Child and family perceptions of satisfaction with neutropenia management in pediatric acute myeloid leukemia

PURPOSE

Chemotherapy for pediatric acute myeloid leukemia (AML) is very intensive and many, but not all centers, require extended hospitalization until neutrophil recovery. Child and family preferences, beliefs, and experiences around hospitalization have not been systematically assessed.

PATIENTS AND METHODS

We recruited children with AML and their parents from nine pediatric cancer centers across the United States for a qualitative interview about their experiences of neutropenia management. Interviews were analyzed using a conventional content analysis approach.

RESULTS

Of 116 eligible individuals, 86 (74.1%) agreed to participate. Interviews were conducted with 32 children and 54 parents from 57 families. Of these 57 families, 39 were cared for as inpatients and 18 were managed as outpatients. A very high proportion of respondents in both groups reported satisfaction with the discharge management strategy recommended by the treating institution: 86% (57 individuals) of respondents who experienced inpatient management and 85% (17 individuals) of respondents who experienced outpatient management expressed satisfaction. Respondent perceptions associated with satisfaction related to safety (access to emergency interventions, infection risk, close monitoring) and psychosocial concerns (family separation, low morale, social support). Respondents believed it could not be assumed that all children would have the same experience due to varied life circumstances.

CONCLUSION

Children with AML and their parents express a very high degree of satisfaction with the discharge strategy recommended by their treating institution. Respondents saw a nuanced tradeoff between patient safety and psychosocial concerns that was mediated by a child's life circumstances.

Ethnic disparities in childhood leukemia survival by border residence: A Texas population-based analysis

BACKGROUND

The US-Mexico border is a medically underserved region where survival disparities have been observed in adults diagnosed and treated for various malignancies. Studies examining survival disparities among children living in this region and diagnosed with cancer are lacking. The objective of this study was to evaluate the impact of border residence on survival among children with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), and living near the Texas-Mexico border at the time of their diagnosis. The authors hypothesized that this group experiences inferior survival compared with patients with childhood leukemia living in nonborder areas.

METHODS

The authors conducted a retrospective survival analysis leveraging data from the Texas Cancer Registry. The study included patients aged birth to 19 years who were diagnosed with ALL or AML between 1995 and 2017. Cox proportional hazards models were used to evaluate the factors associated with the risk of death. Overall survival estimates were calculated using Kaplan-Meier methods.

RESULTS

During the study period, there were 6002 children diagnosed with ALL and 1279 diagnosed with AML. Inferior 5-year overall survival was observed among children with ALL living along the border region compared with those living in nonborder areas (77.5% vs. 85.8%). In adjusted models, children with ALL living along the border experienced a 30% increased hazard of death versus children living in nonborder areas. In contrast, for children with AML, survival estimates did not vary by border versus nonborder residence.

CONCLUSIONS

Living along the border was associated with inferior survival among children with ALL, but not among children with AML. Additional studies are urgently needed to identify the factors driving these disparities to effectively design multilevel interventions and influence state and national cancer control programs.

Clinician perceptions of Passport for Care, a web-based clinical decision support tool for survivorship care plan delivery

BACKGROUND

The Children's Oncology Group Long-Term Follow-Up Guidelines provide exposure-based risks and recommendations for late effects screening of survivors of childhood cancer. Passport for Care (PFC) is a web-based clinical decision support tool for generating a personalized survivorship care plan (SCP) derived from the Guidelines and user-entered exposures. We assessed PFC clinician user practices and perceptions of PFC impact on clinic workflow, guidelines application, and survivor shared decision-making.

PROCEDURE

A 35-item REDCap survey was emailed to all PFC users (n = 936) in 146 current and former PFC user clinics. Anonymous responses were permitted. Results were summarized and compared with a 2012 survey.

RESULTS

Data were available from 148 respondents representing 64 out of 146 PFC user clinics (minimum clinic response rate 44%, excluding 49 anonymous responses). Generation of a personalized SCP was the most common application of PFC, followed by determination of surveillance recommendations and use as a survivor database. Twenty-five respondents (17%) felt data entry was a significant or insurmountable barrier to PFC application. Sixty-nine percent of respondents attributed PFC with a very high/high impact on guidelines adherence in their clinical practice, compared with 40% who attributed PFC with having a significant impact on adherence in 2012 (p < .001).

CONCLUSION

The survey results provide valuable insights on patterns of SCP delivery and Survivor Clinic workflow. User-perceived benefits to PFC included facilitating clinician ability to follow guidelines recommendations in clinical practice. Importantly, some barriers to resource utilization were also identified, suggesting a need for user-informed adaptations to further improve uptake.

Implementation of a provider-focused intervention for maximizing human papillomavirus (HPV) vaccine uptake in young cancer survivors receiving follow-up care in pediatric oncology practices: protocol for a cluster-randomized trial of the HPV PROTECT intervention

BACKGROUND

Childhood cancer survivors are at high risk for developing new cancers (such as cervical and anal cancer) caused by persistent infection with the human papillomavirus (HPV). HPV vaccination is effective in preventing the infections that lead to these cancers, but HPV vaccine uptake is low among young cancer survivors. Lack of a healthcare provider recommendation is the most common reason that cancer survivors fail to initiate the HPV vaccine. Strategies that are most successful in increasing HPV vaccine uptake in the general population focus on enhancing healthcare provider skills to effectively recommend the vaccine, and reducing barriers faced by the young people and their parents in receiving the vaccine. This study will evaluate the effectiveness and implementation of an evidence-based healthcare provider-focused intervention (HPV PROTECT) adapted for use in pediatric oncology clinics, to increase HPV vaccine uptake among cancer survivors 9 to 17 years of age.

METHODS

This study uses a hybrid type 1 effectiveness-implementation approach. We will test the effectiveness of the HPV PROTECT intervention using a stepped-wedge cluster-randomized trial across a multi-state sample of pediatric oncology clinics. We will evaluate implementation (provider perspectives regarding intervention feasibility, acceptability and appropriateness in the pediatric oncology setting, provider fidelity to intervention components and change in provider HPV vaccine-related knowledge and practices [e.g., providing vaccine recommendations, identifying and reducing barriers to vaccination]) using a mixed methods approach.

DISCUSSION

This multisite trial will address important gaps in knowledge relevant to the prevention of HPV-related malignancies in young cancer survivors by testing the effectiveness of an evidence-based provider-directed intervention, adapted for the pediatric oncology setting, to increase HPV vaccine initiation in young cancer survivors receiving care in pediatric oncology clinics, and by procuring information regarding intervention delivery to inform future implementation efforts. If proven effective, HPV PROTECT will be readily disseminable for testing in the larger pediatric oncology community to increase HPV vaccine uptake in cancer survivors, facilitating protection against HPV-related morbidities for this vulnerable population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04469569, prospectively registered on July 14, 2020.

Distribution and frequency of tyrosine kinase inhibitor-associated long-term complications in children with chronic myeloid leukemia

BACKGROUND

Tyrosine kinase inhibitors (TKIs) improve outcomes for pediatric malignancies characterized by specific gene rearrangements and mutations; however, little is known about the long-term impact of TKI exposure. Our objective was to assess the incidence and type of late-onset TKI-related toxicities in children with chronic myeloid leukemia (CML).

METHODS

We reviewed medical records from patients diagnosed with CML between 2006 and 2019 at <21 years of age and prescribed one or more TKIs. Patients treated with stem cell transplant were excluded. Outcomes were captured beginning at 1 year after CML diagnosis. Outcome incidence was described overall and stratified by TKI exposure during the data-capture period.

RESULTS

Twenty-two eligible TKI-exposed patients with CML were identified. The median follow-up was 6.0 years (range: 2.2-14.3). All pericardial (n = 3) or pleural (n = 3) effusion outcomes occurred in patients treated with TKIs during the data-capture period. Other outcomes included hypertension (n = 2), ectopy on electrocardiogram (n = 2), and gastrointestinal bleed (n = 1). All outcomes were graded as mild to moderate: some resulted in a temporary discontinuation of TKI, but none led to a change in TKI. No differences were noted in outcome incidence by type of TKI exposure.

CONCLUSIONS

TKIs have substantially improved prognosis for subsets of childhood leukemia, but there are limited long-term data to inform exposure-based risk for late-onset complications and screening. Our results suggest that TKI-exposed survivors may be at risk for long-term outcomes that extend well into survivorship.

An evidence-based, risk-adapted algorithm for antifungal prophylaxis reduces risk for invasive mold infections in children with hematologic malignancies

BACKGROUND

Children with hematologic malignancies, especially those who receive intensive chemotherapy, are at high risk for invasive mold infections (IMI) that confer substantial mortality. Randomized controlled trials support the use of antifungal prophylaxis with antimold activity as an optimal strategy for risk reduction in this population, but studies outlining the practical application of evidence-based recommendations are lacking.

PROCEDURE

We conducted a 15-year, single-institution retrospective review in a diverse cohort of children with hematologic malignancies treated with chemotherapy to determine the incidence of proven or probable IMI diagnosed between 2006 and 2020. Multivariable logistic regression was used to identify host and disease factors associated with IMI risk. We then compared the incidence and type of IMI and related factors before and after 2016 implementation of an evidence-based, risk-adapted antifungal prophylaxis algorithm that broadened coverage to include molds in patients at highest risk for IMI.

RESULTS

We identified 61 cases of proven or probable IMI in 1456 patients diagnosed with hematologic malignancies during the study period (4.2%). Implementation of an antifungal prophylaxis algorithm reduced the IMI incidence in this population from 4.8% to 2.9%. Both Hispanic ethnicity and cancer diagnosis prior to 2016 were associated with risk for IMI.

CONCLUSION

An evidence-based, risk-adapted approach to antifungal prophylaxis for children with hematologic malignancies is an effective strategy to reduce incidence of IMI.

Short NK and naïve T-cell telomere length is associated with thyroid cancer in childhood cancer survivors: A report from the Childhood Cancer Survivor Study

BACKGROUND

Survivors of childhood cancer are at risk for therapy-related subsequent malignant neoplasms (SMN), including thyroid SMN. Telomere length (TL) is associated with cancer risk, but the relationship between TL and SMN risk among survivors is less clear.

METHODS

We conducted a nested, matched case-control study of radiation-exposed 15-year+ adult survivors of childhood cancer with thyroid SMN (cases) and without SMN (controls). 46 cases were matched to 46 controls by primary diagnosis, chemotherapy (yes/no), radiation field, and follow-up duration. Lymphocyte TL (LTL) was measured by telomere flow-FISH cytometry using blood samples banked at a mean of 38.9 years (cases), 39.2 years (controls). Genetic variation in telomere genes was assessed by whole genome sequencing. Point estimates for LTL <10th percentile were determined for cases and controls.

RESULTS

Cases had shorter median LTL than controls in three out of four leukocyte subsets. Cases were more likely to have NK cell LTL <10th percentile (p=0.01), and 2.8-fold more likely to have naïve T-cell LTL <10th percentile than controls (CI 1.07, 8.78). Five out of 15 cases with a rare indel or missense variant had naïve T-cell LTL <10th percentile, compared with one out of 8 controls.

CONCLUSIONS

Long-term survivors have shorter than expected LTL, a finding that is more pronounced among survivors with thyroid SMN.

IMPACT

The long-term impact of childhood cancer treatment on immune function is poorly understood. Our findings support immune function studies in larger survivor cohorts to assess long-term deficits in adaptive and innate immunity that may underlie SMN risk.

Sensor-Based Frailty Assessment in Survivors of Childhood Cancer: A Pilot Study

BACKGROUND

Survivors of childhood cancer (CCS) are at risk for early aging and frailty. Frailty in CCS has been assessed with established clinical criteria, a time-intensive approach requiring specialized training. There is an unmet need for cost-effective, rapid methods for assessing frailty in at-risk adolescent and young adult (AYA) CCS, which are scalable to large populations.

OBJECTIVES

To validate a sensor-based frailty assessment tool in AYA CCS, compare frailty status between CCS and controls, and assess the correlation between frailty and number of CCS comorbidities.

DESIGN, SETTING, AND PARTICIPANTS

Mean frailty index (MFI) was assessed by a frailty wrist sensor in 32 AYA CCS who were ≥1 year off therapy and in remission. Results were compared with 32 AYA controls without cancer or chronic disease.

MEASUREMENTS

Frailty assessments with and without a simultaneous cognitive task were performed to obtain MFI. Results were compared between cases and controls using a Student t test, and the number of pre-frail/frail subjects by Chi Square test. The contribution of radiation therapy (RT) exposure to MFI was assessed in a sub-analysis, and the correlation between the number of comorbidities and MFI was measured using the Pearson method.

RESULTS

MFI was strongly correlated with gait speed in AYA CCS. CCS were more likely to be pre-frail than controls without cancer history (p=0.032), and CCS treated with RT were more likely to be pre-frail than CCS not treated with RT (p<0.001). The number of comorbidities was strongly correlated with MFI (ρ=0.65), with a 0.028 increase in MFI for each added condition (p<0.001).

CONCLUSIONS

Results from this study support higher risk for frailty among CCS, especially those with multiple comorbidities or who were treated with RT. A wrist-worn sensor-based method is feasible for application in AYA CCS, and provides an opportunity for cost-effective, rapid screening of at-risk AYA CCS who may benefit from early interventions.

Improving reproducibility of left ventricular ejection fraction in pediatric oncology patients: less is more

Reproducible measurement of left ventricular (LV) systolic function by echocardiography is important to detect cancer therapy-related cardiac dysfunction (CTRCD). We hypothesized that limiting the number of imaging operators and use of a single vendor would improve reproducibility of these measures. A standard operating procedure (SOP) whereby LV measurements were standardized and a cardio-oncology imaging team (5 sonographers, 6 cardiologists) was established. All pediatric oncology patient echocardiograms were acquired on a single vendor platform. In total, 100 consecutive pre-SOP and 100 post-SOP studies were reviewed. LV end-diastolic dimension (LVEDD), posterior wall thickness (PW), shortening fraction (SF), and ejection fraction by Simpson's biplane (EF) were re-measured by 2 blinded readers, and compared to what was originally reported. Image quality was scored by number of LV segments imaged (grades 1-4). Inter-observer reproducibility pre/post-SOP was assessed with intra-class coefficient (α). Reducing the number of imaging operators improved image quality (Grade ≥ 3: 13% vs. 46%, p < 0.001). Reproducibility of PW and LVEDD marginally improved (PW: 0.78 to 0.82; LVEDD: 0.96 to 0.97), and SF improved significantly (α = 0.65 vs. 0.79, p < 0.001). Pre-SOP reproducibility of LV EF was poor (α = 0.65), but improved significantly post-SOP (α = 0.83, p < 0.001). Reproducibility of LV EF improved with higher image quality score. Limiting imaging operators and vendor platform for pediatric oncology echocardiograms improves image quality and reproducibility of LV EF. Establishing an SOP and a cardio-oncology echocardiography team may improve precision of measurements used to detect CTRCD.

Incidence and predictors of treatment-related conjugated hyperbilirubinemia during early treatment phases for children with acute lymphoblastic leukemia

Conjugated hyperbilirubinemia (CHB) and liver transaminase elevation are known complications of acute lymphoblastic leukemia (ALL) therapy, but host risk factors are poorly understood. Among 373 children diagnosed with ALL between 2011 and 2016, clinically significant CHB and transaminase elevation were observed in 15 (4.0%) and 12 (3.2%) children, respectively, during induction and consolidation. Body mass index ≥95th percentile (odds ratio 9.20, 95% confidence interval 2.56-32.96) was the only host factor independently associated with CHB, and no host factors were associated with transaminase elevation. Obese patients warrant closer monitoring of hepatic function to facilitate early intervention prior to the development of severe, adverse hepatic events.

Abstract 3287: Survival disparities for second primary malignancies diagnosed among childhood cancer survivors: A population-based assessment

Background: Curative therapy places childhood cancer survivors at increased risk of second primary malignancies (SPMs). However, there have been few population-based attempts to characterize differences in outcomes between SPMs in childhood cancer survivors and comparable de novo first primary malignancies (FPMs).

Methods: We extracted clinical and demographic information from childhood cancer survivors who developed SPMs and from individuals with comparable de novo FPMs using the Surveillance, Epidemiology, and End Results (SEER) 1973-2015 database. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated with Cox proportional hazards models comparing overall survival (OS) between individuals with and without a history of childhood cancer. OS was evaluated overall and within specific cancers diagnosed in ≥50 childhood cancer survivors. Models accounted for potential confounders, including sex, race, age, decade of diagnosis, histology, and disease stage.

Results: Compared to individuals with FPMs (n=1,332,203), childhood cancer survivor with a similar SPM as the FPMs (n=1,409) experienced poorer OS (HR=1.86, 95%CI: 1.72-2.02) after accounting for age, sex, race, and decade of diagnosis. Estimated five-year overall survival for SPMs diagnosed in survivors of childhood cancer was 61.7% (95% CI: 58.9-64.4), compared to 77.4% (95% CI: 75.0-79.5) among de novo FPMs propensity score-matched on confounding factors. A history of childhood cancer remained a poor prognostic factor for all specific cancer evaluated, including: breast (HR=2.07, 95%CI: 1.63-2.62), thyroid (HR=3.59, 95%CI: 2.08-6.19), acute myeloid leukemia (HR=2.38, 95%CI:1.87-3.05), brain (HR=2.09, 95%CI:1.72-2.55), melanoma (HR=2.57, 95%CI: 1.55-4.27), bone (HR=1.88, 95%CI:1.37-2.57), and soft tissue sarcoma (HR=2.44, 95%CI: 1.78-3.33). Survival disparities were most pronounced in survivors diagnosed with a childhood cancer before age 10 (HR=2.83, 95%CI: 2.46-3.25), diagnosed with a SPM within 10 years of the childhood cancer (HR=2.61, 95%CI: 2.29-2.99), and exposed to radiotherapy during childhood (HR=2.13, 95%CI: 1.92-2.37).

Conclusion: Compared to individuals without a prior cancer diagnosis, survivors of childhood cancer with a SPM experience inferior outcomes. These survival disparities persist across cancer types, therapeutic exposures, and clinical factors.

Citation Format: Austin L. Brown, Vidal M. Arroyo, Jennifer Agrusa, Michael E. Scheurer, Maria M. Gramatges, Philip J. Lupo. Survival disparities for second primary malignancies diagnosed among childhood cancer survivors: A population-based assessment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3287.

Abstract 3110: Shorter naïve T cell telomere length is associated with thyroid subsequent malignant neoplasm: A report from the Childhood Cancer Survivor Study (CCSS)

Introduction: Reduced blood telomere content has been associated with an increased risk for subsequent malignant neoplasms of the thyroid (thyroid SMN) in survivors of childhood cancer (PMID 24277454). Here, we further investigate this association by examining telomere length (TL) in leukocyte subsets. Methods: Survivors were enrolled to the CCSS, a multicenter, retrospective cohort of 5-year + survivors of childhood cancer. Cases were survivors with thyroid SMN, and matched (1:1) to survivor controls without SMN by primary diagnosis, year of primary diagnosis (decade), chemotherapy (yes/no), radiation field, and follow-up time (exceeding time to SMN for the case). Stem cell transplant recipients were excluded. Absolute TL was determined from viably frozen leukocytes (lymphocytes, naïve T, memory T, B, and NK cells) by telomere flow cytometry fluorescence in situ hybridization (telomere flow FISH, Repeat Diagnostics), and transformed to age-adjusted percentiles based on age at sample collection. For each leukocyte subset, we used McNemar’s test to compare frequency of very low (VL, ≤1st age-adjusted percentile) or low (L, &gt;1st to ≤10th percentile), and a paired t-test to compare age-adjusted TL between cases and controls. Odds ratios were determined by conditional logistic regression. Results: Of the 52 matched pairs identified, 46 pairs (92 survivors) had sufficient cell recovery for flow FISH: primary diagnoses included Hodgkin lymphoma (20 pairs), acute lymphoblastic leukemia (13 pairs), CNS tumors (7 pairs), neuroblastoma (2 pairs), non-Hodgkin lymphoma (3 pairs), and kidney tumor (1 pair). All survivors had age-adjusted TL below the population median. Cases had shorter age-adjusted TL than controls in 4 out of 5 leukocyte subsets: lymphocytes (p=0.04), naïve T cells (p=0.02), B cells (p=0.01), and NK cells (p=0.01). Naïve T cells had an overrepresentation of VL TL (cases with VL TL in 9/46 pairs vs. controls with VL TL in 2/46 pairs, p=0.04). The odds of L or VL naïve T cell TL was significantly higher in cases compared with controls (OR=2.8, 1.11-7.19, p=0.03), an observation that did not change after adjusting for age at diagnosis. Conclusions: Survivors of childhood cancer had shorter age-adjusted leukocyte TL than the general population. This negative deviation was more pronounced among survivors with thyroid SMN than in survivors without SMN, which may reflect a differential risk among survivors for excess premature aging in the hematopoietic compartment. The effect of SMN treatment on TL is unlikely to be a factor, as treatment for thyroid SMN is primarily surgical. In cancer-naïve populations, VL lymphocyte TL is a sensitive and specific indicator of underlying defects in telomere maintenance. In survivors of childhood cancer, VL TL in naïve T cells may reflect an association between SMN risk and defects in T cell-mediated cancer surveillance.

Citation Format: Maria M. Gramatges, Geraldine Aubert, Elmira Hariri, Yan Chen, John A. Whitton, Wendy M. Leisenring, Michael A. Arnold, Joseph P. Neglia, Yutaka Yasui, Leslie L. Robison, Gregory T. Armstrong, Smita Bhatia. Shorter naïve T cell telomere length is associated with thyroid subsequent malignant neoplasm: A report from the Childhood Cancer Survivor Study (CCSS) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3110.

Telomere Length-Associated Genetic Variants and the Risk of Thyroid Cancer in Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study (CCSS)

BACKGROUND

Given the inverse relationship described previously between telomere content and thyroid subsequent malignant neoplasm (thyroid SMN) in survivors of childhood cancer, we investigated the relationship between known genetic determinants of leukocyte telomere length (LTL) and thyroid SMN among survivors.

METHODS

Leveraging data from a large, genotyped survivor cohort, the Childhood Cancer Survivor Study, we used a well-described genetic risk score method to estimate the HR for thyroid SMN among 5,324 genotyped survivors.

RESULTS

We identified 118 survivors with thyroid SMN and 5,206 without thyroid SMN. No association between genetically estimated LTL and risk for thyroid SMN was identified.

CONCLUSIONS

Our results suggest that variation in common SNPs influencing LTL is not strongly associated with risk for thyroid SMN in survivors of childhood cancer.

IMPACT

The previously observed inverse relationship between LTL and thyroid SMN risk in survivors of childhood cancer may be related to alternative molecular mechanisms and warrants further study.

Abstract 600: Telomere length-associated genetic variants and the risk of thyroid cancer after childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS)

Purpose: We previously reported an association between reduced telomere content and increased risk for radiation-related thyroid subsequent neoplasms (SNs) in childhood cancer survivors. We now extend this work to investigate associations between single nucleotide polymorphisms (SNPs) in the National Human Genome Research Institute-European Bioinformatics Institute (NHGRI-EBI) GWAS Catalog identified to influence telomere length and thyroid SN in a cohort of childhood cancer survivors.

Methods: The population included 5,324 5-year survivors of childhood cancer survivors participating in the CCSS with genome-wide SNP data generated using the Illumina HumanOmni5Exome array, who (1) developed thyroid SN (n=117) or (2) did not develop thyroid SN (n=5,207), censored by date of any SN, death, or last follow-up. Ancestry was estimated using HapMap data as the fixed reference population. Imputation was performed based on the 1000 Genomes Project reference haplotypes. For the analysis, we focused on SNPs in the NHGRI-EBI GWAS Catalog previously identified to influence telomere length (statistical significance threshold P&lt;1.0x10-5). Assuming an additive genetic model, we used multivariable Cox proportional hazards models to estimate the hazard ratio (HR), 95% confidence interval (CI), and P value for the association between each SNP and thyroid SN risk. Covariates evaluated included sex, primary cancer diagnosis, radiation exposure, and exposure to alkylating agents. Analyses were restricted to those of European ancestry to limit bias due to population stratification. Results were also stratified on radiation exposure and primary diagnosis, and the false discovery rate (FDR) was used to account for multiple comparisons.

Results: We identified 30 SNPs in the NHGRI-EBI GWAS Catalog associated with telomere length. Based on the sample size and the number of SNPs evaluated, we had 80% power to identify HRs between 1.7 and 2.0, based on minor allele frequencies (MAFs) of 10-40%. In multivariable analyses, when evaluating associations among those exposed to radiation to the neck, the top hit was rs621559 (HR=1.94, 95% CI: 1.16-3.24, P=0.01), an intronic SNP in WDR65. However, after applying the FDR at &lt;0.05, no SNPs were associated with thyroid SN risk overall, nor after stratifying on radiation exposure or primary diagnosis.

Conclusions: There is an inverse relationship between telomere content and thyroid SN among childhood cancer survivors. Our study was unable to identify an association between common SNPs influencing telomere length and thyroid SN. The observed relationship between reduced telomere content and thyroid SN could possibly be due to alternative molecular mechanisms such as rare or novel variants, or defects in specific genes related to telomere maintenance.

Citation Format: Philip J. Lupo, Lindsay M. Morton, Yutaka Yasui, Wendy M. Leisenring, Gregory T. Armstrong, Leslie L. Robison, Smita Bhatia, Maria M. Gramatges. Telomere length-associated genetic variants and the risk of thyroid cancer after childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 600.

Identifying patient- and family-centered outcomes relevant to inpatient versus at-home management of neutropenia in children with acute myeloid leukemia

Efficacy of therapeutic strategies relative to patient- and family-centered outcomes in pediatric oncology must be assessed. We sought to identify outcomes important to children with acute myeloid leukemia and their families related to inpatient versus at-home management of neutropenia. We conducted qualitative interviews with 32 children ≥8 years old and 54 parents. Analysis revealed the impact of neutropenia management strategy on siblings, parent anxiety, and child sleep quality as being outcomes of concern across respondents. These themes were used to inform the design of a questionnaire that is currently being used in a prospective, multiinstitutional comparative effectiveness trial.

Shorter Remission Telomere Length Predicts Delayed Neutrophil Recovery After Acute Myeloid Leukemia Therapy: A Report From the Children's Oncology Group

Purpose Suboptimal outcomes for children with acute myeloid leukemia (AML) necessitate maximally intensive therapy. Consequently, serious adverse events, such as prolonged periods of profound myelosuppression, contribute to AML treatment-related mortality. Telomeres, the repetitive DNA-protein structures at chromosome ends, influence cellular replicative capacity in that critically short telomeres can induce cell senescence or apoptosis. Our objective was to evaluate the impact of telomere length on duration of post-therapy neutropenia in a pediatric AML cohort. Patients and Methods Patients were diagnosed with de novo AML, enrolled in Children's Oncology Group study AAML0531, and included those with (n = 53) and without (n = 62) significantly delayed neutrophil recovery after chemotherapy. We used quantitative polymerase chain reaction to measure telomere content (TC), a validated proxy for telomere length, from remission bone marrow samples obtained after the second induction chemotherapy course. Results Less TC was significantly associated with prolonged neutropenia after the fourth ( P < .001) and fifth chemotherapy courses ( P = .002). Cox regression adjusting for age at diagnosis confirmed that TC remained independently predictive of time to recovery of absolute neutrophil count for both the fourth and fifth courses ( P = .002 and .009, respectively). DNA from patients was analyzed for germline mutations in four telomere maintenance genes associated with telomere biology disorders. Sequence analysis revealed no enrichment of rare or novel variants in the delayed recovery group. Conclusion Our results suggest that TC at end of AML induction is associated with hematopoietic reconstitution capacity independently of age and may identify those at highest risk for markedly delayed bone marrow recovery after AML therapy.

Expression of CD25 is a specific and relatively sensitive marker for the Philadelphia chromosome (BCR-ABL1) translocation in pediatric B acute lymphoblastic leukemia

BACKGROUND

Precursor B acute lymphoblastic leukemia (B-ALL) is the most common cancer in children and overall, has an excellent prognosis. However, the Philadelphia chromosome translocation (Ph+), t(9;22)(q34;q11), is present in a small subset of patients and confers poor outcomes. CD25 (IL-2 receptor alpha chain) expression has been associated with Ph+ B-ALL in adults, but no similar study has been performed in pediatric B-ALL.

METHODS

A retrospective analysis of 221 consecutive pediatric patients with a diagnosis of B-ALL (blood and/or bone marrow) from 2009 to 2012 was performed to determine an association between Ph+ B-ALL and CD25 expression. A threshold of 25% was used to define positive cases for CD25 expression by flow cytometry.

RESULTS

There were 221 patients with a diagnosis of B-ALL ranging from 2 to 22 years (median, 6 years). Eight (3.6%) B-ALL patients were positive for the Philadelphia chromosome translocation (Ph+ B-ALL) and 213 were negative (Ph-negative B-ALL). CD25 expression was observed in 6 of 8 (75%) Ph+ B-ALL patients and 6 of 213 (2.8%) Ph-negative B-ALL patients. CD25 expression was significantly higher in Ph+ B-ALL compared to Ph-negative B-ALL, with median CD25 expression of 64% (range 0-93%) and 0.1% (range 0-91%), respectively (P ≤ 0.0002). Therefore, CD25 expression as a predictor of Ph+ B-ALL had 75% sensitivity, 97% specificity, 50% positive predictive value and 99% negative predictive value.

CONCLUSIONS

CD25 expression is a specific and relatively sensitive marker for the identification of Ph+ B-ALL in the pediatric population.

Telomere content and risk of second malignant neoplasm in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

PURPOSE

Shorter constitutional telomere length has been associated with increased cancer incidence. Furthermore, telomere shortening is observed in response to intensive chemotherapy and/or ionizing radiation exposure. We aimed to determine whether less telomere content was associated with treatment-related second malignant neoplasms (SMN) in childhood cancer survivors.

EXPERIMENTAL DESIGN

Using a nested case-control design, 147 cancer survivors with breast cancer, thyroid cancer, or sarcoma developing after treatment for childhood cancer (cases) were matched (1:1) with childhood cancer survivors without a SMN (controls). Cases and controls were matched by primary cancer diagnosis, years since diagnosis, age at the time of sample collection, years of follow-up from childhood cancer diagnosis, exposure to specific chemotherapy agents, and to specific radiation fields. We performed conditional logistic regression using telomere content as a continuous variable to estimate ORs with corresponding 95% confidence intervals (CI) for development of SMN. ORs were also estimated for specific SMN types, i.e., breast cancer, thyroid cancer, and sarcoma.

RESULTS

There was an inverse relationship between telomere content and SMN, with an adjusted OR of 0.3 per unit change in telomere length to single-copy gene ratio (95% CI, 0.09-1.02; P = 0.05). Patients with thyroid cancer SMN were less likely to have more telomere content (OR, 0.04; 95% CI, 0.00-0.55; P = 0.01), but statistically significant associations could not be demonstrated for breast cancer or sarcoma.

CONCLUSIONS

A relation between less telomere content and treatment-related thyroid cancer was observed, suggesting that shorter telomeres may contribute to certain SMNs in childhood cancer survivors.

Recommendations for broader coverage antifungal prophylaxis in childhood acute myeloid leukemia: ASH evidence-based review 2011

A 16-year-old female diagnosed with acute myeloid leukemia (AML) with inversion 16, a favorable prognostic indicator, has persistent neutropenia after her fourth cycle of dose-intensified chemotherapy. She was recently admitted for treatment with empiric antibiotics for febrile neutropenia, and an astute intern noticed a new lesion on her right foot with a dark necrotic center. A biopsy of the lesion showed spreading hyphae, consistent with Aspergillus. Despite her compliance with fluconazole fungal prophylaxis, computed tomography imaging revealed disseminated aspergillosis involving her lungs, liver, and kidneys. Amphotericin was started, but systemic fungemia and the development of multiorgan failure resulted in her death. You are in the difficult position of having to explain to her parents that she died in remission from chemotherapy-related complications. All of those involved in this unfortunate scenario wonder if something could have been done to prevent her death.