Increased Cardiac Risk After a Second Malignant Neoplasm Among Childhood Cancer Survivors: A FCCSS Study

Background

Childhood cancer survivors (CCS) are at an elevated risk of developing both a second malignant neoplasm (SMN) and cardiac disease.

Objectives

This study sought to assess the excess of occurrence of cardiac disease after a SMN among CCS.

Methods

Analyses included 7,670 CCS from the French Childhood Cancer Survivors Study cohort diagnosed between 1945 and 2000. To account for the time dependence of the occurrence of a SMN, we employed a landmark approach, considering an additive regression model for the cumulative incidence of cardiac disease. We estimated the effect of a SMN on the instantaneous risk of cardiac disease using a proportional cause-specific hazard model, considering a SMN as a time-dependent exposure. In both models, we adjusted for demographic and treatment information and considered death as a competing event.

Results

In 7,670 CCS over a median follow-up of 30 years (IQR: 22-38 years), there were 378 cases of cardiac disease identified, of which 49 patients experienced a SMN. Patients who survived 25 years after their childhood cancer diagnosis and had a SMN in that time frame had a significantly increased cumulative incidence of cardiac disease, which was 3.8% (95% CI: 0.5% to 7.1%) higher compared with those without a SMN during this period. No SMN-induced excess of cardiac disease was observed at subsequent landmark times. SMNs were associated with a 2-fold increase (cause-specific HR: 2.0; 95% CI: 1.4-2.8) of cardiac disease.

Conclusions

The occurrence of a SMN among CCS is associated with an increased risk of cardiac disease occurrence and risk at younger ages.

Dosiomics-Based Prediction of Radiation-Induced Valvulopathy after Childhood Cancer

Valvular Heart Disease (VHD) is a known late complication of radiotherapy for childhood cancer (CC), and identifying high-risk survivors correctly remains a challenge. This paper focuses on the distribution of the radiation dose absorbed by heart tissues. We propose that a dosiomics signature could provide insight into the spatial characteristics of the heart dose associated with a VHD, beyond the already-established risk induced by high doses. We analyzed data from the 7670 survivors of the French Childhood Cancer Survivors' Study (FCCSS), 3902 of whom were treated with radiotherapy. In all, 63 (1.6%) survivors that had been treated with radiotherapy experienced a VHD, and 57 of them had heterogeneous heart doses. From the heart-dose distribution of each survivor, we extracted 93 first-order and spatial dosiomics features. We trained random forest algorithms adapted for imbalanced classification and evaluated their predictive performance compared to the performance of standard mean heart dose (MHD)-based models. Sensitivity analyses were also conducted for sub-populations of survivors with spatially heterogeneous heart doses. Our results suggest that MHD and dosiomics-based models performed equally well globally in our cohort and that, when considering the sub-population having received a spatially heterogeneous dose distribution, the predictive capability of the models is significantly improved by the use of the dosiomics features. If these findings are further validated, the dosiomics signature may be incorporated into machine learning algorithms for radiation-induced VHD risk assessment and, in turn, into the personalized refinement of follow-up guidelines.

The risk of valvular heart disease in the French Childhood Cancer Survivors' Study: Contribution of dose-volume histogram parameters

BACKGROUND AND PURPOSE

Valvular Heart Disease (VHD) is a known complication of childhood cancer after radiotherapy treatment. However, the dose-volume-effect relationships have not been fully explored.

MATERIALS AND METHODS

We obtained individual heart Dose Volume Histograms (DVH) for survivors of the French Childhood Cancer Survivors Study (FCCSS) who had received radiotherapy. We calculated the Mean Dose to the Heart (MHD) in Gy, as well as the heart DVH parameters (V_{d Gy}, which represents the percentage of heart volume receiving at least d Gy), fixing the thresholds to 0.1 Gy, 5 Gy, 20 Gy, and 40 Gy. We analyzed them furtherly in the subpopulation of the cohort that was treated with a dose lower than 5 Gy (V_0.1Gy|_V5Gy=0%), 20 Gy (V_5Gy|_V20Gy=0%), and 40 Gy (V_20Gy|_V40Gy=0%), respectively. We investigated their role in the occurrence of a VHD in this population-based observational cohort study using the Cox proportional hazard model, adjusting for age at cancer diagnosis and chemotherapy exposure.

RESULTS

Median follow-up was 30.6 years. Eighty-one patients out of the 7462 (1 %) with complete data experienced a severe VHD (grade ≥ 3). The risk of VHD increased along with the MHD, and it was associated with high doses to the heart (V_40Gy < 50 %, hazard ratio (HR) = 7.96, 95 % CI: 4.26-14.88 and V_20Gy|_V40Gy=0% >50 %, HR = 5.03, 95 % CI: [2.35-10.76]). Doses 5-20 Gy to more than 50 % (V_5Gy|_V20Gy=0% >50 %) of the heart induced a marginally non-significant estimated risk. We also observed a remarkable risk increase with attained age.

CONCLUSIONS

Our results provide new insight into the VHD risk that may impact current treatments and long-term follow-up of childhood cancer survivors.

Identifying clusters of health risk behaviors and their predictors in adult survivors of childhood cancer: A report from the French Childhood Cancer Survivor Study

OBJECTIVE

Health risk behaviors (HRB) of childhood cancer survivors (CCS) are generally studied separately, despite the evidence suggesting that HRB are not independent. To our knowledge, few studies have examined HRB profiles in the former pediatric cancer patients. In this study, we identified HRB profiles and examined predictors engaging in unhealthy behaviors in CCS.

METHODS

We used data from a French cohort of CCS that includes five-year survivors diagnosed between 1945 and 2000 and treated before reaching age 18, in five centers in France. A total of 2961 adult CCS answered a self-reported questionnaire pertaining to HRB. Latent class analysis was used to identify HRB profiles combining physical activity, smoking, cannabis use, and alcohol drinking. Multinomial logistic analyses examined predictors for engaging in unhealthy behaviors.

RESULTS

Three HRB patterns emerged: "Low-risk" (n = 1846, 62.3%) included CCS who exhibited the highest frequency for usual physical activity and the lowest probabilities for current smoking or cannabis use, but most drank at least moderately; "Moderate-risk behaviors" (n = 291, 9.8%), and "High-risk behaviors" (n = 824, 27.8%) for CCS who exhibited the highest frequencies for current smoking, cannabis use, and heavy drinking. The multivariable regression revealed that male CCS, less educated or not married were significantly more likely to be in the high-risk behaviors group than the low-risk group.

CONCLUSIONS

As CCS remain a vulnerable population, screening for HRB should be routinized in long-term follow-up care and interventions targeting multiple HRB simultaneously among survivors should be developed.

Comprehensive landscape of immune-checkpoints uncovered in clear cell renal cell carcinoma reveals new and emerging therapeutic targets

Clear cell renal cell carcinoma (ccRCC) constitutes the most common renal cell carcinoma subtype and has long been recognized as an immunogenic cancer. As such, significant attention has been directed toward optimizing immune-checkpoints (IC)-based therapies. Despite proven benefits, a substantial number of patients remain unresponsive to treatment, suggesting that yet unreported, immunosuppressive mechanisms coexist within tumors and their microenvironment. Here, we comprehensively analyzed and ranked forty-four immune-checkpoints expressed in ccRCC on the basis of in-depth analysis of RNAseq data collected from the TCGA database and advanced statistical methods designed to obtain the group of checkpoints that best discriminates tumor from healthy tissues. Immunohistochemistry and flow cytometry confirmed and enlarged the bioinformatics results. In particular, by using the recursive feature elimination method, we show that HLA-G, B7H3, PDL-1 and ILT2 are the most relevant genes that characterize ccRCC. Notably, ILT2 expression was detected for the first time on tumor cells. The levels of other ligand-receptor pairs such as CD70:CD27; 4-1BB:4-1BBL; CD40:CD40L; CD86:CTLA4; MHC-II:Lag3; CD200:CD200R; CD244:CD48 were also found highly expressed in tumors compared to adjacent non-tumor tissues. Collectively, our approach provides a comprehensible classification of forty-four IC expressed in ccRCC, some of which were never reported before to be co-expressed in ccRCC. In addition, the algorithms used allowed identifying the most relevant group that best discriminates tumor from healthy tissues. The data can potentially assist on the choice of valuable immune-therapy targets which hold potential for the development of more effective anti-tumor treatments.

Abstract P2-14-09: Prospective Evaluation of Change in 2-Point Discrimination of Index Finger as a Potential Early Predictive Marker for Carpal Tunnel Syndrome among Women Receiving Adjuvant Aromatase Inhibitor Therapy for Postmenospausal Breast Cancer in the Exemestane and Letrozole Pharmacogenomics (ELPh) Trial

Introduction: Third generation aromatase inhibitors (AIs) represent an integral part of hormonal therapy in postmenopausal women with hormone receptor (HR)-positive breast cancer. AIs are associated with musculoskeletal symptoms in up to 50% of women. Post-hoc analyses of adjuvant AI trials (ATAC and IES) have suggested that AIs might be associated with carpal tunnel syndrome (CTS), a pressure-induced neuropathy disorder caused by compression on the median nerve. The clinical diagnosis of CTS is made with typical symptoms of pain, weakness, and paresthesias in affected arm. A variety of tests, including change in 2-point discrimination (2PD) can be used to aid in diagnosis. However, the actual incidence of CTS and clinical utility of diagnostic tests such as 2PD have not been prospectively examined among women receiving AIs. Methods: Postmenopausal women with stage 0-III HR-positive breast cancer, who had completed local therapy and, if indicated, adjuvant chemotherapy, and who were enrolled in the multi-center Exemestane and Letrozole Pharmacogenetics (ELPh) trial underwent prospective evaluation of 2PD with the Disc-criminator™ (sliding aesthesiometer) at baseline, and 3 months, following initiation of the AI. The end of the Disc-criminator™ was applied at the two points at same time to the skin on the volar tip pulp of the index fingers, and the threshold value (in mm) was determined as the shortest distance between the two points a woman was able to differentiate. The exercise was repeated thrice at each point. Abnormal 2PD thresholds were defined using standard criteria (outside 95 percentile for age). The differences in mean 2PD from baseline to 3 months were analyzed using a multivariate mixed effects model where the correlations from repeated measures were accounted for by assuming an unstructured covariance structure. A p value &lt; 0.05 was considered statistically significant.

Results: A total of 104 women underwent baseline 2PD testing. The mean age was 59 years, 55.8% had stage I disease, and 42.3% received adjuvant chemotherapy. We observed abnormal 2PD thresholds in 1.9% and 3.5% of women at baseline and 3 months respectively. There was a significant worsening in the adjusted mean 2PD from baseline (3.4 mm) to 3 months (4 mm, p=0.01). The increase in mean 2PD following 3 months of AI therapy was higher among women with age &gt; 55 (p=0.02), BMI &gt; 25 (p=0.002), African Americans (p=0.02), and those who received adjuvant chemotherapy (p=0.05), as compared to their counterparts. Conclusion: Adjuvant AI therapy was associated with a significant worsening of 2PD at 3 months, particularly among older women, overweight women, and those receiving adjuvant chemotherapy. Correlation with CTS symptoms and need for surgical release will be presented at the meeting. Our results suggest that 2PD is a non-invasive method that may potentially allow for early detection of CTS. If confirmed, change in 2PD could serve as an objective early predictor for subsequent CTS in postmenopausal women with breast cancer initiating AI therapy.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-14-09.

Modeling hot flushes and quality of life in breast cancer survivors

OBJECTIVES

To evaluate the relationships among measures of hot flushes, perceived hot flush interference, sleep disturbance, and measures of quality of life while controlling for potential covariates (patient and treatment variables).

METHODS

Breast cancer survivors (n = 395) due to receive aromatase inhibitor therapy provided demographic information, physiological hot flush data via sternal skin conductance monitoring, hot flush frequency via written diary and electronic event marker, hot flush severity and bother via written diary, and questionnaire data via the Hot Flash Related Daily Interference Scale, Pittsburgh Sleep Quality Index, the EuroQOL, Hospital Anxiety and Depression Scale and the Center for Epidemiologic Studies Depression Scale.

RESULTS

Confirmatory factor analysis supported a two-factor model for hot flush symptoms (frequency and severity). Although there was strong convergence among self-reported hot flush measures, there was a high degree of unexplained variance associated with physiological measures. This suggests that self-report and physiological measures do not overlap substantially. The structural model showed that greater hot flush frequency and severity were directly related to greater perceived interference with daily life activities. Greater perceived interference, in turn, directly predicted greater sleep disruption, which predicted lower perceived health state and more symptoms of anxiety and depression.

CONCLUSIONS

Findings suggest hot flush interference may be the most appropriate single measure to include in clinical trials of vasomotor symptom therapies. Measuring and ameliorating patients' perceptions of hot flush interference with life activities and subjective sleep quality may be the most direct routes to improving quality of life.

Estrogen receptor genotypes, menopausal status, and the lipid effects of tamoxifen

Tamoxifen induces important changes in serum lipid profiles in some women; however, little information is available to predict which women will experience improved lipid profiles during tamoxifen therapy. As part of a multicenter prospective observational trial in 176 breast cancer patients, we tested the hypothesis that tamoxifen-induced lipid changes were associated with genetic variants in candidate target genes (CYP2D6, ESR1, and ESR2). Tamoxifen lowered low-density lipoprotein cholesterol (P<0.0001) by 23.5 mg/dl (13.5-33.5 mg/dl) and increased triglycerides (P=0.006). In postmenopausal women, the ESR1-XbaI and ESR2-02 genotypes were associated with tamoxifen-induced changes in total cholesterol (P=0.03; GG vs GA/AA) and triglycerides (P=0.01; gene-dose effect), respectively. In premenopausal women, the ESR1-XbaI genotypes were associated with tamoxifen-induced changes in triglycerides (P=0.002; gene-dose effect) and high-density lipoprotein (P=0.004; gene-dose effect). Our results suggest that estrogen receptor genotyping may be useful in predicting which women would benefit more from tamoxifen.

The psychiatric nurse specialist: a valuable asset in the general hospital

In summary, what are the ways in which the psychiatric/mental clinical specialist contributes to cost-effectiveness, the professional growth of nursing staff, and quality patient care in the general hospital setting? All services of the psychiatric/mental health clinical specialist are ultimately directed toward increasing the effectiveness with which staff can deliver care. This goal is accomplished by helping staff nurses maximize their knowledge, by providing needed educational opportunities, by promoting the use of a holistic model of care, and by helping staff cope with their own stress. In our experience, high quality care that meets the physiological, psychological, and sociological needs of patients decreases the length of the hospital stay, prevents repeated hospitalizations, and minimizes the development of psychosocial problems secondary to the illness. With the necessary support and cooperation from administration, this clinical specialist role reduces health care costs, promotes a higher level of functioning in patients and their families, and increases the level of job satisfaction for the staff who provide direct bedside care.