitment in Asian patients. Our aim is to examine the barriers and facilitators for participation in trials among multi-ethnic Asian women with breast cancer.

Methods

We recruited a convenience sample from consecutive women seen at the National Cancer Centre. Two experienced bilingual (English and Chinese) moderators conducted focus groups to theme saturation. The question guide incorporated open-ended questions soliciting opinions about trial participation and knowledge. Women were first asked if they were willing, unwilling, or still open to participate in future trials. Sessions were audiotaped and transcribed. Transcripts were independently coded for emergent themes.

Results

Sixteen of 103 women approached participated in five focus groups. Chinese, Malay, and Indian participants aged 29 to 69 represented different cancer stages. Five had no prior knowledge of trials. We identified three major themes comprising of 22 minor themes for barriers and facilitators. The major themes were: 1) patient-related, 2) trial-related, and 3) sociocultural factors. Women willing to join trials expressed themes representing facilitators (better test therapy, cost-effective profile, or trust in doctors and local healthcare systems). Women unwilling to participate expressed themes associated with barriers, while women still open to participation expressed themes representing both facilitators and barriers. Malay women were more likely to express themes related to ‘fatalism’ as a barrier.

Discussion/Conclusion

We found that facilitators and barriers to trial participation among Asian women were similar to those previously reported in Western women. Knowledge of trials is limited among women receiving breast cancer treatment. Unique sociocultural factors suggest that approaches customised to local and community beliefs are needed to improve trial participation in minority groups.

From evidence to clinical practice in blood and marrow transplantation

Clinical practice in the field of blood and marrow transplantation (BMT) has evolved over time, as a result of thousands of basic and clinical research studies. While it appears that scientific discovery and adaptive clinical research may be well integrated in case of BMT, there is lack of sufficient literature to definitively understand the process of translation of evidence to practice and if it may be selective . In this review, examples from BMT and other areas of medicine are used to highlight the state of and potential barriers to evidence uptake. Strategies to help improve knowledge transfer are discussed and the role of existing framework provided by the Center for International Blood and Marrow Transplant Registry (CIBMTR) to monitor uptake and BMT Clinical Trials Network (BMT CTN) to enhance translation of evidence into practice is highlighted.

Making the Case to Study the Volume-Outcome Relationship in Hematologic Cancers

The positive relationship between the volume of health services (hospital and physician) and health-related outcomes is established in the complex surgical treatment of cancers and certain nononcologic medical conditions. However, this topic has not been systematically explored in the medical management of cancers. We summarize the limited current state of knowledge about the volume-outcome relationship in the management of hematologic cancers and provide reasons why further research on this subject is necessary. We highlight the relatively low annual volume of hematologic cancers in the United States, the increasing complexity of making a diagnosis due to constant change in classification and prognostication, the rapid availability of novel agents with unique mechanisms of action and toxicities, and the proliferation of treatment guidelines distinct to each disease subtype. We also discuss the potential implications pertaining to medical practice and trainee education, including effects on quality of care, access and referral patterns, and subspecialty training.

Comparison of Characteristics and Outcomes of Trial Participants and Nonparticipants: Example of Blood and Marrow Transplant Clinical Trials Network 0201 Trial

Controversy surrounds the question of whether clinical trial participants have better outcomes than comparable patients who are not treated on a trial. We explored this question using a recent large, randomized, multicenter study comparing peripheral blood (PB) with bone marrow transplantation from unrelated donors, conducted by the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). We compared characteristics and outcomes of study participants (n = 494) and nonparticipants (n = 1384) who appeared eligible and received similar treatment without enrolling on the BMT CTN trial at participating centers during the study time period. Data were obtained from the Center for International Blood and Marrow Transplant Research. Outcomes were compared between the 2 groups using Cox proportional hazards regression models. No significant differences in age, sex, disease distribution, race/ethnicity, HLA matching, comorbidities, and interval from diagnosis to hematopoietic cell transplantation were seen between the participants and nonparticipants. Nonparticipants were more likely to have lower performance status, lower risk disease, and older donors, and to receive myeloablative conditioning and antithymocyte globulin. Nonparticipants were also more likely to receive PB grafts, the intervention tested in the trial (66% versus 50%, P < .001). Overall survival, transplantation-related mortality, and incidences of acute or chronic graft-versus-host disease were comparable between the 2 groups though relapse was higher (hazard ratio, 1.22; 95% confidence interval, 1.02 to 1.46; P = .028) in nonparticipants. Despite differences in certain baseline characteristics, survival was comparable between study participants and nonparticipants. The results of the BMT CTN trial appear generalizable to the population of trial-eligible patients.

Rates of complete diagnostic testing for patients with acute myeloid leukemia

In addition to cytogenetics, additional molecular markers of prognosis have been identified and incorporated into the management of patients with acute myeloid leukemia (AML). We hypothesized that rates of molecular testing would be higher in an academic center versus community sites. A retrospective chart review included all de novo AML patients (excluding M3) at Kansas University Medical Center (KUMC) from January 2008 through April 2013. Records were evaluated for completeness of molecular testing as indicated by karyotype (FLT3, CEBPα, NPM1 in normal cytogenetics AML and c-KIT in core binding factor [CBF] AML). 271 charts were reviewed: 98 with CN-AML and 29 with CBF AML. Seventy were diagnosed at KUMC, 57 at a community site. Molecular testing was sent in 76/98 (77%) patients with CN-AML. Patients diagnosed at KUMC had a significantly higher rate of molecular testing (51/55, 93%) as compared to those diagnosed at outside centers (18/43, 41%) (P < 0.001). Of 29 patients with CBF AML, c-kit mutational analysis was performed more frequently at KUMC (14/15, 93%) than in community sites (8/14, 57%) (P = 0.035). There was a trend towards increased testing at both KUMC and community sites in later years. Rates of molecular testing in AML were higher in an academic center versus community sites in the 5 years following the World Health Organization revised classification of AML. All physicians who diagnose and treat AML must remain up to date on the latest recommendations and controversies in molecular testing in order to appropriately risk stratify patients and determine optimal therapy.

Comparison of survival outcomes among cancer patients treated in and out of clinical trials

BACKGROUND

Clinical trials test the efficacy of a treatment in a select patient population. We examined whether cancer clinical trial patients were similar to nontrial, "real-world" patients with respect to presenting characteristics and survival.

METHODS

We reviewed the SWOG national clinical trials consortium database to identify candidate trials. Demographic factors, stage, and overall survival for patients in the standard arms were compared with nontrial control subjects selected from the Surveillance, Epidemiology, and End Results program. Multivariable survival analyses using Cox regression were conducted. The survival functions from aggregate data across all studies were compared separately by prognosis (≥50% vs <50% average 2-year survival). All statistical tests were two-sided.

RESULTS

We analyzed 21 SWOG studies (11 good prognosis and 10 poor prognosis) comprising 5190 patients enrolled from 1987 to 2007. Trial patients were younger than nontrial patients (P < .001). In multivariable analysis, trial participation was not associated with improved overall survival for all 11 good-prognosis studies but was associated with better survival for nine of 10 poor-prognosis studies (P < .001). The impact of trial participation on overall survival endured for only 1 year.

CONCLUSIONS

Trial participation was associated with better survival in the first year after diagnosis, likely because of eligibility criteria that excluded higher comorbidity patients from trials. Similar survival patterns between trial and nontrial patients after the first year suggest that trial standard arm outcomes are generalizable over the long term and may improve confidence that trial treatment effects will translate to the real-world setting. Reducing eligibility criteria would improve access to clinical trials.

Differential survival improvement for patients 20-29 years of age with acute lymphoblastic leukemia

OBJECTIVE

To compare improvement in survival from 1986 to 2009 for acute lymphoblastic leukemia (ALL) patients 1-14, 15-19 and 20-29 years in Ontario and United States.

METHODS

This population-based analysis used data from Ontario Cancer Registry (OCR) and Surveillance Epidemiology and End Results (SEER).

RESULTS

In OCR, there was steady improvement in survival by period of diagnosis in all three age groups. In SEER, there was no improvement in survival for patients aged 20-29 years.

CONCLUSIONS

Survival in Ontario and the United States has improved for patients with ALL aged 1-19 years. However, survival has improved among patients aged 20-29 years only in Ontario.

The volume effect in paediatric oncology: a systematic review

BACKGROUND

For several adult cancer types, there is evidence that treatment in high volume hospitals, high case volume providers, or in specialised hospitals leads to a better outcome. The aim of this study is to give an overview of the existing evidence regarding the volume effect in paediatric oncology related to the quality of care or survival.

MATERIALS AND METHODS

An extensive search was carried out for studies on the effect of provider case volume on the quality of care or survival in childhood cancer. Information about study characteristics, comparisons, results, and quality assessment were abstracted.

RESULTS

In total, 14 studies were included in this systematic review. Studies with a low risk of bias provide evidence that treatment of children with brain tumours, acute lymphoblastic leukaemia, osteosarcoma, Ewing's sarcoma, or children receiving treatment with allogenic bone marrow transplantation in higher volume hospitals, specialised hospitals, or by high case volume providers, is related with a better outcome.

CONCLUSIONS

This systematic review provides support for the statement that higher volume hospitals, higher case volume providers, and specialised hospitals are related to the better outcome in paediatric oncology. No studies reported a negative effect of a higher volume.

Survival and cure of acute myeloid leukaemia in England, 1971-2006: a population-based study

The 5-year relative survival of adults diagnosed with acute myeloid leukaemia (AML) was less than 10% during the 1970s and 1980s in England. This population-based study estimated the 5-year relative survival and 'cure' for 48 380 adult patients diagnosed with AML in England during 1971-2006. Relative survival and cure mixture models were used to produce estimates of 5-year relative survival and the percentage 'cured'. 'Cure' was defined as the proportion of a group of survivors for whom there is no excess mortality compared with the general population. The 5-year relative survival and the percentage 'cured' increased for patients aged under 70 years at diagnosis during 1971-2006, but advancing age was associated with poorer outcome. During the study period a dramatic increase in 5-year relative survival occurred in those aged 15-24 years, from 7% to 53%. The percentage 'cured' was less than 10% for all ages in 1975, but increased to 45% for those aged 15-24 years in 2000. Cure could not be estimated for patients over 70 years, because survival was consistently low (<5%). The long-term outcome of patients with AML has improved substantially, particularly in younger patients. The potential exists for further increasing levels of 'cure'.

Characteristics of advanced cancer patients with cancer-related fatigue enrolled in clinical trials and patients referred to outpatient palliative care clinics

CONTEXT

Limited published data exist on whether characteristics of patients with advanced cancer enrolled in cancer-related fatigue clinical trials (CCTs) differ from patients in outpatient palliative care clinics (OPCs).

OBJECTIVES

The primary aim of this study was to compare the characteristics of two groups of patients with advanced cancer and moderate-to-severe fatigue: patients in CCTs and patients at an OPC.

METHODS

We retrospectively reviewed the records of 337 patients who were enrolled in one of five CCTs for advanced cancer patients at The University of Texas M. D. Anderson Cancer Center as well as the records of 1896 consecutive patients who were referred to our OPC from January 2003 through December 2010. Patients with fatigue scores of ≥4/10 (measured by the Edmonton Symptom Assessment System [ESAS]) were eligible (1252 OPC patients and 337 CCT patients). Patient characteristics, ESAS scores, and survival times were compared using Chi-square tests, Wilcoxon rank sum tests, and the Kaplan-Meier method.

RESULTS

Compared with the CCT patients, OPC patients were more likely to be older (58 vs. 59 years; P=0.009) and male (38% vs. 52%; P<0.001). The most common primary cancer type was breast cancer (22%) in the CCT patients and lung cancer (23%) in the OPC patients (P<0.001). The median ESAS scores in the OPC and CCT groups, respectively, were 6 and 4 for pain (P<0.001), 7 and 7 for fatigue (P=0.525), 3 and 2 for depression (P=0.004), 3 and 2 for anxiety (P<0.001), 3 and 2 for dyspnea (P<0.001), and 43 and 32 for the symptom distress score (P<0.001). The median overall survival times were 17.9 months (95% CI 13.5-22.3 months) in the CCT group and 3.8 months (95% CI 3.5-4.1 months) in the OPC group (P<0.001).

CONCLUSION

Baseline characteristics and overall survival times significantly differed between patients enrolled in the CCT and OPC groups. Therefore, we conclude that the results of CCTs cannot be generalized to patients being treated in OPCs.

Pathways of care for adolescent patients with cancer in France from 2006 to 2007

BACKGROUND

In France, as in other countries, there is a need for a population-based view of access to care and modalities of treatment for adolescents with cancer.

PROCEDURE

Using a population-based registration, we report pathways of care for 15-19-year-old patients, diagnosed with cancer in 2006 and 2007, living in six French regions, accounting for 41% of the French population.

RESULTS

The median times (inter-quartile range) for diagnosis and treatment of the 594 included adolescents were 8 weeks (3-17) and 3 days (0-16), respectively. First physicians met by the patients were mostly general practitioners (59%). Seventeen percent of patients were firstly seen on emergency wards. Most of the patients (82%) were treated in an adult environment. Management decisions were taken within the context of a multi-disciplinary team (MDT) in 54% of cases. Twenty-seven percent of patients were included in randomized or non-randomized clinical studies: percentage depended on the tumor type and on the number of on-going trials at the study period. Fifteen percent of patients were included in pediatric studies, 7% in adult studies, and 5% in studies including both adults and children.

CONCLUSIONS

The pathways of care for French adolescent patients with cancer are heterogeneous. Our results reveal differences in MDT meetings according to tumor types and a lack of effective collaboration between pediatric and adult wards. Efforts must be made to develop cancer networks to ensure that adolescents receive the optimal care in a suitable environment.

The successful integration of research and care: how pediatric oncology became the subspecialty in which research defines the standard of care

Pediatric oncology successfully embodies the integration of patient care with medical research. Several factors may explain this phenomenon. Specifically, the study of childhood leukemia provided scientists with principles by which they could approach other forms of cancer. Multicenter, cooperative group RCTs resulted in meaningful advances. Parents' often desperate hope for a cure, combined with clinician-investigators efforts to continually improve upon treatments resulted in important improvements in children's lives. Finally, the seemingly tolerant regulatory oversight of human subjects research in the early years of childhood cancer research paradoxically helped link research with care, thus solidifying this bond for years to come.

A population-based cytogenetic study of adults with acute lymphoblastic leukemia

Chromosomal abnormalities are increasingly used to risk stratify adults with acute lymphoblastic leukemia. Published data describing the age-specific incidence of chromosomal abnormalities and their prognostic relevance are largely derived from clinical trials. Trials frequently have age restrictions and low recruitment rates. Thus we investigated these factors in a population-based cohort of 349 patients diagnosed during the course of 19 years in the northern part of England. The incidence of most chromosomal abnormalities varied significantly with age. The incidence of t(9;22)(q34;q11) increased in each successive decade, up to 24% among 40- to 49-year-old subjects. Thereafter the incidence reached a plateau. t(4;11)(q21;q23) and t(1;19)(q23;p13) were a rare occurrence among patients older than 60 years of age. In contrast, the frequency of t(8;14)(q24;q32) and t(14;18)(q32;q21) increased with age. High hyperdiploidy occurred in 13% of patients younger than 20 years of age but in only 5% of older patients. The incidence of low hypodiploidy/near-triploidy and complex karyotype increased with age from 4% (15-29 years) to 16% (≥ 60 years). Overall survival varied significantly by age and cytogenetics. Older patients and those with t(9;22), t(4;11), low hypodiploidy/near-triploidy, or complex karyotype had a significantly inferior outcome. These population-based results demonstrate the cytogenetic heterogeneity of adult acute lymphoblastic leukemia. These data will inform the delivery of routine clinical services and the design of new age-focused clinical trials.

Survival of European children and young adults with cancer diagnosed 1995-2002

This study analyses survival in 40,392 children (age 0-14 years) and 30,187 adolescents/young adults (age 15-24 years) diagnosed with cancer between 1995 and 2002. The cases were from 83 European population-based cancer registries in 23 countries participating in EUROCARE-4. Five-year survival in countries and in regional groupings of countries was compared for all cancers combined and for major cancers. Survival for 15 rare cancers in children was also analysed. Five-year survival for all cancers combined was 81% in children and 87% in adolescents/young adults. Between-country survival differences narrowed for both children and adolescents/young adults. Relative risk of death reduced significantly, by 8% in children and by 13% in adolescents/young adults, from 1995-1999 to 2000-2002. Survival improved significantly over time for acute lymphoid leukaemia and primitive neuroectodermal tumours in children and for non-Hodgkin lymphoma in adolescents/young adults. Cancer survival in patients <25 years is poorly documented in Eastern European countries. Complete cancer registration should be a priority for these countries as an essential part of a policy for effective cancer control in Europe.

Epidemiology of leukaemia and lymphoma in children and young adults from the north of England, 1990-2002

AIM

We aimed to describe and contrast the epidemiology of haematological malignancies among 0-14 and 15-24-year-olds in northern England from 1990 to 2002 and compare clinical trial entry by age group.

PATIENTS AND METHODS

Incidence rates were examined by age, sex and period of diagnosis and differences were tested using Poisson regression. Differences and trends in survival were assessed using Cox regression.

RESULTS

1680 subjects were included comprising 948 leukaemias and 732 lymphomas. Incidence rates for acute lymphoblastic leukaemia were significantly higher for 0-14 compared to 15-24-year-olds, whilst Hodgkin lymphoma showed the reverse. No significant changes in incidence were observed. 60% of leukaemia patients aged 15-24 years entered trials compared to 92% of 0-14-year-olds. Survival rates were significantly lower and improved less markedly over time for 15-24 compared to 0-14-year-olds, particularly for leukaemia.

CONCLUSIONS

Trial accrual rates need to be improved amongst 15-24-year-olds and a more structured follow-up approach adopted for this unique population.

Adolescents and young adults with cancer: the scope of the problem and criticality of clinical trials

In the U.S., older adolescents and young adults with cancer have benefited less from therapeutic advances than did either younger or older patients. One factor that may explain this deficit is the relative lack of participation of patients in this age group on clinical trials of therapies that could improve their outcome. Comparisons were made of the participation of cancer patients on clinical trials in the U.S., as a function of patient age, with the change in national cancer mortality rate; and Surveillance, Epidemiology, End Results (SEER) cancer survival rate as a function of age. The participation rate in cancer treatment trials has been strikingly lower in 15-34-year-olds than in younger or older patients. The nadir has been apparent for both males and females in all of the major ethnic and racial groups. The national cancer mortality reduction and SEER survival improvement shows a similar age dependence. In the U.S., the age-dependence of cancer treatment trial participation, and of improvement in survival prolongation and cancer death rates, are correlated. Regardless of whether there is a causal relationship, the impact on the older adolescent and young adult U.S. population is substantial, adversely affecting the national cost of healthcare, the person-years of life lost, the loss of young people entering the job market, and the scientific knowledge and social implications of cancer during adolescence and early adulthood. National initiatives are underway to address these issues, with special emphasis on increasing the availability and access to clinical trials designed for older adolescents and young adults.

Cancer adolescent pathway in France between 1988 and 1997

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

Adolescents with acute lymphoblastic leukaemia: emerging from the shadow of paediatric and adult treatment protocols

Adolescents and young adults (AYA) with acute lymphoblastic leukaemia (ALL) constitute a distinct population from children and older adults. Based on patterns of referral, they may be treated by either paediatric or adult oncologists. As a group, AYA with ALL have a worse survival and event-free survival (EFS) compared to that achieved by younger children. A systematic review of all published clinical trials, which provide data on treatment and outcome of adolescents with ALL, has been summarised in an effort to determine whether they should be treated on paediatric or adult type protocols. Adolescents appear to have a consistent survival advantage when treated on paediatric regimens.

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

BACKGROUND

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

PROCEDURE

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

RESULTS

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

CONCLUSIONS

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

Mothers' attitudes to the randomized controlled trial (RCT): the case of acute lymphoblastic leukaemia (ALL) in children

OBJECTIVES

Survival rates for childhood cancer have improved substantially partly as a result of national and international randomized clinical trials (RCT). However, the decision for families is complex and emotional. Our aim was to describe the views of mothers of children newly diagnosed with ALL regarding consent to randomized controlled trials.

DESIGN

Qualitative interview to explore mothers knowledge, and reasons for involving their child in RCTs. Interviews took place in mothers' homes.

PARTICIPANTS

Fifty mothers of children with newly diagnosed ALL (age 4-16 years; mean = 7.4) recruited through research nurses at outpatient appointments.

RESULTS

All but three families had consented for their child to be treated in the RCT, although there was wide variation in their understanding of the aims, costs and benefits. Most mothers reported the aim of the trial to compare 'old' and 'new' treatments.

CONCLUSION

Despite detailed verbal and written information, mothers were poorly informed about the purpose of the trial, and possibility of side effects. Individual preferences for either standard or new treatment were routinely reported. The data raise questions about the extent to which families give truly informed consent to recruitment of their child to an RCT.

Clinical characteristics, biologic features and outcome for young adult patients with acute lymphoblastic leukaemia

Young adult patients with acute lymphoblastic leukaemia (ALL) represent a unique epidemiologic subgroup in that therapy may be provided by either adult or paediatric oncologists. There seem to be no differences in presenting clinical features, immunophenotypic characteristics, or cytogenetic abnormalities for young adult ALL patients treated on paediatric or adult protocols with the exception of median age (16-paediatric trials versus 19-adult trials). There is no evidence to suggest that age within the 16-21 year old subgroup has any prognostic significance. Compared with patients 1-9 years, young adult ALL patients have a lower incidence of favourable cytogenetics t(12; 21) hyperdiploidy, a slightly increased incidence of the t(9;22), and an increased frequency of T cell immunophenotype. Compared with patients >30 years, young adult ALL patients have a significantly lower incidence of the t(9; 22). In multiple studies, there is a consistent, large event-free survival and survival advantage for young adult patients treated on paediatric versus adult protocols.

Sarcomas in Adolescents and Young Adults

Adolescents and young adults, caught between the traditionally binary medical systems for children and adults, may be treated variably, depending on which side of the dichotomy they find themselves. As a result, their unique needs may go unmet because they occupy the fringes of the more typical child and adult patient populations. Soft tissue sarcomas in adolescents and young adults are a case in point, spanning the gap between the two fields but focusing on neither. Increasing age seems to be a poor prognosticator for soft tissue sarcomas, but is probably only a marker for other biological variables, patient characteristics, and treatment differences. This article discusses the issues unique to the management of soft tissue sarcomas in this population, pointing out what age-specific data are known and what areas are ripe for collaborative research between medical and pediatric oncologists.

Adult acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) in adults is a relatively rare neoplasm with a curability rate around 30% at 5 years. This consideration makes it imperative to dissect further the biological mechanisms of disease, in order to selectively implement an hitherto unsatisfactory success rate. The recognition of discrete ALL subtypes (some of which deserve specific therapeutic approaches, like T-lineage ALL (T-ALL) and mature B-lineage ALL (B-ALL)) is possible through an accurate combination of cytomorphology, immunophenotytpe and cytogenetic assays and has been a major result of clinical research studies conducted over the past 20 years. Two-three major prognostic groups are now easily identifiable, with a survival probability ranging from <10 to 20% (Philadelphia-positive ALL) to about 50-60% (low-risk T-ALL and selected patients with B-lineage ALL). These issues are extensively reviewed and form the basis of current knowledge. The second major point relates to the emerging importance of studies that reveal a dysregulated gene activity and its clinical counterpart. It is now clear that prognostication is a complex matter ranging from patient-related issues to cytogenetics to molecular biology, including the evaluation of minimal residual disease (MRD) and possibly gene array tests. On these bases, the role of a correct, highly personalised therapeutic choice will soon become fundamental. Therapeutic progress may be obtainable through a careful integration of chemotherapy, stem cell transplantation, and the new targeted treatments with highly specific metabolic inhibitors and humanised monoclonal antibodies.

Early deaths from childhood cancer. A report from the Childhood Cancer Registry of Piedmont, Italy, 1967-1998

The population-based Childhood Cancer Registry of Piedmont (CCRP) has collected data on incidence since 1967. The occurrence of early death (i.e. within 30 days of diagnosis) was investigated in 3006 cases of childhood cancer diagnosed during the period 1967-1998. The proportion of early deaths (178 of the 3006 cases) was analysed by period of diagnosis (three decennial periods), age group, major diagnostic group and hospital category, with univariate statistics and logistic regression. The proportion of children with cancer who died within 1 month of diagnosis was 10.8%, 5.3% and 1.8% for cases diagnosed during 1967-1978, 1979-1988 and 1989-1998, respectively. This trend may reflect earlier diagnosis, improved diagnosis, more effective therapy or more frequent referral to specialised centres. The risk factors for early death were: age <1 year and diffuse disease at diagnosis, diagnosis during 1967-1978, a diagnosis of acute non lymphocytic leukaemia, non-Hodgkin lymphoma, central nervous system tumour or hepatic tumour. Early death was not related to the sex of the child. Care in an extra-regional specialised centre was associated with lower risk of early death.

CONCLUSION

No temporal changes in early mortality were found among children with acute non lymphocytic leukaemia diagnosed in the first, second or third decade of activity of the CCRP, the percentages of children dying within 1 month being 12.8%, 10.7% and 12.8%, respectively. This pattern clearly differed from the corresponding trend for acute lymphoid leukaemia (6.4%, 2.0%, 0.4%).

The management of cancer in the older adolescent

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

Comparison of outcomes in cancer patients treated within and outside clinical trials: conceptual framework and structured review

BACKGROUND

Many oncologists believe that patients with cancer who enroll in clinical trials have better outcomes than those who do not enroll. We aimed to assess the empirical evidence that such a trial effect exists.

METHODS

We developed a conceptual framework for comparison of trial and non-trial patients. We then did a comprehensive literature search to identify studies that compared outcomes between these groups. We critically evaluated these studies to assess whether they provide valid and generalizable support for a trial effect.

FINDINGS

We identified 26 comparisons, from 24 published articles, of outcomes among cancer patients enrolled and not enrolled in clinical trials. 21 comparisons used retrospective cohort designs. 14 comparisons provided some evidence that patients enrolled in trials have improved outcomes. However, strategies to control for potential confounding factors were inconsistent and frequently inadequate. Only eight comparisons restricted non-trial patients to those meeting trial eligibility criteria. Of these, three noted better outcomes in trial patients than in non-trial patients. Children with cancer, patients with haematological malignant disease, and patients treated before 1986 were disproportionately represented in positive studies.

INTERPRETATION

Despite widespread belief that enrollment in clinical trials leads to improved outcomes in patients with cancer, there are insufficient data to conclude that such a trial effect exists. Until such data are available, patients with cancer should be encouraged to enroll in clinical trials on the basis of trials' unquestioned role in improving treatment for future patients.

Cancer in adolescents and young adults: treatment and outcome in Victoria

OBJECTIVES

To describe the location of treatment, recruitment to clinical trials and outcomes for adolescents and young adults treated for cancer in Victoria.

DESIGN AND SETTING

Retrospective review of all adolescents and young adults aged 10-24 years diagnosed with cancer between 1992 and 1996, identified from the Victorian Cancer Registry.

MAIN OUTCOME MEASURES

Treatment regimen (clinical trial, treatment protocol or neither), compliance with treatment and 5-year survival.

RESULTS

Questionnaires were completed for 576 of 665 eligible adolescents and young adults (87% response rate). Recruitment into clinical trials decreased with increasing age. Adolescents aged 10-19 years were more likely to be recruited to a clinical trial if treated at a paediatric hospital. For all cancers, 5-year survival was similar across the age groups and was not influenced by the place of treatment. Only 1% of adolescents and young adults failed to complete planned therapy due to non-compliance.

CONCLUSIONS

Despite a similar incidence of cancer to that in younger children, adolescents and young adults with cancer are poorly recruited into clinical trials in Victoria. Establishment of a cancer resource network in Victoria may provide information to both paediatric and adult oncologists about currently available clinical trials.

Cancer survival in European adolescents and young adults

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

Older adolescents with cancer in North America deficits in outcome and research

In the two decades from the mid 1970s to the mid 1990s, the proportion of 5-year survivors among children in North America with cancer has increased nearly 40%. Advances in otherwise fatal leukemias, lymphomas, sarcomas, brain tumors, germ cell neoplasms and cancer of the kidney account for much of the improvement. Unfortunately, older adolescents have not fared as well. Their epidemiological, medical, physical, psychological and social needs remain largely unmet despite their age juxtaposition with younger patients whose outcomes have so much improved. In the United States and Canada, cancer in adolescents 15 to 19 years of age occurs at nearly twice the rate observed in 5 to 14 year-olds. Many of the types of cancer that occur in older adolescents are unique to this age group, and the pattern of distribution occurs at no other age interval. Overall, the cancers in older adolescents are more similar to the spectrum of cancer in children than to the common types of cancer in adults, but they are also distinctly different and require an age-specific approach. There is evidence of a lower degree in reduction in cancer mortality in the United States and Canada in this age range than in younger or older persons. Moreover, the disparity appears to be increasing. The improvement in 5-year survival from diagnosis of cancer from the mid 1970s to the early 1990s was lower than the rate of improvement in the younger age groups. Survival rates of older adolescents with cancer in the general population have not improved as much, especially in comparison with results of the national pediatric cooperative cancer groups. In the United States and Canada, only about 5% of 15 to 25 year-olds with cancer are entered onto clinical trials, in contrast to 60% to 65% of younger patients. Thus, cancer during adolescence and early adulthood has been relatively neglected and merits enhanced national research programs and resources.

Epidemiology of cancer in adolescents

In western populations, the annual incidence rate of cancer among adolescents aged 15-19 years is around 150-200 per million, intermediate between the rates for older children and young adults. The most frequent diagnostic groups are acute leukemia, lymphomas, central nervous system tumors, bone and soft tissue sarcomas, germ cell tumors, thyroid carcinoma, and malignant melanoma. While the causes of most cancers in teenagers are still unknown, health education and promotion and public health programs offer some scope for prevention among people of this age group. Reduction in sun exposure should lead to a reduction in incidence of melanoma, and elimination of hepatitis B in regions where it is endemic should result in a decrease in hepatic carcinoma. Five-year survival of patients diagnosed around 1990 exceeded 70% in the USA and UK. Entry to clinical trials appears to be much less frequent for adolescents with cancer than for children. There is some evidence that higher survival is associated with entry to trials or centralized treatment for certain cancers in this age group.

Cancer in older adolescents and young adults: epidemiology, diagnosis, treatment, survival, and importance of clinical trials

Cancer in adolescents and young adults has unique features in addition to the special medical, physical, psychological, and social needs of patients in this age group. The spectrum of malignant diseases is different from that in any other period in life, and it is strikingly different from the pattern in older persons. More people 15-25 years of age are diagnosed to have cancer than during the first 15 years of life. During the last 25 years, the incidence of cancer in this age range has increased faster while the increase in their cancer survival rates has been significantly lower than in younger or older patients, especially in comparison to results of the national pediatric cooperative cancer groups. Thus the 5-year outcome in 15-19 year olds with leukemias and sarcomas is not only worse than in younger patients, but also lower in this population at large than in patients of the same age treated at Children's Cancer Group institutions. In the United States, only approximately 5% of 15-25 year olds with cancer are entered onto clinical trials, in contrast to 60-65% of younger patients. Thus, cancer during adolescence and early adult life is an underestimated challenge that merits specific resources, solutions, and an international focus.

Is cancer care best at high-volume providers?

For a variety of medical conditions and procedures, a higher volume-better outcome relationship has been hypothesized for over 25 years. An extensive, consistent body of literature supports a relationship between hospital volume and short-term outcomes for cancers treated with technologically complex surgical procedures. For cancer primarily treated by low-risk surgery, there are few studies. Recent studies found a modest (about 2%) difference in survival benefit between high-volume and low-volume providers associated with colon cancer surgery. Few evaluations in the last 15 years have addressed nonsurgical cancers, eg, lymphomas and testicular cancer. No reports have addressed recurrent or metastatic cancer. Care is better at high-volume providers for a select minority of cancers. Whether provider volume matters in the majority of cancers at the time of presentation has not been evaluated.