1
|
Williamson Lewis R, Howell KE, Effinger KE, Meacham LR, Wasilewski-Masker K, Mertens A, Gilleland Marchak J. Feasibility of Fitbit Use in Adolescent Survivors of Pediatric Cancer: Who Consistently Uses It and for How Long? J Adolesc Young Adult Oncol 2023; 12:529-536. [PMID: 36178482 DOI: 10.1089/jayao.2022.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Wearable activity trackers with real-time feedback and goal-setting features are being incorporated into programs to increase physical activity among childhood cancer survivors. This analysis describes the adoption and use of a Fitbit® Flex™ among adolescent-aged survivors of childhood cancer without incentives, reminders, or interventions to encourage use. Procedures: Cancer survivors aged 13-18 and ≥2 years from therapy received a Fitbit Flex with instructions to wear it daily. Researchers downloaded participants' daily total steps and active minutes for 1 year. Participants were classified as consistent (≥5 days/week for >4 weeks during the first 12 weeks) or inconsistent users, and comparisons between user types were made. Longitudinal use of the Fitbit and participants' 1-year acceptability evaluations are described. Results: Overall, 67.1% (47/70) of survivors enrolled, and Fitbit data were available for 36 participants. Initially, 30.6% (11/36) were consistent users. Consistent users had lower body mass index z-scores at enrollment (0.4 ± 0.7 vs. 1.2 ± 0.9; p = 0.01), but were otherwise comparable with inconsistent users. Over time survivors' use declined; at 12 months, only one participant was using his or her Fitbit. Survivors who completed a survey (n = 22) reported their Fitbit helped them self-monitor their exercise (72.7%, 16/22) and lead a more active lifestyle (63.6%, 14/22), but found it challenging to charge and not lose, forget about, or break the device. Conclusions: In the real-world setting, only a small subset of adolescent-aged survivors will initially consistently use a Fitbit and their interest diminishes over time. To maximize engagement, interventions incorporating wearable activity trackers likely need to include additional behavior change strategies.
Collapse
Affiliation(s)
- Rebecca Williamson Lewis
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kristen E Howell
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Karen E Effinger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lillian R Meacham
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen Wasilewski-Masker
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ann Mertens
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jordan Gilleland Marchak
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Self-reported physical activity behaviors of childhood cancer survivors: comparison to a general adolescent population in Korea. Support Care Cancer 2023; 31:164. [PMID: 36781555 DOI: 10.1007/s00520-023-07612-x] [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: 08/12/2022] [Accepted: 01/25/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Adequate physical activity (PA) can significantly contribute to the prevention of undesirable health outcomes in childhood cancer survivors (CCS). This study aimed to identify the patterns of PA and related factors in Korean CCS. METHODS Study subjects were 184 adolescents selected from an ongoing cohort study of Korean CCS and 1,840 sex- and school grade-matched controls randomly selected from the participants of the 2019 Korea Youth Risk Behavior Web-based Survey. Information on PA and sedentary behaviors was collected by self-administered questionnaire. We estimated body mass index (BMI)-adjusted odds ratio (OR) and 95% confidence interval (CI) for the advisable healthy behaviors of CCS compared with healthy controls using conditional logistic regression analysis. In addition, the associations of advisable healthy behaviors of CCS with sociodemographic and clinical factors were estimated using multiple logistic regression analysis. RESULTS CCS were less likely to be physically active than controls, but this finding was evident only in males. The ORs (95% CIs) for regular exercise, moderate intensity PA, vigorous intensity PA, and walking were 0.42 (0.27-0.65), 0.39 (0.24-0.63), 0.53 (0.33-0.84), and 0.64 (0.42-0.98), respectively, in male CCS compared with same-sex controls. Compared with same-sex controls, male CCS were 4.60 times and female survivors were 15.19 times more likely to sleep longer than 8 h a day. Among CCS, males were 2.92 times and 3.07 times more likely to perform moderate intensity PA and muscle-strengthening exercise, respectively, than female. Higher BMI (OR: 1.16), highest family income (OR: 3.98), and a caregiver who performed regular exercise (OR: 2.08) were positively associated with vigorous intensity PA of CCS. With increasing time after treatment completion, the probability of engaging in sedentary activity for less than 6 h per day decreased (OR = 0.89, 95% CI 0.79-1.00). CONCLUSION Korean adolescent CCS were physically inactive compared with control adolescents. Several sociodemographic factors such as sex, family income, caregiver PA, and obesity level were associated with PA behaviors of CCS. IMPLICATIONS Strategic effort would be needed to increase physical activity of childhood cancer survivors in adolescent period with consideration of various sociodemographic factors found in this study.
Collapse
|
3
|
Barbosa-Cortes L, Atilano-Miguel S, Martin-Trejo JA, Jiménez-Aguayo E, Martínez-Becerril FI, López-Alarcón M, Mejía Aranguré JM, Maldonado-Hernández J, Delgadillo-Portillo S, Guzmán-Castro B, Delgadillo-Portillo J, Añoveros-Barrera A, Solis-Labastida KA, Bautista-Martinez BA, Juárez-Moya A, Hernández-Piñón Z, Espinoza Hernández LE, Núñez-Villegas NN, Jiménez-Hernández E, Pérez-Casillas RX. Effect of long-chain omega-3 polyunsaturated fatty acids on cardiometabolic factors in children with acute lymphoblastic leukemia undergoing treatment: a secondary analysis of a randomized controlled trial. Front Endocrinol (Lausanne) 2023; 14:1120364. [PMID: 37124732 PMCID: PMC10140550 DOI: 10.3389/fendo.2023.1120364] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/21/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction Increased triglycerides (TGs) are a major risk factor for cardiovascular disease. Furthermore, hypertriglyceridemia is commonly associated with a reduction of high-density lipoprotein cholesterol (HDL-C) and an increase in atherogenic small-dense low-density lipoprotein (LDL-C) levels. Studies provide support that polyunsaturated omega-3 fatty acids (ω3-LCPUFAs) are cardioprotective and have antithrombotic and anti-inflammatory effects. The potential effects of ω3-LCPUFAs on cardiometabolic factors and anti-inflammatory actions in children with acute lymphoblastic leukemia (ALL) are limited. This is a secondary analysis of a previous clinical trial registered at clinical trials.gov (# NCT01051154) that was conducted to analyze the effect of ω3-LCPUFAs in pediatric patients with ALL who were receiving treatment.Objective: To examine the effect of supplementation with ω3-LCPUFAs on cardiometabolic factors in children with ALL undergoing treatment. Methods Thirty-four children (placebo group: 20 patients; ω3-LCPUFAs group: 14 patients) aged 6.7 ± 2.7 years who were newly diagnosed with ALL were evaluated. Children were randomized to receive either ω3-LCPUFAs or placebo capsules (sunflower oil). ω3-LCPUFAs were administered in the form of 500-mg soft capsules. The ω3-LCPUFA capsules contained 225 mg of DHA, 45 mg of EPA, and 20 mg of another ω3-LCPUFAs. The omega-3 dose was administered at a rate of 0.100 g/kg of body weight/day for three months. Main outcomes: Fasting cholesterol, HDL-C, very-low-density lipoprotein (VLDL-C), TGs, atherogenic index of plasma (AIP), android/gynoid ratio (A/GR), IL-6, TNF-α, and percentage of fat mass (DXA) were measured in all patients. Fatty acid analyses in red blood cells were performed with gas chromatography. Results We found significantly lower levels of TGs (p=0.043), VLDL-C (p=0.039), IL-6 (p=0.025), and AIP (p=0.042) in the ω3-LCPUFAs group than in the placebo group at three months. In contrast, the total cholesterol concentration was higher at 3 months in the ω3-LCPUFAs group than in the placebo group (155 mg/dl vs. 129 mg/dl, p=0.009). The number of children with hypertriglyceridemia (85% vs. 50%; p=0.054) tended to be lower between the time of diagnosis and after 3 months of supplementation with ω3-LCPUFAs. Conclusion These findings support the use of ω3-LCPUFAs to reduce some adverse cardiometabolic and inflammatory risk factors in children with ALL. Clinical trial registration ClinicalTrials.gov, identifier NCT01051154.
Collapse
Affiliation(s)
- Lourdes Barbosa-Cortes
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
- *Correspondence: Lourdes Barbosa-Cortes,
| | - Salvador Atilano-Miguel
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Jorge Alfonso Martin-Trejo
- Servicio de Hematología, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Emmanuel Jiménez-Aguayo
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Fabian Ismael Martínez-Becerril
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Mardia López-Alarcón
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Juan Manuel Mejía Aranguré
- Instituto Nacional de Medicina Genómica, Ciudad de México, Mexico
- Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Jorge Maldonado-Hernández
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Suyly Delgadillo-Portillo
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Brenda Guzmán-Castro
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Jazmín Delgadillo-Portillo
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Ana Añoveros-Barrera
- Unidad de Investigación Médica en Nutrición, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Karina Anastacia Solis-Labastida
- Servicio de Hematología, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Benito Alejandro Bautista-Martinez
- Servicio de Hematología, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Azalia Juárez-Moya
- Servicio de Hematología, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Zaira Hernández-Piñón
- Servicio de Hematología, Unidad Médica de Alta Especialidad (UMAE), Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Laura Eugenia Espinoza Hernández
- Servicio de Hematología Pediátrica, Unidad Médica de Alta Especialidad (UMAE), Hospital General “Dr. Gaudencio González Garza” Centro Médico Nacional la Raza, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Nora N. Núñez-Villegas
- Servicio de Hematología Pediátrica, Unidad Médica de Alta Especialidad (UMAE), Hospital General “Dr. Gaudencio González Garza” Centro Médico Nacional la Raza, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Elva Jiménez-Hernández
- Servicio de Hematología Pediátrica, Unidad Médica de Alta Especialidad (UMAE), Hospital General “Dr. Gaudencio González Garza” Centro Médico Nacional la Raza, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| | - Ruy X. Pérez-Casillas
- Servicio de Hematología Pediátrica, Unidad Médica de Alta Especialidad (UMAE), Hospital General “Dr. Gaudencio González Garza” Centro Médico Nacional la Raza, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
| |
Collapse
|
4
|
Kumar R, Mahan JD, Stanek JR, Reed S. Extent of hypertension and renal injury in children surviving acute lymphoblastic leukemia. Pediatr Blood Cancer 2022; 69:e29628. [PMID: 35234342 DOI: 10.1002/pbc.29628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/31/2022] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Childhood acute lymphoblastic leukemia (ALL) fortunately has high survival rates, and understanding longer term implications of therapy is critical. In this study, we aimed to investigate kidney health outcomes by assessing the prevalence of renal dysfunction and hypertension (HTN) in children with ALL at 1-5 years after ALL diagnosis. METHODS This was a single-center, cross-sectional study of children with ALL who were 1-5 years post diagnosis. Glomerular filtration rate (GFR) measurements were calculated, and urine samples were collected to assess for protein/creatinine and albumin/creatinine. Blood pressure (BP) was determined by standard oscillometric technique, and children ≥6 years of age were eligible for ambulatory blood pressure monitoring (ABPM). RESULTS Forty-five patients enrolled in the study, and 21 completed ABPMs. Fifteen patients (33%, 95% CI: 20%-49%) developed acute kidney injury (AKI) at least once. Thirteen (29%, 95% CI: 16%-44%) had hyperfiltration, and 11 (24%) had abnormal proteinuria and/or albuminuria. Prevalence of HTN based on clinic measurements was 42%. In the 21 ABPM patients, 14 had abnormal results (67%, 95% CI: 43%-85%), with the majority (11/21) demonstrating abnormal nocturnal dipping pattern. CONCLUSIONS Among children with ALL, there is a high prevalence of past AKI. The presence of hyperfiltration, proteinuria, and/or albuminuria at 1-5 years after ALL diagnosis suggests real risk of developing chronic kidney disease (CKD) over time. There is a high prevalence of HTN on casual BP readings and even higher prevalence of abnormal ABPM in this group. The high prevalence of impaired nocturnal dipping by ABPM indicates an increased risk for future cardiovascular or cerebral ischemic events.
Collapse
Affiliation(s)
- Reeti Kumar
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
| | - John D Mahan
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph R Stanek
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Suzanne Reed
- Department of Pediatrics, Division of Hematology/Oncology/Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio, USA
| |
Collapse
|
5
|
The triponderal mass index as a measure of adiposity in pediatric survivors of acute lymphoblastic leukemia: a cross-sectional study. Sci Rep 2022; 12:1404. [PMID: 35082328 PMCID: PMC8792003 DOI: 10.1038/s41598-022-05236-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 01/10/2022] [Indexed: 11/22/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common type of childhood cancer. Treatments of ALL predispose survivors to obesity, which increases the risk of cardiovascular disease and diabetes. The hallmark of obesity is excess fat mass, and adiposity is a superior predictor of cardiometabolic risk when compared to Body Mass Index (BMI), yet clinical measures of adiposity in children are lacking. The Tri-Ponderal Mass Index (TMI) (kg/m3) is a more accurate adiposity measure compared to BMI z-score in the general pediatric population. This cross-sectional study aimed to validate TMI as an adiposity measure against DEXA scan-derived adiposity, and to compare it to BMI z-score, in pediatric ALL survivors. This study was a retrospective chart review of pediatric ALL survivors diagnosed between 2004 and 2015 at McMaster Children’s Hospital, a tertiary pediatric center in Ontario, Canada. One hundred and thirteen patients (Female n = 55, 48.70%) were included, and adiposity was measured using DEXA scans. Exploratory partial correlations and linear regression analyses were adjusted for age, sex, ethnicity, and ALL risk status. Both TMI and BMI z-score correlated with the DEXA-measured fat mass percentage (FM%) (partial correlation TMI versus FM% r = 0.56; p value < 0.0001; BMI z-score versus FM% r = 0.55; p value < 0.0001). In regression analyses, the association of TMI was not inferior to BMI z-score in assessing adiposity (TMI versus FM% estimated unstandardized B 0.80, 95% CI 0.56, 1.02; p value < 0.0001; BMI z-score versus FM% (unstandardized B 0.37, 95% CI 0.26, 0.49; p value < 0.0001). The TMI is a useful clinical adiposity-specific measure in survivors of pediatric ALL.
Collapse
|
6
|
Kartal İ, Alaçam A, Dağdemir A, Kara C, Dinçer OS, Albayrak C, Elli M. Frequency of obesity and metabolic syndrome in childhood leukemia and lymphoma survivors. Diabetol Metab Syndr 2022; 14:16. [PMID: 35073984 PMCID: PMC8785466 DOI: 10.1186/s13098-022-00790-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/07/2022] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES In this study, it was aimed to determine the prevalence and clinical features of obesity and metabolic syndrome, which are long-term effects of survivors after treatment in children with leukemia and lymphoma. PATIENTS AND METHODS Patients with leukemia and lymphoma, who were diagnosed between 2000 and 2012 (at least 2 two years after remission) were included. Data obtained through reviewing the family history, demographic characteristics, anthropometric measurements, and laboratory parameters (blood glucose, lipid, and insulin levels) were analyzed and compared at the time of diagnosis, after the treatment and at time of the study. RESULTS Eighty nine patients (45 boys, 44 girls) were included (mean age: 14.7 ± 4.3 years): 77.5% had acute lymphoblastic leukemia, 11.2% had acute myeloid leukemia, and 11.2% had lymphoma. Overall, 46% patients had received radiotherapy, 7% had undergone surgery, and 2.2% had received stem cell transplantation in addition to chemotherapy. The mean duration of treatment was 2.4 years, and the time elapsed after treatment was 4.9 years. While only one had obesity at the diagnosis, a significant increase in obesity (20%), hypertension (15.7%), hyperglycemia (15%), insulin resistance (35%) were observed at the time of study, and family history of hypertension, dyslipidemia, and cardiovascular diseases were significantly higher in this subgroup. CONCLUSION The prevalence of metabolic syndorme is higher in children with leukemia and lymphoma after treatment, and begins to increase with the initiation of treatment and continues to increase over time. These children should be followed-up for late-effects including metabolic syndrome through life-long period.
Collapse
Affiliation(s)
- İbrahim Kartal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey.
| | - Abdurrahman Alaçam
- Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Ayhan Dağdemir
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Cengiz Kara
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Istinye University, İstanbul, Turkey
| | - Oğuz Salih Dinçer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Canan Albayrak
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Murat Elli
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Medipol University Hospital, İstanbul, Turkey
| |
Collapse
|
7
|
Murphy L, Maloney K, Gore L, Blanchette E. Hypertension in Pediatric Acute Lymphoblastic Leukemia Patients: Prevalence, Impact, and Management Strategies. Integr Blood Press Control 2022; 15:1-10. [PMID: 35082528 PMCID: PMC8784271 DOI: 10.2147/ibpc.s242244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/17/2021] [Indexed: 01/27/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed in children under the age of 18. While modern diagnostic technologies, risk-stratification, and therapy intensification have led to outstanding outcomes for many children with ALL, the side effects and consequences of therapy are not to be underestimated. Hypertension is a well-known acute and chronic side effect of treatment for childhood ALL, although limited data are available regarding the prevalence of hypertension in children undergoing treatment for ALL. In this review of hypertension in pediatric ALL patients, we examine the existing data on incidence and prevalence during treatment and in pediatric ALL survivors. We describe independent risk factors for development of hypertension along with treatment-related causes. Long-term consequences and the risk to survivors of pediatric ALL are further defined. While many ALL patients require antihypertensive medications during some portion of their treatment, there are no clear guidelines on treating inpatient hypertension given challenges that exist in recognizing and managing hypertension in this setting and in this population. Here, we propose an algorithmic approach to diagnose and treat pediatric ALL patients with HTN, along with monitoring and continuation versus cessation of antihypertensive therapy as an outpatient.
Collapse
Affiliation(s)
- Lindsey Murphy
- Department of Pediatrics, Sections of Hematology/Oncology/Bone Marrow Transplant-Cellular Therapeutics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Kelly Maloney
- Department of Pediatrics, Sections of Hematology/Oncology/Bone Marrow Transplant-Cellular Therapeutics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
| | - Lia Gore
- Department of Pediatrics, Sections of Hematology/Oncology/Bone Marrow Transplant-Cellular Therapeutics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
- University of Colorado Cancer Center, Aurora, CO, USA
- Correspondence: Lia Gore Tel +17207776458Fax +17207777339 Email
| | - Eliza Blanchette
- Department of Pediatrics, Section of Nephrology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
8
|
Wogksch MD, Finch ER, Nolan VG, Smeltzer MP, Mzayek F, Goodenough CG, Pui CH, Inaba H, Mulrooney DA, Kaste SC, Brinkman TM, Lanctot JQ, Srivastava DK, Jefferies JL, Armstrong GT, Robison LL, Hudson MM, Ness KK. Energy cost of walking in obese survivors of acute lymphoblastic leukemia: A report from the St. Jude Lifetime Cohort. Front Pediatr 2022; 10:976012. [PMID: 36389386 PMCID: PMC9650430 DOI: 10.3389/fped.2022.976012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Adult survivors of childhood acute lymphoblastic leukemia (ALL) have impaired adaptive physical function and poor health-related quality of life (HRQoL). Obesity may contribute to these impairments by increasing the physiological cost of walking. Due to treatment exposures during ALL therapy, survivors' cost of walking may be more impacted by obesity than the general population. Therefore, we examined associations between obesity, persistent motor neuropathy, and energy cost of walking; and examined associations between energy cost of walking, adaptive physical function, and HRQoL, in adult survivors of childhood ALL vs. community controls. Methods Obesity was measured via body mass index (BMI) and body fat percentage. The physiological cost index (PCI) was calculated from the six-minute walk test. Adaptive physical functioning was measured using two tests: the timed up and go (TUG) test and the physical performance test. Persistent motor neuropathy was measured using the modified total neuropathy score; HRQoL was measured using the Short-Form-36 questionnaire. The associations between obesity and PCI were evaluated using multivariable linear regressions in adult survivors of childhood ALL (n = 1,166) and community controls (n = 491). Then, the associations between PCI, adaptive physical functioning and peripheral neuropathy were examined using multivariable linear regressions. Finally, to determine the association between obesity, and neuropathy on PCI, while accounting for potential lifestyle and treatment confounders, a three model, sequential linear regression was used. Results Obese individuals (BMI > 40 kg/m2 and excess body fat percentage [males: >25%; females: >33%]) had higher PCI compared to those with normal BMI and body fat percentage (0.56 ± 0.01 vs. 0.49 ± 0.009 beats/meter p < .01; and 0.51 ± 0.007 vs. 0.48 ± .0006 beats/meter p < .01, respectively). Treatment exposures did not attenuate this association. Increased PCI was associated with longer TUG time in survivors, but not community controls (6.14 ± 0.02 s vs. 5.19 ± 0.03 s, p < .01). Survivors with PCI impairment >95th percentile of community controls had lower HRQoL compared to un-impaired ALL survivors: 46.9 ± 0.56 vs. 50.4 ± 1.08, respectively (p < .01). Conclusion Obesity was associated with increased PCI. Survivors with high PCI had disproportionately worse adaptive physical function and HRQoL compared to controls. Survivors with increased energy costs of walking may benefit from weight loss interventions.
Collapse
Affiliation(s)
- Matthew D. Wogksch
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Emily R. Finch
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Vikki G. Nolan
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, United States
| | - Matthew P. Smeltzer
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, United States
| | - Fawaz Mzayek
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, United States
| | - Chelsea G. Goodenough
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Sue C. Kaste
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Radiology, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jennifer Q. Lanctot
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - John L. Jefferies
- Division of Cardiovascular Diseases, Institute for Cardiovascular Science, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Correspondence: Kirsten K. Ness
| |
Collapse
|
9
|
Ketterl TG, Ballard S, Bradford MC, Chow EJ, Jenssen K, Myers S, Rosenberg AR, Doren MV, Scott Baker K. Feasibility and acceptability of a home-based resistance training intervention in adolescent and young adult hematopoietic cell transplant survivors. Pediatr Blood Cancer 2021; 68:e29206. [PMID: 34260139 PMCID: PMC8463478 DOI: 10.1002/pbc.29206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Adolescent and young adult (AYA) hematopoietic cell transplantation (HCT) survivors are at increased risk of metabolic syndrome and lean body mass (LBM) deficits. Resistance training (RT) is a potential intervention to improve LBM, metabolic fitness, and reduce risk of cardiovascular disease. PROCEDURE Eligible participants ages 13-39 years, 80-120 days post-HCT, transfusion independent, and prednisone dose ≤1 mg/kg/day were approached. Baseline assessments of body composition (DXA), anthropometrics, and strength testing were completed and participants were taught a 12-week, home-based RT intervention with weekly remote coaching. Follow-up assessments were at day +200 (FU1) and +365 post-HCT (FU2). Feasibility targets were (a) 60% enrollment of approached patients, (b) 80% completion of weekly phone calls, and (c) 80% completion of the RT intervention and FU1 assessments. Acceptability was based on positive responses in qualitative interviews. RESULTS Twenty of 31 (65%) eligible AYAs enrolled. Three participants failed to complete baseline measurements (2 = scheduling barriers, 1 = passive refusal) and four participants who completed baseline assessments did not receive the intervention (1 = medical reasons, 2 = no longer interested). Of those who completed baseline assessments, 13 received the intervention, completed 88.5% of coaching calls, and 11 (65%) completed FU1. LBM (kg) increased or remained unchanged in nine of nine participants with complete body composition data at FU1 (mean 1.1 kg; 95%CI: 0.4, 1.9). All participants who completed FU1 reported they would recommend the intervention to an AYA HCT survivor. CONCLUSIONS A home-based RT intervention in AYA HCT survivors early post HCT is both feasible and acceptable and may maintain or increase LBM.
Collapse
Affiliation(s)
- Tyler G. Ketterl
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, WA,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sheri Ballard
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Miranda C. Bradford
- Core for Biostatistics Epidemiology and Analytics in Research, Seattle Children’s Research Institute, Seattle, WA
| | - Eric J. Chow
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, WA,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kari Jenssen
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Sam Myers
- Exercise Research Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Abby R. Rosenberg
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, WA,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Matt Van Doren
- Exercise Research Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - K. Scott Baker
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, Seattle, WA,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle, WA,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| |
Collapse
|
10
|
van der Haak N, Edwards S, Perem M, Landorf E, Osborn M. Nutritional Status at Diagnosis, During, and After Treatment in Adolescents and Young Adults with Cancer. J Adolesc Young Adult Oncol 2021; 10:668-674. [PMID: 33844931 DOI: 10.1089/jayao.2020.0197] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Malnutrition is commonly observed during cancer treatment, while some cancer survivors are at risk of overweight and obesity. This study investigated nutritional status during and after treatment in adolescents and young adults (AYA) with cancer. Methods: A retrospective chart review of AYA diagnosed with cancer was conducted. Data were collected monthly during treatment, then annually for 3 years of follow-up. Results: Of 93 AYA, 8% were underweight at diagnosis versus 20% during treatment (p = 0.012). Forty-four percent experienced ≥5% loss of weight (LOW) during treatment, and 23% of those were not referred to a dietitian. While 47% were referred to a dietitian at some point during treatment, 77% did not have dietetic involvement in the month after reaching greatest percentage LOW. Different tumor types were associated with different risks of LOW. Eighty-six percent with acute lymphoblastic leukemia (ALL)/lymphoblastic lymphoma (LL) and 86% with acute myeloid leukemia had ≥5% LOW during treatment, compared with 17% with Hodgkin lymphoma (p < 0.0001). In year 3 of follow-up, 36% of all AYA were overweight or obese versus 25% at diagnosis (p = 0.2). Overweight/obesity was more common in ALL/LL survivors than other tumor types (67% vs. 14%, p = 0.037). No patients had dietitian involvement in year 3 of follow-up. Conclusions: AYA, particularly those with ALL/LL, are at risk of significant weight loss during treatment and overweight and obesity during survivorship. Dietetic involvement was inconsistent in this cohort. These data may guide which diagnoses warrant preemptive dietetic input during treatment and highlight the importance of dietetic involvement in survivorship.
Collapse
Affiliation(s)
- Natalie van der Haak
- Department of Nutrition, Women's and Children's Hospital, North Adelaide, South Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, Data, Design and Statistics Service, School of Public Health, The University of Adelaide, Adelaide, South Australia
| | - Merike Perem
- Youth Cancer Service, Royal Adelaide Hospital, Adelaide, South Australia
| | - Emma Landorf
- Department of Nutrition, Women's and Children's Hospital, North Adelaide, South Australia
| | - Michael Osborn
- Youth Cancer Service, Royal Adelaide Hospital, Adelaide, South Australia.,Department of Haematology and Oncology, Women's and Children's Hospital, North Adelaide, South Australia
| |
Collapse
|
11
|
Morel S, Delvin E, Marcil V, Levy E. Intestinal Dysbiosis and Development of Cardiometabolic Disorders in Childhood Cancer Survivors: A Critical Review. Antioxid Redox Signal 2021; 34:223-251. [PMID: 32390455 DOI: 10.1089/ars.2020.8102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Significance: Survivors of pediatric cancers have a high risk of developing side effects after the end of their treatments. Many potential factors have been associated with the onset of cardiometabolic disorders (CMD), including cancer disease itself, chemotherapy, hormonal treatment, radiotherapy, and genetics. However, the precise etiology and underlying mechanisms of these long-term complications are poorly understood. Recent Advances: Greater awareness is currently paid to the role of microbiota in the emergence of cancers and modulation of cancer therapies in both children and adults. Alterations in the composition and diversity of intestinal microbiota can clearly influence tumor development and progression as well as immune responses and clinical output. As dysbiosis is closely linked to the development of host metabolic diseases, including obesity, metabolic syndrome, type 2 diabetes, and non-alcoholic fatty liver disease, it may increase the risk of CMD in cancer populations. Critical Issues: Only limited studies targeting the profile of intestinal dysbiosis before and after cancer treatment have been conducted. Further, the exact contribution of intestinal dysbiosis to the development of CMD in cancer survivors is poorly appreciated. This review intends to clarify the influence of gut microbiota on CMD in childhood cancer survivors, elucidate the potential mechanisms, and evaluate the latest research on the interplay between diet/food supplement, microbiota, and cancer-related CMD. Future Directions: The implication of intestinal dysbiosis in late metabolic complications of childhood cancer survivors should be clarified. Intervention strategies could be developed to reduce the risk of survivors to CMD. Antioxid. Redox Signal. 34, 223-251.
Collapse
Affiliation(s)
- Sophia Morel
- Research Centre, Sainte-Justine University Hospital Health Center, Université de Montréal, Montreal, Canada.,Department of Nutrition and Université de Montréal, Montreal, Canada
| | - Edgard Delvin
- Research Centre, Sainte-Justine University Hospital Health Center, Université de Montréal, Montreal, Canada
| | - Valérie Marcil
- Research Centre, Sainte-Justine University Hospital Health Center, Université de Montréal, Montreal, Canada.,Department of Nutrition and Université de Montréal, Montreal, Canada
| | - Emile Levy
- Research Centre, Sainte-Justine University Hospital Health Center, Université de Montréal, Montreal, Canada.,Department of Nutrition and Université de Montréal, Montreal, Canada.,Department of Pediatrics, Université de Montréal, Montreal, Canada
| |
Collapse
|
12
|
Franca R, Zudeh G, Lucafò M, Rabusin M, Decorti G, Stocco G. Genome wide association studies for treatment-related adverse effects of pediatric acute lymphoblastic leukemia. WIREs Mech Dis 2020; 13:e1509. [PMID: 33016644 DOI: 10.1002/wsbm.1509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/01/2020] [Accepted: 09/04/2020] [Indexed: 12/14/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric hematological malignancy; notwithstanding the success of ALL therapy, severe adverse drugs effects represent a serious issue in pediatric oncology, because they could be both an additional life threatening condition for ALL patients per se and a reason to therapy delay or discontinuation with important fallouts on final outcome. Cancer treatment-related toxicities have generated a significant need of finding predictive pharmacogenomic markers for the a priori identification of at risk patients. In the era of precision medicine, high throughput genomic screening such as genome wide association studies (GWAS) might provide useful markers to tailor therapy intensity on patients' genetic profile. Furthermore, these findings could be useful in basic research for better understanding the mechanistic and regulatory pathways of the biological functions associated with ALL treatment toxicities. The purpose of this review is to give an overview of high throughput genomic screening of the last 10 years that had investigated the landscape of ALL treatment-associated toxicities. This article is categorized under: Cancer > Genetics/Genomics/Epigenetics.
Collapse
Affiliation(s)
- Raffaella Franca
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulia Zudeh
- University of Trieste, PhD Course in Reproductive and Developmental Sciences, Trieste, Italy
| | - Marianna Lucafò
- Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Marco Rabusin
- Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Giuliana Decorti
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal and Child Health I.R.C.C.S Burlo Garofolo, Trieste, Italy
| | - Gabriele Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
| |
Collapse
|
13
|
Chandrasekaran S, Ramli N, Ahmad MJ, Effendi I, Amir NN, Chow RC, Chee CKL, Azanan MS, Abd Ghafar SS, Ariffin H, Kamalden TA. Premature Ocular Aging Features in Childhood Acute Lymphoblastic Leukemia Survivors. J Adolesc Young Adult Oncol 2020; 10:425-431. [PMID: 32996803 DOI: 10.1089/jayao.2020.0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: Childhood cancer survivors (CCS) demonstrate features of premature aging in a multitude of organ systems. The aim of this pilot study is to determine the presence of premature ocular aging features in CCS, specifically childhood acute lymphoblastic leukemia (ALL) survivors. Methods: This prospective case-control study was conducted over a period of 21 months, starting July 2015 till March 2017. A total of 59 childhood ALL survivors who attended the Paediatric Oncology Clinic of University Malaya Medical Centre (UMMC) and 48 age, race, and gender-matched controls went through a series of ocular examinations and tests. Inclusion criteria used to recruit survivors were age above 16 years, history of ALL in childhood, completion of treatment for ALL, and a remission period of at least 5 years. Patients with ocular disease and those who received hematopoietic stem cell transplantation were excluded. The parameters measured were visual acuity, amplitude of accommodation, pupil cycle time (PCT), and tear break-up time (TBUT). Results: Survivors of childhood ALL demonstrated significant differences in amplitude of accommodation, PCT, and TBUT compared to age-matched controls. Survivors had a lower median (interquartile range [IQR]) amplitude of accommodation compared to controls (11.0 D [9.0-13.0] vs. 12.0 D [10.5-15]; p = 0.045). Survivors also showed a longer median (IQR) PCT in comparison to controls (931.00 mseconds (857.00-1063.00) vs. 875.50 mseconds (825.75-966.00); p = 0.024). In addition, median (IQR) TBUT was worse in survivors in comparison to the control group (9 seconds [6-13] vs. 11 seconds [10-15]; p = 0.001). Conclusion: Survivors of childhood ALL demonstrate premature ocular aging features compared to age-matched controls. Thus, survivors may benefit from having ocular examinations as part of their routine late-effects screening to detect age-related ocular morbidities early in its course.
Collapse
Affiliation(s)
| | - Norlina Ramli
- Department of Ophthalmology, UM Eye Research Centre, University Malaya, Kuala Lumpur, Malaysia.,Department of Ophthalmology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Marium Jamaluddin Ahmad
- Department of Ophthalmology, UM Eye Research Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Irina Effendi
- Department of Ophthalmology, UM Eye Research Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Nurul Najieha Amir
- Department of Ophthalmology, UM Eye Research Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Rhuen Chiou Chow
- Department of Ophthalmology, UM Eye Research Centre, University Malaya, Kuala Lumpur, Malaysia
| | - Caroline Ka Lin Chee
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University Hospital, Singapore, Singapore
| | - Mohamad Shafiq Azanan
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | | | - Hany Ariffin
- Department of Paediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Tengku Ain Kamalden
- Department of Ophthalmology, UM Eye Research Centre, University Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
14
|
Siviero-Miachon AA, Spinola-Castro AM, Andreoni S, Lee MLDM, Calixto AR, Geloneze B, Guerra-Junior G. Adipokines in young survivors of childhood acute lymphocytic leukemia revisited: beyond fat mass. Ann Pediatr Endocrinol Metab 2020; 25:174-181. [PMID: 32871655 PMCID: PMC7538299 DOI: 10.6065/apem.1938174.087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/27/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE This cross-sectional study evaluated the relationship between adipokines (leptin, adiponectin, visfatin, and resistin) and adiposity indexes regarding sex and cranial radiotherapy exposure among young acute lymphocytic leukemia survivors. METHODS A multivariate analysis of covariance (MANCOVA) was used to evaluate the joint effect of sex, cranial radiotherapy, and body mass index (BMI) z-score (model 1) or fat mass index (FMI) (model 2) on adipokines. RESULTS This study included 55 survivors of childhood acute lymphocytic leukemia between 15 and 23 years of age from both sexes (56.4% female); 43.6% of the sample had undergone cranial radiotherapy (18-24 Gy). The BMI z-score, the FMI, and sex (P<0.050 for all) influenced at least one adipokine, while cranial radiotherapy exposure was marginal in model 2. Parameter estimates from the MANCOVA's final model showed that the BMI z-score (β=-0.437, P=0.010) and the FMI (β=-0.209, P=0.004) negatively influenced adiponectin, while the FMI positively affected resistin (β=0.142, P=0.020). The relationship between leptin, visfatin, and the adiposity ndexes could not be established. In model 1, females presented with increased adiponectin (β=-1.014, P=0.011) and resistin (β=-1.067, P=0.002) levels; in model 2, female sex positively affected adiponectin (β=-1.515, P=0.001) and marginally influenced resistin (β=-0.707, P=0.054) levels. Cranial radiotherapy negatively determined visfatin levels in both final models (P<0.050). CONCLUSION Changes in body fat may be associated with adipose tissue dysfunction and should be carefully evaluated in survivors of acute lymphocytic leukemia, considering both sex and cranial radiotherapy exposure, to treat disorders that may possibly aggravate their risk for early cardiovascular disease.
Collapse
Affiliation(s)
- Adriana Aparecida Siviero-Miachon
- Division of Pediatric Endocrinology, Federal University of Sao Paulo - UNIFESP/EPM, Sao Paulo, Brazil,Pediatric Oncology Institute - IOP/GRAACC, Sao Paulo, Brazil
| | - Angela Maria Spinola-Castro
- Division of Pediatric Endocrinology, Federal University of Sao Paulo - UNIFESP/EPM, Sao Paulo, Brazil,Pediatric Oncology Institute - IOP/GRAACC, Sao Paulo, Brazil,Address for correspondence: Angela Maria Spinola-Castro, MD, PhD Division of Pediatric Endocrinology, Federal University of Sao Paulo - UNIFESP/EPM, 760 Borges Lagoa Street, Sao Paulo 04038-001, Brazil Tel & Fax: +55-11-5579-9409 E-mail:
| | - Solange Andreoni
- Division of Biostatistics, Department of Preventive Medicine, UNIFESP/EPM, Sao Paulo, Brazil
| | | | - Antonio Ramos Calixto
- Laboratory of Investigation on Metabolism and Diabetes - LIMED, Faculty of Medical Sciences, State University of Campinas - UNICAMP, Campinas, Brazil
| | - Bruno Geloneze
- Laboratory of Investigation on Metabolism and Diabetes - LIMED, Faculty of Medical Sciences, State University of Campinas - UNICAMP, Campinas, Brazil
| | - Gil Guerra-Junior
- Division of Pediatric Endocrinology, Faculty of Medical Sciences, UNICAMP, Campinas, Brazil
| |
Collapse
|
15
|
Fuemmeler BF, Holzwarth E, Sheng Y, Do EK, Miller CA, Blatt J, Rosoff PM, Østbye T. Mila Blooms: A Mobile Phone Application and Behavioral Intervention for Promoting Physical Activity and a Healthy Diet Among Adolescent Survivors of Childhood Cancer. Games Health J 2020; 9:279-289. [PMID: 32391734 DOI: 10.1089/g4h.2019.0060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objectives: Smartphone applications ("apps") can be used to promote health behavior change and expand the reach of behavioral interventions. To date, only a few existing apps have been developed for health promotion among adolescent survivors of childhood cancer. To address this gap, we developed an app-based intervention, using game design characteristics, theory-based behavioral strategies, and assistance from a health coach to motivate health behavior change for adolescent survivors of childhood cancer. This article describes the development and initial feasibility evaluation of the intervention. Methods: Using a theoretical framework and an extensive formative process, we developed an app-based game ("Mila Blooms") that promotes healthy eating and physical activity among adolescent survivors of childhood cancer. A single-arm 8-week intervention, using this app-based game, with assistance from a health coach, was conducted among a sample of pediatric cancer survivors (n = 15) to evaluate its initial feasibility for promoting health behavior change. Results: Results from the feasibility evaluation were encouraging. The majority of enrolled participants were retained throughout the 8-week intervention (93.8%). Participant satisfaction feedback indicated positive experiences, related to ease of use and enjoyment of the app. Although there was little evidence for behavior change attributable to the app in this first stage of development, there was a solid demonstration of the viability and appeal of the game features, and there were no adverse side effects. Conclusions: Results provide insights into how gamification can be used to promote health behaviors through an app-based intervention. Mila Blooms holds promise for promoting health behavior change. Lessons learned from our experiences could be useful for the future development and implementation of app-based adolescent health interventions.
Collapse
Affiliation(s)
- Bernard F Fuemmeler
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | | | - Yaou Sheng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Elizabeth K Do
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Carrie A Miller
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Julie Blatt
- Department of Pediatric Hematology Oncology Program, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - Philip M Rosoff
- Department of Pediatrics and Medicine, Duke University, Durham, North Carolina
| | - Truls Østbye
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina
| |
Collapse
|
16
|
Bariatric interventions in obesity treatment and prevention in pediatric acute lymphoblastic leukemia: a systematic review and meta-analysis. Cancer Metastasis Rev 2020; 39:79-90. [PMID: 31993840 DOI: 10.1007/s10555-020-09849-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Most children are surviving acute lymphoblastic leukemia (ALL) today. Yet, the emergence of cardiometabolic comorbidities in this population may impact long-term outcomes including the quality of life and lifespan. Obesity is a major driver of cardiometabolic disorders in the general population, and in ALL patients it is associated with increased risk of hypertension, dysglycemia, and febrile neutropenia when compared with lean ALL patients undergoing therapy. This systematic review aims to assess the current evidence for bariatric interventions to manage obesity in children with ALL. The primary outcome for this systematic review was the change in BMI z-score with implementation of the interventions studied. Literature searches were conducted in several databases. Ten publications addressing the study question were included in this review, and five studies were used in the meta-analysis to assess the impact of the bariatric interventions on obesity. The BMI z-score did not change significantly with the interventions. However, the quality of evidence was low, which precluded the recommendation of their use. In conclusion, prospective, rigorous, adequately powered, and high-quality longitudinal studies are urgently needed to deliver effective lifestyle interventions to children with ALL to treat and prevent obesity. These interventions, if successful, may improves cardiometabolic health outcomes and enhance the quality of life and life expectancy in children with ALL.
Collapse
|
17
|
de Ferranti SD, Steinberger J, Ameduri R, Baker A, Gooding H, Kelly AS, Mietus-Snyder M, Mitsnefes MM, Peterson AL, St-Pierre J, Urbina EM, Zachariah JP, Zaidi AN. Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e603-e634. [PMID: 30798614 DOI: 10.1161/cir.0000000000000618] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.
Collapse
|
18
|
Cranial Irradiation in Childhood Acute Lymphoblastic Leukemia Is Related to Subclinical Left Ventricular Dysfunction and Reduced Large Artery Compliance in Cancer Survivors. J Clin Med 2019; 8:jcm8111952. [PMID: 31766118 PMCID: PMC6912438 DOI: 10.3390/jcm8111952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 11/17/2022] Open
Abstract
Long-term survivors of acute lymphoblastic leukemia (ALL), the most common childhood malignancy, are at remarkably increased risk of heart failure (HF) in middle age, most likely due anthracycline cardiotoxicity. The role of cranial radiation therapy (CRT) in the development of left ventricular (LV) dysfunction, a predecessor of overt HF, remains unclear. Our aim was to compare LV function and systemic arterial properties according to past CRT in young adult survivors of anthracycline-treated ALL. We studied young adult survivors of childhood ALL at a median of 16 years from diagnosis treated with anthracycline-based chemotherapy, with (n = 12) or without (n = 30) CRT. In addition to fractional shortening (FS) and ejection fraction (EF), LV function was quantified by tissue Doppler imaging of the mitral annulus. Aortic strain/distensibility and arterial compliance were derived from echocardiography and simultaneously recorded pulse pressure. Despite similar FS and EF, peak mitral annular systolic velocity (median (interquartile range): 9.0 (7.5–10.0) vs. 10.0 (8.8–11.5) cm/s, p = 0.05), and early diastolic velocity (13.8 (13.0–14.8) vs. 15.5 (14.0–17.3), p = 0.01) were decreased after chemotherapy combined with CRT compared to chemotherapy without CRT. Systemic arterial compliance was lower in post-CRT subjects (1.0 (0.8–1.2 vs. 1.4 (1.1–1.7) mL/mmHg, p = 0.002). Aortic strain and distensibility were similar regardless of prior CRT. In conclusion, lower arterial compliance and subclinical LV dysfunction may be possible late consequences of past CRT in adult survivors of childhood ALL. Whether arterial stiffening is associated with future HF development in CRT-exposed ALL survivors remains to be investigated.
Collapse
|
19
|
Kooijmans ECM, Bökenkamp A, Tjahjadi NS, Tettero JM, van Dulmen‐den Broeder E, van der Pal HJH, Veening MA. Early and late adverse renal effects after potentially nephrotoxic treatment for childhood cancer. Cochrane Database Syst Rev 2019; 3:CD008944. [PMID: 30855726 PMCID: PMC6410614 DOI: 10.1002/14651858.cd008944.pub3] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Improvements in diagnostics and treatment for paediatric malignancies resulted in a major increase in survival. However, childhood cancer survivors (CCS) are at risk of developing adverse effects caused by multimodal treatment for their malignancy. Nephrotoxicity is a known side effect of several treatments, including cisplatin, carboplatin, ifosfamide, radiotherapy and nephrectomy, and can cause glomerular filtration rate (GFR) impairment, proteinuria, tubulopathy, and hypertension. Evidence about the long-term effects of these treatments on renal function remains inconclusive. It is important to know the risk of, and risk factors for, early and late adverse renal effects, so that ultimately treatment and screening protocols can be adjusted. This review is an update of a previously published Cochrane Review. OBJECTIVES To evaluate existing evidence on the effects of potentially nephrotoxic treatment modalities on the prevalence of renal dysfunction in survivors treated for childhood cancer with a median or mean survival of at least one year after cessation of treatment, where possible in comparison with the general population or CCS treated without potentially nephrotoxic treatment. In addition, to evaluate evidence on associated risk factors, such as follow-up duration, age at time of diagnosis and treatment combinations, as well as the effect of doses. SEARCH METHODS On 31 March 2017 we searched the following electronic databases: CENTRAL, MEDLINE and Embase. In addition, we screened reference lists of relevant studies and we searched the congress proceedings of the International Society of Pediatric Oncology (SIOP) and The American Society of Pediatric Hematology/Oncology (ASPHO) from 2010 to 2016/2017. SELECTION CRITERIA Except for case reports, case series and studies including fewer than 20 participants, we included studies with all study designs that reported on renal function (one year or longer after cessation of treatment), in CCS treated before the age of 21 years with cisplatin, carboplatin, ifosfamide, radiation involving the kidney region, a nephrectomy, or a combination of two or more of these treatments. When not all treatment modalities were described or the study group of interest was unclear, a study was not eligible for the evaluation of prevalence. We still included it for the assessment of risk factors if it had performed a multivariable analysis. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction using standardised data collection forms. We performed analyses according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS Apart from the remaining 37 studies included from the original review, the search resulted in the inclusion of 24 new studies. In total, we included 61 studies; 46 for prevalence, six for both prevalence and risk factors, and nine not meeting the inclusion criteria, but assessing risk factors. The 52 studies evaluating the prevalence of renal dysfunction included 13,327 participants of interest, of whom at least 4499 underwent renal function testing. The prevalence of adverse renal effects ranged from 0% to 84%. This variation may be due to diversity of included malignancies, received treatments, reported outcome measures, follow-up duration and the methodological quality of available evidence.Seven out of 52 studies, including 244 participants, reported the prevalence of chronic kidney disease, which ranged from 2.4% to 32%.Of these 52 studies, 36 studied a decreased (estimated) GFR, including at least 432 CCS, and found it was present in 0% to 73.7% of participants. One eligible study reported an increased risk of glomerular dysfunction after concomitant treatment with aminoglycosides and vancomycin in CCS receiving total body irradiation (TBI). Four non-eligible studies assessing a total cohort of CCS, found nephrectomy and (high-dose (HD)) ifosfamide as risk factors for decreased GFR. The majority also reported cisplatin as a risk factor. In addition, two non-eligible studies showed an association of a longer follow-up period with glomerular dysfunction.Twenty-two out of 52 studies, including 851 participants, studied proteinuria, which was present in 3.5% to 84% of participants. Risk factors, analysed by three non-eligible studies, included HD cisplatin, (HD) ifosfamide, TBI, and a combination of nephrectomy and abdominal radiotherapy. However, studies were contradictory and incomparable.Eleven out of 52 studies assessed hypophosphataemia or tubular phosphate reabsorption (TPR), or both. Prevalence ranged between 0% and 36.8% for hypophosphataemia in 287 participants, and from 0% to 62.5% for impaired TPR in 246 participants. One non-eligible study investigated risk factors for hypophosphataemia, but could not find any association.Four out of 52 studies, including 128 CCS, assessed the prevalence of hypomagnesaemia, which ranged between 13.2% and 28.6%. Both non-eligible studies investigating risk factors identified cisplatin as a risk factor. Carboplatin, nephrectomy and follow-up time were other reported risk factors.The prevalence of hypertension ranged from 0% to 50% in 2464 participants (30/52 studies). Risk factors reported by one eligible study were older age at screening and abdominal radiotherapy. A non-eligible study also found long follow-up time as risk factor. Three non-eligible studies showed that a higher body mass index increased the risk of hypertension. Treatment-related risk factors were abdominal radiotherapy and TBI, but studies were inconsistent.Because of the profound heterogeneity of the studies, it was not possible to perform meta-analyses. Risk of bias was present in all studies. AUTHORS' CONCLUSIONS The prevalence of adverse renal effects after treatment with cisplatin, carboplatin, ifosfamide, radiation therapy involving the kidney region, nephrectomy, or any combination of these, ranged from 0% to 84% depending on the study population, received treatment combination, reported outcome measure, follow-up duration and methodological quality. With currently available evidence, it was not possible to draw solid conclusions regarding the prevalence of, and treatment-related risk factors for, specific adverse renal effects. Future studies should focus on adequate study designs and reporting, including large prospective cohort studies with adequate control groups when possible. In addition, these studies should deploy multivariable risk factor analyses to correct for possible confounding. Next to research concerning known nephrotoxic therapies, exploring nephrotoxicity after new therapeutic agents is advised for future studies. Until more evidence becomes available, CCS should preferably be enrolled into long-term follow-up programmes to monitor their renal function and blood pressure.
Collapse
Affiliation(s)
- Esmee CM Kooijmans
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HV
| | - Arend Bökenkamp
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatric NephrologyPO Box 7057AmsterdamNetherlands1007 MB
| | - Nic S Tjahjadi
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HV
| | - Jesse M Tettero
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HV
| | - Eline van Dulmen‐den Broeder
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HV
| | - Helena JH van der Pal
- Princess Maxima Center for Pediatric Oncology, KE.01.129.2PO Box 85090UtrechtNetherlands3508 AB
| | - Margreet A Veening
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of Pediatrics, Division of Oncology/HematologyDe Boelelaan 1117AmsterdamNetherlands1081 HV
| | | |
Collapse
|
20
|
Lupo PJ, Brown AL, Arroyo VM, Kamdar KY, Belmont JW, Scheurer ME, Leisenring WM, Gramatges MM, Okcu MF, Yasui Y, Oeffinger KC, Robison LL, Armstrong GT, Bhatia S. DNA methylation and obesity in survivors of pediatric acute lymphoblastic leukemia: A report from the Childhood Cancer Survivor Study. Genes Chromosomes Cancer 2018; 58:52-59. [PMID: 30382603 DOI: 10.1002/gcc.22701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/29/2018] [Accepted: 10/29/2018] [Indexed: 12/19/2022] Open
Abstract
Because survivors of pediatric acute lymphoblastic leukemia (ALL) are more likely to be obese than unaffected contemporaries, we compared DNA methylation profiles between normal-weight and obese survivors at adiposity-associated CpG sites previously-reported by epigenome-wide association studies (EWAS) of body mass index (BMI) in the general population. We selected 96 ALL survivors from the Childhood Cancer Survivor Study: 48 obese and 48 normal weight. The Illumina HumanMethylation450 BeadChip was used to compare DNA methylation at 211 loci identified in EWAS of BMI in the general population. Thirty-nine loci were associated (false discovery rate <0.05) with obesity among survivors who only received chemotherapy (n = 49). No loci were significantly associated with obesity among CRT-exposed survivors (n = 47). Our results suggest that previously identified BMI-DNA methylation loci are associated with obesity in ALL survivors who were spared CRT, while no loci were significantly associated with obesity in survivors who received CRT.
Collapse
Affiliation(s)
- Philip J Lupo
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Austin L Brown
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Vidal M Arroyo
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Kala Y Kamdar
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - John W Belmont
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | | | - Wendy M Leisenring
- Fred Hutchinson Cancer Research Center, Division of Public Health Sciences, Seattle, Washington
| | | | - M. Fatih Okcu
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas
| | - Yutaka Yasui
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | | | - Leslie L Robison
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | - Gregory T Armstrong
- St. Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, Tennessee
| | - Smita Bhatia
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, Alabama
| |
Collapse
|
21
|
Duncan CN, Brazauskas R, Huang J, Shaw BE, Majhail NS, Savani BN, Flowers MED, Battiwalla M, Beebe K, Dietz AC, Dvorak CC, Giller R, Jacobsohn DA, Kletzel M, Martin PL, Nemecek ER, Nuechterlein B, Talano JA, Pulsipher MA, Baker KS. Late cardiovascular morbidity and mortality following pediatric allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2018; 53:1278-1287. [PMID: 29581480 PMCID: PMC6158112 DOI: 10.1038/s41409-018-0155-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/19/2018] [Accepted: 02/16/2018] [Indexed: 01/19/2023]
Abstract
We analyzed late cardiovascular outcomes of 661 patients who survived at least 2 years from hematopoietic cell transplantation for childhood hematologic malignancy between 1995 and 2008. Center for International Blood and Marrow Transplant Research data was supplemented with surveys focused on cardiotoxicity and potential risk factors. The median duration of follow-up was 97 months (range 24-230). 4.2% of survivors experienced at least one of the primary outcomes including coronary artery disease (0.2%), cerebrovascular accident (0.6%), cardiomyopathy (3%), and cardiac-related death (0.5%). Patients who received anthracycline chemotherapy (HR 4.67, p = 0.036) or cranial or chest radiation (HR 5.58, p < 0.0001; HR 2.18, p = 0.0087) were at increased risk for developing one of the primary outcomes. Dyslipidemia was diagnosed in 18% of survivors. Pre-transplant anthracycline (HR 1.74, p < 0.0001) and chest radiation (HR 1.34, p = 0.0371) were risk factors for dyslipidemia. Overweight/obese body mass status was present in 63% of patients at baseline, 65% at 2 years, and 52% at most recent evaluation. Diabetes was diagnosed in 7% of subjects. In conclusion, severe cardiovascular complications were infrequently reported. The incidence of risk factors including obesity and dyslipidemia were significant and will likely increase the risk of cardiovascular disease over time in transplant survivors.
Collapse
Affiliation(s)
- Christine N Duncan
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA.
| | - Ruta Brazauskas
- Center of International Blood and Marrow Transplant Research, Froedtert and the Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jiaxing Huang
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bronwen E Shaw
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Navneet S Majhail
- Department of Hematology and Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Minoo Battiwalla
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Kristen Beebe
- Phoenix Children's Center for Cancer and Blood Disorders, Phoenix, AZ, USA
| | - Andrew C Dietz
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplantation, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Roger Giller
- University of Colorado Cancer Center, Aurora, CO, USA
| | - David A Jacobsohn
- Division of Blood and Marrow Transplantation, Center for Cancer and Blood Disorders, Children's National Health System, Washington, DC, USA
| | - Morris Kletzel
- Division of Hematology, Oncology, and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Paul L Martin
- Pediatric Division of Blood and Marrow Transplantation, Duke School of Medicine, Durham, NC, USA
| | - Eneida R Nemecek
- Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA
| | | | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael A Pulsipher
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - K Scott Baker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| |
Collapse
|
22
|
Cardiovascular risk factors are important determinants of platelet-dependent thrombin generation in adult survivors of childhood cancer. Clin Res Cardiol 2018; 108:438-447. [DOI: 10.1007/s00392-018-1374-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/14/2018] [Indexed: 10/28/2022]
|
23
|
Leahy J, Spahis S, Bonneil E, Garofalo C, Grimard G, Morel S, Laverdière C, Krajinovic M, Drouin S, Delvin E, Sinnett D, Marcil V, Levy E. Insight from mitochondrial functions and proteomics to understand cardiometabolic disorders in survivors of acute lymphoblastic leukemia. Metabolism 2018; 85:151-160. [PMID: 29563052 DOI: 10.1016/j.metabol.2018.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Childhood acute lymphoblastic leukemia (cALL) is the most prevalent form of cancer in children. Due to advances in treatment and therapy, young cALL subjects now achieve a 90% survival rate. However, this tremendous advance does not come without consequence since ~2/3 of cALL survivors are affected by long-term and late, severe complications. Although the metabolic syndrome is a very serious sequel of cALL, the mechanisms remain undefined. It is also surprising to note that the mitochondrion, a central organelle in metabolic functions and the main cellular energy generator, have not yet been explored. OBJECTIVES To determine whether cALL survivors exhibit impairments in their mitochondrial functions and proteomic profiling in relationship with metabolic disorders in cALL survivors compared to healthy controls. METHODS AND RESULTS Anthropometric measures, metabolic characteristics and lipid profiles were assessed, mitochondria isolated from peripheral blood mononuclear cells, and proteomic analyzed. Our data demonstrated that metabolically. Unhealthy survivors exhibited several metabolic syndrome components (e.g. overweight, insulin resistance, dyslipidemia, inflammation) whereas Healthy cALL survivors resemble the Controls. In line with these abnormalities, functional experiments in these subjects revealed a significant decrease in the protein expression of mitochondrial antioxidant superoxide dismutase, PGC1-α transcription factor (a key modulator of mitochondrion biogenesis), and an increase in pro-apoptotic cytochrome c. Proteomic analysis of mitochondria by mass spectrometry revealed changes in the regulation of proteins related to inflammation, apoptosis, energy production, redox and antioxidant activity, fatty acid β-oxidation, protein transport and metabolism, and signalling pathways between groups. CONCLUSIONS Through the use of proteomic analysis, our work demonstrated a number of significant alterations in protein expression in mitochondria of cALL survivors, especially the metabolically Unhealthy survivor group. Further investigation of these proteins may help delineate the mechanisms by which mitochondrial dysfunctions exert cardiometabolic derangements in cALL survivors.
Collapse
Affiliation(s)
- Jade Leahy
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Schohraya Spahis
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Eric Bonneil
- Proteomic Platform, IRIC Université de Montréal, Montreal, Quebec, Canada
| | - Carole Garofalo
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Guy Grimard
- Department of Paediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Sophia Morel
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Caroline Laverdière
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Paediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Maja Krajinovic
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Paediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Simon Drouin
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Edgard Delvin
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Daniel Sinnett
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Paediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Valérie Marcil
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada
| | - Emile Levy
- Research Centre, CHU-Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Department of Nutrition, Université de Montréal, Montreal, Quebec, Canada.
| |
Collapse
|
24
|
Ketterl TG, Chow EJ, Leisenring WM, Goodman P, Koves IH, Petryk A, Steinberger J, Baker KS. Adipokines, Inflammation, and Adiposity in Hematopoietic Cell Transplantation Survivors. Biol Blood Marrow Transplant 2018; 24:622-626. [PMID: 29197678 PMCID: PMC5831197 DOI: 10.1016/j.bbmt.2017.11.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/22/2017] [Indexed: 12/15/2022]
Abstract
Adult survivors of acute leukemia in childhood have a higher-than-expected frequency of obesity and are at increased risk for metabolic syndrome and early mortality from cardiovascular disease (CVD). Adipose tissue has been recognized as an endocrine and paracrine organ that secretes various adipokines involved in metabolic regulation and inflammatory processes. In this study, we examined inflammatory factors (IL-6 and TNF-α) and adipokines (adiponectin, leptin), in addition to body composition and adiposity, in cancer survivors who underwent hematopoietic cell transplantation (HCT) during childhood compared with sibling controls. Over 2-year survivors of HCT for hematologic malignancies during childhood were recruited from 2 institutions along with a control population of siblings. Participants underwent evaluation for body composition, anthropometric measurements, and assessment of CVD risk factors and adipokines. Cases were stratified by radiation exposure in the preparative regimen (total body irradiation [TBI] + central nervous system [CNS] irradiation, TBI only, chemotherapy only) and adjusted least squares means were estimated for each adipokine and adjusted by age, sex, race, Tanner stage, and percent fat mass (PFM) percentiles (0-24, 25-74, 75+). A total of 151 HCT survivors and 92 siblings underwent evaluation. Significant differences in mean adipokine levels were detected between survivors and siblings; leptin was significantly higher and adiponectin significantly lower in HCT survivors who received TBI with or without CNS irradiation compared with siblings. IL-6 was significantly higher in all groups of HCT survivors compared with siblings. Body mass index (BMI) was similar in survivors and controls, although PFM was significantly higher in all groups of HCT survivors and lean body mass (LBM) was lower in survivors who received TBI with or without CNS radiation compared with siblings. HCT survivors showed an unfavorable profile of inflammation, adipokines, and adiposity, despite similar BMI as controls. Higher PFM and lower LBM may contribute to these findings. TBI exposure is correlated with greater severity of these observations. Increasing LBM may represent a tangible target for mitigating the high cardiometabolic risks of HCT survivors.
Collapse
Affiliation(s)
- Tyler G Ketterl
- Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Eric J Chow
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Pam Goodman
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ildi H Koves
- Seattle Children's Hospital, Seattle, Washington
| | - Anna Petryk
- University of Minnesota Medical Center, Minneapolis, Minnesota
| | | | - K Scott Baker
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| |
Collapse
|
25
|
Guler E, Col N, Buyukcelik M, Balat A. Prevalence of hypertension determined by ambulatory blood pressure monitoring (ABPM) and body composition in long-term survivors of childhood cancer. Pediatr Hematol Oncol 2018. [PMID: 29528260 DOI: 10.1080/08880018.2018.1425784] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
AIM In recent years, survival rates of childhood cancers have significantly increased, and occurrence of long-term adverse late effects (eg, insulin resistance, diabetes mellitus, metabolic syndrome, hypertension) has become increasingly important. Early diagnosis of obesity/hypertension in childhood is essential to avoid morbidity in the adulthood. Therefore, this study was aimed to determine the blood pressure (BP) profile by ambulatory BP monitoring (ABPM) method, and prevalence of hypertension, obesity, abdominal obesity among childhood cancer survivors. MATERIAL AND METHOD The study was carried out with 52 cancer survivors. The ABPM measurement was performed during 24 hours. The anthropometric measurements of patients were performed using standardized protocols. The body composition analysis was performed with bioelectrical impedance analysis (BIA) method. Statistical significance was considered at p < 0.05. RESULTS The mean age of patients was 12.84 ± 3.88 years. Time off therapy ranged 24-125 month. The prevalence of prehypertension and hypertension were 57.7% and 9.6%, respectively. There was no statistically significant relationship between diagnosis and BP status (p = 0.59). The prevalence of obesity, and abdominal obesity were 1.9% and 30.4%, respectively. There was a positive correlation between waist circumference (WC) and time off therapy (p = 0.046). The WC was found to be higher in patients who received cranial irradiation (p = 0.048). Weight/WC were higher in patients who used corticosteroids in the treatment (p = 0.019). CONCLUSION Careful follow up of BP, weight and WC is necessary for long-term cancer survivors to prevent complications. Especially patients who receive cranial radiotherapy and use corticosteroid are at increased risk of abdominal obesity.
Collapse
Affiliation(s)
- Elif Guler
- a Department of Pediatric Hematology Oncology, Faculty of Medicine , University of Akdeniz , Antalya , Turkey
| | - Nilgun Col
- b Department of Social Pediatrics , Faculty of Medicine, University of Gaziantep , Gaziantep , Turkey
| | - Mithat Buyukcelik
- c Department of Pediatric Nephrology , Faculty of Medicine, University of Gaziantep , Gaziantep , Turkey
| | - Ayse Balat
- d Department of Pediatric Nephrology , Faculty of Medicine, University of İstanbul Aydın , İstanbul , Turkey
| |
Collapse
|
26
|
Orgel E, Mueske NM, Sposto R, Gilsanz V, Freyer DR, Mittelman SD. Limitations of body mass index to assess body composition due to sarcopenic obesity during leukemia therapy. Leuk Lymphoma 2018; 59:138-145. [PMID: 26818609 PMCID: PMC5362342 DOI: 10.3109/10428194.2015.1136741] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Obesity as defined by body mass index percentile (BMI%) is strongly associated with relapse and poorer survival in childhood ALL. Whether BMI% accurately reflects body fat percentage (BF%) in this population is unknown. We conducted a prospective study assessing body composition during frontline ALL therapy. Dual-energy X-ray absorptiometry measured BF% and lean muscle mass (LMM) at diagnosis, end of Induction, and end of Delayed Intensification. Sarcopenic obesity (gain in BF% with loss of LMM) was surprisingly common during ALL treatment, resulting in poor correlation between changes in BMI% (expressed as Z-score) and BF% overall (r = -0.05) and within patients (r = -0.09). BMI Z-score and BF% changed in opposite directions in >50% of interval assessments. While BMI% at diagnosis is a suitable predictor of obesity/BF% for epidemiological studies, change in BMI% (as expressed as Z-score) does not reflect body composition. Studies evaluating obesity in leukemia should consider using direct measures of body composition.
Collapse
Affiliation(s)
- Etan Orgel
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- Jonathan Jaques Children’s Cancer Center, Miller Children’s Hospital Long Beach, Long Beach, CA
- University of Southern California, Los Angeles, CA
| | - Nicole M Mueske
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Richard Sposto
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- University of Southern California, Los Angeles, CA
| | - Vicente Gilsanz
- University of Southern California, Los Angeles, CA
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - David R Freyer
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- University of Southern California, Los Angeles, CA
| | - Steven D Mittelman
- University of Southern California, Los Angeles, CA
- Center for Endocrinology, Children’s Hospital Los Angeles, Los Angeles, CA
| |
Collapse
|
27
|
England J, Drouin S, Beaulieu P, St-Onge P, Krajinovic M, Laverdière C, Levy E, Marcil V, Sinnett D. Genomic determinants of long-term cardiometabolic complications in childhood acute lymphoblastic leukemia survivors. BMC Cancer 2017; 17:751. [PMID: 29126409 PMCID: PMC5681795 DOI: 10.1186/s12885-017-3722-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 10/30/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND While cure rates for childhood acute lymphoblastic leukemia (cALL) now exceed 80%, over 60% of survivors will face treatment-related long-term sequelae, including cardiometabolic complications such as obesity, insulin resistance, dyslipidemia and hypertension. Although genetic susceptibility contributes to the development of these problems, there are very few studies that have so far addressed this issue in a cALL survivorship context. METHODS In this study, we aimed at evaluating the associations between common and rare genetic variants and long-term cardiometabolic complications in survivors of cALL. We examined the cardiometabolic profile and performed whole-exome sequencing in 209 cALL survivors from the PETALE cohort. Variants associated with cardiometabolic outcomes were identified using PLINK (common) or SKAT (common and rare) and a logistic regression was used to evaluate their impact in multivariate models. RESULTS Our results showed that rare and common variants in the BAD and FCRL3 genes were associated (p<0.05) with an extreme cardiometabolic phenotype (3 or more cardiometabolic risk factors). Common variants in OGFOD3 and APOB as well as rare and common BAD variants were significantly (p<0.05) associated with dyslipidemia. Common BAD and SERPINA6 variants were associated (p<0.05) with obesity and insulin resistance, respectively. CONCLUSIONS In summary, we identified genetic susceptibility loci as contributing factors to the development of late treatment-related cardiometabolic complications in cALL survivors. These biomarkers could be used as early detection strategies to identify susceptible individuals and implement appropriate measures and follow-up to prevent the development of risk factors in this high-risk population.
Collapse
Affiliation(s)
- Jade England
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
| | - Simon Drouin
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
| | - Patrick Beaulieu
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
| | - Pascal St-Onge
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
| | - Maja Krajinovic
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
| | - Caroline Laverdière
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
- Departments of Pediatrics, Université de Montréal, Montreal, Quebec, H3T 1C5 Canada
| | - Emile Levy
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
- Departments of Nutrition, Université de Montréal, Montreal, Quebec, H3T 1C5 Canada
| | - Valérie Marcil
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
- Departments of Nutrition, Université de Montréal, Montreal, Quebec, H3T 1C5 Canada
| | - Daniel Sinnett
- Research Centre, Sainte-Justine University Health Center, 3175 chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5 Canada
- Departments of Pediatrics, Université de Montréal, Montreal, Quebec, H3T 1C5 Canada
| |
Collapse
|
28
|
Devine KA, Mertens AC, Whitton JA, Wilson CL, Ness KK, Gilleland Marchak J, Leisenring W, Oeffinger KC, Robison LL, Armstrong GT, Krull KR. Factors associated with physical activity among adolescent and young adult survivors of early childhood cancer: A report from the childhood cancer survivor study (CCSS). Psychooncology 2017; 27:613-619. [PMID: 28805953 DOI: 10.1002/pon.4528] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/21/2017] [Accepted: 08/04/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate concurrent and longitudinal associations between psychosocial functioning and physical activity in adolescent and young adult survivors of early childhood cancer. METHODS Adolescent survivors of early childhood cancer (diagnosed before age four) participating in the Childhood Cancer Survivor Study completed the Coping Health and Illness Profile-Adolescent Edition (CHIP-AE; n = 303; mean age at survey: 17.6 years). A subset of these survivors (n = 248) completed a follow-up survey an average of 6.0 years later (range: 4-10). Logistic regression identified associations between psychosocial functioning in adolescence and physical activity levels in adolescence and young adulthood. RESULTS Survivors reported low physical activity as adolescents (46.1% scored below CHIP-AE cut-point) and young adults (40.8% below Centers for Disease Control guidelines). Poor physical activity during adolescence was associated with female sex (OR = 2.06, 95% CI, 1.18-3.68), parents with less than a college education (OR = 1.91, 95% CI, 1.11-3.32), previous treatment with cranial radiation (OR = 3.35, 95% CI, 1.69-6.88), TV time (OR = 1.77, 95% CI, 1.00-3.14), and limitations of activity due to health or mobility restrictions (OR = 8.28, 95% CI, 2.87-30.34). Poor diet (OR = 1.84, 95% CI, 1.05-3.26) and low self-esteem (OR = 1.80, 95% CI, 0.99-3.31) during adolescence were associated with lower odds of meeting Centers for Disease Control physical activity guidelines in young adulthood. CONCLUSION These findings provide targets for future interventional studies to improve physical activity in this high-risk population.
Collapse
Affiliation(s)
- Katie A Devine
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Ann C Mertens
- Aflac Cancer and Blood Disorders Center, Emory University School of Medicine, Atlanta, GA, USA
| | - John A Whitton
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Kevin R Krull
- St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
29
|
Marlatt KL, Steinberger J, Rudser KD, Dengel DR, Sadak KT, Lee JL, Blaes AH, Duprez DA, Perkins JL, Ross JA, Kelly AS. The Effect of Atorvastatin on Vascular Function and Structure in Young Adult Survivors of Childhood Cancer: A Randomized, Placebo-Controlled Pilot Clinical Trial. J Adolesc Young Adult Oncol 2017; 8:442-450. [PMID: 28853979 DOI: 10.1089/jayao.2017.0075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose: Many adult survivors of childhood cancer are at high-risk of developing cardiovascular disease. Cancer therapy may cause damage to the vascular endothelium, thereby initiating atherosclerosis. Atorvastatin has been shown to improve endothelial function independent of reducing cholesterol, as well as reduce/slow arterial stiffness and thickening, yet has never been studied in childhood cancer survivors (CCS). Methods: Twenty-seven young adult (age 26.8 ± 6.2 years) survivors of childhood acute lymphoblastic leukemia or Non-Hodgkin's lymphoma were randomly assigned (1:1) 40 mg/day of atorvastatin or placebo for 6 months. Brachial artery flow-mediated dilation (FMD), small artery reactive hyperemia index (RHI), arterial stiffness, and carotid artery elasticity/thickness were assessed. Results: Fifteen participants completed the trial. No significant treatment effect for any vascular outcomes was observed at 6 months; however, a significant decrease in peak FMD (-3.0 [95% confidence interval [CI]: -5.3, -0.7]) and a trending significant decrease in RHI (-0.3 [95% CI: -0.62, 0.01]) was observed in the placebo group, resulting in a trend toward a treatment effects (p < 0.10). No effect on arterial stiffness, carotid arterial elasticity, or thickness was observed. Conclusion: Six months of atorvastatin treatment did not improve endothelial function or arterial stiffness in young adult CCS. While a trend toward an improvement in endothelial function was present, findings should be interpreted with caution owing to the small number of evaluable participants and subsequent lack of sufficient power. Further research in a larger sample size is needed to fully elucidate the effects of atorvastatin on vascular function. Trial registered at clinicaltrials.gov as NCT01733953.
Collapse
Affiliation(s)
- Kara L Marlatt
- 1Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Julia Steinberger
- 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kyle D Rudser
- 3Division of Biostatistics, School of Public Health, and Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota
| | - Donald R Dengel
- 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.,4Laboratory of Integrative Human Physiology, School of Kinesiology, University of Minnesota, Minneapolis, Minnesota
| | - Karim T Sadak
- 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Jill L Lee
- 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Anne H Blaes
- 5Cancer and Blood Disorders Program, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.,6Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Daniel A Duprez
- 6Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Joanna L Perkins
- 5Cancer and Blood Disorders Program, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Julie A Ross
- 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Aaron S Kelly
- 2Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.,6Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| |
Collapse
|
30
|
Parental Perceptions of Obesity and Obesity Risk Associated With Childhood Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2017; 39:370-375. [PMID: 28538500 DOI: 10.1097/mph.0000000000000852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The prevalence of obesity and related comorbidities in survivors of childhood acute lymphoblastic leukemia (ALL) is well established and ranges anywhere from 29% to 69% depending on the study. We sought to explore the awareness of parents of survivors of childhood ALL regarding the increased risk of obesity and their perceptions regarding the overall health of their child. One hundred twenty-one parents of 99 survivors of pediatric ALL completed surveys regarding perceptions of obesity risk in survivors. Eighty percent of parents of overweight and obese survivors correctly identified their child as "a little overweight" or "overweight." Few parents recalled discussing weight gain (21%) or obesity risk (36%) with their practitioner. Parents that did recall having these discussions and/or reported a decreased level of posttherapy activity in their child were more likely to be concerned about their child's weight status. Improved awareness and education regarding the risk of obesity and associated comorbid conditions may provide an avenue for future prevention of obesity in survivors of pediatric ALL. Discussion and education regarding a healthy lifestyle, including proper diet and exercise, should be incorporated early in routine patient visits.
Collapse
|
31
|
Development and validation of a screening instrument to identify cardiometabolic predictors of mortality in older individuals with cancer: Secondary analysis of the Australian Longitudinal Study of Ageing (ALSA). J Geriatr Oncol 2017. [PMID: 28642039 DOI: 10.1016/j.jgo.2017.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of this study was to identify significant cardiometabolic predictors of mortality among older cancer survivors and develop and validate a screening instrument to assess individual risk of mortality. MATERIALS AND METHODS Retrospective cohort study used collected data from the ALSA. Cox proportional hazards model was used to derive the risk equation for mortality that could be evaluated at 10years. Measures of discrimination and calibration were calculated in the validation cohort. RESULTS The equation was developed using 294 cancer survivors and validated in 127 different cancer survivors. Significant cardiometabolic predictors of mortality included in the final model are age, sex, history of cerebrovascular disease, non-adherence to exercise guidelines (150min moderate activity per week), and smoking. Discrimination and calibration were acceptable with minimal differences in C statistics (0.0442, 95% CI: -0.0149 to 0.103) and adjusted R2 values (0.0407, 95% CI: -0.181 to 0.0998) between the development and validation cohorts, respectively. CONCLUSION We have developed and validated the first screening tool to predict cardiometabolic risk of mortality in older cancer survivors and defined centile values for risk classification. Further validation and research on the usability and usefulness of the tool in clinical practice are recommended in order to target cancer survivors for interventions. Cost effectiveness of such an approach should also be examined.
Collapse
|
32
|
Collins L, Beaumont L, Cranston A, Savoie S, Nayiager T, Barr R. Anthropometry in Long-Term Survivors of Acute Lymphoblastic Leukemia in Childhood and Adolescence. J Adolesc Young Adult Oncol 2017; 6:294-298. [DOI: 10.1089/jayao.2016.0091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Laura Collins
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lesley Beaumont
- Department of Nuclear Medicine, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Amy Cranston
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Stefanie Savoie
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Trishana Nayiager
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ronald Barr
- Service of Hematology-Oncology, McMaster Children's Hospital, Hamilton, Ontario, Canada
- Division of Hematology-Oncology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
33
|
Marcoux S, Drouin S, Laverdière C, Alos N, Andelfinger GU, Bertout L, Curnier D, Friedrich MG, Kritikou EA, Lefebvre G, Levy E, Lippé S, Marcil V, Raboisson MJ, Rauch F, Robaey P, Samoilenko M, Séguin C, Sultan S, Krajinovic M, Sinnett D. The PETALE study: Late adverse effects and biomarkers in childhood acute lymphoblastic leukemia survivors. Pediatr Blood Cancer 2017; 64. [PMID: 27917589 DOI: 10.1002/pbc.26361] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/27/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Childhood cancer survivorship issues represent an established public health challenge. Most late adverse effects (LAEs) have been demonstrated to be time and treatment dependent. The PETALE study is a multidisciplinary research project aiming to comprehensively characterize LAEs and identify associated predictive biomarkers in childhood acute lymphoblastic leukemia (cALL) survivors. METHODS cALL survivors treated at Sainte-Justine University Health Center with Dana-Farber Cancer Institution-ALL protocols 87-01 through 2005-01 were eligible. During Phase I of the study, the participants underwent comprehensive clinical, biologic, and psychosocial investigation targeting metabolic syndrome, cardiotoxicity, bone morbidity, neurocognitive problems, and quality of life issues. Whole-exome sequencing was performed for all participants. Subjects identified with an extreme phenotype during Phase I were recalled for additional testing (Phase II). RESULTS Phase I included 246 survivors (recall rate 71.9%). Of those, 85 participants completed Phase II (recall rate 88.5%). Survivors agreeing to participate in Phase I (n = 251) were similar to those who refused (n = 31) in terms of relapse risk profile, radiotherapy exposure, and age at the time of study. Participants, however, tended to be slightly older at diagnosis (6.1 vs. 4.7 years old, P = 0.08), with a higher proportion of female agreeing to participate compared with males (93.2 vs. 86.5%, P = 0.07). CONCLUSION The PETALE study will contribute to comprehensively characterize clinical, psychosocial, biologic, and genomic features of cALL survivors using an integrated approach. Expected outcomes include LAE early detection biomarkers, long-term follow-up guidelines, and recommendations for physicians and health professionals.
Collapse
Affiliation(s)
- Sophie Marcoux
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Simon Drouin
- Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Caroline Laverdière
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Nathalie Alos
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Gregor U Andelfinger
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Laurence Bertout
- Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Daniel Curnier
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | | | | | | | - Emile Levy
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Sarah Lippé
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Valérie Marcil
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Marie-Josée Raboisson
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Frank Rauch
- Shriners Hospitals for Children, Montréal, Québec, Canada
| | - Philippe Robaey
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada.,Children's Hospital of Eastern Ontario (CHEO), Ottawa, Ontario, Canada
| | | | - Chantal Séguin
- McGill University Health Center Research Institute, Montréal, Québec, Canada
| | - Serge Sultan
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Maja Krajinovic
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| | - Daniel Sinnett
- Université de Montréal, Montréal, Québec, Canada.,Sainte-Justine University Health Center (SJUHC), Montréal, Québec, Canada
| |
Collapse
|
34
|
Delvecchio M, Muggeo P, Monteduro M, Lassandro G, Novielli C, Valente F, Salinaro E, Zito A, Ciccone MM, Miniello VL, Santoro N, Giordano P, Faienza MF. Non-alcoholic fatty liver disease is associated with early left ventricular dysfunction in childhood acute lymphoblastic leukaemia survivors. Eur J Endocrinol 2017; 176:111-121. [PMID: 27913605 DOI: 10.1530/eje-16-0608] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/11/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Childhood acute lymphoblastic leukaemia (ALL) survivors have an increased risk of metabolic and cardiovascular disease. We aimed to assess the presence of non-alcoholic fatty liver disease (NAFLD) in childhood ALL and if it is associated with early cardiovascular dysfunction. METHODS In total, 53 childhood ALL survivors and 34 controls underwent auxological evaluation, biochemical assay, liver, heart and vascular ultrasound study. RESULTS NAFLD was more frequent in ALL patients than in controls (39.6% vs 11.7%, P < 0.01). Patients with NAFLD were more obese and insulin resistant than patients without NAFLD. Flow-mediated dilatation and interventricular septum were lower in the ALL group than those in the control group (P < 0.001 for both). The patients with NAFLD showed lower left ventricular ejection fraction than those without NAFLD (P = 0.011). In ALL survivors, BMI-SDS and subcutaneous fat were the strongest predictors of NAFLD, whereas preperitoneal adipose tissue and C-reactive protein were the strongest predictors of left ventricular ejection fraction. CONCLUSIONS Childhood ALL survivors had higher prevalence of NAFLD than healthy controls, which is associated with early left ventricular impairment. In the case of fatty liver, a comprehensive heart evaluation is mandatory. We strongly recommend to prevent visceral adiposity in ALL survivors, to search for metabolic syndrome or its components and to reinforce the need of intervention on diet and lifestyle during the follow-up of these patients.
Collapse
Affiliation(s)
- Maurizio Delvecchio
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | - Paola Muggeo
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | | | - Giuseppe Lassandro
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | - Chiara Novielli
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | - Federica Valente
- Department of Emergency and Organ Transplantation (DETO)Cardiovascular Diseases Section, University 'A. Moro' of Bari, Bari, Italy
| | - Emanuela Salinaro
- Department of Diagnostic ImagingUniversity of Bari 'A. Moro', Bari, Italy
| | - Annapaola Zito
- Department of Emergency and Organ Transplantation (DETO)Cardiovascular Diseases Section, University 'A. Moro' of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Department of Emergency and Organ Transplantation (DETO)Cardiovascular Diseases Section, University 'A. Moro' of Bari, Bari, Italy
| | - Vito Leonardo Miniello
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | - Nicola Santoro
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | - Paola Giordano
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| | - Maria Felicia Faienza
- Department of Biomedicine and Human OncologyPediatric Section, University 'A. Moro' of Bari, Bari, Italy
| |
Collapse
|
35
|
Gibson TM, Ehrhardt MJ, Ness KK. Obesity and Metabolic Syndrome Among Adult Survivors of Childhood Leukemia. Curr Treat Options Oncol 2016; 17:17. [PMID: 26951206 DOI: 10.1007/s11864-016-0393-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Treatment-related obesity and the metabolic syndrome in adult survivors of childhood acute lymphoblastic leukemia (ALL) are risk factors for cardiovascular disease. Both conditions often begin during therapy. Preventive measures, including dietary counseling and tailored exercise, should be initiated early in the course of survivorship, with referral to specialists to optimize success. However, among adults who develop obesity or the metabolic syndrome and who do not respond to lifestyle therapy, medical intervention may be indicated to manage underlying pathology, such as growth hormone deficiency, or to mitigate risk factors of cardiovascular disease. Because no specific clinical trials have been done in this population to treat metabolic syndrome or its components, clinicians who follow adult survivors of childhood ALL should use the existing American Heart Association/National Heart Lung and Blood Institute Scientific Statement to guide their approach.
Collapse
Affiliation(s)
- Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 735, Memphis, TN, 38105, USA.
| | - Matthew J Ehrhardt
- Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 735, Memphis, TN, 38105, USA.
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 735, Memphis, TN, 38105, USA.
| |
Collapse
|
36
|
The Estimation of Intima-Media Thickness and Cardiovascular Risk Factors in Young Survivors of Childhood Cancer. J Pediatr Hematol Oncol 2016; 38:549-54. [PMID: 26907643 DOI: 10.1097/mph.0000000000000513] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cancer treatment in childhood is thought to accelerate the development of atherosclerosis, leading to significant cardiovascular complications and, ultimately, increasing cardiovascular mortality in childhood cancer survivors, which explains the need to assess vascular status in this group. The purpose of this paper was to assess early atherosclerotic lesions based on the analysis of intima-media thickness (IMT) of the common carotid artery, as well as to analyze cardiovascular risk factors in young childhood cancer survivors. The analysis of 158 patients aged 6 to29 years, with a history of previous cancer treatment for different childhood malignancies, revealed a statistically significant difference in IMT between them and 66 age-matched healthy controls. The observed higher IMT scores in childhood cancer survivors may be indicative of premature atherosclerosis. The actual scores were 0.056±0.007 versus 0.052±0.003 (P=0.0001) as a mean score for both carotid arteries in the study group and controls, respectively. We did not observe significant differences in IMT between cancer survivors treated with chemotherapy only versus those treated with chemotherapy and radiotherapy. Similar to the general population, childhood cancer survivors are affected by different cardiovascular risk factors. These factors may enhance the direct cardiotoxicity of cancer treatment, leading to symptomatic incidents in further life, which emphasizes the need of early prevention and/or treatment in this subpopulation.
Collapse
|
37
|
Abstract
This integrative literature review focuses on (1) the spectrum of cardiovascular late effects; (2) the factors that can influence the development of cardiovascular late effects; and (3) the role of the pediatric oncology nurse in minimizing the risks of cardiovascular late effects and associated disabilities in childhood cancer survivorship. The results showed that survivors who have been treated with radiation therapy, especially when the field includes the heart or the hypothalamic-pituitary axis (HPA), and specific chemotherapies are at increased risk for developing particular cardiovascular risk factors and/or cardiovascular disease. Younger age at diagnosis, longer time since treatment, and family history of early heart disease can further heighten the risks. The role of pediatric oncology nurses in the promotion of cardiovascular health for children with cancer across the illness trajectory is discussed.
Collapse
Affiliation(s)
- Dawn M Greving
- Hematology/Oncology Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA.
| | | |
Collapse
|
38
|
Krawczuk-Rybak M, Tomczuk-Ostapczuk M, Panasiuk A, Goscik E. Carotid intima-media thickness in young survivors of childhood cancer. J Med Imaging Radiat Oncol 2016; 61:85-92. [DOI: 10.1111/1754-9485.12510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/23/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Maryna Krawczuk-Rybak
- Department of Pediatric Oncology and Hematology; Medical University of Bialystok; Bialystok Poland
| | - Monika Tomczuk-Ostapczuk
- Department of Pediatric Radiology; Medical University of Bialystok; Children's Clinical Hospital of L. Zamenhof; Bialystok Poland
| | - Anna Panasiuk
- Department of Pediatric Oncology and Hematology; Medical University of Bialystok; Bialystok Poland
| | - Elzbieta Goscik
- Department of Pediatric Radiology; Medical University of Bialystok; Children's Clinical Hospital of L. Zamenhof; Bialystok Poland
| |
Collapse
|
39
|
Jahnukainen K, Heikkinen R, Henriksson M, Andersson S, Ivaska KK, Puukko-Viertomies LR, Mäkitie O. Increased Body Adiposity and Serum Leptin Concentrations in Very Long-Term Adult Male Survivors of Childhood Acute Lymphoblastic Leukemia. Horm Res Paediatr 2016; 84:108-15. [PMID: 26088403 DOI: 10.1159/000431092] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 04/28/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We evaluated the body composition and its association with hypogonadism in adult male long-term acute lymphoblastic leukemia (ALL) survivors. METHODS The cohort included 49 long-term male ALL survivors and 55 age-matched healthy controls. Fat and lean mass was assessed by dual-energy X-ray absorptiometry; blood biochemistry was obtained for adipokines and testicular endocrine markers. RESULTS As compared with controls, the ALL survivors (median age 29 years, range 25-38), assessed 10-28 years after ALL diagnosis, had higher percentages of body (p < 0.05) and trunk fat mass (p < 0.05), and a lower body lean mass (p < 0.001). Survivors had significantly higher levels of leptin and adiponectin and lower levels of insulin-like growth factor-binding protein 3. Body fat mass and percent fat mass correlated with serum leptin and sex hormone-binding globulin (SHBG) levels. Altogether, 15% of the ALL survivors and 9% of age-matched controls were obese (BMI ≥ 30). Obese survivors more often had hypogonadism, had received testicular irradiation, and needed testosterone replacement therapy compared to nonobese survivors. CONCLUSION At young adulthood, long-term male ALL survivors have significantly increased body adiposity despite normal weight and BMI. Potential indicators of increased adiposity included high leptin and low SHBG levels. Serum testicular endocrine markers did not correlate with body adiposity.
Collapse
Affiliation(s)
- Kirsi Jahnukainen
- Divisions of Hematology-Oncology and Stem Cell Transplantation, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | | | | | | | | | | | | |
Collapse
|
40
|
Abnormal correlation of circulating endothelial progenitor cells and endothelin-1 concentration may contribute to the development of arterial hypertension in childhood acute lymphoblastic leukemia survivors. Hypertens Res 2016; 39:530-5. [PMID: 26935039 DOI: 10.1038/hr.2016.22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/17/2015] [Accepted: 01/25/2016] [Indexed: 12/26/2022]
Abstract
It is well known that the rate of arterial hypertension (AH) in childhood acute lymphoblastic leukemia (ALL) survivors is significantly higher than that in the healthy pediatric population; however, the mechanism of this phenomenon is not fully understood. The developing cardiovascular system in children is thought to be highly susceptible to the toxic effects of chemotherapy, which causes damage to the blood vessel wall, including the endothelium. Endothelin-1 (ET-1) is a marker of endothelial damage, and it contributes to AH. Endothelial progenitor cells (EPCs) are derived from the bone marrow and participate in the process of blood vessel repair. The aim of this study was to determine the relationship between the rate of circulating EPCs and plasma levels of ET-1 with respect to hypertension in childhood ALL survivors. The study included 88 childhood ALL survivors and 44 healthy children as controls. All patients and controls had 24-h blood pressure monitoring with a HolCARD CR-07 device. The number of EPCs and the ET-1 serum concentration were measured in the peripheral blood of patients and controls using flow cytometry and enzyme-linked immunosorbent assay, respectively. A correlation was found between the number of EPCs and the ET-1 concentration in the peripheral blood of healthy children and normotensive ALL survivors. However, such a correlation was not found in hypertensive childhood ALL survivors. We conclude that dysregulation of the 'ET-1 and EPC axis' may contribute to the development of AH in some childhood ALL survivors.
Collapse
|
41
|
Mohapatra S, Bansal D, Bhalla AK, Verma Attri S, Sachdeva N, Trehan A, Marwaha RK. Is there an increased risk of metabolic syndrome among childhood acute lymphoblastic leukemia survivors? A developing country experience. Pediatr Hematol Oncol 2016; 33:136-49. [PMID: 26984439 DOI: 10.3109/08880018.2016.1152335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Data on metabolic syndrome (MS) in survivors of childhood acute lymphoblastic leukemia (ALL) from developing countries are lacking. The purpose of this single-center, uncontrolled, observational study was to assess the frequency of MS in our survivors. The survivors of ALL ≤15 years at diagnosis, who had completed therapy ≥2 years earlier, were enrolled. Anthropometric measurements (weight, height, waist circumference), biochemistry (glucose, insulin, triglycerides, high-density lipoprotein [HDL], thyroid function tests, C-reactive protein [CRP], magnesium), measurement of blood pressure, and Tanner staging were performed. MS was defined by International Diabetes Federation (IDF) and the National Cholesterol Education Program Third Adult Treatment Panel guidelines (NCEP ATP III) criteria, modified by Cook et al. (Arch Pediatr Adolesc Med. 2003;157:821-827) and Ford et al. (Diabetes Care. 2005;28:878-881). The median age of 76 survivors was 11.9 years (interquartile range [IQR]: 9.6-13.5). Twenty-four (32%) survivors were obese or overweight. The prevalence of insulin resistance (17%), hypertension (7%), hypertriglyceridemia (20%), and low HDL (37%) was comparable to the prevalence in children/adolescents in historical population-based studies from India. The prevalence of MS ranged from 1.3% to 5.2%, as per different defining criteria. Cranial radiotherapy, age at diagnosis, sex, or socioeconomic status were not risk factors for MS. The prevalence of MS in survivors of childhood ALL, at a median duration of 3 years from completion of chemotherapy, was comparable to the reference population. The prevalence of being obese or overweight was, however, greater than historical controls.
Collapse
Affiliation(s)
- Sonali Mohapatra
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Deepak Bansal
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - A K Bhalla
- b Growth and Anthropology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Savita Verma Attri
- c Biochemistry Unit, Department of Pediatrics, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Naresh Sachdeva
- d Department of Endocrinology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Amita Trehan
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - R K Marwaha
- a Hematology-Oncology Unit, Advanced Pediatric Center, Post Graduate Institute of Medical Education and Research , Chandigarh , India
| |
Collapse
|
42
|
Shepard CW, Steinberger J. Premature Atherosclerotic Cardiovascular Disease in Childhood Cancer Survivors. PROGRESS IN PEDIATRIC CARDIOLOGY 2016; 39:59-66. [PMID: 26823646 DOI: 10.1016/j.ppedcard.2015.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Survival rates of childhood cancer have increased over the last 30 years, revealing a population with unique characteristics and risks. The effects of radiation and cardiotoxic chemotherapy predispose these children to both early and late cardiovascular disease. Cranial radiation also increases the likelihood of growth hormone deficiency, which leads to metabolic disturbances. Childhood cancer survivors are less likely to be active than their healthy siblings, and have a lower aptitude for physical activity. These issues are additive to the usual risks experienced by the general population, thereby significantly increasing the likelihood of premature cardiovascular disease. Early and regular screening and risk factor management in this population is recommended.
Collapse
Affiliation(s)
- Charles W Shepard
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Julia Steinberger
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| |
Collapse
|
43
|
Abstract
A high prevalence of obesity and cardiometabolic conditions has been increasingly recognized in childhood cancer survivors. In particular, survivors of pediatric acute lymphoblastic leukemia have been found to be at risk of becoming overweight or obese early in treatment, with increases in weight maintained throughout treatment and beyond. Nutrition plays an important role in the etiology of obesity and cardiometabolic conditions and is among the few modifiable factors that can prevent or delay the early onset of these chronic conditions. However, nutritional intake in childhood cancer survivors has not been adequately examined and the evidence is built on data from small cohorts of survivors. In addition, the long-term impact of cancer diagnosis and treatment on survivors' nutritional intake as well as how survivors' nutritional intake is associated with chronic health conditions have not been well quantified in large-scale studies. Promoting family-based healthy lifestyles, preferably at a sensitive window of unhealthy weight gain, is a priority for preventing the early onset of obesity and cardiometabolic conditions in childhood cancer survivors.
Collapse
Affiliation(s)
- Fang Fang Zhang
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy, and Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA;
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; and Departments of Medicine, Pediatrics, and Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA
| |
Collapse
|
44
|
Siviero-Miachon AA, Spinola-Castro AM, de Martino Lee ML, de Castro Monteiro CM, de Camargo Carvalho AC, Calixto AR, Geloneze B, Guerra-Junior G. Subcutaneous adipose tissue plays a beneficial effect on subclinical atherosclerosis in young survivors of acute lymphocytic leukemia. Vasc Health Risk Manag 2015; 11:479-88. [PMID: 26316772 PMCID: PMC4547649 DOI: 10.2147/vhrm.s86883] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose The aim of this study was to evaluate the relationship between body composition, metabolic profile, adipokines, and carotid intima-media thickness (cIMT) in young survivors of childhood acute lymphocytic leukemia (ALL). Patients and methods This cross-sectional study compared 55 ALL survivors, of chronological age between 15 years and 24 years, assigned into two groups according to the exposure to cranial radiation therapy (CRT; 25 irradiated and 30 nonirradiated) with 24 leukemia-free controls, and assessed body fat mass (dual-energy X-ray absorptiometry), computed tomography scan-derived abdominal adipose tissue, lipid profile, blood pressure (BP), adipokines, and cIMT by a multiple regression analysis. Results Treatment with CRT had an effect on all of the variables derived from the computed tomography scan: visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) (P<0.050). In a multiple linear regression model, cIMT positively correlated with exposure to CRT (P=0.029), diastolic BP (P=0.016), and leptin-to-adiponectin ratio (P=0.048), while negatively related to SAT (P=0.007). Conclusion In young survivors of childhood ALL, CRT modified the distribution of fat and played a critical role in determining cIMT. Leptin-to-adiponectin ratio, a biomarker of abdominal obesity and metabolic syndrome, and diastolic BP also influenced cIMT, a marker of subclinical atherosclerosis. Nonetheless, adiposity-associated vascular disease might be attenuated by SAT. Changes in body fat must be evaluated in this group of patients in the early course of survivorship in order to avoid premature cardiovascular disease associated with atherosclerosis. Yet, further research as regards the possible protective effect of SAT on vascular disease is warranted.
Collapse
Affiliation(s)
- Adriana Aparecida Siviero-Miachon
- Division of Pediatric Endocrinology, Department of Pediatrics, Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, Brazil ; Pediatric Oncology Institute - IOP/GRAACC, Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, Brazil
| | - Angela Maria Spinola-Castro
- Division of Pediatric Endocrinology, Department of Pediatrics, Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, Brazil ; Pediatric Oncology Institute - IOP/GRAACC, Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, Brazil
| | - Maria Lucia de Martino Lee
- Pediatric Oncology Institute - IOP/GRAACC, Federal University of Sao Paulo (UNIFESP/EPM), Sao Paulo, Brazil
| | | | | | - Antonio Ramos Calixto
- Laboratory of Investigation on Metabolism and Diabetes (LIMED), Faculty of Medical Sciences, State University of Campinas (UNICAMP), Brazil
| | - Bruno Geloneze
- Laboratory of Investigation on Metabolism and Diabetes (LIMED), Faculty of Medical Sciences, State University of Campinas (UNICAMP), Brazil
| | - Gil Guerra-Junior
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Brazil
| |
Collapse
|
45
|
Al-Kindi SG, Abu-Zeinah GF, Kim CH, Hejjaji V, William BM, Caimi PF, Oliveira GH. Trends and Disparities in Cardiovascular Mortality Among Survivors of Hodgkin Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:748-52. [PMID: 26324747 DOI: 10.1016/j.clml.2015.07.638] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/28/2015] [Accepted: 07/28/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND Over the past decades, survival of patients with Hodgkin lymphoma (HL) has increased but remains curtailed by cardiovascular mortality (CVM). HL survivors at greatest risk for cardiovascular death have not been clearly identified. We sought to report trends of CVM identify HL survivors at highest risk. METHODS The Surveillance, Epidemiology, and End Results (SEER) database was queried for all adult patients diagnosed with HL (age 20-49 years) between 1990 and 2011. The trend of CVM and disparities are presented. RESULTS Of 19,781 HL patients, 53% were male and 83% were white; patients had a mean age of 33 ± 8.3 years at diagnosis. Eighteen percent had stage I disease, 45% stage II, 18% stage III, and 15% stage IV. The risk for CVM was higher in blacks (adjusted hazard ratio [HR], 1.97; P = .002), men (adjusted HR, 2.2; P < .001), and patients with older age at diagnosis (adjusted HR, 1.073 per year; P < .001). CVM has decreased, with 5-year cumulative incidence decreasing from 1.17% in 1990 to 0.18% in 2006, averaging 7% per year (adjusted HR, 0.927; P < .001). This trend was seen only in patients with early disease (P < .001) but not with advanced disease (P = NS). CVM as a proportion of all-cause mortality increases sharply at 50 years of age, constituting more than 30% of all causes of death. CONCLUSION Despite an overall decrease in CVM in HL survivors over the last decades, older patients, black patients, and men, especially those who have advanced-stage disease at diagnosis, are at the highest risk of cardiovascular death. Cardiovascular screening and risk modification should be intensified in HL patients with these characteristics.
Collapse
Affiliation(s)
- Sadeer G Al-Kindi
- Onco-cardiology program, Harrington Heart and Vascular Institute, and Seidman Cancer Center, University Hospitals, Cleveland, OH; School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Chang H Kim
- Onco-cardiology program, Harrington Heart and Vascular Institute, and Seidman Cancer Center, University Hospitals, Cleveland, OH; School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Vittal Hejjaji
- Onco-cardiology program, Harrington Heart and Vascular Institute, and Seidman Cancer Center, University Hospitals, Cleveland, OH
| | - Basem M William
- School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Seidman Cancer Center, Cleveland, OH
| | - Paolo F Caimi
- School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Seidman Cancer Center, Cleveland, OH
| | - Guilherme H Oliveira
- Onco-cardiology program, Harrington Heart and Vascular Institute, and Seidman Cancer Center, University Hospitals, Cleveland, OH; School of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Seidman Cancer Center, Cleveland, OH.
| |
Collapse
|
46
|
Oudin C, Auquier P, Bertrand Y, Contet A, Kanold J, Sirvent N, Thouvenin S, Tabone MD, Lutz P, Ducassou S, Plantaz D, Dalle JH, Gandemer V, Beliard S, Berbis J, Vercasson C, Barlogis V, Baruchel A, Leverger G, Michel G. Metabolic syndrome in adults who received hematopoietic stem cell transplantation for acute childhood leukemia: an LEA study. Bone Marrow Transplant 2015; 50:1438-44. [DOI: 10.1038/bmt.2015.167] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 01/13/2023]
|
47
|
Faienza MF, Delvecchio M, Giordano P, Cavallo L, Grano M, Brunetti G, Ventura A. Metabolic syndrome in childhood leukemia survivors: a meta-analysis. Endocrine 2015; 49:353-60. [PMID: 25154516 DOI: 10.1007/s12020-014-0395-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/12/2014] [Indexed: 01/05/2023]
Abstract
A significant number of long-term complications have been described in childhood leukemia survivors. In particular, these patients may present features of metabolic syndrome (MetS), and therefore increased risk for cardiovascular diseases. The aim of this meta-analysis is to evaluate the prevalence and the risk of MetS in survivors of childhood leukemia. Two authors independently performed a systematic literature search in PubMed and EMBASE to March 2014, reviewed and selected articles, based on pre-determined selection criteria. Twelve articles, comprising 2,337 participants (1,462 cases and 875 controls), were included in the meta-analysis. Only three of them were case-control studies eligible for the meta-analysis. The childhood leukemia survivors showed an increased risk of MetS as compared to healthy controls (OR = 4.36; 95 % CI 1.19-16.22). The risk was significantly increased only in patients treated with chemotherapy and radiotherapy (OR = 7.79; 95 % CI 1.27-47.77), and not in patients treated with only chemotherapy (OR = 2.35; 95 % CI 0.40-13.78). Childhood leukemia survivors, in particular if treated also with radiotherapy, are prone to develop MetS more than healthy controls. Monitoring of MetS components in these patients is necessary to avoid cardiovascular consequences later in life.
Collapse
Affiliation(s)
- Maria Felicia Faienza
- Department of Biomedical Sciences and Human Oncology, Pediatrics Unit, University of Bari 'A. Moro', Piazza G. Cesare, 11, 70124, Bari, Italy,
| | | | | | | | | | | | | |
Collapse
|
48
|
Berkman AM, Lakoski SG. Treatment, behavioral, and psychosocial components of cardiovascular disease risk among survivors of childhood and young adult cancer. J Am Heart Assoc 2015; 4:jah3923. [PMID: 25836057 PMCID: PMC4579959 DOI: 10.1161/jaha.115.001891] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Amy M Berkman
- Office of Health Promotion Research, University of Vermont, Burlington, VT (A.M.B.)
| | - Susan G Lakoski
- Department of Internal Medicine, University of Vermont, Burlington, VT (S.G.L.) Vermont Center on Behavior Health and Vermont Cancer Center, Burlington, VT (S.G.L.)
| |
Collapse
|
49
|
Shalitin S, Laur E, Lebenthal Y, Ash S, Yaniv I, Phillip M. Endocrine complications and components of the metabolic syndrome in survivors of childhood malignant non-brain solid tumors. Horm Res Paediatr 2015; 81:32-42. [PMID: 24246763 DOI: 10.1159/000355577] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 09/11/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The substantial improvement in survival of children with cancer has been achieved at the cost of late effects. We aimed to evaluate the endocrine outcome in survivors of childhood non-brain malignant solid tumors (NBMST). METHODS We performed a retrospective medical record review for medical history, clinical and laboratory data of survivors (n = 139) followed at the endocrine clinic of a tertiary medical center. Outcome measures were frequency and types of endocrine dysfunction and components of the metabolic syndrome. RESULTS Median follow-up time was 9.0 years (range 1.2-29.5 years). At least one endocrine abnormality was found in 44 patients (31.7%). Abnormalities included hypogonadism (11.5%), hypothyroidism (9.4%), short stature (9.4%), growth hormone deficiency (8.6%) and components of the metabolic syndrome (15.1%). Height SDS decreased significantly (p = 0.004) during follow-up, whereas body mass index SDS tended to increase. On logistic regression analysis, treatment with cranial irradiation (p = 0.003), local radiation (p = 0.042), or bone marrow transplantation (p = 0.0001), and older age at last visit (p < 0.001) were associated with a significantly higher hazard of an endocrinopathy. CONCLUSIONS The high rate of late endocrine dysfunction among survivors of childhood NBMST highlights the need to optimize the follow-up at the late-effects clinics to identify endocrine problems and allow early and effective intervention.
Collapse
Affiliation(s)
- Shlomit Shalitin
- The Jesse Z. and Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | | | | | | | | | | |
Collapse
|
50
|
Li C, Liu P, Liu L, Zhang X, Yang P, Sheng H, Bu L, Li H, Qu S. Metabolic syndrome in hematologic malignancies survivors: a meta-analysis. Med Oncol 2014; 32:422. [DOI: 10.1007/s12032-014-0422-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 11/27/2014] [Indexed: 12/26/2022]
|