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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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de Blank PMK, Lange KR, Xing M, Mirzaei Salehabadi S, Srivastava D, Brinkman TM, Ness KK, Oeffinger KC, Neglia J, Krull KR, Nathan PC, Howell R, Turcotte LM, Leisenring W, Armstrong GT, Okcu MF, Bowers DC. Temporal changes in treatment and late mortality and morbidity in adult survivors of childhood glioma: a report from the Childhood Cancer Survivor Study. Nat Cancer 2024; 5:590-600. [PMID: 38429413 DOI: 10.1038/s43018-024-00733-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/19/2024] [Indexed: 03/03/2024]
Abstract
Pediatric glioma therapy has evolved to delay or eliminate radiation for low-grade tumors. This study examined these temporal changes in therapy with long-term outcomes in adult survivors of childhood glioma. Among 2,501 5-year survivors of glioma in the Childhood Cancer Survivor Study diagnosed 1970-1999, exposure to radiation decreased over time. Survivors from more recent eras were at lower risk of late mortality (≥5 years from diagnosis), severe/disabling/life-threatening chronic health conditions (CHCs) and subsequent neoplasms (SNs). Adjusting for treatment exposure (surgery only, chemotherapy, or any cranial radiation) attenuated this risk (for example, CHCs (1990s versus 1970s), relative risk (95% confidence interval), 0.63 (0.49-0.80) without adjustment versus 0.93 (0.72-1.20) with adjustment). Compared to surgery alone, radiation was associated with greater than four times the risk of late mortality, CHCs and SNs. Evolving therapy, particularly avoidance of cranial radiation, has improved late outcomes for childhood glioma survivors without increased risk for late recurrence.
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Affiliation(s)
- Peter M K de Blank
- The Cure Starts Now Brain Tumor Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Katharine R Lange
- Division of Pediatric Oncology, Hackensack Meridian Children's Health, Hackensack, NJ, USA
| | - Mengqi Xing
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Deokumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Tara M Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, 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
| | | | - Joseph Neglia
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Paul C Nathan
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lucie M Turcotte
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Wendy Leisenring
- Cancer Prevention and Clinical Statistics Programs, 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
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - M Fatih Okcu
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Centers, Houston, TX, USA
| | - Daniel C Bowers
- Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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3
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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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George IA, Souder B, Berkman A, Noyd DH, Jay Campbell M, Barker PCA, Roth M, Hildebrandt MAT, Oeffinger KC, McCrary AW, Landstrom AP. Obesity Predisposes Anthracycline-Treated Survivors of Childhood and Adolescent Cancers to Subclinical Cardiac Dysfunction. Pediatr Cardiol 2024:10.1007/s00246-024-03423-x. [PMID: 38456890 DOI: 10.1007/s00246-024-03423-x] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024]
Abstract
Anthracyclines are effective chemotherapeutics used in approximately 60% of pediatric cancer cases but have a well-documented risk of cardiotoxicity. Existing cardiotoxicity risk calculators do not include cardiovascular risk factors present at the time of diagnosis. The goal of this study is to leverage the advanced sensitivity of strain echocardiography to identify pre-existing risk factors for early subclinical cardiac dysfunction among anthracycline-exposed pediatric patients. We identified 115 pediatric patients with cancer who were treated with an anthracycline between 2013 and 2019. Peak longitudinal left ventricular strain was retroactively calculated on 495 surveillance echocardiograms via the TOMTEC AutoSTRAIN software. Cox proportional hazards models were employed to identify risk factors for abnormal longitudinal strain (> - 16%) following anthracycline treatment. High anthracycline dose (≥ 250 mg/m2 doxorubicin equivalents) and obesity at the time of diagnosis (BMI > 95th percentile-for-age) were both significant predictors of abnormal strain with hazard ratios of 2.79, 95% CI (1.07-7.25), and 3.85, 95% CI (1.42-10.48), respectively. Among pediatric cancer survivors, patients who are obese at the time of diagnosis are at an increased risk of sub-clinical cardiac dysfunction following anthracycline exposure. Future studies should explore the incidence of symptomatic cardiomyopathy 10-15 years post-treatment among patients with early subclinical cardiac dysfunction.
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Affiliation(s)
- Ian A George
- Duke University School of Medicine, Durham, NC, USA
| | - BriAnna Souder
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Amy Berkman
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - David H Noyd
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - M Jay Campbell
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Piers C A Barker
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Michael Roth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle A T Hildebrandt
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University and Duke Cancer Institute, Durham, NC, USA
| | - Andrew W McCrary
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
- Duke University Medical Center, Box 3090, Durham, NC, 27710, USA.
| | - Andrew P Landstrom
- Duke Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
- Duke University Medical Center, Box 2652, Durham, NC, 27710, USA.
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5
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Otth M, Kasteler R, Mulder RL, Agrusa J, Armenian SH, Barnea D, Bergeron A, Bhatt NS, Bourke SJ, Constine LS, Goutaki M, Green DM, Hennewig U, Houdouin V, Hudson MM, Kremer L, Latzin P, Ng A, Oeffinger KC, Schindera C, Skinner R, Sommer G, Srinivasan S, Stokes DC, Versluys B, Waespe N, Weiner DJ, Dietz AC, Kuehni CE. Recommendations for surveillance of pulmonary dysfunction among childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. EClinicalMedicine 2024; 69:102487. [PMID: 38420219 PMCID: PMC10900250 DOI: 10.1016/j.eclinm.2024.102487] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Childhood, adolescent, and young adult (CAYA) cancer survivors are at risk of pulmonary dysfunction. Current follow-up care guidelines are discordant. Therefore, the International Late Effects of Childhood Cancer Guideline Harmonization Group established and convened a panel of 33 experts to develop evidence-based surveillance guidelines. We critically reviewed available evidence regarding risk factors for pulmonary dysfunction, types of pulmonary function testing, and timings of surveillance, then we formulated our recommendations. We recommend that CAYA cancer survivors and healthcare providers are aware of reduced pulmonary function risks and pay vigilant attention to potential symptoms of pulmonary dysfunction, especially among survivors treated with allogeneic haematopoietic stem cell transplantation, thoracic radiotherapy, and thoracic surgery. Based on existing limited evidence and current lack of interventions, our panel recommends pulmonary function testing only for symptomatic survivors. Since scarce existing evidence informs our recommendation, we highlight the need for prospective collaborative studies to address pulmonary function knowledge gaps among CAYA cancer survivors.
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Affiliation(s)
- Maria Otth
- Department of Oncology, Haematology, Immunology, Stem Cell Transplantation and Somatic Gene Therapy, University Children's Hospital Zurich, Zurich, Switzerland
- Pediatric Hematology-Oncology Center, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Rahel Kasteler
- Department of Oncology, Haematology, Immunology, Stem Cell Transplantation and Somatic Gene Therapy, University Children's Hospital Zurich, Zurich, Switzerland
- Pediatric Hematology-Oncology Center, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
| | - Renée L. Mulder
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Jennifer Agrusa
- Department of Pediatric Hematology Oncology, C.S. Mott Children's Hospital, University of Michigan, Michigan, USA
| | | | - Dana Barnea
- Department of Hematology and Department of Oncology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anne Bergeron
- Hôpitaux Universitaires de Genève, Université de Genève, Genève, Switzerland
| | - Neel S. Bhatt
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Stephen J. Bourke
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Louis S. Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel M. Green
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ulrike Hennewig
- University Hospital of Giessen and Marburg, Pediatric Hematology and Oncology, Giessen, Germany
| | | | - Melissa M. Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Leontien Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Philipp Latzin
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Antony Ng
- Department of Paediatric Oncology, Royal Hospital for Children, Bristol, UK
| | - Kevin C. Oeffinger
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Christina Schindera
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Pediatric Oncology/Haematology, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Roderick Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and Newcastle University Centre for Cancer, Newcastle upon Tyne, UK
| | - Grit Sommer
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Saumini Srinivasan
- Division of Pulmonology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Dennis C. Stokes
- Division of Pulmonology, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Birgitta Versluys
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Nicolas Waespe
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Pediatric Hematology and Oncology, University Children's Hospital Bern, University of Bern, Bern, Switzerland
- CANSEARCH Research Platform for Paediatric Oncology and Haematology, Department of Pediatrics, Gynecology and Obstetrics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Daniel J. Weiner
- Division of Pediatric Pulmonology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Claudia E. Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Pediatric Hematology and Oncology, University Children's Hospital Bern, University of Bern, Bern, Switzerland
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6
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Bottinor W, Im C, Doody DR, Armenian SH, Arynchyn A, Hong B, Howell RM, Jacobs DR, Ness KK, Oeffinger KC, Reiner AP, Armstrong GT, Yasui Y, Chow EJ. Mortality After Major Cardiovascular Events in Survivors of Childhood Cancer. J Am Coll Cardiol 2024; 83:827-838. [PMID: 38383098 DOI: 10.1016/j.jacc.2023.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/05/2023] [Accepted: 12/07/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Adult survivors of childhood cancer are at risk for cardiovascular events. OBJECTIVES In this study, we sought to determine the risk for mortality after a major cardiovascular event among childhood cancer survivors compared with noncancer populations. METHODS All-cause and cardiovascular cause-specific mortality risks after heart failure (HF), coronary artery disease (CAD), or stroke were compared among survivors and siblings in the Childhood Cancer Survivor Study (CCSS) and participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study. Cox proportional hazard regression models were used to estimate HRs and 95% CIs between groups, adjusted for demographic and clinical factors. RESULTS Among 25,658 childhood cancer survivors (median age at diagnosis 7 years, median age at follow-up or death 38 years) and 5,051 siblings, 1,780 survivors and 91 siblings had a cardiovascular event. After HF, CAD, and stroke, 10-year all-cause mortalities were 30% (95% CI: 26%-33%), 36% (95% CI: 31%-40%), and 29% (95% CI: 24%-33%), respectively, among survivors vs 14% (95% CI: 0%-25%), 14% (95% CI: 2%-25%), and 4% (95% CI: 0%-11%) among siblings. All-cause mortality risks among childhood cancer survivors were increased after HF (HR: 7.32; 95% CI: 2.56-20.89), CAD (HR: 5.54; 95% CI: 2.37-12.93), and stroke (HR: 3.57; 95% CI: 1.12-11.37). CAD-specific mortality risk was increased (HR: 3.70; 95% CI: 1.05-13.02). Among 5,114 CARDIA participants, 345 had a major event. Although CARDIA participants were on average decades older at events (median age 57 years vs 31 years), mortality risks were similar, except that all-cause mortality after CAD was significantly increased among childhood cancer survivors (HR: 1.85; 95% CI: 1.16-2.95). CONCLUSIONS Survivors of childhood cancer represent a population at high risk for mortality after major cardiovascular events.
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Affiliation(s)
- Wendy Bottinor
- Virginia Commonwealth University, Richmond, Virginia, USA.
| | - Cindy Im
- University of Minnesota, Minneapolis, Minnesota, USA
| | - David R Doody
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | | | | | - Borah Hong
- Seattle Children's Hospital, Seattle, Washington, USA
| | | | | | - Kirsten K Ness
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | | | | | - Yutaka Yasui
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Eric J Chow
- Fred Hutchinson Cancer Center, Seattle, Washington, USA; Seattle Children's Hospital, Seattle, Washington, USA; University of Washington, Seattle, Washington, USA
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7
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Papini C, Mirzaei S. S, Xing M, Tonning Olsson I, de Blank PMK, Lange KR, Salloum R, Srivastava D, Leisenring WM, Howell RM, Oeffinger KC, Robison LL, Armstrong GT, Krull KR, Brinkman TM. Evolving therapies, neurocognitive outcomes, and functional independence in adult survivors of childhood glioma. J Natl Cancer Inst 2024; 116:288-298. [PMID: 37688569 PMCID: PMC10852618 DOI: 10.1093/jnci/djad190] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/11/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Treatment of childhood glioma has evolved to reduce radiotherapy exposure with the goal of limiting late toxicity. However, the associations between treatment changes and neurocognition, and the contribution of neurocognition and chronic health conditions to attainment of adult independence, remain unknown. METHODS Adult survivors of childhood glioma diagnosed in 1970-1999 in the Childhood Cancer Survivor Study (n = 1284; median [minimum-maximum] 30 [18-51] years of age at assessment; 22 [15-34] years from diagnosis) self-reported neurocognitive impairment and chronic health conditions. Multivariable models evaluated associations between changes in treatment exposures (surgery only, chemotherapy [with or without surgery], cranial radiation [with or without chemotherapy and/or surgery]), and neurocognitive impairment. Latent class analysis with 5 indicators (employment, independent living, assistance with routine and/or personal care needs, driver's license, marital or partner status) identified classes of functional independence. Path analysis tested associations among treatment exposures, neurocognitive impairment, chronic health conditions, and functional independence. Statistical tests were 2-sided. RESULTS Cranial radiation exposure decreased over time (51%, 1970s; 46%, 1980s; 27%, 1990s]. However, compared with siblings, survivors with any treatment exposure were at elevated risk for neurocognitive impairment, including surgery only (eg, memory: relative risk = 2.22; task efficiency: relative risk = 1.88; both P < .001). Three classes of functional independence were identified: independent (58%), moderately independent (20%), and nonindependent (22%). Cranial radiation was associated with nonindependence through impaired task efficiency (β = 0.06), sensorimotor (β = 0.06), and endocrine (β = 0.10) chronic health conditions and through the associations between these conditions and task efficiency (each β = 0.04). Sensorimotor and endocrine chronic health conditions were associated with nonindependence through memory. CONCLUSION Most long-term glioma survivors achieve adult independence. However, functional nonindependence is associated with treatment-related neurocognitive impairment and chronic health conditions.
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Affiliation(s)
- Chiara Papini
- Department of Psychology and Biobehavioral Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Sedigheh Mirzaei S.
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Mengqi Xing
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ingrid Tonning Olsson
- Department of Pediatrics, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Pediatrics, Lund University, Lund, Sweden
| | - Peter M K de Blank
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, The Cure Starts Now Brain Tumor Center, Cincinnati, OH, USA
| | - Katharine R Lange
- Divison of Pediatric Oncology, Hackensack Meridian Children’s Health, Hackensack, NJ, USA
| | - Ralph Salloum
- Pediatric Brain Tumor Program, Division of Hematology, Oncology & Bone Marrow Transplant, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Deokumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca M Howell
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | | | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kevin R Krull
- Department of Psychology and Biobehavioral Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Tara M Brinkman
- Department of Psychology and Biobehavioral Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
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8
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Vuotto SC, Wang M, Okcu MF, Bowers DC, Ullrich NJ, Ness KK, Li C, Srivastava DK, Howell RM, Gibson TM, Leisenring WM, Oeffinger KC, Robison LL, Armstrong GT, Krull KR, Brinkman TM. Neurologic morbidity and functional independence in adult survivors of childhood cancer. Ann Clin Transl Neurol 2024; 11:291-301. [PMID: 38013658 PMCID: PMC10863908 DOI: 10.1002/acn3.51951] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE To examine associations between neurologic late effects and attainment of independence in adult survivors of childhood cancer treated with central nervous system (CNS)-directed therapies. METHODS A total of 7881 survivors treated with cranial radiation therapy (n = 4051; CRT) and/or intrathecal methotrexate (n = 4193; IT MTX) ([CNS-treated]; median age [range] = 25.5 years [18-48]; time since diagnosis = 17.7 years [6.8-30.2]) and 8039 without CNS-directed therapy reported neurologic conditions including stroke, seizure, neurosensory deficits, focal neurologic dysfunction, and migraines/severe headaches. Functional independence was assessed using latent class analysis with multiple indicators (independent living, assistance with routine and personal care needs, ability to work/attend school, attainment of driver's license, marital/partner status). Multivariable regression models, adjusted for age, sex, race/ethnicity, and chronic health conditions, estimated odds ratios (OR) or relative risks (RR) for associations between neurologic morbidity, functional independence, and emotional distress. RESULTS Among CNS-treated survivors, three classes of independence were identified: (1) moderately independent, never married, and non-independent living (78.7%); (2) moderately independent, unable to drive (15.6%); and (3) non-independent (5.7%). In contrast to 50% of non-CNS-treated survivors and 60% of siblings, a fourth fully independent class of CNS-treated survivors was not identified. History of stroke (OR = 2.50, 95% CI: 1.70-3.68), seizure (OR = 9.70, 95% CI: 7.37-12.8), neurosensory deficits (OR = 2.67, 95% CI: 2.16-3.31), and focal neurologic dysfunction (OR = 3.05, 95% CI: 2.40-3.88) were associated with non-independence among CNS-treated survivors. Non-independence was associated with emotional distress symptoms. INTERPRETATION CNS-treated survivors do not attain full independence comparable to non-CNS-treated survivors or siblings. Interventions to promote independence may be beneficial for survivors with treatment-related neurological sequalae.
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Affiliation(s)
| | - Mingjuan Wang
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - M. Fatih Okcu
- Texas Children's Hospital, Baylor College of MedicineHoustonTexasUSA
| | | | - Nicole J. Ullrich
- Dana‐Farber/Boston Children's Cancer and Blood Disorders CenterBostonMassachusettsUSA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Chenghong Li
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Deo Kumar Srivastava
- Department of BiostatisticsSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | | | - Todd M. Gibson
- National Cancer InstituteDivision of Cancer Epidemiology & GeneticsBethesdaMarylandUSA
| | | | - Kevin C. Oeffinger
- Duke Univeristy School of MedicineDuke Cancer InstituteDurhamNorth CarolinaUSA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Kevin R. Krull
- Department of Psychology & Biobehavioral SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalMemphisTennesseeUSA
- Department of Psychology & Biobehavioral SciencesSt. Jude Children's Research HospitalMemphisTennesseeUSA
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9
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Meernik C, Dorfman CS, Zullig LL, Lazard AJ, Fish L, Farnan L, Nichols HB, Oeffinger KC, Akinyemiju T. Health Care Access Barriers and Self-Reported Health Among Adolescent and Young Adult Cancer Survivors. J Adolesc Young Adult Oncol 2024; 13:112-122. [PMID: 37307018 DOI: 10.1089/jayao.2023.0024] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Purpose: Adolescents and young adult (AYA) cancer survivors (15-39 years at diagnosis) are at risk for treatment-related late effects but face barriers in accessing survivorship care. We examined the prevalence of five health care access (HCA) barriers: affordability, accessibility, availability, accommodation, and acceptability. Methods: We identified AYA survivors from the University of North Carolina (UNC) Cancer Survivorship Cohort who completed a baseline questionnaire in 2010-2016. Participants had a history of cancer, were ≥18 years of age, and receiving care at a UNC oncology clinic. The sample was restricted to AYA survivors who were interviewed ≥1 year postdiagnosis. We used modified Poisson regression to estimate prevalence ratios (PRs) for the association between HCA barriers and self-reported fair or poor health, adjusted for sociodemographic and cancer characteristics. Results: The sample included 146 AYA survivors who were a median age of 39 at the time of the survey. The majority (71%)-and 92% of non-Hispanic Black survivors-reported at least one HCA barrier, including acceptability (40%), accommodation (38%), or affordability (31%). More than one-quarter of survivors (28%) reported fair or poor health. Affordability barriers (PR: 1.89, 95% confidence interval [CI]: 1.13-3.18) and acceptability barriers (PR: 1.60, 95% CI: 0.96-2.66) were associated with a higher prevalence of fair/poor health, as were the cumulative effects of multiple HCA dimensions reported as barriers. Conclusions: Barriers across multiple HCA dimensions were prevalent and associated with worse health in AYA survivors. Findings highlight the need to better understand and target specific barriers to care for diverse AYA survivors to improve their long-term health.
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Affiliation(s)
- Clare Meernik
- Department of Population Health Sciences and Duke University School of Medicine, Durham, North Carolina, USA
| | - Caroline S Dorfman
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Leah L Zullig
- Department of Population Health Sciences and Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA
| | - Allison J Lazard
- Hussman School of Journalism and Media, and University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laura Farnan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hazel B Nichols
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tomi Akinyemiju
- Department of Population Health Sciences and Duke University School of Medicine, Durham, North Carolina, USA
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10
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Wolf AMD, Oeffinger KC, Shih TYC, Walter LC, Church TR, Fontham ETH, Elkin EB, Etzioni RD, Guerra CE, Perkins RB, Kondo KK, Kratzer TB, Manassaram-Baptiste D, Dahut WL, Smith RA. Screening for lung cancer: 2023 guideline update from the American Cancer Society. CA Cancer J Clin 2024; 74:50-81. [PMID: 37909877 DOI: 10.3322/caac.21811] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/14/2023] [Indexed: 11/03/2023] Open
Abstract
Lung cancer is the leading cause of mortality and person-years of life lost from cancer among US men and women. Early detection has been shown to be associated with reduced lung cancer mortality. Our objective was to update the American Cancer Society (ACS) 2013 lung cancer screening (LCS) guideline for adults at high risk for lung cancer. The guideline is intended to provide guidance for screening to health care providers and their patients who are at high risk for lung cancer due to a history of smoking. The ACS Guideline Development Group (GDG) utilized a systematic review of the LCS literature commissioned for the US Preventive Services Task Force 2021 LCS recommendation update; a second systematic review of lung cancer risk associated with years since quitting smoking (YSQ); literature published since 2021; two Cancer Intervention and Surveillance Modeling Network-validated lung cancer models to assess the benefits and harms of screening; an epidemiologic and modeling analysis examining the effect of YSQ and aging on lung cancer risk; and an updated analysis of benefit-to-radiation-risk ratios from LCS and follow-up examinations. The GDG also examined disease burden data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms. The GDG judged that the overall evidence was moderate and sufficient to support a strong recommendation for screening individuals who meet the eligibility criteria. LCS in men and women aged 50-80 years is associated with a reduction in lung cancer deaths across a range of study designs, and inferential evidence supports LCS for men and women older than 80 years who are in good health. The ACS recommends annual LCS with low-dose computed tomography for asymptomatic individuals aged 50-80 years who currently smoke or formerly smoked and have a ≥20 pack-year smoking history (strong recommendation, moderate quality of evidence). Before the decision is made to initiate LCS, individuals should engage in a shared decision-making discussion with a qualified health professional. For individuals who formerly smoked, the number of YSQ is not an eligibility criterion to begin or to stop screening. Individuals who currently smoke should receive counseling to quit and be connected to cessation resources. Individuals with comorbid conditions that substantially limit life expectancy should not be screened. These recommendations should be considered by health care providers and adults at high risk for lung cancer in discussions about LCS. If fully implemented, these recommendations have a high likelihood of significantly reducing death and suffering from lung cancer in the United States.
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Affiliation(s)
- Andrew M D Wolf
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine and Duke Cancer Institute Center for Onco-Primary Care, Durham, North Carolina, USA
| | - Tina Ya-Chen Shih
- David Geffen School of Medicine and Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, California, USA
| | - Louise C Walter
- Department of Medicine, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Timothy R Church
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Elizabeth T H Fontham
- Health Sciences Center, School of Public Health, Louisiana State University, New Orleans, Louisiana, USA
| | - Elena B Elkin
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Ruth D Etzioni
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Carmen E Guerra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca B Perkins
- Obstetrics and Gynecology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Karli K Kondo
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
| | - Tyler B Kratzer
- Cancer Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
| | | | | | - Robert A Smith
- Early Cancer Detection Science, American Cancer Society, Atlanta, Georgia, USA
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11
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Keefe KW, Lanes A, Stratton K, Green DM, Chow EJ, Oeffinger KC, Barton S, Diller L, Yasui Y, Leisenring WM, Armstrong GT, Ginsburg ES. Assisted reproductive technology use and outcomes in childhood cancer survivors. Cancer 2024; 130:128-139. [PMID: 37732943 PMCID: PMC10841316 DOI: 10.1002/cncr.34995] [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: 01/31/2023] [Revised: 05/29/2023] [Accepted: 06/15/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Treatment exposures for childhood cancer reduce ovarian reserve. However, the success of assisted reproductive technology (ART) among female survivors is not well established. METHODS Five-year survivors of childhood cancer in the Childhood Cancer Survivor Study were linked to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System, which captures national ART outcomes. The authors assessed the live birth rate, the relative risk (RR) with 95% confidence intervals (95% CIs), and associations with treatment exposure using generalized estimating equations to account for multiple ovarian stimulations per individual. Siblings from a random sample of survivors were recruited to serve as a comparison group. RESULTS Among 9885 female survivors, 137 (1.4%; median age at diagnosis, 10 years [range, 0-20 years]; median years of follow-up after age 18 years, 11 years [range, 2-11 years]) underwent 224 ovarian stimulations using autologous or donor eggs and/or gestational carriers (157 autologous ovarian stimulation cycles, 67 donor ovarian stimulation cycles). In siblings, 33 (1.4%) underwent 51 autologous or donor ovarian stimulations. Of those who used embryos from autologous eggs without using gestational carriers, 97 survivors underwent 155 stimulations, resulting in 49 live births, for a 31.6% chance of live birth per ovarian stimulation (vs. 38.3% for siblings; p = .39) and a 43.9% chance of live birth per transfer (vs. 50.0%; p = .33). Prior treatment with cranial radiation therapy (RR, 0.44; 95% CI, 0.20-0.97) and pelvic radiation therapy (RR, 0.33; 95% CI, 0.15-0.73) resulted in a reduced chance of live birth compared with siblings. The likelihood of live birth after ART treatment in survivors was not affected by alkylator exposure (cyclophosphamide-equivalent dose, ≥8000 mg/m2 vs. none; RR, 1.04; 95% CI, 0.52-2.05). CONCLUSIONS Childhood cancer survivors are as likely to undergo treatment using ART as sibling controls. The success of ART treatment was not reduced after alkylator exposure. The results from the current study provide needed guidance on the use of ART in this population.
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Affiliation(s)
- Kimberly W Keefe
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrea Lanes
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Daniel M Green
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Eric J Chow
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | | | - Sara Barton
- Colorado Center for Reproductive Medicine, Denver, Colorado, USA
| | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | | | - Elizabeth S Ginsburg
- Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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12
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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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13
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Wilson CL, Bjornard KL, Partin RE, Kadan-Lottick NS, Nathan PC, Oeffinger KC, Hayashi RJ, Hyun G, Armstrong GT, Leisenring WM, Howell RM, Yasui Y, Dixon SB, Ehrhardt MJ, Robison LL, Ness KK. Trends in physical functioning in acute lymphoblastic leukemia and non-Hodgkin lymphoma survivors across three decades. J Cancer Surviv 2023:10.1007/s11764-023-01483-1. [PMID: 37938431 DOI: 10.1007/s11764-023-01483-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023]
Abstract
PURPOSE The impact of changes in therapy for childhood acute lymphoblastic leukemia (ALL) and non-Hodgkin lymphoma (NHL) on the prevalence of physical performance limitations and participation restrictions among survivors is unknown. We aimed to describe the prevalence of reduced function among ALL and NHL survivors by treatment era. METHODS Participants included survivors of childhood ALL and NHL, and a cohort of their siblings, participating in the Childhood Cancer Survivor Study (CCSS). Physical function was measured using questionnaire. The prevalence of reduced function was compared to siblings using generalized estimating equations, overall and stratified by treatment decade. Associations between organ system-specific chronic conditions (CTCAE v4.03) and function were also evaluated. RESULTS Among 6511 survivors (mean age 25.9 years (standard deviation 6.5)) and 4127 siblings, risk of performance limitations (15.2% vs. 12.5%, prevalence ratio [PR] = 1.5, 95%CI = 1.3-1.6), restrictions in personal care (2.0% vs. 0.6%, PR = 3.1, 95% CI = 2.0-4.8), routine activities (5.5% vs. 1.6%, PR = 3.6, 95% CI = 2.7-4.8), and work/school attendance (8.8% vs. 2.1%, PR = 4.5, 95% CI = 3.6-5.7) was increased in survivors vs. siblings. The prevalence of survivors reporting reduced function did not decrease between the 1970s and 1990s. The presence of neurological and cardiovascular conditions was associated with reduced function regardless of treatment decade. CONCLUSIONS Despite changes in therapy, the prevalence of poor physical function remained constant between the 1970s and 1990s. The CCSS clinical trial registration number is NCT01120353 (registered May 6, 2010). IMPLICATIONS FOR CANCER SURVIVORS Our findings support screening for reduced physical function so that early interventions to improve physical performance and mitigate chronic disease can be initiated.
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Affiliation(s)
- Carmen L Wilson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Kari L Bjornard
- Department of Hematology/Oncology, Riley Children's Hospital, Indianopolis, IN, USA
| | - Robyn E Partin
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nina S Kadan-Lottick
- Cancer Prevention and Control Program, Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Paul C Nathan
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Robert J Hayashi
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Geehong Hyun
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wendy M Leisenring
- Cancer Prevention and Clinical Statistics Program, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Rebecca M Howell
- Radiation Physics Department, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Stephanie B Dixon
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, 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
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- 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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14
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Belle FN, Schindera C, Ansari M, Armstrong GT, Beck‐Popovic M, Howell R, Leisenring WM, Meacham LR, Rössler J, Spycher BD, Tonorezos E, von der Weid NX, Yasui Y, Oeffinger KC, Kuehni CE. Risk factors for overweight and obesity after childhood acute lymphoblastic leukemia in North America and Switzerland: A comparison of two cohort studies. Cancer Med 2023; 12:20423-20436. [PMID: 37807946 PMCID: PMC10652345 DOI: 10.1002/cam4.6588] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 07/26/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND After childhood acute lymphoblastic leukemia (ALL), sequelae include overweight and obesity, yet with conflicting evidence. We compared the prevalence of overweight and obesity between ≥5-year ALL survivors from the North American Childhood Cancer Survivor Study (CCSS) and the Swiss Childhood Cancer Survivor Study (SCCSS) and described risk factors. METHODS We included adult childhood ALL survivors diagnosed between 1976 and 1999. We matched CCSS participants (3:1) to SCCSS participants by sex and attained age. We calculated body mass index (BMI) from self-reported height and weight for 1287 CCSS and 429 SCCSS participants; we then compared those with siblings (2034) in North America and Switzerland (678) siblings. We assessed risk factors for overweight (BMI 25-29.9 kg/m2 ) and obesity (≥30 kg/m2 ) using multinomial regression. RESULTS We found overweight and obesity significantly more common among survivors in North America when compared with survivors in Switzerland [overweight: 30%, 95% confidence interval (CI): 27-32 vs. 24%, 21-29; obesity: 29%, 27-32 vs. 7%, 5-10] and siblings (overweight: 30%, 27-32 vs. 25%, 22-29; obesity: 24%, 22-26 vs. 6%, 4-8). Survivors in North America [odds ratio (OR) = 1.24, 1.01-1.53] and Switzerland (1.27, 0.74-2.21) were slightly more often obese than siblings. Among survivors, risk factors for obesity included residency in North America (5.8, 3.7-9.0); male (1.7, 1.3-2.3); attained age (≥45 years: 5.1, 2.4-10.8); Non-Hispanic Black (3.4, 1.6-7.0); low household income (2.3, 1.4-3.5); young age at diagnosis (1.6, 1.1-2.2). Cranial radiotherapy ≥18 Gray was only a risk factor for overweight (1.4, 1.0-1.8); steroids were not associated with overweight or obesity. Interaction tests found no evidence of difference in risk factors between cohorts. CONCLUSIONS Although treatment-related risk for overweight and obesity were similar between regions, higher prevalence among survivors in North America identifies important sociodemographic drivers for informing health policy and targeted intervention trials.
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Affiliation(s)
- Fabiën N. Belle
- Childhood Cancer Research Group, Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
- Center for Primary Care and Public Health (Unisanté)University of LausanneLausanneSwitzerland
| | - Christina Schindera
- Childhood Cancer Research Group, Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
- Division of Pediatric Oncology/Hematology, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | - Marc Ansari
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Cansearch Research platform for pediatric oncology and hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and ObstetricsUniversity of GenevaGenevaSwitzerland
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalTennesseeMemphisUSA
| | - Maja Beck‐Popovic
- Pediatric Hematology‐Oncology UnitUniversity Hospital (CHUV)LausanneSwitzerland
| | - Rebecca Howell
- Department of Radiation PhysicsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | | | - Lillian R. Meacham
- Aflac Cancer CenterChildren's Healthcare of Atlanta/Emory UniversityAtlantaGeorgiaUSA
| | - Jochen Rössler
- Division of Pediatric Hematology and Oncology, University Children's Hospital BernUniversity of BernBernSwitzerland
| | - Ben D. Spycher
- Childhood Cancer Research Group, Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Emily Tonorezos
- Division of Cancer Control and Population SciencesNational Cancer InstituteRockvilleMarylandUSA
| | - Nicolas X. von der Weid
- Division of Pediatric Oncology/Hematology, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | - Yutaka Yasui
- Department of Epidemiology and Cancer ControlSt. Jude Children's Research HospitalTennesseeMemphisUSA
| | - Kevin C. Oeffinger
- Department of MedicineDuke University and Duke Cancer InstituteDurhamNorth CarolinaUSA
| | - Claudia E. Kuehni
- Childhood Cancer Research Group, Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
- Division of Pediatric Hematology and Oncology, University Children's Hospital BernUniversity of BernBernSwitzerland
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15
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Hesko C, Liu W, Srivastava D, Brinkman TM, Diller L, Gibson TM, Oeffinger KC, Leisenring WM, Howell R, Armstrong GT, Krull KR, Henderson TO. Neurocognitive outcomes in adult survivors of neuroblastoma: A report from the Childhood Cancer Survivor Study. Cancer 2023; 129:2904-2914. [PMID: 37199722 PMCID: PMC10523930 DOI: 10.1002/cncr.34847] [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: 07/01/2022] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Despite survival improvements, there is a paucity of data on neurocognitive outcomes in neuroblastoma survivors. This study addresses this literature gap. METHODS Neurocognitive impairments in survivors were compared to sibling controls from the Childhood Cancer Survivor Study (CCSS) using the CCSS Neurocognitive Questionnaire. Impaired emotional regulation, organization, task efficiency, and memory defined as scores ≥90th percentile of sibling norms. Modified Poisson regression models evaluated associations with treatment exposures, era of diagnosis, and chronic conditions. Analyses were stratified by age at diagnosis (≤1 and >1 year) as proxy for lower versus higher risk disease. RESULTS Survivors (N = 837; median [range] age, 25 [17-58] years, age diagnosed, 1 [0-21] years) were compared to sibling controls (N = 728; age, 32 [16-43] years). Survivors had higher risk of impaired task efficiency (≤1 year relative risk [RR], 1.48; 95% confidence interval [CI], 1.08-2.03; >1 year RR, 1.58; 95% CI, 1.22-2.06) and emotional regulation (≤1 year RR, 1.51; 95% CI, 1.07-2.12; >1 year RR, 1.44; 95% CI, 1.06-1.95). Impaired task efficiency associated with platinum exposure (≤1 year RR, 1.74; 95% CI, 1.01-2.97), hearing loss (≤1 year RR, 1.95; 95% CI, 1.26-3.00; >1 year RR, 1.56; 95% CI, 1.09-2.24), cardiovascular (≤1 year RR, 1.83; 95% CI, 1.15-2.89; >1 year RR, 1.74; 95% CI, 1.12-2.69), neurologic (≤1 year RR, 2.00; 95% CI, 1.32-3.03; >1 year RR, 2.29; 95% CI, 1.64-3.21), and respiratory (>1 year RR, 2.35; 95% CI, 1.60-3.45) conditions. Survivors ≤1 year; female sex (RR, 1.54; 95% CI, 1.02-2.33), cardiovascular (RR, 1.71; 95% CI, 1.08-2.70) and respiratory (RR, 1.99; 95% CI, 1.14-3.49) conditions associated impaired emotional regulation. Survivors were less likely to be employed full-time (p < .0001), graduate college (p = .035), and live independently (p < .0001). CONCLUSIONS Neuroblastoma survivors report neurocognitive impairment impacting adult milestones. Identified health conditions and treatment exposures can be targeted to improve outcomes. PLAIN LANGUAGE SUMMARY Survival rates continue to improve in patients with neuroblastoma. There is a lack of information regarding neurocognitive outcomes in neuroblastoma survivors; most studies examined survivors of leukemia or brain tumors. In this study, 837 adult survivors of childhood neuroblastoma were compared to siblings from the Childhood Cancer Survivorship Study. Survivors had a 50% higher risk of impairment with attention/processing speed (task efficiency) and emotional reactivity/frustration tolerance (emotional regulation). Survivors were less likely to reach adult milestones such as living independently. Survivors with chronic health conditions are at a higher risk of impairment. Early identification and aggressive management of chronic conditions may help mitigate the level of impairment.
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Affiliation(s)
- Caroline Hesko
- University of Vermont Children’s Hospital, Burlington, VT
| | - Wei Liu
- St. Jude Children’s Research Hospital, Memphis, TN
| | | | | | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | | | | | - Rebecca Howell
- The University of Texas MD Anderson Cancer Center, Houston, TX
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16
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Wang Y, Ronckers CM, van Leeuwen FE, Moskowitz CS, Leisenring W, Armstrong GT, de Vathaire F, Hudson MM, Kuehni CE, Arnold MA, Demoor-Goldschmidt C, Green DM, Henderson TO, Howell RM, Ehrhardt MJ, Neglia JP, Oeffinger KC, van der Pal HJH, Robison LL, Schaapveld M, Turcotte LM, Waespe N, Kremer LCM, Teepen JC. Subsequent female breast cancer risk associated with anthracycline chemotherapy for childhood cancer. Nat Med 2023; 29:2268-2277. [PMID: 37696934 PMCID: PMC10504074 DOI: 10.1038/s41591-023-02514-1] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/26/2023] [Indexed: 09/13/2023]
Abstract
Anthracycline-based chemotherapy is associated with increased subsequent breast cancer (SBC) risk in female childhood cancer survivors, but the current evidence is insufficient to support early breast cancer screening recommendations for survivors treated with anthracyclines. In this study, we pooled individual patient data of 17,903 survivors from six well-established studies, of whom 782 (4.4%) developed a SBC, and analyzed dose-dependent effects of individual anthracycline agents on developing SBC and interactions with chest radiotherapy. A dose-dependent increased SBC risk was seen for doxorubicin (hazard ratio (HR) per 100 mg m-2: 1.24, 95% confidence interval (CI): 1.18-1.31), with more than twofold increased risk for survivors treated with ≥200 mg m-2 cumulative doxorubicin dose versus no doxorubicin (HR: 2.50 for 200-299 mg m-2, HR: 2.33 for 300-399 mg m-2 and HR: 2.78 for ≥400 mg m-2). For daunorubicin, the associations were not statistically significant. Epirubicin was associated with increased SBC risk (yes/no, HR: 3.25, 95% CI: 1.59-6.63). For patients treated with or without chest irradiation, HRs per 100 mg m-2 of doxorubicin were 1.11 (95% CI: 1.02-1.21) and 1.26 (95% CI: 1.17-1.36), respectively. Our findings support that early initiation of SBC surveillance may be reasonable for survivors who received ≥200 mg m-2 cumulative doxorubicin dose and should be considered in SBC surveillance guidelines for survivors and future treatment protocols.
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Affiliation(s)
- Yuehan Wang
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Cécile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Department of Health Services Research, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
- Division of Childhood Cancer Epidemiology (EpiKiK), Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | | | | | | | - Florent de Vathaire
- Radiation Epidemiology Team, INSERM U1018, Gustave Roussy, Université Paris-Saclay, Villejuif, France
| | | | - Claudia E Kuehni
- Childhood Cancer Research Group, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Pediatric Hematology and Oncology, University Children's Hospital Bern, University of Bern, Bern, Switzerland
| | - Michael A Arnold
- Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, Aurora, CO, USA
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Charlotte Demoor-Goldschmidt
- Radiation Epidemiology Team, INSERM U1018, Gustave Roussy, Université Paris-Saclay, Villejuif, France
- Department of Pediatric Hematology and Oncology, University-Hospital of Angers, Angers, France
- Radiotherapy Department, Francois Baclesse Center, Caen, France
| | | | - Tara O Henderson
- University of Chicago Medicine Comer Children's Hospital, Chicago, IL, USA
| | - Rebecca M Howell
- University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
| | | | - Joseph P Neglia
- University of Minnesota Masonic Cancer Center, Minneapolis, MN, USA
| | | | | | | | | | - Lucie M Turcotte
- University of Minnesota Masonic Cancer Center, Minneapolis, MN, USA
| | - Nicolas Waespe
- Childhood Cancer Research Group, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Pediatric Hematology and Oncology, University Children's Hospital Bern, University of Bern, Bern, Switzerland
- CANSEARCH research platform in pediatric oncology and hematology of the University of Geneva, Geneva, Switzerland
| | - Leontien C M Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Jop C Teepen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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17
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Noyd DH, Liu Q, Yasui Y, Chow EJ, Bhatia S, Nathan PC, Landstrom AP, Tonorezos E, Casillas J, Berkman A, Ness KK, Mulrooney DA, Leisenring WM, Howell CR, Shoag J, Kirchhoff A, Howell RM, Gibson TM, Zullig LL, Armstrong GT, Oeffinger KC. Cardiovascular Risk Factor Disparities in Adult Survivors of Childhood Cancer Compared With the General Population. JACC CardioOncol 2023; 5:489-500. [PMID: 37614575 PMCID: PMC10443116 DOI: 10.1016/j.jaccao.2023.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/18/2023] [Accepted: 01/26/2023] [Indexed: 08/25/2023] Open
Abstract
Background It is unknown whether a history of childhood cancer modifies the established disparities in cardiovascular risk factors (CVRFs) observed in the general population. Objectives We sought to determine if disparities in CVRFs by race/ethnicity are similar among childhood cancer survivors compared with the general population. Methods The Childhood Cancer Survivor Study (CCSS) is a retrospective cohort with a longitudinal follow-up of 24,084 5-year survivors diagnosed between 1970 and 1999. Multivariable piecewise exponential regression estimated incidence rate ratios (IRRs) for hypertension, hyperlipidemia, diabetes, obesity, and ≥2 CVRFs by race/ethnicity. The CCSS sibling cohort and the National Health and Nutrition Examination Survey cohort were used to compare the sociodemographic-adjusted IRRs for same-race/same-ethnicity disparities. Results Non-Hispanic Black (NHB) (n = 1,092) and Hispanic (n = 1,405) survivors compared with non-Hispanic White (NHW) (n = 13,960) survivors reported a higher cumulative incidence of diabetes (8.4%, 9.7%, and 5.1%, respectively); obesity (47.2%, 48.9%, and 30.2%, respectively); multiple CVRFs (17.7%, 16.6%, and 12.3%, respectively); and, for NHB survivors, hypertension (19.5%, 13.6%, and 14.3%, respectively) by 40 years of age (P < 0.001). Controlling for sociodemographic and treatment factors compared with NHW survivors, IRRs for NHB were increased for hypertension (IRR: 1.4; 95% CI: 1.1-1.8), obesity (IRR: 1.7; 95% CI: 1.4-2.1), and multiple CVRFs (IRR: 1.6; 95% CI: 1.2-2.1). IRRs for Hispanic survivors were increased for diabetes (IRR: 1.8; 95% CI: 1.2-2.6) and obesity (IRR: 1.4; 95% CI: 1.2-1.7). The pattern of IRRs for CVRF differences was similar among CCSS sibling and National Health and Nutrition Examination Survey cohorts. Conclusions The higher burden of CVRFs among NHB and Hispanic survivors compared with NHW survivors was similar to the general population. The promotion of cardiovascular health equity is critical in this high-risk population.
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Affiliation(s)
- David H. Noyd
- Duke University Medical Center, Durham, North Carolina, USA
- The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Qi Liu
- University of Alberta, Edmonton, Canada
| | - Yutaka Yasui
- University of Alberta, Edmonton, Canada
- St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Eric J. Chow
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul C. Nathan
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Jacqueline Casillas
- University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Amy Berkman
- Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten K. Ness
- St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | | | | | | | | | | | - Rebecca M. Howell
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Leah L. Zullig
- Duke University Medical Center, Durham, North Carolina, USA
- Durham Veterans Administration Health Care System, Durham, North Carolina, USA
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18
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Dorfman CS, Shelby RA, Stalls JM, Somers TJ, Keefe FJ, Vilardaga JP, Winger JG, Mitchell K, Ehren C, Oeffinger KC. Improving Symptom Management for Survivors of Young Adult Cancer: Development of a Novel Intervention. J Adolesc Young Adult Oncol 2023; 12:472-487. [PMID: 36178972 PMCID: PMC10457621 DOI: 10.1089/jayao.2022.0100] [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] [Indexed: 11/13/2022] Open
Abstract
Purpose: Improved symptom management is a critical although unmet post-treatment need for young adult (YA) cancer survivors (aged 18-39 at diagnosis). This study aimed to develop and refine a behavioral symptom management intervention for YA survivors. Methods: Phase I: YA survivors (N = 21) and oncology providers (N = 11) completed individual interviews and an online, self-report assessment to examine symptom experiences, the need for a behavioral symptom management intervention for YAs, and perceptions about potential intervention components, structure, and format. Phase II: YA survivors (N = 10) completed user testing sessions, providing feedback on the prototype intervention materials (paper manual and mobile application), and completed an online assessment. Quantitative data were examined using descriptive statistics. Rapid qualitative analysis, a methodologically rigorous standardized approach, was used. Results: Pain, fatigue, and distress were ranked as top concerns by most YAs and providers. Phase I interviews underscored the need for a symptom management intervention for YAs. YAs and providers highlighted potential coping strategies and program format/structure suggestions (e.g., small group format) to best meet YAs' needs. A prototype intervention was developed combining the following: traditional behavioral symptom coping skills; home-based physical activity; strategies from Acceptance and Commitment Therapy and Meaning-Centered Psychotherapy; and strategies to foster self-compassion. Phase II user testing sessions highlighted strengths and suggestions for refining the prototype materials. Conclusion: Post-treatment symptoms are common for YAs. A tailored behavioral symptom management program was developed and refined with input from YAs and providers and will be examined for feasibility and acceptability in a pilot randomized controlled trial. Clinical Trial: Clinicaltrials.gov identifier NCT04035447.
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Affiliation(s)
- Caroline S. Dorfman
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca A. Shelby
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Juliann M. Stalls
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Tamara J. Somers
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Francis J. Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer Plumb Vilardaga
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joseph G. Winger
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kara Mitchell
- Duke Health and Fitness Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher Ehren
- Duke Health and Fitness Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin C. Oeffinger
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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19
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Bates JE, Shrestha S, Liu Q, Smith SA, Mulrooney DA, Leisenring W, Gibson T, Robison LL, Chow EJ, Oeffinger KC, Armstrong GT, Constine LS, Hoppe BS, Lee C, Yasui Y, Howell RM. Cardiac Substructure Radiation Dose and Risk of Late Cardiac Disease in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:3826-3838. [PMID: 37307512 PMCID: PMC10419575 DOI: 10.1200/jco.22.02320] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 06/14/2023] Open
Abstract
PURPOSE Radiation-associated cardiac disease is a major cause of morbidity/mortality among childhood cancer survivors. Radiation dose-response relationships for cardiac substructures and cardiac diseases remain unestablished. METHODS Using the 25,481 5-year survivors of childhood cancer treated from 1970 to 1999 in the Childhood Cancer Survivor Study, we evaluated coronary artery disease (CAD), heart failure (HF), valvular disease (VD), and arrhythmia. We reconstructed radiation doses for each survivor to the coronary arteries, chambers, valves, and whole heart. Excess relative rate (ERR) models and piecewise exponential models evaluated dose-response relationships. RESULTS The cumulative incidence 35 years from diagnosis was 3.9% (95% CI, 3.4 to 4.3) for CAD, 3.8% (95% CI, 3.4 to 4.2) for HF, 1.2% (95% CI, 1.0 to 1.5) for VD, and 1.4% (95% CI, 1.1 to 1.6) for arrhythmia. A total of 12,288 survivors (48.2%) were exposed to radiotherapy. Quadratic ERR models improved fit compared with linear ERR models for the dose-response relationship between mean whole heart and CAD, HF, and arrhythmia, suggesting a potential threshold dose; however, such departure from linearity was not observed for most cardiac substructure end point dose-response relationships. Mean doses of 5-9.9 Gy to the whole heart did not increase the risk of any cardiac diseases. Mean doses of 5-9.9 Gy to the right coronary artery (rate ratio [RR], 2.6 [95% CI, 1.6 to 4.1]) and left ventricle (RR, 2.2 [95% CI, 1.3 to 3.7]) increased risk of CAD, and to the tricuspid valve (RR, 5.5 [95% CI, 2.0 to 15.1]) and right ventricle (RR, 8.4 [95% CI, 3.7 to 19.0]) increased risk of VD. CONCLUSION Among children with cancer, there may be no threshold dose below which radiation to the cardiac substructures does not increase the risk of cardiac diseases. This emphasizes their importance in modern treatment planning.
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Affiliation(s)
- James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Suman Shrestha
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, AB
| | - Susan A. Smith
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Daniel A. Mulrooney
- 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
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Todd Gibson
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Louis S. Constine
- Department of Radiation Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
- Department of Pediatrics, University of Rochester, Rochester, NY
| | - Bradford S. Hoppe
- Department of Radiation Oncology, Mayo Clinic-Jacksonville, Jacksonville, FL
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Rebecca M. Howell
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
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20
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Bhatia S, Pappo AS, Acquazzino M, Allen-Rhoades WA, Barnett M, Borinstein SC, Casey R, Choo S, Chugh R, Dinner S, Ermoian R, Fair D, Federman N, Folbrecht J, Gandhi S, Germann J, Goldsby R, Hayashi R, Huang AY, Huang MS, Jacobs LA, Lee-Miller C, Link MP, Livingston JA, Lustberg M, Malogolowkin M, Oeffinger KC, Pratilas CA, Reed D, Skiles J, von Mehren M, Yeager N, Montgomery S, Hang L. Adolescent and Young Adult (AYA) Oncology, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2023; 21:851-880. [PMID: 37549914 DOI: 10.6004/jnccn.2023.0040] [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] [Indexed: 08/09/2023]
Abstract
This selection from the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology focuses on considerations for the comprehensive care of AYA patients with cancer. Compared with older adults with cancer, AYA patients have unique needs regarding treatment, fertility counseling, psychosocial and behavioral issues, and supportive care services. The complete version of the NCCN Guidelines for Adolescent and Young Adult (AYA) Oncology addresses additional aspects of caring for AYA patients, including risk factors, screening, diagnosis, and survivorship.
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Affiliation(s)
| | - Alberto S Pappo
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | | | | | | | | | - Sun Choo
- UC San Diego Moores Cancer Center
| | | | - Shira Dinner
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Douglas Fair
- Huntsman Cancer Institute at the University of Utah
| | | | | | | | | | | | - Robert Hayashi
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Alex Y Huang
- University Hospitals Rainbow Babies & Children's Hospital/Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Mary S Huang
- Dana-Farber/Brigham and Women's Cancer Center | Massachusetts General Hospital Cancer Center
| | - Linda A Jacobs
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | | | | | | | | | | | - Jodi Skiles
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center
| | | | - Nicholas Yeager
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | - Lisa Hang
- National Comprehensive Cancer Center
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21
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KC M, Fan J, Hyslop T, Hassan S, Cecchini M, Wang SY, Silber A, Leapman MS, Leeds I, Wheeler SB, Spees LP, Gross CP, Lustberg M, Greenup RA, Justice AC, Oeffinger KC, Dinan MA. Relative Burden of Cancer and Noncancer Mortality Among Long-Term Survivors of Breast, Prostate, and Colorectal Cancer in the US. JAMA Netw Open 2023; 6:e2323115. [PMID: 37436746 PMCID: PMC10339147 DOI: 10.1001/jamanetworkopen.2023.23115] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/28/2023] [Indexed: 07/13/2023] Open
Abstract
Importance Improvements in cancer outcomes have led to a need to better understand long-term oncologic and nononcologic outcomes and quantify cancer-specific vs noncancer-specific mortality risks among long-term survivors. Objective To assess absolute and relative cancer-specific vs noncancer-specific mortality rates among long-term survivors of cancer, as well as associated risk factors. Design, Setting, and Participants This cohort study included 627 702 patients in the Surveillance, Epidemiology, and End Results cancer registry with breast, prostate, or colorectal cancer who received a diagnosis between January 1, 2003, and December 31, 2014, who received definitive treatment for localized disease and who were alive 5 years after their initial diagnosis (ie, long-term survivors of cancer). Statistical analysis was conducted from November 2022 to January 2023. Main Outcomes and Measures Survival time ratios (TRs) were calculated using accelerated failure time models, and the primary outcome of interest examined was death from index cancer vs alternative (nonindex cancer) mortality across breast, prostate, colon, and rectal cancer cohorts. Secondary outcomes included subgroup mortality in cancer-specific risk groups, categorized based on prognostic factors, and proportion of deaths due to cancer-specific vs noncancer-specific causes. Independent variables included age, sex, race and ethnicity, income, residence, stage, grade, estrogen receptor status, progesterone receptor status, prostate-specific antigen level, and Gleason score. Follow-up ended in 2019. Results The study included 627 702 patients (mean [SD] age, 61.1 [12.3] years; 434 848 women [69.3%]): 364 230 with breast cancer, 118 839 with prostate cancer, and 144 633 with colorectal cancer who survived 5 years or more from an initial diagnosis of early-stage cancer. Factors associated with shorter median cancer-specific survival included stage III disease for breast cancer (TR, 0.54; 95% CI, 0.53-0.55) and colorectal cancer (colon: TR, 0.60; 95% CI, 0.58-0.62; rectal: TR, 0.71; 95% CI, 0.69-0.74), as well as a Gleason score of 8 or higher for prostate cancer (TR, 0.61; 95% CI, 0.58-0.63). For all cancer cohorts, patients at low risk had at least a 3-fold higher noncancer-specific mortality compared with cancer-specific mortality at 10 years of diagnosis. Patients at high risk had a higher cumulative incidence of cancer-specific mortality than noncancer-specific mortality in all cancer cohorts except prostate. Conclusions and Relevance This study is the first to date to examine competing oncologic and nononcologic risks focusing on long-term adult survivors of cancer. Knowledge of the relative risks facing long-term survivors may help provide pragmatic guidance to patients and clinicians regarding the importance of ongoing primary and oncologic-focused care.
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Affiliation(s)
- Madhav KC
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Jane Fan
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
| | - Terry Hyslop
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sirad Hassan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
| | - Michael Cecchini
- Section of Medical Oncology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Shi-Yi Wang
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
| | - Andrea Silber
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michael S. Leapman
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
- Department of Urology, Yale University School of Medicine, New Haven, Connecticut
| | - Ira Leeds
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Lisa P. Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Cary P. Gross
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Maryam Lustberg
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Rachel A. Greenup
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Amy C. Justice
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin C. Oeffinger
- Department of Population Health Sciences, Duke University, Durham, North Carolina
- Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Michaela A. Dinan
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
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22
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Yu AF, Moore ZR, Moskowitz CS, Liu JE, Dang CT, Ramanathan L, Oeffinger KC, Steingart RM, Schmitt AM. Association of Circulating Cardiomyocyte Cell-Free DNA With Cancer Therapy-Related Cardiac Dysfunction in Patients Undergoing Treatment for ERBB2-Positive Breast Cancer. JAMA Cardiol 2023; 8:697-702. [PMID: 37256614 PMCID: PMC10233452 DOI: 10.1001/jamacardio.2023.1229] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/07/2023] [Indexed: 06/01/2023]
Abstract
Importance Cancer therapy-related cardiac dysfunction (CTRCD) is a potentially serious cardiotoxicity of treatments for ERBB2-positive breast cancer (formerly HER2). Identifying early biomarkers of cardiotoxicity could facilitate an individualized approach to cardiac surveillance and early pharmacologic intervention. Circulating cell-free DNA (cfDNA) of cardiomyocyte origin is present during acute cardiac injury but has not been established as a biomarker of CTRCD. Objective To determine whether circulating cardiomyocyte cfDNA is associated with CTRCD in patients with ERBB2-positive breast cancer treated with anthracyclines and ERBB2-targeted therapy. Design, Setting, and Participants A prospective cohort of 80 patients with ERBB2-positive breast cancer enrolled at an academic cancer center between July 2014 and April 2016 underwent echocardiography and blood collection at baseline, after receiving anthracyclines, and at 3 months and 6 months of ERBB2-targeted therapy. Participants were treated with doxorubicin-based chemotherapy followed by trastuzumab (+/- pertuzumab). The current biomarker study includes participants with sufficient biospecimen available for analysis after anthracycline therapy. Circulating cardiomyocyte-specific cfDNA was quantified by a methylation-specific droplet digital polymerase chain reaction assay. Data for this biomarker study were collected and analyzed from June 2021 through April 2022. Main Outcomes and Measures The outcome of interest was 1-year CTRCD, defined by symptomatic heart failure or an asymptomatic decline in left ventricular ejection fraction (≥10% from baseline to less than lower limit of normal or ≥16%). Values for cardiomyocyte cfDNA and high-sensitivity cardiac troponin I (hs-cTnI) measured after patients completed treatment with anthracyclines were compared between patients who later developed CTRCD vs patients who did not using the Wilcoxon rank sum test, and the association of post-anthracycline cardiomyocyte cfDNA level with CTRCD was estimated using logistic regression. Results Of 71 patients included in this study, median (IQR) age was 50 (44-58) years, all were treated with dose-dense doxorubicin, and 48 patients underwent breast radiotherapy. Ten of 71 patients (14%) in this analysis developed CTRCD. The level of cardiomyocyte cfDNA at the post-anthracycline time point was higher in patients who subsequently developed CTRCD (median, 30.5 copies/mL; IQR, 24-46) than those who did not (median, 7 copies/mL; IQR, 2-22; P = .004). Higher cardiomyocyte cfDNA level after completion of anthracycline chemotherapy was associated with risk of CTRCD (hazard ratio, 1.02 per 1-copy/mL increase; 95% CI, 1.00-1.03; P = .046). Conclusions and Relevance This study found that higher cardiomyocyte cfDNA level after completion of anthracycline chemotherapy was associated with risk of CTRCD. Cardiomyocyte cfDNA quantification shows promise as a predictive biomarker to refine risk stratification for CTRCD among patients with breast cancer receiving cardiotoxic cancer therapy, and its use warrants further validation. Trial Registration ClinicalTrials.gov Identifier: NCT02177175.
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Affiliation(s)
- Anthony F. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Zachary R. Moore
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chaya S. Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jennifer E. Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Chau T. Dang
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Lakshmi Ramanathan
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Richard M. Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Cornell Medical College, New York, New York
| | - Adam M. Schmitt
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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23
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Noyd DH, Chen S, Bailey AM, Janitz AE, Baker AA, Beasley WH, Etzold NC, Kendrick DC, Kibbe WA, Oeffinger KC. Informatics tools to implement late cardiovascular risk prediction modeling for population management of high-risk childhood cancer survivors. Pediatr Blood Cancer 2023; 70:e30474. [PMID: 37283294 DOI: 10.1002/pbc.30474] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/04/2023] [Accepted: 05/17/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Clinical informatics tools to integrate data from multiple sources have the potential to catalyze population health management of childhood cancer survivors at high risk for late heart failure through the implementation of previously validated risk calculators. METHODS The Oklahoma cohort (n = 365) harnessed data elements from Passport for Care (PFC), and the Duke cohort (n = 274) employed informatics methods to automatically extract chemotherapy exposures from electronic health record (EHR) data for survivors 18 years old and younger at diagnosis. The Childhood Cancer Survivor Study (CCSS) late cardiovascular risk calculator was implemented, and risk groups for heart failure were compared to the Children's Oncology Group (COG) and the International Guidelines Harmonization Group (IGHG) recommendations. Analysis within the Oklahoma cohort assessed disparities in guideline-adherent care. RESULTS The Oklahoma and Duke cohorts both observed good overall concordance between the CCSS and COG risk groups for late heart failure, with weighted kappa statistics of .70 and .75, respectively. Low-risk groups showed excellent concordance (kappa > .9). Moderate and high-risk groups showed moderate concordance (kappa .44-.60). In the Oklahoma cohort, adolescents at diagnosis were significantly less likely to receive guideline-adherent echocardiogram surveillance compared with survivors younger than 13 years old at diagnosis (odds ratio [OD] 0.22; 95% confidence interval [CI]: 0.10-0.49). CONCLUSIONS Clinical informatics tools represent a feasible approach to leverage discrete treatment-related data elements from PFC or the EHR to successfully implement previously validated late cardiovascular risk prediction models on a population health level. Concordance of CCSS, COG, and IGHG risk groups using real-world data informs current guidelines and identifies inequities in guideline-adherent care.
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Affiliation(s)
- David H Noyd
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma, USA
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma, USA
| | - Anna M Bailey
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma, USA
| | - Amanda E Janitz
- Department of Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma, USA
| | - Ashley A Baker
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma, USA
| | - William H Beasley
- Department of Pediatrics, The University of Oklahoma Health Sciences Center, College of Medicine, Oklahoma City, Oklahoma, USA
| | - Nancy C Etzold
- Biostatistics and Epidemiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - David C Kendrick
- Department of Medical Informatics, The University of Oklahoma Health Sciences Center, Tulsa, Oklahoma, USA
| | - Warren A Kibbe
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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24
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Dieffenbach BV, Murphy AJ, Liu Q, Ramsey DC, Geiger EJ, Diller LR, Howell RM, Oeffinger KC, Robison LL, Yasui Y, Armstrong GT, Chow EJ, Weil BR, Weldon CB. Cumulative burden of late, major surgical intervention in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study (CCSS) cohort. Lancet Oncol 2023; 24:691-700. [PMID: 37182536 PMCID: PMC10348667 DOI: 10.1016/s1470-2045(23)00154-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/15/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Multimodal cancer therapy places childhood cancer survivors at increased risk for chronic health conditions, subsequent malignancies, and premature mortality as they age. We aimed to estimate the cumulative burden of late (>5 years from cancer diagnosis), major surgical interventions among childhood cancer survivors, compared with their siblings, and to examine associations between specific childhood cancer treatments and the burden of late surgical interventions. METHODS We analysed data from the Childhood Cancer Survivor Study (CCSS), a retrospective cohort study with longitudinal prospective follow-up of 5-year survivors of childhood cancer (diagnosed before age 21 years) treated at 31 institutions in the USA, with a comparison group of nearest-age siblings of survivors selected by simple random sampling. The primary outcome was any self-reported late, major surgical intervention (defined as any anaesthesia-requiring operation) occurring 5 years or more after the primary cancer diagnosis. The cumulative burden was assessed with mean cumulative counts (MCC) of late, major surgical interventions. Piecewise exponential regression models with calculation of adjusted rate ratios (RRs) evaluated associations between treatment exposures and late, major surgical interventions. FINDINGS Between Jan 1, 1970, and Dec 31, 1999, 25 656 survivors were diagnosed (13 721 male, 11 935 female; median follow-up 21·8 years [IQR 16·5-28·4]; median age at diagnosis 6·1 years [3·0-12·4]); 5045 nearest-age siblings were also included as a comparison group. Survivors underwent 28 202 late, major surgical interventions and siblings underwent 4110 late, major surgical interventions. The 35-year MCC of a late, major surgical intervention was 206·7 per 100 survivors (95% CI 202·7-210·8) and 128·9 per 100 siblings (123·0-134·7). The likelihood of a late, major surgical intervention was higher in survivors versus siblings (adjusted RR 1·8, 95% CI 1·7-1·9) and in female versus male survivors (1·4; 1·4-1·5). Survivors diagnosed in the 1990s (adjusted RR 1·4, 95% CI 1·3-1·5) had an increased likelihood of late surgery compared with those diagnosed in the 1970s. Survivors received late interventions more frequently than siblings in most anatomical regions or organ systems, including CNS (adjusted RR 16·9, 95% CI 9·4-30·4), endocrine (6·7, 5·2-8·7), cardiovascular (6·6, 5·2-8·3), respiratory (5·3, 3·4-8·2), spine (2·4, 1·8-3·2), breast (2·1, 1·7-2·6), renal or urinary (2·0, 1·5-2·6), musculoskeletal (1·5, 1·4-1·7), gastrointestinal (1·4, 1·3-1·6), and head and neck (1·2, 1·1-1·4) interventions. Survivors of Hodgkin lymphoma (35-year MCC 333·3 [95% CI 320·1-346·6] per 100 survivors), Ewing sarcoma (322·9 [294·5-351·3] per 100 survivors), and osteosarcoma (269·6 [250·1-289·2] per 100 survivors) had the highest cumulative burdens of late, major surgical interventions. Locoregional surgery or radiotherapy cancer treatment were associated with undergoing late surgical intervention in the same body region or organ system. INTERPRETATION Childhood cancer survivors have a significant burden of late, major surgical interventions, a late effect that has previously been poorly quantified. Survivors would benefit from regular health-care evaluations aiming to anticipate impending surgical issues and to intervene early in the disease course when feasible. FUNDING US National Institutes of Health, US National Cancer Institute, American Lebanese Syrian Associated Charities, and St Jude Children's Research Hospital.
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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 Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Andrew J Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Duncan C Ramsey
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Erik J Geiger
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Leslie L Robison
- 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
| | - Gregory T Armstrong
- 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 Center, Seattle, WA, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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25
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Oeffinger KC. Care of Cancer Survivors: Special Issues for Prostate Cancer Survivors. FP Essent 2023; 529:19-22. [PMID: 37307153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In the United States, prostate cancer is the most common nonskin cancer in men. Approximately 12.6% of US men will be diagnosed with this cancer in their lifetimes. Although the overall 5-year relative survival rate is high (96.8%), ethnic and racial disparities have been shown to affect survival. There also are genetic risks. If the family history of the patient includes familial cancers, the patient and family members should be referred for genetic counseling and testing for cancer-associated sequence variants. Prostate cancer treatments have significant long-term effects. After radical prostatectomy, 27% to 29% of patients experience urinary incontinence and 66% to 70% have erectile dysfunction. These effects also can occur after radiation therapy, though at lower rates. Mild urinary incontinence can be managed with incontinence pads. The most effective treatments are artificial urinary sphincter implantation and urethral sling procedure. Urinary incontinence after radiation therapy tends to decrease over time. Symptoms of urinary urgency or nocturia can be managed with anticholinergic drugs. Erectile dysfunction typically is managed with oral phosphodiesterase type 5 inhibitors and/or vacuum pump erectile devices. Androgen deprivation therapy increases cardiovascular risk by increasing insulin resistance and blood pressure. This therapy also is associated with osteoporosis, so patients with nonmetastatic cancer and one or more risk factors for fracture should be offered fracture risk assessment and bone mineral density testing.
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Affiliation(s)
- Kevin C Oeffinger
- Department of Family Medicine and Community Health - Duke University School of Medicine, DUMC 2914 Durham, NC 27710
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26
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Cai CR, Cornelius S, Demedis J, Hagen AM, Abbey-Lambertz M, Armstrong GT, Oeffinger KC, Syrjala KL, Taylor SL, Yi JC, Chow EJ. Experiences of adult survivors of childhood cancer in a randomized cardiovascular health promotion trial: a qualitative report from the Childhood Cancer Survivor Study. J Cancer Surviv 2023:10.1007/s11764-023-01406-0. [PMID: 37253902 PMCID: PMC10228426 DOI: 10.1007/s11764-023-01406-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/17/2023] [Indexed: 06/01/2023]
Abstract
PURPOSE To better understand preferences and attitudes that adult-aged survivors of childhood cancer have toward survivorship care plans (SCP) and related SCP-based counseling. METHODS Semi-structured qualitative interviews were conducted with 20 survivors participating in the Childhood Cancer Survivor Study who were at increased risk for cardiovascular disease secondary to their original cancer treatment. All participants were part of a larger randomized clinical trial (NCT03104543) testing the efficacy of an SCP-based counseling intervention with goal-setting designed to improve control of cardiovascular risk factors (i.e., hypertension, dyslipidemia, diabetes). A primarily deductive thematic analysis methodology guided interpretation; coded interview segments were grouped into primary themes of facilitators, barriers, suggestions, and positive sentiments. RESULTS Participants described benefits of the intervention including facilitation of accountability, goal-setting, and increased knowledge of their health. Many participants also noted improved knowledge of their cancer treatment and subsequent risks, and they were interested in sharing this information with their primary care provider. However, several participants were disappointed when they did not achieve their goals or felt that they had low motivation. Participants generally wanted increased flexibility in the intervention, whether in the duration, frequency, or method of delivery. CONCLUSIONS The SCP-based intervention was generally well-received by those interviewed and appears promising for promoting goal-setting and accountability as part of an SCP-based intervention to improve control of cardiovascular risk factors. IMPLICATIONS FOR CANCER SURVIVORS Many survivors are at risk for cardiovascular disease or other potentially modifiable effects of their treatment. SCP-based interventions may facilitate improved control of these late effects.
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Affiliation(s)
- Casey R Cai
- School of Medicine, The University of Texas Southwestern Medical Center, Dallas, TX, USA
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Shelby Cornelius
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jenna Demedis
- Department of Pediatrics, University of Colorado, Children's Hospital Colorado, Denver, CO, USA
| | - Anna M Hagen
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Mark Abbey-Lambertz
- Department of Radiation-Oncology, University of Washington, Seattle, WA, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Karen L Syrjala
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Sarah L Taylor
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jean C Yi
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Eric J Chow
- Public Health Sciences and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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27
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Esbenshade AJ, Lu L, Friedman DL, Oeffinger KC, Armstrong GT, Krull KR, Neglia JP, Leisenring WM, Howell R, Partin R, Sketch A, Robison LL, Ness KK. Accumulation of Chronic Disease Among Survivors of Childhood Cancer Predicts Early Mortality. J Clin Oncol 2023:JCO2202240. [PMID: 37216619 DOI: 10.1200/jco.22.02240] [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: 10/09/2022] [Revised: 03/07/2023] [Accepted: 04/05/2023] [Indexed: 05/24/2023] Open
Abstract
PURPOSE Cancer survivors develop cancer and treatment-related morbidities at younger than normal ages and are at risk for early mortality, suggestive of an aging phenotype. The Cumulative Illness Rating Scale for Geriatrics (CIRS-G) is specifically designed to describe the accumulation of comorbidities over time with estimates of severity such as total score (TS) which is a sum of possible conditions weighted by severity. These severity scores can then be used to predict future mortality. METHODS CIRS-G scores were calculated in cancer survivors and their siblings from Childhood Cancer Survivor Study cohort members from two time points 19 years apart and members of the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004. CIRS-G metrics were analyzed using Cox proportional hazards regression to determine subsequent mortality risk. RESULTS In total, 14,355 survivors with a median age of 24 (IQR, 18-30) years and 4,022 siblings with a median age of 26 (IQR, 19-33) years provided baseline data; 6,138 survivors and 1,801 siblings provided follow-up data. Cancer survivors had higher median baseline TS than siblings at baseline (5.75 v 3.44) and follow-up (7.76 v 4.79), all P < .01. The mean increase in TS from baseline to follow-up was significantly steeper in cancer survivors (2.89 males and 3.18 females) vs. siblings (1.79 males and 1.69 females) and NHANES population (2.0 males and 1.94 females), all P < .01. Every point increase in baseline TS increased hazard for death by 9% (95% CI, 8 to 10) among survivors. CONCLUSION Application of a geriatric rating scale to characterize disease supports the hypothesis that morbidity accumulation is accelerated in young adult survivors of childhood cancer when compared with siblings and the general population.
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Affiliation(s)
- Adam J Esbenshade
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Lu Lu
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Debra L Friedman
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
- Vanderbilt-Ingram Cancer Center, Nashville, TN
| | | | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN
| | - Joseph P Neglia
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Wendy M Leisenring
- Clincal Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Rebecca Howell
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, TX
| | - Robyn Partin
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Amy Sketch
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
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28
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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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29
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Weil BR, Murphy AJ, Liu Q, Howell RM, Smith SA, Weldon CB, Mullen EA, Madenci AL, Leisenring WM, Neglia JP, Turcotte LM, Oeffinger KC, Termuhlen AM, Mostoufi-Moab S, Levine JM, Krull KR, Yasui Y, Robison LL, Armstrong GT, Chow EJ, Armenian SH. Late Health Outcomes Among Survivors of Wilms Tumor Diagnosed Over Three Decades: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:2638-2650. [PMID: 36693221 PMCID: PMC10414738 DOI: 10.1200/jco.22.02111] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 09/21/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To evaluate long-term morbidity and mortality among unilateral, nonsyndromic Wilms tumor (WT) survivors according to conventional treatment regimens. METHODS Cumulative incidence of late mortality (≥ 5 years from diagnosis) and chronic health conditions (CHCs) were evaluated in WT survivors from the Childhood Cancer Survivor Study. Outcomes were evaluated by treatment, including nephrectomy combined with vincristine and actinomycin D (VA), VA + doxorubicin + abdominal radiotherapy (VAD + ART), VAD + ART + whole lung radiotherapy, or receipt of ≥ 4 chemotherapy agents. RESULTS Among 2,008 unilateral WT survivors, 142 deaths occurred (standardized mortality ratio, 2.9, 95% CI, 2.5 to 3.5; 35-year cumulative incidence of death, 7.8%, 95% CI, 6.3 to 9.2). The 35-year cumulative incidence of any grade 3-5 CHC was 34.1% (95% CI, 30.7 to 37.5; rate ratio [RR] compared with siblings 3.0, 95% CI, 2.6 to 3.5). Survivors treated with VA alone had comparable risk for all-cause late mortality relative to the general population (standardized mortality ratio, 1.0; 95% CI, 0.5 to 1.7) and modestly increased risk for grade 3-5 CHCs compared with siblings (RR, 1.5; 95% CI, 1.1 to 2.0), but remained at increased risk for intestinal obstruction (RR, 9.4; 95% CI, 3.9 to 22.2) and kidney failure (RR, 11.9; 95% CI, 4.2 to 33.6). Magnitudes of risk for grade 3-5 CHCs, including intestinal obstruction, kidney failure, premature ovarian insufficiency, and heart failure, increased by treatment group intensity. CONCLUSION With approximately 40% of patients with newly diagnosed WT currently treated with VA alone, the burden of late mortality/morbidity in future decades is projected to be lower than that for survivors from earlier eras. Nevertheless, the risk of late effects such as intestinal obstruction and kidney failure was elevated across all treatment groups, and there was a dose-dependent increase in risk for all grade 3-5 CHCs by treatment group intensity.
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Affiliation(s)
- Brent R. Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Andrew J. Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - 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
| | - Christopher B. Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Elizabeth A. Mullen
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Arin L. Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Wendy M. Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Joseph P. Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Lucie M. Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | | | - Amanda M. Termuhlen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope, Duarte, CA
- Department of Pediatrics, City of Hope, Duarte, CA
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Noyd DH, Janitz AE, Baker AA, Beasley WH, Etzold NC, Kendrick DC, Oeffinger KC. Rural, Large Town, and Urban Differences in Optimal Subspecialty Follow-up and Survivorship Care Plan Documentation among Childhood Cancer Survivors. Cancer Epidemiol Biomarkers Prev 2023; 32:634-641. [PMID: 36827210 DOI: 10.1158/1055-9965.epi-22-0966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 09/08/2022] [Revised: 11/14/2022] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Children with cancer from rural and nonurban areas face unique challenges. Health equity for this population requires attention to geographic disparities in optimal survivorship-focused care. METHODS The Oklahoma Childhood Cancer Survivor Cohort was based on all patients reported to the institutional cancer registry and ≤ 18 years old at diagnosis between January 1, 2005, and September 24, 2014. Suboptimal follow-up was defined as no completed oncology-related clinic visit five to 7 years after their initial diagnosis (survivors were 7-25 years old at end of the follow-up period). The primary predictor of interest was rurality. RESULTS Ninety-four (21%) of the 449 eligible survivors received suboptimal follow-up. There were significant differences (P = 0.01) as 36% of survivors from large towns (n = 28/78) compared with 21% (n = 20/95) and 17% (n = 46/276) of survivors from small town/isolated rural and urban areas received suboptimal follow-up, respectively. Forty-five percent of adolescents at diagnosis were not seen in the clinic compared with 17% of non-adolescents (P < 0.01). An adjusted risk ratio of 2.2 (95% confidence interval, 1.5, 3.2) was observed for suboptimal follow-up among survivors from large towns, compared with survivors from urban areas. Seventy-three percent of survivors (n = 271/369) had a documented survivorship care plan with similar trends by rurality. CONCLUSIONS Survivors from large towns and those who were adolescents at the time of diagnosis were more likely to receive suboptimal follow-up care compared with survivors from urban areas and those diagnosed younger than thirteen. IMPACT Observed geographic disparities in survivorship care will inform interventions to promote equitable care for survivors from nonurban areas.
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Affiliation(s)
- David H Noyd
- Department of Pediatrics, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Department of Medical Informatics, The University of Oklahoma School of Community Medicine, Oklahoma City, Oklahoma
| | - Amanda E Janitz
- Department of Epidemiology and Biostatistics, College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Ashley A Baker
- Department of Pediatrics, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - William H Beasley
- Department of Pediatrics, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Nancy C Etzold
- The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - David C Kendrick
- Department of Medical Informatics, The University of Oklahoma School of Community Medicine, Oklahoma City, Oklahoma
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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31
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Wu NL, Chen Y, Dieffenbach BV, Ehrhardt MJ, Hingorani S, Howell RM, Jefferies JL, Mulrooney DA, Oeffinger KC, Robison LL, Weil BR, Yuan Y, Yasui Y, Hudson MM, Leisenring WM, Armstrong GT, Chow EJ. Development and Validation of a Prediction Model for Kidney Failure in Long-Term Survivors of Childhood Cancer. J Clin Oncol 2023; 41:2258-2268. [PMID: 36795981 PMCID: PMC10448933 DOI: 10.1200/jco.22.01926] [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: 08/23/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 02/18/2023] Open
Abstract
PURPOSE Kidney failure is a rare but serious late effect following treatment for childhood cancer. We developed a model using demographic and treatment characteristics to predict individual risk of kidney failure among 5-year survivors of childhood cancer. METHODS Five-year survivors from the Childhood Cancer Survivor Study (CCSS) without history of kidney failure (n = 25,483) were assessed for subsequent kidney failure (ie, dialysis, kidney transplantation, or kidney-related death) by age 40 years. Outcomes were identified by self-report and linkage with the Organ Procurement and Transplantation Network and the National Death Index. A sibling cohort (n = 5,045) served as a comparator. Piecewise exponential models accounting for race/ethnicity, age at diagnosis, nephrectomy, chemotherapy, radiotherapy, congenital genitourinary anomalies, and early-onset hypertension estimated the relationships between potential predictors and kidney failure, using area under the curve (AUC) and concordance (C) statistic to evaluate predictive power. Regression coefficient estimates were converted to integer risk scores. The St Jude Lifetime Cohort Study and the National Wilms Tumor Study served as validation cohorts. RESULTS Among CCSS survivors, 204 developed late kidney failure. Prediction models achieved an AUC of 0.65-0.67 and a C-statistic of 0.68-0.69 for kidney failure by age 40 years. Validation cohort AUC and C-statistics were 0.88/0.88 for the St Jude Lifetime Cohort Study (n = 8) and 0.67/0.64 for the National Wilms Tumor Study (n = 91). Risk scores were collapsed to form statistically distinct low- (n = 17,762), moderate- (n = 3,784), and high-risk (n = 716) groups, corresponding to cumulative incidences in CCSS of kidney failure by age 40 years of 0.6% (95% CI, 0.4 to 0.7), 2.1% (95% CI, 1.5 to 2.9), and 7.5% (95% CI, 4.3 to 11.6), respectively, compared with 0.2% (95% CI, 0.1 to 0.5) among siblings. CONCLUSION Prediction models accurately identify childhood cancer survivors at low, moderate, and high risk for late kidney failure and may inform screening and interventional strategies.
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Affiliation(s)
- Natalie L. Wu
- Division of Oncology, Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, Oakland, CA
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Yan Chen
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - Matthew J. Ehrhardt
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Sangeeta Hingorani
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Rebecca M. Howell
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John L. Jefferies
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Brent R. Weil
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Yan Yuan
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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32
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Dixon SB, Liu Q, Chow EJ, Oeffinger KC, Nathan PC, Howell RM, Leisenring WM, Ehrhardt MJ, Ness KK, Krull KR, Mertens AC, Hudson MM, Robison LL, Yasui Y, Armstrong GT. Specific causes of excess late mortality and association with modifiable risk factors among survivors of childhood cancer: a report from the Childhood Cancer Survivor Study cohort. Lancet 2023; 401:1447-1457. [PMID: 37030315 PMCID: PMC10149583 DOI: 10.1016/s0140-6736(22)02471-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/15/2022] [Accepted: 11/22/2022] [Indexed: 04/10/2023]
Abstract
BACKGROUND 5-year survival after childhood cancer does not fully describe life-years lost due to childhood cancer because there are a large number of deaths occurring beyond 5-years (late mortality) related to cancer and cancer treatment. Specific causes of health-related (non-recurrence, non-external) late mortality and risk reduction through modifiable lifestyle and cardiovascular risk factors are not well described. Through using a well-characterised cohort of 5-year survivors of the most common childhood cancers, we evaluated specific health-related causes of late mortality and excess deaths compared with the general US population and identified targets to reduce future risk. METHODS In this multi-institutional, hospital-based, retrospective cohort study, late mortality (death ≥5 years from diagnosis) and specific causes of death were evaluated in 34 230 5-year survivors of childhood cancer diagnosed at an age younger than 21 years from 1970 to 1999 at 31 institutions in the USA and Canada; median follow-up from diagnosis was 29 years (range 5-48) in the Childhood Cancer Survivor Study. Demographic, self-reported modifiable lifestyle (ie, smoking, alcohol, physical activity, and BMI) and cardiovascular risk factors (ie, hypertension, diabetes, and dyslipidaemia) associated with health-related mortality (which excludes death from primary cancer and external causes and includes death from late effects of cancer therapy) were evaluated. FINDINGS 40-year cumulative all-cause mortality was 23·3% (95% CI 22·7-24·0), with 3061 (51·2%) of 5916 deaths from health-related causes. Survivors 40 years or more from diagnosis experienced 131 excess health-related deaths per 10 000 person-years (95% CI 111-163), including those due to the top three causes of health-related death in the general population: cancer (absolute excess risk per 10 000 person-years 54, 95% CI 41-68), heart disease (27, 18-38), and cerebrovascular disease (10, 5-17). Healthy lifestyle and absence of hypertension and diabetes were each associated with a 20-30% reduction in health-related mortality independent of other factors (all p values ≤0·002). INTERPRETATION Survivors of childhood cancer are at excess risk of late mortality even 40 years from diagnosis, due to many of the leading causes of death in the US population. Modifiable lifestyle and cardiovascular risk factors associated with reduced risk for late mortality should be part of future interventions. FUNDING US National Cancer Institute and the American Lebanese Syrian Associated Charities.
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Affiliation(s)
- Stephanie B Dixon
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA.
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Eric J Chow
- Cancer Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Paul C Nathan
- Division of Hematology and Oncology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Rebecca M Howell
- Radiation Physics Department, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Wendy M Leisenring
- Cancer Prevention, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Clinical Statistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Matthew J Ehrhardt
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K Ness
- Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin R Krull
- Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA; Psychology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Ann C Mertens
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Melissa M Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
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Check DK, Jones KF, Fish LJ, Dinan MA, Dunbar TK, Farley S, Ma J, Merlin JS, O'Regan A, Oeffinger KC. Clinician Perspectives on Managing Chronic Pain After Curative-Intent Cancer Treatment. JCO Oncol Pract 2023; 19:e484-e491. [PMID: 36595729 PMCID: PMC10530392 DOI: 10.1200/op.22.00410] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/19/2022] [Accepted: 11/04/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Among cancer survivors who have completed curative-intent treatment, the high prevalence and adverse consequences of chronic pain are well documented. Yet, research on clinicians' experiences with and perspectives on managing chronic pain among cancer survivors is critically lacking. METHODS We conducted semistructured interviews with 17 clinicians (six oncology, three palliative care, and eight primary care) affiliated with an academic medical center. Interview questions addressed clinicians' experiences with and perspectives on managing chronic pain (with or without opioid therapy) during the transition from active treatment to survivorship. A multidisciplinary team conducted content analysis of interview transcripts to identify and refine themes related to current practices and challenges in managing chronic pain in this context. RESULTS Overall, clinicians perceived chronic pain to be relatively uncommon among cancer survivors. Identified challenges included a lack of clarity about which clinician (or clinicians) are best positioned to manage chronic pain among cancer survivors, and (relatedly) complexities introduced by long-term opioid management, with many clinicians describing this practice as outside their skill set. Additionally, although most clinicians recognized chronic pain as a biopsychosocial phenomenon, they described challenges with effectively managing psychosocial stressors, including difficulty accessing mental or behavioral health services for cancer survivors. CONCLUSION Discovered challenges highlight unmet needs related to cancer survivor-clinician communication about chronic pain and the absence of a chronic pain management home for cancer survivors, including those requiring long-term opioid therapy. Research evaluating routine pain monitoring and accessible, tailored models of multimodal pain care in survivorship may help to address these challenges.
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Affiliation(s)
- Devon K. Check
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke Cancer Institute, Durham, NC
| | - Katie F. Jones
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA
| | - Laura J. Fish
- Duke Cancer Institute, Durham, NC
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, NC
| | - Michaela A. Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, CT
| | - T. Kayla Dunbar
- Doctor of Osteopathic Medicine Program, Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | | | - Jessica Ma
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jessica S. Merlin
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amy O'Regan
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Kevin C. Oeffinger
- Duke Cancer Institute, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
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34
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Fayanju OM, Oyekunle T, Thomas SM, Ingraham KL, Fish LJ, Greenup RA, Oeffinger KC, Zafar SY, Hyslop T, Hwang ES, Patierno SR, Barrett NJ. Modifiable patient-reported factors associated with cancer-screening knowledge and participation in a community-based health assessment. Am J Surg 2023; 225:617-629. [PMID: 36411107 PMCID: PMC10085670 DOI: 10.1016/j.amjsurg.2022.10.059] [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: 08/25/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND We sought to identify modifiable factors associated with cancer screening in a community-based health assessment. METHODS 24 organizations at 47 community events in central North Carolina distributed a 91-item survey from April-December 2017. Responses about (1) interest in disease prevention, (2) lifestyle choices (e.g., diet, tobacco), and (3) perceptions of primary care access/quality were abstracted to examine their association with self-reported screening participation and knowledge about breast, prostate, and colorectal cancer. RESULTS 2135/2315 participants (92%; 38.5% White, 38% Black, 9.9% Asian) completed screening questions. >70% of screen-eligible respondents reported guideline-concordant screening. Healthy dietary habits were associated with greater knowledge about breast and colorectal cancer screening; reporting negative attitudes about and barriers to healthcare were associated with less breast, prostate, and colorectal cancer screening. Having a place to seek medical care (a proxy for primary care access) was independently associated with being ∼5 times as likely to undergo colorectal screening (OR 4.66, 95% CI 1.58-13.79, all p < 0.05). CONCLUSIONS In this diverse, community-based sample, modifiable factors were associated with screening engagement, highlighting opportunities for behavioral intervention.
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Affiliation(s)
- Oluwadamilola M Fayanju
- Department of Surgery, Duke University Medical Center, Box 3513, Durham, NC, 27710, USA; Duke Cancer Institute, Durham, NC, 27710, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA; Duke Forge, Duke University, Durham, NC, 27710, USA; Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.
| | - Taofik Oyekunle
- Duke Cancer Institute, Durham, NC, 27710, USA; Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Box 2717, Durham, NC, 27710, USA
| | | | - Laura J Fish
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Family Medicine and Community Health, Duke University Medical Center, Box 2914, Durham, NC, 27710, USA
| | - Rachel A Greenup
- Department of Surgery, Duke University Medical Center, Box 3513, Durham, NC, 27710, USA; Duke Cancer Institute, Durham, NC, 27710, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA; Duke Margolis Center for Health Policy, Duke University, Durham, NC, 27708, USA
| | - Kevin C Oeffinger
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Medicine, Duke University Medical Center, Box 3893, Durham, NC, 27710, USA
| | - S Yousuf Zafar
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Durham, NC, 27701, USA; Duke Margolis Center for Health Policy, Duke University, Durham, NC, 27708, USA; Department of Medicine, Duke University Medical Center, Box 3893, Durham, NC, 27710, USA; Change Healthcare, 216 Centerview Dr #300, Nashville, TN, 37219, USA
| | - Terry Hyslop
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Biostatistics and Bioinformatics, Duke University Medical Center, Box 2717, Durham, NC, 27710, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, Box 3513, Durham, NC, 27710, USA; Duke Cancer Institute, Durham, NC, 27710, USA
| | - Steven R Patierno
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Medicine, Duke University Medical Center, Box 3893, Durham, NC, 27710, USA
| | - Nadine J Barrett
- Duke Cancer Institute, Durham, NC, 27710, USA; Department of Family Medicine and Community Health, Duke University Medical Center, Box 2914, Durham, NC, 27710, USA; Duke Clinical and Translation Science Institute, Duke University School of Medicine, Durham, NC, 27710, USA
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Papini C, Fayad AA, Wang M, Schulte FSM, Huang IC, Chang YP, Howell RM, Srivastava D, Leisenring WM, Armstrong GT, Gibson TM, Robison LL, Oeffinger KC, Krull KR, Brinkman TM. Emotional, behavioral, and physical health consequences of loneliness in young adult survivors of childhood cancer: Results from the Childhood Cancer Survivor Study. Cancer 2023; 129:1117-1128. [PMID: 36645710 PMCID: PMC9998368 DOI: 10.1002/cncr.34633] [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: 08/09/2022] [Revised: 10/27/2022] [Accepted: 12/01/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Young adults in the general population are at risk of experiencing loneliness, which has been associated with physical and mental health morbidities. The prevalence and consequences of loneliness in young adult survivors of childhood cancer remain unknown. METHODS A total of 9664 young adult survivors of childhood cancer (median age at diagnosis 10.5 years [interquartile range (IQR), 5-15], 27.1 years at baseline [IQR, 23-32]) and 2221 siblings enrolled in the Childhood Cancer Survivor Study completed a self-reported survey question assessing loneliness on the Brief Symptom Inventory-18 at baseline and follow-up (median follow-up, 6.6 years). Multivariable models evaluated the prevalence of loneliness at baseline only, follow-up only, and baseline + follow-up, and its associations with emotional distress, health behaviors, and chronic conditions at follow-up. RESULTS Survivors were more likely than siblings to report loneliness at baseline + follow-up (prevalence ratio [PR] 2.2; 95% confidence interval [CI], 1.7-3.0) and at follow-up only (PR, 1.4; 95% CI, 1.1-1.7). Loneliness at baseline + follow-up was associated with elevated risk of anxiety (relative risk [RR], 9.8; 95% CI, 7.5-12.7), depression (RR, 17.9; 95% CI, 14.1-22.7), and current smoking (odds ratio [OR], 1.7; 95% CI, 1.3-2.3) at follow-up. Loneliness at follow-up only was associated with suicidal ideation (RR, 1.5; 95% CI, 1.1-2.1), heavy/risky alcohol consumption (RR, 1.3; 95% CI, 1.1-1.5), and new-onset grade 2-4 chronic conditions (RR, 1.3; 95% CI, 1.0-1.7). CONCLUSIONS Young adult survivors of childhood cancer have elevated risk of experiencing loneliness, which is associated with future emotional distress, risky health behaviors, and new-onset chronic conditions.
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Affiliation(s)
- Chiara Papini
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - Mingjuan Wang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, The State University of New York, NY, USA
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deokumar Srivastava
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Wendy M. Leisenring
- Clinical Research 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
| | | | - 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 University School of Medicine, Durham, NC, USA
| | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Tara M. Brinkman
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Psychology, St. Jude Children’s Research Hospital, Memphis, TN, USA
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36
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Wang X, Singh P, Zhou L, Sharafeldin N, Landier W, Hageman L, Burridge P, Yasui Y, Sapkota Y, Blanco JG, Oeffinger KC, Hudson MM, Chow EJ, Armenian SH, Neglia JP, Ritchey AK, Hawkins DS, Ginsberg JP, Robison LL, Armstrong GT, Bhatia S. Genome-Wide Association Study Identifies ROBO2 as a Novel Susceptibility Gene for Anthracycline-Related Cardiomyopathy in Childhood Cancer Survivors. J Clin Oncol 2023; 41:1758-1769. [PMID: 36508697 PMCID: PMC10043563 DOI: 10.1200/jco.22.01527] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 07/04/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Interindividual variability in the dose-dependent association between anthracyclines and cardiomyopathy suggests a modifying role of genetic susceptibility. Few previous studies have examined gene-anthracycline interactions. We addressed this gap using the Childhood Cancer Survivor Study (discovery) and the Children's Oncology Group (COG) study COG-ALTE03N1 (replication). METHODS A genome-wide association study (Illumina HumanOmni5Exome Array) in 1,866 anthracycline-exposed Childhood Cancer Survivor Study participants (126 with heart failure) was used to identify single-nucleotide polymorphisms (SNPs) with either main or gene-environment interaction effect on anthracycline-related cardiomyopathy that surpassed a prespecified genome-wide threshold for statistical significance. We attempted replication in a matched case-control set of anthracycline-exposed childhood cancer survivors with (n = 105) and without (n = 160) cardiomyopathy from COG-ALTE03N1. RESULTS Two SNPs (rs17736312 [ROBO2]) and rs113230990 (near a CCCTC-binding factor insulator [< 750 base pair]) passed the significance cutoff for gene-anthracycline dose interaction in discovery. SNP rs17736312 was successfully replicated. Compared with the GG/AG genotypes on rs17736312 and anthracyclines ≤ 250 mg/m2, the AA genotype and anthracyclines > 250 mg/m2 conferred a 2.2-fold (95% CI, 1.2 to 4.0) higher risk of heart failure in discovery and an 8.2-fold (95% CI, 2.0 to 34.4) higher risk in replication. ROBO2 encodes transmembrane Robo receptors that bind Slit ligands (SLIT). Slit-Robo signaling pathway promotes cardiac fibrosis by interfering with the transforming growth factor-β1/small mothers against decapentaplegic (Smad) pathway, resulting in disordered remodeling of the extracellular matrix and potentiating heart failure. We found significant gene-level associations with heart failure: main effect (TGF-β1, P = .007); gene*anthracycline interaction (ROBO2*anthracycline, P = .0003); and gene*gene*anthracycline interaction (SLIT2*TGF-β1*anthracycline, P = .009). CONCLUSION These findings suggest that high-dose anthracyclines combined with genetic variants involved in the profibrotic Slit-Robo signaling pathway promote cardiac fibrosis via the transforming growth factor-β1/Smad pathway, providing credence to the biologic plausibility of the association between SNP rs17736312 (ROBO2) and anthracycline-related cardiomyopathy.
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Affiliation(s)
| | | | - Liting Zhou
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - Yutaka Yasui
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | | | - Eric J. Chow
- Seattle Children's Hospital, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | | | | | - A. Kim Ritchey
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Douglas S. Hawkins
- Seattle Children's Hospital, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | | | | | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
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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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38
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Yu AF, Dang CT, Jorgensen J, Moskowitz CS, DeFusco P, Oligino E, Oeffinger KC, Liu JE, Steingart RM. Rationale and design of a cardiac safety study for reduced cardiotoxicity surveillance during HER2-targeted therapy. Cardiooncology 2023; 9:13. [PMID: 36895062 PMCID: PMC9996968 DOI: 10.1186/s40959-023-00163-4] [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] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 02/15/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Echocardiograms are recommended every 3 months in patients receiving human epidermal growth factor 2 (HER2)-targeted therapy for surveillance of left ventricular ejection fraction (LVEF). Efforts to tailor treatment for HER2-positive breast cancer have led to greater use of non-anthracycline regimens that are associated with lower cardiotoxicity risk, raising into question the need for frequent cardiotoxicity surveillance for these patients. This study seeks to evaluate whether less frequent cardiotoxicity surveillance (every 6 months) is safe for patients receiving a non-anthracycline HER2-targeted treatment regimen. METHODS/DESIGN We will enroll 190 women with histologically confirmed HER2-positive breast cancer scheduled to receive a non-anthracycline HER2-targeted treatment regimen for a minimum of 12 months. All participants will undergo echocardiograms before and 6-, 12-, and 18-months after initiation of HER2-targeted treatment. The primary composite outcome is symptomatic heart failure (New York Heart Association class III or IV) or death from cardiovascular causes. Secondary outcomes include: 1) echocardiographic indices of left ventricular systolic function; 2) incidence of cardiotoxicity, defined by a ≥ 10% absolute reduction in left ventricular ejection fraction (LVEF) from baseline to < 53%; and 3) incidence of early interruption of HER2-targeted therapy. CONCLUSIONS To our knowledge, this will be the first prospective study of a risk-based approach to cardiotoxicity surveillance. We expect findings from this study will inform the development of updated clinical practice guidelines to improve cardiotoxicity surveillance practices during HER2-positive breast cancer treatment. TRIAL REGISTRATION The trial was registered in the ClinicalTrials.gov registry (identifier NCT03983382) on June 12, 2019.
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Affiliation(s)
- Anthony F Yu
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA. .,Weill Cornell Medical College, New York, NY, USA.
| | - Chau T Dang
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Justine Jorgensen
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Chaya S Moskowitz
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Jennifer E Liu
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Richard M Steingart
- Department of Medicine, Cardiology Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.,Weill Cornell Medical College, New York, NY, USA
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39
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Shamseddine A, Patel SH, Chavez V, Moore ZR, Adnan M, Di Bona M, Li J, Dang CT, Ramanathan LV, Oeffinger KC, Liu JE, Steingart RM, Piersigilli A, Socci ND, Chan AT, Yu AF, Bakhoum SF, Schmitt AM. Innate immune signaling drives late cardiac toxicity following DNA-damaging cancer therapies. J Exp Med 2023; 220:213768. [PMID: 36534085 PMCID: PMC9767651 DOI: 10.1084/jem.20220809] [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: 05/09/2022] [Revised: 09/15/2022] [Accepted: 11/22/2022] [Indexed: 12/24/2022] Open
Abstract
Late cardiac toxicity is a potentially lethal complication of cancer therapy, yet the pathogenic mechanism remains largely unknown, and few treatment options exist. Here we report DNA-damaging agents such as radiation and anthracycline chemotherapies inducing delayed cardiac inflammation following therapy due to activation of cGAS- and STING-dependent type I interferon signaling. Genetic ablation of cGAS-STING signaling in mice inhibits DNA damage-induced cardiac inflammation, rescues late cardiac functional decline, and prevents death from cardiac events. Treatment with a STING antagonist suppresses cardiac interferon signaling following DNA-damaging therapies and effectively mitigates cardiac toxicity. These results identify a therapeutically targetable, pathogenic mechanism for one of the most vexing treatment-related toxicities in cancer survivors.
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Affiliation(s)
- Achraf Shamseddine
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Suchit H. Patel
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, LA, USA
| | - Valery Chavez
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zachary R. Moore
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mutayyaba Adnan
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melody Di Bona
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jun Li
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Chau T. Dang
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lakshmi V. Ramanathan
- Clinical Chemistry Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C. Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer E. Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard M. Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessandra Piersigilli
- Laboratory of Comparative Pathology, Rockefeller University, Weill Cornell Medicine and Memorial Sloan-Kettering Cancer Center, New York, NY, USA
- Takeda Development Center Americas, Drug Safety Research Evaluation, Cambridge, MA, USA
| | - Nicholas D. Socci
- Marie-Josee & Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Angel T. Chan
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anthony F. Yu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samuel F. Bakhoum
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adam M. Schmitt
- Division of Translational Oncology, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Correspondence to Adam M. Schmitt:
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40
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Yu AF, Dang C, Jorgensen J, Liu JE, Moskowitz C, Oligino EJ, Oeffinger KC, Steingart RM. CARDIAC SAFETY STUDY FOR REDUCED CARDIOTOXICITY SURVEILLANCE IN PATIENTS WITH HER2-POSITIVE BREAST CANCER. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02674-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Geiger EJ, Liu W, Srivastava DK, Bernthal NM, Weil BR, Yasui Y, Ness KK, Krull KR, Goldsby RE, Oeffinger KC, Robison LL, Dieffenbach BV, Weldon CB, Gebhardt MC, Howell R, Murphy AJ, Leisenring WM, Armstrong GT, Chow EJ, Wustrack RL. What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report. Clin Orthop Relat Res 2023; 481:526-538. [PMID: 35583517 PMCID: PMC9928620 DOI: 10.1097/corr.0000000000002243] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 12/13/2021] [Accepted: 04/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although pediatric lower extremity sarcoma once was routinely treated with amputation, multiagent chemotherapy as well as the evolution of tumor resection and reconstruction techniques have enabled the wide adoption of limb salvage surgery (LSS). Even though infection and tumor recurrence are established risk factors for early amputation (< 5 years) after LSS, the frequency of and factors associated with late amputation (≥ 5 years from diagnosis) in children with sarcomas are not known. Additionally, the resulting psychosocial and physical outcomes of these patients compared with those treated with primary amputation or LSS that was not complicated by subsequent amputation are not well studied. Studying these outcomes is critical to enhancing the quality of life of patients with sarcomas. QUESTIONS/PURPOSES (1) How have treatments changed over time in patients with lower extremity sarcoma who are included in the Childhood Cancer Survivor Study (CCSS), and did primary treatment with amputation or LSS affect overall survival at 25 years among patients who had survived at least 5 years from diagnosis? (2) What is the cumulative incidence of amputation after LSS for patients diagnosed with pediatric lower extremity sarcomas 25 years after diagnosis? (3) What are the factors associated with time to late amputation (≥ 5 years after diagnosis) in patients initially treated with LSS for lower extremity sarcomas in the CCSS? (4) What are the comparative social, physical, and emotional health-related quality of life (HRQOL) outcomes among patients with sarcoma treated with primary amputation, LSS without amputation, or LSS complicated by late amputation, as assessed by CCSS follow-up questionnaires, the SF-36, and the Brief Symptom Inventory-18 at 20 years after cancer diagnosis? METHODS The CCSS is a long-term follow-up study that began in 1994 and is coordinated through St. Jude Children's Research Hospital. It is a retrospective study with longitudinal follow-up of more than 38,000 participants treated for childhood cancer when younger than 21 years at one of 31 collaborating institutions between 1970 and 1999 in the United States and Canada. Participants were eligible for enrollment in the CCSS after they had survived 5 years from diagnosis. Within the CCSS cohort, we included participants who had a diagnosis of lower extremity sarcoma treated with primary amputation (547 patients with a mean age at diagnosis of 13 ± 4 years) or primary LSS (510 patients with a mean age 14 ± 4 years). The LSS cohort was subdivided into LSS without amputation, defined as primary LSS without amputation at the time of latest follow-up; LSS with early amputation, defined as LSS complicated by amputation occurring less than 5 years from diagnosis; or LSS with late amputation, defined as primary LSS in study patients who subsequently underwent amputation 5 years or more from cancer diagnosis. The cumulative incidence of late amputation after primary LSS was estimated. Cox proportional hazards regression with time-varying covariates identified factors associated with late amputation. Modified Poisson regression models were used to compare psychosocial, physical, and HRQOL outcomes among patients treated with primary amputation, LSS without amputation, or LSS complicated by late amputation using validated surveys. RESULTS More study participants were treated with LSS than with primary amputation in more recent decades. The overall survival at 25 years in this population who survived 5 years from diagnosis was not different between those treated with primary amputation (87% [95% confidence interval [CI] 82% to 91%]) compared with LSS (88% [95% CI 85% to 91%]; p = 0.31). The cumulative incidence of amputation at 25 years after cancer diagnosis and primary LSS was 18% (95% CI 14% to 21%). With the numbers available, the cumulative incidence of late amputation was not different among study patients treated in the 1970s (27% [95% CI 15% to 38%]) versus the 1980s and 1990s (19% [95% CI 13% to 25%] and 15% [95% CI 10% to 19%], respectively; p = 0.15). After controlling for gender, medical and surgical treatment variables, cancer recurrence, and chronic health conditions, gender (hazard ratio [HR] 2.02 [95% CI 1.07 to 3.82]; p = 0.03) and history of prosthetic joint reconstruction (HR 2.58 [95% CI 1.37 to 4.84]; p = 0.003) were associated with an increased likelihood of late amputation. Study patients treated with a primary amputation (relative risk [RR] 2.04 [95% CI 1.15 to 3.64]) and LSS complicated by late amputation (relative risk [RR] 3.85 [95% CI 1.66 to 8.92]) were more likely to be unemployed or unable to attend school than patients treated with LSS without amputation to date. The CCSS cohort treated with primary amputation and those with LSS complicated by late amputation reported worse physical health scores than those without amputation to date, although mental and emotional health outcomes did not differ between the groups. CONCLUSION There is a substantial risk of late amputation after LSS, and both primary and late amputation status are associated with decreased physical HRQOL outcomes. Children treated for sarcoma who survive into adulthood after primary amputation and those who undergo late amputation after LSS may benefit from interventions focused on improving physical function and reaching educational and employment milestones. Efforts to improve the physical function of people who have undergone amputation either through prosthetic design or integration into the residuum should be supported. Understanding factors associated with late amputation in the setting of more modern surgical approaches and implants will help surgeons more effectively manage patient expectations and adjust practice to mitigate these risks over the life of the patient. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Erik J. Geiger
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Wei Liu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Brent R. Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Yutaka Yasui
- 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
| | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Robert E. Goldsby
- Division of Oncology, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - Kevin C. Oeffinger
- Department of Medicine and Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Bryan V. Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Christopher B. Weldon
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
- Department of Surgery and Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark C. Gebhardt
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J. Murphy
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wendy M. Leisenring
- Clinical Research 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
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rosanna L. Wustrack
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA, USA
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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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Wong FL, Lee JM, Leisenring WM, Neglia JP, Howell RM, Smith SA, Oeffinger KC, Moskowitz CS, Henderson TO, Mertens A, Nathan PC, Yasui Y, Landier W, Armstrong GT, Robison LL, Bhatia S. Health Benefits and Cost-Effectiveness of Children's Oncology Group Breast Cancer Screening Guidelines for Chest-Irradiated Hodgkin Lymphoma Survivors. J Clin Oncol 2023; 41:1046-1058. [PMID: 36265088 PMCID: PMC9928841 DOI: 10.1200/jco.22.00574] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the outcomes and cost-effectiveness of the Children's Oncology Group Guideline recommendation for breast cancer (BC) screening using mammography (MAM) and breast magnetic resonance imaging (MRI) in female chest-irradiated childhood Hodgkin lymphoma (HL) survivors. Digital breast tomosynthesis (DBT), increasingly replacing MAM in practice, was also examined. METHODS Life years (LYs), quality-adjusted LYs (QALYs), BC mortality, health care costs, and false-positive screen frequencies of undergoing annual MAM, DBT, MRI, MAM + MRI, and DBT + MRI from age 25 to 74 years were estimated by microsimulation. BC risks and non-BC mortality were estimated from female 5-year survivors of HL in the Childhood Cancer Survivor Study and the US population. Test performance of MAM and MRI was synthesized from HL studies, and that of DBT from the general population. Costs (2017 US dollars [USD]) and utility weights were obtained from the medical literature. Incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS With 100% screening adherence, annual BC screening extended LYs by 0.34-0.46 years over no screening. If the willingness-to-pay threshold to gain a quality-adjusted LY was ICER < $100,000 USD, annual MAM at age 25-74 years was the only cost-effective strategy. When nonadherence was taken into consideration, only annual MAM at age 30-74 years (ICER = $56,972 USD) was cost-effective. Supplementing annual MAM with MRI costing $545 USD was not cost-effective under either adherence condition. If MRI costs were reduced to $300 USD, adding MRI to annual MAM at age 30-74 years could become more cost-effective, particularly in the reduced adherence condition (ICER = $133,682 USD). CONCLUSION Annual BC screening using MAM at age 30-74 years is effective and cost-effective in female chest-irradiated HL survivors. Although annual adjunct MRI is not cost-effective at $545 USD cost, it could become cost-effective as MRI cost is reduced, a plausible scenario with the emergent use of abbreviated MRI.
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Affiliation(s)
| | - Janie M. Lee
- University of Washington School of Medicine, Seattle, WA
| | | | | | | | - Susan A. Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Ann Mertens
- Emory University School of Medicine, Atlanta, GA
| | - Paul C. Nathan
- The Hospital for Sick Children, University of Toronto, Toronto, ON
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
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Turcotte LM, Whitton JA, Leisenring WM, Howell RM, Neglia JP, Phelan R, Oeffinger KC, Ness KK, Woods WG, Kolb EA, Robison LL, Armstrong GT, Chow EJ. Chronic conditions, late mortality, and health status after childhood AML: a Childhood Cancer Survivor Study report. Blood 2023; 141:90-101. [PMID: 36037430 PMCID: PMC9837436 DOI: 10.1182/blood.2022016487] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/28/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 01/21/2023] Open
Abstract
Five-year survival following childhood acute myeloid leukemia (AML) has increased following improvements in treatment and supportive care. Long-term health outcomes are unknown. To address this, cumulative incidence of late mortality and grades 3 to 5 chronic health condition (CHC) were estimated among 5-year AML survivors diagnosed between 1970 and 1999. Survivors were compared by treatment group (hematopoietic cell transplantation [HCT], chemotherapy with cranial radiation [chemo + CRT], chemotherapy only [chemo-only]), and diagnosis decade. Self-reported health status was compared across treatments, diagnosis decade, and with siblings. Among 856 survivors (median diagnosis age, 7.1 years; median age at last follow-up, 29.4 years), 20-year late mortality cumulative incidence was highest after HCT (13.9%; 95% confidence interval [CI], 10.0%-17.8%; chemo + CRT, 7.6%; 95% CI, 2.2%-13.1%; chemo-only, 5.1%; 95% CI, 2.8%-7.4%). Cumulative incidence of mortality for HCT survivors diagnosed in the 1990s (8.5%; 95% CI, 4.1%-12.8%) was lower vs those diagnosed in the 1970s (38.9%; 95% CI, 16.4%-61.4%). Most survivors did not experience any grade 3 to 5 CHC after 20 years (HCT, 45.8%; chemo + CRT, 23.7%; chemo-only, 27.0%). Furthermore, a temporal reduction in CHC cumulative incidence was seen after HCT (1970s, 76.1%; 1990s, 38.3%; P = .02), mirroring reduced use of total body irradiation. Self-reported health status was good to excellent for 88.2% of survivors; however, this was lower than that for siblings (94.8%; P < .0001). Although HCT is associated with greater long-term morbidity and mortality than chemotherapy-based treatment, gaps have narrowed, and all treatment groups report favorable health status.
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Affiliation(s)
- Lucie M. Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Jillian A. Whitton
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Wendy M. Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Rebecca M. Howell
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph P. Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Rachel Phelan
- Center for International Blood and Marrow Transplantation, Milwaukee, WI
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | | | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - William G. Woods
- Aflac Cancer Center, Children’s Healthcare of Atlanta/Emory University, Atlanta, GA
| | - E. Anders Kolb
- Nemours Center for Cancer and Blood Disorders, Nemours Children’s Health System, Wilmington, DE
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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Henderson TO, Liu Q, Turcotte LM, Neglia JP, Leisenring W, Hodgson D, Diller L, Kenney L, Morton L, Berrington de Gonzalez A, Arnold M, Bhatia S, Howell RM, Smith SA, Robison LL, Armstrong GT, Oeffinger KC, Yasui Y, Moskowitz CS. Association of Changes in Cancer Therapy Over 3 Decades With Risk of Subsequent Breast Cancer Among Female Childhood Cancer Survivors: A Report From the Childhood Cancer Survivor Study (CCSS). JAMA Oncol 2022; 8:2797487. [PMID: 36227603 PMCID: PMC9562103 DOI: 10.1001/jamaoncol.2022.4649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/26/2022] [Indexed: 01/25/2023]
Abstract
Importance Breast cancer is the most common invasive subsequent malignant disease in childhood cancer survivors, though limited data exist on changes in breast cancer rates as primary cancer treatments have evolved. Objective To quantify the association between temporal changes in cancer treatment over 3 decades and subsequent breast cancer risk. Design, Setting, and Participants Retrospective cohort study of 5-year cancer survivors diagnosed when younger than 21 years between 1970 and 1999, with follow-up through December 5, 2020. Exposures Radiation and chemotherapy dose changes over time. Main Outcomes and Measures Breast cancer cumulative incidence rates and age-specific standardized incidence ratios (SIRs) compared across treatment decades (1970-1999). Piecewise exponential models estimated invasive breast cancer and ductal carcinoma in situ (DCIS) risk and associations with treatment exposures, adjusted for age at childhood cancer diagnosis and attained age. Results Among 11 550 female survivors (median age, 34.2 years; range 5.6-66.8 years), 489 developed 583 breast cancers: 427 invasive, 156 DCIS. Cumulative incidence was 8.1% (95% CI, 7.3%-9.0%) by age 45 years. An increased breast cancer risk (SIR, 6.6; 95% CI, 6.1-7.2) was observed for survivors compared with the age-sex-calendar-year-matched general population. Changes in therapy by decade included reduced rates of chest (34% in the 1970s, 22% in the 1980s, and 17% in the 1990s) and pelvic radiotherapy (26%, 17%, and 13% respectively) and increased rates of anthracycline chemotherapy exposures (30%, 51%, and 64%, respectively). Adjusting for age and age at diagnosis, the invasive breast cancer rate decreased 18% every 5 years of primary cancer diagnosis era (rate ratio [RR], 0.82; 95% CI, 0.74-0.90). When accounting for chest radiotherapy exposure, the decline attenuated to an 11% decrease every 5 years (RR, 0.89; 95% CI, 0.81-0.99). When additionally adjusted for anthracycline dose and pelvic radiotherapy, the decline every 5 years increased to 14% (RR, 0.86; 95% CI, 0.77-0.96). Although SIRs of DCIS generally increased over time, there were no statistically significant changes in incidence. Conclusions and Relevance Invasive breast cancer rates in childhood cancer survivors have declined with time, especially in those younger than 40 years. This appears largely associated with the reduced use of chest radiation therapy, but was tempered by concurrent changes in other therapies.
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Affiliation(s)
| | - Qi Liu
- University of Alberta, Alberta, Canada
| | | | | | | | | | - Lisa Diller
- Dana-Farber Cancer Institute/Children’s Hospital Boston, Boston, Massachusetts
| | - Lisa Kenney
- Dana-Farber Cancer Institute/Children’s Hospital Boston, Boston, Massachusetts
| | | | | | - Michael Arnold
- Children’s Hospital of Colorado, Denver, Colorado
- University of Colorado, Anschutz Medical Campus, Aurora
| | | | | | | | | | | | | | - Yutaka Yasui
- St. Jude Children’s Research Hospital, Memphis, Tennessee
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46
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Dorfman CS, Stalls J, Lachman S, Shelby RA, Somers TJ, Oeffinger KC. Symptom Communication Preferences and Communication Barriers for Young Adult Cancer Survivors and Their Health Care Providers. J Adolesc Young Adult Oncol 2022; 11:506-517. [PMID: 35049386 PMCID: PMC9595618 DOI: 10.1089/jayao.2021.0172] [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] [Indexed: 11/13/2022] Open
Abstract
Purpose: Effective communication between young adult (YA; aged 18-39 years) cancer survivors and their health care providers is critical for managing post-treatment symptoms. Yet, little is known about YAs' and providers' preferences for and barriers to symptom communication, variables important for developing interventions to improve and optimize YA-provider communication. Methods: YA survivors (N = 21) and oncology providers (N = 11) rank ordered their preferred methods for symptom communication and top communication barriers. Interviews were conducted to obtain qualitative data (i.e., preferred methods for, barriers, and suggestions to improve symptom communication). Interviews were transcribed, and thematic qualitative analysis was used. Results: Sixty-two percent of YAs preferred communicating using the electronic messaging system affiliated with the medical record (MyChart), whereas providers (100%) preferred communicating during in-person clinic visits. Qualitative data from YAs pointed to benefits of MyChart, including ease of use and rapid responses. Providers acknowledged that, although efficient, high message volumes and expectations for rapid responses were barriers to MyChart. Providers described benefits of in-person visits, including visually assessing patients' concerns, providing immediate support, and more safely managing symptoms. Lack of time (48%) was YAs' top communication barrier, whereas providers endorsed patients not bringing up symptoms (64%). Qualitative data reflected patient-level (e.g., embarrassment/discomfort, lack of skills) and provider-level (e.g., forgetting to ask about a symptom) barriers. YAs and providers offered strategies to improve communication. Conclusion: Survivor- and provider-level communication interventions that account for YAs' and providers' differing communication preferences and directly address communication barriers unique to survivors' developmental stage may be necessary to improve symptom communication.
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Affiliation(s)
- Caroline S. Dorfman
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Juliann Stalls
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Sage Lachman
- Department of Psychology and Neuroscience, Duke University, Durham, North Carolina, USA
| | - Rebecca A. Shelby
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Tamara J. Somers
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin C. Oeffinger
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina, USA
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47
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Rotz SJ, Worley S, Hu B, Bazeley P, Baedke JL, Hudson MM, Kuo DJ, Oeffinger KC, Robison LL, Sahoo D, Wang F, Yasui Y, Armstrong GT, Bhatia S. Genome-Wide Association Study of Pregnancy in Childhood Cancer Survivors: A Report from the Childhood Cancer Survivor Study. Cancer Epidemiol Biomarkers Prev 2022; 31:1858-1862. [PMID: 35700038 PMCID: PMC9444932 DOI: 10.1158/1055-9965.epi-22-0314] [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: 03/18/2022] [Revised: 05/10/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Gonadotoxic treatment-related infertility has a significant impact on quality of life in childhood cancer survivors. Genome-wide association analyses to delineate the risk of infertility in childhood cancer survivors have not been previously reported. METHODS Leveraging genotype data from a large survivor cohort, the Childhood Cancer Survivor Study (CCSS), we investigated the role of SNPs on future pregnancy or siring a pregnancy in survivors without pelvic, testicular, or brain radiation who had ever been married. We calculated sex-stratified hazard ratios, using Cox proportional hazards modeling, adjusting for birth cohort (before 1965 vs. 1965 or later) and doses of relevant chemotherapies; replication was attempted in the independent St. Jude Lifetime Cohort study (SJLIFE). RESULTS In the CCSS cohort, nine SNPs were found to be suggestive (P < 10-7) or statistically significantly (P < 5 × 10-8) associated with pregnancy, however, none of the SNPs were replicated in SJLIFE. Cohorts differed based on the overall pregnancy rate, frequency of sterilizing procedures, and birth cohort. CONCLUSIONS We were not able to replicate our findings of SNPs associated with pregnancy in childhood cancer survivors. IMPACT Future attempts at replication should be considered in cohorts treated in a comparable era. In addition, understanding the role of genetics in fertility in childhood cancer survivors may be better approached using more advanced sequencing techniques.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children’s Hospital, Cleveland, OH
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Peter Bazeley
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Jessica L Baedke
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital,Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Dennis J Kuo
- Division of Pediatric Hematology-Oncology, University of California, San Diego, San Diego, CA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital
| | - Debashis Sahoo
- Department of Pediatrics, University of California, San Diego, San Diego, CA
| | - Fan Wang
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
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48
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Salz T, Zabor EC, Brown PDN, Dalton SO, Raghunathan NJ, Matasar MJ, Steingart R, Hjalgrim H, Specht L, Vickers AJ, Oeffinger KC, Johansen C. Cardiovascular risk factors, radiation therapy, and myocardial infarction among lymphoma survivors. Acta Oncol 2022; 61:1064-1068. [PMID: 36256902 PMCID: PMC9888465 DOI: 10.1080/0284186x.2022.2107402] [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: 02/09/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mediastinal radiation is associated with increased risk of myocardial infarction (MI) among non-Hodgkin lymphoma (NHL) survivors. OBJECTIVE To evaluate how preexisting cardiovascular risk factors (CVRFs) modify the association of mediastinal radiation and MI among a national population of NHL survivors with a range of CVRFs. MATERIAL AND METHODS Using Danish registries, we identified adults diagnosed with lymphoma 2000-2010. We assessed MI from one year after diagnosis through 2016. We ascertained CVRFs (hypertension, dyslipidemia, and diabetes), vascular disease, and intrinsic heart disease prevalent at lymphoma diagnosis. We used multivariable Cox regression to test the interaction between preexisting CVRFs and receipt of mediastinal radiation on subsequent MI. RESULTS Among 3151 NHL survivors (median age 63, median follow-up 6.5 years), 96 were diagnosed with MI. Before lymphoma, 32% of survivors had ≥1 CVRF. 8.5% of survivors received mediastinal radiation. In multivariable analysis, we found that mediastinal radiation (HR = 1.96; 95% CI = 1.09-3.52), and presence of ≥1 CVRF (HR = 2.71; 95% CI = 1.77-4.15) were associated with an increased risk of MI. Although there was no interaction on the relative scale (p = 0.14), we saw a clinically relevant absolute increase in risk for patients with CVRF from 10-year of MI of 10.5% without radiation to 29.5% for those undergoing radiation. CONCLUSION Patients with CVRFs have an importantly higher risk of subsequent MI if they have mediastinal radiation. Routine evaluation of CVRFs and optimal treatment of preexisting cardiovascular disease should continue after receiving cancer therapy. In patients with CVRFs, mediastinal radiation should only be given if oncologic benefit clearly outweighs cardiovascular harm.
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Affiliation(s)
- Talya Salz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Department of Quantitative Health Sciences & Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Nirupa J Raghunathan
- Department of General Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew J Matasar
- Lymphoma Survivorship Clinic, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard Steingart
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Christoffer Johansen
- CASTLE - Cancer Late Effect Research, Oncology Clinic, Center for Surgery and Cancer, Copenhagen, Denmark
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49
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Michael ZD, Kotamarti S, Arcot R, Morris K, Shah A, Anderson J, Armstrong AJ, Gupta RT, Patierno S, Barrett NJ, George DJ, Preminger GM, Moul JW, Oeffinger KC, Shah K, Polascik TJ. Initial Longitudinal Outcomes of Risk-Stratified Men in Their Forties Screened for Prostate Cancer Following Implementation of a Baseline Prostate-Specific Antigen. World J Mens Health 2022:40.e60. [PMID: 36047079 DOI: 10.5534/wjmh.220068] [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: 04/25/2022] [Revised: 06/27/2022] [Accepted: 07/21/2022] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Prostate cancer (PCa) screening can lead to potential over-diagnosis/over-treatment of indolent cancers. There is a need to optimize practices to better risk-stratify patients. We examined initial longitudinal outcomes of mid-life men with an elevated baseline prostate-specific antigen (PSA) following initiation of a novel screening program within a system-wide network. MATERIALS AND METHODS We assessed our primary care network patients ages 40 to 49 years with a PSA measured following implementation of an electronic health record screening algorithm from 2/2/2017-2/21/2018. The multidisciplinary algorithm was developed taking factors including age, race, family history, and PSA into consideration to provide a personalized approach to urology referral to be used with shared decision-making. Outcomes of men with PSA ≥1.5 ng/mL were evaluated through 7/2021. Statistical analyses identified factors associated with PCa detection. Clinically significant PCa (csPCa) was defined as Gleason Grade Group (GGG) ≥2 or GGG1 with PSA ≥10 ng/mL. RESULTS The study cohort contained 564 patients, with 330 (58.5%) referred to urology for elevated PSA. Forty-nine (8.7%) underwent biopsy; of these, 20 (40.8%) returned with PCa. Eleven (2.0% of total cohort and 55% of PCa diagnoses) had csPCa. Early referral timing (odds ratio [OR], 4.58) and higher PSA (OR, 1.07) were significantly associated with PCa at biopsy on multivariable analysis (both p<0.05), while other risk factors were not. Referred patients had higher mean PSAs (2.97 vs. 1.98, p=0.001). CONCLUSIONS Preliminary outcomes following implementation of a multidisciplinary screening algorithm identified PCa in a small, important percentage of men in their forties. These results provide insight into baseline PSA measurement to provide early risk stratification and detection of csPCa in patients with otherwise extended life expectancy. Further follow-up is needed to possibly determine the prognostic significance of such mid-life screening and optimize primary care physician-urologist coordination.
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Affiliation(s)
- Zoe D Michael
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Srinath Kotamarti
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Rohith Arcot
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kostantinos Morris
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Anand Shah
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John Anderson
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Andrew J Armstrong
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Rajan T Gupta
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Steven Patierno
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Department of Family Medicine and Community Health, Duke University Medical Center, Durham, NC, USA
| | - Nadine J Barrett
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Daniel J George
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Glenn M Preminger
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Judd W Moul
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin C Oeffinger
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Kevin Shah
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Thomas J Polascik
- The Duke Cancer Institute Center for Prostate and Urologic Cancers, Durham, NC, USA.,Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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50
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Schulte F, Chen Y, Yasui Y, Ruiz ME, Leisenring W, Gibson TM, Nathan PC, Oeffinger KC, Hudson MM, Armstrong GT, Robison LL, Krull KR, Huang IC. Development and Validation of Models to Predict Poor Health-Related Quality of Life Among Adult Survivors of Childhood Cancer. JAMA Netw Open 2022; 5:e2227225. [PMID: 35976647 PMCID: PMC9386537 DOI: 10.1001/jamanetworkopen.2022.27225] [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] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Risk prediction models are important to identify survivors of childhood cancer who are at risk of experiencing poor health-related quality of life (HRQOL) as they age. OBJECTIVE To develop and validate prediction models for a decline in HRQOL among adult survivors of childhood cancer. DESIGNS, SETTING, AND PARTICIPANTS This prognostic study included 4755 adults from the Childhood Cancer Survivor Study (CCSS) diagnosed between January 5, 1970, and December 31, 1986, who completed baseline (time 0 [November 3, 1992, to August 28, 2003]) and 2 follow-up (time 1 [February 12, 2002, to May 21, 2005] and time 2 [January 6, 2014, to November 30, 2016]) surveys. Data were analyzed from June 19, 2019, to February 2, 2022. EXPOSURES Sociodemographic, lifestyle, and emotional factors, and chronic health conditions (CHCs) were assessed at time 0 and time 1, and neurocognitive factors were assessed at time 1 to predict HRQOL at time 2 and a decline in HRQOL between time 1 and time 2. Impaired health states were defined as CHC grades 2 to 4 using the modified Common Terminology Criteria for Adverse Events, version 4.03, and mental and neurocognitive status as 1 SD or more below reference levels. MAIN OUTCOMES AND MEASURES Health-related quality of life was operationalized using the Medical Outcomes Study 36-Item Short Form Health Survey Physical (PCS) and Mental (MCS) Component Summary and classified by optimal (≥40) or suboptimal (<40) at each point (main outcome). A decline in HRQOL was defined as a change from optimal to suboptimal between time 1 and time 2. Multivariable logistic regression identified factors associated with HRQOL decline. The cohort was randomly split into training (80%) and test (20%) data sets for model development and validation; the area under the receiver operating characteristic curve was used to evaluate prediction performance. RESULTS A total of 4755 adults (mean [SD] age at time 0, 24.3 [7.6] years; 2623 [55.2%] women) were included in the analysis. Between time 1 and time 2, 285 of 3294 survivors (8.7%) had declining PCS and 278 of 3294 (8.4%) had declining MCS. Risk factors associated with PCS decline included female sex (odds ratio [OR], 1.67 [95% CI, 1.25-2.24]), family income less than $20 000 vs $80 000 or more (OR, 2.00 [95% CI, 1.21-3.30]), presence of CHCs (OR for neurological, 2.16 [95% CI, 1.51-3.10]; OR for endocrine, 2.25 [95% CI, 1.44-3.52]; OR for gastrointestinal tract, 1.89 [95% CI, 1.32-2.69]; OR for respiratory, 1.66 [95% CI, 1.06-2.59]; OR for cardiovascular, 1.53 [95% CI, 1.14-2.06]), and depression (OR, 1.79 [95% CI, 1.20-2.67]). Risk factors associated with MCS decline included unemployment vs full-time employment (OR, 1.68; [95% CI, 1.19-2.38]), current vs never cigarette smoking (OR, 2.03 [95% CI, 1.37-3.00]), depression (OR, 4.29 [95% CI, 2.44-7.55]), somatization (OR, 1.63 [95% CI, 1.05-2.53]), impaired task efficiency (OR, 1.90 [95% CI, 1.34-2.68]), and impaired organization (OR, 1.67 [95% CI, 1.12-2.48]). The areas under the receiver operating characteristic curve for the test models were 0.74 (95% CI, 0.67-0.81) for declining PCS and 0.68 (95% CI, 0.60-0.75) for declining MCS. CONCLUSIONS AND RELEVANCE In this prognostic study of adult survivors of childhood cancer who experienced declining HRQOL, CHCs were associated with a decline in physical HRQOL, whereas current smoking and emotional and neurocognitive impairment were associated with a decline in mental HRQOL. These findings suggest that interventions targeting modifiable risk factors are needed to prevent poor HRQOL in this population.
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Affiliation(s)
- Fiona Schulte
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Yan Chen
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Maritza E. Ruiz
- Department of Pediatric Hematology/Oncology, MemorialCare Miller Children’s & Women’s Hospital Long Beach,Long Beach, California
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Todd M. Gibson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Psychology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
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