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Friedman DN, Chou JF, Clark JM, Moskowitz CS, Ford JS, Armstrong GT, Mubdi NZ, McDonald A, Nathan PC, Sklar CA, Ramanathan LV, Robison LL, Oeffinger KC, Tonorezos ES. Exercise and QUality diet After Leukemia (EQUAL): A randomized weight loss trial among adult survivors of childhood leukemia in the Childhood Cancer Survivor Study. Cancer Epidemiol Biomarkers Prev 2024:743207. [PMID: 38652494 DOI: 10.1158/1055-9965.epi-23-1601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/02/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Obesity is prevalent in childhood cancer survivors and interacts with cancer treatments to potentiate risk for cardiovascular (CV) death. We tested a remote weight-loss intervention that was effective among adults with CV risk factors in a cohort of adult survivors of childhood acute lymphoblastic leukemia (ALL) with overweight/obesity. METHODS In this phase 3 efficacy trial, survivors of ALL enrolled in the Childhood Cancer Survivor Study with body mass index (BMI)≥25 kg/m2 were randomized to a remotely-delivered weight-loss intervention versus self-directed weight loss, stratified by history of cranial radiotherapy (CRT). The primary endpoint was the difference in weight loss at 24-months in an intent-to-treat analysis. Analyses were performed using linear mixed effects models. RESULTS Among 358 survivors (59% female, median attained age: 37 years, IQR: 33-43), baseline mean (SD) weight was 98.6 kg (24.0) for the intervention group (n=181) and 94.9 kg (20.3) for controls (n=177). Adherence to the intervention was poor; 15% of individuals in the intervention completed 24/30 planned coaching calls. Weight at 24-months was available for 274 (77%) participants. After controlling for CRT, sex, race/ethnicity, and age, the mean (SE) change in weight from baseline to 24-months was -0.4 kg (0.8) for intervention and 0.2 kg (0.6) for control participants (p=0.59). CONCLUSIONS A remote weight-loss intervention that was successful among adults with CV conditions did not result in significant weight loss among adult survivors of childhood ALL. IMPACT Future interventions in this population must be tailored to the unique needs of survivors to encourage engagement and adherence.
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Affiliation(s)
| | - Joanne F Chou
- Memorial Sloan Kettering Cancer Center, NYC, United States
| | | | | | | | | | | | - Aaron McDonald
- St. Jude Children's Research Hospital, Memphis, TN, United States
| | | | - Charles A Sklar
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | | | - Leslie L Robison
- St. Jude Children's Research Hospital, Memphis, TN, United States
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2
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Brick RS, Gallicchio L, Mollica MA, Zaleta AK, Tonorezos ES, Jacobsen PB, Castro KM, Miller MF. Survivorship concerns among individuals diagnosed with metastatic cancer: Findings from the Cancer Experience Registry. J Cancer Surviv 2024:10.1007/s11764-024-01573-8. [PMID: 38592607 DOI: 10.1007/s11764-024-01573-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/17/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Individuals with metastatic cancer experience many medical, physical, and emotional challenges due to changing medical regimens, oscillating disease states, and side effects. The purpose of this study was to describe the type and prevalence of survivorship concerns reported by individuals with metastatic cancer, and their associations with cancer diagnosis, treatment, and socio-demographic variables. METHODS This study utilized data from the Cancer Support Community's Cancer Experience Registry. Individuals were included if they self-reported a solid tumor metastatic cancer and completed CancerSupportSource, which evaluates five domains of concerns (emotional well-being, symptom burden, body image/healthy lifestyle, healthcare team communication, and relationships/intimacy). Multivariable linear regression examined associations between independent predictors of each survivorship concern domain. RESULTS Of the 403 included participants, individuals reported a metastatic diagnosis of breast (43%), colorectal (20%), prostate (7%), lung (7%), gynecologic cancer (6%) and other. Nearly all (96%) reported at least one survivorship concern, with the most prevalent concern about cancer progression or recurrence. Survivorship concerns were higher across multiple domains for individuals unemployed due to disability. Individuals who were less than five years since diagnosis reported higher concerns related to emotional well-being, symptom burden, and healthcare communication compared to those more than five years since diagnosis. CONCLUSION Individuals with metastatic cancer experience a variety of moderate-to-severe survivorship concerns that warrant additional investigation. IMPLICATIONS FOR CANCER SURVIVORS As the population of individuals with metastatic cancer lives longer, future research must investigate solutions to address modifiable factors associated with survivorship concerns, such as unemployment due to disability.
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Affiliation(s)
- Rachelle S Brick
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Lisa Gallicchio
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Michelle A Mollica
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Alexandra K Zaleta
- Department of Research, CancerCare, 275 Seventh Avenue, New York, NY, 10001, USA
| | - Emily S Tonorezos
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Paul B Jacobsen
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Kathleen M Castro
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
| | - Melissa F Miller
- Research and Training Institute, Cancer Support Community, 5614 Connecticut Avenue NW, Suite 280, Washington, D.C, 20015, USA.
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3
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Guida JL, Hyun G, Belsky DW, Armstrong GT, Ehrhardt MJ, Hudson MM, Green PA, Robison LL, Streck BP, Tonorezos ES, Yasui Y, Wilson CL, Wang Z, Ness KK. Associations of seven measures of biological age acceleration with frailty and all-cause mortality among adult survivors of childhood cancer in the St. Jude Lifetime Cohort. Nat Cancer 2024:10.1038/s43018-024-00745-w. [PMID: 38553617 DOI: 10.1038/s43018-024-00745-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/19/2024] [Indexed: 04/04/2024]
Abstract
Survivors of childhood cancer may experience accelerated biological aging, resulting in premature frailty and death. We used seven measures of biological age in the St. Jude Lifetime (SJLIFE) Cohort to compare biological age acceleration between the SJLIFE Cohort and the third United States National Health and Nutrition Examination Survey controls, explore trajectories of biological age according to cancer treatment and type, and test associations of biological age acceleration with frailty and death (mean follow-up of 26.5 years) among survivors. Survivors of cancer aged 5% faster per year and measured, on average, 0.6-6.44 years biologically older compared to controls and 5-16 years biologically older compared to age-matched individuals at the population level. Survivors treated with hematopoietic cell transplant and vinca alkaloid chemotherapy evidenced the fastest trajectories of biological aging. Biologically, older and faster-aging survivors consistently and robustly had a higher risk of frailty and died earlier than those with slower biological aging, suggesting a potential opportunity to intervene on excess aging.
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Affiliation(s)
- Jennifer L Guida
- Division of Cancer Control and Populations Sciences, National Cancer Institute, Rockville, MD, USA
| | - Geehong Hyun
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Daniel W Belsky
- Department of Epidemiology and Butler Columbia Aging Center, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Matthew J Ehrhardt
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Paige A Green
- Division of Cancer Control and Populations Sciences, National Cancer Institute, Rockville, MD, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Brennan P Streck
- Division of Cancer Control and Populations Sciences, National Cancer Institute, Rockville, MD, USA
| | - Emily S Tonorezos
- Office of Cancer Survivorship, National Cancer Institute, Rockville, MD, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Zhaoming Wang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
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4
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Halpern M, Mollica MA, Han PKJ, Tonorezos ES. Reply to M. Jefford et al. J Clin Oncol 2024:JCO2400137. [PMID: 38498809 DOI: 10.1200/jco.24.00137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Michael Halpern
- Michael Halpern, MD, PhD, MPH, Michelle A. Mollica, PhD, MPH, RN, OCN, Paul K.J. Han, MD, MA, MPH, Emily S. Tonorezos, MD, MPH, Division of Cancer Control and Population Sciences; National Cancer Institute; National Institutes of Health, Rockville, MD
| | - Michelle A Mollica
- Michael Halpern, MD, PhD, MPH, Michelle A. Mollica, PhD, MPH, RN, OCN, Paul K.J. Han, MD, MA, MPH, Emily S. Tonorezos, MD, MPH, Division of Cancer Control and Population Sciences; National Cancer Institute; National Institutes of Health, Rockville, MD
| | - Paul K J Han
- Michael Halpern, MD, PhD, MPH, Michelle A. Mollica, PhD, MPH, RN, OCN, Paul K.J. Han, MD, MA, MPH, Emily S. Tonorezos, MD, MPH, Division of Cancer Control and Population Sciences; National Cancer Institute; National Institutes of Health, Rockville, MD
| | - Emily S Tonorezos
- Michael Halpern, MD, PhD, MPH, Michelle A. Mollica, PhD, MPH, RN, OCN, Paul K.J. Han, MD, MA, MPH, Emily S. Tonorezos, MD, MPH, Division of Cancer Control and Population Sciences; National Cancer Institute; National Institutes of Health, Rockville, MD
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5
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Friedman DN, Goodman PJ, Leisenring WM, Diller LR, Cohn SL, Howell RM, Smith SA, Tonorezos ES, Wolden SL, Neglia JP, Ness KK, Gibson TM, Nathan PC, Turcotte LM, Weil BR, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Impact of Risk-Based therapy on late morbidity and mortality in neuroblastoma survivors: a report from the childhood cancer survivor study. J Natl Cancer Inst 2024:djae062. [PMID: 38460547 DOI: 10.1093/jnci/djae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/14/2024] [Accepted: 02/28/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND Early efforts at risk-adapted therapy for neuroblastoma are predicted to result in differential late effects; the magnitude of these differences have not been well-described. METHODS Late mortality, subsequent malignant neoplasms (SMN), and severe/life-threatening chronic health conditions (CHCs), graded according to CTCAE v4.03, were assessed among 5-year CCSS survivors of neuroblastoma diagnosed 1987-1999. Using age, stage at diagnosis, and treatment, survivors were classified into risk groups (low [n = 425]; intermediate [n = 252]; high [n = 245]). Standardized mortality ratios (SMR) and standardized incidence ratios (SIR) of SMNs were compared to matched population controls. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for CHC compared to 1,029 CCSS siblings. RESULTS Among survivors (49.8% male; median age 21 years, range 7-42; median follow-up 19.3 years, range 5-29.9), 80% with low-risk disease were treated with surgery alone, while 79.1% with high-risk disease received surgery, radiation, chemotherapy ± autologous stem cell transplant (ASCT). All-cause mortality was elevated across risk groups (SMRhigh=27.7 [21.4-35.8]; SMRintermediate=3.3 [1.7-6.5]; SMRlow=2.8 [1.7-4.8]). SMN risk was increased among high- and intermediate-risk survivors (SIRhigh=28.0 [18.5-42.3]; SIRintermediate=3.7 [1.2-11.3]), but did not differ from the US population for survivors of low-risk disease. Compared to siblings, survivors had an increased risk of grade 3-5 CHCs, particularly among those with high-risk disease (HRhigh=16.1 [11.2-23.2]; HRintermediate=6.3 [3.8-10.5]; HRlow=1.8 [1.1-3.1]). CONCLUSION Survivors of high-risk disease treated in the early days of risk stratification carry a markedly elevated burden of late recurrence, SMN, and organ-related multi-morbidity, while survivors of low/intermediate-risk disease have a modest risk of late adverse outcomes.
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Affiliation(s)
- Danielle Novetsky Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Pamela J Goodman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa R Diller
- Department of Pediatrics, The Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan L Cohn
- Department of Pediatrics, The University of Chicago, Chicago, IL, USA
| | - Rebecca M Howell
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Susan A Smith
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Emily S Tonorezos
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph P Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Todd M Gibson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Paul C Nathan
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lucie M Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Brent R Weil
- Department of Pediatrics, The Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Tara O Henderson
- Department of Pediatrics, The University of Chicago, Chicago, IL, USA
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6
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Bhatia S, Tonorezos ES, Landier W. Survival of Childhood Cancer and Subsequent Clinical Care-Reply. JAMA 2024; 331:617. [PMID: 38497699 DOI: 10.1001/jama.2023.26984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham
| | - Emily S Tonorezos
- Office of Cancer Survivorship, National Cancer Institute, Rockville, Maryland
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham
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7
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Halpern M, Mollica MA, Han PK, Tonorezos ES. Myths and Presumptions About Cancer Survivorship. J Clin Oncol 2024; 42:134-139. [PMID: 37972343 PMCID: PMC10824378 DOI: 10.1200/jco.23.00631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 11/19/2023] Open
Abstract
Identifying cancer survivorship myths and presumptions perpetuated in survivorship circles.
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Affiliation(s)
- Michael Halpern
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Michelle A. Mollica
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Paul K.J. Han
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Emily S. Tonorezos
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD
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8
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Funt SA, Knezevic A, Wilson K, Bromberg M, Budnick A, O'Connor KL, McHugh DJ, Larsen E, Bajorin DF, Motzer RJ, Tonorezos ES, Patil S, Feldman DR. Ototoxicity associated with high-dose carboplatin for patients with previously treated germ cell tumors. Cancer 2023; 129:3952-3961. [PMID: 37715631 DOI: 10.1002/cncr.34991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/26/2023] [Accepted: 07/18/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND High-dose carboplatin is an essential part of curative high-dose chemotherapy (HDCT) for patients with previously treated germ cell tumors (GCTs). Although hearing loss (HL) is a known side effect of HDCT, data on its severity and characteristics are limited. METHODS Eligible patients received HDCT for GCTs from 1993 to 2017 and had audiograms before and after HDCT. HL severity was classified by American Speech-Language-Hearing Association criteria, and mean change in hearing threshold at each frequency (0.25-8 kHz) was estimated from pre- to post-HDCT and between HDCT cycles. RESULTS Of 115 patients (median age, 32 years), 102 (89%) received three cycles of HDCT. Of 106 patients with normal hearing to mild HL in the speech frequencies (0.5-4 kHz) before HDCT, 70 (66%) developed moderate to profound HL in the speech frequencies after HDCT. Twenty-five patients (22%) were recommended for hearing aids after HDCT. Patients with moderate to profound HL isolated to the higher frequencies (6-8 kHz) before HDCT were more likely to develop moderate to profound HL in the speech frequencies after HDCT (94% vs. 61%; p = .01) and to be recommended for hearing aids (39% vs. 18%; p = .05). CONCLUSIONS HL was frequent after HDCT for GCTs, with most patients developing at least moderate HL in the speech frequencies and approximately one in five recommended for hearing aids. Moderate to profound HL isolated to high frequencies at baseline was predictive of more clinically significant hearing impairment after HDCT. PLAIN LANGUAGE SUMMARY Some patients with germ cell tumors, the most common malignancy in adolescent and young adult men, are not cured with standard-dose chemotherapy and require high-dose chemotherapy (HDCT). Using detailed hearing assessments of patients receiving HDCT, we found that most patients developed significant hearing loss and that one in five needed hearing aids. Thus, strategies to reduce this side effect are urgently needed, and all patients receiving HDCT should have a hearing test after therapy.
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Affiliation(s)
- Samuel A Funt
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Andrea Knezevic
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kaamilah Wilson
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria Bromberg
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amy Budnick
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kerri L O'Connor
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Deaglan J McHugh
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Erik Larsen
- Formerly of Decibel Therapeutics, Boston, Massachusetts, USA
| | - Dean F Bajorin
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - Robert J Motzer
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | | | - Sujata Patil
- Department of Biostatistics, Cleveland Clinic, Cleveland, Ohio, USA
| | - Darren R Feldman
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
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Ohlsen TJD, Chen Y, Baldwin LM, Hudson MM, Nathan PC, Snyder C, Syrjala KL, Tonorezos ES, Yasui Y, Armstrong GT, Oeffinger KC, Chow EJ. Primary Care Utilization and Cardiovascular Screening in Adult Survivors of Childhood Cancer. JAMA Netw Open 2023; 6:e2347449. [PMID: 38091040 PMCID: PMC10719759 DOI: 10.1001/jamanetworkopen.2023.47449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/30/2023] [Indexed: 12/17/2023] Open
Abstract
Importance Cardiovascular disease is the leading noncancer cause of premature death among survivors of childhood cancer. Adult survivors of childhood cancer are largely managed by primary care practitioners (PCPs), and health care utilization patterns related to cardiovascular screening are not well described. Objective To examine screening and health care utilization among survivors of childhood cancer at high risk for cardiovascular complications. Design, Setting, and Participants This multicenter cross-sectional study included participants enrolled in a randomized clinical trial from 2017 to 2021. Abstracted documentation of participants' cancer history, cardiotoxic treatment exposures, and survivorship care plans were obtained from participants' PCPs spanning 2 years preceding trial enrollment. Participants were members of the Childhood Cancer Survivor Study cohort at elevated risk for ischemic heart disease or heart failure, enrolled in a randomized trial focused on improving cardiovascular risk factor control. Data were analyzed from November 2022 to July 2023. Main Outcomes and Measures Outcomes of interest were numbers of PCP and specialist visits, cardiovascular risk factors (hypertension, dyslipidemia, and diabetes), risk factor screening, and cardiac testing. Multivariable logistic regression assessed characteristics associated with up-to-date cardiac testing at enrollment. Results Of 347 enrolled participants, 293 (84.4%) had evaluable medical records (median [range] age, 39.9 [21.5-65.0] years; 149 [50.9%] male) and were included in analyses. At baseline, 238 participants (81.2%) had a documented PCP encounter; 241 participants (82.3%) had undergone blood pressure screening, 179 participants (61.1%) had undergone lipid testing, and 193 participants (65.9%) had undergone diabetes screening. A total of 63 participants (21.5%) had echocardiography completed or planned. Only 198 participants (67.6%) had records referencing a cancer history. PCP documentation of prior cardiotoxic exposures was low compared with known exposures, including radiation therapy (103 participants [35.2%] vs 203 participants [69.3%]; P < .001) and anthracycline chemotherapy (27 participants [9.2%] vs 222 participants [75.8%]; P = .008). Few records referenced a need for cancer-related late effects surveillance (95 records [32.4%]). Independent factors associated with cardiac screening included documentation of increased cardiovascular disease risk (odds ratio [OR], 11.94; 95% CI, 3.37-42.31), a late-effects surveillance plan (OR, 3.92; 95% CI, 1.69-9.11), and existing cardiovascular risk factors (OR per each additional factor, 2.09; 95% CI, 1.32-3.31). Conclusions and Relevance This cross-sectional study of adult survivors of childhood cancer at increased risk of cardiovascular disease found low adherence to recommended cardiac testing and documentation of risk for these individuals. Improving accuracy of reporting of survivors' exposures and risks within the medical record may improve screening.
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Affiliation(s)
- Timothy J. D. Ohlsen
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, University of Washington, Seattle
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Yan Chen
- University of Alberta, Calgary, Canada
| | | | - Melissa M. Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Paul C. Nathan
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Claire Snyder
- Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Emily S. Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Yutaka Yasui
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Gregory T. Armstrong
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | | | - Eric J. Chow
- Cancer and Blood Disorders Center, Seattle Children’s Hospital, University of Washington, Seattle
- Fred Hutchinson Cancer Center, Seattle, Washington
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10
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Abstract
Importance An estimated 15 000 children and adolescents aged 0 to 19 years are diagnosed with cancer each year in the US, and more than 85% survive for at least 5 years. By 45 years of age, approximately 95% of people who survive childhood cancer will develop a significant health problem related to the childhood cancer diagnosis or its treatment. Observations Approximately 500 000 people currently alive in the US have survived childhood cancer. The most common severe or life-threatening chronic health problems related to childhood cancer or its treatment are endocrine disorders such as hypothyroidism or growth hormone deficiency (44%), subsequent neoplasms such as breast cancer or thyroid cancer (7%), and cardiovascular disease such as cardiomyopathy or congestive heart failure, coronary artery disease, and cerebrovascular disease (5.3%). Medical conditions related to a cancer diagnosis during childhood or adolescence are most commonly caused by the radiation therapy and the chemotherapies used to treat cancer and may develop at varying lengths of time after exposure to these treatments. Individuals at highest risk for developing treatment-related health problems include patients with brain cancer treated with cranial irradiation (approximately 70% develop severe or life-threatening health problems) and allogeneic hematopoietic stem cell transplant recipients (approximately 60% develop severe or life-threatening health problems). Individuals at the lowest risk for developing treatment-related health problems include those who survived solid tumors (such as Wilms tumor) treated with surgical resection alone or with minimal chemotherapy, for whom the prevalence of subsequent health problems is similar to people who did not have cancer during childhood or adolescence. People diagnosed with childhood cancer in the 1990s who survived for at least 5 years after the cancer diagnosis have a shorter lifespan (by about 9 years) vs children who were not diagnosed with cancer in the 1990s. Conclusions and Relevance Approximately 500 000 individuals currently alive in the US have survived childhood cancer. The most common adverse effects in individuals who survived childhood cancer are endocrine disorders, subsequent neoplasms, and cardiovascular disease. There is a need for clinicians and patients to have heightened awareness of these complications.
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Affiliation(s)
- Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, Heersink School of Medicine, University of Alabama at Birmingham
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Heersink School of Medicine, University of Alabama at Birmingham
| | - Emily S Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, Heersink School of Medicine, University of Alabama at Birmingham
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Heersink School of Medicine, University of Alabama at Birmingham
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11
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Barnea D, Tonorezos ES, Khan A, Chou JF, Moskowitz CS, Kaplan R, Wolden SL, Bryce Y, Oeffinger KC. Benign and malignant pulmonary parenchymal findings on chest CT among adult survivors of childhood and young adult cancer with a history of chest radiotherapy. J Cancer Surviv 2023:10.1007/s11764-023-01405-1. [PMID: 37209240 DOI: 10.1007/s11764-023-01405-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/14/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE Childhood and young adult cancer survivors exposed to chest radiotherapy are at increased risk of lung cancer. In other high-risk populations, lung cancer screening has been recommended. Data is lacking on prevalence of benign and malignant pulmonary parenchymal abnormalities in this population. METHODS We conducted a retrospective review of pulmonary parenchymal abnormalities in chest CTs performed more than 5 years post-cancer diagnosis in survivors of childhood, adolescent, and young adult cancer. We included survivors exposed to radiotherapy involving the lung field and followed at a high-risk survivorship clinic between November 2005 and May 2016. Treatment exposures and clinical outcomes were abstracted from medical records. Risk factors for chest CT-detected pulmonary nodule were assessed. RESULTS Five hundred and ninety survivors were included in this analysis: median age at diagnosis, 17.1 years (range, 0.4-39.8); and median time since diagnosis, 22.3 years (range, 1-58.6). At least one chest CT more than 5 years post-diagnosis was performed in 338 survivors (57%). Among these, 193 (57.1%) survivors had at least one pulmonary nodule detected on a total of 1057 chest CTs, resulting in 305 CTs with 448 unique nodules. Follow-up was available for 435 of these nodules; 19 (4.3%) were malignant. Risk factors for first pulmonary nodule were older age at time of CT, CT performed more recently, and splenectomy. CONCLUSIONS Benign pulmonary nodules are very common among long-term survivors of childhood and young adult cancer. IMPLICATIONS FOR CANCER SURVIVORS High prevalence of benign pulmonary nodules in cancer survivors exposed to radiotherapy could inform future guidelines on lung cancer screening in this population.
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Affiliation(s)
- Dana Barnea
- Department of Hematology, Tel Aviv Sourasky Medical Center, 6 Weizmann St, 64239, Tel Aviv, Israel.
| | - Emily S Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Amber Khan
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center-Albert Einstein College of Medicine, New York, NY, USA
| | - Joanne F Chou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chaya S Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rana Kaplan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yolanda Bryce
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Tonorezos ES, Marcil V. Childhood cancer survivors: healthy behaviours and late mortality. Lancet 2023; 401:1403-1405. [PMID: 37030313 DOI: 10.1016/s0140-6736(22)02632-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 04/10/2023]
Affiliation(s)
- Emily S Tonorezos
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD 20954, USA.
| | - Valérie Marcil
- Research Center of the Centre Hospitalier Universitaire Sainte-Justine and Department of Nutrition, Faculty of Medicine, University de Montréal, QC, Canada
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13
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Friedman DN, Goodman PJ, Leisenring WM, Diller LR, Cohn SL, Howell RM, Smith SA, Tonorezos ES, Wolden SL, Neglia JP, Ness KK, Gibson TM, Nathan PC, Weil BR, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Long-Term Morbidity and Mortality Among Survivors of Neuroblastoma Diagnosed During Infancy: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:1565-1576. [PMID: 36525618 PMCID: PMC10043581 DOI: 10.1200/jco.22.01732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/02/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To describe the risk of late mortality, subsequent malignant neoplasms (SMNs), and chronic health conditions (CHCs) in survivors of neuroblastoma diagnosed in infancy by treatment era and exposures. METHODS Among 5-year survivors of neuroblastoma in the Childhood Cancer Survivor Study diagnosed age < 1 year between 1970 and 1999, we examined the cumulative incidence of late (> 5 years from diagnosis) mortality, SMN, and CHCs (grades 2-5 and 3-5). Multivariable Cox regression models estimated hazard ratios (HRs) and 95% CIs by decade and treatment (surgery-alone v chemotherapy with or without surgery [C ± S] v radiation with or without chemotherapy ± surgery [R ± C ± S]) among survivors and between survivors and 5,051 siblings. RESULTS Among 1,397 eligible survivors, the 25-year cumulative incidence of late mortality was 2.1% (95% CI, 1.3 to 3.9) with no difference by treatment era. Among 990 participants who completed a baseline survey, fewer survivors received radiation in more recent eras (51.2% 1970s, 20.4% 1980s, and 10.1% 1990s; P < .001). Risk of SMN was elevated only among individuals treated with radiation-containing regimens compared with surgery alone (HR[C ± S], 3.2 [95% CI, 0.9 to 11.6]; HR[R ± C ± S], 5.7 [95% CI, 1.2 to 28.1]). In adjusted models, there was a 50% reduction in risk of grade 3-5 CHCs in the 1990s versus 1970s (HR, 0.5 [95% CI, 0.3 to 0.9]; P = .01); individuals treated with radiation had a 3.6-fold risk for grade 3-5 CHCs (95% CI, 2.1 to 6.2) versus those treated with surgery alone. When compared with siblings, risk of grade 3-5 CHCs for survivors was lowest in the most recent era (HR[1970s], 4.7 [95% CI, 3.4 to 6.5]; HR[1980s], 4.6 [95% CI, 3.3 to 6.4]; HR[1990s], 2.5 [95% CI, 1.7 to 3.9]). CONCLUSION Neuroblastoma survivors treated during infancy have a relatively low absolute burden of late mortality and SMN. Encouragingly, risk of CHCs has declined in more recent eras with reduced exposure to radiation therapy.
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Affiliation(s)
| | | | | | | | | | | | - Susan A. Smith
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Suzanne L. Wolden
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | | | - Todd M. Gibson
- National Cancer Institute, National Institutes of Health, Rockville, MD
| | | | - Brent R. Weil
- Dana Farber Cancer Institute, Boston, MA
- Boston Children's Hospital, Boston, MA
| | | | | | | | - Charles A. Sklar
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
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14
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Barnea D, Tonorezos ES, Khan A, Chou JF, Moskowitz CS, Kaplan R, Oeffinger KC. Benign and Malignant Findings on Chest CT Among Adult Survivors of Childhood and Young Adult Cancer with a History of Chest Radiotherapy. Res Sq 2023. [PMID: 36865217 PMCID: PMC9980193 DOI: 10.21203/rs.3.rs-2599972/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Purpose : Childhood and young adult cancer survivors exposed to chest radiotherapy are at increased risk of lung cancer. In other high-risk populations, lung cancer screening has been recommended. Data is lacking on prevalence of benign and malignant imaging abnormalities in this population. Methods : We conducted a retrospective review of imaging abnormalities in chest CTs performed more than 5 years post-cancer diagnosis in survivors of childhood, adolescent, and young adult cancer. We included survivors exposed to radiotherapy involving the lung field and followed at a high-risk survivorship clinic between November 2005 and May 2016. Treatment exposures and clinical outcomes were abstracted from medical records. Risk factors for chest CT-detected pulmonary nodule were assessed. Results : Five hundred and ninety survivors were included in this analysis; median age at diagnosis, 17.1 years (range, 0.4-39.8) and median time since diagnosis, 21.1 years (range, 0.4-58.6). At least one chest CT more than 5 years post-diagnosis was performed in 338 survivors (57%). Among these, 193 (57.1%) survivors had at least one pulmonary nodule detected on a total of 1057 chest CTs, resulting in 305 CTs with 448 unique nodules. Follow-up was available for 435 of these nodules; 19 (4.3%) were malignant. Risk factors for first pulmonary nodule were older age at time of CT, CT performed more recently and splenectomy. Conclusions : Benign pulmonary nodules are very common among long-term survivors of childhood and young adult cancer. Implications for Cancer Survivors: High prevalence of benign pulmonary nodules in cancer survivors exposed to radiotherapy could inform future guidelines on lung cancer screening in this population.
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Affiliation(s)
| | | | - Amber Khan
- Montefiore Medical Center-Albert Einstein College of Medicine
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15
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Delavar A, Boutros C, Barnea D, Schaffer WL, Tonorezos ES. Correction: Approaches for monitoring and treating cardiomyopathy among cancer survivors following anthracycline or thoracic radiation treatment. Cardio-Oncology 2022; 8:15. [PMID: 35986386 PMCID: PMC9389675 DOI: 10.1186/s40959-022-00141-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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16
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Chow EJ, Chen Y, Armstrong GT, Baldwin LM, Cai CR, Gibson TM, Hudson MM, McDonald A, Nathan PC, Olgin JE, Syrjala KL, Tonorezos ES, Oeffinger KC, Yasui Y. Underdiagnosis and Undertreatment of Modifiable Cardiovascular Risk Factors Among Survivors of Childhood Cancer. J Am Heart Assoc 2022; 11:e024735. [PMID: 35674343 PMCID: PMC9238650 DOI: 10.1161/jaha.121.024735] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Determine the prevalence and predictors associated with underdiagnosis and undertreatment of modifiable cardiovascular disease (CVD) risk factors (hypertension, dyslipidemia, glucose intolerance/diabetes) among adult survivors of childhood cancer at high risk of premature CVD. Methods and Results This was a cross‐sectional study of adult‐aged survivors of childhood cancer treated with anthracyclines or chest radiotherapy, recruited across 9 US metropolitan regions. Survivors completed questionnaires and in‐home clinical assessments. The comparator group was a matched sample from the National Health and Nutrition Examination Survey. Multivariable logistic regression estimated the risk (odds ratios) of CVD risk factor underdiagnosis and undertreatment among survivors compared with the National Health and Nutrition Examination Survey. Survivors (n=571; median age, 37.7 years and 28.5 years from cancer diagnosis) were more likely to have a preexisting CVD risk factor than the National Health and Nutrition Examination Survey (n=345; P<0.05 for all factors). While rates of CVD risk factor underdiagnosis were similar (27.1% survivors versus 26.1% National Health and Nutrition Examination Survey; P=0.73), survivors were more likely undertreated (21.0% versus 13.9%, P=0.007; odds ratio, 1.8, 95% CI, 1.2–2.7). Among survivors, the most underdiagnosed and undertreated risk factors were hypertension (18.9%) and dyslipidemia (16.3%), respectively. Men and survivors who were overweight/obese were more likely to be underdiagnosed and undertreated. Those with multiple adverse lifestyle factors were also more likely undertreated (odds ratio, 2.2, 95% CI, 1.1–4.5). Greater health‐related self‐efficacy was associated with reduced undertreatment (odds ratio, 0.5; 95% CI, 0.3–0.8). Conclusions Greater awareness of among primary care providers and cardiologists, combined with improving self‐efficacy among survivors, may mitigate the risk of underdiagnosed and undertreated CVD risk factors among adult‐aged survivors of childhood cancer. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03104543.
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Affiliation(s)
- Eric J Chow
- Public Health Sciences and Clinical Research Divisions Fred Hutchinson Cancer Research Center Seattle WA.,Department of Pediatrics Seattle Children's HospitalUniversity of Washington Seattle WA
| | - Yan Chen
- University of Alberta Edmonton Alberta Canada
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control St. Jude Children's Research Hospital Memphis TN
| | | | - Casey R Cai
- School of Medicine University of Texas Southwestern Dallas TX
| | - Todd M Gibson
- Division of Cancer Epidemiology and Genetics National Cancer Institute Rockville MD
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control St. Jude Children's Research Hospital Memphis TN.,Department of Oncology St. Jude Children's Research Hospital Memphis TN
| | - Aaron McDonald
- Department of Epidemiology and Cancer Control St. Jude Children's Research Hospital Memphis TN
| | - Paul C Nathan
- Department of Pediatrics The Hospital for Sick Children University of Toronto Ontario Canada
| | - Jeffrey E Olgin
- Division of Cardiology Department of Medicine University of California San Francisco CA
| | - Karen L Syrjala
- Public Health Sciences and Clinical Research Divisions Fred Hutchinson Cancer Research Center Seattle WA
| | - Emily S Tonorezos
- Division of Cancer Control and Population Science National Cancer Institute Rockville MD
| | | | - Yutaka Yasui
- University of Alberta Edmonton Alberta Canada.,Department of Epidemiology and Cancer Control St. Jude Children's Research Hospital Memphis TN
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17
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Bryce YC, Armstrong GT, Leisenring WM, Whitton J, Chow EJ, Weil BR, Dieffenbach B, Howell RM, Oeffinger KC, Nathan PC, Tonorezos ES. Use and correlates of carotid ultrasound in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e22023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e22023 Background: Survivors of childhood cancer with history of radiation therapy (RT) to the head/neck/chest are at increased risk for stroke. Children’s Oncology Group Guidelines recommend carotid ultrasound (CU) when clinically indicated or 10 years after RT ≥ 40Gy to the neck. Yet, the use of CU has not been previously described. Methods: 8,693 survivors of childhood cancer (median age at diagnosis 8.0 years, range 0-20; median age at evaluation 37.4, range 18-65) diagnosed between 1970-1999 were asked if they had ever had a CU. Cardiovascular disease (CVD) was defined as any of the following: stroke, congestive heart failure, hypertension, myocardial infarction, coronary heart disease, or arrythmia. Prevalence ratios (PR) were calculated; age and sex-adjusted multivariable Poisson regression models evaluated factors associated with CU. Results: 4.9% (427) of survivors had a history of stroke and 28% (2,442) had a history of any CVD. Of these, 40.0% (171) with a history of stroke and 28.6% (748) with any CVD had CU. Comparatively, 14.6% (1,404) without a stroke and 11.1% (798) without any CVD had a CU (both p<0.0001 vs those with condition). Among survivors without CVD, having seen only a primary care physician was not associated with CU (PR 0.84 95% CI 0.58-1.25, p = 0.36), while seeing a cancer specialist (+/- a primary care physician) (PR 1.83 95% CI 1.23-2.79, p = 0.036) was associated with increased likelihood of CU compared to seeing neither. Survivors who had had other surveillance studies, including a colonoscopy (PR 1.76 95% CI 1.44-2.17, p<0.0001), skin cancer exam (PR 1.62 95% CI 1.30-2.03, p=0.0002), or mammogram (PR 2.06 95%CI 1.42-3.07, p<0.0001) were more likely to have a carotid ultrasound, compared to those without that test. Having a history of anthracyclines or RT to the neck were associated with higher prevalence of CU, with RT to the neck exhibiting a dose-response relationship (Table). Conclusions: CU was more common among survivors with a history of stroke or other CVD event. In those without CVD, CU use was associated with anthracyclines and RT dose exposures and with care provided by a cancer specialist. A high proportion (70%) of survivors who received >40Gy RT to the neck have never had a CU, suggesting that greater awareness of guidelines is needed.[Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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18
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Doose M, Mollica MA, Attai DJ, Nasso SF, Elena JW, Jacobsen PB, Tonorezos ES, Nekhlyudov L. Reply to "Switching the scope from 'how to identify cancer survivors' to 'who is participating in cancer survivorship research': A proposal for a new focus". Cancer 2022; 128:2038-2039. [PMID: 35132639 DOI: 10.1002/cncr.34129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Michelle Doose
- Division of Clinical and Health Services Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland
| | - Michelle A Mollica
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Deanna J Attai
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Joanne W Elena
- Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Paul B Jacobsen
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Emily S Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Larissa Nekhlyudov
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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19
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Delavar A, Boutros C, Barnea D, Schaffer WL, Tonorezos ES. Approaches for monitoring and treating cardiomyopathy among cancer survivors following anthracycline or thoracic radiation treatment. Cardio-Oncology 2022; 8:11. [PMID: 35551674 PMCID: PMC9097116 DOI: 10.1186/s40959-022-00138-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 05/03/2022] [Indexed: 12/20/2022]
Abstract
Background Anthracycline chemotherapy and thoracic radiation therapy (RT) are known causes of cardiomyopathy among cancer survivors, however, management guidelines for this population are lacking. In this study we describe our single institution management approach for cancer survivors with low left ventricular ejection fraction (LVEF) secondary to cancer treatment. Methods We conducted a retrospective descriptive study of childhood and young adult (CAYA) cancer survivors in the Adult Long-Term Follow-Up Clinic at Memorial Sloan Kettering Cancer Center enrolled between November 2005 and July 2019. Those included were treated with anthracycline and/or thoracic RT as a part of their cancer therapy and had recorded a LVEF of < 55% on at least one post-treatment echocardiogram. Details regarding survivor characteristics, screening, and management were abstracted. Differences in management approaches among survivors with LVEF of 50–54.9%, 40–49.9%, and < 40% were described. Qualitative management approaches were abstracted as well. Results Among 668 CAYA survivors in the initial cohort, 80 were identified who had received anthracycline and/or thoracic RT and had a LVEF of < 55%. Median age at cancer diagnosis was 16.1 years, median time from cancer diagnosis was 25.8 years, and 55% of survivors were female. Cardiology referrals, nuclear stress tests, multi-gated acquisition scans, angiograms, echocardiograms, treatment with angiotensin converting enzyme inhibitors or receptor blockers, beta-blockers, diuretics, aldosterone antagonists, aspirin, and insertion of pacemaker or implantable cardioverter-defibrillators differed by LVEF category. Documentation suggested uncertainty regarding management of survivors with borderline low-LVEF, with low-LVEF that improved on follow-up, and with subsequent cancers requiring additional treatment. Conclusions The management of CAYA cancer survivors with low-LVEF largely followed guidelines designed for the general population, however, uncertainty remains for issues specific to cancer survivors. Cardiomyopathy management guidelines that address issues specific to cancer survivors are needed.
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20
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Tonorezos ES, Cohn RJ, Glaser AW, Lewin J, Poon E, Wakefield CE, Oeffinger KC. Long-term care for people treated for cancer during childhood and adolescence. Lancet 2022; 399:1561-1572. [PMID: 35430023 PMCID: PMC9082556 DOI: 10.1016/s0140-6736(22)00460-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 01/31/2022] [Accepted: 03/03/2022] [Indexed: 12/25/2022]
Abstract
Worldwide advances in treatment and supportive care for children and adolescents with cancer have resulted in a increasing population of survivors growing into adulthood. Yet, this population is at very high risk of late occurring health problems, including significant morbidity and early mortality. Unique barriers to high-quality care for this group include knowledge gaps among both providers and survivors as well as fragmented health-care delivery during the transition from paediatric to adult care settings. Survivors of childhood and adolescent cancer are at risk for a range of late-occuring side-effects from treatment, including cardiac, endocrine, pulmonary, fertility, renal, psychological, cognitive, and socio-developmental impairments. Care coordination and transition to adult care are substantial challenges, but can be empowering for survivors and improve outcomes, and could be facilitated by clear, effective communication and support for self-management. Resources for adult clinical care teams and primary care providers include late-effects surveillance guidelines and web-based support services.
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Affiliation(s)
- Emily S Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA.
| | - Richard J Cohn
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Kensington, NSW, Australia
| | - Adam W Glaser
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Jeremy Lewin
- ONTrac at Peter Mac Victorian Adolscent and Young Adult Cancer Service, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Eileen Poon
- Division of Medical Oncology, National Cancer Centre, Singapore
| | - Claire E Wakefield
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia; School of Women's and Children's Health, UNSW Medicine, UNSW Sydney, Kensington, NSW, Australia
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21
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Vanderpool RC, Gaysynsky A, Chou WYS, Tonorezos ES. Using Behavioral Science to Address COVID-19 Vaccine Hesitancy Among Cancer Survivors: Communication Strategies and Research Opportunities. J Behav Med 2022; 46:366-376. [PMID: 35305205 PMCID: PMC8933612 DOI: 10.1007/s10865-022-00304-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/22/2022] [Indexed: 11/28/2022]
Abstract
Due to cancer survivors’ increased vulnerability to complications from COVID-19, addressing vaccine hesitancy and improving vaccine uptake among this population is a public health priority. However, several factors may complicate efforts to increase vaccine confidence in this population, including the underrepresentation of cancer patients in COVID-19 vaccine trials and distinct recommendations for vaccine administration and timing for certain subgroups of survivors. Evidence suggests vaccine communication efforts targeting survivors could benefit from strategies that consider factors such as social norms, risk perceptions, and trust. However, additional behavioral research is needed to help the clinical and public health community better understand, and more effectively respond to, drivers of vaccine hesitancy among survivors and ensure optimal protection against COVID-19 for this at-risk population. Knowledge generated by this research could also have an impact beyond the current COVID-19 pandemic by informing future vaccination efforts and communication with cancer survivors more broadly.
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Affiliation(s)
- Robin C Vanderpool
- Health Communication and Informatics Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, 20850, Rockville, MD, USA.
| | - Anna Gaysynsky
- Health Communication and Informatics Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, 20850, Rockville, MD, USA.,ICF Next, Rockville, MD, USA
| | - Wen-Ying Sylvia Chou
- Health Communication and Informatics Research Branch, Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, 20850, Rockville, MD, USA
| | - Emily S Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
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22
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Carlson LE, Watt GP, Tonorezos ES, Chow EJ, Yu AF, Woods M, Lynch CF, John EM, Mellemkjӕr L, Brooks JD, Knight JA, Reiner AS, Liang X, Smith SA, Bernstein L, Dauer LT, Cerviño LI, Howell RM, Shore RE, Boice JD, Bernstein JL. Coronary Artery Disease in Young Women After Radiation Therapy for Breast Cancer: The WECARE Study. JACC CardioOncol 2021; 3:381-392. [PMID: 34604798 PMCID: PMC8463731 DOI: 10.1016/j.jaccao.2021.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/14/2021] [Accepted: 07/18/2021] [Indexed: 01/23/2023]
Abstract
Background Radiation therapy (RT) for breast cancer increases risk of coronary artery disease (CAD). Women treated for left- vs right-sided breast cancer receive greater heart radiation exposure, which may further increase this risk. The risk of radiation-associated CAD specifically among younger breast cancer survivors is not well defined. Objectives The purpose of this study was to report CAD risk among participants in the Women's Environmental Cancer and Radiation Epidemiology Study. Methods A total of 1,583 women who were <55 years of age when diagnosed with breast cancer between 1985 and 2008 completed a cardiovascular health questionnaire. Risk of radiation-associated CAD was evaluated by comparing women treated with left-sided RT with women treated with right-sided RT using multivariable Cox proportional hazards models. Effect modification by treatment and cardiovascular risk factors was examined. Results In total, 517 women who did not receive RT and 94 women who had a pre-existing cardiovascular disease diagnosis were excluded, leaving 972 women eligible for analysis. Their median follow-up time was 14 years (range 1-29 years). The 27.5-year cumulative incidences of CAD for women receiving left- vs right-sided RT were 10.5% and 5.8%, respectively (P = 0.010). The corresponding HR of CAD for left- vs right-sided RT in the multivariable Cox model was 2.5 (95% CI: 1.3-4.7). There was no statistically significant effect modification by any factor evaluated. Conclusions Young women treated with RT for left-sided breast cancer had over twice the risk of CAD compared with women treated with RT for right-sided breast cancer. Laterality of RT is independently associated with an increased risk of CAD and should be considered in survivorship care of younger breast cancer patients.
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Affiliation(s)
| | - Gordon P. Watt
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Address for correspondence: Dr Gordon P. Watt, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, Second Floor, New York, New York 10017. @gp_watt
| | - Emily S. Tonorezos
- National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, Maryland, USA
| | - Eric J. Chow
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Anthony F. Yu
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghan Woods
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | | | | | - Jennifer D. Brooks
- University of Toronto, Dalla Lana School of Public Health Sciences, Toronto, Ontario, Canada
| | - Julia A. Knight
- University of Toronto, Dalla Lana School of Public Health Sciences, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Anne S. Reiner
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Xiaolin Liang
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan A. Smith
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Leslie Bernstein
- Beckman Research Institute, City of Hope National Medical Center, Duarte, California, USA
| | | | | | - Rebecca M. Howell
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Roy E. Shore
- New York University Grossman School of Medicine, New York, New York, USA
| | - John D. Boice
- National Council on Radiation Protection and Measurements, Bethesda, Maryland, USA
- Vanderbilt University, Nashville, Tennessee, USA
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Doose M, Mollica MA, Attai DJ, Nasso SF, Elena JW, Jacobsen PB, Tonorezos ES, Nekhlyudov L. Identifying and describing cancer survivors: Implications for cancer survivorship research and clinical care. Cancer 2021; 128:383-390. [PMID: 34597418 PMCID: PMC8738118 DOI: 10.1002/cncr.33937] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/27/2021] [Accepted: 08/20/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Gathering information directly from cancer survivors has advanced our understanding of the cancer survivorship experience. However, it is unknown whether surveys can distinguish important subgroups of cancer survivors. This study aimed to describe the current landscape of survey questions used to identify and describe cancer survivors in national cross-sectional studies. METHODS Using publicly available databases, the authors identified national cross-sectional surveys used in the United States within the past 15 years that included a question on self-reported history of cancer. After abstracting questions and response items used to identify cancer survivors, they conducted a descriptive analysis. RESULTS The authors identified 14 national cross-sectional surveys, with half administered to the general population and the other half administered to cancer survivors. The most common question used to identify cancer survivors was "Have you ever been told by a doctor or other health professional that you had cancer?" Most surveys had questions asking participants to identify a single cancer type (n = 11), multiple prior cancer diagnoses or types (n = 11), and the time from diagnosis (n = 12). Treatment questions varied from active treatment status to specific treatments received. Questions addressing cancer stage (n = 2), subtypes (n = 1), metastatic status (n = 3), and recurrence (n = 4) were less frequently included. CONCLUSIONS There is no standard method for assessing self-reported cancer history, and this limits the ability to distinguish among potentially important subgroups of survivors. Future cross-sectional surveys that capture nuanced data elements, such as cancer types, stages/subtypes, metastatic/recurrent status, and treatments received, can help to fill important gaps in cancer survivorship research and clinical care.
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Affiliation(s)
- Michelle Doose
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Michelle A Mollica
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Deanna J Attai
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | | | - Joanne W Elena
- Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Paul B Jacobsen
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Emily S Tonorezos
- Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Larissa Nekhlyudov
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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24
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van Dalen EC, Mulder RL, Suh E, Ehrhardt MJ, Aune GJ, Bardi E, Benson BJ, Bergler-Klein J, Chen MH, Frey E, Hennewig U, Lockwood L, Martinsson U, Muraca M, van der Pal H, Plummer C, Scheinemann K, Schindera C, Tonorezos ES, Wallace WH, Constine LS, Skinner R, Hudson MM, Kremer LCM, Levitt G, Mulrooney DA. Coronary artery disease surveillance among childhood, adolescent and young adult cancer survivors: A systematic review and recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Eur J Cancer 2021; 156:127-137. [PMID: 34450551 DOI: 10.1016/j.ejca.2021.06.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/28/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is a concerning late outcome for cancer survivors. However, uniform surveillance guidelines are lacking. AIM To harmonise international recommendations for CAD surveillance for survivors of childhood, adolescent and young adult (CAYA) cancers. METHODS A systematic literature review was performed and evidence graded using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Eligibility included English language studies, a minimum of 20 off-therapy cancer survivors assessed for CAD, and 75% diagnosed prior to age 35 years. All study designs were included, and a multidisciplinary guideline panel formulated and graded recommendations. RESULTS 32 of 522 identified articles met eligibility criteria. The prevalence of CAD ranged from 0 to 72% and was significantly increased compared to control populations. The risk of CAD was increased among survivors who received radiotherapy exposing the heart, especially at doses ≥15 Gy (moderate-quality evidence). The guideline panel agreed that healthcare providers and CAYA cancer survivors treated with radiotherapy exposing the heart should be counselled about the increased risk for premature CAD. While the evidence is insufficient to support primary screening, monitoring and early management of modifiable cardiovascular risk factors are recommended. Initiation and frequency of surveillance should be based on the intensity of treatment exposures, family history, and presence of co-morbidities but at least by age 40 years and at a minimum of every 5 years. All were strong recommendations. CONCLUSION These systematically assessed and harmonised recommendations for CAD surveillance will inform care and guide research concerning this critical outcome for CAYA cancer survivors.
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Affiliation(s)
| | - Renée L Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Eugene Suh
- Loyola University Chicago Health Sciences Division, Maywood, USA
| | | | - Gregory J Aune
- Greehey Children's Cancer Research Institute, University of Texas Health Science Center San Antonio, San Antonio, USA
| | - Edit Bardi
- Kepler University Clinic, Department of Pediatrics, Division of Pediatric Hemato-Oncology, Linz, Austria; St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | | | | | - Ming H Chen
- Boston Children's Hospital/Dana Farber Cancer Institute, Department of Cardiology, Harvard Medical School, Boston, USA
| | - Eva Frey
- St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Ulrike Hennewig
- University Hospital of Giessen and Marburg, Pediatric Hematology and Oncology, Giessen, Germany
| | - Liane Lockwood
- Children's Health Queensland Hospital and Health Service, South Brisbane, Australia
| | - Ulla Martinsson
- Department of Genetics, Immunology and Pathology, Section of Experimental and Clinical Oncology, Uppsala University, Uppsala, Sweden
| | | | | | - Chris Plummer
- Department of Cardiology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katrin Scheinemann
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kantonsspital Aarau, Aarau, Switzerland; University of Basel, Basel, Switzerland; McMaster Children's Hospital and McMaster University, Hamilton, Canada
| | - Christina Schindera
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Pediatric Hematology and Oncology, University Children's Hospital Basel, Basel, Switzerland
| | | | - W Hamish Wallace
- Department of Paediatric Haematology and Oncology & University of Edinburgh, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Roderick Skinner
- Great North Children's Hospital, and Newcastle University Centre for Cancer, Newcastle Upon Tyne, UK
| | | | - Leontien C M Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gill Levitt
- Department of Haematology/Oncology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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25
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Tonorezos ES, Barnea D, Sklar CA, Friedman DN. Training in Long-Term Follow-Up: Fellowship in Childhood Cancer Survivorship. J Cancer Educ 2021; 36:689-692. [PMID: 31960227 PMCID: PMC7369245 DOI: 10.1007/s13187-020-01688-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Childhood cancer survivors are a growing population with high morbidity and many healthcare needs. As time from treatment lengthens, these patients are more and more likely to be followed in community primary care. Yet, studies suggest that primary care providers are unprepared (although not unwilling) to care for childhood cancer survivors. The 1-year fellowship in childhood cancer survivorship presented herein represents an educational intervention designed to prepare clinical leaders in survivorship. Ultimately, this effort may help address current gaps in care for childhood cancer survivors.
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Affiliation(s)
- Emily S Tonorezos
- Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd Floor, New York, NY, 10017, USA.
- Weill Cornell Medical College, 485 Lexington Ave, 2nd Floor, New York, NY, 10017, USA.
| | - Dana Barnea
- Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
| | - Charles A Sklar
- Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd Floor, New York, NY, 10017, USA
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26
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Friedman DN, Goodman PJ, Leisenring WM, Diller L, Cohn SL, Tonorezos ES, Howell RM, Smith SA, Wolden SL, Neglia JP, Ness KK, Gibson TM, Nathan PC, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Late morbidity and mortality among survivors of neuroblastoma treated with contemporary therapy: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10044 Background: Survival rates for neuroblastoma vary widely based on risk group. Therapies have evolved over the past four decades to de-intensify treatment for individuals with low/intermediate risk disease and intensify therapy for those with high risk disease. Risk stratification is predicted to result in differential outcomes in late morbidity and mortality; the magnitude of these differences has not been well studied. Methods: We evaluated late mortality, subsequent malignant neoplasms (SMN) and chronic health conditions (CHC) graded according to CTCAE v4.03 among 491 5-year CCSS survivors of neuroblastoma diagnosed 1987-1999 at ≥1 year of age. Using age, stage at diagnosis, and treatment, survivors were classified into risk groups (low [n=182]; intermediate [n=70]; high [n=239]). Standardized mortality ratios (SMR) and standardized incidence ratios (SIR) of SMN were calculated using rates from NCHS and SEER, respectively. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for CHC compared to 1,029 CCSS siblings. Results: Among survivors (48% male; median age 22 years, range 7-42; median follow-up 19 years, range 5-29), 80.4% with low risk disease were treated with surgery alone, while 77.8% with high risk disease received surgery, radiation, chemotherapy ± transplant. The 15-year cumulative incidence of all-cause mortality was 9.2% (CI: 7.1-11.4), with a recurrence-related mortality of 7.3% (CI: 5.3-9.3) and SMN-related mortality of 0.3% (CI: 0-0.7). All-cause mortality was significantly higher in all risk groups: (low, SMR=5.8 [CI: 2.6-13.0]; intermediate, SMR=5.7 [CI: 1.4-23.5]; high, SMR=38.6 [CI: 27.9-53.5]). The risk of SMN was elevated among high risk survivors (SIR=25.1, CI: 16.7-37.6), but did not differ from the US population for survivors of low or intermediate risk disease. Table describes the HR of CHCs (grades 1-5 and 3-5) in survivors, by risk group, as compared with siblings, as well as categories of CHCs for which survivors were at increased risk. Conclusions: Long-term survivors of neuroblastoma have a high risk of late morbidity and mortality; risk is particularly pronounced among survivors of high risk disease. Vigilant lifelong medical surveillance will be required for this relatively young population as they age.[Table: see text]
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Affiliation(s)
| | | | | | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan A. Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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27
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Tonorezos ES, Clark JM, Moskowitz CS, Ford JS, Armstrong GT, Chou JF, Mubdi NZ, McDonald A, Sklar CA, Ramanathan L, Robison LL, Oeffinger KC. Exercise and QUality diet After Leukemia (The EQUAL Study): An intervention trial in the Childhood Cancer Survivor Study (CCSS). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10015 Background: Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for obesity and cardiovascular (CV) disease. Exposure to cranial radiotherapy (CRT) increases risks. We tested whether a weight loss intervention that was successful in the general population could result in weight loss or improvements CV risk factors for ALL survivors. Methods: Obese and overweight 5-year ALL survivors diagnosed < age 21 from CCSS were randomized to a 24-month remotely delivered diet/physical activity intervention or self-directed weight loss (control), stratified by CRT. The intervention emphasized a low calorie DASH diet and physical activity via an app, a website, and weekly coach calls. The primary endpoint was difference in weight loss after 24 months, using an intent-to-treat analysis. Secondary endpoints: differences in changes in blood pressure, cholesterol, and triglycerides. Analyses were performed using linear mixed effects; the study was designed to detect a difference of 2.75 kg. Results: Of 358 survivors (59% female, 91% White non-Hispanic, median age 37, IQR: 33-43), 181 were randomized to the intervention and 177 to control. Baseline mean (SD) weight was 98.6 kg (24.0) for intervention and 94.9 kg (20.3) for controls. 55 (30%) of intervention participants were adherent beyond one year. At 12 months, after controlling for CRT, sex, race/ethnicity, and age, the adjusted mean (SE) change in weight from baseline was -1.83kg (0.7) for intervention and -0.16kg (0.64) for control participants. At 24 months, the adjusted mean (SE) change in weight was -0.36kg (0.78) for intervention and +0.18kg (0.66) for control participants with the average difference of -0.54 kg (95%CI: -2.5,1.5, p=0.59) between the arms. A small proportion had at least 5% weight loss at 24 months (intervention 24%; control 17%). No significant differences in CV risk factors were observed. Conclusions: A 24-month phone and app/web-based diet and physical activity intervention that was successful for weight loss in the general population did not result in greater weight loss or improvement in CV risk factors among adult survivors of childhood ALL. Reduced adherence to the intervention beyond 12 months, or lack of ALL survivor-specific tailoring, may account for these findings. Clinical trial information: NCT02244411. [Table: see text]
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Noyd DH, Yasui Y, Li N, Chow EJ, Bhatia S, Landstrom A, Gilchrist S, Tonorezos ES, Zullig LL, Casillas JN, Berkman AM, Ness KK, Mulrooney DA, Leisenring WM, Howell CR, Shoag JM, Kirchhoff AC, Howell RM, Armstrong GT, Oeffinger KC. Disparities in cardiovascular risk factors by race/ethnicity among adult survivors of childhood cancer: A report from the Childhood Cancer Survivorship Study (CCSS). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10017 Background: Racial, ethnic, and socioeconomic disparities are documented in outcomes for childhood cancer survivors. Understanding whether childhood cancer modifies established disparities in cardiovascular risk factors (CVRFs) in the general population would inform strategies to reduce health inequities among survivors. Methods: The CCSS is a retrospectively constructed cohort with prospective follow-up consisting of 25,579 five year survivors of childhood cancer diagnosed between 1970 and 1999. We estimated the incidence of self-reported Common Terminology Criteria for Adverse Events (CTCAE) grade >2 CVRFs (hypertension, diabetes, dyslipidemia, and obesity) and multiple (>2) CVRFs among survivors. Multivariable Poisson regression estimated the rate ratios (RR) of CVRFs by race/ethnicity, adjusted for key treatment exposures and sociodemographics. Results: Within the CCSS cohort, there were 20,416 non-Hispanic White (NHW), 1625 non-Hispanic Black (NHB), and 2043 Hispanic survivors with the cumulative incidence estimates of each CVRF at age 40 displayed in Table. Survivors who self-reported “Other” or mixed race were excluded for this analysis (n=1495). NHB survivors were more likely to report hypertension (unadjusted RR 1.3; 95% Confidence Interval [CI] 1.0-1.6), diabetes (RR 1.6; 95% CI 1.0-2.4), obesity (RR 1.6; 95% CI 1.4-1.9), and multiple CVRF (RR 1.3; 95% CI 1.2-1.5), whereas Hispanic survivors were more likely to report diabetes (RR 1.7; 95% CI 1.2-2.4), obesity (RR 1.4; 95% CI 1.2-1.5), and multiple CVRFs (RR 1.1; 95% CI 1.0-1.3) compared with NHW survivors. These observed disparities in risks of CVRFs remained nearly unchanged even after adjustment for sociodemographic factors (age, sex, household income, education, marital status, employment, and insurance) and treatment exposures (Yes/No for anthracyclines, alkylators, and chest radiation). Conclusions: NHB and Hispanic adult survivors demonstrate a higher burden of CVRF compared with NHW survivors, particularly diabetes and obesity. The associated morbidity of these conditions and established increase they incur in risk of more severe cardiovascular disease emphasizes the need for interventions to mitigate CVRFs to promote health equity among these survivors.[Table: see text]
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Affiliation(s)
| | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
| | - Nan Li
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | | | | | | | | | | | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Mollica MA, Tesauro G, Tonorezos ES, Jacobsen PB, Smith AW, Gallicchio L. Current state of funded National Institutes of Health grants focused on individuals living with advanced and metastatic cancers: a portfolio analysis. J Cancer Surviv 2021; 15:370-374. [PMID: 33651327 DOI: 10.1007/s11764-021-01008-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/17/2021] [Indexed: 01/13/2023]
Abstract
PURPOSE The National Cancer Institute has supported cancer survivorship science for many years, yet few funded studies have examined the needs of individuals living with cancer that is advanced or has metastasized. This report analyzes currently active National Institutes of Health (NIH) grants focused on survivorship for patients living with advanced or metastatic cancers to identify emerging research topics in this population and gaps in current science. METHODS A search of all NIH research grants that received funding in Fiscal Year 2020 focused on this population was conducted, excluding grants with a primary focus on end-of-life care, tumor progression or staging and grants for which the only outcome was survival. RESULTS A total of 25 active grants met the inclusion criteria. Most were funded using the R01 grant mechanism and included a range of cancer types and topics such as palliative/supportive care, psychosocial support, health services, and symptom sequelae. CONCLUSIONS Although currently funded grants focus on several important topics, gaps in the portfolio remain. There is a need to enhance the grant portfolio of research studies focused on the longitudinal examination of unmet needs, models of care delivery, impact of innovative therapies, and the impact of financial hardship for individuals living with advanced or metastatic cancer. IMPLICATIONS FOR CANCER SURVIVORS This review of current NIH studies suggests a need for expanded research on individuals living with advanced or metastatic cancer. Moving forward, enhancing research focused on key gap areas will be critical to improve care and outcomes for this growing population.
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Affiliation(s)
- Michelle A Mollica
- Healthcare Delivery Research Program, Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, MSC 9712, Room 3E436, Bethesda, MD, 20892-9762, USA.
| | - Gina Tesauro
- Healthcare Delivery Research Program, Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, MSC 9712, Room 3E436, Bethesda, MD, 20892-9762, USA
| | - Emily S Tonorezos
- Healthcare Delivery Research Program, Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, MSC 9712, Room 3E436, Bethesda, MD, 20892-9762, USA
| | - Paul B Jacobsen
- Healthcare Delivery Research Program, Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, MSC 9712, Room 3E436, Bethesda, MD, 20892-9762, USA
| | - Ashley Wilder Smith
- Healthcare Delivery Research Program, Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, MSC 9712, Room 3E436, Bethesda, MD, 20892-9762, USA
| | - Lisa Gallicchio
- Healthcare Delivery Research Program, Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, MSC 9712, Room 3E436, Bethesda, MD, 20892-9762, USA
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Friedman DN, Moskowitz CS, Hilden P, Howell RM, Weathers RE, Smith SA, Wolden SL, Tonorezos ES, Mostoufi-Moab S, Chow EJ, Meacham LR, Chou JF, Whitton JA, Leisenring WM, Robison LL, Armstrong GT, Oeffinger KC, Sklar CA. Radiation Dose and Volume to the Pancreas and Subsequent Risk of Diabetes Mellitus: A Report from the Childhood Cancer Survivor Study. J Natl Cancer Inst 2021; 112:525-532. [PMID: 31329225 DOI: 10.1093/jnci/djz152] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/05/2019] [Accepted: 07/16/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Childhood cancer survivors exposed to abdominal radiation (abdRT) are at increased risk for diabetes mellitus, but the association between risk and radiation dose and volume is unclear. METHODS Participants included 20 762 5-year survivors of childhood cancer (4568 exposed to abdRT) and 4853 siblings. For abdRT, we estimated maximum dose to abdomen; mean doses for whole pancreas, pancreatic head, body, tail; and percent pancreas volume receiving no less than 10, 20, and 30 Gy. Relative risks (RRs) were estimated with a Poisson model using generalized estimating equations, adjusted for attained age. All statistical tests were two-sided. RESULTS Survivors exposed to abdRT (median age = 31.6 years, range = 10.2-58.3 years) were 2.92-fold more likely than siblings (95% confidence interval [CI] = 2.02 to 4.23) and 1.60-times more likely than survivors not exposed to abdRT (95%CI = 1.24 to 2.05) to develop diabetes. Among survivors treated with abdRT, greater attained age (RRper 10 years = 2.11, 95% CI = 1.70 to 2.62), higher body mass index (RRBMI 30+ = 5.00, 95% CI = 3.19 to 7.83 with referenceBMI 18.5-24.9), and increasing pancreatic tail dose were associated with increased diabetes risk in a multivariable model; an interaction was identified between younger age at cancer diagnosis and pancreatic tail dose with much higher diabetes risk associated with increasing pancreatic tail dose among those diagnosed at the youngest ages (P < .001). Radiation dose and volume to other regions of the pancreas were not statistically significantly associated with risk. CONCLUSIONS Among survivors treated with abdRT, diabetes risk was associated with higher pancreatic tail dose, especially at younger ages. Targeted interventions are needed to improve cardiometabolic health among those at highest risk.
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Affiliation(s)
| | - Chaya S Moskowitz
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | | | | | - Rita E Weathers
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Susan A Smith
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Suzanne L Wolden
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | - Emily S Tonorezos
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
| | | | - Eric J Chow
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Joanne F Chou
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | - Charles A Sklar
- Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY
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31
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Mollica MA, Chou WYS, Tonorezos ES, Smith AW. Young adult caregivers' perceptions of cancer misinformation on social media: Response to Warner et al. Cancer 2020; 127:1177-1179. [PMID: 33368152 DOI: 10.1002/cncr.33382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 01/21/2023]
Affiliation(s)
- Michelle A Mollica
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Wen-Ying Sylvia Chou
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Emily S Tonorezos
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | - Ashley Wilder Smith
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
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Abstract
Endocrine late effects, including reproductive disorders and secondary thyroid cancer, have been reported in up to 50 %childhood cancer survivors (CCS) more than 5 years after treatment. Most endocrine disorders are amenable to treatment; awareness of symptoms is therefore of great importance. Recognition of these symptoms may be delayed however because many are nonspecific. Timely treatment of endocrine disorders improves quality of life in CCS and prevents possible consequences, such as short stature, bone and cardiovascular disorders, and depression. At-risk CCS must therefore be regularly and systematically monitored. This article provides a summary of the most commonly reported endocrine late effects in CCS.
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Affiliation(s)
- Hanneke M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Children's Hospital, UMCU, PO Box 85090, Utrecht 3505 AB, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
| | - Wassim Chemaitilly
- Division of Endocrinology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lillian R Meacham
- Division of Hematology/Oncology/BMT, Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering and Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, 485 Lexington Avenue, 2nd Floor, New York, NY 10017, USA
| | - Sogol Mostoufi-Moab
- Division of Endocrinology, Department of Pediatrics, The Children's Hospital of Philadelphia, Roberts Pediatric Clinical Research Building, 2716 South Street, Philadelphia, PA 19146, USA; Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia, Roberts Pediatric Clinical Research Building, 2716 South Street, Philadelphia, PA 19146, USA
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Tonorezos ES, Friedman DN, Barnea D, Bosscha MI, Chantada G, Dommering CJ, de Graaf P, Dunkel IJ, Fabius AWM, Francis JH, Greer MLC, Kleinerman RA, Kors WA, Laughlin S, Moll AC, Morton LM, Temming P, Tucker MA, van Leeuwen FE, Walsh MF, Oeffinger KC, Abramson DH. Recommendations for Long-Term Follow-up of Adults with Heritable Retinoblastoma. Ophthalmology 2020; 127:1549-1557. [PMID: 32422154 PMCID: PMC7606265 DOI: 10.1016/j.ophtha.2020.05.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To generate recommendations for long-term follow-up of adult survivors of heritable retinoblastoma. DESIGN We convened a meeting of providers from retinoblastoma centers around the world to review the state of the science and to evaluate the published evidence. PARTICIPANTS Retinoblastoma is a rare childhood cancer of the retina. Approximately 40% of retinoblastoma cases are heritable, resulting from a germline mutation in RB1. Dramatic improvements in treatment and supportive care have resulted in a growing adult survivor population. However, survivors of heritable retinoblastoma have a significantly increased risk of subsequent malignant neoplasms, particularly bone and soft tissue sarcomas, uterine leiomyosarcoma, melanomas, and radiotherapy-related central nervous system tumors, which are associated with excess morbidity and mortality. Despite these risks, no surveillance recommendations for this population currently are in place, and surveillance practices vary widely by center. METHODS Following the Institute of Medicine procedure for clinical practice guideline development, a PubMed, EMBASE, and Web of Science search was performed, resulting in 139 articles; after abstract and full-text review, 37 articles underwent detailed data abstraction to quantify risk and evidence regarding surveillance, if available. During an in-person meeting, evidence was presented and discussed, resulting in consensus recommendations. MAIN OUTCOME MEASURES Diagnosis and mortality from subsequent neoplasm. RESULTS Although evidence for risk of subsequent neoplasm, especially sarcoma and melanoma, was significant, evidence supporting routine testing of asymptomatic survivors was not identified. Skin examination for melanoma and prompt evaluation of signs and symptoms of head and neck disease were determined to be prudent. CONCLUSIONS This review of the literature confirmed some of the common second cancers in retinoblastoma survivors but found little evidence for a benefit from currently available surveillance for these malignancies. Future research should incorporate international partners, patients, and family members.
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Affiliation(s)
- Emily S Tonorezos
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | | | - Dana Barnea
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | | | | | - Pim de Graaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ira J Dunkel
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Armida W M Fabius
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | | | - Ruth A Kleinerman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Wijnanda A Kors
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Suzanne Laughlin
- Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Annette C Moll
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lindsay M Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Margaret A Tucker
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | - David H Abramson
- Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
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Anderson N, Delavar A, Friedman DN, Joseph V, Mubdi N, Oeffinger KC, Sklar CA, Offit K, Matasar M, Raghunathan N, Antal Z, Straus D, Walsh M, Latham A, Tonorezos ES. Utilization of clinical genetic counseling among childhood and young adult cancer survivors in a registry trial. J Community Genet 2020; 11:501-504. [PMID: 32676930 DOI: 10.1007/s12687-020-00478-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 07/10/2020] [Indexed: 10/23/2022] Open
Abstract
We describe utilization of clinical genetic services among survivors of childhood and young adult cancer after participation in a genetic registry. Clinical genetic counselors flagged 162 out of 1069 pedigrees (15.2%) as suggestive of inheritable cancer susceptibility, resulting in 126 (11.8%) referral letters. Following delivery of the referral letters, 19 (15.1%) participants completed clinical genetic counseling, 16 (12.7%) received testing, and four (3.2%) were found to have actionable results. Our results suggest a discordance between reported willingness to undergo genetic counseling and real-world utilization.
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Affiliation(s)
| | - Arash Delavar
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,School of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Vijai Joseph
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nidha Mubdi
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Kenneth Offit
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Matthew Matasar
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Nirupa Raghunathan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Zoltan Antal
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Straus
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Michael Walsh
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alicia Latham
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Emily S Tonorezos
- Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Weill Cornell Medical College, New York, NY, USA. .,Adult Long-Term Follow-Up Program, Memorial Sloan Kettering, 485 Lexington Avenue, 2nd Floor, New York, NY, 10017, USA.
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Thorsness SL, Freites-Martinez A, Marchetti MA, Navarrete-Dechent C, Lacouture ME, Tonorezos ES. Nonmelanoma Skin Cancer in Childhood and Young Adult Cancer Survivors Previously Treated With Radiotherapy. J Natl Compr Canc Netw 2020; 17:237-243. [PMID: 30865918 DOI: 10.6004/jnccn.2018.7096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 10/11/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Radiotherapy (RT) is a risk factor for nonmelanoma skin cancer (NMSC), specifically basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), but whether features, histology, or recurrence of NMSC after RT resemble those observed in the general population is unknown. METHODS A retrospective review (1994-2017) was performed within the Adult Long-Term Follow-Up Program and Dermatology Service at Memorial Sloan Kettering Cancer Center. Demographics, clinical features, histology, treatment, and recurrence were collected for this patient cohort that was under close medical surveillance. Pathology images were reviewed when available. RESULTS A total of 946 survivors (mean age, 40 years [SD, 13]) were assessed for NMSC. The mean age at first cancer diagnosis was 16 years (range, 0-40 years [11]), and the most common diagnosis was Hodgkin lymphoma (34%; n=318). In 63 survivors, 281 primary in-field lesions occurred, of which 273 (97%) were BCC and 8 (3%) were SCC. Mean intervals from time of RT to BCC and SCC diagnosis were 24 years (range, 2-44 years) and 32 years (range, 14-46 years), respectively. The most common clinical presentation of BCC was macule (47%; n=67), and the most common histologic subtypes were superficial for BCC (48%; n=131) and in situ for SCC (55%; n=5). Mohs surgery predominated therapeutically (42%; n=117), the mean duration of follow-up after treatment was 6 years (range, 12 days-23 years), and the 5-year recurrence rate was 1% (n=1). CONCLUSIONS Most NMSCs arising in sites of prior RT were of low-risk subtypes. Recurrence was similar to that observed in the general population. Current guidelines recommend surgical intervention for tumors arising in sites of prior RT because they are considered to be at high risk for recurrence. These findings suggest that an expanded role for less aggressive therapy may be appropriate, but further research is needed.
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Affiliation(s)
| | - Azael Freites-Martinez
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Marchetti
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cristian Navarrete-Dechent
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Dermatology, Facultad de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile; and
| | - Mario E Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily S Tonorezos
- Adult Long-Term Follow-Up Program, Department of Medicine, Memorial Sloan Kettering Cancer Center, and.,Weill Cornell Medical College, New York, New York
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Friedman DN, Hsu M, Moskowitz CS, Francis JH, Lis E, Fleischut MH, Oeffinger KC, Walsh M, Tonorezos ES, Sklar CA, Abramson DH, Dunkel IJ. Whole-body magnetic resonance imaging as surveillance for subsequent malignancies in preadolescent, adolescent, and young adult survivors of germline retinoblastoma: An update. Pediatr Blood Cancer 2020; 67:e28389. [PMID: 32386119 PMCID: PMC8177753 DOI: 10.1002/pbc.28389] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/06/2020] [Accepted: 04/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Germline retinoblastoma (Rb) survivors are at lifelong risk for developing subsequent malignancies (SMNs). Optimal surveillance modalities are needed to detect SMN at an early stage in this high-risk cohort. We investigated the use of rapid whole-body magnetic resonance imaging (WB-MRI) as a noninvasive screening modality in this cohort. PROCEDURE WB-MRI was performed in asymptomatic preadolescent, adolescent, or young adult survivors of germline Rb from February 1, 2008 to December 31, 2018 at a tertiary cancer center. We calculated sensitivity and specificity of WB-MRI and rate of false-positive findings requiring additional evaluation. RESULTS Overall, 110 WB-MRI were performed in 47 germline Rb survivors (51% female; median age at initial WB-MRI: 15.5 years [range 8-25.3]). Patients received 1-10 annual WB-MRI examinations (median: two). Thirteen patients had an abnormal WB-MRI; three findings were deemed to be likely benign and were not evaluated further. Ten patients required dedicated imaging and three required biopsy; two patients were diagnosed with localized high-grade osteosarcoma, while the other eight had benign findings. One patient was diagnosed with secondary osteosarcoma 3 months after normal WB-MRI. In total, there were 96 true negatives, 11 false positives, two true positives, and one false negative. The sensitivity of WB-MRI in this cohort was 66.7% (95% confidence interval [CI], 14.2-96.0) and the specificity was 89.7% (95% CI, 83.6-93.7). CONCLUSIONS Based on our 10-year experience, surveillance WB-MRI appears to have limited utility as a surveillance modality for SMN in germline Rb survivors. Alternate screening modalities should be investigated.
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Affiliation(s)
- Danielle Novetsky Friedman
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
| | - Meier Hsu
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Chaya S. Moskowitz
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
| | | | - Eric Lis
- Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | | | | | - Michael Walsh
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
| | - Emily S. Tonorezos
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
| | - Charles A. Sklar
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
| | - David H. Abramson
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
| | - Ira J. Dunkel
- Memorial Sloan Kettering Cancer Center, New York, NY, United States,Weill Cornell Medical College, New York, NY, United States
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Chow EJ, Chen Y, Armstrong GT, Baldwin LM, Gibson TM, Hudson MM, McDonald A, Nathan PC, Syrjala KL, Tonorezos ES, Oeffinger KC, Yasui Y. Underdiagnosis and undertreament of modifiable cardiovascular risk factors: A Childhood Cancer Survivor Study (CCSS) report. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.10515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10515 Background: Survivors of childhood cancer exposed to cardiotoxic therapies are at increased risk of heart disease. Hypertension, dyslipidemia, and diabetes are modifiable cardiovascular risk factors (CVRFs) that synergistically increase this risk. Therefore, we aimed to determine the prevalence of and predictors associated with CVRF underdiagnosis and undertreatment in this population. Methods: CCSS participants at increased risk of heart disease due to prior cancer therapy were enrolled in an ongoing randomized intervention trial (NCT03104543) to improve CVRF identification and treatment. Participants completed a baseline survey (CVRF status, lifestyle habits, attitudes towards healthcare), anthropometry, and blood draw. Blood pressure, low density lipoprotein, triglyceride, glucose and Hgb A1c were measured and classified as normal/abnormal per standard clinical criteria. Multivariable logistic regression estimated odds ratios (OR [95% confidence intervals]) associated with predictors and risk of CVRF underdiagnosis and undertreatment. Results: As of January 2020, 522 participants (43% male) were available for analysis (47% response), with a median age 38y (range 20-65) and 28y (18-49) from original cancer treatment (75% anthracycline, 47% chest radiation). With mean measured BMI 27.3±6.5 kg/m2, self-reported prevalence rates were hypertension 27%, dyslipidemia 33%, and diabetes 9%. While 90% of participants had a routine check-up ≤2y ago, 58% had a measured CVRF in the abnormal range. Specifically, among previously undiagnosed participants, we observed rates of abnormal blood pressure (26%), lipids (17%), and glucose tolerance (27%). Among those with pre-existing hypertension, dyslipidemia, and diabetes, 11%, 49%, and 54%, respectively, had measurements outside of the usual therapeutic target range. In multivariable analysis, BMI ≥25 kg/m2 (vs < 25) was associated with risk of underdiagnosis (OR 1.8 [1.2-2.8]). For undertreatment, significant adverse factors included older age ( > 35 vs ≤35y: OR 2.5 [1.2-5.1]), BMI ≥30 kg/m2 (vs < 25: OR 3.3 [1.7-6.4]), and greater perceived reliance on others for healthcare decisions (OR 1.7 [1.2-2.4]). Those with greater health-related self-efficacy were less likely to be undertreated (OR 0.5 [0.3-0.96]). Conclusions: CVRF underdiagnosis and undertreatment among childhood cancer survivors at increased risk of heart disease was common. Greater awareness among survivors and primary care providers and more aggressive control of CVRFs may mitigate this risk.
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Affiliation(s)
| | - Yan Chen
- University of Alberta, Edmonton, AB, Canada
| | | | | | | | | | | | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Karen L Syrjala
- Fred Hutchinson Cancer Research Center & University of Washington, Department of Public Health, Seattle, WA
| | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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Dieffenbach BV, Li N, Madenci AL, Murphy AJ, Barnea D, Gibson TM, Tonorezos ES, Leisenring WM, Howell RM, Diller LR, Liu Q, Chow EJ, Armstrong GT, Yasui Y, Oeffinger KC, Weldon CB, Weil BR. Incidence of and risk factors for late cholecystectomy in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Eur J Cancer 2020; 133:4-13. [PMID: 32422507 DOI: 10.1016/j.ejca.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/28/2020] [Accepted: 03/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gallbladder disease and need for cholecystectomy are common and significant contributors to patient morbidity and healthcare costs. Childhood cancer survivors are at elevated risk for developing cholelithiasis. However, their incidence of and risk factors for late (>5 years from diagnosis) cholecystectomy have not been studied. METHODS A total of 25,549 survivors (median age at diagnosis 6.9 years, range 0-21.0; current age 30.7 years, range 5.6-65.9) diagnosed between 1970 and 1999 and 5037 siblings were queried for self-reported cholecystectomy occurring five or more years from primary cancer diagnosis. Piecewise exponential models evaluated associations between cancer treatment exposures and late cholecystectomy. RESULTS Over a median follow-up period of 21.9 and 26.0 years, respectively, 789 survivors and 168 siblings underwent late cholecystectomy (cumulative incidence 7.2%, 95% confidence interval [CI] = 6.5-7.8% and 6.6%, 95% CI = 5.4-7.6%, respectively; rate ratio [RR] = 1.3, 95% CI = 1.1-1.5). Compared with siblings, survivors of acute lymphoblastic leukaemia (RR = 1.4, 95% CI = 1.2-1.8), soft tissue sarcoma (RR = 1.4, 95% CI = 1.0-1.8) and bone cancer (RR = 1.3, 95% CI = 1.0-1.8) were at the greatest risk. In addition to attained age, female sex and increasing body mass index, exposure to high-dose (≥750 mg/m2) platinum chemotherapy (RR = 2.6, 95% CI = 1.5-4.5), vinca alkaloid chemotherapy (RR = 1.4, 95% CI = 1.1-1.8) or total body irradiation (TBI; RR = 2.2, 95% CI = 1.2-4.2) were each associated with late cholecystectomy. CONCLUSIONS Independent of traditional risk factors for gallbladder disease, exposure to high-dose platinum chemotherapy, vinca alkaloid chemotherapy or TBI increased risk for late cholecystectomy. These findings should inform current long-term follow-up guidelines and education regarding risk for late cholecystectomy.
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Affiliation(s)
- Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Nan Li
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Dana Barnea
- Survivorship Clinic, Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisa R Diller
- Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Qi Liu
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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Feldman DR, Knezevic A, Wilson K, Bromberg M, Budnick A, McHugh DJ, Larsen E, Bajorin DF, Motzer RJ, Tonorezos ES, Patil S, Funt SA. Detailed evaluation of hearing loss (HL) associated with high-dose (HD) carboplatin for salvage treatment of germ cell tumors (GCT). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
401 Background: HD carboplatin is an essential part of curative salvage high-dose chemotherapy (HDCT) for GCT. Although ototoxicity is a known side effect of HD carboplatin, data on severity and characteristics of HL in this population are limited. Methods: Eligible patients (pts) received salvage HD carboplatin for GCT at our center from 1993-2017 and had audiograms pre- and post-HDCT. All pts were planned for 3 sequential cycles of HD carboplatin; some had audiograms after each cycle. HL severity was classified by ASHA criteria (slight: 15-24dB; mild: 25-40dB; moderate: 41-55dB; moderately severe: 56-70dB; severe: 71-90dB; profound: >90dB). Change in hearing threshold at each frequency (0.25 – 8 kHz) was analyzed by clinical and treatment variables using the Wilcoxon rank-sum test. The proportion of pts recommended for hearing aids was also recorded. Results: Of 115 pts (median age 31, 77% nonseminoma), 96 received TI-CE and 19 received TI-TIC on a clinical trial (Feldman CGUC 2015). Pts varied by prior cisplatin exposure (77% with ≤4 vs 23% with 5-9 cycles) and number of HD carboplatin cycles (89% had 3, 10% had 2, and 2% had 1). Carboplatin AUC was 21 in 23%, 24 in 75%, and 28 in 3%. Moderate to profound HL was present in 23% pre-HD carboplatin vs 82% post, preferentially at high frequencies (Table). Of 89 pts with normal to mild HL at baseline, 78% developed moderate or worse HL post-HD carboplatin, including 61% with moderately severe or severe HL. Higher AUC (24 vs 21) and number of HD carboplatin cycles were associated with greater HL with HD carboplatin whereas prior cisplatin exposure was not. Due to moderate or severe HL in the vital speech frequency range (2 – 4kHz), 20 (17%) pts were recommended for hearing aids post-HD carboplatin. Conclusions: In the largest series to detail ototoxicity in pts receiving salvage HD carboplatin for GCT, we show HL, particularly at high frequencies, is a major dose-dependent toxicity. Most pts will have at least moderate high frequency HL after HD carboplatin with approximately 1 in 6 recommended for hearing aids. [Table: see text]
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Affiliation(s)
| | | | | | | | - Amy Budnick
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sujata Patil
- Memorial Sloan Kettering Cancer Center, New York, NY
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Raghunathan NJ, Zabor EC, Anderson N, Oeffinger K, Tonorezos ES, Korenstein D. Communicating cardiovascular risk to high-risk cancer survivors: a mixed-methods pilot study of a statin risk communication tool. J Cancer Surviv 2020; 14:417-423. [PMID: 32043205 DOI: 10.1007/s11764-020-00860-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/29/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Childhood, adolescent, and young adult cancer survivors treated with radiation therapy (RT) may be unaware of their high cardiovascular disease (CVD) risk or how to mitigate it. Tools are needed to improve understanding. We developed and pilot-tested a risk communication tool for shared decision-making with survivors regarding CVD risk reduction with statin therapy. We included quantitative and qualitative arms to further tool development and testing. METHODS The statin risk communication tool was adapted from a previously validated tool. Patients were at increased risk for CVD due to history of chest RT and recruited to usual care and intervention arms. The post-visit survey included Likert-like scales to explore acceptability of the tool, knowledge questions, and a decisional conflict scale. This pilot study used descriptive statistics and was not powered for significance. Semi-structured interviews with intervention arm participants explored shared decision-making processes. RESULTS Median participant (n = 46) age was 45. Most intervention patients (22/24, 92%) and 50% (11/22) of controls found statin information acceptable while 31% (7/22) of the control arm selected "not applicable" regarding information acceptability. Most participants were unaware of their personal CVD risk or potential statin side effects. In semi-structured interviews, participants found the tool is helpful to visualize risk and aid conversations. CONCLUSIONS The risk communication tool was acceptable. Qualitative data suggested the tool improved decisional clarity and comfort. IMPLICATIONS FOR CANCER SURVIVORS Poor knowledge of CVD and statins and poor recall of CVD risk conversation suggest a need to continue to optimize conversations regarding cardiovascular risk and statin therapy.
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Affiliation(s)
- Nirupa J Raghunathan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd Floor, New York City, NY, 10017, USA.
| | - Emily C Zabor
- Department of Quantitative Health Sciences, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Nassim Anderson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd Floor, New York City, NY, 10017, USA
| | | | - Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd Floor, New York City, NY, 10017, USA.,Weill Cornell Medicine, New York City, NY, USA
| | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd Floor, New York City, NY, 10017, USA.,Weill Cornell Medicine, New York City, NY, USA
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Chow EJ, Baldwin LM, Hagen AM, Hudson MM, Gibson TM, Kochar K, McDonald A, Nathan PC, Syrjala KL, Taylor SL, Tonorezos ES, Yasui Y, Armstrong GT, Oeffinger KC. Communicating health information and improving coordination with primary care (CHIIP): Rationale and design of a randomized cardiovascular health promotion trial for adult survivors of childhood cancer. Contemp Clin Trials 2020; 89:105915. [PMID: 31862436 PMCID: PMC7242131 DOI: 10.1016/j.cct.2019.105915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Long-term survival for children diagnosed with cancer exceeds 80%. Notably, premature cardiovascular disease has become the leading non-cancer cause of late mortality among these survivors. METHODS/DESIGN This randomized controlled trial (RCT; NCT03104543) focuses on adult participants in the Childhood Cancer Survivor Study identified as high risk for ischemic heart disease or heart failure due to their cancer treatment. Participants undergo a home-based evaluation of blood pressure and laboratory tests to determine the prevalence of undiagnosed and/or undertreated hypertension, dyslipidemia, and diabetes. Those with abnormal values are then enrolled in an RCT to test the efficacy of a 12-month personalized, remotely delivered survivorship care plan (SCP) intervention designed to reduce undertreatment of these three target conditions. The intervention approximates a clinical encounter and is based on chronic disease self-management strategies. RESULTS With a goal of 750, currently 342 out of 742 eligible participants approached have enrolled (46.1%). Initially, we randomized participants to different recruitment strategies, including shorter approach packets and a tiered consent, but did not find significant differences in participation rates (40.7% to 42.9%; p = .95). Subsequently, slightly greater participation was seen with larger upfront unconditional incentive checks ($50 vs. $25: 50.7% vs. 44.1%; p = .10). Overall, the financial impact of the $50 upfront incentive was cost neutral, and possibly cost-saving, vs. a $25 upfront incentive. CONCLUSION The overall study will determine if a National Academy of Medicine-recommended SCP intervention can improve cardiovascular outcomes among long-term survivors of childhood cancer. Modifications to the recruitment strategy may improve participation rates over time.
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Affiliation(s)
- Eric J Chow
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, United States of America.
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, WA, United States of America
| | - Anna M Hagen
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, United States of America; Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States of America
| | - Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States of America
| | - Komal Kochar
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States of America
| | - Aaron McDonald
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States of America
| | - Paul C Nathan
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Karen L Syrjala
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Sarah L Taylor
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States of America
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States of America
| | - Kevin C Oeffinger
- Department of Medicine, Duke University, Durham, NC, United States of America
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Khan A, Mubdi N, Budnick A, Feldman DR, Williams SW, Patel S, Tonorezos ES. The experience of hearing loss in adult survivors of childhood and young adult cancer: A qualitative study. Cancer 2020; 126:1776-1783. [PMID: 31899553 DOI: 10.1002/cncr.32698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/10/2019] [Accepted: 12/11/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Hearing loss is a prevalent late effect among cancer survivors. Despite the significant social costs, there is a noted delay in seeking care and to the authors' knowledge there are limited data regarding the lived experiences of cancer survivors with hearing loss. The objective of the current study was to explore the lived experience of hearing loss in survivors of childhood and young adult cancers to guide survivorship care. METHODS A total of 24 survivors participated in semistructured telephone interviews. Inclusion criteria consisted of a clinical visit at the Adult Long-Term Follow-Up Program at Memorial Sloan Kettering Cancer Center in New York City between September 2005 and January 2019; exposure to cranial radiotherapy, platinum chemotherapy, or both; and hearing loss as evidenced by clinical notes, use of hearing aids, or audiogram levels consistent with severe ototoxicity. RESULTS Three primary themes emerged from the interviews. First, posttreatment hearing loss is associated with isolation and feelings of exclusion. Second, clinicians play an important role in providing survivors with education regarding hearing loss and hearing aids. Finally, hearing loss for survivors may be deprioritized because it is a reminder of the cancer history and is interpreted within the context of other treatment-related late effects. CONCLUSIONS Clinicians play an important role in initiating the discussion regarding hearing loss with survivors given the importance of hearing in maintaining social relationships, the availability of hearing care interventions, and the invisibility of hearing loss. Education regarding the value of treatment may have implications for how survivors choose to prioritize hearing loss and seek care.
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Affiliation(s)
- Amber Khan
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Nidha Mubdi
- Adult Long-Term Follow-Up Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy Budnick
- Head and Neck Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Darren R Feldman
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Sharon W Williams
- Division of Speech and Hearing Sciences, Department of Allied Health Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Seema Patel
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey
| | - Emily S Tonorezos
- Adult Long-Term Follow-Up Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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Ford JS, Tonorezos ES, Mertens AC, Hudson MM, Casillas J, Foster BM, Moskowitz CS, Smith SM, Chou JF, Buchanan G, Robison LL, Oeffinger KC. Barriers and facilitators of risk-based health care for adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer 2019; 126:619-627. [PMID: 31626337 DOI: 10.1002/cncr.32568] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Optimal risk-based survivor health care includes surveillance for late effects and education targeted at reducing or preventing risky health behaviors. Understanding the reasons for a lack of risk-based follow-up care is essential. METHODS Adult participants from the Childhood Cancer Survivor Study were surveyed about having a cancer-related visit in the past 2 years and the likelihood of having a cancer-related visit in the future. Additional factors thought to be related to the primary outcomes were also assessed. RESULTS Nine hundred seventy-five survivors completed the survey. Twenty-seven percent (95% confidence interval [CI], 24%-30%) had a cancer-related medical visit in the previous 2 years, and 41% (95% CI, 38%-44%) planned to have such a visit within the next 2 years. The likelihood of having had a cancer-related visit within the last 2 years was higher among survivors assigning greater importance to these visits (relative risk [RR], 1.2; 95% CI, 1.1-1.3), perceiving greater susceptibility to health problems (RR, 1.2; 95% CI, 1.1-1.3), having a moderate to life-threatening chronic health problem related to their cancer (RR, 2.1; 95% CI, 1.7-2.7), seeing a primary care provider for a cancer-related problem (RR, 1.3; 95% CI, 1.0-1.6), having a cancer treatment summary (RR, 1.3; 95% CI, 1.0-1.6), and endorsing greater confidence in physicians' abilities to address questions and concerns (RR, 1.2; 95% CI, 1.0-1.3). CONCLUSIONS Educational interventions improving awareness of treatment history and susceptibility to cancer-related late effects and corresponding risk-based care are likely to be beneficial for survivors of childhood cancers.
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Affiliation(s)
- Jennifer S Ford
- Hunter College and Graduate Center, City University of New York, New York, New York
| | | | - Ann C Mertens
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Jacqueline Casillas
- University of California Los Angeles School of Medicine, Los Angeles, California
| | | | | | | | - Joanne F Chou
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - George Buchanan
- University of Texas Southwestern Medical Center, Dallas, Texas
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Qureshi TA, Veeraraghavan H, Sung JS, Kaplan JB, Flynn J, Tonorezos ES, Wolden SL, Morris EA, Oeffinger KC, Pike MC, Moskowitz CS. Automated Breast Density Measurements From Chest Computed Tomography Scans. J Med Syst 2019; 43:242. [PMID: 31230138 DOI: 10.1007/s10916-019-1363-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
To develop an automated method for quantifying percent breast density from chest computed tomography (CT) scans. A naïve Bayesian classifier based on gray-level intensities and spatial relationships was developed on CT scans from 10 patients diagnosed with Hodgkin lymphoma (HL) and imaged as part of routine clinical care. The algorithm was validated on CT scans from 75 additional HL patients. The classifier was developed and validated using a reference dataset with consensus manual segmentation of fibroglandular tissue. Accuracy was evaluated at the pixel-level to examine how well the algorithm identified pixels with fibroglandular tissue using true and false positive fractions (TPF and FPF, respectively). Quantitative estimates of the patient-level CT percent density were contrasted to each other using the concordance correlation coefficient, ρc, and to subjective ACR BI-RADS density assessments using Kendall's τb. The pixel-level TPF for identifying pixels with fibroglandular tissue was 82.7% (interquartile range of patient-specific TPFs 65.5%-89.6%). The pixel-level FPF was 9.2% (interquartile range of patient-specific FPFs 2.5%-45.3%). Patient-level agreement of the algorithm's automated density estimate with that obtained from the reference dataset was high, ρc = 0.93 (95% CI 0.90-0.96) as was agreement with a radiologist's subjective ACR-BI-RADS assessments, τb = 0.77. It is possible to obtain automated measurements of percent density from clinical CT scans.
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Affiliation(s)
- Touseef A Qureshi
- Cedars-Sinai Medical Center, Biomedical Imaging Research Institute, 8700 Beverly Blvd, Pact 400, Los Angeles, CA, 90048, USA
| | - Harini Veeraraghavan
- Memorial Sloan Kettering Cancer Center, Department of Medical Physics, 485 Lexington Avenue, New York, NY, 10017, USA
| | - Janice S Sung
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY, 10065, USA
| | - Jennifer B Kaplan
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY, 10065, USA
| | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, 485 Lexington Avenue, New York, NY, 10017, USA
| | - Emily S Tonorezos
- Memorial Sloan Kettering Cancer Center, Department of Medicine, 485 Lexington Avenue, New York, NY, USA
| | - Suzanne L Wolden
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, 1275 York Avenue, New York, NY, 10065, USA
| | - Elizabeth A Morris
- Memorial Sloan Kettering Cancer Center, Department of Radiology, 1275 York Avenue, New York, NY, 10065, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University, 2424 Erwin Dr, Suite, e 601, Durham, NC, 27705, USA
| | - Malcolm C Pike
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, 485 Lexington Avenue, New York, NY, 10017, USA
| | - Chaya S Moskowitz
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, 485 Lexington Avenue, New York, NY, 10017, USA.
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Mulrooney DA, Hyun G, Ness KK, Ehrhardt MJ, Yasui Y, Duprez D, Howell RM, Leisenring W, Constine LS, Oeffinger KC, Gibson TM, Tonorezos ES, Robison LL, Hudson MM, Armstrong GT. Cardiac events in survivors of childhood cancer treated in more recent eras: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10058 Background: Contemporary cancer protocols have incorporated modifications to minimize cardiotoxic exposures and preserve long-term health. We investigated the impact of these changes on late cardiac outcomes in a large cohort of adult survivors of childhood cancer. Methods: Congestive heart failure (CHF), myocardial infarction (MI), valvular disease, pericardial disease, and arrhythmias were graded by the National Cancer Institute’s Common Terminology Criteria for Adverse Events among 23,462 five-year cancer survivors [6,193 (26%) treated in the 1970s, 9,363 (40%) in the 1980s, and 7,906 (34%) in the 1990s] and 5,057 siblings. Cumulative incidence and 95% confidence intervals (95% CI) were estimated by treatment decade. Adjusted multivariable subdistribution hazard models were used to estimate hazard ratios (HR) and 95% CI for cardiac outcomes by decade. Mediation analysis examined risks with and without cardiotoxic exposures. Results: For survivors [median age 6 years (range: 0-21) at diagnosis, 28 years (8.2-58) at follow-up], cardiac radiation (RT) exposure declined from 77% of those treated in the 1970s to 55% and 40% in the 1980s and 1990s. Anthracycline exposure increased from 28% to 50% to 64%. The 20-year cumulative incidence of CHF (0.69% for those treated in 1970s, 0.74% in the 1980s, 0.54% in the 1990s) and MI (0.38%, 0.24%, 0.19%) declined in more recent treatment eras (p < 0.01). This change was not seen for valvular disease (0.06%, 0.06%, 0.05%), pericardial disease (0.04%, 0.02%, 0.03%) or arrhythmias (0.08%, 0.09%, 0.13%). Compared to survivors diagnosed in the 1970s, the risk of CHF, MI, and valvular disease decreased in the 1980s and 1990s, but only significantly for MI (HR 0.64 95% CI 0.47-0.89 and 0.52 95% CI 0.32-0.83). The overall MI risk was attenuated by adjustment for cardiac RT exposure (HR 0.94 95% CI 0.80-1.11), mostly among Hodgkin lymphoma (HL) survivors (HR 0.82 95% CI 0.69-0.98 [unadjusted for RT]; 1.03 95% CI 0.83-1.28 [adjusted for RT]). Conclusions: Reductions in exposure to cardiotoxic cancer therapies have resulted in declines in adverse cardiac outcomes, particularly for the RT-associated risk of myocardial infarction among HL survivors.
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Affiliation(s)
| | - Geehong Hyun
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
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Dieffenbach BV, Li N, Madenci AL, Barnea D, Murphy AJ, Tonorezos ES, Gibson TM, Liu Q, Leisenring W, Howell RM, Diller L, Armstrong GT, Yasui Y, Oeffinger KC, Weldon CB, Weil B. Late cholecystectomy in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e21525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21525 Background: Cholecystectomy (CCY) is among the most common operations performed in the developed world and is offered as a cure for symptomatic gallbladder disease. Whether survivors of childhood cancer undergo CCY at a higher rate than the general population is unknown. Methods: We identified 5-year survivors diagnosed between 1970 and 1999 who self-reported late (> 5 years after cancer diagnosis) CCY. Rates of CCY were determined among the entire cohort and in association with various risk factors and treatment exposures. Adjusted rate ratios (ARR) were estimated with multivariable piecewise exponential models. Results: Among 24,248 survivors (median follow-up 22.3, interquartile range [IQR] 16.2-30.1 years) and 5,038 siblings (median follow-up 26.4, IQR 19.3-33.7 years), the unadjusted cumulative incidence of CCY at age 50 was 7.2% (n = 757) in survivors and 6.5% (n = 168) in siblings. After adjusting for age, sex and race/ethnicity, survivors underwent CCY at higher rates compared to siblings (ARR = 1.3, 95% CI = 1.1-1.5). Relative to siblings, acute lymphoblastic leukemia survivors underwent CCY at a higher rate (ARR = 1.6, 95% CI = 1.3-2.0), all other diagnoses were not independently associated with higher rates of CCY. Among survivors, risk factors for late CCY included female sex, increasing body mass index (BMI) class, exposure to platinum agents and total body irradiation (TBI) (Table). Conclusions: CCY is performed more commonly among childhood cancer survivors relative to siblings. In addition to known risk factors for gallbladder disease, cancer treatment exposures may further enhance risk for CCY. Awareness and education regarding this observation may ensure timely diagnosis and treatment of symptomatic disease. [Table: see text]
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Affiliation(s)
| | - Nan Li
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Dana Barnea
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Qi Liu
- University of Alberta, Edmonton, AB, Canada
| | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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Friedman DN, Goodman PJ, Leisenring W, Diller L, Cohn SL, Tonorezos ES, Howell RM, Smith SA, Wolden SL, Nathan PC, Neglia JP, Ness KK, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Long term morbidity and mortality among survivors of infant neuroblastoma: A report from the Childhood Cancer Survivor Study (CCSS). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10051 Background: Infants with neuroblastoma typically have low-risk disease with excellent survival. Therapy has been de-intensified over time to minimize late effects, however the impact on survivors’ risk of late mortality, subsequent malignant neoplasms (SMN), and chronic health conditions (CHC) is unclear. Methods: We evaluated late mortality, SMNs and CHCs (graded according to CTCAE v4.03), overall and by diagnosis era, among 990 5-year neuroblastoma survivors diagnosed at < 1 year of age between 1970-1999. Cumulative mortality, standardized mortality ratios (SMR), and standardized incidence ratios (SIR) of SMNs were estimated using the National Death Index and SEER rates, respectively. Cox proportional hazards estimated hazard ratios (HR) and 95% confidence intervals (CI) for CHC, compared to 5,051 CCSS siblings. Results: Among survivors (48% female; median attained age: 24 years, range 6-46), there was increased treatment with surgery alone across the 1970s, 1980s and 1990s (21.5%, 35.3%, 41.1%, respectively), but decreased treatment with combination surgery + radiation (22.5%, 5.3%, 0.3%, respectively) and surgery + radiation + chemotherapy (28.7%, 14.7%, 9.3%, respectively). The 20-year cumulative mortality was 2.3% (95% CI, 1.4-3.8), primarily due to SMNs (SMRSMN= 10.0, 95% CI, 4.5-22.3). The 20-year cumulative incidence of SMN was 1.2% (95% CI, 0.3-3.2), 2.5% (95% CI, 1.3-4.4), and zero for those diagnosed in the 1970s, 1980s, and 1990s, respectively. SIR was highest for renal SMNs (SIR 12.5, 95% CI, 1.7-89.4). Compared to siblings, survivors were at increased risk for grade 1-5 CHC (HR 2.1, 95% CI, 1.9-2.3) with similar HR across eras (HR1970s= 1.9, 95% CI, 1.6-2.2; HR1980s= 2.2, 95% CI, 1.9-2.6; HR1990s= 2.0, 95% CI, 1.7-2.4). The HR of severe, disabling, life-threatening and fatal CHC (grades 3-5) decreased in more recent eras (HR1970s= 4.7, 95% CI, 3.4-6.6; HR1980s= 4.4, 95% CI, 3.2-6.2; HR1990s= 2.9, 95% CI, 2.0-4.3). Conclusions: Survivors of infant neuroblastoma remain at increased risk for late mortality, SMN, and CHCs many years after diagnosis. However, the risk of grade 3-5 CHCs has declined in more recent eras, likely reflecting de-intensification of therapy.
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Affiliation(s)
| | | | | | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan A Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Lopez CA, Tonorezos ES. Non-Small-Cell Lung Cancer After Mantle Radiation: A Case Report and Brief Review. Oncology (Williston Park) 2019; 33:174-177. [PMID: 31095715 PMCID: PMC7424540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Survivors of childhood and young adult cancer are at risk for developing subsequent malignant neoplasms, including lung cancer. As survival rates in this group continue to improve and patients enter later decades in life, determining the optimal surveillance and counseling strategies with regards to subsequent cancers remains a challenge. In this case report, we present a non-Hodgkin lymphoma survivor who was incidentally found to have non-small-cell lung cancer 30 years after undergoing treatment that included mantle radiation. We discuss the treatment-related risk factors for lung cancer in this population and potential implications for long-term follow-up.
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Tonorezos ES, Ford JS, Wang L, Ness KK, Yasui Y, Leisenring W, Sklar CA, Robison LL, Oeffinger KC, Nathan PC, Armstrong GT, Krull K, Jones LW. Impact of exercise on psychological burden in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer 2019; 125:3059-3067. [PMID: 31067357 DOI: 10.1002/cncr.32173] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/26/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Childhood cancer survivors are at risk for adverse psychological outcomes. Whether exercise can attenuate this risk is unknown. METHODS In total, 6199 participants in the Childhood Cancer Survivor Study (median age, 34.3 years [range, 22.0-54.0 years]; median age at diagnosis, 10.0 years [range, 0-21.0 years]) completed a questionnaire assessing vigorous exercise and medical/psychological conditions. Outcomes were evaluated a median of 7.8 years (range, 0.1-10.0 years) later and were defined as: symptom level above the 90th percentile of population norms for depression, anxiety, or somatization on the Brief Symptom Inventory-18; cancer-related pain; cognitive impairment using a validated self-report neurocognitive questionnaire; or poor health-related quality of life. Log-binomial regression estimated associations between exercise (metabolic equivalent [MET]-hours per week-1 ) and outcomes adjusting for cancer diagnosis, treatment, demographics, and baseline conditions. RESULTS The prevalence of depression at follow-up was 11.4% (95% CI, 10.6%-12.3%), anxiety 7.4% (95% CI, 6.7%-8.2%) and somatization 13.9% (95% CI, 13.0%-14.9%). Vigorous exercise was associated with lower prevalence of depression and somatization. The adjusted prevalence ratio for depression was 0.87 (95% CI, 0.72-1.05) for 3 to 6 MET hours per week-1 , 0.76 (95% CI, 0.62-0.94) for 9 to 12 MET-hours per week-1 , and 0.74 (95% CI, 0.58-0.95) for 15 to 21 MET-hours per week-1 . Compared with 0 MET hours per week-1 , 15 to 21 MET-hours per week-1 were associated with an adjusted prevalence ratio of 0.79 (95% CI, 0.62-1.00) for somatization. Vigorous exercise also was associated with less impairment in the physical functioning, general health and vitality (Ptrend < .001), emotional role limitations (Ptrend = .02), and mental health (Ptrend = .02) domains as well as higher cognitive function in the domains of task completion, organization, and working memory (P < .05 for all), but not in the domain of cancer pain. CONCLUSIONS Vigorous exercise is associated with less psychological burden and cognitive impairment in childhood cancer survivors.
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Affiliation(s)
- Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jennifer S Ford
- Department of Psychology, Hunter College, City University of New York, New York, New York
| | - Linwei Wang
- Department of Epidemiology and Public Health, British Columbia Center for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wendy Leisenring
- Clinical Research Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kevin C Oeffinger
- Duke Center for Onco-Primary Care, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Paul C Nathan
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kevin Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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Friedman DN, Tonorezos ES, Cohen P. Diabetes and Metabolic Syndrome in Survivors of Childhood Cancer. Horm Res Paediatr 2019; 91:118-127. [PMID: 30650414 PMCID: PMC6610586 DOI: 10.1159/000495698] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/21/2018] [Indexed: 12/15/2022] Open
Abstract
Endocrine complications, including diabetes and metabolic syndrome, are highly prevalent in childhood cancer survivors. These metabolic derangements may contribute to survivors' risk of excess cardiovascular morbidity and premature mortality. This review summarizes existing knowledge on risk of diabetes and metabolic syndrome among childhood cancer survivors, focusing specifically on known risk factors, potential mechanisms, and screening recommendations. Early diagnosis via standardized risk-based screening can improve long-term outcomes in this population. Additional work is needed to elucidate the mechanisms underlying these metabolic complications and to inform the design of risk-reducing interventions and optimize long-term cardiometabolic health among survivors of childhood cancer.
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Affiliation(s)
| | - Emily S. Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Paul Cohen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States,Laboratory of Molecular Metabolism, The Rockefeller University, New York, New York, United States
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