Adolescent and Young Adult Cancer Biology. ACTA ACUST UNITED AC. 2018;24:267-274. [PMID: 30480571 DOI: 10.1097/ppo.0000000000000343]

Incidence of papillary thyroid cancer: Comparison of the military and the general population by race and tumor stage/size

BACKGROUND

A previous study found higher papillary thyroid cancer incidence in the US military than the general population with larger differences among Black than White individuals. This study compared the two populations in the incidence by sex, race, tumor stage, and size to assess possible factors related to identified differences.

METHODS

Subjects were aged 18-59 in the military and general populations. Papillary thyroid cancer patients diagnosed during 1990-2013 were identified from the Department of Defense's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Age-adjusted rates and incidence rate ratios (IRR) comparing ACTUR to SEER were calculated.

RESULTS

Higher incidence rates in ACTUR than SEER were more obvious for Black (IRR=2.07, 95%CI=1.56-2.70) than White men (IRR=1.17, 95%CI=1.07-1.26) and for Black (IRR=2.30, 95%CI=1.91-2.71) than White women (IRR=1.50, 95%CI=1.38-1.64). Population differences by race were observed for localized tumors among both men and women and were larger for Black individuals. Differences were observed regardless of tumor size among Black men and White women, and in smaller tumors among Black women.

CONCLUSION

Higher incidence in the military than general population primarily in localized tumors suggests universal healthcare in the military may lead to earlier detection. The differences were larger among Blacks than Whites, suggesting universal access in the military may be more impactful among Black persons, who are less likely to have timely care than White persons in the general population. Nevertheless, observed differences for tumors > 2 cm suggest other factors may also play a role.

Epithelial ovarian cancer in younger age versus older age groups: Survival and clinicopathological features

OBJECTIVES

This study aimed to analyze the survivals and clinicopathological features of epithelial ovarian cancer (EOC) in younger age patients and to determine the impact of age on survival.

METHODS

EOC patients aged ≤40 years were matched to patients aged >40 years at a 1:4 ratio. Disease-specific survival (DSS), progression-free survival (PFS), and clinicopathological and treatment features were compared between patients aged ≤40 and >40 years.

RESULTS

A total of 763 EOC patients were reviewed. During a median follow-up period of 41 (range, 1-195) months, EOC patients aged ≤40 and >40 years did not show any statistically significant difference in median DSS (120 versusversus 84.7 months; hazard ratio, 0.78; 95% confidence interval, 0.58, 1.06); however, the median PFS was better in patients aged ≤40 years (median PFS not reached versusversus 41 months; HR, 0.65; 95% CI, 0.5, 0.85). Age ≤40 years was an independent favorable prognostic factor for DSS at 3 years after diagnosis. In contrast, younger age was an independent poor prognostic factor prior to this time point. EOC patients aged ≤40 years exhibited a significantly higher rate of early-stage disease, a higher proportion of mucinous subtype, and lower cancer antigen-125 level.

CONCLUSION

Overall, EOC patients in the younger age group were associated with more favorable prognostic factors and showed better PFS, but not DSS, than those in the older age group. Younger age was identified as an unfavorable prognostic factor within 3 years of diagnosis and became a favorable prognostic factor after 3 years.

Challenges and limitations of clinical trials in the adolescent and young adult CNS cancer population: A systematic review

Background

The adolescent and young adult (AYA) cancer population, aged 15-39, carries significant morbidity and mortality. Despite growing recognition of unique challenges with this age group, there has been little documentation of unmet needs in their care, trial participation, and quality of life, particularly in those with primary brain tumors.

Methods

A systematic literature review of 4 databases was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Studies included editorials, reviews, and practice guidelines on the challenges and limitations faced by the AYA population. Papers had to address CNS tumors.

Results

Sixty-eight studies met the inclusion criteria. The challenges and limitations in clinical trials in the AYA population were synthesized into 11 categories: molecular heterogeneity, tumor biology, diagnostic delay, access to care, physician factors, patient factors, primary brain tumor (PBT) factors, accrual, limited trials, long term follow up, and trial design. The published papers' recommendations were categorized based on the target of the recommendation: providers, coordination of care, organizations, accrual, and trial design. The AYA cancer population was found to suffer from unique challenges and barriers to care and the construction of trials.

Conclusions

The AYA CNS cancer population suffers from unique challenges and barriers to care and construction of trials that make it critical to acknowledge AYAs as a distinct patient population. In addition, AYAs with primary brain tumors are underrecognized and underreported in current literature. More studies in the AYA primary brain tumor patient population are needed to improve their care and participation in trials.

Age-related differences in symptom distress among patients with cancer

INTRODUCTION

Differences in symptom distress among older (age 65-74) and very old (age 75+) patients with cancer, compared to younger patients, remain to be well explored. These differences are important to understand given the heterogeneity of older populations and may have implications for age-appropriate symptom detection and management.

MATERIALS AND METHODS

We examined routinely collected Edmonton Symptom Assessment System Revised (ESAS-r) scores from 9,143 patients age 40+ initiating chemotherapy for solid malignancies at a single academic cancer centre, between September 2011 and May 2019. We used multivariable logistic regression models to determine associations between the most common symptoms and age group (ages 40-64, 65-74, 75-84, and 85+), cancer site, clinical stage, sex, and income levels. We focused our findings on patients with the five most common cancers, breast (n = 1,532), prostate (n = 923), lung (n = 889), pancreatic (n = 429), and colorectal (n = 368), prior to receiving treatment.

RESULTS

Within our sample, 58.0% were age 40-64, 27.3% age 65-74, 11.8% age 75-84, and 2.9% age 85+. Among the nine symptoms in the ESAS-r (anxiety, depression, tiredness, wellbeing, nausea, pain, drowsiness, appetite, and shortness of breath), the most common symptoms overall were anxiety (moderate-severe scores [ESAS-r 4 or higher] were reported by 33.8% of patients), lack of well-being (38.3%), and tiredness (38.3%). Older age was associated with lower odds of moderate/severe anxiety (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.73-0.90 for age 65-74; OR 0.81, 95%CI 0.70-0.93 for age 75-84; OR 0.62, 95%CI 0.47-0.82 for age 85+; referent is 40-64-year-olds for all analyses), and increased odds of tiredness (OR 1.00, 95%CI 0.90-1.11 for age 65-74; OR 1.19, 95%CI 1.04-1.37 for age 75-84; and OR 1.34, 95%CI 1.04-1.72 for age 85+). Advanced stage, female sex, and lower income levels were associated with higher odds of moderate/severe tiredness, anxiety, and lack of well-being in adjusted models. Patients with pancreatic and lung cancers reported worse scores for these three symptoms than patients with other cancers.

DISCUSSION

Older age was associated with differences in symptom experiences such as increased tiredness and reduced anxiety. Supportive care interventions and future research should focus on addressing these symptoms to improve patient quality of life.

Prognosis of early-stage lung adenocarcinoma in young patients

Lung adenocarcinoma (LUAD) is a familiar lung cancer with a poor prognosis. This study was meant to determine whether there are differences in survival between younger and older patients with early-stage LUAD because of the rise in the incidence of LUAD in young individuals over the previous few decades. We analysed the clinical, therapeutic and prognostic features of a cohort (2012-2013) of 831 consecutive patients with stage I/II LUAD who underwent curative surgical resection at Shanghai Pulmonary Hospital. Propensity score matching (PSM) was performed for age, sex, tumour size, tumour stage and therapy in a 2:1 ratio between the two groups without taking gender, illness stage at operation or decisive treatment into account. Following PSM analysis to create a 2:1 match for comparison, the final survival study included 163 patients with early-stage LUAD <50 years and 326 patients ≥50 years. Surprisingly, younger patients were overwhelmingly female (65.6%) and never smokers (85.9%). There were no statistical differences between the two groups in terms of the overall survival rate (P = 0.067) or time to advancement (P = 0.76). In conclusion, no significant differences stood out between older and younger patients with stage I/II LUAD regarding overall and disease-free survival rates. Younger patients with early-stage LUAD were more likely to be female and never smokers, which suggests that risk factors other than active smoking may be responsible for lung carcinogenesis in these patients.

Cancers of Unknown Primary: A Descriptive Study in the U.S. Military Health System

INTRODUCTION

Cancers of unknown primary (CUP) are defined as histologically confirmed metastatic cancers that do not have an identified primary site of origin despite an appropriate diagnostic workup. Although accessibility to and quality of medical care influence diagnosis of cancer including CUP, previous studies describing CUP have generally been conducted in patients with various accessibilities to care. This study aimed to describe the demographic, histologic, and temporal trend characteristics of CUP patients in the DoD Cancer Registry of the Military Health System (MHS), which provides universal health care access, reducing the potential effects of accessibility to care on research results.

MATERIALS AND METHODS

The data were obtained from the DoD's Automated Central Tumor Registry (ACTUR), which collects cancer data from beneficiaries who were diagnosed or received treatment in the MHS. We described the demographic and histologic distributions in CUP patients aged 18 years or older diagnosed from 1987 to 2013. We calculated the proportion of CUP patients among all metastatic cancers and the most common histologic categories of those tumors. We then evaluated whether the proportion of histologic types changed over time.

RESULTS

CUP comprised 13.3% of all metastatic cancers in ACTUR during the study period. The majority of CUP within ACTUR was moderately and well-differentiated adenocarcinoma (51.3%) and poorly differentiated carcinomas (23.2%) followed by squamous cell carcinomas (12.5%). The percentages of CUP among metastasized cancers of the same histologic category ranged 12%-15% for moderately and well-differentiated adenocarcinomas, squamous cell, and poorly differentiated carcinomas, and 41%-46% for malignant neuroendocrine carcinomas and undifferentiated neoplasms. However, the percentages varied by sex, race, and age for certain pathologies. The proportion of CUP patients among all metastatic cancer patients has steadily declined from 22.4% to 8.3% from 1987 to 2013.

CONCLUSION

The proportion and trends of CUP in the ACTUR were generally consistent with other descriptive CUP studies. This study provides a description of CUP in a health care system with universal access in the USA and provides a foundation for future studies on CUP.

Adolescent cancer care: What has changed in Spain in the past decade?

INTRODUCTION AND OBJECTIVES

In 2012, the Adolescents with Cancer Working Group published the results of a survey on care delivery for the adolescent population in Spain as a starting point for future intervention. The aim of this nationwide survey was to outline the current situation and assess whether the implemented strategies have resulted in changes in care delivery.

MATERIAL AND METHODS

Survey consisting of the same items analysed and published in 2012. The questionnaire was structured into sections devoted to epidemiology, psychosocial care, infrastructure, treatment and follow-up of adolescents with cancer. It was submitted to all hospitals in Spain with a paediatric haematology and oncology unit. We conducted a descriptive analysis of the results.

RESULTS

The percentage of patients aged up to 18 years managed in paediatric units has increased from 35.9% to 77.5% in the past decade. The proportion of malignant blood tumours treated in paediatric units increased from 31% to 52%, and the proportion of solid tumours from 49% to 85%. In 2012, 30 units (out of 39) reported that new cases in adolescents amounted to up to 10% of the total. At present, only 14 (out of 40) continue to report this percentage. A decade ago, there were no specific adolescent cancer units in Spain. Now, 7 centres (out of 40) have specific multidisciplinary units. There has been little change in psychological support services for adolescents. The follow-up of survivors is carried out by paediatric specialists in 82.5% of the hospitals.

CONCLUSIONS

The efforts made to centralise the care of adolescents with cancer in specific multidisciplinary adolescent units or, failing that, paediatric units, is reflected in the changes in care delivery in Spain in the past decade. Much remains to be done in key components of the management of adolescents with cancer.

Cancers Among Adolescents and Young Adults in Maine 2001-2017: A Descriptive Analysis and Model for Future Studies

Purpose: Maine has had a high age-adjusted incidence rate of cancer and a high incidence rate of childhood cancer. However, it is unknown if Maine adolescents and young adults (AYAs) have a higher-than-expected cancer incidence rate. Methods: Based on the International Classification of Diseases of Oncology, Third Edition (ICD-0-3) classification system, we obtained the incidence rates of AYA cancers by state, sex, race, and ethnicity from 2001 to 2017 using CDC WONDER. Overall, all cancer rates and age-adjusted incidence rates for specific cancers were compared and ranked by state. Results: Maine had a similar overall age-adjusted cancer incidence rate among non-Hispanic white AYAs compared with the national rate from 2001 to 2017. Among non-Hispanic white AYA cancers of the respiratory system, lung and bronchial cancers, uterine cancer, female breast cancer, thyroid cancer, lymphomas, and Hodgkin's lymphoma were significantly greater in Maine than the state with the lowest incidence rate for that cancer. Specifically, Maine was ranked as one of the top 10 states for the highest incidence rate of lung cancer, uterine cancer, Hodgkin's lymphoma, thyroid cancer (males only), and female breast cancer. Conclusion: Although the cancer incidence rate among AYAs in Maine was not significantly higher than the national average, Maine AYAs had a significantly higher incidence of lung cancer, uterine cancer, Hodgkin's lymphoma, thyroid cancer, and breast cancer. This information may direct future studies to identify regional cancer risk factors in Maine, which may account for this elevated rate. The described methodology is an innovative approach to identifying states with high cancer rates and directing future studies.

High early death rates, treatment resistance, and short survival of Black adolescents and young adults with AML

Survival of patients with acute myeloid leukemia (AML) is inversely associated with age, but the impact of race on outcomes of adolescent and young adult (AYA; range, 18-39 years) patients is unknown. We compared survival of 89 non-Hispanic Black and 566 non-Hispanic White AYA patients with AML treated on frontline Cancer and Leukemia Group B/Alliance for Clinical Trials in Oncology protocols. Samples of 327 patients (50 Black and 277 White) were analyzed via targeted sequencing. Integrated genomic profiling was performed on select longitudinal samples. Black patients had worse outcomes, especially those aged 18 to 29 years, who had a higher early death rate (16% vs 3%; P=.002), lower complete remission rate (66% vs 83%; P=.01), and decreased overall survival (OS; 5-year rates: 22% vs 51%; P<.001) compared with White patients. Survival disparities persisted across cytogenetic groups: Black patients aged 18 to 29 years with non-core-binding factor (CBF)-AML had worse OS than White patients (5-year rates: 12% vs 44%; P<.001), including patients with cytogenetically normal AML (13% vs 50%; P<.003). Genetic features differed, including lower frequencies of normal karyotypes and NPM1 and biallelic CEBPA mutations, and higher frequencies of CBF rearrangements and ASXL1, BCOR, and KRAS mutations in Black patients. Integrated genomic analysis identified both known and novel somatic variants, and relative clonal stability at relapse. Reduced response rates to induction chemotherapy and leukemic clone persistence suggest a need for different treatment intensities and/or modalities in Black AYA patients with AML. Higher early death rates suggest a delay in diagnosis and treatment, calling for systematic changes to patient care.

Risk of Presenting with Poor-Prognosis Metastatic Cancer in Adolescents and Young Adults: A Population-Based Study

Having metastatic disease at diagnosis poses the great risk of death among AYAs with cancer from all sociodemographic subgroups. This “landscape” study utilized United States Surveillance, Epidemiology, and End Results Program data from 2000−2016 to identify subgroups of AYAs at highest risk for presenting with metastases across twelve cancer sites having a poor-prognosis (5-year survival <50% with metastases). Adjusted odds ratios for risk of metastatic disease presentation were compared for AYAs in aggregate and by sociodemographic subgroup (race/ethnicity, sex, socioeconomic status [SES]). In general, AYAs who were male, racial/ethnic minorities, or low SES were at consistently greatest risk of metastases. Strikingly, having metastatic melanoma was independently associated with multiple AYA sociodemographic subgroups, including males (aOR 3.11 [95% CI 2.64−3.66]), non-Hispanic Blacks (4.04 [2.32−7.04]), Asian Pacific Islanders (2.99 [1.75−5.12]), Hispanics (2.37 [1.85−3.04]), and low SES (2.30 [1.89−2.80]). Non-Hispanic Blacks were more likely to present with metastatic cancer in all sites, except for bone, rhabdomyosarcoma, and stomach. Low SES AYAs are more likely to present with metastatic melanoma, bone tumors, soft tissue sarcomas, breast, cervical, lung, and stomach carcinomas. Building on these results, future cancer-specific studies should investigate the connection between sociodemographic risk factors and biological drivers of metastases. This line of research has potential to inform targeted public health and screening efforts to facilitate risk reduction and earlier detection of these deadly diseases.

Needs, Barriers and Facilitators of Adolescents Participating in a Lifestyle Promotion Program in Oncology: Stakeholders, Adolescents and Parents’ Perspective

Treatments for adolescent cancer can cause debilitating side effects in the short- and long-term such as nausea and malnutrition but also cardiometabolic disturbances. Although the risk for cardiometabolic complications is greater for adolescents with cancer than younger ones, adolescents typically respond poorly to family-oriented health promotion programs. This study aims to assess the needs, barriers and facilitators to healthy lifestyle promotion interventions for adolescents with cancer and how to best adapt these interventions for them. Interviews were held with adolescents treated for cancer (n = 9) and parents (n = 6), focus groups were conducted with stakeholders working in oncology (n = 12) and self-report questionnaires were sent to stakeholders involved in a health promotion intervention (n = 6). At the time of interview, mean age of adolescent participants (40% female) was 17.0 ± 1.9 years (mean age at diagnosis: 14.6 ± 1.6 years). Verbatim and responses to questionnaires were coded and analyzed using qualitative methods. Stakeholder stated that adolescents with cancer need to access activities adapted to their age, to communicate with peers going through a similar experience, and to preserve their schooling and friendships. Barriers to intervention reported by adolescents, parents and stakeholders include lack of motivation, schedule conflicts, fatigue and treatment side effects. Some of the barriers mentioned by adolescents and parents include pain, post-surgery problems, school, physical deconditioning, and lack of time. Facilitators mentioned by adolescents and parents comprise trust in stakeholders’ expertise, personalized approaches, scheduling flexibility. Stakeholders recommended to build trust in the relationship, favoring non-moralizing teachings, adapt interventions to adolescents’ limited attention span and avoiding the use of long-term health benefits as a motivator.

Day-to-Day Decision Making by Adolescents and Young Adults with Cancer

Background: Adolescents and young adults (AYAs) with cancer must negotiate the transition between childhood and adulthood while dealing with a life-threatening illness. AYA involvement in decision making varies depending on the type of decision and when decisions occur during treatment, and evidence suggests that AYAs want to be involved in decision making. Objective: To explore involvement of AYAs with cancer in day-to-day decisions affected by their cancer and treatment. Methods: This qualitative study used interpretive focused ethnography within the sociologic tradition, informed by symbolic interactionism. Semi-structured interviews and informal participant observation took place at two quaternary pediatric oncology programs. Results: Thirty-one interviews were conducted with 16 AYAs ages 15 to 20 years. Major day to day decision-making categories identified included: (1) mental mindset, (2) self-care practices, (3) self-advocacy, and (4) negotiating relationships. Participants described how they came to grips with their illness early on and decided to fight their cancer. They described decisions they made to protect their health, how they advocated for themselves and decisions they made about relationships with family and friends. Conclusions: Through day-to-day decisions, participants managed the impact of cancer and its treatment on their daily lives. Research should focus on developing and implementing interventions to empower AYAs to participate in day-to-day decisions that will affect how they manage their cancer, its treatment and ultimately their outcomes. Implications for Practice: Healthcare providers can facilitate AYA's participation in day-to-day decision making through encouraging autonomy and self-efficacy by providing support and through effective communication.

Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions

OBJECTIVES

To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs).

METHODS

A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP.

RESULTS

At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC.

SIGNIFICANCE OF RESULTS

Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.

A framework for fibrolamellar carcinoma research and clinical trials

Fibrolamellar carcinoma (FLC), a rare, lethal hepatic cancer, occurs primarily in adolescents and young adults. Unlike hepatocellular carcinoma, FLC has no known association with viral, metabolic or chemical agents that cause cirrhosis. Currently, surgical resection is the only treatment demonstrated to achieve cure, and no standard of care exists for systemic therapy. Progress in FLC research illuminates a transition from an obscure cancer to one for which an interactive community seems poised to uncover fundamental mechanisms and initiate translation towards novel therapies. In this Roadmap, we review advances since the seminal discovery in 2014 that nearly all FLC tumours express a signature oncogene (DNAJB1-PRKACA) encoding a fusion protein (DNAJ-PKAc) in which the J-domain of a heat shock protein 40 (HSP40) co-chaperone replaces an amino-terminal segment of the catalytic subunit of the cyclic AMP-dependent protein kinase (PKA). Important gains include increased understanding of oncogenic pathways driven by DNAJ-PKAc; identification of potential therapeutic targets; development of research models; elucidation of immune mechanisms with potential for the development of immunotherapies; and completion of the first multicentre clinical trials of targeted therapy for FLC. In each of these key areas we propose a Roadmap for future progress.

Real-World Data of Different Immune Checkpoint Inhibitors for Non-Small Cell Lung Cancer in China

Background

Patients treated with immunotherapy in the real-world may have significantly different responses to those meeting inclusion criteria for random controlled clinical studies. There is a partial overlap in approved indications for the use of the different immune checkpoint inhibitors (ICIs) currently available. A comprehensive assessment of the efficacy, safety and economic effects of various ICIs is a problem that clinicians need to address.

Methods

Analyzed real-world data was collected from non-small cell lung cancer (NSCLC) patients who were treated with ICIs from hospitalized patients in the Lung Cancer Center of Peking Union Medical College Hospital between 2018 and 2021. The objectives were to evaluate the efficacy and safety of different ICIs for the treatment of NSCLC in China and to investigate the factors affecting their curative effects.

Results

Overall, 351 patients were included in the retrospective study. The median PFS for the NSCLC patient cohort treated with medication regimens that included ICIs was 9.5 months, with an ORR of 47.3%. There were no significant discrepancies in efficacy and safety between the different ICIs administered. Factors that had the greatest impact on the efficacy of ICIs were the disease stage, ECOG-PS scores and treatment lines. Gender, age, smoking history, PD-L1 TPS expression, history of targeted therapy and irAEs all had a degree of influence on patient prognosis.

Conclusions

The study reports the experience of real-world usage of ICIs for the treatment of NSCLC patients in China. The results were generally consistent with those of clinical trials, while the efficacy and safety of different ICIs exhibited no statistically significant differences. Therefore, physicians can make a comprehensive choice based on the indications and cost of different ICIs and the preferences of patients.

Survival of Adolescents and Young Adults with Prevalent Poor-Prognosis Metastatic Cancers: A Population-Based Study of Contemporary Patterns and Their Implications

BACKGROUND

Although survival has improved dramatically for most adolescents and young adults (AYA; 15-39 years old) with cancer, it remains poor for those presenting with metastatic disease. To better characterize this subset, we conducted a landscape survival comparison with older adults (40-79 years).

METHODS

Using Surveillance, Epidemiology, and End Results Program data from 2000 to 2016, we examined incident cases of poor-prognosis metastatic cancers (5-year survival < 50%) among AYAs (n = 11,518) and older adults (n = 345,681) and compared cause-specific survival by sociodemographic characteristics (race/ethnicity, sex, and socioeconomic status). Adjusted HRs (aHR) for death from metastatic disease [95% confidence intervals (95% CI)] were compared between AYAs and older adults (Pint).

RESULTS

AYAs had significantly better survival than older adults for every cancer site except kidney, where it was equivalent (range of aHRs = 0.91; 95% CI, 0.82-1.02 for kidney cancer to aHR = 0.33; 95% CI, 0.26-0.42 for rhabdomyosarcoma). Compared with their older adult counterparts, greater survival disparities existed for AYAs who were non-Hispanic Black with uterine cancer (aHR = 2.20; 95% CI, 1.25-3.86 versus aHR = 1.40; 95% CI, 1.28-1.54; Pint = 0.049) and kidney cancer (aHR = 1.51; 95% CI, 1.15-1.98 versus aHR = 1.10; 95% CI, 1.03-1.17; Pint = 0.04); non-Hispanic Asian/Pacific Islanders with ovarian cancer (aHR = 1.47; 95% CI, 1.12-1.93 versus aHR = 0.89; 95% CI, 0.84-0.95; Pint<0.001); and males with colorectal cancer (aHR = 1.21; 95% CI, 1.10-1.32 versus aHR = 1.08; 95% CI, 1.06-1.10; Pint = 0.045).

CONCLUSIONS

AYAs diagnosed with these metastatic cancers have better survival than older adults, but outcomes remain dismal.

IMPACT

Overcoming the impact of metastasis in these cancers is necessary for continuing progress in AYA oncology. Sociodemographic disparities affecting AYAs within kidney, uterine, ovarian, and colorectal cancer could indicate plausible effects of biology, environment, and/or access and should be explored.

Comparisons of Outcomes Between Adolescent and Young Adult with Older Patients After Radical Resection of Pancreatic Ductal Adenocarcinoma by Propensity Score Matching: A Single-Center Study

Purpose

Adolescent and young adult (AYA) pancreatic ductal adenocarcinoma (PDAC) occurs in patients below 40 years old. Whether AYA patients have worse outcomes compared with older patients is still controversial. The purpose of this study is to compare the outcomes of AYA patients and older patients after radical surgery for PDAC.

Methods

A single-center, retrospective, cohort study was conducted in patients who underwent radical surgery for PDAC in Xiangya Hospital Central South University from January 2007 to December 2019. The clinicopathological data and results of patients with PDAC were collected and analyzed retrospectively. They were divided into AYA group and older group based on age (<40, AYA group; ≥40, older group). Based on all the considered covariates except age, we estimated 1:2 case propensity score matching (PSM).

Results

A total of 1033 cases were enrolled, 46 cases (4.45%) in the AYA group. Both before and after PSM, the AYA patients have a higher preoperative CA19-9 than the older patients (P < 0.001) and (P < 0.001). Pathological results showed that AYA group had a higher microvascular invasion rate (P < 0.001 and P = 0.045) than older group. The median time of overall survival (OS) in AYA group and older group were 13 months (95% CI = 11.50-14.50) and 14 months (95% CI = 13.50-14.50), respectively. Additionally, AYA group have a worse 2-year OS rate than older group (8.70% vs 25.23%, P = 0.011 and 8.70% vs 25.00%, P = 0.023). According to the Log rank test, AYA group have a worse cumulative OS rate than older group (P = 0.002) and (P = 0.030), respectively.

Conclusion

PDAC might be more aggressive in AYA, and the cumulative OS after radical PDAC surgery in AYA patients is worse than that in older patients.

Cancer in adolescents and young adults in Japan: epidemiology and cancer strategy

According to national cancer registry data in Japan, approximately 20,000 adolescents and young adults (AYAs, age 15–39 years) are newly diagnosed with cancer each year. Improvements in treatment and care for AYAs with cancer are included in the Phase Three Basic Plan to Promote Cancer Control Programs in Japan. This article reviews current cancer incidence and survival for AYAs with cancer in Japan using population-based cancer registry data. Mortality data through 2019 from the Vital Statistics of Japan are also described. Encouragingly, the 5-year survival probability for AYA cancers has continued to improve, in parallel with childhood cancers, and the mortality rate has decreased. There has been increasing attention to these vulnerable patients and improved partnerships and collaboration between adult and pediatric oncology; however, obstacles to the care of this population still exist at multiple levels. These obstacles relate to specific areas: research efforts and enrollment in clinical trials on AYA malignancies, AYA-specific psychosocial support such as education, financial support, and oncofertility care, and cancer care systems. It is important for Japanese oncologists, health care providers, and health policy makers to recognize that the AYA population remains vulnerable and still have unmet needs.

Multicenter retrospective analysis of clinicopathological features and prognosis of oral tongue squamous cell carcinoma in adolescent and young adult patients

ABSTRACT

The aim of this study is to report the differences in clinicopathological features of oral tongue squamous cell carcinoma (OTSCC) and survival between adolescent and young adult (AYA) patients and elderly patients and to find the prognosticators. The medical records of 101 AYA patients and 175 control patients with OTSCC who underwent surgery were reviewed. Variables related to prognosis and their clinicopathological associations were analyzed. The 5-year overall survival (5y-OS) rates of AYA and control patients with stage I and II OTSCC were 94.4% and 89.6% (P = .353), respectively, and their 5-year disease-free survival (5y-DFS) rates were 82.0% and 76.6%, respectively (P = .476). The 5y-OS rates of patients with stages III and IV OTSCC were 83.3% and 66.7% (P = .333), respectively, and their 5y-DFS rates were 75.0% and 57.1% (P = .335), respectively. Logistic regression analysis revealed that there was no significant clinicopathological difference in AYA and control group. Furthermore, there was no significant difference in 5y-OS rates between patients who underwent elective neck dissection (END) and those who underwent therapeutic neck dissection (TND) in both group (P = 0.717 and 0.688). Overall, the present study revealed the clinicopathological features and prognosis of OTSCC were similar in AYA patients and elderly patients. Moreover, as there was no significant difference in OS between patients who underwent END and those who underwent TND in AYA and control groups, our results suggest that the indication for END in AYA patients with clinical N0 OTSCC is similar to that for elderly patients.

Immunotherapy in Adolescents and Young Adults: What Remains in Cancer Survivors?

Immunotherapy has changed the landscape of treatments for advanced disease in multiple neoplasms. More and more patients are long survivors from a metastatic disease. Most recently, the extension of indications and evidence of efficacy in early disease settings, such as the adjuvant and neoadjuvant setting in breast cancer, lung cancer, glioma, and gastric cancer, places more attention on what happens to patients who survive cancer. In particular, we evaluated what happens in young patients, a population in whom some immune-related effects are still poorly described. Immunotherapy is already a reality in early disease settings and the scientific community is lagging in describing what to expect in adolescent and young adult (AYA) patients. For instance, the impact of these therapies on female and male fertility is not clear, similarly to the interaction that may occur between these drugs and pregnancy. This review aims to highlight these little-known topics that are difficult to evaluate in ad hoc studies.

Adolescent and Young Adult (AYA) Cancer Survivorship Practices: An Overview

Worldwide, more than 1.2 million adolescents and young adults (AYAs; those aged 15-39 years) are diagnosed with cancer each year. Although considerable variability exists according to cancer site and stage of disease, the 5-year relative survival at the time of diagnosis has been estimated at >80% for all AYA patients with cancer combined. Extensive survivorship research in recent decades has focused on patients diagnosed with cancer as children (<15 years) and older adults (>39 years), yet few studies to date have reported outcomes specifically for patients diagnosed as AYAs. With increasing incidence and improving survival for many tumor types, leading to the majority of AYA patients with cancer becoming long-term survivors, there is a critical need for research efforts to inform the survivorship care of this growing population. This article describes the population of AYA cancer survivors according to their epidemiology and late and long-term effects, the challenges and models of AYA survivorship care, as well as future opportunities for research and healthcare.

Survivorship in Adolescents and Young Adults With Cancer

Adolescents and young adults with cancer have an estimated 5-year overall survival rate of more than 75%. It can be difficult to immediately return to a "normal" life after cancer therapy because of a range of physical and psychosocial effects associated not only to the disease but also to late effects that can extend long into survivorship. Adolescents and young adult cancer survivors in the United States are more prone to several adverse treatment effects than those who had no history of cancer. A multidisciplinary health-care team that is well versed in caring for specific developmental issues, as well as addressing onco-fertility, psychosocial and socioeconomic issues, school and work obligations, and long-term side effects is important to meet the needs of this population.

Poor-Prognosis Metastatic Cancers in Adolescents and Young Adults: Incidence Patterns, Trends, and Disparities

Background

For adolescents and young adults (AYAs, aged 15-39 years) with cancer, metastatic disease at diagnosis is the strongest predictor of mortality, but its associations with age and sociodemographic factors are largely unexplored.

Methods

Using Surveillance, Epidemiology, and End Results Program data from 2000 to 2016, we collected incident cases of poor-prognosis metastatic cancer (5-year survival < 50%) and compared the proportion, incidence, time trends, and incidence rate ratios for race and ethnicity, sex, and socioeconomic status among AYAs, middle-aged adults (aged 40-64 years) and older adults (aged 65-79 years).

Results

From 2000 to 2016, a total of 17 210 incident cases of poor-prognosis metastatic cancer were diagnosed in AYAs, 121 274 in middle-aged adults, and 364 228 in older adults. Compared with older patients, the proportion of AYAs having metastatic disease was equivalent or substantially lower in nearly every site except stomach and breast cancers, which were statistically significantly higher for AYAs compared with middle-aged and older adults (stomach: 57.3% vs 46.4% and 39.5%; breast: 6.6% vs 4.4% and 5.6%, respectively; 2-sided P < .001 for all comparisons). Incidence rates rose significantly faster among AYAs for breast, stomach, and kidney cancers and among AYAs and middle-aged adults for colorectal cancer. Markedly higher incidence rate ratios were noted for AYA racial and ethnic minorities with breast, stomach, and especially kidney cancer, where only non-Hispanic Black AYAs were at considerably higher risk. For most sites, incidence rate ratios were higher among male patients and individuals of low socioeconomic status across age groups.

Conclusions

For most cancers, AYAs are not more likely to present with metastases than middle-aged and older adults. Further investigation is warranted for the disproportionate rise in incidence of metastatic breast, stomach, and kidney cancer among AYAs and their excess burden among AYA racial and ethnic minorities. The rising incidence of colorectal cancer among AYAs and middle-aged adults remains an additional concern.

The incidence and risk factors for venous thromboembolism in adolescent and young adult oncology patients

BACKGROUND

Venous thromboembolism (VTE) is a known complication among pediatric and adult cancer patients. Adolescent and young adult oncology (AYAO) patients have unique biological and physiological characteristics that make them distinct from other populations. Our objective was to study the VTE incidence, risk factors, and outcomes, which have been understudied in this population.

PROCEDURE

A retrospective case-control study was conducted on AYAO participants with new or relapsed cancer and an imaging confirmed VTE from January 2011 to November 2016 at our institution. Eligible AYAO participants without a history of VTE were designated as controls and were randomly selected from our institution's tumor registry. Demographics, medical history, surgeries, central venous catheter (CVC) data, VTE diagnosis and treatment, relapses, and deaths were abstracted.

RESULTS

Thirty-five VTE cases and 70 controls were included in this analysis. Eighty percent of cases had leukemia or lymphoma (vs. a solid tumor) compared to 58% of controls. The majority of VTEs (57%) were CVC associated, and more than 70% of cases had more than one CVC placed during their cancer treatment versus 34% of controls. Infection was associated with increased VTE risk (OR = 6.35, 95% CI = 2.30, 17.55, p < .0001). VTE cases had increased cancer relapse (23% vs. 10%) and mortality rates (29% vs. 16%) than controls.

CONCLUSION

AYAO participants with a VTE were more likely to have leukemia or lymphoma, more than one CVC or infection. Further studies are needed to identify patients who would benefit from modifiable prevention measures, such as limiting to one CVC, preventing infections, or considering prophylactic anticoagulation for those with a liquid tumor.

Association of body mass index with toxicity and survival in pediatric patients treated with cisplatin-containing regimens

Malnutrition is associated with treatment-related toxicities (TRT) in adults with solid tumors and in children with leukemia. Few studies have assessed whether malnutrition in pediatric patients treated for solid tumors impacts risk for TRT, relapse, and/or survival. To address this knowledge gap, this retrospective study evaluated the association between body mass index (BMI) at diagnosis, and imputed BMI during therapy, on the prevalence of TRT, specific toxicities, relapse, and survival in pediatric patients with solid tumors treated with cisplatin-containing regimens. Kaplan-Meier curves and regression models evaluated the association between patient-specific characteristics (including BMI) and TRT, relapse, and survival. The cohort included 221 patients, of whom 22% were malnourished at diagnosis (10% were underweight and 12% were obese). Most patients (60%) experienced at least one severe TRT, and 30% developed more than one severe TRT. Most patients with obesity at diagnosis remained obese during therapy (62%). In multivariable analysis, obesity at diagnosis was significantly associated with a more than threefold greater risk for developing severe TRT (p = 0.037), specifically for acute or chronic kidney injury (p = 0.014). Obesity at diagnosis and adolescent and young adult age (≥15 years at diagnosis) were associated with worse event-free survival (hazard ratio [HR] 2.32, p = 0.024 and HR 2.28, p = 0.010, respectively) and overall survival (HR 3.69, p = 0.006 and HR 2.6, p = 0.012, respectively). Obese and older patients therefore constitute populations at risk for poorer outcomes. Prospective studies are warranted to gain further insight into the mechanism and role of obesity and adolescence in developing TRT and/or treatment failure.

Epidemiology of Anthropometric Factors in Glioblastoma Multiforme-Literature Review

Although glioblastoma multiforme (GBM) is a widely researched cancer of the central nervous system, we still do not know its full pathophysiological mechanism and we still lack effective treatment methods as the current combination of surgery, radiotherapy, and chemotherapy does not bring about satisfactory results. The median survival time for GBM patients is only about 15 months. In this paper, we present the epidemiology of central nervous system (CNS) tumors and review the epidemiological data on GBM regarding gender, age, weight, height, and tumor location. The data indicate the possible influence of some anthropometric factors on the occurrence of GBM, especially in those who are male, elderly, overweight, and/or are taller. However, this review of single and small-size epidemiological studies should not be treated as definitive due to differences in the survey methods used. Detailed epidemiological registers could help identify the main at-risk groups which could then be used as homogenous study groups in research worldwide. Such research, with less distortion from various factors, could help identify the pathomechanisms that lead to the development of GBM.

Comparison of survival between adolescent and young adult vs older patients with hepatocellular carcinoma

BACKGROUND

Due to the special clinical features and biologic characteristics of adolescent and young adult (AYA) cancers, AYA cancers are different from cancers in children and elderly individuals. However, there are few reports on AYA hepatocellular carcinoma (HCC).

AIM

To investigate the overall survival (OS) of AYA (15-39 years) and elderly (40-74 years) patients with HCC.

METHODS

The data of all the HCC cases were extracted from the Surveillance, Epidemiology, and End Results database from 2004 to 2015 and were then divided into two groups based on age: AYA group (15-39 years) and older group (40-74 years). Kaplan-Meier curves and log-rank tests were used to compare the OS of the two groups. Propensity score matching (PSM) was employed to analyze the OS difference between the two groups. The Cox proportional hazards regression model was used to perform multivariate analysis to explore the risk factors for OS of HCC patients.

RESULTS

Compared to elderly cancer patients, AYA patients with HCC had a worse Surveillance, Epidemiology, and End Results stage, including the distant stage (22.1% vs 15.4%, P < 0.001), and a more advanced American Joint Committee on Cancer (AJCC) stage, including AJCC III and IV (49.2% vs 38.3%, P < 0.001), and were more likely to receive surgery (64.5% vs 47.5%, P < 0.001). Before PSM, the AYA group had a longer survival in months (median: 20.00, interquartile range [IQR]: 5.00-62.50) than the older group (median: 15.00, IQR: 4.00-40.00) (P < 0.001). After PSM, the AYA group still had a longer survival in months (median: 21.00, IQR: 5.00-64.50) than the older group (median: 18.00, IQR: 6.00-53.00) (P < 0.001). The Cox proportional hazards regression model showed that advanced age (hazard ratio [HR] = 1.405, 95%CI: 1.218-1.621, P < 0.001) was a risk factor for OS of HCC patients. In the subgroup analysis, the Cox proportional hazards regression model showed that in AJCC I/II HCC patients, advanced age (HR = 1.749, 95%CI: 1.352-2.263, P < 0.001) was a risk factor for OS, while it was not a risk factor in AJCC III/IV HCC patients (HR = 1.186, 95%CI: 0.997-1.410, P = 0.054) before PSM. After PSM, advanced age (HR = 1.891, 95%CI: 1.356-2.637, P < 0.001) was still a risk factor for OS in AJCC I/II HCC patients, but was not a risk factor for OS in AJCC III/IV HCC patients (HR = 1.192, 95%CI: 0.934-1.521, P = 0.157) after PSM.

CONCLUSION

AYA patients with HCC have different clinical characteristics from older adults. In different AJCC stages, the two groups of patients have different OS: In AJCC I/II HCC patients, advanced age is a risk factor for OS, but it is not a risk factor for OS in the AJCC III/IV HCC patient group.

Cancer Incidence, Mortality, and Survival for Children, Adolescents, and Young Adults in Queensland Between 1987 and 2016

Purpose: Cancer remains the most common cause of disease-related death among young people and carries a significant burden. In the absence of prior state-based Australian epidemiological studies, this retrospective cohort study reviewed all cases of invasive cancer diagnosed in Queensland children, adolescents, and young adults (AYAs) (0-39 years) from 1987 to 2016 using the Queensland Oncology Repository (QOR). Methods: Cancers were classified according to Surveillance, Epidemiology and End Results (SEER) AYA site recode. Age-standardized rates (ASRs) were calculated. JoinPoint regression examined trends in ASRs across three age cohorts, for three decades (1987-1996, 1997-2006, and 2007-2016). Results: In total, 3,576 children aged 0-14 years (ASR = 15.2/100,000), 6,441 aged 15-24 years (ASR = 39.3/100,000), and 29,923 (ASR = 122.6/100,000) aged 25-39 years were diagnosed. Incidence increased for female children, and leukemia was the most common diagnosis. For those 15-24 years, incidence increased initially before decreasing and was higher than other nationally reported rates. For those 25-39 years, incidence increased. For the older cohorts, the most common diagnosis was melanoma. All cohorts demonstrated a decline in mortality and improvement in 5-year relative survival, with those 0-14 years demonstrating the greatest gains. The lowest survival for all cohorts was associated with central nervous system tumors. Conclusion: These results highlight areas in need of further investigation to improve survival, reduce the burden of cancer for young people, and aid service delivery. Future studies should focus on cancer biology, early detection, barriers in access to clinical trials, innovative models of care, improved data collection, and patient-reported outcomes.

Genomic and molecular alterations associated with early-onset and adolescent and young adult colorectal cancer

While the incidence of colorectal cancer (CRC) in the US has declined at a pace of 3% annually between 2003 and 2012, there has been an increase in the incidence of early-onset colorectal cancer (EOCRC). The reasons for this increase are unclear. Diet, the environment, the microbiome and alcohol consumption have all been proposed as contributing factors. There is the possibility that EOCRC has a unique biology. Overlapping with the EOCRC age range is CRC in adolescent and young adults (AYA) that share many molecular characteristics with EOCRC. The purpose of this review is to cover current progress in our understanding of the biology of CRC in the context of adolescent and young adult CRC and EOCRC and discuss future directions.

Impact of a Genetic Evaluation Initiative to Increase Access to Genetic Services for Adolescent and Young Adults at a Tertiary Cancer Hospital

Purpose: Adolescents and young adults (AYAs) with cancer are at increased risk for inherited cancer predisposition syndromes. Genetic counseling (GC) is important for accurate risk assessment, diagnosis, and management of inherited cancers. Numerous barriers prevent AYA access to genetic services. This study describes outcomes of a genetic evaluation initiative (GEI) regarding utilization of genetic services among AYAs. Methods: To improve AYA access to GC, the AYA program at UT MD Anderson Cancer Center implemented GEI, a process for identifying and referring eligible patients for GC. We collected retrospective electronic medical record data between July 12, 2018 and July 12, 2019 to capture AYA's clinical characteristics, genetic referral, scheduled appointments, counseling, testing, and results. Results: In total, 516 AYAs were referred to the AYA clinic during the study period with a median age of first cancer diagnosis of 17 years. One hundred sixty-six AYAs were identified who would benefit from genetic evaluation, 57 (34.3%) of whom had previously undergone counseling. One hundred nine patients were recommended for referral to GC, and 64.2% (70/109) were referred by the AYA team. To date, 58.6% (41/70) met with a genetic counselor and 75.6% (31/41) completed genetic testing, which yielded 1 pathogenic, 2 uncertain, and 29 benign results. Conclusion: The GEI resulted in a 72.0% relative increase in the rate of GC utilization and represents a novel approach to increasing AYA patient access to cancer genetic services in this population.

Exercise as a Potential Intervention to Modulate Cancer Outcomes in Children and Adults?

Exercise is recommended for the healthy population as it increases fitness and prevents diseases. Moreover, exercise is also applied as an adjunct therapy for patients with various chronic diseases including cancer. Childhood cancer is a rare, heterogeneous disease that differs from adult cancer. Improved therapeutic strategies have increased childhood cancer survival rates to above 80% in developed countries. Although this is higher than the average adult cancer survival rate of about 50%, therapy results often in substantial long-term side effects in childhood cancer survivors. Exercise in adult cancer patients has many beneficial effects and may slow down tumor progression and improve survival in some cancer types, suggesting that exercise may influence cancer cell behavior. In contrast to adults, there is not much data on general effects of exercise in children. Whilst it seems possible that exercise might delay cancer progression or improve survival in children as well, there is no reliable data yet to support this hypothesis. Depending on the type of cancer, animal studies of adult cancer types show that the exercise-induced increase of the catecholamines epinephrine and norepinephrine, have suppressive as well as promoting effects on cancer cells. The diverse effects of exercise in adult cancer patients require investigating whether these results can be achieved in children with cancer.

Adolescent and young adult oncology-past, present, and future

There are nearly 70,000 new cancer diagnoses made annually in adolescents and young adults (AYAs) in the United States. Historically, AYA patients with cancer, aged 15 to 39 years, have not shown the same improved survival as older or younger cohorts. This article reviews the contemporary cancer incidence and survival data through 2015 for the AYA patient population based on the National Cancer Institute's Surveillance, Epidemiology, and End Results registry program and the North American Association of Central Cancer Registries. Mortality data through 2016 from the Centers for Disease Control and Prevention's National Center for Health Statistics are also described. Encouragingly, absolute and relative increases in 5-year survival for AYA cancers have paralleled those of childhood cancers since the year 2000. There has been increasing attention to these vulnerable patients and improved partnerships and collaboration between adult and pediatric oncology; however, obstacles to the care of this population still occur at multiple levels. These vulnerabilities fall into 3 significant categories: research efforts and trial enrollment directed toward AYA malignancies, access to care and insurance coverage, and AYA-specific psychosocial support. It is critical for providers and health care delivery systems to recognize that the AYA population remains vulnerable to provider and societal complacency.