Survival difference between secondary and de novo acute myeloid leukemia by age, antecedent cancer types, and chemotherapy receipt

BACKGROUND

This study compared the survival of persons with secondary acute myeloid leukemia (sAML) to those with de novo AML (dnAML) by age at AML diagnosis, chemotherapy receipt, and cancer type preceding sAML diagnosis.

METHODS

Data from Surveillance, Epidemiology, and End Results 17 Registries were used, which included 47,704 individuals diagnosed with AML between 2001 and 2018. Multivariable Cox proportional hazards regression was used to compare AML-specific survival between sAML and dnAML. Trends in 5-year age-standardized relative survival were examined via the Joinpoint survival model.

RESULTS

Overall, individuals with sAML had an 8% higher risk of dying from AML (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.05-1.11) compared to those with dnAML. Disparities widened with younger age at diagnosis, particularly in those who received chemotherapy for AML (HR, 1.14; 95% CI, 1.10-1.19). In persons aged 20-64 years and who received chemotherapy, HRs were greatest for those with antecedent myelodysplastic syndrome (HR, 2.04; 95% CI, 1.83-2.28), ovarian cancer (HR, 1.91; 95% CI, 1.19-3.08), head and neck cancer (HR, 1.55; 95% CI, 1.02-2.36), leukemia (HR, 1.45; 95% CI, 1.12-1.89), and non-Hodgkin lymphoma (HR, 1.42; 95% CI, 1.20-1.69). Among those aged ≥65 years and who received chemotherapy, HRs were highest for those with antecedent cervical cancer (HR, 2.42; 95% CI, 1.15-5.10) and myelodysplastic syndrome (HR, 1.28; 95% CI, 1.19-1.38). The 5-year relative survival improved 0.3% per year for sAML slower than 0.86% per year for dnAML. Consequently, the survival gap widened from 7.2% (95% CI, 5.4%-9.0%) during the period 2001-2003 to 14.3% (95% CI, 12.8%-15.8%) during the period 2012-2014.

CONCLUSIONS

Significant survival disparities exist between sAML and dnAML on the basis of age at diagnosis, chemotherapy receipt, and antecedent cancer, which highlights opportunities to improve outcomes among those diagnosed with sAML.

Testing the What Matters to Me workbook in a diverse sample of seriously ill patients and caregivers

Objectives

We evaluated the What Matters to Me Workbook, a patient-facing version of the Serious Illness Conversation Guide co-created by Ariadne Labs and The Conversation Project.

Methods

We purposively recruited diverse seriously ill patients and caregivers in the US. Participants completed the Workbook, a survey, and a semi-structured in-depth interview about their experience. Qualitative analysis of interviews and notes was employed to extract themes. Simple descriptive statistics were employed to analyze eight investigator authored questions.

Results

Twenty-nine study participants completed twenty-one interviews and twenty-five surveys. Ratings for safety (3.87/4, SD = 0.43) and acceptability (3.59/4, SD = 0.956) were higher than ratings for ease of use (3.30/4, SD = 0.97) and usefulness (3.24/4, SD = 0.80). Qualitative analysis identified that while the workbook was safe, acceptable, easy to use, and useful, it is more important who is recommending it and how they are explaining it.

Conclusion

If presented in the right way by a trustworthy person, the What Matters to Me Workbook can be an easy to use, useful, and safe resource for patients with serious illness and their caregivers.

Innovation

The Workbook focuses on serious illness rather than end-of-life and meshes with a clinician-facing conversation guide and a health-system level intervention.

Racial and Ethnic Disparities in Survival Among People With Second Primary Cancer in the US

Importance

Comprehensive data for racial and ethnic disparities after second primary cancers (SPCs) are lacking despite the growing burden of SPCs.

Objective

To quantify racial and ethnic disparities in survival among persons with SPCs.

Design, Setting, and Participants

This population-based, retrospective cohort study used data from 18 Surveillance, Epidemiology, and End Results registries in the US for persons diagnosed with the most common SPCs at age 20 years or older from January 1, 2000, to December 31, 2013 (with follow-up through December 31, 2018). Data were analyzed between January and April 2023.

Exposure

Race and ethnicity (Hispanic, non-Hispanic Asian or Pacific Islander, non-Hispanic Black, and non-Hispanic White).

Main Outcomes and Measures

The main outcomes were 5-year relative survival and cause-specific survival. Cause-specific hazard ratios (HRs) were calculated for death from cancer or cardiovascular disease (CVD) in each racial and ethnic minority population compared with the White population overall and stratified by SPC type, with adjustment for sex, year and age at SPC diagnosis, and prior cancer type and stage (baseline model) and additionally for county attributes (household income, urbanicity), SPC characteristics (stage, subtype), and treatment.

Results

Among 230 370 persons with SPCs (58.4% male), 4.5% were Asian or Pacific Islander, 9.6% were Black, 6.4% were Hispanic, and 79.5% were White. A total of 109 757 cancer-related deaths (47.6%) and 18 283 CVD-related deaths (7.9%) occurred during a median follow-up of 54 months (IQR, 12-93 months). In baseline models, compared with the White population, the risk of cancer-related death overall was higher in the Black (HR, 1.21; 95% CI, 1.18-1.23) and Hispanic (HR, 1.10; 95% CI, 1.07-1.13) populations but lower in the Asian or Pacific Islander population (HR, 0.93; 95% CI, 0.90-0.96). When stratified by 13 SPC types, the risk of cancer-related death was higher for 10 SPCs in the Black population, with the highest HR for uterine cancer (HR, 1.87; 95% CI, 1.63-2.15), and for 7 SPCs in the Hispanic population, most notably for melanoma (HR, 1.46; 95% CI, 1.21-1.76). For CVD-related death, the overall HR was higher in the Black population (HR, 1.41; 95% CI, 1.34-1.49), with elevated risks evident for 11 SPCs, but lower in the Asian or Pacific Islander (HR, 0.75; 95% CI, 0.69-0.81) and Hispanic (HR, 0.90; 95% CI, 0.84-0.96) populations than in the White population. After further adjustments for county attributes and SPC characteristics and treatment, HRs were reduced for cancer-related death and for CVD-related death and associations in the same direction remained.

Conclusions and Relevance

In this cohort study of SPC survivors, the Black population had the highest risk of both death from cancer and death from CVD, and the Hispanic population had a higher risk of death from cancer than the White population. Attenuations in HRs after adjustment for potentially modifiable factors highlight opportunities to reduce survival disparities among persons with multiple primary cancers.

Abstract 4379: Survival among adults diagnosed with secondary acute myeloid leukemia

Background: The burden of second primary cancers including secondary acute myeloid leukemia (sAML) is increasing in the United States; however, limited data exist regarding survival among individuals with sAML. This study aims to examine survival differences between sAML and AML arising de novo (dnAML) in relation to antecedent cancer types and the receipt of prior cancer treatment.

Methods: Individuals aged ≥20 years and diagnosed with sAML or dnAML between 2001 and 2018 and followed for vital status through 2019 were identified from Surveillance, Epidemiology, and End Results 17 database, covering 27% of the US population. The differences in AML-specific survival between individuals with sAML and dnAML were examined using multivariable Cox proportional hazards regression. Trends in five-year age-standardized relative survival from 2001-2014 were assessed using Joinpoint survival model for sAML and dnAML, separately.

Results: A total of 7,306 individuals diagnosed with sAML and 40,398 individuals with dnAML were included. During a median follow-up of 6 months, 78% of individuals with sAML died from AML compared to 71% of those with dnAML. In multivariable models, the risk of AML-specific mortality was 8% higher in individuals diagnosed with sAML than in those diagnosed with dnAML (hazard ratio [HR]=1.08, 95%CI=1.05-1.11), with the elevated risk more pronounced among those with younger ages at diagnosis (HR20-54 years=1.60, 95%CI=1.46-1.75 versus HR65+ years=0.99, 95%CI=0.96-1.03; Pinteraction<0.0001) and those who received chemotherapy (HRchemotherapy yes=1.14, 95%CI=1.10-1.19 versus HRchemotherapy no/unknown=0.95, 95%CI=0.90-0.99; Pinteraction=0.0004). Subgroup analysis by antecedent cancer types showed that HRs substantially varied ranging from 0.74 (95%CI=0.57-0.95) for individuals with a history of thyroid cancer to 1.78 (95%CI=1.04-3.07) for those with a history of soft tissue sarcomas. Further subgroup analysis by the receipt of chemotherapy for antecedent cancers showed that the elevated risk was generally restricted to individuals with a history of chemotherapy receipt with some variations by cancer types. Five-year relative survival significantly increased from 2001 to 2014 for both sAML and dnAML; though the increase was slower for sAML (annual percent change [APC]=0.30%, 95% CI 0.20-0.40) compared with dnAML (APC=0.77%, 95%CI=0.69-0.84). Likewise, five-year survival for the most contemporary period (2010-2018) was substantially lower for sAML (9.8%, 95%CI=9.3-10.3) than for dnAML (22.8%, 95%CI=22.3-23.2).

Conclusion: Individuals with sAML had in general worse AML cause-specific survival compared with their dnAML counterparts, with the differences most pronounced among those diagnosed at younger ages and who received chemotherapy. The findings may inform targeted treatment and survivorship recommendations for cancer survivors who develop sAML.

Citation Format: Ephrem Sedeta, Ahmedin Jemal, Lauren Nisotel, Hyuna Sung. Survival among adults diagnosed with secondary acute myeloid leukemia. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4379.

Patient and clinician experience of a serious illness conversation guide in oncology: A descriptive analysis

BACKGROUND/OBJECTIVE

Oncology guidelines recommend earlier communication with patients about prognosis and goals-of-care in serious illness. However, current evidence leaves gaps in our understanding of the experience of these conversations. This analysis evaluates the patient and clinician experience of a conversation using a Serious Illness Conversation Guide (SICG).

DESIGN/SETTING

Secondary analysis from a cluster-randomized clinical trial in a northeastern cancer center.

PARTICIPANTS

Physicians, advanced practice clinicians, and patients with advanced cancer who received the intervention.

INTERVENTION

SICG, clinician training, systems-changes.

MAIN OUTCOMES AND MEASURES

The patient questionnaire assessed perceptions of the conversation and impact on anxiety, hopefulness, peacefulness, sense of control over medical decisions, closeness with their clinician, and behaviors. The clinician questionnaire assessed feasibility, acceptability, and impact on satisfaction in their role.

RESULTS

We enrolled 54 clinicians and 163 patients; 41 clinicians and 118 patients had a SICG discussion. Most patients described the conversation as worthwhile (79%) and reported no change or improvement in their sense of peacefulness, hopefulness, and anxiety (on average 79%); 56% reported feeling closer with their clinician. Qualitative patient data described positive behavior changes, including enhanced planning for future care and increased focus on personal priorities. Nearly 90% of clinicians agreed that the SICG facilitated timely, effective conversations, and 70% reported increased satisfaction in their role.

CONCLUSION

Conversations using a SICG were feasible, acceptable, and were associated with positive experiences for both patients and clinicians in oncology in ways that align with national recommendations for serious illness communication. This trial is registered at ClinicalTrials.gov: NCT01786811 https://clinicaltrials.gov/ct2/show/NCT01786811.

A Systematic Review of Adherence to Oral Antineoplastic Therapies

BACKGROUND

Oral antineoplastic therapies not only improve survival but also reduce the burden of care for patients. Yet patients and clinicians face new challenges in managing adherence to these oral therapies. We conducted a systematic literature review to assess rates and correlates of adherence to oral antineoplastic therapies and interventions aimed at improving adherence.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive literature search of the Ovid MEDLINE database from January 1, 2003 to June 30, 2015, using relevant terminology for oral antineoplastic agents. We included observational, database, and intervention studies. At least two researchers evaluated each paper to ensure accuracy of results and determine risk of bias.

RESULTS

We identified 927 records from the search and screened 214 abstracts. After conducting a full-text review of 167 papers, we included in the final sample 51 papers on rates/correlates of adherence to oral antineoplastic therapy and 12 papers on intervention studies to improve adherence. Rates of adherence varied widely, from 46% to 100%, depending on patient sample, medication type, follow-up period, assessment measure, and calculation of adherence. Of the intervention studies, only 1 of the randomized trials and 2 of the cohort studies showed benefit regarding adherence, with the majority suffering high risk of bias.

CONCLUSIONS

Although no reliable estimate of adherence to oral antineoplastic therapies can be gleaned from the literature, a substantial proportion of patients struggle to adhere to these medications as prescribed. The few intervention studies for adherence have notable methodological concerns, thereby limiting the evidence to guide practice in promoting medication adherence among patients with cancer.

Development of a mobile application (app) for improving symptoms and adherence to oral chemotherapy in patients with cancer

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Background: An advantage of oral chemotherapy is ease of administration, yet patients and family caregivers receive less support for adherence and monitoring of side effects. Effective interventions should support adherence to oral chemotherapy. We conducted qualitative interviews with patients, clinicians, and relevant stakeholders to inform the development of a proposed mobile app intervention to improve adherence and symptoms to oral chemotherapy. Methods: We conducted qualitative interviews and focus groups with multiple stakeholder groups (18 oncology physicians, 8 healthcare representatives, 8 cancer practice administrators, 18 patients and family members). Eligible patients had a diagnosis of cancer, a prescription for oral chemotherapy, cancer care at the MGH Cancer Center, and access to a smart phone. Stakeholders and clinicians evaluated the study approach, patient engagement, and intervention implementation. Patients reviewed wireframes of the mobile app to evaluate the components, usability, feasibility, and acceptability. Results: The app features include a treatment plan, medication reminders, symptom reporting, and cancer-specific resources. The themes from the qualitative interviews suggest that this mobile app would be helpful in improving adherence to oral chemotherapy and symptom management. Patients reported the wireframes to be acceptable and potentially user-friendly. Clinicians found that ongoing symptom reports would be helpful for proactively managing patients’ symptoms. Stakeholders recognized the importance of an app with functional tools to aid adherence and symptom management. All parties agreed that app features should remain simple, avoid undue burden, and thus enhance usability. Conclusions: Our findings suggest that a mobile app could be helpful for adherence and improving symptoms to oral chemotherapy in patients with cancer. Patients and clinicians rated the wireframe content favorably and commended the different features. We refined and finalized the mobile app based on feedback from the qualitative interviews. These findings support our plan to test the efficacy of this intervention in a randomized controlled trial. Clinical trial information: NCT02157519.

Mobile application of cognitive behavioral therapy for anxiety and advanced cancer

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Background: We previously demonstrated the efficacy of a brief, in-person cognitive behavioral therapy (CBT) program for alleviating anxiety in patients with advanced cancer. The aim of the current study was to adapt this program to an interactive, patient-centered mobile tablet application (CBT app) for self-delivery, ideally to enhance dissemination and patient access to the CBT intervention. Methods: Development of the CBT app proceeded in two phases. First, we enrolled five patients with advanced cancer and anxiety (HADS-Anxiety subscale score ≥ 8) to review a preliminary CBT app prototype and to provide qualitative feedback regarding intervention acceptability and utility. Using content analysis of the recorded data, we identified key themes in patient feedback and refined the CBT app content and design accordingly. Finally, a multidisciplinary team of clinical researchers (n=7) specializing in healthcare technology, psychiatry, and psychology conducted an extensive iterative review process to vet and finalize the CBT app intervention. Results: Patients reported that the CBT app content was comprehensible, easily navigated, and helpful in addressing a breadth of concerns relevant to patients with anxiety and advanced cancer. Specifically, patients reported that case examples, tailored feedback, accessible interactive features, and content summaries were important for engagement with the program. The multidisciplinary study team used patient feedback to adapt the CBT app prototype to a tablet design consisting of six modules that teach skills for practicing relaxation, staying present-focused, coping with fears related to cancer, and pacing activities. To enhance patient engagement, features also included homework assignments, symptom distress tracking, and tailored algorithms and branching logic based on patient responses. Conclusions: Patient interviews confirmed acceptability of the CBT app content. Expert clinician feedback also supported the tablet design for self-administration of the intervention to reduce patient burden. We are currently conducting a randomized controlled trial to assess the efficacy of the CBT app for improving anxiety symptoms in patients with advanced cancer. Clinical trial information: NCT02286466.