AYA & XYZ: Care of the Childhood Cancer Survivor & Adolescent/Young Adult Oncology

Transcription

1 AYA & XYZ: Care of the Childhood Cancer Survivor & Adolescent/Young Adult Oncology ST E P H A N I E H O W E G UA R I N O, M D, MSHP, FA A P S I C K L E C E L L PROGRAM C L I N I CAL L EAD, C H R I ST I A N A C A R E H EALT H SYST E M P E D I AT R I C H E M ATO LO GY/ O N COLO GY, N E M O URS

2 DISCLOSURES I have no relevant disclosures

3 OBJECTIVES Describe the health issues that affect adult survivors of childhood cancer Discuss appropriate follow up strategies for the general internist Discuss the unique considerations for Adolescent/Young Adult (AYA) patients with oncology diagnoses for the general internist and hospitalist

4 The Good News Children with cancer are surviving into adulthood St Jude Children s Research Hospital acrcrd&vgnextchannel=4bbafe08dc835110vgnvcm e0215acrcrd

5 Cancer Research UK, Accessed February 2019.

6 Childhood Cancer Survivors More than 25% of adult survivors report at least one severe, lifethreatening or disabling condition 25 years after treatment (compared to 5% in siblings of similar age) As time from diagnosis increases, risk of recurrence plateaus but risk of late effects continues to increase Armstrong G. et al. J Clin Oncol. 27, no. 14 (May 2009)

7 Mechanism Causing Late Effects Ness K et al. J Clin Oncol 36, no 21 (July 2018)

8 Late Effects What are they? Avascular Necrosis (AVN) Bone Health Osteoradionecrosis Breast Cancer Chronic Pain Educational Issues Emotional Health Gastrointestinal System Hormones and Reproduction Central Adrenal Insufficiency Early Puberty Female Reproductive Issues Growth Hormone (GH) Deficiency; Male Reproductive Issues Hepatitis Hyperprolactinemia Hypopituitarism Limb Salvage Managing Amputation Organs Heart Problems Kidney Health Lung (Pulmonary) Health Liver Health Spleen Bladder Health Neurogenic Bladder Peripheral Neuropathy Raynaud s Phenomenon Scoliosis and Kyphosis Secondary Cancers Colorectal Cancer Sensory Dental Health Eye Problems Hearing Problems Skin Health Thyroid Problems

9 Childhood Cancer Survivor Study (CCSS) Cohort study with survivors and 3737 sibling controls from 26 institutions diagnosed between Included those treated for leukemia, CNS tumors, Hodgkin s lymphoma, Non-Hodgkin s lymphoma, Wilm s tumor, Neuroblastoma, soft tissue sarcomas, and bone tumors 25 years after treatment: 27.5% of adult survivors report at least one severe, life-threatening, or disabling condition VS. 5.2% of age matched siblings

10 Relative Risk of Selected Severe (Grade 3) or Life-Threatening or Disabling (Grade 4) Health Conditions among Cancer Survivors, as Compared with Siblings. Oeffinger KC et al. N Engl J Med 2006;355:

11 Treatment Related Late Effects Ness K et al. J Clin Oncol 36, no 21 (July 2018)

12 Survivorship Brings Increased Risk of Chronic Health Conditions Oeffinger KC et al. N Engl J Med 2006;355:

13 Second Malignancies Leading cause of non-relapse death Cumulative incidence of up to 20% at 30 years following diagnosis Majority are solid tumors/sarcomas Related to radiation exposure, especially younger age, increased dose Risk increases over time after radiation exposure Treatment-related MDS/AML Related to chemotherapy exposures

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15 Cardiovascular Late Effects Leading cause of non-oncologic death in survivors Congestive Heart Failure due to Cardiomyopathy Dose-dependent risk after exposure to anthracycline chemotherapy Slightly increased risk after chest XRT Coronary Artery Disease Radiation therapy predisposes to ischemic heart disease Higher risk with co-morbidities- hypertension, dyslipidemia, obesity Pericarditis, valvular heart disease, conduction abnormalities

16 I need HELP!!! Ask for a treatment summary from treating oncologist- includes cumulative doses, areas of radiation

17 Dexamethasone Avascular Necrosis MRI after symptom onset Yearly musculoskeletal exam

18 Daunorubicin Cardiomyopathy

19 Cyclophosphamide hemorrhagic cystitis Yearly urinalysis

20 How can we reduce late effects? Change the therapy we give, or how we give it: Reduce therapies or replace toxic therapies (e.g. decrease amount of brain radiation) Use better technologies (e.g. new radiation approaches) Detect late effects earlier to prevent progression (risk-based care, screening/surveillance) Change lifestyle factors that contribute to late effects (e.g. diet, exercise, smoking, sunscreen, regular medical care)

21 Nathan P C et al. Ann Intern Med 2010;153:

22 When do you get a Mammogram? If you have received radiation therapy to the chest at a dose of 20 Gy or higher, you should have a yearly mammogram and breast MRI starting at age: A)40 B) 25 or 8 years after you received radiation (whichever is last) C) 10 years after the earliest relative to get diagnosed

23 When do you get a Mammogram? If you have received radiation therapy to the chest at a dose of 20 Gy or higher, you should have a yearly mammogram and breast MRI starting at age: A)40 B) 25 or 8 years after you received radiation (whichever is last) C) 10 years after the earliest relative to get diagnosed

24 Colon Cancer Screening Radiation therapy to the abdomen, pelvis, or spine at doses of 30 Gy or higher during childhood, adolescences or young adulthood should have a colonoscopy: A) Every 5 years starting at age of 35 or 10 years after radiation B) Age 50 C) 10 years before age at which first degree relative

25 Colon Cancer Screening Radiation therapy to the abdomen, pelvis, or spine at doses of 30 Gy or higher during childhood, adolescences or young adulthood should have a colonoscopy: A) Every 5 years starting at age of 35 or 10 years after radiation B) Age 50 C) 10 years before age at which first degree relative

26 Adolescent/Young Adult Oncology National Cancer Institute: Adolescent/Young Adults (AYA) age = vulnerable population Different biology/genetics of cancers Psychosocial needs Survivorship Survival differences How do we approach and treat AYAs? -> Different answer for different diseases Bleyer et al. NCI SEER AYA Monograph 2006;

27 Adolescent/Young Adult Oncology Clinical trial enrollment in the National Comprehensive Cancer Network 10% of 15 to 19-year-old patients VS. 1-2% of 20 to 39-year-old patients Single Pediatric Institution 92% of 0-4 year old patients VS. 72% of year old patients Aristizabal, P. et al. Pediatr Blood Cancer. 2015; 62(8):

28 Common Cancer Types in AYAs Source: SEER 18, , ages 15-39

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30 AYA Trends in CNS Tumors Site of treatment associated with better outcomes in AYA population Wolfson et al. JNCI (2014):106(8).

31 AYA Trends in ALL (Acute Lymphoblastic Leukemia) Pediatric regimen vs. adult regimen 25/25 pts- pediatric protocol achieved CR 19/22 pts- adult protocol achieved CR OS at 3 years 80% peds group and 59% in adult group EFS at 3 years 80% peds group and 45% in adult group Increased intensity chemo well tolerated, no statistically significant increase in adverse events Kliman et al, Leukemia and Lymphoma, 2016: doi /

32 AYA Trends in AML (Acute Myeloid Leukemia) Survival is not different but treatment related mortality much higher in AYA patients Canner et al. Cancer (2013) doi /cncr.28342

33 AYA outcomes- Ewings Sarcoma AYA M:F 1.8 (p <0.01) Khamly et al. Int J Cancer (2009) 125,

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35 Questions?

36 References Andemariam, B., Owarish-Gross, J., Grady, J., Boruchov, D., Thrall, R. S., & Hagstrom, J. N. (2014). Identification of risk factors for an unsuccessful transition from pediatric to adult sickle cell disease care. Pediatric Blood and Cancer, 61, 697. Aristizabal, P. e. a. (2015). Participation in pediatric oncology research protocols: Racial/Ethnic, language, and age-based disparities. Pediatric Blood and Cancer, 62(8), Brodsky, M. A. e. a. (2017). Risk factors for 30-day readmission in adults with sickle-cell disease. The American Journal of Medicine, Canner, J. e. a. (2013). Differences in outcomes of newly diagnosed acute myeloid leukemia for Adolescent/Young adult and younger patients: A report from the children's oncology group. Cancer,, Collins, M. e. a. (2013). Benefits and adverse events in younger versus older patients receiving neoadjuvant chemotherapy for osteosarcoma: Findings from a meta-analysis. Journal of Clinical Oncology, 18, Curtis, S. A., Danda, N., Etzion, Z., Cohen, H. W., & Billett, H. H. (2016). Longitudinal analysis of patient specific pedictors for mortality in sickle cell disease. PLOS One, 11 Elmariah, H., Garrett, M. E., DeCastro, L. M., Jonassaint, J. C., Ataga, K. I., Eckman, J. R., et al. (2014). Factors associated with suvrivial in a contemporary adult sickle cell disease cohort. American Journal of Hematology, 89, 530. Gardner, K., Douiri, A., Drasar, E., Allman, M., Mwirigi, A., Awogbade, M., et al. (2016). Survival in adults with sickle cell disease in a high-income setting. Blood, 128(10), Hamideh, D., & Alvarex, O. (2013). Sickle cell disease related mortality in the united states ( ). Pediatric Blood and Cancer, 60, Hunger, S. P., & Mullighan, C. G. (2015). Acute lymphoblastic leukemia in children. New England Journal of Medicine, 373(16), Keegan, T. H. M. e. a. (2016). Comparison of cancer survival trends in the united states of adolescents and young adults with those in children and older adults. Cancer,, Khamly, K. K. e. a. (2009). Gender-specific activity of chemotherapy correlates with outcomes in chemosensitive cancers of young adulthood. International Journal of Cancer, 125, 425. Kliman, D. e. a. (2016). Comparison of a pediatric-inspired treatment protocol versus standard-intensity chemotherapy for young adults with standard-risk BCR-ABL negative acute lymphoblastic leukemia. Leukemia & Lymphoma, Lanzkron, S., Carroll, C. P., & Haywood, C. (2013). Mortality rates and age at death from sickle cell disease: U.S., Public Health Reports, 128, 110. McLaughlin, J. F., & Ballas, S. K. (2016). High mortality among children with sickel cell anemia and overt stroke who discontinue blood transfusion after transition to an adult program. Transfusion, 56, Muffly, L. e. a. (2017). Adoption of pediatric-inspired acute lymphoblastic leukemia regiments by adult oncologists treating adolescents and young adults: A population-based study. Cancer,, 122. Robison, L. L., & Hudson, M. M. (2014). Survivors of childhood and adolescent cancer: Life-long risks and responsibilities. Nature Reviews: Cancer, 14, 61. Wolfson, J., Sun, C., Kang, T., Wyatt, L., D'Appuzzo, M., & Bhatia, S. (2014). Impact of treatment site in adolescents and young adults with central nervous system tumors. Journal of the National Cancer Institute, 106(8) Woods, W. G. e. a. (2013). Outcome of adolescents and young adults with acute myeloid leukemia treated on COG trials compared to CALGB and SWOG trials. Cancer,, 4170.