Transcript neoplasm screening in adults who survived childhood cancer

Surveillance and screening for new neoplasms
in adult survivors of childhood cancer
A report from the Childhood Cancer Survivor Study (CCSS)
Paul Nathan MD, MSc
The Hospital for Sick Children
Toronto, Canada
Background
The childhood cancer survivor population
• 5-year cancer survival in children ~80%
• Over 325,000 childhood cancer survivors
alive in United States
• Over 40% of survivors will develop a severe
or life threatening late effect of therapy
Second malignant neoplasms (SMN) in
childhood cancer survivors
SMN in the CCSS cohort
• 30-year cumulative incidence of
SMN = 9.3%
• 30-year cumulative incidence of
non-melanoma skin cancer = 6.9%
• Leading cause of death in 20+ year
survivors
• Standardized incidence ratio = 9.0
• Standardized mortality ratio = 15.2
Meadows et al. JCO, 2009; Mertens et al. JNCI, 2008
Study Aims
1. To assess adherence to published cancer
surveillance guidelines by survivors at high
risk for breast, colorectal or skin cancer as a
result of their therapy
2. To compare non-high risk survivors’
adherence to national screening guidelines
for breast, colorectal and cervical cancer
with the general population
Childhood Cancer Survivor Study
• Retrospective cohort study
• 26 centers: USA and Canada
• Diagnosis 1970-1986
• < 21 years at diagnosis
• Alive at 5 years
• Selected malignancies
Participating Centers
Coordinating Center
Contributing Institutions
Resource Center
Study participants
Eligible
n=20,602
Contacted
n=17,567
Participants in Baseline Survey
n=14,370
Participants in Follow-up 2000
n=10,388
Participants in Follow-up 2003
n=9,308
Eligible for Current Analysis
n=8,318
Lost to Follow-up
n=3,035
Declined Participation
n=3,197
Deceased Cases
n=1,541
Exclusions n=990
Developed SMN (n=960)
Race/ethnicity unknown (n=29)
Other (n=1)
Demographics of Study Population
Survivors
(8,318)
Population
control (8,318)*
Gender (male)
51.9%
Race (White, non-Hispanic)
88.7%
Mean age at diagnosis (SD),
years
Mean age at interview (SD),
years
Cancer center visit in last 2
years
7.8 (5.7)
-
31.2 (7.3)
32.7 (10.6)
12.5%
-
*Matched 1:1 by age, gender, race/ethnicity from 2003 National Health Interview Survey
Cancer Diagnosis in 8,318 Survivors
Bone cancer
8%
Soft tissue
sarcoma
9%
Leukemia
35%
Neuroblastoma
7%
Wilms' tumor
10%
Non-Hodgkin's
lymphoma
8%
Hodgkin's
lymphoma
10%
CNS tumor
13%
Specific Aim 1
Adherence to published cancer
surveillance guidelines by survivors
at high risk for breast, colorectal or
skin cancer
Risk Definitions and Recommended
Surveillance
COLORECTAL
HIGH-RISK
BREAST
SKIN
>30 Gy to abdomen,
pelvis or spine
Female, >20 Gy to
breast
Any radiation
therapy
N=794
N=521
N=4,833
Annual
mammogram
starting at later of 8
years after
radiation or age 25
Annual
dermatologic exam
of irradiated areas
Colonoscopy every 5
RECOMMENDED
years starting at age
SURVEILLANCE
35
% complying with guidelines
Compliance with Recommended
Surveillance Tests
100%
80%
60%
46.3%
40%
20%
26.7%
11.5%
0%
Colorectal
cancer
Breast cancer
High-risk group
Skin cancer
Predictors of Adherence
Multivariable Logistic Regression Models
Covariates
• Sex
• Race/ethnicity
• Age at diagnosis and interview
• Employment, education, insurance
• Chronic disease, mental health, physical
impairment, concern about future health
• Survivor or doctor has cancer treatment summary
• Medical care in last 2 years, care at a cancer center
Significant Predictors of Adherence
Multivariable Logistic Regression Models
• Colonoscopy
Older age at interview
RR=1.08 (1.00-1.17)
• Mammogram
Older age at interview
RR=1.09 (1.04-1.13)
Care at cancer center
RR=1.70 (1.04-2.76)
• Skin exam
Non-white
RR=0.63 (0.42-0.95)
Care at cancer center
RR=1.55 (1.22-1.96)
Survivor has treatment summary
RR=1.30 (1.07-1.58)
Specific Aim 2
Comparison of “non-high risk”
survivors vs. general population on
adherence to national screening
guidelines for breast, colorectal and
cervical cancer
US Preventive Services Task Force
Cancer Screening Recommendations
• Breast
Screening mammography every 1-2 years for
women aged 40 and older
• Colorectal
Colonoscopy at intervals of 10 years between
ages of 50-75 years*
• Cervix
Pap smear beginning within 3 years of onset of
sexual activity or age 21 (whichever comes first)
and screening at least every 3 years
* OR annual fecal occult blood testing OR sigmoidoscopy every 5 years combined with fecal occult blood testing every 3 years
US Preventive Services Task Force
Cancer Screening Recommendations
Breast
Colon
Cervix
RR=1.29
RR=0.97
RR=1.17
95% CI, 1.12-1.48 95% CI, 0.31-3.00 95% CI, 1.14-1.20
P=0.95
P=<0.001
Compliance with screening
P<0.001
Survivor
Gen. Pop.
Survivor
Gen. Pop.
Survivor
Gen. Pop.
Significant Predictors of Adherence
Multivariable Logistic Regression Models
• Breast
None
• Colon
Too few survivors over 50 years to analyse in detail
Emerging evidence of increased GI malignancies in
survivor cohort
• Cervix
Only being “married or living as married” predicted
PAP smear compliance (RR 1.17, 1.03-1.34)
Conclusions (1)
Adherence to Guidelines for Cancer Survivors
• Rates of colonoscopy, mammography and
skin exams in high-risk patients are very low.
• Care at a cancer center modestly increases
surveillance for breast and skin cancer.
• Patients and their physicians need to be
educated about recommended surveillance.
Conclusions (2)
Adherence to National Screening Guidelines
Survivors
• Cancer survivors are more likely to undergo
mammograms and PAP smears than general
population.
• BUT: Compliance rates are very low for
colonoscopy and only moderate for
mammography.
• Health care providers must take opportunity to
promote early cancer detection strategies in
survivors.
Study Considerations
1. Self-report data
2. CCSS cohort is a select group – study may
overestimate care received
3. Cohort 1970-1986
4. Did not assess all screening/surveillance
modalities (e.g. breast MRI, fecal occult blood)
Co-Investigators
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Kevin Oeffinger, Memorial Sloan-Kettering Cancer Center
Kirsten Ness, St. Jude Children’s Research Hospital
Martin Mahoney, Roswell Park Cancer Institute
Zhenghong Li, St. Jude Children’s Research Hospital
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Melissa Hudson, St. Jude Children’s Research Hospital
Jennifer Ford, Memorial Sloan-Kettering Cancer Center
Wendy Landier, City of Hope
Greg Armstrong, St. Jude Children’s Research Hospital
Tara Henderson, University of Chicago
Leslie Robison, St. Jude Children’s Research Hospital
CCSS Institutions
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St. Jude Children’s Research Hospital
Roswell Park Cancer Center
Mayo Clinic
Children’s Health Care Minneapolis
Children’s Hospital of Philadelphia
St. Louis Children’s Hospital
Children’s Hospital of Los Angeles
UCLA Medical Center
Miller Children’s Hospital Long Beach
Children’s Hospital of Orange County
Riley Hospital for Children – Indiana
Univ.
UAB/Children’s Hospital of Alabama
University of Michigan – Mott Children’s
Fred Hutchinson Cancer Research
Center
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University of Minnesota
Denver Children’s Hospital
Children’s Hospital of Pittsburgh
Stanford University
Dana-Farber Cancer Institute
Children’s National Medical Center
M.D. Anderson Cancer Center
Memorial Sloan-Kettering Cancer
Center
Texas Children’s Hospital
University of California, San
Francisco
Seattle Children’s Hospital
Toronto Hospital for Sick Children
Children’s Medical Center of Dallas
Children’s Hospital of Columbus
Emory University
A Resource for Research
• The Childhood Cancer Survivor Study is an
NCI-funded resource to promote and facilitate
research among long-term survivors of
cancer diagnosed during childhood and
adolescence.
• Investigators interested in potential uses of
this resource are encouraged to visit:
www.stjude.org/ccss