Early and late deaths after elective end of therapies for childhood cancer in Italy

Childhood cancer survivor cohorts in Europe

With the advent of multimodality therapy, the overall five-year survival rate from childhood cancer has improved considerably now exceeding 80% in developed European countries. This growing cohort of survivors, with many years of life ahead of them, has raised the necessity for knowledge concerning the risks of adverse long-term sequelae of the life-saving treatments in order to provide optimal screening and care and to identify and provide adequate interventions. Childhood cancer survivor cohorts in Europe. Considerable advantages exist to study late effects in individuals treated for childhood cancer in a European context, including the complementary advantages of large population-based cancer registries and the unrivalled opportunities to study lifetime risks, together with rich and detailed hospital-based cohorts which fill many of the gaps left by the large-scale population-based studies, such as sparse treatment information. Several large national cohorts have been established within Europe to study late effects in individuals treated for childhood cancer including the Nordic Adult Life after Childhood Cancer in Scandinavia study (ALiCCS), the British Childhood Cancer Survivor Study (BCCSS), the Dutch Childhood Oncology Group (DCOG) LATER study, and the Swiss Childhood Cancer Survivor Study (SCCSS). Furthermore, there are other large cohorts, which may eventually become national in scope including the French Childhood Cancer Survivor Study (FCCSS), the French Childhood Cancer Survivor Study for Leukaemia (LEA), and the Italian Study on off-therapy Childhood Cancer Survivors (OTR). In recent years significant steps have been taken to extend these national studies into a larger pan-European context through the establishment of two large consortia - PanCareSurFup and PanCareLIFE. The purpose of this paper is to present an overview of the current large, national and pan-European studies of late effects after childhood cancer. This overview will highlight the strong cooperation across Europe, in particular the EU-funded collaborative research projects PanCareSurFup and PanCareLIFE. Overall goal. The overall goal of these large cohort studies is to provide every European childhood cancer survivor with better care and better long-term health so that they reach their full potential, and to the degree possible, enjoy the same quality of life and opportunities as their peers.

Marriage and parenthood among childhood cancer survivors: a report from the Italian AIEOP Off-Therapy Registry

BACKGROUND

The aim of this study was to describe the patterns of marriage and parenthood in a cohort of childhood cancer survivors included in the Off-Therapy Registry maintained by the Italian Association of Pediatric Hematology and Oncology.

DESIGN AND METHODS

We analyzed a cohort of 6,044 patients diagnosed with cancer between 1960 and 1998, while aged 0 to 14 years and who were 18 years old or older by December 2003. They were followed up through the regional vital statistics registers until death or the end of follow up (October 30, 2006), whichever occurred first, and their marital status and date of birth of their children were recorded. The cumulative probabilities of being married and having a first child were computed by gender and compared by tumor type within the cohort. Marriage and fertility rates (the latter defined as the number of live births per woman-year) were compared with those of the Italian population of the same age, gender, area of residence and calendar period by means of the observed to expected (O/E) ratios.

RESULTS

During the follow-up period, 4,633 (77%) subjects had not married. The marriage O/E ratios were 0.56 (95% CI: 0.51-0.61) and 0.70 (95% CI: 0.65-0.76) among men and women, respectively. Overall, 263 men had 367 liveborn children, and 473 women had 697 liveborn children. The female fertility O/E ratio was 0.57 (95% CI: 0.53-0.62) overall, and 1.08 (95% CI: 0.99-1.17) when analyses were restricted to married/cohabiting women

CONCLUSIONS

Childhood cancer survivors are less likely to marry and to have children than the general population, confirming the life-long impact of their previous disease on their social behavior and choices. The inclusion of counseling in the strategies of management and long-term surveillance of childhood cancer patients could be beneficial to survivors as they approach adulthood.

Non-cancer mortality among long-term survivors of adult cancer in Korea: national cancer registry study

OBJECTIVES

To investigate the pattern of non-cancer deaths and to determine whether there is excess mortality from non-cancer causes among Korean long-term survivors of adult cancer.

METHODS

We merged national cancer registry data and national death registration data to determine non-cancer death patterns of 243,713 people who were diagnosed with cancer from 1993 to 2000 and who survived > or =5 years. We calculated standardized mortality ratios (SMRs) by an indirect standardization method.

RESULTS

Of the patient population, 26,498 (10.9%) had died as of December 2005; the cause of death for 6,364 (24.0%) of those was not cancer. The proportion of non-cancer mortality increased with age at diagnosis and correlated with the 5-year survival rate (r = 0.336 for women, 0.571 for men). Although the risk for non-cancer death was lower among long-term survivors in general (SMR, 0.78; 95% CI, 0.76-0.80), it was higher among younger survivors (SMR, 1.23-2.50, for those who died before 50) than the general population. Survivors had an elevated suicide rate (SMR, 1.28; 95% CI, 1.15-1.42), especially male (SMR, 1.35; 95% CI, 1.19-1.53) and stomach cancer survivors (SMR, 1.38; 95% CI, 1.14-1.66).

CONCLUSIONS

Appropriate medical attention for long-term adult cancer survivors, especially younger survivors, is warranted to prevent premature deaths from non-cancer causes.

Risk of Second Malignant Neoplasms After Childhood Leukemia and Lymphoma: An International Study

BACKGROUND

Survivors of childhood leukemia and lymphoma experience high risks of second malignant neoplasms. We quantified such risk using a large dataset from 13 population-based cancer registries.

METHODS

The registries provided individual data on cases of leukemia, Hodgkin lymphoma, and non-Hodgkin lymphoma occurring in children aged 0-14 years and on subsequent second malignant neoplasms for different time periods from 1943 to 2000. Risks of second malignant neoplasms were assessed through standardized incidence ratios (SIRs) and corresponding 95% confidence intervals (CIs), using the incidence rates in the general populations covered by the registries as a reference. Cumulative absolute risks were also calculated.

RESULTS

A total of 133 second malignant neoplasms were observed in 16,540 patients (12,731 leukemias, 1246 Hodgkin lymphomas, and 2563 non-Hodgkin lymphomas) after an average follow-up of 6.5 years. The most frequent second malignancies after leukemia were brain cancer (19 cases, SIR = 8.52, 95% CI = 5.13 to 13.3), non-Hodgkin lymphoma (nine cases, SIR = 9.41, 95% CI = 4.30 to 17.9), and thyroid cancer (nine cases, SIR = 18.8, 95% CI = 8.60 to 35.7); the most frequent after Hodgkin lymphoma were thyroid cancer (nine cases, SIR = 52.5, 95% CI = 24.0 to 99.6), breast cancer (six cases, SIR = 20.9, 95% CI = 7.66 to 45.4), and neoplasms of skin (non-melanoma) (six cases, SIR = 34.0, 95% CI = 12.5 to 74.0); and the most frequent after non-Hodgkin lymphoma were thyroid cancer (six cases, SIR = 40.4, 95% CI = 14.8 to 88.0) and brain cancer (four cases, SIR = 6.97, 95% CI = 1.90 to 17.9). Cumulative incidence of any second malignant neoplasm was 2.43% (95% CI = 1.09 to 3.78), 12.7% (95% CI = 8.29 to 17.2), and 2.50% (95% CI = 1.04 to 3.96) within 30 years from diagnosis of leukemia, Hodgkin lymphoma, and non-Hodgkin lymphoma, respectively.

CONCLUSIONS

This population-based study provides, to our knowledge, the most precise and up-to-date estimates for relative and absolute risks of second malignant neoplasms after childhood leukemia and lymphoma.

Survival after relapse in children with solid tumors: a follow-up study from the Italian off-therapy registry

BACKGROUND

Despite the increased survival of children with solid tumors, a significant proportion of cases still relapse following treatment discontinuation, and knowledge about the long-term outcome of this selected group of patients remains incomplete.

OBJECTIVE

To describe the long-term outcome of children treated for a solid tumor who relapsed after the elective end of therapy, and to explore factors associated with survival.

METHODS

All patients with the selected diagnoses-Hodgkin disease (HD), neuroblastoma (NB), tumor of the central nervous system (CNS), Wilms tumor (WT), or soft tissue sarcoma (STS)-enrolled in the Italian Pediatric Off-Therapy Registry in the period 1980-1998 were evaluated. Out of 3,927 patients, 694 had relapsed after treatment suspension; 639 were available for analysis. Survival and event-free survival were estimated by the Kaplan-Meier method. The log-rank test was used to assess differences in survival among the various types of cancer considered. Multivariate Cox proportional hazards analysis was adopted to explore possible prognostic factors.

RESULTS

There were 335 deaths: most of them (93%) were related to the primary cancer. The overall survival rate after relapse was 38% (95% CI 33-42) at 5 years, and 32% (95% CI 27-36%) at 15 years, while event free survival was 31% (95% CI 26-35) and 26% (95% CI 22-30%), respectively. There were significant differences according to the original diagnosis, with patients with HD doing better, and those with NB, CNS, and STS worse. No improvement of prognosis was evident over time. Post-relapse stem cell transplantation was associated with decreased risk of death only in the first year, not thereafter.

CONCLUSIONS

Overall, patients with solid tumors who relapse after treatment discontinuation have a poor outcome, but significant differences exist according to the tumor types.

Updating long-term childhood cancer survival trend with period and mixed analysis: Good news from population-based estimates in Italy

An empirical evaluation of long-term period survival analysis was performed using data from the Childhood Cancer Registry of Piedmont, Italy. The aim was to update survival time trends and provide 25-year projections for children currently diagnosed with cancer. The observed survival experiences up to 15 years after diagnosis of five quinquennial cohorts (cohort analysis) were compared to the corresponding estimates obtained by period analysis. The two methods generally produced very similar findings, although period analysis estimates were slightly lower than those obtained from cohort analysis. We then used mixed analysis to assess time trends in long-term survival. This showed that the probability of surviving 25 years after a cancer in childhood has more than doubled compared to cohort analysis estimates from patients diagnosed more than 25 years ago (73% vs. 32%), providing further evidence of an ongoing improvement in prognosis.

Role of active follow-up for early diagnosis of relapse after elective end of therapies

OBJECTIVE

To evaluate the role of active follow-up for the detection of relapses occurring after completion of therapy in children with cancer.

METHODS

The clinical records of all children who had a cancer relapse more than 3 months after the end of therapies in the period 1985-2000 were reviewed. Relapses were defined "diagnosed at a scheduled visit" or "at an unscheduled visit" based upon how the visit that lead to the suspected diagnosis was scheduled. Information was collected on how the first suspicion of relapse was made. Survival after relapse was calculated, by type of visit and tumor type.

RESULTS

Among 739 children who completed therapy for a malignant tumor in first complete remission (CR), 101 relapses [74 after solid tumors (ST), 27 after leukemia/lymphoma (L)] occurred after a median time of 12 months (range 3-87). Fifty-one (50.5%) first relapses were diagnosed during a visit scheduled because of symptoms (36 ST, 15 L), and 50 relapses (49.5%) at a regularly scheduled visit (38 ST, 12 L). Overall, 75% of relapses were first suspected on clinical basis, 16% via imaging, and only 9% via lab tests. Survival more than 10 years from first relapse was 25.7% (SE: 0.05%), with no significant differences between relapses diagnosed at a scheduled visit (20.5%), or at an unscheduled visit (32.1%; P = 0.826). Children with L had a better overall survival (OS, 70.6%) as compared to those with ST (9.2%, P < 0.001), probably because of a more extensive use of stem cell transplantation (SCT) as part of the salvage regimens.

CONCLUSIONS

Scheduled follow-up programs failed to detect relapses in 50% of cases presented here. Survival after relapse is not affected by whether relapse was detected at a scheduled or an unscheduled visit.

Cause of death and long-term survival in patients with neuro-epithelial brain tumours: a population-based study

Long-term survivors of neuro-epithelial brain tumours have a higher death rate compared with the general population and the aims of this study were to investigate the causes of death and analyse long-term survival using population-based material. A total of 6209 patients were registered in the period of 1970-1993 with a primary intracranial neuro-epithelial tumour in the The Norwegian Cancer Registry. In a pilot study, a high level of agreement with regard to the cause of death was found between clinical data and the registered cause of death. Underlying causes of death in the whole population were therefore analysed. Most deaths were caused by the primary neuro-epithelial brain tumour within 10 years of diagnosis. Although the numbers were small, the proportion of patients dying from other cancers, vascular disease, infections and accidents continued to rise with time. Survival was computed using the Kaplan-Meier method. For children, survival at 5, 10 and 15 years significantly improved from the time period of 1970-1981 to 1982-1993 (47.9, 43.6 and 43.3% versus 63.8, 59.8 and 59.8%, respectively, P <0.0001). Similar improvements in survival at 5, 10 and 15 years were observed for young adults aged 15-49 years (32.7, 21.3 and 16.5% versus 50.1, 37.5 and 33.1%, for the same time periods, P<0.0001). No such improvement for those aged 50 years and over was observed (corresponding figures of 6.6, 3.8 and 2.8% versus 7.7, 4.8 and 3.4%). Prognosis for those with childhood medulloblastomas improved significantly, as did the prognosis of younger adults with low-grade gliomas and unbiopsied/ unclassifiable grade gliomas.

Childhood cancer survival in Europe: an overview

Other articles in this issue of the European Journal of Cancer have described population-based survival analyses of specific types of childhood cancer included in the EUROCARE database, diagnosed since 1979. The present paper summarises the relevant estimates and comments on intercountry differences, focusing on possible distortions in the intercountry comparisons based on data produced by the cancer registries. Potential biases include a lack of exhaustiveness of both case ascertainment and follow-up for living status and also a lack of consistency in the use of classification of the childhood cancer types. Nevertheless, despite such biases, consistent differences are observed between European countries in the probability of survival following the diagnosis of a paediatric cancer. In most cases, poor population-based survival rates are probably explained by inadequacies in the adoption and implementation of therapeutic protocols that have been proved to be effective. In some instances, the cause of unsatisfactory estimates was the inclusion of a sizeable proportion of children with cancer in clinical trials which were found to be ineffective. A regression analysis of incidence, mortality and survival rates during 1978-1989 over the whole EUROCARE database strongly indicates that the prognostic improvements over time are real and cannot be attributed to changes in diagnostic procedures.