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Fauer AJ, Qiu W, Huang IC, Ganz PA, Casillas JN, Yabroff KR, Armstrong GT, Leisenring W, Howell R, Howell CR, Kirchhoff AC, Yasui Y, Nathan PC. Financial Hardship & Neighborhood Socioeconomic Disadvantage in Long-term Childhood Cancer Survivors. JNCI Cancer Spectr 2024:pkae033. [PMID: 38676662 DOI: 10.1093/jncics/pkae033] [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: 04/11/2024] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Long-term survivors of childhood cancer face elevated risk for financial hardship. We evaluate whether childhood cancer survivors live in areas of greater deprivation and the association with self-reported financial hardships. METHODS Cross-sectional analysis of data from the Childhood Cancer Survivor Study (CCSS) between 1970 and 1999, and self-reported financial information from 2017-2019. We measured neighborhood deprivation with the Area Deprivation Index (ADI) based on current zip code. Financial hardship was measured with validated surveys that captured behavioral, material/financial sacrifice, and psychological hardship. Bivariate analyses described neighborhood differences between survivors and siblings. Generalized linear models estimated effect sizes between ADI and financial hardship adjusting for clinical factors and personal socioeconomic status. RESULTS Analysis was restricted to 3,475 long-term childhood cancer survivors and 923 sibling controls. Median ages at time of evaluation was 39 [IQR 33,46] and 47 [39,59] years, respectively. Survivors resided in areas with greater deprivation (ADI ≥ 50: 38.7% survivors vs 31.8% siblings, P < .001). One quintile increases in deprivation were associated with small increases in behavioral (2nd quintile P = .017) and psychological financial hardship (2nd quintile P = .009; 3rd quintile, P = .014). Lower psychological financial hardship was associated with individual factors including greater household income ($60,000+ income, P < .001) and being single (P = .048). CONCLUSIONS AND RELEVANCE Childhood cancer survivors were more likely to live in areas with socioeconomic deprivation. Both neighborhood level disadvantage and personal socioeconomic circumstances should be evaluated when trying to assist childhood cancer survivors with financial hardships.
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Affiliation(s)
- Alex J Fauer
- Family Caregiving Institute, Betty Irene Moore School of Nursing
- Comprehensive Cancer Center, University of California, Davis, Sacramento, CA, USA
| | - Weiyu Qiu
- University of Alberta; University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - I-Chan Huang
- St Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, TN, USA
| | - Patricia A Ganz
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jacqueline N Casillas
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA, USA
| | - Gregory T Armstrong
- St Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, TN, USA
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca Howell
- Department of Radiation Physics, Division of Radiation Oncology, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Carrie R Howell
- Nutrition Obesity Research Center, Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Anne C Kirchhoff
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, and University of Utah Department of Pediatrics, Salt Lake City, UT, USA
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Department of Epidemiology and Cancer Control, Memphis, TN, USA
| | - Paul C Nathan
- The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
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2
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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 PMCID: PMC11058025 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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Ohlsen TJD, Wang H, Buchbinder D, Huang IC, Desai AD, Zheng Z, Kirchhoff AC, Park ER, Krull K, Conti RM, Yasui Y, Leisenring W, Armstrong GT, Yabroff KR, Nathan PC, Chow EJ. Financial hardship among siblings of long-term survivors of childhood cancer: A Childhood Cancer Survivor Study report. Cancer 2024; 130:1125-1136. [PMID: 38100563 PMCID: PMC10939878 DOI: 10.1002/cncr.35150] [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: 09/06/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Siblings of children with cancer may experience adverse household economic consequences, but their financial outcomes in adulthood are unknown. METHODS A total of 880 siblings (aged 18-64 years) of adult-aged childhood cancer survivors were surveyed to estimate the prevalence of financial hardship by three established domains (behavioral, material, and psychological). For individual financial hardship items matching the contemporaneous National Health Interview Survey or Behavioral Risk Factor Surveillance System, siblings were compared with the general population by calculating adjusted prevalence odds ratios (ORs) to sample-weighted responses. Multivariable logistic regression models examined associations between sibling characteristics and each hardship domain and between sibling hardship and survivors' cancer/treatment characteristics. RESULTS Behavioral, material, and psychological hardship was reported by 24%, 35%, and 28%, respectively. Compared with national survey respondents, siblings were more likely to report worries about medical bills (OR, 1.14; 95% confidence interval [CI], 1.06-1.22), difficulty affording nutritious foods (OR, 1.79; 95% CI, 1.54-2.07), and forgoing needed medical care (OR, 1.38; 95% CI, 1.10-1.73), prescription medications (OR, 2.52; 95% CI, 1.99-3.20), and dental care (OR, 1.34; 95% CI, 1.15-1.57) because of cost. Sibling characteristics associated with reporting financial hardship in one or more domains included female sex, older age, chronic health conditions, lower income, not having health insurance, high out-of-pocket medical expenditures, and nonmedical/nonhome debt. No survivor cancer/treatment characteristics were associated with sibling financial hardship. CONCLUSIONS Adult siblings of childhood cancer survivors were more likely to experience financial hardship compared with the general population. Childhood cancer may adversely affect entire households, with potentially lasting implications.
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Affiliation(s)
- Timothy J. D. Ohlsen
- Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Huiqi Wang
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - I-Chan Huang
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Arti D. Desai
- Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | | | - Anne C. Kirchhoff
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Kevin Krull
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Rena M. Conti
- Questrom School of Business, Boston University, Boston, MA, USA
| | - Yutaka Yasui
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | | | | | - Paul C. Nathan
- The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Eric J. Chow
- Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
- Fred Hutchinson Cancer Center, Seattle, WA, USA
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4
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Park ER, Kirchhoff AC, Donelan K, Perez GK, McDonald A, Bliss CC, Foor A, van Thiel Berghuijs KM, Waters AR, Durieux N, Leisenring W, Armstrong GT, Ponzani C, Lopez A, Vaca Lopez PL, Battaglia T, Galbraith AA, Kuhlthau KA. Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study. JCO Oncol Pract 2024:OP2300680. [PMID: 38471048 DOI: 10.1200/op.23.00680] [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: 10/18/2023] [Revised: 12/01/2023] [Accepted: 01/31/2024] [Indexed: 03/14/2024] Open
Abstract
PURPOSE Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed. METHODS We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews. RESULTS Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03). CONCLUSION Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ana Lopez
- Massachusetts General Hospital, Boston, MA
| | | | - Tracy Battaglia
- Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Alison A Galbraith
- Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, MA
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5
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van der Plas E, Darji H, Srivastava DK, Schapiro M, Jeffe D, Perkins S, Howell R, Leisenring W, Armstrong GT, Oeffinger K, Krull K, Edelstein K, Hayashi RJ. Risk factors for neurocognitive impairment, emotional distress, and poor quality of life in survivors of pediatric rhabdomyosarcoma: A report from the Childhood Cancer Survivor Study. Cancer 2024. [PMID: 38373075 DOI: 10.1002/cncr.35236] [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: 09/06/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Prevalence and risk of poor psychological outcomes following rhabdomyosarcoma (RMS) are not well-established. METHODS Participants in this cross-sectional, case-control study (n = 713 survivors, 42.5% female; mean [SD] age, 30.5 [6.6] years; n = 706 siblings, 57.2% female; mean age, 32.8,[7.9] years) completed measures of neurocognition, emotional distress, and health-related quality of life (HRQOL). Multivariable logistic regression models identified treatments, health behaviors, and chronic conditions associated with impairment. RESULTS Relative to siblings, more survivors reported neurocognitive impairment (task efficiency: 21.1% vs. 13.7%, emotional regulation: 16.7% vs. 11.0%, memory: 19.3% vs. 15.1%), elevated emotional distress (somatic distress: 12.9% vs. 4.7%, anxiety: 11.7% vs. 5.9%, depression: 22.8% vs. 16.9%) and poorer HRQOL (physical functioning: 11.1% vs. 2.8%, role functioning due to physical problems: 16.8% vs. 8.2%, pain: 17.5% vs. 10.0%, vitality: 22.3% vs. 13.8%, social functioning: 14.4% vs. 6.8%, emotional functioning: 17.1% vs. 10.6%). Cranial radiation increased risk for impaired task efficiency (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.14-4.63), whereas chest and pelvic radiation predicted increased risk of physical functioning (OR, 2.68; 95% CI, 1.16-6.21 and OR, 3.44; 95% CI, 1.70-6.95, respectively). Smoking was associated with impaired task efficiency (OR, 2.06; 95% CI, 1.14-3.70), memory (OR, 2.23; 95% CI, 1.26-3.95), anxiety (OR, 2.71; 95% CI, 1.36-5.41) and depression (OR, 1.77; 95% CI, 1.01-3.11). Neurologic conditions increased risk of anxiety (OR, 2.30; 95% CI, 1.04-5.10), and hearing conditions increased risk of depression (OR, 1.79; 95% CI, 1.05-3.03). Neurologic and hearing conditions, respectively, were associated with impaired memory (OR, 2.44; 95% CI, 1.20-4.95 and OR, 1.87; 95% CI, 1.05-3.35) and poor health perception (OR, 2.62; 95% CI, 1.62-1.28 and OR, 2.33; 95% CI, 1.34-4.06). CONCLUSIONS RMS survivors are at significant risk for poor psychological outcomes. Advancing therapies for local control, smoking cessation, and managing chronic medical conditions may mitigate poor outcomes following RMS.
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Affiliation(s)
- Ellen van der Plas
- Department of Hematology/Oncology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Himani Darji
- Quantitative Sciences Unit, Department of Medicine, Stanford University, Stanford, California, USA
- Biostatistics Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Deo K Srivastava
- Biostatistics Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melissa Schapiro
- Department of Pediatrics, SSM Health Cardinal Glennon Children's Hospital-St. Louis University, St. Louis, Missouri, USA
| | - Donna Jeffe
- John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Stephanie Perkins
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rebecca Howell
- Department of Radiation Physics, The MD Anderson Cancer Center, Houston, Texas, USA
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutch Cancer Center, Seattle, Washington, USA
| | - Gregory T Armstrong
- Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kevin Oeffinger
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Kevin Krull
- Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kim Edelstein
- Department of Supportive Care, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Robert J Hayashi
- Washington University School of Medicine in St. Louis, Department of Pediatrics, St. Louis Childrens Hospital, Siteman Cancer Center, St. Louis, Missouri, USA
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6
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Waters AR, Liu Q, Ji X, Yasui Y, Yabroff KR, Conti RM, Henderson T, Huang IC, Leisenring W, Armstrong GT, Nathan PC, Park E, Kirchhoff AC. Job lock among survivors of childhood cancer and their spouses post Affordable Care Act implementation: A Childhood Cancer Survivor Study brief report. Pediatr Blood Cancer 2024; 71:e30790. [PMID: 38053241 PMCID: PMC10841982 DOI: 10.1002/pbc.30790] [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: 09/17/2023] [Revised: 11/10/2023] [Accepted: 11/15/2023] [Indexed: 12/07/2023]
Abstract
It is unknown how common job lock (i.e., staying at job to maintain health insurance) remains among childhood cancer survivors after Affordable Care Act (ACA) implementation in 2010. We examined prevalence of and factors associated with job lock using a cross-sectional survey from the Childhood Cancer Survivor Study (3503 survivors; 942 siblings). Survivor, spousal, and any survivor/spouse job lock were more frequently reported by survivors than siblings. Survivor job lock/any job lock was associated with older age, low income, severe chronic conditions, and debt/inability to pay debt. Job lock remains more common among survivors than siblings after ACA implementation.
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Affiliation(s)
- Austin R Waters
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Qi Liu
- University of Alberta, Edmonton, Alberta, Canada
| | - Xu Ji
- Department of Pediatrics, Emory University School of Medicine/Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Yutaka Yasui
- University of Alberta, Edmonton, Alberta, Canada
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - K Robin Yabroff
- Department of Surveillance and Health Equity Science, American Cancer Society, Atlanta, Georgia, USA
| | - Rena M Conti
- Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, Massachusetts, USA
| | - Tara Henderson
- Department of Pediatrics, University of Chicago, Chicago, Illinois, USA
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Paul C Nathan
- The Hospital for Sick Children, The University of Toronto, Toronto, Ontario, Canada
| | - Elyse Park
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anne C Kirchhoff
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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7
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Buchbinder D, Bhatt NS, Wang H, Yasui Y, Armenian S, Bhatia S, Chow EJ, Huang IC, Kirchoff AC, Leisenring W, Park ER, Yabroff KR, Armstrong GT, Nathan PC, Khera N. Financial Hardship in Childhood Cancer Survivors Treated with Hematopoietic Cell Transplantation: A Report from the Childhood Cancer Survivor Study. Transplant Cell Ther 2023; 29:705.e1-705.e9. [PMID: 37541329 PMCID: PMC10834839 DOI: 10.1016/j.jtct.2023.07.024] [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: 06/10/2023] [Revised: 07/25/2023] [Accepted: 07/30/2023] [Indexed: 08/06/2023]
Abstract
Long-term survivors of childhood cancer are at risk for financial hardship. However, it is not known if HCT leads to an incremental change in financial hardship for survivors who received it versus those who did not. We examined financial outcomes among adult survivors of childhood cancer who had undergone HCT. Using a cross-sectional survey in the Childhood Cancer Survivor Study population between 2017 and 2019, self-reported financial hardship was compared between survivors who received HCT, survivors treated without HCT ("non-HCT"), and siblings and categorized into 3 domains: material hardship/financial sacrifices, behavioral, and psychological hardship. The standardized score of each domain of financial hardship was calculated by adding the item responses and dividing by the standard deviation among siblings. Multivariable linear and logistic regression were used to evaluate associations between sociodemographic characteristics, cancer diagnosis, post-treatment complications, and financial hardship among survivors. The mean adjusted score for each hardship domain was not significantly different between HCT survivors (n = 133) and non-HCT survivors (n = 2711); mean differences were .18 (95% confidence interval [CI], -.05 to .41) for material hardship/financial sacrifices, .07 (95% CI, -.18 to .32) for behavioral hardship, and .19 (95% CI, -.04 to .42) for psychological hardship. Within specific items, a higher proportion of survivors treated with HCT reported greater financial hardship compared to non-HCT survivors. HCT survivors also had significantly higher mean domain scores compared to sibling controls (n = 1027) in all domains. Household income and chronic health conditions, but not HCT, were associated with financial hardship among all survivors. Adult survivors of childhood cancer treated with HCT do not report greater overall financial hardship compared to non-HCT survivors but do report greater overall financial hardship compared to sibling controls. Surveillance and intervention may be necessary for all survivors regardless of HCT status.
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Affiliation(s)
- David Buchbinder
- Department of Pediatrics, University of California at Irvine, Irvine, California; Division of Hematology, Oncology at Children's Hospital of Orange County, Orange, California.
| | - Neel S Bhatt
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Huiqi Wang
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Saro Armenian
- Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eric J Chow
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Anne C Kirchoff
- Cancer Control and Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah; Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elyse R Park
- Mongan Institute, Harvard Medical School, Boston, Massachusetts
| | - K Robin Yabroff
- Surveillane and Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Paul C Nathan
- Institute of Health Policy, Management and Evaluation, The University of Toronto, Toronto, Ontario, Canada; Division of Hematology, Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nandita Khera
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona
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8
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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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9
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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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10
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Nathan PC, Huang IC, Chen Y, Henderson TO, Park ER, Kirchhoff AC, Robison LL, Krull K, Leisenring W, Armstrong GT, Conti RM, Yasui Y, Yabroff KR. Financial Hardship in Adult Survivors of Childhood Cancer in the Era After Implementation of the Affordable Care Act: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:1000-1010. [PMID: 36179267 PMCID: PMC9928627 DOI: 10.1200/jco.22.00572] [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: 03/08/2022] [Revised: 07/09/2022] [Accepted: 08/05/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act. METHODS A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors. RESULTS Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg, CONCLUSION Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.
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Affiliation(s)
- Paul C. Nathan
- The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
| | - I-Chan Huang
- St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
| | - Yan Chen
- University of Alberta, Edmonton, School of Public Health Alberta, Edmonton, Alberta, Canada
| | - Tara O. Henderson
- University of Chicago Comer Children's Hospital, Section of Pediatric Hematology, Oncology and Stem Cell Transplantation, Chicago, IL
| | - Elyse R. Park
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Anne C. Kirchhoff
- Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, Salt Lake City, UT
| | - Leslie L. Robison
- St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
| | - Kevin Krull
- St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
| | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA
| | - Gregory T. Armstrong
- St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
| | - Rena M. Conti
- Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, MA
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
| | - K. Robin Yabroff
- Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA
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11
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Wang Y, Kremer LCM, van Leeuwen FE, Armstrong GT, Leisenring W, de Vathaire F, Hudson MM, Kuehni CE, Arnold MA, Haddy N, Demoor-Goldschmidt C, Diallo I, Howell RM, Ehrhardt MJ, Moskowitz CS, Neglia JP, van der Pal HJH, Robison LL, Schaapveld M, Turcotte LM, Waespe N, Ronckers CM, Teepen JC. Cohort profile: Risk and risk factors for female breast cancer after treatment for childhood and adolescent cancer: an internationally pooled cohort. BMJ Open 2022; 12:e065910. [PMID: 36344003 PMCID: PMC9644351 DOI: 10.1136/bmjopen-2022-065910] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The International Consortium for Pooled Studies on Subsequent Malignancies after Childhood and Adolescent Cancer was established in 2018 to address gaps in knowledge of risk and risk factors for breast cancer subsequent to childhood/adolescent cancer by pooling individual patient data from seven cohorts. Initially, the pooled cohort will focus on three clinically relevant questions regarding treatment-related subsequent breast cancer risk in female survivors, which are the risk related to low-dose radiotherapy exposure to the chest, specific chemotherapy agents and attained age. PARTICIPANTS The consortium database includes pooled data on 21 892 female survivors from seven cohorts in North America and Europe with a primary cancer diagnosis at <21 years of age, and survival ≥5 years from diagnosis. FINDINGS TO DATE This is a newly established pooled study. The cohort profile summarised the data collected from each included cohort, including childhood cancer diagnosis information and treatment details (ie, radiotherapy fields and cumulative doses, and chemotherapy agents and cumulative doses for each agent). Included cohorts' follow-up started 1951-1981 and ended 2013-2021, respectively, for a median follow-up duration of 24.3 (IQR 18.0-32.8) years since primary cancer diagnosis. The median age at primary cancer diagnosis was 5.4 (IQR 2.5-11.9) years. And the median attained age at last follow-up was 32.2 (IQR 24.0-40.4) years. In all, 4240 (19.4%) survivors were treated with radiotherapy to the chest and 9308 (42.5%) with anthracyclines. At the end of the follow-up, 835 females developed a first subsequent breast cancer, including 635 invasive breast cancer only, 184 carcinomas in situ only (172 ductal carcinomas in situ and 12 lobular carcinomas in situ), and 16 with both an invasive and in situ diagnosis at the same moment. The cumulative incidences of subsequent breast cancer (both invasive and in situ) 25 and 35 years after primary cancer diagnosis were 2.2% and 6.2%, respectively. FUTURE PLANS The consortium is intended to serve as a model and robust source of childhood/adolescent cancer survivor data for elucidating other knowledge gaps on subsequent breast cancer risk, and risk of other subsequent malignancies (including data on males) in the future.
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Affiliation(s)
- Yuehan Wang
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Leontien C M Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- University Medical Center Utrecht, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- Emma Children's Hospital, Amsterdam University Medical Center (UMC), University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Florent de Vathaire
- Radiation Epidemiology Team, INSERM U1018, Gustave Roussy, 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, Colorado, USA
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Nadia Haddy
- Radiation Epidemiology Team, INSERM U1018, Gustave Roussy, Villejuif, France
| | - Charlotte Demoor-Goldschmidt
- Radiation Epidemiology Team, INSERM U1018, Gustave Roussy, Villejuif, France
- Department of Pediatric Hematology and Oncology, University-Hospital of Angers, Angers, France
- Radiotherapy department, Francois Baclesse center, Caen, France
- Supportive care department, Francois Baclesse center, Caen, France
| | - Ibrahima Diallo
- Radiation Epidemiology Team, INSERM U1018, Gustave Roussy, Villejuif, France
| | - Rebecca M Howell
- University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | | | | | - Joseph P Neglia
- University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota, USA
| | | | | | | | - Lucie M Turcotte
- University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota, 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, University of Geneva, Geneva, Switzerland
| | - 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
| | - Jop C Teepen
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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12
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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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13
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Sapkota Y, Qiu W, Dixon SB, Wilson CL, Wang Z, Zhang J, Leisenring W, Chow EJ, Bhatia S, Armstrong GT, Robison LL, Hudson MM, Delaney A, Yasui Y. Genetic risk score enhances the risk prediction of severe obesity in adult survivors of childhood cancer. Nat Med 2022; 28:1590-1598. [PMID: 35879615 PMCID: PMC9391312 DOI: 10.1038/s41591-022-01902-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/14/2022] [Indexed: 02/03/2023]
Abstract
Adult survivors of childhood cancer have high rates of obesity, which, in combination with the cardiotoxic effects of specific cancer therapies, places them at high risk for cardiovascular morbidity. Here we show the contribution of genetic risk scores (GRSs) to increase prediction of those survivors of childhood cancer who are at risk for severe obesity (body mass index ≥40 kg m-2) as an adult. Among 2,548 individuals of European ancestry from the St. Jude Lifetime Cohort Study who were 5-year survivors of childhood cancer, the GRS was found to be associated with 53-fold-higher odds of severe obesity. Addition of GRSs to risk prediction models based on cancer treatment exposures and lifestyle factors significantly improved model prediction (area under the curve increased from 0.68 to 0.75, resulting in the identification of 4.3-times more high-risk survivors), which was independently validated in 6,064 individuals from the Childhood Cancer Survivor Study. Genetic predictors improve identification of patients who could benefit from heightened surveillance and interventions to mitigate the risk of severe obesity and associated cardio-metabolic complications.
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Affiliation(s)
- Yadav Sapkota
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Weiyu Qiu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Zhaoming Wang
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jinghui Zhang
- St. Jude Children’s Research Hospital, Memphis, TN, USA
| | | | - Eric J. Chow
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | | | | | - Yutaka Yasui
- St. Jude Children’s Research Hospital, Memphis, TN, USA
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14
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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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15
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Doney K, Leisenring W, Linden H. Allogeneic hematopoietic cell transplantation in patients with a hematologic malignancy and a prior history of breast cancer. Breast Cancer Res Treat 2022; 194:507-516. [PMID: 35779160 DOI: 10.1007/s10549-022-06658-5] [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: 03/29/2022] [Accepted: 06/08/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To compare the outcome of allogeneic stem cell transplantation for myeloid malignancies in breast cancer survivors to a contemporaneous control group. METHODS Medical records of all patients with a history of breast cancer who received allogeneic stem cell transplants at a single, tertiary referral Comprehensive Cancer Center between 2002 and 2019 were reviewed. Transplant outcomes were compared to 289 control patients without a history of breast cancer from the same time period. Main outcomes included survival, disease-free survival, non-relapse mortality, relapse or progression of hematologic malignancy, and incidence of recurrent breast cancer after hematopoietic cell transplantation. Comparisons between women with a history of breast cancer and controls utilized propensity score weighting to balance patient characteristics. RESULTS Forty women, ages 30-74 years, with a history of breast cancer received an allogeneic hematopoietic cell transplant for a hematologic malignancy between December 2002 and February 2019. Twelve of the 40 patients are alive with a median survival of 7.4 years (range, 1.9-16.8 years). None of the patients had evidence of recurrent breast cancer prior to death or date of last contact. In multivariable Cox models, all transplant outcomes were similar between the patients and the control group with hematopoietic cell transplant comorbidity score as the most important confounding factor for adjustment in these models. CONCLUSION A history of treated breast cancer should not exclude patients from consideration for allogeneic hematopoietic cell transplantation.
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Affiliation(s)
- Kristine Doney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N, D5-280, PO Box 19024, Seattle, WA, 98109-1024, USA. .,University of Washington Medical Center, Seattle, WA, USA.
| | - Wendy Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N, D5-280, PO Box 19024, Seattle, WA, 98109-1024, USA.,University of Washington Medical Center, Seattle, WA, USA
| | - Hannah Linden
- University of Washington Medical Center, Seattle, WA, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
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16
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de Blank PMK, Lange KR, Xing M, Salehabadi SM, Srivatava D, Brinkman TM, Ness KK, Oeffinger KC, Neglia J, Krull KR, Yasui Y, Nathan P, Howell R, Turcotte L, Leisenring W, Armstrong GT, Bowers DC, Okcu MF. LGG-15. Late mortality and morbidity of adult survivors of childhood glioma treated across three decades: a report from the Childhood Cancer Survivor Study. Neuro Oncol 2022. [PMCID: PMC9164667 DOI: 10.1093/neuonc/noac079.330] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE: Pediatric low-grade glioma therapy has evolved to delay or eliminate radiation. The impact of therapy changes on long-term outcomes remains unknown. METHODS: Cumulative incidence of late mortality (death >5 years from diagnosis), subsequent neoplasms (SNs), and chronic health conditions (CHCs, CTCAE grading criteria) were evaluated in the Childhood Cancer Survivor Study among 5-year survivors of glioma diagnosed 1970-1999. Outcomes were evaluated by diagnosis decade and by treatment exposures received ≤5 years following diagnosis (surgery-only, chemotherapy ± surgery, and cranial radiation ± surgery or chemotherapy). Relative risk (RRs) with 95%CIs estimated long-term outcomes using multivariable piecewise exponential models. RESULTS: Among 2,684 eligible survivors (age at diagnosis (median [range]), 7 years [0-20 years]; time from diagnosis, 24 years [5-48 years]), exposure to cranial radiation decreased [51% (1970s), 45% (1980s), 25% (1990s)] along with late tumor recurrence (>5 & ≤15 years from diagnosis) [9.8% (1970s), 8.8% (1980s), 5.0% (1990s)]. The 15-year cumulative incidence of late mortality was 10.3% (1970s), 6.5% (1980s), and 6.0% (1990s) (p<0.001, comparison of cumulative incidence curves). The 15-year cumulative incidence of grade 3-5 CHCs was 19.7% (1970s), 17.8% (1980s), and 14.2% (1990s) (p<0.0001). A reduction in SN incidence was not observed. In multivariable analyses excluding treatment exposure, later diagnosis (1990s vs. 1970s) was associated with lower risk of late mortality, grade 3-5 CHCs and SNs. Inclusion of treatment exposure in the model attenuated the effect of diagnosis decade. Radiation or chemotherapy exposure increased risk compared to surgery alone for late mortality (radiation RR 4.95, 95%CI 3.79-6.47; chemotherapy RR 2.88, 95%CI 1.85-4.48), CHCs (radiation RR 4.02, 95%CI 3.28-4.94; chemotherapy RR 1.66, 95%CI 1.13-2.45), and SNs (radiation RR 4.02, 95%CI 3.06-6.13, chemotherapy RR 2.08, 95%CI 1.03-4.23)). CONCLUSION: Late mortality and CHCs decreased in childhood glioma survivors diagnosed from 1970-1999 largely due to therapy changes, particularly avoidance of cranial radiation, without increased late recurrence.
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Affiliation(s)
- Peter M K de Blank
- University of Cincinnati Medical Center , Cincinnati, OH , USA
- Cincinnati Children's Hospital Medical Center , Cincinnati, OH , USA
| | | | - Mengqi Xing
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | | | | | | | - Kirsten K Ness
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | | | - Joseph Neglia
- University of Minnesota Medical School , Minneapolis, MN , USA
| | - Kevin R Krull
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | - Yutaka Yasui
- St. Jude Children's Research Hospital , Memphis, TN , USA
| | - Paul Nathan
- The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Rebecca Howell
- University of Texas MD Anderson Cancer Center , Houston, TX , USA
| | - Lucie Turcotte
- University of Minnesota Medical School , Minneapolis, MN , USA
| | | | | | - Daniel C Bowers
- University of Texas Southwestern Medical Center , Dallas, TX , USA
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17
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Williams AM, Mirzaei Salehabadi S, Xing M, Phillips NS, Ehrhardt MJ, Howell R, Yasui Y, Oeffinger KC, Gibson T, Chow EJ, Leisenring W, Srivastava D, Hudson MM, Robison LL, Armstrong GT, Krull KR. Modifiable risk factors for neurocognitive and psychosocial problems after Hodgkin lymphoma. Blood 2022; 139:3073-3086. [PMID: 34861035 PMCID: PMC9121843 DOI: 10.1182/blood.2021013167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 07/02/2021] [Accepted: 11/12/2021] [Indexed: 11/20/2022] Open
Abstract
Long-term survivors of childhood Hodgkin lymphoma (HL) experience a high burden of chronic health morbidities. Correlates of neurocognitive and psychosocial morbidity have not been well established. A total of 1760 survivors of HL (mean ± SD age, 37.5 ± 6.0 years; time since diagnosis, 23.6 ± 4.7 years; 52.1% female) and 3180 siblings (mean age, 33.2 ± 8.5 years; 54.5% female) completed cross-sectional surveys assessing neurocognitive function, emotional distress, quality of life, social attainment, smoking, and physical activity. Treatment exposures were abstracted from medical records. Chronic health conditions were graded according to the National Cancer Institute's Common Terminology Criteria for Adverse Events version 4.3 (1 = mild, 2 = moderate, 3 = severe/disabling, and 4 = life-threatening). Multivariable analyses, adjusted for age, sex, and race, estimated relative risk (RR) of impairment in survivors vs siblings and, among survivors, risk of impairment associated with demographic, clinical, treatment, and grade 2 or higher chronic health conditions. Compared with siblings, survivors had significantly higher risk (all, P < .05) of neurocognitive impairment (eg, memory, 8.1% vs 5.7%), anxiety (7.0% vs 5.4%), depression (9.1% vs 7%), unemployment (9.6% vs 4.4%), and impaired physical/mental quality of life (eg, physical function, 11.2% vs 3.0%). Smoking was associated with a higher risk of impairment in task efficiency (RR, 1.56; 95% confidence interval [CI], 1.02-2.39), emotional regulation (RR, 1.84; 95% CI, 1.35-2.49), anxiety (RR, 2.43; 95% CI, 1.51-3.93), and depression (RR, 2.73; 95% CI, 1.85-4.04). Meeting the exercise guidelines of the Centers for Disease Control and Prevention was associated with a lower risk of impairment in task efficiency (RR, 0.70; 95% CI, 0.52-0.95), organization (RR, 0.60; 95% CI, 0.45-0.80), depression (RR, 0.66; 95% CI, 0.48-0.92), and multiple quality of life domains. Cardiovascular and neurologic conditions were associated with impairment in nearly all domains. Survivors of HL are at elevated risk for neurocognitive and psychosocial impairment, and risk is associated with modifiable factors that provide targets for interventions to improve long-term functional outcomes.
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Affiliation(s)
| | | | | | | | - Matthew J Ehrhardt
- Department of Epidemiology and Cancer Control
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Kevin C Oeffinger
- Department of Medicine, Duke University and Duke Cancer Institute, Durham, NC
| | - Todd Gibson
- Division of Cancer Epidemiology and Genetics, Radiation Epidemiology Branch, National Cancer Institute, Rockville, MD
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA; and
| | - Wendy Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA; and
| | | | - Melissa M Hudson
- Department of Epidemiology and Cancer Control
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Kevin R Krull
- Department of Epidemiology and Cancer Control
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN
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18
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Xie H, Waghmare A, Cheng GS, Stamatatos L, Jerome K, Leisenring W, Englund JA, Boeckh M, Ogimi C. 923. Respiratory Syncytial and Parainfluenza Virus Infection Increase the Risk of Cytomegalovirus Reactivation in Allogeneic Hematopoietic Cell Transplant Recipients. Open Forum Infect Dis 2021. [PMCID: PMC8690804 DOI: 10.1093/ofid/ofab466.1118] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Respiratory virus infections are associated with significant and specific local and systemic inflammatory response patterns, which may lead to reactivation of latent viruses. We examined whether viral upper (URTI) or lower respiratory tract infection (LRTI) with common respiratory viruses increased the risk of CMV viremia after allogeneic hematopoietic cell transplantation (HCT).
Methods
We retrospectively analyzed patients undergoing allogeneic HCT between 4/2008 and 9/2018. CMV surveillance was performed weekly and the presence of upper and lower respiratory symptoms were evaluated by multiplex respiratory viral PCR. We used Cox proportional hazards models to evaluate risk factors for development of any CMV viremia or high level CMV viremia in the first 100 days post-HCT. Each respiratory virus infection episode was considered positive for 30 days beginning the day of diagnosis.
Results
Among 2,545 patients (404 children, 2141 adults), 1,221 and 247 developed CMV viremia and high level CMV viremia, respectively, in the first 100 days post-HCT. Infections due to human rhinoviruses (HRV, N=476) were most frequent, followed by parainfluenza viruses 1-4 (PIV, N=139), seasonal human coronaviruses (COV, N=134), respiratory syncytial virus (RSV, N=77), influenza A/B (FLU, N=35), human metapneumovirus (MPV, N=37), and adenovirus (ADV, N=61). In adjusted models, RSV LRTI was associated with increased risk of developing CMV viremia at all levels (Figures 1 and 2), and PIV or RSV URTI increased the risk of high level CMV viremia; all other viruses showed no association in univariable models.
Figure 1. Model estimates for associations between LRTI and development of any CMV viremia
Figure 2. Model estimates for associations between LRTI and development of high level CMV viremia
Conclusion
We demonstrated that RSV and PIV infections are associated with an increased risk for development of CMV viremia after allogeneic HCT. This novel association provides the rationale to explore virus-specific inflammatory pathways that may trigger CMV reactivation. CMV viremia may also serve as an endpoint in clinical trials that assess new preventative or therapeutic interventions of RSV or PIV infection.
Disclosures
Alpana Waghmare, MD, Allovir (Scientific Research Study Investigator)Ansun Biopharma (Scientific Research Study Investigator)Kyorin Pharmaceutical (Advisor or Review Panel member) Janet A. Englund, MD, AstraZeneca (Consultant, Grant/Research Support)GlaxoSmithKline (Research Grant or Support)Meissa Vaccines (Consultant)Pfizer (Research Grant or Support)Sanofi Pasteur (Consultant)Teva Pharmaceuticals (Consultant) Michael Boeckh, MD PhD, AlloVir (Consultant)Ansun Biopharma (Grant/Research Support)Astellas (Grant/Research Support)EvrysBio (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Gilead Sciences (Consultant, Grant/Research Support)GlaxoSmithKline (Consultant)Helocyte (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Janssen (Grant/Research Support)Kyorin (Consultant)Merck (Consultant, Grant/Research Support)Moderna (Consultant)Symbio (Consultant)Takeda (formerly known as Shire) (Consultant, Grant/Research Support)VirBio (Consultant, Grant/Research Support)
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Affiliation(s)
- Hu Xie
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Alpana Waghmare
- Seattle Children’s Hospital/University of Washington/Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Janet A Englund
- Seattle Children’s Hospital/Univ. of Washington, Seattle, Washington
| | - Michael Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Chikara Ogimi
- Seattle Children’s Hospital/University of Washington/Fred Hutchinson Cancer Research Center, Seattle, Washington
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19
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Zamora D, Perchetti G, Biernacki M, Xie H, Castor JL, Joncas-schronce L, Blazevic R, Leisenring W, Huang ML, Jerome K, Martin PJ, Boeckh M, Greninger AL. 20. Risk Factors for Breakthrough Cytomegalovirus (CMV) Infection and De Novo Resistance in Hematopoietic Cell Transplantation (HCT) Recipients Receiving Letermovir Prophylaxis. Open Forum Infect Dis 2021. [PMCID: PMC8643935 DOI: 10.1093/ofid/ofab466.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Subclinical CMV reactivation on letermovir prophylaxis may be important for CMV-specific immune reconstitution after HCT (Zamora et al. Blood 2021) but concerns remain regarding the development of antiviral resistance. Here we analyze risk factors associated with breakthrough CMV infection on letermovir and describe the incidence of de novo letermovir resistance. Methods All CMV-seropositive, allogeneic HCT recipients who received letermovir prophylaxis from 10/2018-2020 were analyzed. Weekly proportions and cumulative incidences of CMV reactivation in the first 100 days post-HCT were calculated at different levels. Clinically significant CMV infection was treated preemptively with (val)ganciclovir or foscarnet. Univariable/multivariable Cox regression models for breakthrough CMV reactivation at each viral threshold were performed. Patients with CMV reactivation ≥ 200 IU/mL were tested by UL56 sequencing to identify de novo letermovir resistance. Results Two hundred thirty HCT recipients who received letermovir prophylaxis were identified. Weekly proportions and cumulative incidences of CMV reactivation are shown in Figure 1. Nine of 15 patients with CMV reactivation had sufficient serum for letermovir resistance testing. One C325Y mutation was identified in an umbilical cord blood transplant recipient who developed 4 weeks of CMV DNAemia with a peak of 2512 IU/mL. The patient received 56 days of letermovir prior to reactivation and responded to treatment initially with foscarnet (due to cytopenias) followed by ganciclovir. Greater cumulative steroid exposure was associated with increased risk of CMV reactivation and the association remained statistically significant at any level (adjusted Hazard Ratio [aHR] 10.8 mg/kg*days, 95% confidence interval [CI] 5.18-22.7) and ≥ 150 IU/mL (aHR 15.9 mg/kg*days, 95% CI 7.07-35.6) after adjusting for underlying disease and GVHD prophylaxis (Figure 2). ![]()
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Conclusion Letermovir prophylaxis was effective at preventing clinically significant CMV infection but subclinical reactivation continued to occur. Cumulative steroid exposure was the strongest risk factor for reactivation while on letermovir. Development of de novo letermovir resistance on prophylaxis occurred infrequently. Disclosures Michael Boeckh, MD PhD, AlloVir (Consultant)Ansun Biopharma (Grant/Research Support)Astellas (Grant/Research Support)EvrysBio (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Gilead Sciences (Consultant, Grant/Research Support)GlaxoSmithKline (Consultant)Helocyte (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Janssen (Grant/Research Support)Kyorin (Consultant)Merck (Consultant, Grant/Research Support)Moderna (Consultant)Symbio (Consultant)Takeda (formerly known as Shire) (Consultant, Grant/Research Support)VirBio (Consultant, Grant/Research Support) Alexander L. Greninger, MD, PhD, Abbott (Grant/Research Support)Gilead (Grant/Research Support)Merck (Grant/Research Support)
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Affiliation(s)
| | | | | | - Hu Xie
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | | | | | | | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
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20
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Summers C, Wu QV, Annesley C, Bleakley M, Dahlberg A, Narayanaswamy P, Huang W, Voutsinas J, Brand A, Leisenring W, Jensen MC, Park JR, Gardner RA. Hematopoietic Cell Transplantation after CD19 Chimeric Antigen Receptor T Cell-Induced Acute Lymphoblastic Lymphoma Remission Confers a Leukemia-Free Survival Advantage. Transplant Cell Ther 2021; 28:21-29. [PMID: 34644605 DOI: 10.1016/j.jtct.2021.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022]
Abstract
Consolidative hematopoietic cell transplantation (HCT) after CD19 chimeric antigen receptor (CAR) T cell therapy is frequently performed for patients with refractory/ relapsed B cell acute lymphoblastic leukemia (B-ALL). However, there is controversy regarding the role of HCT following remission attainment. We evaluated the effect of consolidative HCT on leukemia-free survival (LFS) in pediatric and young adult subjects following CD19 CAR T cell induced remission. We evaluated the effect of consolidative HCT on LFS in pediatric and young adult subjects treated with a 41BB-CD19 CAR T cell product on a phase 1/2 trial, Pediatric and Young Adult Leukemia Adoptive Therapy (PLAT)-02 (ClinicalTrials.gov identifier NCT02028455), using a time-dependent Cox proportional hazards statistical model. Fifty of 64 subjects enrolled in PLAT-02 phase 1 and early phase 2 were evaluated, excluding 14 subjects who did not achieve remission, relapsed, or died before day 63 post-CAR T cell therapy. An improved LFS (P = .01) was observed in subjects who underwent consolidative HCT after CAR T cell therapy versus watchful waiting. Consolidative HCT improved LFS specifically in subjects who had no prior history of HCT, with a trend toward significance (P = .09). This benefit was not evident when restricted to the cohort of 34 subjects with a history of prior HCT (P = .45). However, for subjects who had CAR T cell functional persistence of 63 days or less, inclusive of those with a history of prior HCT, HCT significantly improved LFS outcomes (P = .01). These data support the use of consolidative HCT following CD19 CAR T cell-induced remission for patients with no prior history of HCT and those with short functional CAR T cell persistence.
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Affiliation(s)
- Corinne Summers
- Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Qian Vicky Wu
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Colleen Annesley
- Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Marie Bleakley
- Department of Pediatrics, University of Washington, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Ann Dahlberg
- Department of Pediatrics, University of Washington, Seattle, Washington; Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Wenjun Huang
- Seattle Children's Research Institute, Seattle, Washington
| | | | - Adam Brand
- Seattle Children's Research Institute, Seattle, Washington
| | | | - Michael C Jensen
- Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington; Department of Bioengineering, University of Washington, Seattle, Washington
| | - Julie R Park
- Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Rebecca A Gardner
- Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington.
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21
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Stefanski KJ, Anixt JS, Goodman P, Bowers K, Leisenring W, Scott Baker K, Burns K, Howell R, Davies S, Robison LL, Armstrong GT, Krull KR, Recklitis C. Long-Term Neurocognitive and Psychosocial Outcomes After Acute Myeloid Leukemia: A Childhood Cancer Survivor Study Report. J Natl Cancer Inst 2021; 113:481-495. [PMID: 32797189 DOI: 10.1093/jnci/djaa102] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/11/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Survivors of childhood acute myeloid leukemia (AML) are vulnerable to medical late effects of treatment; however, less is known about their psychosocial outcomes. This study evaluated neurocognitive and psychosocial outcomes in long-term AML survivors treated with bone marrow transplantation (BMT) or intensive chemotherapy (IC) without BMT. METHODS AML survivors (N = 482; median age at diagnosis = 8 [range = 0-20] years; median age at evaluation = 30 [range = 18-49] years) treated with BMT (n = 183) or IC (n = 299) and sibling controls (N = 3190; median age at evaluation = 32 [range = 18-58] years) from the Childhood Cancer Survivor Study were compared on emotional distress (Brief Symptom Inventory-18), neurocognitive problems (Childhood Cancer Survivor Study Neurocognitive Questionnaire), health-related quality of life (SF-36), and social attainment. Outcomes were dichotomized (impaired vs nonimpaired) using established criteria, and relative risks (RRs) were estimated with multivariable Poisson regression, adjusted for age at evaluation and sex. RESULTS AML survivors were more likely than siblings to report impairment in overall emotional (RR = 2.19, 95% confidence interval [CI] = 1.51 to 3.18), neurocognitive (RR = 2.03, 95% CI = 1.47 to 2.79), and physical quality of life (RR = 2.71, 95% CI = 1.61 to 4.56) outcomes. Survivors were at increased risk for lower education (RR = 1.15, 95% CI = 1.03 to 1.30), unemployment (RR = 1.41, 95% CI = 1.16 to 1.71), lower income (RR = 1.39, 95% CI = 1.17 to 1.65), and not being married or having a partner (RR = 1.33, 95% CI = 1.17 to 1.51). BMT-treated survivors did not differ statistically significantly from IC-treated on any outcome measure. CONCLUSIONS AML survivors are at increased risk for psychosocial impairment compared with siblings; however, BMT does not confer additional risk for psychosocial late effects compared with treatment without BMT.
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Affiliation(s)
| | - Julia S Anixt
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Pamela Goodman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Katherine Bowers
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - K Scott Baker
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Karen Burns
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rebecca Howell
- The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Stella Davies
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Kevin R Krull
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Christopher Recklitis
- Department of Pediatrics, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA, USA
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22
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Fair D, Park ER, Nipp RD, Rabin J, Hyland K, Kuhlthau K, Perez GK, Nathan PC, Armstrong GT, Oeffinger KC, Robison LL, Leisenring W, Kirchhoff AC. Material, behavioral, and psychological financial hardship among survivors of childhood cancer in the Childhood Cancer Survivor Study. Cancer 2021; 127:3214-3222. [PMID: 34061973 PMCID: PMC8489494 DOI: 10.1002/cncr.33613] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/03/2021] [Accepted: 03/28/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Medical financial burden includes material, behavioral, and psychological hardship and has been underinvestigated among adult survivors of childhood cancer. METHODS A survey from 698 survivors and 210 siblings from the Childhood Cancer Survivor Study was analyzed. The intensity of financial hardship was estimated across 3 domains: 1) material, including conditions that arise from medical expenses; 2) behavioral, including coping behaviors to manage medical expenses; and 3) psychological hardship resulting from worries about medical expenses and insurance, as measured by the number of instances of each type of financial hardship (0, 1-2, and ≥3 instances). Multivariable logistic regressions were conducted to examine the clinical and sociodemographic predictors of experiencing financial hardship (0-2 vs ≥3 instances). RESULTS The intensity of financial hardship did not significantly differ between survivors and siblings. Survivors reported more instances of material hardship than siblings (1-2 instances: 27.2% of survivors vs 22.6% of siblings; ≥3 instances: 15.9% of survivors vs 11.4% siblings; overall P = .03). In multivariable regressions, insurance was protective against all domains of financial hardship (behavioral odds ratio [OR], 0.12; 95% confidence interval [CI], 0.06-0.22; material OR, 0.37; 95% CI, 0.19-0.71; psychological OR, 0.10; 95% CI, 0.05-0.21). Survivors who were older at diagnosis, female, and with chronic health conditions generally had higher levels of hardship. Brain radiation and alkylating agents were associated with higher levels of hardship. CONCLUSIONS Material, behavioral, and psychological financial burden among survivors of childhood cancer is common.
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Affiliation(s)
- Douglas Fair
- University of Utah, Salt Lake City, Utah
- Huntsman Cancer Institute, Salt Lake City, Utah
| | - Elyse R Park
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ryan D Nipp
- Massachusetts General Hospital, Boston, Massachusetts
| | - Julia Rabin
- Massachusetts General Hospital, Boston, Massachusetts
| | - Kelly Hyland
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Paul C Nathan
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | - Anne C Kirchhoff
- University of Utah, Salt Lake City, Utah
- Huntsman Cancer Institute, Salt Lake City, Utah
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23
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Bates J, Shrestha S, Liu Q, Smith S, Mulrooney D, Leisenring W, Gibson T, Robison L, Chow E, Oeffinger K, Armstrong G, Constine L, Hoppe B, Lee C, Yasui Y, Howell R. OC-0208 Cardiac substructure dosimetry and late cardiac arrhythmia in the Childhood Cancer Survivor Study. Radiother Oncol 2021. [DOI: 10.1016/s0167-8140(21)06823-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Yeh JM, Lowry KP, Schechter CB, Diller LR, O'Brien G, Alagoz O, Armstrong GT, Hampton JM, Hudson MM, Leisenring W, Liu Q, Mandelblatt JS, Miglioretti DL, Moskowitz CS, Nathan PC, Neglia JP, Oeffinger KC, Trentham-Dietz A, Stout NK. Breast Cancer Screening Among Childhood Cancer Survivors Treated Without Chest Radiation: Clinical Benefits and Cost-Effectiveness. J Natl Cancer Inst 2021; 114:235-244. [PMID: 34324686 DOI: 10.1093/jnci/djab149] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/22/2021] [Accepted: 07/22/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Early initiation of breast cancer screening is recommended for high-risk women, including survivors of childhood cancer treated with chest radiation. Recent studies suggest that female survivors of childhood leukemia or sarcoma treated without chest radiation are also at elevated early onset breast cancer risk. However, the potential clinical benefits and cost-effectiveness of early breast cancer screening among these women are uncertain. METHODS Using data from the Childhood Cancer Survivor Study, we adapted two Cancer Intervention and Surveillance Modeling Network (CISNET) breast cancer simulation models to reflect the elevated risks of breast cancer and competing mortality among leukemia and sarcoma survivors. Costs and utility weights were based on published studies and databases. Outcomes included breast cancer deaths averted, false-positive-screening results, benign biopsies, and incremental cost-effectiveness ratios (ICERs). RESULTS In the absence of screening, the lifetime risk of dying from breast cancer among survivors was 6.8% to 7.0% across models. Early initiation of annual mammography with MRI screening between ages 25 and 40 would avert 52.6% to 64.3% of breast cancer deaths. When costs and quality of life impacts were considered, screening starting at age 40 was the only strategy with an ICER below the $100,000 per quality-adjusted life-year (QALY) gained cost-effectiveness threshold ($27,680 to $44,380 per QALY gained across models). CONCLUSIONS Among survivors of childhood leukemia or sarcoma, early initiation of breast cancer screening at age 40 may reduce breast cancer deaths by half and is cost-effective. These findings could help inform screening guidelines for survivors treated without chest radiation.
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Affiliation(s)
- Jennifer M Yeh
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kathryn P Lowry
- University of Washington, Seattle Cancer Care Alliance, Seattle, WA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Lisa R Diller
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA
| | - Grace O'Brien
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | | | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - John M Hampton
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Qi Liu
- University of Alberta, Edmonton, Alberta, Canada
| | | | - Diana L Miglioretti
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA
| | - Chaya S Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY, NY
| | | | - Joseph P Neglia
- Department of Pediatrics, University of Minnesota Medical School
| | | | - Amy Trentham-Dietz
- Department of Population Health Sciences and Carbone Cancer Center, University of Wisconsin-Madison, Madison, WI
| | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Moskowitz CS, Ronckers CM, Chou JF, Smith SA, Friedman DN, Barnea D, Kok JL, de Vries S, Wolden SL, Henderson TO, van der Pal HJH, Kremer LCM, Neglia JP, Turcotte LM, Howell RM, Arnold MA, Schaapveld M, Aleman B, Janus C, Versluys B, Leisenring W, Sklar CA, Begg CB, Pike MC, Armstrong GT, Robison LL, van Leeuwen FE, Oeffinger KC. Development and Validation of a Breast Cancer Risk Prediction Model for Childhood Cancer Survivors Treated With Chest Radiation: A Report From the Childhood Cancer Survivor Study and the Dutch Hodgkin Late Effects and LATER Cohorts. J Clin Oncol 2021; 39:3012-3021. [PMID: 34048292 DOI: 10.1200/jco.20.02244] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Women treated with chest radiation for childhood cancer have one of the highest risks of breast cancer. Models producing personalized breast cancer risk estimates applicable to this population do not exist. We sought to develop and validate a breast cancer risk prediction model for childhood cancer survivors treated with chest radiation incorporating treatment-related factors, family history, and reproductive factors. METHODS Analyses were based on multinational cohorts of female 5-year survivors of cancer diagnosed younger than age 21 years and treated with chest radiation. Model derivation was based on 1,120 participants in the Childhood Cancer Survivor Study diagnosed between 1970 and 1986, with median attained age 42 years (range 20-64) and 242 with breast cancer. Model validation included 1,027 participants from three cohorts, with median age 32 years (range 20-66) and 105 with breast cancer. RESULTS The model included current age, chest radiation field, whether chest radiation was delivered within 1 year of menarche, anthracycline exposure, age at menopause, and history of a first-degree relative with breast cancer. Ten-year risk estimates ranged from 2% to 23% for 30-year-old women (area under the curve, 0.63; 95% CI, 0.50 to 0.73) and from 5% to 34% for 40-year-old women (area under the curve, 0.67; 95% CI, 0.54 to 0.84). The highest risks were among premenopausal women older than age 40 years treated with mantle field radiation within a year of menarche who had a first-degree relative with breast cancer. It showed good calibration with an expected-to-observed ratio of the number of breast cancers of 0.92 (95% CI, 0.74 to 1.16). CONCLUSION Breast cancer risk varies among childhood cancer survivors treated with chest radiation. Accurate risk prediction may aid in refining surveillance, counseling, and preventive strategies in this population.
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Affiliation(s)
| | - Cécile M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Joanne F Chou
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Susan A Smith
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Dana Barnea
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Judith L Kok
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | - Tara O Henderson
- University of Chicago Medicine Comer Children's Hospital, Chicago, IL
| | | | | | - Joseph P Neglia
- University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | | | | | | | | | - Berthe Aleman
- Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Birgitta Versluys
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | | | - Colin B Begg
- Memorial Sloan Kettering Cancer Center, New York, NY
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26
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Sim JA, Hyun G, Gibson TM, Yasui Y, Leisenring W, Hudson MM, Robison LL, Armstrong GT, Krull KR, Huang IC. Negligible Effects of the Survey Modes for Patient-Reported Outcomes: A Report From the Childhood Cancer Survivor Study. JCO Clin Cancer Inform 2021; 4:10-24. [PMID: 31951475 DOI: 10.1200/cci.19.00135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE This study compared the measurement properties for multiple modes of survey administration, including postal mail, telephone interview, and Web-based completion of patient-reported outcomes (PROs) among survivors of childhood cancer. METHODS The population included 6,974 adult survivors of childhood cancer in the Childhood Cancer Survivor Study who completed the Brief Symptom Inventory-18 (BSI-18), which measured anxiety, depression, and somatization symptoms. Scale reliability, construct validity, and known-groups validity related to health status were tested for each mode of completion. The multiple indicators and multiple causes technique was used to identify differential item functioning (DIF) for the BSI-18 items that responded through a specific survey mode. The impact of the administration mode was tested by comparing differences in BSI-18 scores between the modes accounting for DIF effects. RESULTS Of the respondents, 58%, 27%, and 15% completed postal mail, Web-based, and telephone surveys, respectively. Survivors who were male; had lower education, lower household income, or poorer health status; or were treated with cranial radiotherapy were more likely to complete a telephone-based survey compared with either a postal mail or Web-based survey (all P < .05). Scale reliability and validity were equivalent across the 3 survey options. One, 2, and 5 items from the anxiety, depression, and somatization domains, respectively, were identified as having significant DIF among survivors who responded by telephone (P < .05). However, estimated BSI-18 domain scores, especially depression and anxiety, between modes did not differ after accounting for DIF effects. CONCLUSION Certain survivor characteristics were associated with choosing a specific mode for PRO survey completion. However, measurement properties among these modes were equivalent, and the impact of using a specific mode on scores was minimal.
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Affiliation(s)
- Jin-Ah Sim
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Geehong Hyun
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Todd M Gibson
- 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
| | - Wendy Leisenring
- Clinical Research Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN.,Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - 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
| | - 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
| | - I-Chan Huang
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
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27
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Boonyaratanakornkit J, Vivek M, Xie H, Pergam SA, Cheng GS, Mielcarek M, Hill JA, Jerome KR, Limaye AP, Leisenring W, Boeckh MJ, Waghmare A. Predictive Value of Respiratory Viral Detection in the Upper Respiratory Tract for Infection of the Lower Respiratory Tract With Hematopoietic Stem Cell Transplantation. J Infect Dis 2020; 221:379-388. [PMID: 31541573 PMCID: PMC7107470 DOI: 10.1093/infdis/jiz470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/11/2019] [Indexed: 12/30/2022] Open
Abstract
Background Hematopoietic cell transplant (HCT) recipients are frequently infected with respiratory viruses (RVs) in the upper respiratory tract (URT), but the concordance between URT and lower respiratory tract (LRT) RV detection is not well characterized. Methods Hematopoietic cell transplant candidates and recipients with respiratory symptoms and LRT and URT RV testing via multiplex PCR from 2009 to 2016 were included. Logistic regression models were used to analyze risk factors for LRT RV detection. Results Two-hundred thirty-five HCT candidates or recipients had URT and LRT RV testing within 3 days. Among 115 subjects (49%) positive for a RV, 37% (42 of 115) had discordant sample pairs. Forty percent (17 of 42) of discordant pairs were positive in the LRT but negative in the URT. Discordance was common for adenovirus (100%), metapneumovirus (44%), rhinovirus (34%), and parainfluenza virus type 3 (28%); respiratory syncytial virus was highly concordant (92%). Likelihood of LRT detection was increased with URT detection (oods ratio [OR] = 73.7; 95% confidence interval [CI], 26.7–204) and in cytomegalovirus-positive recipients (OR = 3.70; 95% CI, 1.30–10.0). Conclusions High rates of discordance were observed for certain RVs. Bronchoalveolar lavage sampling may provide useful diagnostic information to guide management in symptomatic HCT candidates and recipients.
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Affiliation(s)
- Jim Boonyaratanakornkit
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Meghana Vivek
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Hu Xie
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Guang-Shing Cheng
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua A Hill
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Keith R Jerome
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Ajit P Limaye
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Michael J Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alpana Waghmare
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
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28
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van der Plas E, Qiu W, Nieman BJ, Yasui Y, Liu Q, Dixon SB, Kadan-Lottick NS, Weldon CB, Weil BR, Jacola LM, Gibson TM, Leisenring W, Oeffinger K, Hudson MM, Robison LL, Armstrong GT, Krull KR. Sex-Specific Associations Between Chemotherapy, Chronic Conditions, and Neurocognitive Impairment in Acute Lymphoblastic Leukemia Survivors: A Report From the Childhood Cancer Survivor Study. J Natl Cancer Inst 2020; 113:588-596. [PMID: 32882041 PMCID: PMC8096369 DOI: 10.1093/jnci/djaa136] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The purpose was to examine associations between treatment and chronic health conditions with neurocognitive impairment survivors of acute lymphoblastic leukemia (ALL) treated with chemotherapy only. METHODS This cross-sectional study included 1207 ALL survivors (54.0% female; mean age 30.6 years) and 2273 siblings (56.9% female; mean age 47.6 years), who completed the Childhood Cancer Survivor Study Neurocognitive Questionnaire. Multivariable logistic regression compared prevalence of neurocognitive impairment between survivors and siblings by sex. Associations between neurocognitive impairment with treatment exposures and chronic conditions (graded according to Common Terminology Criteria for Adverse Events) were also examined. Statistical tests were 2-sided. RESULTS Relative to same-sex siblings, male and female ALL survivors reported increased prevalence of impaired task efficiency (males: 11.7% vs 16.9%; adjusted odds ratio [OR] = 1.89, 95% confidence interval [CI] = 1.31 to 2.74; females: 12.5% vs 17.6%; OR = 1.50, 95% CI = 1.07 to 2.14), as well as impaired memory (males: 11.6% vs 19.9%, OR = 1.89, CI = 1.31 to 2.74; females: 14.78% vs 25.4%, OR = 1.96, 95% CI = 1.43 to 2.70, respectively). Among male survivors, impaired task efficiency was associated with 2-4 neurologic conditions (OR = 4.33, 95% CI = 1.76 to 10.68) and with pulmonary conditions (OR = 4.99, 95% CI = 1.51 to 16.50), and impaired memory was associated with increased cumulative dose of intrathecal methotrexate (OR = 1.68, 95% CI = 1.16 to 2.46) and with exposure to dexamethasone (OR = 2.44, 95% CI = 1.19 to 5.01). In female survivors, grade 2-4 endocrine conditions were associated with higher risk of impaired task efficiency (OR = 2.19, 95% CI = 1.20 to 3.97) and memory (OR = 2.26, 95% CI = 1.31 to 3.92). CONCLUSION Neurocognitive impairment is associated with methotrexate, dexamethasone, and chronic health conditions in a sex-specific manner, highlighting the need to investigate physiological mechanisms and monitor impact through survivorship.
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Affiliation(s)
- Ellen van der Plas
- University of Iowa Hospital & Clinics, Department of Psychiatry, Iowa City, IA, USA
| | - Weiyu Qiu
- University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - Brian J Nieman
- The Hospital for Sick Children, Translational Medicine, Toronto, Ontario, Canada
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Epidemiology and Cancer Control Department, Memphis, TN, USA
| | - Qi Liu
- University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - Stephanie B Dixon
- St Jude Children's Research Hospital, Oncology Department, Memphis, TN, USA
| | - Nina S Kadan-Lottick
- Yale University School of Medicine, Pediatric Hematology & Oncology, New Haven, CT, USA
| | | | - Brent R Weil
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Lisa M Jacola
- St Jude Children's Research Hospital, Psychology Department, Memphis, TN, USA
| | - Todd M Gibson
- National Institutes of Health, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | | | - Melissa M Hudson
- St Jude Children's Research Hospital, Oncology Department, Memphis, TN, USA
| | - Leslie L Robison
- St Jude Children's Research Hospital, Epidemiology and Cancer Control Department, Memphis, TN, USA
| | - Gregory T Armstrong
- St Jude Children's Research Hospital, Epidemiology and Cancer Control Department, Memphis, TN, USA
| | - Kevin R Krull
- St Jude Children's Research Hospital, Psychology Department, Memphis, TN, USA
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29
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Yeh JM, Lowry KP, Schechter CB, Diller LR, Alagoz O, Armstrong GT, Hampton JM, Leisenring W, Liu Q, Mandelblatt JS, Miglioretti DL, Moskowitz CS, Oeffinger KC, Trentham-Dietz A, Stout NK. Clinical Benefits, Harms, and Cost-Effectiveness of Breast Cancer Screening for Survivors of Childhood Cancer Treated With Chest Radiation : A Comparative Modeling Study. Ann Intern Med 2020; 173:331-341. [PMID: 32628531 PMCID: PMC7510774 DOI: 10.7326/m19-3481] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Surveillance with annual mammography and breast magnetic resonance imaging (MRI) is recommended for female survivors of childhood cancer treated with chest radiation, yet benefits, harms, and costs are uncertain. OBJECTIVE To compare the benefits, harms, and cost-effectiveness of breast cancer screening strategies in childhood cancer survivors. DESIGN Collaborative simulation modeling using 2 Cancer Intervention and Surveillance Modeling Network breast cancer models. DATA SOURCES Childhood Cancer Survivor Study and published data. TARGET POPULATION Women aged 20 years with a history of chest radiotherapy. TIME HORIZON Lifetime. PERSPECTIVE Payer. INTERVENTION Annual MRI with or without mammography, starting at age 25, 30, or 35 years. OUTCOME MEASURES Breast cancer deaths averted, false-positive screening results, benign biopsy results, and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS Lifetime breast cancer mortality risk without screening was 10% to 11% across models. Compared with no screening, starting at age 25 years, annual mammography with MRI averted the most deaths (56% to 71%) and annual MRI (without mammography) averted 56% to 62%. Both strategies had the most screening tests, false-positive screening results, and benign biopsy results. For an ICER threshold of less than $100 000 per quality-adjusted life-year gained, screening beginning at age 30 years was preferred. RESULTS OF SENSITIVITY ANALYSIS Assuming lower screening performance, the benefit of adding mammography to MRI increased in both models, although the conclusions about preferred starting age remained unchanged. LIMITATION Elevated breast cancer risk was based on survivors diagnosed with childhood cancer between 1970 and 1986. CONCLUSION Early initiation (at ages 25 to 30 years) of annual breast cancer screening with MRI, with or without mammography, might reduce breast cancer mortality by half or more in survivors of childhood cancer. PRIMARY FUNDING SOURCE American Cancer Society and National Institutes of Health.
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Affiliation(s)
- Jennifer M. Yeh
- Department of Pediatrics, Harvard Medical School and Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Kathryn P. Lowry
- University of Washington, Seattle Cancer Care Alliance, 825 Eastlake Ave. E., Seattle, WA 98109
| | - Clyde B. Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Block Building 406, Bronx, NY 10461
| | - Lisa R. Diller
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, 450 Brookline Avenue, Boston, MA 02115
| | - Oguzhan Alagoz
- University of Wisconsin–Madison, 1513 University Avenue, Madison, WI 53706
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, 262 Danny Thomas Pl, Memphis, TN 38105
| | - John M. Hampton
- University of Wisconsin Carbone Cancer Center, 610 Walnut Street, WARF Room 307, Madison, WI 53726
| | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Seattle, WA, 98109
| | - Qi Liu
- University of Alberta, 11405 87th Avenue, Edmonton, Alberta, Canada T6G 1C9
| | - Jeanne S. Mandelblatt
- Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street Northwest, Suite 4100, Washington, DC 20007
| | - Diana L. Miglioretti
- Department of Public Health Sciences, University of California Davis School of Medicine, One Shields Avenue, Med-Sci 1C, Room 145, Davis, CA 95616
| | - Chaya S. Moskowitz
- Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, 2nd floor, NY, NY 10017
| | | | - Amy Trentham-Dietz
- University of Wisconsin Carbone Cancer Center, 610 Walnut Street, WARF Room 307, Madison, WI 53726
| | - Natasha K. Stout
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Landmark Center, 401 Park Drive, Suite 401, Boston, MA 02215
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30
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Zhou X, Bhakta N, Wang J, Sioson E, Patel J, Shelton K, Wang Z, Lei S, Gout AM, Wilson CL, Leisenring W, Bhatia S, Yasui Y, Hudson MM, Armstrong GT, Robison LL, Zhang J. Abstract 1198: The St. Jude Survivorship Portal links whole-genome genetic data with clinical therapy and outcome phenotypes for 7302 pediatric cancer survivors. Cancer Res 2020. [DOI: 10.1158/1538-7445.am2020-1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Clinical and basic research addressing the long-term outcomes of the increasing and high-risk population of pediatric cancer survivors requires large cohorts with high quality information. We have assembled the largest group of pediatric cancer survivors to date with comprehensive clinical characterization and germline whole-genome sequencing (WGS), and made these data available through the Survivorship Portal on St. Jude Cloud (https://survivorship.stjude.cloud).
The Portal contains data from 7302 survivors from two large studies, including 4402 from the St. Jude Lifetime Cohort Study (SJLIFE) with clinically-assessed outcome phenotypes, and 2900 from the Childhood Cancer Survivor Study (CCSS) with self-reported outcome phenotypes. High-quality germline variants and genotype calls from WGS were generated and curated by an in-house pipeline with corrected indel alleles and read counts. Germline variants of individual survivors are linked with standardized phenotypes described by >300 variables, spanning cancer-related data including diagnosis, length of follow-up, treatment (cumulative doses of chemotherapy, region-specific radiation therapy doses, surgery), demographic characteristics, selected health behaviors, and long-term outcomes (severity-graded chronic health conditions including second cancers). In addition, clinically-relevant genetic variables including ancestry admixture, HLA alleles, leukocyte telomere length, and blood type have been computed from WGS. Both phenotypic and genetic variables are represented by the Dictionary Browser that allows to quickly identify variables of interest, view summary graphics, cross-tabulate variables by default or user-defined categories and test for association between categories. Using GenomePaint on the Portal, investigators can navigate to a locus of interest and explore the presence and frequencies of variants in the cohort, filter variants with multiple criteria including LD r2 values, and identify DNA binding motif change for non-coding variants. Combining GenomePaint with Dictionary Browser, the real-time association analysis allows to identify trait-associated variants at a locus, through the definition of traits, covariates, and inclusion/exclusion criteria using the Dictionary Browser. Future implementation includes supporting copy number and structural variations, characterization of pharmacogenetic diplotypes, gene-level rare variant analysis, polygenic scores, time-to-event survival analysis, and data download and session management enabled by user login. We envision this cohort with high quality phenotypic and genetic information, together with an enabling software platform co-developed with multidisciplinary principal investigators, will accelerate the discovery in both survivorship research and human genetics in general.
Citation Format: Xin Zhou, Nickhill Bhakta, Jian Wang, Edgar Sioson, Jaimin Patel, Kyla Shelton, Zhaoming Wang, Shaohua Lei, Alexander M. Gout, Carmen L. Wilson, Wendy Leisenring, Smita Bhatia, Yutaka Yasui, Melissa M. Hudson, Gregory T. Armstrong, Leslie L. Robison, Jinghui Zhang. The St. Jude Survivorship Portal links whole-genome genetic data with clinical therapy and outcome phenotypes for 7302 pediatric cancer survivors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1198.
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Affiliation(s)
- Xin Zhou
- 1St. Jude Children's Research Hospital, Memphis, TN
| | | | - Jian Wang
- 1St. Jude Children's Research Hospital, Memphis, TN
| | - Edgar Sioson
- 1St. Jude Children's Research Hospital, Memphis, TN
| | - Jaimin Patel
- 1St. Jude Children's Research Hospital, Memphis, TN
| | - Kyla Shelton
- 1St. Jude Children's Research Hospital, Memphis, TN
| | | | - Shaohua Lei
- 1St. Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Smita Bhatia
- 3University of Alabama at Birmingham, Birmingham, AL
| | - Yutaka Yasui
- 1St. Jude Children's Research Hospital, Memphis, TN
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31
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de Blank P, Li N, Fisher MJ, Ullrich NJ, Bhatia S, Yasui Y, Sklar CA, Leisenring W, Howell R, Oeffinger K, Hardy K, Okcu MF, Gibson TM, Robison LL, Armstrong GT, Krull KR. Late morbidity and mortality in adult survivors of childhood glioma with neurofibromatosis type 1: report from the Childhood Cancer Survivor Study. Genet Med 2020; 22:1794-1802. [PMID: 32572180 PMCID: PMC7606750 DOI: 10.1038/s41436-020-0873-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Neurofibromatosis type 1 (NF1) is associated with tumor predisposition and non-malignant health conditions. Whether survivors of childhood cancer with NF1 are at increased risk for poor long-term health outcomes is unknown. Methods 147 5+ year survivors of childhood glioma with NF1 from the Childhood Cancer Survivor Study were compared to 2 629 non-NF1 glioma survivors and 5 051 siblings for late mortality, chronic health conditions, psychosocial, neurocognitive, and socioeconomic outcomes. Results Survivors with NF1 (age at diagnosis: 6.8±4.8 years) had greater cumulative incidence of late mortality 30 years after diagnosis (46.3%[95% confidence interval: 23.9%−62.2%]) compared to non-NF1 survivors (18.0%[16.1%−20.0%]) and siblings (0.9%[0.6%−1.2%]), largely due to subsequent neoplasms. Compared to survivors without NF1, those with NF1 had more severe/life-threatening chronic conditions at cohort entry (46.3%[38.1%−54.4%] vs. 30.8%[29.1%−32.6%]), but similar rates of new conditions during follow-up (Rate Ratio: 1.26 [0.90–1.77]). Survivors with NF1 were more likely to report psychosocial impairments, neurocognitive deficits, and socioeconomic difficulties compared to survivors without NF1. Conclusion Late mortality among glioma survivors with NF1 is twice that of other survivors, due largely to subsequent malignancies. Screening, prevention and early intervention for chronic health conditions, psychosocial and neurocognitive deficits may reduce long-term morbidity in this vulnerable population.
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Affiliation(s)
- Peter de Blank
- University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Nan Li
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Michael J Fisher
- University of Pennsylvania Perlman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicole J Ullrich
- Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yutaka Yasui
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Wendy Leisenring
- Cancer Prevention and Clinical Statistics Programs, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - M Fatih Okcu
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Todd M Gibson
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Leslie L Robison
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin R Krull
- Departments of Epidemiology and Cancer Control, Oncology and Psychology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Crochet E, Tyc VL, Wang M, Srivastava DK, Van Sickle K, Nathan PC, Leisenring W, Gibson TM, Armstrong GT, Krull K. Posttraumatic stress as a contributor to behavioral health outcomes and healthcare utilization in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. J Cancer Surviv 2019; 13:981-992. [PMID: 31691097 DOI: 10.1007/s11764-019-00822-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 06/28/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To examine the association between posttraumatic stress symptoms (PTSS), neurocognitive and psychosocial late-effects, health behaviors, and healthcare utilization in long-term survivors of childhood cancer. METHODS Participants included individuals (N = 6844; 52.5% female; mean [SD] age at diagnosis = 7.6 [5.8], at follow-up = 34.9 [7.5]) in the Childhood Cancer Survivor Study (CCSS). Follow-up included the Posttraumatic Stress Scale, Brief Symptom Inventory-18, Short-form 36 Health-related quality of life (HRQOL) survey, CCSS Neurocognitive Questionnaire, and questions about sociodemographics, physical health, health behaviors, and healthcare utilization. Modified Poisson regression and multinomial logistic regression models examined associations between posttraumatic stress symptoms (PTSS) and neurocognitive, HRQOL, health behavior, and healthcare outcomes when adjusting for sociodemographics, disease, and treatment. RESULTS Long-term survivors with PTSS (N = 995, 14.5%) reported more impairment in mental (relative risk [RR] 3.42, 95% confidence interval [CI] 3.05-3.85), and physical (RR = 2.26, CI = 1.96-2.61) HRQOL. PTSS was also associated with increased impairment in task efficiency (RR = 3.09, CI = 2.72-3.51), working memory (RR = 2.55, CI = 2.30-2.83), organization (RR = 2.11, CI = 1.78-2.50), and emotional regulation (RR = 3.67, CI = 3.30-4.09). Survivors with PTSS were significantly more likely to attend cancer-specific health visits in the past 2 years (OR = 1.89, CI = 1.50-2.39), and showed greater likelihood of either high frequency (OR = 1.89, CI = 1.50-2.39) or complete lack of (OR = 1.63, CI = 1.32-2.01) primary care visits compared to survivors without PTSS. CONCLUSIONS Survivors with PTSS reported significantly more psychosocial and neurocognitive late effects, and were more likely to engage in variable use of healthcare. IMPLICATIONS FOR CANCER SURVIVORS PTSS is associated with additional challenges for a population vulnerable to adverse late effects. Inclusion of integrative services during follow-up visits may benefit functional outcomes.
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Affiliation(s)
- Emily Crochet
- Florida Institute of Technology, Melbourne, FL, USA.
| | - Vida L Tyc
- Florida Institute of Technology, Melbourne, FL, USA
| | - Mingjuan Wang
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | - Paul C Nathan
- The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | | | - Todd M Gibson
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | - Kevin Krull
- St. Jude Children's Research Hospital, Memphis, TN, USA
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Zamora D, Xie H, Kimball LE, Golob J, Fredericks D, Liu C, Petersen F, Leisenring W, Boeckh M. 1751. The Impact of Prophylactic Systemic Antibiotics (PSA) on Cytomegalovirus (CMV) Infection: A Post-hoc Analysis of a Randomized Controlled Trial (RCT) in Hematopoietic Cell Transplantation (HCT) Recipients. Open Forum Infect Dis 2019. [PMCID: PMC6808705 DOI: 10.1093/ofid/ofz360.1614] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Prophylactic systemic antibiotics (PSA) during conditioning regimen-induced neutropenia after hematopoietic cell transplantation (HCT) reduce bacteremia but may disrupt the gut microbiota, potentially affecting viral immunity and risk for viral infections. Prior studies suggest a critical role of gut microbiota in the reconstitution of CMV-specific CD8+ T cells and in protection from respiratory viral infections after HCT (J Immunol 2007; 178: 5209; Blood 2018; 131:2978). To identify whether PSA is associated with differences in CMV infection outcomes after HCT, we conducted a post-hoc analysis of CMV infection in the only RCT of PSA exclusively performed in HCT recipients (Infection 1986; 14:115). In that trial, HCT patients received either PSA (ticarcillin/tobramycin/vancomycin or mezlocillin/ceftizoxime) or no systemic antibiotics during neutropenia (absolute neutrophil count <500/mm3). Methods A post-hoc analysis was performed of a previously conducted RCT in the pre-antiviral era (1984–1986) at the Fred Hutch. Patients received unscreened blood products and were tested weekly by CMV culture in throat, and disease was evaluated by tissue biopsy or bronchoalveolar lavage. CMV disease was confirmed by chart review. We compared the cumulative incidence of CMV at any site, CMV throat shedding, and CMV disease between randomization groups by day 100 post-transplant, treating death as a competing risk. Overall survival was also compared using Kaplan–Meier method. Results 119 and 125 allograft recipients were randomized to PSA and no prophylaxis, respectively. Baseline characteristics in both groups were balanced. CMV infection at any site and CMV throat shedding were greater in the PSA group (Figures 1 and 2); CMV disease was numerically reduced in the no PSA group (Figure 3). Overall survival by day 100 was not different between the groups (Figure 4). Conclusion CMV infection risk appeared to be increased in recipients of PSA with a significant anaerobic spectrum. While current PSA regimens have narrower spectrum activity, these results provide the rationale to study if changes in gut microbiota play a role in CMV reactivation and adaptive immunity after HCT. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Hu Xie
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | - Catherine Liu
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Michael Boeckh
- Fred Hutchinson Cancer Research Center/University of Washington, Seattle, Washington
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Ogimi C, Martin ET, Xie H, Campbell AP, Waghmare A, Kuypers J, Jerome K, Leisenring W, Englund JA, Boeckh M. 1756. Role of Human bocavirus Respiratory Tract Infection in Hematopoietic Cell Transplant Recipients. Open Forum Infect Dis 2019. [PMCID: PMC6808672 DOI: 10.1093/ofid/ofz360.1619] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Limited data exist regarding the impact of human bocavirus (BoV) in hematopoietic cell transplant (HCT) recipients. We examined incidence and disease spectrum of BoV respiratory tract infection (RTI) in HCT recipients. Methods In a longitudinal surveillance study of viral RTIs among allogeneic HCT recipients, pre-HCT and weekly post-HCT nasal washes and symptom surveys were collected through day 100, then every 3 months, and whenever respiratory symptoms occurred through 1-year post-HCT. Samples were tested by multiplex semi-quantitative PCR for RSV, parainfluenza virus 1–4, influenza A/B, adenovirus, human metapneumovirus, rhinovirus, coronavirus, and BoV. Plasma samples from BoV+ subjects were analyzed by PCR. In addition, we conducted a retrospective review of HCT recipients with BoV detected in bronchoalveolar lavage or lung biopsy. Results Among 469 patients in the prospective cohort, 21 distinct BoV RTIs (3 pre-HCT and 18 post-HCT) were observed by 1-year post-HCT in 19 patients (median 42 years old, range 0–67) without apparent seasonality. BoV was more frequently detected in the latter half of the first 100 days post-HCT (Figure 1). The frequencies of respiratory symptoms in patients with BoV detected did not appear to be higher than those without any virus detected, with the exception of watery eyes (P < 0.01) (Figure 2). Univariable models among patients with BoV RTI post-HCT showed higher peak viral load in nasal samples (P = 0.04) and presence of respiratory copathogens (P = 0.03) were associated with presence of respiratory symptoms; however, BoV detection in plasma was not (P = 0.8). Retrospective review identified 6 allogeneic HCT recipients (range 1–64 years old) with BoV detected in lower respiratory tract specimens [incidence rate of 0.4% (9/2,385) per sample tested]. Although all 6 cases presented with hypoxemia, 4 had significant respiratory copathogens or concomitant conditions that contributed to respiratory compromise. No death was attributed mainly to BoV lower RTI. Conclusion BoV is infrequently detected in respiratory tract in HCT recipients. Our studies did not demonstrate convincing evidence that BoV is a significant pathogen in either upper or lower respiratory tracts. Watery eyes were associated with BoV detection. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Chikara Ogimi
- Seattle Children’s Hospital/University of Washington, Seattle, Washington
| | - Emily T Martin
- University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Hu Xie
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Alpana Waghmare
- University of Washington, Seattle Children's Hospital, Seattle, Washington
| | | | - Keith Jerome
- University of Washington/Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Janet A Englund
- Seattle Children’s Hospital/University of Washington, Seattle, Washington
| | - Michael Boeckh
- Fred Hutchinson Cancer Research Center/University of Washington, Seattle, Washington
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Turcotte LM, Liu Q, Yasui Y, Henderson TO, Gibson TM, Leisenring W, Arnold MA, Howell RM, Green DM, Armstrong GT, Robison LL, Neglia JP. Chemotherapy and Risk of Subsequent Malignant Neoplasms in the Childhood Cancer Survivor Study Cohort. J Clin Oncol 2019; 37:3310-3319. [PMID: 31622130 DOI: 10.1200/jco.19.00129] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Therapeutic radiation in childhood cancer has decreased over time with a concomitant increase in chemotherapy. Limited data exist on chemotherapy-associated subsequent malignant neoplasm (SMN) risk. PATIENTS AND METHODS SMNs occurring > 5 years from diagnosis, excluding nonmelanoma skin cancers, were evaluated in survivors diagnosed when they were < 21 years old, from 1970 to 1999 in the Childhood Cancer Survivor Study (median age at diagnosis, 7.0 years; median age at last follow-up, 31.8 years). Thirty-year SMN cumulative incidence and standardized incidence ratios (SIRs) were estimated by treatment: chemotherapy-only (n = 7,448), chemotherapy plus radiation (n = 10,485), radiation only (n = 2,063), or neither (n = 2,158). Multivariable models were used to assess chemotherapy-associated SMN risk, including dose-response relationships. RESULTS Of 1,498 SMNs among 1,344 survivors, 229 occurred among 206 survivors treated with chemotherapy only. Thirty-year SMN cumulative incidence was 3.9%, 9.0%, 10.8%, and 3.4% for the chemotherapy-only, chemotherapy plus radiation, radiation-only, or neither-treatment groups, respectively. Chemotherapy-only survivors had a 2.8-fold increased SMN risk compared with the general population (95% CI, 2.5 to 3.2), with SIRs increased for subsequent leukemia/lymphoma (1.9; 95% CI, 1.3 to 2.7), breast cancer (4.6; 95% CI, 3.5 to 6.0), soft-tissue sarcoma (3.4; 95% CI, 1.9 to 5.7), thyroid cancer (3.8; 95% CI, 2.7 to 5.1), and melanoma (2.3; 95% CI, 1.5 to 3.5). SMN rate was associated with > 750 mg/m2 platinum (relative rate [RR] 2.7; 95% CI, 1.1 to 6.5), and a dose response was observed between alkylating agents and SMN rate (RR, 1.2/5,000 mg/m2; 95% CI, 1.1 to 1.3). A linear dose response was also demonstrated between anthracyclines and breast cancer rate (RR, 1.3/100 mg/m2; 95% CI, 1.2 to 1.6). CONCLUSION Childhood cancer survivors treated with chemotherapy only, particularly higher cumulative doses of platinum and alkylating agents, face increased SMN risk. Linear dose responses were seen between alkylating agents and SMN rates and between anthracyclines and breast cancer rates. Limiting cumulative doses and consideration of alternate chemotherapies may reduce SMN risk.
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Affiliation(s)
| | - Qi Liu
- University of Alberta School of Public Health, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Memphis, TN
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Scott JM, Li N, Liu Q, Yasui Y, Leisenring W, Nathan PC, Gibson T, Armenian SH, Nilsen TS, Oeffinger KC, Ness KK, Adams SC, Robison LL, Armstrong GT, Jones LW. Association of Exercise With Mortality in Adult Survivors of Childhood Cancer. JAMA Oncol 2019; 4:1352-1358. [PMID: 29862412 DOI: 10.1001/jamaoncol.2018.2254] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Adult survivors of childhood cancer are at excess risk for mortality compared with the general population. Whether exercise attenuates this risk is not known. Objective To examine the association between vigorous exercise and change in exercise with mortality in adult survivors of childhood cancer. Design, Setting, and Participants Multicenter cohort analysis among 15 450 adult cancer survivors diagnosed before age 21 years from pediatric tertiary hospitals in the United States and Canada between 1970 and 1999 enrolled in the Childhood Cancer Survivor Study, with follow-up through December 31, 2013. Exposures Self-reported vigorous exercise in metabolic equivalent task (MET) hours per week. The association between vigorous exercise and change in vigorous exercise and cause-specific mortality was assessed using multivariable piecewise exponential regression analysis to estimate rate ratios. Main Outcomes and Measures The primary outcome was all-cause mortality. Secondary end points were cause-specific mortality (recurrence/progression of primary malignant neoplasm and health-related mortality). Outcomes were assessed via the National Death Index. Results The 15 450 survivors had a median age at interview of 25.9 years (interquartile range [IQR], 9.5 years) and were 52.8% male. During a median follow-up of 9.6 years (IQR, 15.5 years), 1063 deaths (811 health-related, 120 recurrence/progression of primary cancer, 132 external/unknown causes) were documented. At 15 years, the cumulative incidence of all-cause mortality was 11.7% (95% CI, 10.6%-12.8%) for those who exercised 0 MET-h/wk, 8.6% (95% CI, 7.4%-9.7%) for 3 to 6 MET-h/wk, 7.4% (95% CI, 6.2%-8.6%) for 9 to 12 MET-h/wk, and 8.0% (95% CI, 6.5%-9.5%) for 15 to 21 MET-h/wk (P < .001). There was a significant inverse association across quartiles of exercise and all-cause mortality after adjusting for chronic health conditions and treatment exposures (P = .02 for trend). Among a subset of 5689 survivors, increased exercise (mean [SD], 7.9 [4.4] MET-h/wk) over an 8-year period was associated with a 40% reduction in all-cause mortality rate compared with maintenance of low exercise (rate ratio, 0.60; 95% CI, 0.44-0.82; P = .001). Conclusions and Relevance Vigorous exercise in early adulthood and increased exercise over 8 years was associated with lower risk of mortality in adult survivors of childhood cancer.
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Affiliation(s)
- Jessica M Scott
- Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
| | - Nan Li
- St Jude Children's Research Hospital, Memphis, Tennessee
| | - Qi Liu
- University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Paul C Nathan
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Todd Gibson
- St Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | | | - Kirsten K Ness
- St Jude Children's Research Hospital, Memphis, Tennessee
| | - Scott C Adams
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Lee W Jones
- Memorial Sloan Kettering Cancer Center, New York, New York.,Weill Cornell Medical College, New York, New York
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Bhatia S, Chen Y, Wong FL, Hageman L, Smith K, Korf B, Cannon A, Leidy DJ, Paz A, Andress JE, Friedman GK, Metrock K, Neglia JP, Arnold M, Turcotte LM, de Blank P, Leisenring W, Armstrong GT, Robison LL, Clapp DW, Shannon K, Nakamura JL, Fisher MJ. Subsequent Neoplasms After a Primary Tumor in Individuals With Neurofibromatosis Type 1. J Clin Oncol 2019; 37:3050-3058. [PMID: 31532722 DOI: 10.1200/jco.19.00114] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Fundamental gaps in knowledge regarding the risk of subsequent neoplasms (SNs) in children with pathogenic neurofibromatosis type 1 (NF1) variants exposed to radiation and/or alkylator chemotherapy have limited the use of these agents. METHODS We addressed these gaps by determining the SN risk in 167 NF1-affected versus 1,541 non-NF1-affected 5-year childhood cancer survivors from the Childhood Cancer Survivor Study and 176 nonoverlapping NF1-affected individuals with primary tumors from University of Alabama at Birmingham and Children's Hospital of Philadelphia exposed to radiation and/or chemotherapy. Proportional subdistribution hazards multivariable regression analysis was used to examine risk factors, adjusting for type and age at primary tumor diagnosis and therapeutic exposures. RESULTS In the Childhood Cancer Survivor Study cohort, the 20-year cumulative incidence of SNs in NF1 childhood cancer survivors was 7.3%, compared with 2.9% in the non-NF1 childhood cancer survivors (P = .003), yielding a 2.4-fold higher risk of SN (95% CI, 1.3 to 4.3; P = .005) in the NF1-affected individuals. In the University of Alabama at Birmingham and Children's Hospital of Philadelphia cohort, among NF1-affected individuals with a primary tumor, the risk of SNs was 2.8-fold higher in patients with irradiated NF1 (95% CI, 1.3 to 6.0; P = .009). In contrast, the risk of SNs was not significantly elevated after exposure to alkylating agents (hazard ratio, 1.27; 95% CI, 0.3 to 3.0; P = .9). CONCLUSION Children with NF1 who develop a primary tumor are at increased risk of SN when compared with non-NF1 childhood cancer survivors. Among NF1-affected children with a primary tumor, therapeutic radiation, but not alkylating agents, confer an increased risk of SNs. These findings can inform evidence-based clinical management of primary tumors in NF1-affected children.
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Affiliation(s)
- Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
| | - Yanjun Chen
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | - Bruce Korf
- University of Alabama at Birmingham, Birmingham, AL
| | | | - Daniel J Leidy
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Alejandro Paz
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | | | | | | | | | | | | | - Kevin Shannon
- University of California, San Francisco, San Francisco, CA
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Oeffinger KC, Ford JS, Moskowitz CS, Chou JF, Henderson TO, Hudson MM, Diller L, McDonald A, Ford J, Mubdi NZ, Rinehart D, Vukadinovich C, Gibson TM, Anderson N, Elkin EB, Garrett K, Rebull M, Leisenring W, Robison LL, Armstrong GT. Promoting Breast Cancer Surveillance: The EMPOWER Study, a Randomized Clinical Trial in the Childhood Cancer Survivor Study. J Clin Oncol 2019; 37:2131-2140. [PMID: 31260642 PMCID: PMC6698920 DOI: 10.1200/jco.19.00547] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The aim of the current study was to increase the uptake of screening mammography among high-risk women who were treated for a childhood cancer with chest radiotherapy. PATIENTS AND METHODS Two hundred four female survivors in the Childhood Cancer Survivor Study who were treated with chest radiotherapy with 20 Gy or greater, age 25 to 50 years, and without breast imaging in the past 24 months were randomly assigned 2:1 to receive a mailed informational packet followed by a tailored telephone-delivered brief motivational interview (intervention) versus an attention control. Primary outcome was the difference in the proportion of participants who completed a screening mammogram by 12 months as evaluated in an intent-to-treat analysis. Stratum-adjusted relative risk (RR) and 95% CI were estimated using the Cochran-Mantel-Haenszel method. Secondary outcomes included the completion of screening breast magnetic resonance imaging (MRI) and barriers to screening and moderating factors. RESULTS Women in the intervention group were significantly more likely than those in the control group to report a mammogram (45 [33.1%] of 136 v 12 [17.6%] of 68; RR, 1.9; 95% CI, 1.1 to 3.3). The intervention was more successful among women age 25 to 39 years (RR, 2.2; 95% CI, 1.1 to 4.7) than among those age 40 to 50 years (RR, 1.4; 95% CI, 0.6 to 3.2). The proportion of women who reported a breast MRI at 12 months was similar between the two groups: 16.2% (intervention) compared with 13.2% (control; RR, 1.2; 95% CI, 0.6 to 2.5). Primary barriers to completing a screening mammogram and/or breast MRI included lack of physician recommendation, deferred action by survivor, cost, and absence of symptoms. CONCLUSION Use of mailed materials followed by telephone-delivered counseling increased mammography screening rates in survivors at high risk for breast cancer; however, this approach did not increase the rate of breast MRI. Cost of imaging and physician recommendation were important barriers that should be addressed in future studies.
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Affiliation(s)
| | - Jennifer S Ford
- 2Hunter College, City University of New York, New York, NY.,3The Graduate Center of the City University of New York, New York, NY
| | | | - Joanne F Chou
- 4Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Lisa Diller
- 7Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - James Ford
- 6St Jude Children's Research Hospital, Memphis, TN
| | - Nidha Z Mubdi
- 4Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | - Elena B Elkin
- 4Memorial Sloan Kettering Cancer Center, New York, NY
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Inskip PD, Veiga LHS, Brenner AV, Sigurdson AJ, Ostroumova E, Chow EJ, Stovall M, Smith SA, Leisenring W, Robison LL, Armstrong GT, Sklar CA, Lubin JH. Hyperthyroidism After Radiation Therapy for Childhood Cancer: A Report from the Childhood Cancer Survivor Study. Int J Radiat Oncol Biol Phys 2019; 104:415-424. [PMID: 30769174 PMCID: PMC6818231 DOI: 10.1016/j.ijrobp.2019.02.009] [Citation(s) in RCA: 10] [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: 07/17/2018] [Revised: 12/21/2018] [Accepted: 02/05/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE The association of hyperthyroidism with exposure to ionizing radiation is poorly understood. This study addresses the risk of hyperthyroidism in relation to incidental therapeutic radiation dose to the thyroid and pituitary glands in a large cohort of survivors of childhood cancer. METHODS AND MATERIALS Using the Childhood Cancer Survivor Study's cohort of 5-year survivors of childhood cancer diagnosed at hospitals in the United States and Canada between 1970 and 1986, the occurrence of hyperthyroidism through 2009 was ascertained among 12,183 survivors who responded to serial questionnaires. Radiation doses to the thyroid and pituitary glands were estimated from radiation therapy records, and chemotherapy exposures were abstracted from medical records. Binary outcome regression was used to estimate prevalence odds ratios (ORs) for hyperthyroidism at 5 years from diagnosis of childhood cancer and Poisson regression to estimate incidence rate ratios (RRs) after the first 5 years. RESULTS Survivors reported 179 cases of hyperthyroidism, of which 148 were diagnosed 5 or more years after their cancer diagnosis. The cumulative proportion of survivors diagnosed with hyperthyroidism by 30 years after the cancer diagnosis was 2.5% (95% confidence interval [CI], 2.0%-2.9%) among those who received radiation therapy. A linear relation adequately described the thyroid radiation dose response for prevalence of self-reported hyperthyroidism 5 years after cancer diagnosis (excess OR/Gy, 0.24; 95% CI, 0.06-0.95) and incidence rate thereafter (excess RR/Gy, 0.06; 95% CI, 0.03-0.14) over the dose range of 0 to 63 Gy. Neither radiation dose to the pituitary gland nor chemotherapy was associated significantly with hyperthyroidism. Radiation-associated risk remained elevated >25 years after exposure. CONCLUSIONS Risk of hyperthyroidism after radiation therapy during childhood is positively associated with external radiation dose to the thyroid gland, with radiation-related excess risk persisting for >25 years. Neither radiation dose to the pituitary gland nor chemotherapy exposures were associated with hyperthyroidism among childhood cancer survivors through early adulthood.
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Affiliation(s)
- Peter D Inskip
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland; Retired.
| | - Lene H S Veiga
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland
| | - Alina V Brenner
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland; Radiation Effects Research Foundation, Hiroshima, Japan
| | - Alice J Sigurdson
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland; Retired
| | - Evgenia Ostroumova
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland; International Agency for Research on Cancer, Lyon, France
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Marilyn Stovall
- Retired; Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan A Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wendy Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, 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
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jay H Lubin
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland
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Dixon S, Chen Y, Yasui Y, Pui CH, Hunger S, Silverman LB, Green DM, Kadan-Lottick NS, Ness KK, Leisenring W, Howell RM, Oeffinger KC, Neglia JP, Krull KR, Hudson MM, Robison LL, Mertens AC, Armstrong GT, Nathan PC. Chronic health conditions (CHC) and late mortality in survivors of acute lymphoblastic leukemia (ALL) in the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10016 Background: The impact of evolving risk-stratified therapy on long-term morbidity and mortality in survivors of childhood ALL remains largely unknown. Methods: All-cause and health-related late mortality (HRM; captures death from late-effects occurring > 5 yrs from diagnosis), subsequent (malignant) neoplasm [S(M)N], CTCAE graded CHC and neurocognitive outcomes were assessed in 5-yr survivors of ALL diagnosed < 21 yrs of age from 1970-99. Therapy combinations defined 6 groups: 1970s-like ( 70s), standard and high risk 1980s- and 1990s-like ( 80sSR, 80sHR, 90sSR, 90sHR), relapse/transplant ( R/BMT). Cumulative incidence and standardized mortality ratios (SMR) were calculated. Piecewise exponential and log-binomial models estimated rate ratios (RR) with 95% confidence intervals (CI). Results: Among 6148 survivors (median age 31.5 yrs), 15-yr cumulative incidence of all-cause mortality was 5.8% (CI 5.3-6.2) and HRM was 1.5% (1.2-1.7). Compared to 70s, HRM was lower for 90sSR and 90sHR (RR 0.1, CI 0.0-0.3; 0.2, 0.1-0.7), similar to that in the US population (SMR; CI: 90sSR 1.1; 0.6-1.9, 90sHR 1.9; 0.8-3.7). 20-yr cumulative incidence of SN was 3.5% (CI 3.1-3.9). Compared to 70s, 90sSR had lower risk of benign meningioma (RR 0.1, CI 0.0-0.3) and SMN (0.3, 0.1-0.6) with no absolute excess risk compared to the US population. 90sSR was associated with a lower risk of CHCs (Table). Conclusions: More recent risk-stratified therapy has succeeded in reducing risk of late mortality and CHCs among long-term survivors of ALL. [Table: see text]
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Affiliation(s)
| | - Yan Chen
- University of Alberta, Calgary, AB, Canada
| | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Lewis B. Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | | | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Yeh J, Lowry KP, Schechter CB, Diller L, Alagoz O, Armstrong GT, Hampton JM, Leisenring W, Liu Q, Mandelblatt JS, Miglioretti DL, Moskowitz CS, Oeffinger KC, Trentham-Dietz A, Stout NK. Clinical outcomes and cost-effectiveness of breast cancer screening for childhood cancer survivors treated with chest radiation: A comparative modeling study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6525 Background: Survivors of childhood cancer previously treated with chest radiation face elevated breast cancer risk similar to BRCA1 carriers. Children’s Oncology Group (COG) guidelines recommend annual mammography with breast MRI, yet the benefits and costs of various screening strategies are uncertain. Methods: We used two breast cancer simulation models (Model 1 and 2) from the Cancer Intervention and Surveillance Modeling Network (CISNET) and data from the Childhood Cancer Survivor Study to reflect high breast cancer and competing mortality risks among survivors. We simulated 3 screening strategies: annual mammography with MRI starting at age 25 (COG25), annual MRI starting at 25 (MRI25), and biennial mammography starting at 50 (Mammo50). Performance of mammography+/-MRI was based on published studies in BRCA1/2 carriers who have similar cancer risk. Costs and quality of life weights were based on US averages and published studies. Results: Among a simulated cohort of 25-year-old survivors treated with chest radiation, the lifetime breast cancer mortality risk in the absence of screening was 10-11% across models. Compared to no screening, Mammo50, MRI25, and COG25 screening avert approximately 23-25%, 56-62% and 56-71% of deaths, respectively; averted deaths for COG25 compared to MRI25 were higher in Model 1 than Model 2 (9% vs. <1%). In Model 1, both MRI25 and COG25 were cost-effective; in Model 2, MRI25 was preferable (more effective, less costly than COG25). Conclusions: Compared to no screening, initiating annual screening at younger ages for at-risk survivors averts >50% of breast cancer deaths and is cost-effective. Additional data on test performance are needed to inform recommendations on screening modality. [Table: see text]
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Affiliation(s)
- Jennifer Yeh
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Clyde B. Schechter
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY
| | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | | | | | | | - Qi Liu
- University of Alberta, Edmonton, AB, Canada
| | | | | | | | | | | | - Natasha K. Stout
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Mulrooney DA, Hyun G, Ness KK, Ehrhardt MJ, Yasui Y, Duprez D, Howell RM, Leisenring W, Constine LS, Oeffinger KC, Gibson TM, Tonorezos ES, Robison LL, Hudson MM, Armstrong GT. Cardiac events in survivors of childhood cancer treated in more recent eras: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10058 Background: Contemporary cancer protocols have incorporated modifications to minimize cardiotoxic exposures and preserve long-term health. We investigated the impact of these changes on late cardiac outcomes in a large cohort of adult survivors of childhood cancer. Methods: Congestive heart failure (CHF), myocardial infarction (MI), valvular disease, pericardial disease, and arrhythmias were graded by the National Cancer Institute’s Common Terminology Criteria for Adverse Events among 23,462 five-year cancer survivors [6,193 (26%) treated in the 1970s, 9,363 (40%) in the 1980s, and 7,906 (34%) in the 1990s] and 5,057 siblings. Cumulative incidence and 95% confidence intervals (95% CI) were estimated by treatment decade. Adjusted multivariable subdistribution hazard models were used to estimate hazard ratios (HR) and 95% CI for cardiac outcomes by decade. Mediation analysis examined risks with and without cardiotoxic exposures. Results: For survivors [median age 6 years (range: 0-21) at diagnosis, 28 years (8.2-58) at follow-up], cardiac radiation (RT) exposure declined from 77% of those treated in the 1970s to 55% and 40% in the 1980s and 1990s. Anthracycline exposure increased from 28% to 50% to 64%. The 20-year cumulative incidence of CHF (0.69% for those treated in 1970s, 0.74% in the 1980s, 0.54% in the 1990s) and MI (0.38%, 0.24%, 0.19%) declined in more recent treatment eras (p < 0.01). This change was not seen for valvular disease (0.06%, 0.06%, 0.05%), pericardial disease (0.04%, 0.02%, 0.03%) or arrhythmias (0.08%, 0.09%, 0.13%). Compared to survivors diagnosed in the 1970s, the risk of CHF, MI, and valvular disease decreased in the 1980s and 1990s, but only significantly for MI (HR 0.64 95% CI 0.47-0.89 and 0.52 95% CI 0.32-0.83). The overall MI risk was attenuated by adjustment for cardiac RT exposure (HR 0.94 95% CI 0.80-1.11), mostly among Hodgkin lymphoma (HL) survivors (HR 0.82 95% CI 0.69-0.98 [unadjusted for RT]; 1.03 95% CI 0.83-1.28 [adjusted for RT]). Conclusions: Reductions in exposure to cardiotoxic cancer therapies have resulted in declines in adverse cardiac outcomes, particularly for the RT-associated risk of myocardial infarction among HL survivors.
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Affiliation(s)
| | - Geehong Hyun
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
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Dieffenbach BV, Li N, Madenci AL, Barnea D, Murphy AJ, Tonorezos ES, Gibson TM, Liu Q, Leisenring W, Howell RM, Diller L, Armstrong GT, Yasui Y, Oeffinger KC, Weldon CB, Weil B. Late cholecystectomy in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.e21525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21525 Background: Cholecystectomy (CCY) is among the most common operations performed in the developed world and is offered as a cure for symptomatic gallbladder disease. Whether survivors of childhood cancer undergo CCY at a higher rate than the general population is unknown. Methods: We identified 5-year survivors diagnosed between 1970 and 1999 who self-reported late (> 5 years after cancer diagnosis) CCY. Rates of CCY were determined among the entire cohort and in association with various risk factors and treatment exposures. Adjusted rate ratios (ARR) were estimated with multivariable piecewise exponential models. Results: Among 24,248 survivors (median follow-up 22.3, interquartile range [IQR] 16.2-30.1 years) and 5,038 siblings (median follow-up 26.4, IQR 19.3-33.7 years), the unadjusted cumulative incidence of CCY at age 50 was 7.2% (n = 757) in survivors and 6.5% (n = 168) in siblings. After adjusting for age, sex and race/ethnicity, survivors underwent CCY at higher rates compared to siblings (ARR = 1.3, 95% CI = 1.1-1.5). Relative to siblings, acute lymphoblastic leukemia survivors underwent CCY at a higher rate (ARR = 1.6, 95% CI = 1.3-2.0), all other diagnoses were not independently associated with higher rates of CCY. Among survivors, risk factors for late CCY included female sex, increasing body mass index (BMI) class, exposure to platinum agents and total body irradiation (TBI) (Table). Conclusions: CCY is performed more commonly among childhood cancer survivors relative to siblings. In addition to known risk factors for gallbladder disease, cancer treatment exposures may further enhance risk for CCY. Awareness and education regarding this observation may ensure timely diagnosis and treatment of symptomatic disease. [Table: see text]
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Affiliation(s)
| | - Nan Li
- St. Jude Children's Research Hospital, Memphis, TN
| | | | - Dana Barnea
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Qi Liu
- University of Alberta, Edmonton, AB, Canada
| | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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Arsenault V, Qiu W, Liu Q, Yeh J, Leisenring W, Ness KK, Armstrong GT, Henderson TO, Walsh AM, Yabroff KR, Oeffinger KC, Hudson MM, Yasui Y, Nathan PC. Emergency department (ED) visits and hospitalizations in survivors of childhood cancer in the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10056 Background: Chronic health conditions are frequent among childhood cancer survivors and lead to increased health care resource utilization. We compared rates of ED visits and hospitalizations between survivors and siblings. Methods: Analyses included 10,762 ≥5-year survivors and 2,069 siblings who completed a questionnaire from 2014-2016. We calculated ED visits and non-obstetric hospitalizations in the last 12 months per 1,000 person-years (PY) and evaluated cause-specific hospitalization rates using ICD-10 categories. Multivariable Poisson regression models evaluated predictors of survivor visits. Results: Median age in survivors and siblings was 35.3 years (interquartile range [IQR] 29.0-43.1) and 42.9 years (IQR 35.6-50.2), respectively; time from cancer diagnosis was 27.8 years (IQR 21.7-34.1). 24.2% of survivors and 16.2% of siblings had ≥1 ED visit (p < 0.001); rates were 521/1,000 PY for survivors and 246/1,000 PY for siblings (age/sex-adjusted relative rate [RR] 2.0; 95% confidence interval [CI] 1.7 - 2.3). Factors associated with increased survivor ED visits were black race (RR 1.6, CI 1.2-2.0), being obese (RR 1.4, CI 1.2-1.7) or underweight (RR 1.9, CI 1.2-3.0), female sex (RR 1.3, CI 1.1-1.5), younger age (p = 0.02) or abdomen/pelvis (RR 1.2, CI 1.1-1.4) or brain irradiation (RR 1.2, CI 1.0-1.4). 13.3% of survivors and 8.3% of siblings had ≥1 hospitalization (p < 0.001); rates were 219/1,000 PY for survivors and 130/1,000 PY for siblings (RR 1.9; CI 1.3 - 2.9). Factors associated with increased survivor hospitalizations were female sex (RR 1.3, 1.1-1.5), younger age (p < 0.0001), being obese (RR 1.3, CI 1.0-1.6) or underweight (RR 1.5, 95% CI 1.1-2.2) or platinum chemotherapy exposure (RR 1.6, CI 1.3-2.0). The most common indications for hospitalization were diseases of the digestive (21.9/1,000 PY; CI 18.7 - 25.7) and circulatory (20.9/1,000 PY; CI 17.8 – 24.4) systems. Leukemia survivors had the highest ED visit and hospitalization rates. Conclusions: Childhood cancer survivors had a 2-fold increased likelihood of an ED visit or hospitalization compared with their siblings. This increases the economic burden on survivors and the health care system.
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Affiliation(s)
| | - Weiyu Qiu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Surrey, BC, Canada
| | - Jennifer Yeh
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | | | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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Friedman DN, Goodman PJ, Leisenring W, Diller L, Cohn SL, Tonorezos ES, Howell RM, Smith SA, Wolden SL, Nathan PC, Neglia JP, Ness KK, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Long term morbidity and mortality among survivors of infant neuroblastoma: A report from the Childhood Cancer Survivor Study (CCSS). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10051 Background: Infants with neuroblastoma typically have low-risk disease with excellent survival. Therapy has been de-intensified over time to minimize late effects, however the impact on survivors’ risk of late mortality, subsequent malignant neoplasms (SMN), and chronic health conditions (CHC) is unclear. Methods: We evaluated late mortality, SMNs and CHCs (graded according to CTCAE v4.03), overall and by diagnosis era, among 990 5-year neuroblastoma survivors diagnosed at < 1 year of age between 1970-1999. Cumulative mortality, standardized mortality ratios (SMR), and standardized incidence ratios (SIR) of SMNs were estimated using the National Death Index and SEER rates, respectively. Cox proportional hazards estimated hazard ratios (HR) and 95% confidence intervals (CI) for CHC, compared to 5,051 CCSS siblings. Results: Among survivors (48% female; median attained age: 24 years, range 6-46), there was increased treatment with surgery alone across the 1970s, 1980s and 1990s (21.5%, 35.3%, 41.1%, respectively), but decreased treatment with combination surgery + radiation (22.5%, 5.3%, 0.3%, respectively) and surgery + radiation + chemotherapy (28.7%, 14.7%, 9.3%, respectively). The 20-year cumulative mortality was 2.3% (95% CI, 1.4-3.8), primarily due to SMNs (SMRSMN= 10.0, 95% CI, 4.5-22.3). The 20-year cumulative incidence of SMN was 1.2% (95% CI, 0.3-3.2), 2.5% (95% CI, 1.3-4.4), and zero for those diagnosed in the 1970s, 1980s, and 1990s, respectively. SIR was highest for renal SMNs (SIR 12.5, 95% CI, 1.7-89.4). Compared to siblings, survivors were at increased risk for grade 1-5 CHC (HR 2.1, 95% CI, 1.9-2.3) with similar HR across eras (HR1970s= 1.9, 95% CI, 1.6-2.2; HR1980s= 2.2, 95% CI, 1.9-2.6; HR1990s= 2.0, 95% CI, 1.7-2.4). The HR of severe, disabling, life-threatening and fatal CHC (grades 3-5) decreased in more recent eras (HR1970s= 4.7, 95% CI, 3.4-6.6; HR1980s= 4.4, 95% CI, 3.2-6.2; HR1990s= 2.9, 95% CI, 2.0-4.3). Conclusions: Survivors of infant neuroblastoma remain at increased risk for late mortality, SMN, and CHCs many years after diagnosis. However, the risk of grade 3-5 CHCs has declined in more recent eras, likely reflecting de-intensification of therapy.
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Affiliation(s)
| | | | | | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | - Emily S. Tonorezos
- Adult Long Term Follow-Up Program, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan A Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Fidler MM, Oeffinger KC, Yasui Y, Winter DL, Leisenring W, Robison LL, Reulen R, Chen Y, Armstrong GT, Hawkins M. Comparing late mortality risks among childhood cancer survivors: A report from the Childhood Cancer Survivor Study and British Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10017 Background: It is unclear whether late-effect risks are comparable across international settings. We compared late mortality risks in the Childhood Cancer Survivor Study (CCSS) and British Childhood Cancer Survivor Study (BCCSS). Methods: 46,474 5-year survivors of childhood cancer diagnosed from 1970-1999 and < 15 years age were included: 28,248 from the CCSS and 18,226 from the BCCSS. Late mortality (death ≥5 years from diagnosis) was assessed by linking to national vital statistics records. Adjusted ratios of the standardized mortality ratio (RSMR) and cumulative mortality probabilities were used to compare risks between cohorts. Treatment exposures were not available for the BCCSS, precluding comparison. Results: The cumulative all-cause mortality at 10 years from diagnosis was significantly lower in the CCSS (4.8%;95%CI:4.6%-5.0%) compared to the BCCSS (6.9%;95%CI:6.5%-7.2%); this was due to a lower probability of death from recurrence/progression of the primary cancer (CCSS = 3.3% vs. BCCSS = 5.8%), with significant differences observed in survivors of leukemia (7.9% vs 4.0%), Hodgkin lymphoma (2.5% vs 1.3%), CNS tumors (6.4% vs 4.4%), and sarcoma (6.5% vs 4.0%). However, with increasing time from diagnosis, risks became more similar. The CCSS ultimately had a greater cumulative mortality at 40 years from diagnosis, attributable to a 2-fold higher mortality from subsequent neoplasms (SNs) (RSMR:2.0;95%CI:1.8-2.3), cardiac (RSMR:1.7;95%CI:1.4-2.3) and pulmonary (RSMR:1.9;95%CI:1.4-2.5) causes, and other health-related deaths (RSMR:2.4;95%CI:2.1-2.9). When assessed by follow-up interval, the differences between the CCSS and BCCSS increased significantly for deaths due to SNs, cardiac and pulmonary causes, and other health-related deaths as time increased. Among those diagnosed more recently, the gap in all-cause mortality widened, with CCSS survivors diagnosed 1990-1999 experiencing approximately half the excess (RSMR:0.5;95%CI:0.5-0.6) observed in the BCCSS; this widening was driven by declines in the RSMR for most non-recurrence/progression causes of death. Conclusions: Our findings suggest that North American survivors may have received more intensive regimens during this time period to achieve sustainable remission and cure. However, the cost of this approach was a higher risk of death from late-effects. Which approach confers a net survival advantage will depend critically on the magnitude of the excess risk of late-effect deaths as the cohorts age.
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Affiliation(s)
| | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Raoul Reulen
- University of Birmingham, Birmingham, United Kingdom
| | - Yan Chen
- University of Alberta, Calgary, AB, Canada
| | | | - Mike Hawkins
- University of Birmingham, Birmingham, United Kingdom
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Veiga LHS, Curtis RE, Morton LM, Withrow D, Howell RM, Smith SA, Weathers R, Oeffinger KC, Moskowitz CS, Henderson TO, Arnold MA, Gibson TM, Leisenring W, Neglia JP, Turcotte LM, Whitton J, Robison LL, Inskip P, Armstrong GT, Berrington de González A. Combined effect of radiotherapy and anthracyclines on risk of breast cancer among female childhood cancer survivors: A report from the Childhood Cancer Survivor Study (CCSS). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10053 Background: Breast cancer is a common late-effect for female childhood cancer survivors and chest radiotherapy is an established risk factor. Recent findings showed that treatment with anthracyclines also increases breast cancer risk. However, the risk from the combined effect of radiotherapy and anthracyclines is unknown. Methods: We conducted a matched case-control study of 271 subsequent breast cancer and 1044 controls nested within the CCSS - a North-American cohort of five-year survivors of childhood cancer, diagnosed from 1970-1986 and followed-up through 2016. Detailed treatment records were abstracted to estimate radiation dose (Gy) to the breast cancer location and ovaries and calculate cumulative chemotherapy doses (mg/m2). Multivariable conditional logistic regression was used to estimate Odds ratios (OR) and 95% confidence intervals (CI). Results: Breast cancer risk increased linearly with radiation dose to the breast (OR per 10Gy = 3.9, 95%CI:2.5-6.5) and decreased with increasing ovarian dose (p < 0.01). Adjusted for radiation dose, the highest quartile of dose (455+mg/m2) of anthracyclines was associated with a 3.8-fold increased risk of breast cancer (95%CI:1.8-8.2) compared to no anthracyclines. This risk increased with cumulative anthracycline dose (p-trend < 0.01) and was non-significantly higher for ER+ than ER- breast cancers. For a breast dose of 10+Gy, the OR was 19.1 (95%CI:7.6-48.0) with anthracyclines versus 9.6 (95%CI:4.4-20.7) without anthracyclines, compared to 0- < 1Gy breast dose and no anthracyclines (p-additive interaction = 0.04). Conclusions: The combination of anthracyclines and radiotherapy doses to the breast can markedly increase breast cancer risk compared to those who receive neither treatment. Our results can be used to inform risk management for childhood cancer patients treated in the past, as well as project potential breast cancer risk from current treatment protocols.
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Affiliation(s)
- Lene H. S. Veiga
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Rochelle E. Curtis
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lindsay M. Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Diana Withrow
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - 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
| | - Rita Weathers
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | - John Whitton
- Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Peter Inskip
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Amy Berrington de González
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD
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Hesko C, Liu W, Srivastava D, Brinkman TM, Diller L, Gibson TM, Oeffinger KC, Leisenring W, Howell RM, Armstrong GT, Krull KR, Henderson TO. Neurocognitive outcomes in adult survivors of neuroblastoma: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.11563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
11563 Background: Long-term survivors of neuroblastoma may be at risk for neurocognitive impairment due to young age at diagnosis and intensive multimodal therapies. Methods: 837 survivors of neuroblastoma (57% female; median [range] age 25 [17-58] years, age at diagnosis 1 [0-21] years) and 728 siblings (56% female; age 32[16-43] years) self-reported neurocognitive problems using a neurocognitive questionnaire. Impairment was defined as scores ≥90th percentile of siblings in emotional regulation (ER), organization, task efficiency (TE), and memory. Multivariable log-binomial models evaluated associations with treatment exposures, era and chronic conditions (Grade 2-4 CTCAE v5) adjusting for sex, age, and race. Analyses were stratified by age at diagnosis (≤1 and > 1 year) as proxy for risk group. Results: Rates of impairment were 19.7% (ER), 25.3% organization, 21.9% TE and 19.4% for memory. Survivors had 50% higher risk of impaired TE (≤1 year relative risk [RR] 1.48, 95% confidence interval [CI] 1.08-2.03; > 1 year: RR 1.58, CI 1.22-2.06) and ER (≤1 year RR 1.51, CI 1.07-2.12; > 1 year RR 1.44, CI 1.06-1.95) versussiblings. Among survivors ≤1 year at diagnosis, treatment with platinum (RR 1.74, CI 1.01-2.97), hearing loss (RR 1.95, CI 1.26-3.00), cardiovascular (RR 1.83, CI 1.15-2.89) and neurologic (RR 2.00, CI 1.32-3.03) conditions were associated with higher risk of impaired TE. Female sex (RR = 1.54, CI, 1.02-2.33), cardiovascular (RR 1.71, CI 1.08-2.70) and respiratory (RR 1.99, CI 1.14-3.49) conditions were associated with higher risk of impaired ER. Among survivors > 1 year at diagnosis those treated in 1970-79 vs. 1990-99 had 80% higher risk of impaired ER (RR 1.77, CI 1.02-3.06). Hearing loss (RR 1.56 (1.09-2.24), respiratory (RR 2.35, CI 1.60-3.45) and cardiovascular (RR 1.74, CI 1.12-2.69) conditions were associated with higher risk of impaired TE. Conclusions: Adult survivors of neuroblastoma are at-risk for neurocognitive impairment. Differences associated with age at diagnosis, chronic disease and treatment exposures may inform risk-stratified inventions to improve neurocognitive outcomes. Reduced risk in later eras may reflect improved supportive care and knowledge of late effects.
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Affiliation(s)
- Caroline Hesko
- University of Chicago Comer Children's Hospital, Chicago, IL
| | - Wei Liu
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Lisa Diller
- Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | | | | | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
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Hayek S, Gibson TM, Leisenring W, Guida JL, Gramatges MM, Lupo P, Howell RM, Oeffinger KC, Bhatia S, Edelstein K, Hudson MM, Robison LL, Nathan PC, Yasui Y, Krull KR, Armstrong GT, Ness KK. Frailty among childhood cancer survivors: A report from the Childhood Cancer Survivor Study (CCSS). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10026 Background: Childhood cancer survivors are at increased risk for frailty, which is a loss of physiological capacity that is typically observed among older adults. Aims: Estimate the prevalence of frailty among survivors, and examine direct and indirect effects of treatment, lifestyle, and chronic disease factors on frailty. Methods: CCSS participants who were > 5-year survivors of childhood cancer, diagnosed between 1970-1999 at <21 years of age (n=10,899, 48% male), and siblings (n=2,097, 42% male) were included. Frailty was defined from self-reported data at mean ages of 37.6±9.4 and 42.9±9.8 years for survivors and siblings, respectively, as ≥3 of the following: low lean mass, exhaustion, low energy expenditure, slow walking, and weakness. Results: The prevalence of frailty among survivors was higher compared to siblings (5.8%, 95% CI: 5.4-6.3% vs. 1.9%, 95% CI 1.4-2.5%). Prevalence was highest in survivors of CNS tumors (9.5%, 5.2-13.8%), bone sarcomas (8.1%, 5.1-11.1%) and Hodgkin lymphoma (7.5%, 4.9-10.1%). In models adjusted for sex, age at assessment, and race/ethnicity, treatment exposures were associated with frailty (Table). After adjusting for the presence of chronic diseases and lifestyle factors, these associations were attenuated. Conclusions: The prevalence of frailty among survivors (6.0% at 38 years of age) was similar to the general population aged ≥65 years (9.0%). Radiation, platinum, amputation and thoracotomy increased risk for frailty. Findings suggest interventions to prevent, delay onset, or remediate chronic disease and/or promote healthy lifestyle are needed to preserve function in this population. [Table: see text]
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Affiliation(s)
- Samah Hayek
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | | | | | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
| | - Kim Edelstein
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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Tonorezos ES, Ford JS, Wang L, Ness KK, Yasui Y, Leisenring W, Sklar CA, Robison LL, Oeffinger KC, Nathan PC, Armstrong GT, Krull K, Jones LW. Impact of exercise on psychological burden in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer 2019; 125:3059-3067. [PMID: 31067357 DOI: 10.1002/cncr.32173] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/26/2018] [Accepted: 12/17/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Childhood cancer survivors are at risk for adverse psychological outcomes. Whether exercise can attenuate this risk is unknown. METHODS In total, 6199 participants in the Childhood Cancer Survivor Study (median age, 34.3 years [range, 22.0-54.0 years]; median age at diagnosis, 10.0 years [range, 0-21.0 years]) completed a questionnaire assessing vigorous exercise and medical/psychological conditions. Outcomes were evaluated a median of 7.8 years (range, 0.1-10.0 years) later and were defined as: symptom level above the 90th percentile of population norms for depression, anxiety, or somatization on the Brief Symptom Inventory-18; cancer-related pain; cognitive impairment using a validated self-report neurocognitive questionnaire; or poor health-related quality of life. Log-binomial regression estimated associations between exercise (metabolic equivalent [MET]-hours per week-1 ) and outcomes adjusting for cancer diagnosis, treatment, demographics, and baseline conditions. RESULTS The prevalence of depression at follow-up was 11.4% (95% CI, 10.6%-12.3%), anxiety 7.4% (95% CI, 6.7%-8.2%) and somatization 13.9% (95% CI, 13.0%-14.9%). Vigorous exercise was associated with lower prevalence of depression and somatization. The adjusted prevalence ratio for depression was 0.87 (95% CI, 0.72-1.05) for 3 to 6 MET hours per week-1 , 0.76 (95% CI, 0.62-0.94) for 9 to 12 MET-hours per week-1 , and 0.74 (95% CI, 0.58-0.95) for 15 to 21 MET-hours per week-1 . Compared with 0 MET hours per week-1 , 15 to 21 MET-hours per week-1 were associated with an adjusted prevalence ratio of 0.79 (95% CI, 0.62-1.00) for somatization. Vigorous exercise also was associated with less impairment in the physical functioning, general health and vitality (Ptrend < .001), emotional role limitations (Ptrend = .02), and mental health (Ptrend = .02) domains as well as higher cognitive function in the domains of task completion, organization, and working memory (P < .05 for all), but not in the domain of cancer pain. CONCLUSIONS Vigorous exercise is associated with less psychological burden and cognitive impairment in childhood cancer survivors.
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Affiliation(s)
- Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Jennifer S Ford
- Department of Psychology, Hunter College, City University of New York, New York, New York
| | - Linwei Wang
- Department of Epidemiology and Public Health, British Columbia Center for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wendy Leisenring
- Clinical Research Division and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kevin C Oeffinger
- Duke Center for Onco-Primary Care, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Paul C Nathan
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kevin Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Lee W Jones
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
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