15 a texas aya oncology conference
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Cancer in Adolescents Cancer in Adolescents and Young Adultsand Young Adults
An International PerspectiveAn International Perspective
Ronald D. Barr MB ChB, MDProfessor of Pediatrics, Pathology and Medicine
McMaster UniversityHamilton, Ontario Canada
2010 Texas AYA Oncology Conference
Brunfelsia pauciflora
WHO ARE AYA WITH CANCER?
• Adolescents – 15 to 19 years of age• Young adults – 20 to ?
• SEER: 29• NCI/LAF/PRG: 39• Eurocare: 24
* Major resource implications
INCIDENCE OF CANCER(per million per year)
Age (years) Rate(0 – 14)15 – 1920 – 2425 – 29(40 – 44)
1502003505502,000
Communication from Charles StillerCancer Research Group
Oxford, UKDecember 2006
• Estimates from IARC database• GLOBOCAN 2002: worldwide• Annual incidence –• 15-29 years old: more than 350,000 cases• 30-39 years old: more than 650,000 cases
Challenge of AYA Oncology
Of more than 1 million new cases per year
• Many are never diagnosed• Most receive inadequate therapy
Mortality
After homicides, suicides and unintentional injury (accidents) CANCER IS THE COMMONEST
CAUSE OF DEATH IN THE 15-39 YEAR AGE GROUP IN
INDUSTRIALISED SOCIETIES
1.431.53
1.63
0.90
0.59
0.03 -0.18
0.23
0.53
1.04
1.26
1.43
1.61
1.87
1.99
1.83
1.59
1.14
0
0.5
1.0
1.5
2.0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Change in 5-Year Relative Survival Rate of All Invasive Cancer, SEER, 1975-1997
Age at Diagnosis (Years)
Ave
rage
Ann
ual %
Cha
nge
Non-Hodgkin Lymphoma7%
HodgkinLymphoma12%
Melanoma11%
FemaleGenital10%
Testis Cancer11%Thyroid
Carcinoma10%
CNS Neoplasms6%
Soft-Tissue Sarcomas8%
Bone Tumors3%
Non-Gonadal Germ Cell Tumors 2%
Other2%
Other Carcinomas6%
Breast Cancer5%
Leukemia6%
AYA Cancers are Unique in Type and Biology
Age 15-29 Years
AAPC – Two Disease ClustersHigh survival rates: Hodgkin lymphoma, testicular tumors, thyroid cancer and melanoma• More than 40% of incident cases aged 15 – 29 years• Range of 5 year survival rates is 90 – 99%
Lower survival rates: all other diseases• Less than 60% of incident cases aged 15 – 29 years• Range of 5 year survival rates is 40 – 75%
Survival of European children and young adults with cancer diagnosed 1995-2002
Gatta G et al. Eur J Cancer 2009; 45: 992-1005
Overall 5 year survival in 23 countries for those age 15-24 years at diagnosis: 87 percent
Study sample: more than 30,000 BUT incident cases 20,000 per year
Regional variation: highest in North, lowest in East
Improvement in 5-Year Relative Survival, CanadaOntario, Canada - Courtesy of Loraine Marrett
Age at Diagnosis (Years)0 15 30 50 65 80
Are disparities in 5 year survival rates and AAPC reflections of
differences in health care systems?
Personal communicationMarch 11, 2010Barack Obama
Age at Diagnosis (Years)
Ave
rage
Ann
ual %
Cha
nge
0
1
2
0 10 20 25 30 35 40 50 60 70 805 15 90
Australia UnitedStates
Improvement in Relative Survival by Age at Diagnosis of Invasive Cancer, 1982-1997
Prepared by A. Bleyer from data provided by the Australia Institute of Health and Welfare and from U.S. SEER9
50%
60%
70%
80%
90%
0 5 10 15 20 25 30 35 40 50 60 70
Australia
Age at Diagnosis (Years)
RelativeRelative Survival, All Invasive CancerSurvival, All Invasive CancerAustralia vs. United States, 1992-1997Australia vs. United States, 1992-1997
5-Year Survival
80
5%
8%12%
8%5%
U.S.
Australia data provided by:
Chris Stevenson, AIHW
AAPC – THE INTERNATIONAL PICTUREAAPC – THE INTERNATIONAL PICTURE
Australia – David RoderCanada – Loraine MarrettEurope – Gemma GattaUnited Kingdom – Jill BirchUnited States – Archie Bleyer
Locus of Care
Determines access to age and disease appropriate
• Health care system and providers
• Infrastructure, such as physical facilities
• Treatment including clinical trials
Why does it matter?
• In Canada and the USA only 30-40% of adolescents are treated in pediatric cancer centres
• Survival advantage in some instances• Pediatric v. adult protocols e.g. A.L.L (USA, France, Italy,
the Netherlands, Denmark, UK) and soft tissue sarcomas (INT, Italy)
• Pediatric v. adult centres e.g. Ewing sarcoma (Germany)
OBSERVED CASES IN THE AIEOP CENTERS versus EXPECTED NUMBER OF CASES IN ITALY (from population-based childhood cancer registries in Italy)
A.Ferrari, A.Pession, M.Aricò,R.Rondelli, and G.Pastore
patients 0-14 years patients 15-19 years
all childhood cancers
82% 10%
LLA
98% 23%
HD
89% 9%
NHL
80% 14%
patients 0-14 years patients 15-19 years
CNS tumors
66% 14%
NBL91% 43%
renal tumors
85% 15%
bone sarcomas
93%OS 28%EW 43%
OBSERVED CASES IN THE AIEOP CENTERS versus EXPECTED NUMBER OF CASES IN ITALY
soft tissue sarcomas
RMS 97%NRSTS 74%
RMS 33%NRSTS 39%
ependymoma 35%PNET 41%
germ-cell 53%
carcinomas 1%
Age (Years)
Number of
Patientswith
Cancerin theU.S.A.
On Cooperative Group Trial
60%
2%
33% 29%
11%6%
60%
40%
50%10%
0-4 5-9 10-14 15-19
Not at NCI-Sponsored Cooperative Group Institution
At Cooperative Group Institution
20-30
The Adolescent-Young Adult
Gap in Cancer
Clinical Trials79%
92%
21%
Clinical Trial Accrual in the U.S.
0
2001-2003
Patient Age (Years)
No.
Acc
rual
s
2004-2006 decreasing
05 10 15 20 25 30 35 40 45 50 55
2,000
4,000
6,000
8,000
10,000
10 15 20 25 30
2004-2006 increasing
Courtesy of A. Bleyer. MD
No. Accruals
0-14 15-29 30-44 45-59 60-74Age (Years)
0
5,000
10,000
15,000
20,000
25,000
30,000
2000-2 2003-5
Change from 2000-2 to 2003-5
42%
-3% -4%
-40%
0%
40%
-28%-50%
9,767
3,687
7,506
28,369 28,015
7,0175,219
3,749
27,487 26,962
U.S. Cancer Patients Entered onto National Treatment Trials 2003-5 vs. 2000-2
5 10 15 20 25 30 35 40
Ave.
Ann
. Cha
nge,
5-Y
r Sur
viva
l
0%
0.5%
1.0%
1.5%
0
0%
1%
2%
1% 10%
p = .0003
Accrual Proportion (log))
Ave.
Ann
. Cha
nge,
5y
Surv
.
Age (Years)
Accr
ual P
ropo
rtion
0%
10%
20%
30%
Survival improvement is correlated with clinical trial participation
AIEOP Experience of Adolescents
• From 1989-2006 the O/E ratio was 0.10 (1.745/16,711); rising from 0.05 to 0.18
• Higher for sarcomas (bone and soft tissue) – of almost 0.50 in recent years – and lowest for gonadal tumours and carcinomas (<0.05)
• Overall enrollment on AIEOP clinical trials: 53% of children and 5.5 % of 15-19 years olds
• Enrollment on AIEOP clinical trials in AIEOP centres: 69% of children and 55% of adolescents
AYA CommitteeNCI Progress Review Group
1. Identify the characteristics that distinguish the unique cancer burden in the AYAO patient
2. Provide education, training, and communication to improve awareness, prevention, access, and quality cancer care for AYAs
3. Create the tools to study the AYA cancer problem
4. Ensure excellence in service delivery across the cancer control continuum (from prevention to end of life)
5. Strengthen and promote advocacy and support of the AYA cancer patient
Canadian National Task ForceAdolescent and Young Adult Oncology
A Conjunction of C17 and CPAC
Co-Chairs: R Barr, P Rogers, B SchacterInternational Workshop,
Toronto, March 11-13, 2010
Themes from the Workshop
Publication as a supplement to Cancer
• Awareness and advocacy• Active therapy and supportive care• Palliation and symptom management• Psychosocial needs• Survivorship• RESEARCH AND METRICS
The Adolescence of Young Adult Oncology
Albritton K, Barr R, Bleyer A.Semin Oncol 2009; 36: 478-488
• Definition of the AYA patient• Clinical trials• Health Services delivery• Oncofertility• Training• Developmental theory and psychosocial impact of cancer• Peer support and advocacy