Trends in cancer survival among U.S. white children, 1955-1971

Precision based approach to tailoring radiotherapy in the multidisciplinary management of pediatric central nervous system tumors

Modern day survivorship from childhood malignancies is estimated to be over 80%. However, central nervous system tumors remain the leading cause of cancer mortality in children and is the most common solid tumor in this population. Improved survivorship is, in part, a result of improved multidisciplinary care, often with a combination of surgery, radiation therapy, and systemic therapy. With improved survival, long term effects of treatment and quality of life impacts have been recognized and pose a challenge to maximize the therapeutic ratio of treatment. It has been increasingly more apparent that precise risk stratification, such as with the inclusion of molecular classification, is instrumental in efforts to tailor radiotherapy for appropriate treatment, generally towards de-intensification for this vulnerable patient population. In addition, advances in radiotherapy techniques have allowed greater conformality and accuracy of treatment for those who do require radiotherapy for tumor control. Ongoing efforts to tailor radiotherapy, including de-escalation, omission, or intensification of radiotherapy, continue to improve as increasing insight into tumor heterogeneity is recognized, coupled with advances in precision medicine employing novel molecularly-targeted therapeutics.

Trends in Childhood Cancer Mortality in Italy, 1955-78

Trends in childhood cancer death rates in Italy from 1955 to 1978 were analyzed. All cancer age-standardized mortality below age 15 fell about 20%, with a clear downward trend since the early 1970's. Declines were evident for leukemias (–25%), Hodgkin's disease (–56%), non-Hodgkin's lymphomas (–27%), kidney cancer (–25%), retinoblastoma (–50%), and bone sarcomas (–31%), for a total number of about 200-250 fewer deaths per year in the late 1970's compared to the expected values using rates of the 1950's. The observed fall was apparently confined within the first age group considered (0-4 years), but the age-specific patterns of trend were partly influenced by simple postponement of some deaths to older age groups. Comparisons with similar data in other developed countries suggest that, although there has undoubtedly been some progress, there is still wide scope for further reduction in childhood cancer mortality in Italy, simply through more rational use of currently available diagnostic and therapeutic knowledge.

Malignant mesothelioma following radiation therapy

BACKGROUND

Studies of the growing population of long-term survivors of cancer have led to increased recognition of the neoplastic complications of therapy. The causes of secondary malignancies are probably multifactorial, but radiation therapy and chemotherapy have certainly been implicated in the development of posttherapy neoplasia.

PATIENTS AND METHODS

A case of pleural mesothelioma after successful radiation therapy for Hodgkin's disease is described with a review of radiation-associated mesotheliomas reported in the literature. In Hodgkin's disease, patients may receive radiation, chemotherapy, or combined treatment; the most common secondary malignancy is acute nonlymphocytic leukemia while sarcomas are the second most common solid tumors.

CONCLUSIONS

Although mesothelioma is an uncommon sarcoma, its occurrence has been documented numerous times after exposure to diagnostic or therapeutic radiation.

Forty-year experience with second malignancies after treatment of childhood cancer: analysis of outcome following the development of the second malignancy

As the cure rate for childhood malignancies increases, the number of patients at risk for development of second malignancies also increases. Due to the potentially long remaining life span, long-term follow-up is difficult and patients are often at risk after presumptive cures. Some authors believe that cure rates for second malignancies are similar to cure rates for primary malignancies. We reviewed the records of 162 patients seen at our institution who had developed a second malignancy after treatment for childhood cancer. Presentation, age at diagnosis, tumor histology, extent of tumor, treatment (including radiotherapy with dosage when available, and chemotherapy) plus outcome were recorded. Mean age at diagnosis of the primary malignancy was 10.3 years. The most common primary malignancy was Hodgkin's disease (33) followed by soft tissue sarcoma (28), retinoblastoma (20), bone tumor (17), central nervous system (CNS) tumor (13), leukemia (8), Wilms' tumor (7), non-Hodgkin's lymphoma (6), neuroblastoma (5), thyroid neoplasm (5), and others (20). The average interval between diagnosis of the first and second malignancy was 10.8 years. These second tumors carried a high mortality. Only 56 patients have no evidence of disease. Five patients are known to be alive with disease and 92 patients have expired due to their second malignancy. Disease status in 8 patients is unknown. The most common second malignancy was osteosarcoma (35) followed by soft tissue sarcoma (24), breast cancer (15), leukemia (14), thyroid carcinoma (14), CNS tumors (12), melanoma (8), nonmelanomatous skin cancer (8), lymphoma (5), and others (27).(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in childhood and adolescent cancer survival in Sweden 1960 through 1984

The temporal changes in childhood and adolescent cancer survival in Sweden 1960-1984 were analyzed. Complete follow-up through 1986 of 6,262 patients younger than 20 years at diagnosis revealed that the overall 5-year survival rates increased from 36.1 to 65.7% in males and from 43.6 to 73.6% in females. The temporal trends differed markedly between age groups and tumour sites and types. Over the study period, 5-years, survival for testicular cancer increased from 46.9 to 87.2%, kidney cancer, predominantly Wilms' tumour from 35.5 to 77.1% (with a higher rate of 89.1% in 1975-1979), Hodgkin's disease from 61.2 to 91.9%, non-Hodgkin's lymphoma from 32.5 to 76.6%, and all leukemias from 8.9 to 58.7%. Only a moderate improvement was noted for tumours of the bone, muscle and connective tissue, and survival rates for tumours of the nervous system remained largely unchanged. Our data reflect the remarkable therapeutic improvements that have occurred for cancer in the young and indicate that these improvements have rapidly become available in Sweden.

Second intracranial neoplasms following treatment of childhood acute lymphoblastic leukaemia

We report a boy with acute lymphoblastic leukaemia (ALL) treated with chemotherapy and prophylactic cranial irradiation to a dose of 24 Gy. Six years after diagnosis he developed a glioma and died. Prior to 1979, four cases of second malignant neoplasm (SMN) of the brain had been reported in children treated for ALL. These SMNs occurred within 2 years of the original diagnosis (median 1.3 years) and at least two of four patients had not received prior radiotherapy. Since 1979, 28 cases of SMN of the brain have been reported including nine of 468 (1.9%) long-term survivors in one study. All occurred more than 3.7 years from diagnosis (median 6.5 years; range 4-13 years) and all received cranial irradiation (median 24 Gy; range 20-48 Gy). These data indicate a change in the pattern of SMNs which is most likely due to the introduction of cranial irradiation. As well, the frequency of SMNs in children treated for ALL appears to have increased, although it is still no greater than the risk of SMNs developing following the treatment of any other primary childhood neoplasm.

Neuroblastoma and other childhood neural tumors: a review

Neuroblastoma is the most common nonhematopoietic solid tumor of childhood and has been intensively studied for at least 4 decades. Despite this, few predictive histopathologic clues to its behavior exist. Age, anatomic sites of occurrence, and clinical stage have traditionally been the only reliable prognostic factors in this disease. A number of laboratory studies that focus on biologic features such as neurotransmitter synthesis (adrenergic and noradrenergic catecholamines), neurotransmitter enzyme expression (dopamine beta hydroxylase, choline acetyl transferase), cytogenetics (homogeneously staining regions, double minute chromosomes, chromosome 1p deletions), molecular genetics (N-myc oncogene amplification and expression), and immunophenotype (surface epitopes such as HLA antigens and GD2 ganglioside and intracytoplasmic determinants such as neurofilament protein, synaptophysin, chromogranin, and neuron specific enolase) now enable the pathologist to predict clinical course in many cases and to distinguish bona fide neuroblastomas, regardless of age, site, or histologic appearance, from a host of related but distinctly separate neuroectodermal tumor entities with apparent different histogenesis, treatment sensitivity, and prognosis.

Improvements in survival from childhood cancer: results of a population based survey over 30 years

Survival from cancer of children whose cancer was diagnosed during the 30 years 1954-83 was analysed. The study was population based with nearly 3000 cases covering about 30 million child years at risk. When survival during the three decades 1954-63, 1964-73, and 1974-83 was compared striking improvements were observed. For all childhood cancer five year survival increased from 21% in the first decade to 49% in the third decade. During the first and third decades five year survival rates for acute lymphocytic leukaemia increased from 2% to 47%, Hodgkin's disease from 44% to 91%, non-Hodgkin's lymphoma from 18% to 45%, Wilms's tumour from 31% to 85%, and germ cell tumours from 10% to 64%. Twenty patients developed second primary tumours, but otherwise there were few late deaths. Less than 1% of children who survived without a relapse for 10 years subsequently died of their initial cancer. Survival from childhood cancer is no longer rare, and people who have been cured of cancer during childhood should be accepted as normal members of society.

Recent trends in incidence and mortality rates for leukemias, and in survival rates for childhood acute lymphocytic leukemia, in Upstate New York

Analysis of mortality rates for all childhood (age less than 20 years) leukemias in upstate New York showed declines between 1969-1971 and 1978-1980 for ages 0-4 and 5-9 years, while data from a population-based cancer registry for a population of about 10.5 million indicated no decline in incidence rates. Survival rates were examined for 552 children diagnosed with acute lymphocytic leukemia (ALL) in 1973-1980 at less than 15 years of age. There was some evidence for improvement in survival rates over these years of diagnosis, especially among children diagnosed at ages 1-4 and 10-14 years. Hazard rates increased among cases (especially males) diagnosed in 1979 and 1980, however, and this finding requires confirmation from other studies; the possible effect of influenza epidemics also should be explored. Only one confirmed second primary cancer, a rhabdomyosarcoma of the eye, was ascertained (as of the end of 1983), but longer follow-up is needed on children with ALL.

The epidemiology of primary nervous system tumors in children

A study of the descriptive epidemiology of primary tumors of the brain and nervous system in children aged 0-14 was undertaken using international incidence data. The median cumulative incidence rates for this age group were found to be 0.47 per thousand for boys and 0.39 per thousand for girls with a male: female sex ratio of 1.2. Variation in incidence rates by geographic area and race are discussed and are compared to descriptive findings for tumors of this site among adults. Data on suggested risk factors for childhood brain tumors are reviewed.

Childhood cancer survival trends in Queensland 1956-80

The true survival rates for the various forms of childhood cancer are best determined from a population-based study rather than from the results of clinical trials. Population-based survival rates have been calculated for four periods between 1956 and 1980 in Queensland. There was a significant improvement in survival for children who developed cancer after 1973 compared with those diagnosed before this date. There has however been no significant improvement in the survival rate for childhood cancer overall, or for acute lymphoblastic leukaemia since 1973. Over the 25 year period significant trends in survival rates were seen in acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin's disease, Wilms' tumour, medulloblastoma, and retinoblastoma. No such trend was seen for acute non-lymphoblastic leukaemia, neuroblastoma, rhabdomyosarcoma, juvenile or anaplastic astrocytoma, brain stem glioma, histiocytosis X, or bone tumours. There is a need for continuing research into better methods of treatment of childhood cancer.

Survival of children with cancer in Torino, Italy

During 1967-78, cancer was diagnosed in 870 children living in the Province of Torino. Survival until the end of 1978 is reported separately for cases diagnosed in 1967-70, in 1971-74, and in 1975-78. Comparisons between the three series indicate a statistically significant (p less than 0.05) increase in survival rates for children with leukemia and cancer of the central nervous system as well as a nonstatistically significant increase for children with lymphoma (both Hodgkin's and non-Hodgkin's). No consistent changes in time were noticed for neuroblastomas, nephroblastomas, soft tissue sarcomas, and retinoblastomas. Survival rates for both types of lymphomas and for leukemias (at least for cases diagnosed after 1975) were very similar to corresponding population-derived data from the U.S. and other Western countries. Rates for other cancers were relatively poor in the Province of Torino. It is suggested that relatively high care standards are easier to achieve in the case of childhood cancers requiring chemotherapy than in cancers commonly treated through radiotherapy and/or surgery.

Incidence of second malignant neoplasms in children: results of an international study

The incidence of second malignant neoplasms (SMNs) in children was estimated from data provided by ten paediatric oncology centres. During 1950-70 nearly 15 000 new patients were seen at these institutions. With follow-up through 1979, 113 eligible cases of SMN were reported. To estimate the number of person-years at risk, a common set of survival distributions, specific for tumour type and calendar period, was applied to the patient entry data at each institution. The annual incidence of SMNs 5-15 years after diagnosis of first tumour was found to be 188/100 000; this represents an approximate ten-fold increase over the age-adjusted expected rate of cancer in the general population. The corresponding incidence during the first 5 years was 85/100 000/year, a seven-fold increase in risk. The estimated cumulative probability of SMN reached 3.3% at 20 years.

Comparison of morbidity in children requiring abdominal radiation and chemotherapy, with and without total parenteral nutrition

We evaluated the effectiveness of total parenteral nutrition and placing the "bowel at rest," as compared to that of ad libitum food intake, on nutritional status and tolerance to combined chemotherapy and radiotherapy in a randomized, prospective trial in children with previously untreated malignancy requiring abdominal and pelvic irradiation and chemotherapy. Administration of TPN was found to be safe and efficacious in maintaining the children in good nutritional status during combined therapy; one-third of the control patients became malnourished and required TPN. There was no beneficial effect of "bowel at rest" and TPN on the ability of patients to tolerate combined therapies in terms of decreased toxicity; however, use of TPN was associated with improved adherence to chemotherapy schedules. Following termination of TPN or ad libitum food intake, and while receiving chemotherapy, the majority of the children who had previously received TPN lost significant weight. To date there has been no difference in mortality rate between the control and TPN groups. Although we conclude that TPN per se had little beneficial effect beyond that of maintaining good nutritional status, every child undergoing intensive combined therapy should have early and periodic assessments of nutritional status, so that the early signs of malnutrition can be detected, and the adverse effects of malnutrition can be prevented by nutritional replenishment, by TPN, or by other methods.

A prospective randomized clinical trial of total parenteral nutrition in children with cancer

A prospective randomized clinical trial was undertaken to test the efficacy of total parenteral nutrition (TPN) among previously untreated children receiving abdominal/pelvic irradiation with or without adjuvant chemotherapy who were at risk for weight loss, malnutrition, and complications from treatment. Children were evaluated by weight/height determinations, anthropomorphic measurements, and laboratory studies. TPN was associated with an improved nutritional status during therapy as compared with control patients on ad libitum intake. However, when TPN was discontinued, weight declined and there were no differences among treated and control patients detected at three-month follow-up. Likewise there was no obvious effect from TPN on tolerance to therapy in the adequately nourished child. TPN as initial supportive therapy should be reserved for those children who are malnourished or marginally malnourished at the time of presentation. Close nutritional assessment during treatment is essential since approximately 25% of children undergoing abdominal/pelvic radiotherapy with chemotherapy can be expected to become malnourished during an initial course of therapy.

The course of five-year survivors of cancer in childhood

A follow-up study was made of two independent series of 1,807 and 425 children who were alive five years after diagnosis of a malignant neoplasm. Over the subsequent 20 years (5 to 24 years after initial diagnosis), actuarial survival rates for the cohorts were 83% and 79%, respectively, compared to 97% for matched control subjects in the general population (P less than 0.01). Cure was achieved in a large majority of the 5-year relapse-free survivors of cancer in this study.

The changing survivorship of white and black children with leukemia

A study was conducted in metropolitan Baltimore to examine changes in survival of white and black children with acute leukemia from 1960 through 1975. Two-hundred eighty-seven cases were identified, of which 77% were acute lymphocytic leukemia (ALL). Eighty-three percent of all cases occurred in white children. In white children with ALL, two-year survival rates increased from 32% in 1960--64 to 47% in 1965--69, and to 79% in 1970--75 (p less than .005). In the small sample of black children with ALL, two-year survival rates increased from 25% in 1960--64 to 59% in 1965--69 (p less than .01), with no further increase in 1970--75. For acute nonlymphocytic leukemia (ANLL), survivorship was analyzed in white children, among whom one-year survival rates increased from 42% in 1965--69 to 71% in 1970--75 (p less than .005). The increasingly better survival over time of white children with acute leukemia probably reflects the increasing efficacy of new therapeutic approaches.

Second malignant tumors after cancer in childhood

Studies were made of the development of second malignant tumors in children treated at the Sidney Farber Cancer Institute. In 1973 a retrospective analysis identified second cancers in 15 of 410 patients who survived a childhood cancer. During the period 5-24 years after diagnosis of the first cancer, the cumulative probability of developing a new cancer was 12%. This frequency was approximately 20-fold higher than the expected rate for the general population. Prospective study of the series since 1973 has identified a second primary cancer in five additional patients. The majority of second cancers were in the field of prior radiotherapy, and were attributable to the oncogenic effect of radiation. Genetic susceptibility factors were identified in individual patients.