Iatrogenic risk factors are associated with occurrence of nonmelanoma skin cancer and poor prognosis in children. A PeDRA STARC Project

Transcription

1 Iatrogenic risk factors are associated with occurrence of nonmelanoma skin cancer and poor prognosis in children A PeDRA STARC Project

2 Nonmelanoma skin cancer is tradi0onally associated with predisposing condi0ons

3 Iatrogenic exposures associated with NMSC in adults include immunosuppression, radia0on, and voriconazole

4 Lack of risk factor iden0fica0on and access to care may delay diagnosis of NMSC in children

5 To describe clinical characteris0cs of NMSC in children and young adults. Survival No Yes Overall Survival With Number of Subjects at Risk + Censored + Censored Years from inital skin cancer diagnosis To iden0fy risk factors associated with occurrence and outcomes of NMSC. Has the patient received voriconazole? No Yes Pa#ents with iatrogenic exposures To characterize access to dermatologic care in these pa0ents.

6 Multi-center, retrospective case controlled study of 11 major academic hospitals

7 What we ve accomplished so far PeDRA 2014 PeDRA 2015 PeDRA 2016 PeDRA /14: 4/15: Global Ini0al IRB approved brainstorming 11/15: Data collec0on form finalized 3/16: IRB approval and DTAs obtained by all sites 9/16: Study pa0ent data collected by all sites 3/17: Control data collected 9/17: Data analysis 6/15: PeDRA Seed Grant 1/16: ASA Grant awarded 10/17: Data presented

8 This cohort is from a database of 438 pa0ents with melanoma or NMSC 321 with melanoma with NMSC Controls matched by sex, age, and skin type

9 126 NMSC pa#ents 126 Control pa#ents Medical record review Data collec0on into shared Redcap form Data analysis by DFCI CTIP

10 We iden0fied 96 pa0ents with BCC, 40 with SCC, and 9 with melanoma

11 We iden0fied 845 occurrences of skin cancer # of NMSC occurrences by skin cancer type Diagnosis # overall occurrences (%) BCC 718 (85) SCC invasive 87 (10) SCC in situ 36 (4) Keratoacanthoma 8 (1) Melanoma 9 (1) Total 845

12 50.4% of pa0ents had 2 skin cancers Number of Skin Cancer Lesions (Initial and Subsequent) 50 Number of patients =>18 Number of lesions

13 One-third of pa0ents were of nonwhite race and/or skin phototype BCC SCC Non-white FPT 3

14 44% of pa0ents had a predisposing condi0on Basal cell nevus syndrome (34) Xeroderma pigmentosum (11) Immunodeficiency Dyskeratosis congenita Bloom syndrome Incon0nen0a pigmen0 Epidermolysis bullosa Morphea Nevus sebaceous Wart

15 29% had 1 iatrogenic exposure Characteris#c n (%) SCC (n=40) BCC (n=97) Therapies 14 (35) 26 (27) Immunosuppression > 6 mos 12 (30) 5 (5) Radia1on therapy 5 (13) 19 (20) Chemotherapy 3 (8) 21 (22) Voriconazole use 6 (15) 2 (2) Malignancy 7/38 (18) 26/94 (28) Stem cell transplant 6 (15) 9 (9) Chronic GVHD 5/5 (100) 1/5 (25) Organ transplant 6 (15) 2 (2)

16 Immunosuppression and voriconazole use are associated with SCC occurrence SCC pa#ents vs. controls (n=40 each) Risk factors SCC, n (%) Control, n (%) p-value* Immunosuppression 12 (30) 0 (0) Radia#on therapy 5 (13) 0 (0) Chemotherapy 3 (8) 0 (0) 0.24 Voriconazole use 6 (15) 0 (0) Malignancy 7/38 (18) 0 (0) Stem cell transplant 6 (15) 0 (0) 0.03 Organ transplant 6 (15) 0 (0) 0.03

17 Radia0on and chemotherapy are associated with BCC occurrence BCC pa#ents vs. controls (n=97 each) Risk factors BCC, n (%) Control, n (%) p-value* Immunosuppression 5 (5) 2 (2) 0.44 Radia#on therapy 19 (20) 1 (1) < Chemotherapy 21 (22) 1 (1) < Voriconazole use 2 (2) 0 (0) 0.5 Malignancy 26/94 (28) 3/95 (3) < Stem cell transplant 9 (9) 0 (0) Organ transplant 2 (2) 0 (0) 0.5

18 Of 6 deaths reported, one was related to skin cancer Life status SCC (n=40) n (%) BCC (n=97) Follow-up #me in years [median (range),n] 4 (0-20.7), n= (0-22.1), n=94 Dead 4 (10) 3 (3) Life status Alive 35 (90) 89 (97) Unknown 1 5

19 Voriconazole use was significantly associated with worse overall 5-year survival Overall Survival With Number of Subjects at Risk + Censored Survival No Yes + Censored Years from inital skin cancer diagnosis Has the patient received voriconazole? No Yes

20 Pa0ents with iatrogenic exposures have decreased access to dermatologic care All pa#ents Pa#ents with iatrogenic exposures 19% 32% Saw derm before NMSC diagnosis Did not see derm before NMSC diagnosis

21 Median 0me from onset to diagnosis was 9 months, with 80% present for > 6 months prior to diagnosis

22 Children with iatrogenic exposures are at risk for nonmelanoma skin cancer Immunosuppression Voriconazole use Squamous cell carcinoma Radia0on therapy Chemotherapy Basal cell carcinoma

23 Set up referral pagerns with oncologists Educate our pa0ents Improve our access Educate our peers/ colleagues

24 Investigators and contributors Carrie C. Coughlin, MD Lawrence F. Eichenfield, MD Pedram Gerami, MD Elena Hawryluk, MD, PhD Kristen Hook, MD Jennifer T. Huang, MD Stephen Humphrey, MD Lacey Kruse, MD Leslie Lawley, MD Hasan Al-Sayegh, MBChB, MPH Wendy London, PhD Ashfaq Marghoob, MD Thuy Phung, MD, PhD Elena Pope, MD Birgitta Schmidt, MD Eman Bahrani, MD Diana Bartenstein MD Meera Brahmbhatt, MD Lily Chen, MD Kaitlyn Kollman, MD Ellen Haddock MD Danny Mansour MD Julie Nguyen, MD Tom Raisanen MD Sarah Robinson, MD Tova Rogers, MD Gary Tran, MD Kate Travis, BA Zachary Wolner, MD