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Gore L. What are the Long-Term Complications of Pediatric ALL Treatments and How Can They Be Mitigated? Perspectives on Long-term Complications of Curative Treatment in Childhood ALL. Best Pract Res Clin Haematol 2022; 35:101403. [DOI: 10.1016/j.beha.2022.101403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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2
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Bodaar K, Yamagata N, Barthe A, Landrigan J, Chonghaile TN, Burns M, Stevenson KE, Devidas M, Loh ML, Hunger SP, Wood B, Silverman LB, Teachey DT, Meijerink JP, Letai A, Gutierrez A. JAK3 mutations and mitochondrial apoptosis resistance in T-cell acute lymphoblastic leukemia. Leukemia 2022; 36:1499-1507. [PMID: 35411095 PMCID: PMC9177679 DOI: 10.1038/s41375-022-01558-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 03/15/2022] [Accepted: 03/24/2022] [Indexed: 11/09/2022]
Abstract
Resistance to mitochondrial apoptosis predicts inferior treatment outcomes in patients with diverse tumor types, including T-cell acute lymphoblastic leukemia (T-ALL). However, the genetic basis for variability in this mitochondrial apoptotic phenotype is poorly understood, preventing its rational therapeutic targeting. Using BH3 profiling and exon sequencing analysis of childhood T-ALL clinical specimens, we found that mitochondrial apoptosis resistance was most strongly associated with activating mutations of JAK3. Mutant JAK3 directly repressed apoptosis in leukemia cells, because its inhibition with mechanistically distinct pharmacologic inhibitors resulted in reversal of mitochondrial apoptotic blockade. Inhibition of JAK3 led to loss of MEK, ERK and BCL2 phosphorylation, and BH3 profiling revealed that JAK3-mutant primary T-ALL patient samples were characterized by a dependence on BCL2. Treatment of JAK3-mutant T-ALL cells with the JAK3 inhibitor tofacitinib in combination with a spectrum of conventional chemotherapeutics revealed synergy with glucocorticoids, in vitro and in vivo. These findings thus provide key insights into the molecular genetics of mitochondrial apoptosis resistance in childhood T-ALL, and a compelling rationale for a clinical trial of JAK3 inhibitors in combination with glucocorticoids for patients with JAK3-mutant T-ALL.
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Affiliation(s)
- Kimberly Bodaar
- Division of Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Natsuko Yamagata
- Division of Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Anais Barthe
- Division of Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Jack Landrigan
- Division of Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Triona Ni Chonghaile
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA.,Deparment of Physiology and Medical Physics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Melissa Burns
- Division of Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA
| | - Kristen E. Stevenson
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Mignon L. Loh
- Ben Towne Center for Childhood Cancer Research, Seattle Children’s Research Institute, and the Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, 98105, USA
| | - Stephen P. Hunger
- Division of Oncology and the Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Brent Wood
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | - Lewis B. Silverman
- Division of Hematology/Oncology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, 02115, USA.,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA
| | - David T. Teachey
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA
| | | | - Anthony Letai
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA
| | - Alejandro Gutierrez
- Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA. .,Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, 02215, USA.
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3
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Muñoz-Aguirre P, Huerta-Gutierrez R, Zamora S, Mohar A, Vega-Vega L, Hernández-Ávila JE, Morales-Carmona E, Zapata-Tarres M, Bautista-Arredondo S, Perez-Cuevas R, Rivera-Luna R, Reich MR, Lajous M. Acute Lymphoblastic Leukaemia Survival in Children Covered by Seguro Popular in Mexico: A National Comprehensive Analysis 2005-2017. Health Syst Reform 2021; 7:e1914897. [PMID: 34125000 DOI: 10.1080/23288604.2021.1914897] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The aim of the study was to measure survival of children with acute lymphoblastic leukemia (ALL) under Mexico's public health insurance for the population treated under Seguro Popular. A retrospective cohort study using claims data from Mexico's Seguro Popular program, covering cancer treatment from 2005 to 2015 was conducted. Overall 5-year national and state-specific survival for children with ALL across Mexico who initiated cancer treatment under this program was estimated. From 2005 to 2015, 8,977 children with ALL initiated treatment under Seguro Popular. Under this financing scheme, the annual number of treated children doubled from 535 in 2005 to 1,070 in 2015. The estimates for 5-year overall survival of 61.8% (95%CI 60.8, 62.9) remained constant over time. We observed wide gaps in risk-standardized 5-year overall survival among states ranging from 74.7% to 43.7%. We found a higher risk of mortality for children who received treatment in a non-pediatric specialty hospital (Hazards Ratio, HR = 1.18; 95%CI 1.09, 1.26), facilities without a pediatric oncology/hematology specialist (HR = 2.17; 95%CI 1.62, 2.90), and hospitals with low patient volume (HR = 1.22; 95%CI 1.13, 1.32). In a decade Mexico's Seguro Popular doubled access to ALL treatment for covered children and by 2015 financed the vast majority of estimated ALL cases for that population. While some progress in ALL survival may have been achieved, nationwide 5-year overall survival did not improve over time and did not achieve levels found in comparable countries. Our results provide lessons for Mexico's evolving health system and for countries moving toward universal health coverage.
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Affiliation(s)
| | - Rodrigo Huerta-Gutierrez
- Centre for Research on Population Health, INSP (Instituto Nacional de Salud Pública), Cuernavaca, Mexico
| | - Salvador Zamora
- Instituto de Investigaciones en Matemáticas Aplicadas y en Sistemas, UNAM (Universidad Nacional Autónoma de México), Mexico City, Mexico
| | - Alejandro Mohar
- Epidemiology Unit, INCan (Instituto Nacional de Cancerología), Mexico City, Mexico.,Departement of Genetics and Environmenatl Toxicology, Instituto de Investigaciones Biomédicas-UNAM, Mexico City, Mexico
| | - Lourdes Vega-Vega
- Dirección General, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | | | | | - Marta Zapata-Tarres
- Division of Paediatric Haematology/Oncology, National Institute of Paediatrics, Mexico City, México
| | - Sergio Bautista-Arredondo
- Centre for Research on Health Systems, INSP (Instituto Nacional de Salud Pública), Cuernavaca, Mexico
| | - Ricardo Perez-Cuevas
- Division of Social Protection and Health, Jamaica Country Office, Inter-American Development Bank, Kingston, Jamaica
| | - Roberto Rivera-Luna
- Division of Paediatric Haematology/Oncology, National Institute of Paediatrics, Mexico City, México
| | - Michael R Reich
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Martin Lajous
- Centre for Research on Population Health, INSP (Instituto Nacional de Salud Pública), Cuernavaca, Mexico.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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4
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In-Hospital Management Might Reduce Induction Deaths in Pediatric Patients With Acute Lymphoblastic Leukemia: Results From a Japanese Cohort. J Pediatr Hematol Oncol 2021; 43:39-46. [PMID: 32852400 DOI: 10.1097/mph.0000000000001926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
Induction deaths (ID) remain a critical issue in the treatment of pediatric patients with acute lymphoblastic leukemia (ALL). The reported rate of ID in this population is 1% or higher. We speculate that this proportion might be lower in Japan because of mandatory hospitalization during induction therapy to manage complications. We retrospectively analyzed the incidence of ID among children with ALL enrolled in 4 Japanese study groups between 1994 and 2013. Among 5620 children, 41 (0.73%) cases of ID were noted. The median age was 6.5 years; 24 children were female, and 7 had T-cell ALL. Infection was the most common cause of ID (n=22), but the incidence (0.39%) was lower than that reported in western countries. Mortality within 48 hours from the onset of infection was low, comprising 25% of infection-related deaths. The incidence of infections caused by Bacillus species was low. Only 1 patient died because of Aspergillus infection. Fatal infections mostly occurred during the third week of induction therapy. Our findings suggest that close monitoring, stringent infection control, and immediate administration of appropriate antibiotics through hospitalization might be important strategies in reducing the rate of infection-related ID in pediatric patients with ALL.
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5
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Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients. Virchows Arch 2021; 478:1179-1185. [PMID: 33392797 DOI: 10.1007/s00428-020-03002-4] [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] [Received: 09/26/2020] [Revised: 12/12/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
Prevalence of discrepancies between antemortem clinical diagnoses and postmortem autopsy findings is uncertain in pediatric oncology given improving diagnostic capabilities over time. Primary objective was to describe discrepancies between antemortem and postmortem diagnosis of pediatric cancer deaths. Secondary objective was to compare clinical characteristics of deaths with and without major diagnostic discrepancies. This was a retrospective study that included pediatric cancer patients diagnosed and treated in Ontario and who died from 2003 to 2012. Antemortem clinical diagnoses associated with mortality were determined by reviewing the patient's health records 2 weeks prior to death while the postmortem diagnoses were determined by the autopsy report. Discrepancies among these diagnoses were classified using the Goldman criteria where major discrepancies were directly related to the cause of death in contrast to minor discrepancies. Among the 821 patients who died, 118 (14%) had an autopsy and were included. Of these autopsies, 12 (10%) had a major diagnostic discrepancy between antemortem and postmortem diagnoses. Major discrepancies consisted of opportunistic infections (n = 5), missed cancer diagnosis (n = 3), and organ complications (n = 4). Death in a high acuity setting (12/12, 100% vs. 60/106, 57%; P = 0.003) and treatment-related mortality (12/12, 100% vs. 60/106, 57%; P = 0.003) were significantly associated with major discrepancy. Major diagnostic discrepancy was found in 10% of pediatric oncology autopsies. Missed infections and organ complications were predominant etiologies. Death in a high acuity setting and treatment-related mortality were associated with major diagnostic discrepancies. Autopsies continue to be important for improving diagnostic insight and may improve future clinical care.
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6
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Locatelli F, Zugmaier G, Mergen N, Bader P, Jeha S, Schlegel PG, Bourquin JP, Handgretinger R, Brethon B, Rossig C, Chen-Santel C. Blinatumomab in pediatric patients with relapsed/refractory acute lymphoblastic leukemia: results of the RIALTO trial, an expanded access study. Blood Cancer J 2020; 10:77. [PMID: 32709851 PMCID: PMC7381625 DOI: 10.1038/s41408-020-00342-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/18/2020] [Accepted: 06/25/2020] [Indexed: 01/28/2023] Open
Affiliation(s)
- Franco Locatelli
- Department of Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Rome, Sapienza, University of Rome, Rome, Italy
| | | | | | - Peter Bader
- Department for Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Sima Jeha
- St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Jean-Pierre Bourquin
- Department of Pediatric Oncology, Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Rupert Handgretinger
- Department of Hematology/Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Benoit Brethon
- Pediatric Hematology and Immunology Department, Robert Debre Hospital, APHP, Paris, France
| | - Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster, Muenster, Germany
| | - Christiane Chen-Santel
- Department of Pediatrics, Division of Oncology and Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
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Behjati S, Ruffle A, Kelly A, Dickens E. Fifteen-minute consultation: Initial management of suspected acute leukaemia by non-specialists. Arch Dis Child Educ Pract Ed 2020; 105:66-70. [PMID: 31278078 DOI: 10.1136/archdischild-2017-314043] [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: 11/11/2018] [Revised: 04/07/2019] [Accepted: 04/14/2019] [Indexed: 11/03/2022]
Abstract
Leukaemia is the most common cancer of childhood. Most children with a new diagnosis of leukaemia are clinically stable at initial presentation. However, there are a number of life-threatening complications that have to be considered and monitored for. These complications include sepsis, tumour lysis syndrome, mediastinal masses, bleeding and pain. The aim of this article is to equip the general paediatrician with a framework for managing children with suspected leukaemia, prior to transfer to the primary treatment centre. The presentation, diagnosis and definitive treatment of acute leukaemia is not in the remit of this article.
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Affiliation(s)
- Sam Behjati
- Department of Paediatrics, University of Cambridge, Cambridge, UK.,Department of Paediatric Oncology and Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Amy Ruffle
- Department of Paediatric Oncology and Haematology, Addenbrooke's Hospital, Cambridge, UK.,Department of Haematology and Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anne Kelly
- Department of Paediatric Oncology and Haematology, Addenbrooke's Hospital, Cambridge, UK
| | - Emmy Dickens
- Department of Paediatric Oncology and Haematology, Addenbrooke's Hospital, Cambridge, UK
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8
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Hasegawa D, Imamura T, Yumura-Yagi K, Takahashi Y, Usami I, Suenobu SI, Nishimura S, Suzuki N, Hashii Y, Deguchi T, Moriya-Saito A, Kato K, Kosaka Y, Hirayama M, Iguchi A, Kawasaki H, Hori H, Sato A, Kudoh T, Nakahata T, Oda M, Hara J, Horibe K. Risk-adjusted therapy for pediatric non-T cell ALL improves outcomes for standard risk patients: results of JACLS ALL-02. Blood Cancer J 2020; 10:23. [PMID: 32107374 PMCID: PMC7046744 DOI: 10.1038/s41408-020-0287-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/01/2020] [Accepted: 02/07/2020] [Indexed: 11/14/2022] Open
Abstract
This study was a second multicenter trial on childhood ALL by the Japan Childhood Leukemia Study Group (JACLS) to improve outcomes in non-T ALL. Between April 2002 and March 2008, 1138 children with non-T ALL were enrolled in the JACLS ALL-02 trial. Patients were stratified into three groups using age, white blood cell count, unfavorable genetic abnormalities, and treatment response: standard risk (SR), high risk (HR), and extremely high risk (ER). Prophylactic cranial radiation therapy (PCRT) was abolished except for CNS leukemia. Four-year event-free survival (4yr-EFS) and 4-year overall survival (4yr-OS) rates for all patients were 85.4% ± 1.1% and 91.2% ± 0.9%, respectively. Risk-adjusted therapy resulted in 4yr-EFS rates of 90.4% ± 1.4% for SR, 84.9% ± 1.6% for HR, and 66.5% ± 4.0% for ER. Based on NCI risk classification, 4yr-EFS rates were 88.2% in NCI-SR and 76.4% in NCI-HR patients, respectively. Compared to previous trial ALL-97, 4yr-EFS of NCI-SR patients was significantly improved (88.2% vs 81.2%, log rank p = 0.0004). The 4-year cumulative incidence of isolated (0.9%) and total (1.5%) CNS relapse were significantly lower than those reported previously. In conclusion, improved EFS in NCI-SR patients and abolish of PCRT was achieved in ALL-02.
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Affiliation(s)
- Daiichiro Hasegawa
- Department of Hematology/Oncology, Hyogo Prefectural Children's Hospital, Kobe, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan. .,Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.
| | | | - Yoshihiro Takahashi
- Department of Pediatrics, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Ikuya Usami
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.,Department of Pediatric Hematology and Oncology, Hyogo Prefectural Amagasaki General Medical Center, Hyogo, Japan
| | - So-Ichi Suenobu
- Division of General Pediatrics and Emergency Medicine, Department of Pediatrics, Oita University, Oita, Japan
| | | | - Nobuhiro Suzuki
- Department of Pediatrics, Hokkaido Medical Center for Child Health and Rehabilitation, Sapporo, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University, Suita, Japan
| | - Takao Deguchi
- Department of Pediatrics, Mie University, Tsu, Japan
| | - Akiko Moriya-Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Koji Kato
- Department of Hematology Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology/Oncology, Hyogo Prefectural Children's Hospital, Kobe, Japan
| | | | - Akihiro Iguchi
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | | | - Hiroki Hori
- Department of Pediatrics, Mie University, Tsu, Japan
| | - Atsushi Sato
- Department of Hematology/Oncology, Miyagi Children's Hospital, Sendai, Japan
| | | | - Tatsutoshi Nakahata
- Department of Clinical Application, Center for iPS Cell Research and Application (CiRA), Kyoto University, Kyoto, Japan
| | - Megumi Oda
- Department of Pediatrics, Okayama University, Okayama, Japan
| | - Junichi Hara
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Seah T, Zhang C, Halbert J, Prabha S, Gupta S. The magnitude and predictors of therapy abandonment in pediatric central nervous system tumors in low- and middle-income countries: Systematic review and meta-analysis. Pediatr Blood Cancer 2019; 66:e27692. [PMID: 30835958 DOI: 10.1002/pbc.27692] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Outcomes of pediatric central nervous system (CNS) tumors in low- to middle-income countries (LMIC) are poorer than their high-income counterparts. Abandonment of therapy is increasingly recognized as a key contributor to this disparity, but has been poorly quantified. We performed a meta-analysis to determine the magnitude of abandonment in pediatric CNS tumors in LMIC, and risk factors and interventions aimed at reducing this. PATIENTS AND METHODS We searched seven databases for pediatric CNS tumor cohorts followed up from diagnosis and treated in LMIC. All languages were included. Two reviewers independently selected articles and extracted data on abandonment rates (ARs) and predictors. The authors were contacted for additional information. RESULTS Of 50 660 publications, 643 in five languages met criteria for full review; 131 met analysis inclusion criteria. ARs were not reported in the majority, and a small number were available from the authors. Available ARs ranged from 0% to 59%, from 38 studies (2497 children in 14 countries), and these were quantitatively analyzed. Lower-middle-income countries had higher ARs than upper-middle-income countries (27%, 95% confidence interval [CI] 20%-36% vs 9%, 95% CI 6%-14%, P < 0.0001), with significant heterogeneity within each (LMIC I2 = 78%, P < 0.00001, UMIC I2 = 85%, P < 0.00001). Common predictors for abandonment included distance to treatment centers, financial hardship, and prognostic misconceptions. CONCLUSION In LMICs, ARs are highest in lower-MICs. However, the paucity of published data limits further evaluation. Given the increasing burden of pediatric CNS tumors in LMIC, addressing deficits in abandonment reporting is critical. Consistent reporting is needed for developing interventions to improve outcomes.
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Affiliation(s)
| | - Chuer Zhang
- Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Jay Halbert
- Royal London Hospital, London, United Kingdom
| | - Shashi Prabha
- Department of Clinical Biochemistry, B.J. Medical College, Ahmedabad, Gujarat, India
| | - Sumit Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, Faculty of Medicine, University of Toronto, Ontario, Canada
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Hafez HA, Soliaman RM, Bilal D, Hashem M, Shalaby LM. Early Deaths in Pediatric Acute Leukemia: A Major Challenge in Developing Countries. J Pediatr Hematol Oncol 2019; 41:261-266. [PMID: 30615014 DOI: 10.1097/mph.0000000000001408] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Children with acute leukemia may experience high treatment-related mortality, which often occurs early in the induction phase. The aim of the study was to assess the incidence and risk factors related to increased mortality during induction therapy of pediatric patients with acute leukemia. This is a retrospective study that included pediatric acute leukemia patients who presented to the National Cancer Institute, Cairo University, between January 2011 and December 2013. The study included 370 patients, 253 with acute lymphoblastic leukemia, 100 with acute myeloid leukemia, and 17 with mixed phenotype acute leukemia. The total and induction death rates were 40.5% and 19.2%, respectively. Most of the early deaths were attributed to infections (64.7%) and cerebrovascular accidents (18.3%). Using enhanced supportive care measures during 2013 had significantly reduced the overall and induction mortality rates (29% and 13.6%, respectively, in 2013 vs. 46% and 20.3% in 2011). Induction deaths in pediatric acute leukemia remain a major challenge in developing countries, and using enhanced supportive care measures is effective to improve the survival outcome in this group of patients.
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Affiliation(s)
| | | | - Dalia Bilal
- Biostatistics, National Cancer Institute, Cairo University
| | - Mohamed Hashem
- Research Department, Children's Cancer Hospital, Cairo, Egypt
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11
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Elements Associated With Early Mortality in Children With B Cell Acute Lymphoblastic Leukemia in Chiapas, Mexico: A Case-control Study. J Pediatr Hematol Oncol 2019; 41:1-6. [PMID: 30339656 DOI: 10.1097/mph.0000000000001337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Childhood Lymphoblastic leukemia's (ALL) early mortality (EM) is an undesirable treatment outcome for a disease for which >90% long term success is achievable. In the Western world EM constitutes no >3%; yet, in Chiapas, Mexico, remains around 15%. With the objective of improving on EM, we determined associated elements in 28 ALL who died within 60 days of arriving at Hospital de Especialidades Pediátricas in Chiapas (HEP), by comparing them to those in 84 controls who lived beyond the first 90 days. χ, t test, and binary logistic regression (BLR) were used to determine significant individual and multiple variables associated to outcome. On arrival, fever, liver and spleen enlargement, active bleeding, lower albumin, less platelets, higher creatinine, and uric acid, more diploid and less hyperdiploid cases were associated with EM cases. Time to diagnosis, nutritional status, risk group and leukocyte count were not related. Antileukemic treatment approach was similar in both groups. The BLR model including fever, active bleeding, liver enlargement, <10,000 platelets/µL, and >2X upper normal lactic dehydrogenase, determined outcome in 66.7% EM and 90.2% controls. To improve on EM in ALL, patients with characteristics defined here ought to be treated differently at HEP.
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12
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Gibson P, Pole JD, Lazor T, Johnston D, Portwine C, Silva M, Alexander S, Sung L. Treatment-related mortality in newly diagnosed pediatric cancer: a population-based analysis. Cancer Med 2018; 7:707-715. [PMID: 29473334 PMCID: PMC5852352 DOI: 10.1002/cam4.1362] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/20/2017] [Accepted: 01/04/2018] [Indexed: 11/07/2022] Open
Abstract
Using a previously developed reliable and valid treatment‐related mortality (TRM) definition, our objective was to describe the proportion of children newly diagnosed with cancer experiencing TRM and to identify risk factors for TRM in a population‐based cohort. We included children with cancer <19 years diagnosed and treated in Ontario who were diagnosed between 2003 and 2012. Children with cancer were identified using data in a provincial registry. Cumulative incidence of TRM was calculated where progressive disease death was considered a competing event. Among the 5179 children included, 179 had TRM, 478 died of progressive disease, and 4522 were still alive. At 5 years, the cumulative incidence of TRM among the entire cohort was 3.9% (95% confidence interval (CI) 3.3–4.5%). When compared to brain tumor patients, leukemia and lymphoma patients had a significantly higher risk of TRM (hazard ratio (HR) 2.5, 95% CI: 1.6–4.0; P < 0.0001). Infants were at significantly higher risk of TRM across diagnostic groups. Other factors associated with higher risks of TRM were metastatic disease (P < 0.0001), diagnosis prior to 1 January 2008 (P = 0.001), hematopoietic stem cell transplantation (HSCT) (P < 0.0001), and relapse (P < 0.0001). The 5‐year cumulative incidence of TRM was 3.9% among newly diagnosed children with cancer. Infants were at higher risk of TRM across diagnostic groups. Other risk factors for TRM were leukemia or lymphoma, metastatic disease, earlier diagnosis year, HSCT, and relapse. Future work should further refine prognostic factors by specific cancer diagnosis to best understand when and how to intervene to improve outcomes.
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Affiliation(s)
- Paul Gibson
- Division of Haematology/Oncology, Children's Hospital, London Health Sciences Centre, 800 Commissioners Rd E, London, Ontario, N6A 5W9, Canada
| | - Jason D Pole
- Pediatric Oncology Group of Ontario, 480 University Ave, Toronto, Ontario, M5G 1V2, Canada
| | - Tanya Lazor
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada
| | - Donna Johnston
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada
| | - Carol Portwine
- Department of Pediatrics, McMaster Children's Hospital, 1200 Main St West, Hamilton, Ontario, L8N 3Z5, Canada
| | - Mariana Silva
- Department of Pediatrics, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, K7L 2V7, Canada
| | - Sarah Alexander
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
| | - Lillian Sung
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St, Toronto, Ontario, M5G 0A4, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8, Canada
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Johnston EE, Alvarez E, Saynina O, Sanders L, Bhatia S, Chamberlain LJ. Disparities in the Intensity of End-of-Life Care for Children With Cancer. Pediatrics 2017; 140:peds.2017-0671. [PMID: 28963112 PMCID: PMC9923617 DOI: 10.1542/peds.2017-0671] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Many adult patients with cancer who know they are dying choose less intense care; additionally, high-intensity care is associated with worse caregiver outcomes. Little is known about intensity of end-of-life care in children with cancer. METHODS By using the California Office of Statewide Health Planning and Development administrative database, we performed a population-based analysis of patients with cancer aged 0 to 21 who died between 2000 and 2011. Rates of and sociodemographic and clinical factors associated with previously-defined end-of-life intensity indicators were determined. The intensity indicators included an intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis) within 30 days of death, intravenous chemotherapy within 14 days of death, and hospital death. RESULTS The 3732 patients were 34% non-Hispanic white, and 41% had hematologic malignancies. The most prevalent intensity indicators were hospital death (63%) and ICU admission (20%). Sixty-five percent had ≥1 intensity indicator, 23% ≥2, and 22% ≥1 intense medical intervention. There was a bimodal association between age and intensity: ages <5 years and 15 to 21 years was associated with intense care. Patients with hematologic malignancies were more likely to have high-intensity end-of-life care, as were patients from underrepresented minorities, those who lived closer to the hospital, those who received care at a nonspecialty center (neither Children's Oncology Group nor National Cancer Institute Designated Cancer Center), and those receiving care after 2008. CONCLUSIONS Nearly two-thirds of children who died of cancer experienced intense end-of-life care. Further research needs to determine if these rates and disparities are consistent with patient and/or family goals.
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Affiliation(s)
- Emily E. Johnston
- Divisions of Pediatric Hematology/Oncology and,Address correspondence to Emily E. Johnston, MD, Division of Pediatric Hematology/Oncology, Department of Pediatrics, Stanford University School of Medicine, 1000 Welch Rd, Suite 300, Palo Alto, CA 94304. E-mail:
| | | | - Olga Saynina
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
| | - Lee Sanders
- General Pediatrics, Department of Pediatrics, School of Medicine, and,Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa J. Chamberlain
- General Pediatrics, Department of Pediatrics, School of Medicine, and,Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; and
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14
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Koizumi A, Ohta Y, Sakuma M, Okamoto R, Matsumoto C, Bates DW, Morimoto T. Differences in Adverse Drug Events Among Pediatric Patients With and Without Cancer: Sub-Analysis of a Retrospective Cohort Study. Drugs Real World Outcomes 2017; 4:167-173. [PMID: 28779391 PMCID: PMC5567460 DOI: 10.1007/s40801-017-0115-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives This study investigated the differences in the incidence and severity of adverse drug events (ADEs) in pediatric patients with and without cancer. Methods We used data from the Japan Adverse Drug Events Study for pediatrics, a cohort study enrolling pediatric inpatients at two tertiary care teaching hospitals in Japan. ADEs were identified by on-site review of all medical charts, incident reports, and prescription queries by pharmacists. Two independent physicians reviewed all potential ADEs and classified ADEs in terms of severity and class of causative medication. We compared the incidence and characteristics of ADEs between pediatric cancer patients and non-cancer patients. Results We enrolled 1189 patients during the study period, 27 with cancer and 1162 without cancer. We identified 480 ADEs in 234 patients (20%): 191 ADEs among 21 cancer patients and 289 ADEs among 213 non-cancer patients (7.1 per patient vs. 0.25 per patient, respectively; p < 0.0001). The most common medications associated with ADEs in cancer patients were antitumor agents; in contrast, medications associated with fatal or life-threatening ADEs in cancer patients were most often sedatives (25%) and blood products (25%). Medications associated with fatal or life-threatening ADEs among non-cancer patients were most often sedatives (15%). The percentages of fatal or life-threatening ADEs in cancer patients and non-cancer patients were 2.1 and 4.5%, respectively. Conclusions Pediatric patients with cancer have a higher risk for ADEs. Although the overall severity was similar between patients with and without cancer, the most common classes of causative medication and medications associated with a higher rate of severe ADEs differed. Application of this information may help minimize the impact of ADEs in pediatric patients.
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Affiliation(s)
- Akira Koizumi
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Yoshinori Ohta
- Division of General Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Mio Sakuma
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Rika Okamoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Chisa Matsumoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan.
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15
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Pole JD, Gibson P, Ethier MC, Lazor T, Johnston DL, Portwine C, Silva M, Alexander S, Sung L. Evaluation of treatment-related mortality among paediatric cancer deaths: a population based analysis. Br J Cancer 2017; 116:540-545. [PMID: 28095399 PMCID: PMC5318976 DOI: 10.1038/bjc.2016.443] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/02/2016] [Accepted: 12/08/2016] [Indexed: 11/16/2022] Open
Abstract
Background: Objectives were to describe the proportion of deaths due to treatment-related mortality (TRM) and to identify risk factors and probable causes of TRM among paediatric cancer deaths in a population-based cohort. Methods: We included children with cancer ⩽18 years diagnosed and treated in Ontario who died between January 2003 and December 2012. Deaths were identified using a provincial registry, the Pediatric Oncology Group of Ontario Networked Information System. Probable causes of TRM were described. Results: Among the 964 deaths identified, 821 were included. The median age at diagnosis was 6.6 years (range 0–18.8) and 51.8% had at least one relapse. Of the deaths examined, TRM occurred in 217/821 (26.4%) while 604/821 (73.6%) were due to progressive cancer. Deaths from TRM did not change over time. Using multiple regression, younger age, leukaemia diagnosis and absence of relapse were independently positively associated with TRM. The most common probable causes of TRM were respiratory, infection and haemorrhage. Conclusions: TRM was responsible for 26.4% of deaths in paediatric cancer. Underlying diagnosis, younger age and absence of relapse were associated with TRM and causes of TRM differed by diagnosis group. Future work should evaluate TRM rate and risk factors among newly diagnosed cancer patients.
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Affiliation(s)
- Jason D Pole
- Pediatric Oncology Group of Ontario, 480 University Ave., Toronto, Ontario, M5G 1V2, Canada
| | - Paul Gibson
- Division of Haematology/Oncology, Children's Hospital, London Health Sciences Centre, 800 Commissioners Rd. E., London, Ontario, N6A 5W9, Canada
| | - Marie-Chantal Ethier
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., Toronto, Ontario, M5G 0A4, Canada
| | - Tanya Lazor
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., Toronto, Ontario, M5G 0A4, Canada
| | - Donna L Johnston
- Department of Pediatrics, Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, K1H 8L1, Canada
| | - Carol Portwine
- Department of Pediatrics, McMaster Children's Hospital, 1280 Main St West, Hamilton, Ontario, L8N 3Z5, Canada
| | - Mariana Silva
- Department of Pediatrics, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, K7L 2V7, Canada
| | - Sarah Alexander
- Department of Pediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada
| | - Lillian Sung
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St., Toronto, Ontario, M5G 0A4, Canada.,Department of Pediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada
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Hassan H, Rompola M, Glaser AW, Kinsey SE, Phillips RS. Validation of a classification system for treatment-related mortality in children with cancer. BMJ Paediatr Open 2017; 1:e000082. [PMID: 29637120 PMCID: PMC5862234 DOI: 10.1136/bmjpo-2017-000082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/10/2017] [Accepted: 10/15/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Death not directly due to cancer has been termed 'treatment-related mortality' (TRM). Appreciating the differences between TRM and disease-related death is critical in directing strategies to improve supportive care, interventions delivered or disease progression. Recently, a global collaboration developed and validated a consensus-based classification tool and attribution system. OBJECTIVES To evaluate the reliability of the newly developed consensus-based definition of TRM and explore the use of the cause-of-death attribution system outside the centre it was initially validated (Toronto, Canada). In the initial study, reviewers listed multiple causes of death. In this study, reviewers identified a primary cause for simplicity. SETTING The paediatric haematology and oncology department at Leeds Teaching Hospital in Leeds, UK. PARTICIPANTS Two consultants and two clinical research associates (CRAs). METHODS Thirty medical records of the most recent deaths in children with cancer, 2 and 4 weeks prior to death, were anonymised and presented to the participants. Reviewers independently classified deaths as 'treatment related mortality' or 'not treatment related' according to the algorithm developed. When TRM occurred, reviewers applied the cause-of-death attribution system to identify the primary cause of death. Inter-relater reliability was assessed using the kappa statistic (k). MAIN OUTCOME Inter-relater reliability between CRA and consultants. RESULTS Reliability of the classification was deemed 'very good' between CRA and consultants (k=0.86, 95% CI 0.72 to 0.97). Ten deaths were classified as TRM, of which infection was the most frequent cause identified. Reviewers disagreed on the primary cause of death (eg, respiratory vs infection) when applying the cause-of-death attribution system in six cases and probable and possible causes in four cases. The study identified how the algorithm may not detect TRM in patients receiving non-curative therapy. CONCLUSIONS The classification and cause of death attribution system could be implemented in different healthcare settings. Adaptation of the classification tool in patients receiving non-curative interventions and the cause of death attribution system should be considered.
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Affiliation(s)
- Hadeel Hassan
- Department of Paediatric Haematology and Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Menie Rompola
- Department of Paediatric Haematology and Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Adam Woolf Glaser
- Department of Paediatric Haematology and Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Sally Elizabeth Kinsey
- Department of Paediatric Haematology and Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Robert Stephen Phillips
- Department of Paediatric Haematology and Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Centre for Reviews and Dissemination, University of York, York, UK
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Classification of treatment-related mortality in children with cancer: a systematic assessment. Lancet Oncol 2015; 16:e604-10. [PMID: 26678213 DOI: 10.1016/s1470-2045(15)00197-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 07/20/2015] [Accepted: 07/23/2015] [Indexed: 11/23/2022]
Abstract
Treatment-related mortality is an important outcome in paediatric cancer clinical trials. An international group of experts in supportive care in paediatric cancer developed a consensus-based definition of treatment-related mortality and a cause-of-death attribution system. The reliability and validity of the system was tested in 30 deaths, which were independently assessed by two clinical research associates and two paediatric oncologists. We defined treatment-related mortality as death occurring in the absence of progressive cancer. Of the 30 reviewed deaths, the reliability of classification for treatment-related mortality was noted as excellent by clinical research associates (κ=0·83, 95% CI 0·60-1·00) and paediatric oncologists (0·84, 0·63-1·00). Criterion validity was established because agreement between the consensus classifications by clinical research associates and paediatric oncologists was almost perfect (0·92, 0·78-1·00). Our approach should allow comparison of treatment-related mortality across trials and across time.
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Jastaniah W, Elimam N, Abdalla K, Iqbal BAC, Khattab TM, Felimban S, Abrar MB. Identifying causes of variability in outcomes in children with acute lymphoblastic leukemia treated in a resource-rich developing country. Pediatr Blood Cancer 2015; 62:945-50. [PMID: 25557583 DOI: 10.1002/pbc.25374] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/03/2014] [Indexed: 11/12/2022]
Abstract
BACKGROUND The outcome of children with acute lymphoblastic leukemia (ALL) in developing countries is less favorable than in developed countries, primarily due to resource constraints. However, it is unknown whether the therapeutic results differ. Thus, we hypothesized that outcomes in resource-rich developing countries would be similar to those in industrialized regions. PROCEDURE We performed a retrospective analysis of 224 consecutive children with ALL, who were treated according to the Children's Cancer Group (CCG) protocols between January 2001 and December 2007. High-risk (HR) and standard-risk (SR) patients were treated with modified CCG-1961 and CCG-1991 protocols, respectively. Modifications included substitution of dexamethasone for prednisone in HR patients and addition of two intrathecal methotrexate treatments for CNS2 patients during induction. All patients received double delayed intensification with two interim maintenance phases. RESULTS Five-year overall survival (OS), event-free survival (EFS) and disease-free survival (DFS) were 84.7 ± 2.4%, 77.0 ± 2.9%, and 81.4 ± 2.7%, respectively. Remission was achieved in 98.1% of the patients. Induction failure and relapse rates were 1.9% and 15.1%, respectively. Death as the first event occurred in 6.4% of cases, of which 2.7% and 3.7% involved deaths in induction and remission, respectively. Interestingly, a significant reduction in induction deaths was observed over time. CONCLUSIONS Despite the encouraging results observed in the present study, our patients displayed significantly lower survival outcomes compared to subjects treated in major clinical trials conducted by leading leukemia cooperative groups. Furthermore, this work underscores the need for targeted interventions to reduce death as the first event in developing regions.
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Affiliation(s)
- Wasil Jastaniah
- Princess Noorah Oncology Center, King Saud Bin Abdulaziz University and King Abdulaziz Medical City, Jeddah, Saudi Arabia; Department of Pediatrics, Faculty of Medicine, Umm AlQura University, Makkah, Saudi Arabia
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20
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Alexander S. Clinically defining and managing high-risk pediatric patients with acute lymphoblastic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:181-189. [PMID: 25696853 DOI: 10.1182/asheducation-2014.1.181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
For children with acute lymphoblastic leukemia, the identification of those at higher risk of disease recurrence and modifying therapy based on this risk is a critical component to the provision of optimal care. The specific definitions of high-risk ALL vary across cooperative groups, but the themes are consistent, being largely based on leukemia biology and disease response. Intensification of conventional chemotherapy for those with high-risk disease has led to improved outcomes. It is anticipated that the development of rational targeted therapy for specific biologically unique subsets of children with leukemia will contribute to ongoing progress in improving the outcomes for children with acute lymphoblastic anemia.
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Abstract
For children with acute lymphoblastic leukemia, the identification of those at higher risk of disease recurrence and modifying therapy based on this risk is a critical component to the provision of optimal care. The specific definitions of high-risk ALL vary across cooperative groups, but the themes are consistent, being largely based on leukemia biology and disease response. Intensification of conventional chemotherapy for those with high-risk disease has led to improved outcomes. It is anticipated that the development of rational targeted therapy for specific biologically unique subsets of children with leukemia will contribute to ongoing progress in improving the outcomes for children with acute lymphoblastic anemia.
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Wong FL, Bhatia S, Landier W, Francisco L, Leisenring W, Hudson MM, Armstrong GT, Mertens A, Stovall M, Robison LL, Lyman GH, Lipshultz SE, Armenian SH. Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure. Ann Intern Med 2014; 160:672-83. [PMID: 24842414 PMCID: PMC4073480 DOI: 10.7326/m13-2498] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD. OBJECTIVE To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies. DESIGN Simulation of life histories using Markov health states. DATA SOURCES Childhood Cancer Survivor Study; published literature. TARGET POPULATION Childhood cancer survivors. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis. OUTCOME MEASURES Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure. RESULTS OF BASE-CASE ANALYSIS The COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits. RESULTS OF SENSITIVITY ANALYSIS The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER. LIMITATION Lifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown). CONCLUSION The COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.
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Abstract
The purpose was to describe the incidence and risk factors associated with early deaths (≤ 42 days from diagnosis) among children with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) in Ontario, Canada. The data source for this population-based, retrospective cohort study was the Pediatric Oncology Group of Ontario Networked Information System (POGONIS). Patients with acute leukemia aged ≤ 18 years diagnosed between 1990 and 2010 were included. The study population consisted of 1954 children with ALL and 403 with AML. The early death rate was 40/2357 (1.7%), with 1.1% of patients with ALL and 4.7% of patients with AML dying early. Among all 442 deaths recorded, 9.0% occurred early. Twelve/40 (30.0%) early deaths were attributed to infection. Factors associated with early deaths were AML (p < 0.0001) and age ≥ 10 years at diagnosis (p = 0.038). Future interventions to improve survival may consider focusing on the early treatment period and may target AML and older patients.
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Affiliation(s)
- Sylvia Cheng
- Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada
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Gupta S, Yeh S, Martiniuk A, Lam CG, Chen HY, Liu YL, Tsimicalis A, Arora RS, Ribeiro RC. The magnitude and predictors of abandonment of therapy in paediatric acute leukaemia in middle-income countries: A systematic review and meta-analysis. Eur J Cancer 2013; 49:2555-64. [DOI: 10.1016/j.ejca.2013.03.024] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 03/02/2013] [Accepted: 03/19/2013] [Indexed: 11/30/2022]
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