Second malignant neoplasms within 5 years from first primary diagnosis in pediatric oncology patients in Canada: a population-based retrospective cohort study

Introduction

From the advancement of treatment of pediatric cancer diagnosis, the five-year survival rate has increased significantly. However, the adverse consequence of improved survival rate is the second malignant neoplasm. Although previous studies provided information on the incidence and risk of SMN in long term survivors of childhood cancer, there is still scarce information known for short term (< 5 years) prognosis. This study aims to assess the incidence, characteristics, management, and outcome of children who develop SMN malignancies within 5 years of diagnosis of their initial cancer.

Method

This is a retrospective cohort study of early Second Malignant Neoplasms (SMN) in pediatric oncology patients. The Cancer in Young People - Canada (CYP-C) national pediatric cancer registry was used and reviewed pediatric patients diagnosed with their first cancer from 2000-2015.

Results

A total of 20,272 pediatric patients with a diagnosis of a first malignancy were analyzed. Of them, 0.7% were diagnosed with a SMN within the first 5 years following their first cancer diagnosis. Development of a SMN impacted survival, shown by an inferior survival rate in the SMN cohort (79.1%) after three years compared to that of the non-SMN cohort (89.7%). Several possible risk factors have been identified in the study including the use of epipodophyllotoxins, exposure to radiation, and hematopoietic stem cell 169 transplant.

Discussion

This is the first national study assessing the incidence, 170 characteristics, risk factors and outcome of early SMN in Canadian children 171 from age 0-15 from 2000-2015.

KIdney aNd blooD prESsure ouTcomes in Childhood Cancer Survivors: Description of Clinical Research Protocol of the KINDEST-CCS Study

Background

Approximately 30% of childhood cancer survivors (CCSs) will develop chronic kidney disease (CKD) or hypertension 15 to 20 years after treatment ends. The incidence of CKD and hypertension in the 5-year window after cancer therapy is unknown. Moreover, extent of monitoring of CCS with CKD and associated complications in current practice is underexplored. To inform the development of new and existing care guidelines for CCS, the epidemiology and monitoring of CKD and hypertension in the early period following cancer therapy warrants further investigation.

Objective

To describe the design and methods of the KIdney aNd blooD prESsure ouTcomes in Childhood Cancer Survivors study, which aims to evaluate the burden of late kidney and blood pressure outcomes in the first ~10 years after cancer therapy, the extent of appropriate screening and complications monitoring for CKD and hypertension, and whether patient, disease/treatment, or system factors are associated with these outcomes.

Design

Two distinct, but related studies; a prospective cohort study and a retrospective cohort study.

Setting

Five Ontario pediatric oncology centers.

Patients

The prospective study will involve 500 CCS at high risk for these late effects due to cancer therapy, and the retrospective study involves 5,000 CCS ≤ 18 years old treated for cancer between January 2008 and December 2020.

Measurements

Chronic kidney disease is defined as Estimated glomerular filtration rate <90 mL/min/1.73 m² or albumin-to-creatinine ratio ≥ 3mg/mmol. Hypertension is defined by 2017 American Academy of Pediatrics guidelines.

Methods

Prospective study: we aim to investigate CKD and hypertension prevalence and the extent to which they persist at 3- and 5-year follow-up in CCS after cancer therapy. We will collect detailed biologic and clinical data, calculate CKD and hypertension prevalence, and progression at 3- and 5-years post-therapy. Retrospective study: we aim to investigate CKD and hypertension monitoring using administrative and health record data. We will also investigate the validity of CKD and hypertension administrative definitions in this population and the incidence of CKD and hypertension in the first ~10 years post-cancer therapy. We will investigate whether patient-, disease/treatment-, or system-specific factors modify these associations in both studies.

Limitations

Results from the prospective study may not be generalizable to non-high-risk CCS. The retrospective study is susceptible to surveillance bias.

Conclusions

Our team and knowledge translation plan is engaging patient partners, researchers, knowledge users, and policy group representatives. Our work will address international priorities to improve CCS health, provide the evidence of new disease burden and practice gaps to improve CCS guidelines, implement and test revised guidelines, plan trials to reduce CKD and hypertension, and improve long-term CCS health.

Development of paediatric non-stage prognosticator guidelines for population-based cancer registries and updates to the 2014 Toronto Paediatric Cancer Stage Guidelines

Population-based cancer registries (PBCRs) generate measures of cancer incidence and survival that are essential for cancer surveillance, research, and cancer control strategies. In 2014, the Toronto Paediatric Cancer Stage Guidelines were developed to standardise how PBCRs collect data on the stage at diagnosis for childhood cancer cases. These guidelines have been implemented in multiple jurisdictions worldwide to facilitate international comparative studies of incidence and outcome. Robust stratification by risk also requires data on key non-stage prognosticators (NSPs). Key experts and stakeholders used a modified Delphi approach to establish principles guiding paediatric cancer NSP data collection. With the use of these principles, recommendations were made on which NSPs should be collected for the major malignancies in children. The 2014 Toronto Stage Guidelines were also reviewed and updated where necessary. Wide adoption of the resultant Paediatric NSP Guidelines and updated Toronto Stage Guidelines will enhance the harmonisation and use of childhood cancer data provided by PBCRs.

Survival outcomes of a population-based cohort of adolescent and young adult (AYA), acute lymphoblastic leukemia (ALL) patients in Ontario, Canada: The IMPACT Cohort

IntroductionAdolescents and young adults (AYA) are an understudied population in cancer research. The Initiative to Maximize Progress in Adolescent and Young Adult Cancer Therapy (IMPACT) cohort includes Ontario individuals aged 15-21 years, diagnosed with a malignancy during 1992-2011. This cohort contains a rich source of patient, disease, and treatment data. Objectives and ApproachThe IMPACT cohort was created using chart review and linkages to population-based health services databases. The cohort is comprised of AYA with a primary diagnosis of acute leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, sarcoma, or testicular cancer. For the current study, we focused on acute lymphoblastic leukemia (ALL) patients, and examined survival outcomes of those treated at pediatric vs adult centers, with adult vs pediatric protocols. We assessed 5-year event-free survival (first of relapse, progression, secondary malignant neoplasm, or death) and overall survival. ResultsThe IMPACT cohort contains 2,963 patients, of which 152/271 ALL patients were treated at adult centers. The 5-year event-free survival (EFS ± standard error) among those treated at a pediatric vs. adult center was 72%±4% vs. 56%±4% (p = 0.03), respectively. The 5-year overall survival (OS) was 82%±4% vs. 64%±4% (p Conclusion/ImplicationsALL patients treated with a pediatric protocol at a pediatric center experienced better, crude survival outcomes compared to those at an adult center. The IMPACT cohort offers the opportunity to study a myriad of questions on different cancer groups, with the ultimate goal of improving outcomes among the AYA population.

Thromboembolism Incidence and Risk Factors in Children with Cancer: A Population-Based Cohort Study

There is conflicting information about the epidemiology of thromboembolism (TE) in paediatric oncology. Objectives were to describe the incidence and risk factors of TE in children with cancer. We included all children with cancer less than 15 years of age diagnosed from 2001 to 2016, treated at one of the 12 Canadian paediatric centres outside of Ontario and entered into the Cancer in Young People-Canada database. Potential risk factors for TE were evaluated using Cox proportional hazards regression stratified by haematological malignancies versus solid tumours. Factors associated with vascular access- and non-vascular access-related TE were compared using chi-square or Fisher's exact tests. Of the 7,471 children included, 283 experienced TE requiring medical intervention; cumulative incidence of TE at 5 years was 3.8 ± 0.2% and 0.36% ± 0.07% for life-threatening or fatal TE. For haematological malignancies, the following factors were associated with TE in multivariable regression: age < 1 year, 5 to 9.99 years and 10 to 14.99 years (relative to age 1–4.99 years), haematopoietic stem cell transplant (hazard ratio [HR] = 1.49, 95% confidence interval [CI], 1.00–2.32), anthracyclines (HR = 2.21, 95% CI, 1.12–4.37) and asparaginase (HR = 1.68, 95% CI, 1.15–2.44). For solid tumours, obesity (HR = 1.92, 95% CI, 1.01–3.68), surgery (HR = 2.70, 95% CI, 1.44–5.08), radiation (HR = 47.51, 95% CI, 24.01–94.01), anthracyclines (HR = 2.74, 95% CI, 1.29–5.82) and platinum agents (HR = 2.26, 95% CI, 1.19–4.28) were associated with TE. Life-threatening and fatal TEs were more common among non-vascular access TEs (14.5% vs. 3.3% p = 0.001). In a population-based cohort, 4% of children with cancer developed a clinically significant TE. Accurate risk stratification tools are needed specific to malignancy type.

Early healthcare provider communication with patients and their workplace following a lost-time claim for an occupational musculoskeletal injury

PROBLEM

One of the key players in the return-to-work (RTW) and work accommodation process is the healthcare provider (HCP). This study examines the association between RTW approximately one month post injury and early, proactive HCP communication with the patient and workplace.

METHODS

In this cross-sectional study 187 Ontario workers completed a telephone survey 17-43 days post injury. All had accepted or pending lost-time claims for back, neck or upper extremity occupational musculoskeletal injuries. Logistic regression was used to analyze the effects of three self-reported items "your HCP told you the date you could RTW," "your HCP advised you on how to prevent re-injury or recurrence," "your HCP made contact with your workplace" on self-reported RTW. Fourteen potential confounders were also tested in the model including sex, age, income, education, occupational classification, worksite size, co-morbidity, psycho-physical work demands, pain, job satisfaction, depression, and time from injury to interview.

RESULTS

The HCP giving a patient a RTW date (adjusted OR=3.33, 95% CI=1.62-6.87) and giving a patient guidance on how to prevent recurrence and re-injury (adjusted OR=2.71, 95% CI=1.24-5.95) were positively associated with an early RTW. Contact by the HCP with the workplace was associated with RTW, however, this association became weaker upon adjusting for confounding variables (crude OR=2.11, 95% C1=1.09-4.09; adjusted OR=1.72, 95% CI=0.83-3.58).

INTERPRETATION

Our study lends support to the HCP playing an active role early in the RTW process, one that includes direct contact with the workplace and proactive communication with the patient.

Declining trends in work-related morbidity and disability, 1993-1998: a comparison of survey estimates and compensation insurance claims

OBJECTIVES

This study compared trends in the incidence of work-related morbidity and disability across 3 sources of surveillance data in a Canadian province.

METHODS

Time series estimates of workplace injuries and work-related disability based on 2 panel surveys in the province of Ontario, Canada, for the period 1993-1998 were compared with rates of work-related injury and illness compensation claims during the same period.

RESULTS

Lost-time compensation claims declined by 28.8% over this 6-year period. The incidence of self-reported work-related injury declined by 28.2%, and the self-reported incidence of work absence for work-related causes declined by 32.2%.

CONCLUSIONS

Parallel reductions in work-related morbidity were seen in 3 independent data sources. These results support an interpretation that there has been an important reduction in injury risk in Ontario workplaces over the past decade.

Caspases mediate C2-ceramide-induced apoptosis of the human oligodendroglial cell line, MO3.13

The signalling molecule ceramide participates in the sphingomyelin pathway and accumulates intracellularly in response to inflammatory mediators. Here we show that membrane permeable C2-ceramide is apoptogenic in the immortalised human oligodendroglial cell line MO3.13. Apoptosis (defined by cell shrinkage and chromatin condensation) is accompanied by caspase enzyme activation. Immunoblotting analysis of extracts from differentiated MO3.13 cells revealed the presence of caspase-3 proenzyme, activation by cleavage of pro-caspase-3 in cells treated with C2-ceramide and cleavage of the caspase substrates fodrin and rabaptin. Lysates also showed cleavage of a fluorogenic peptide substrate. Addition of the general caspase inhibitor BAF markedly attenuated apoptosis of MO3.13 oligodendroglia. A role for caspase-3-like enzymes in ceramide-induced apoptosis of oligodendroglia may have important implications for approaches to treatment of demyelinating diseases.

IncC of broad-host-range plasmid RK2 modulates KorB transcriptional repressor activity In vivo and operator binding in vitro

The korAB operon of broad-host-range plasmid RK2 encodes five genes, two of which, incC and korB, belong to the parA and parB families, respectively, of genome partitioning functions. Both korB and a third gene, korA, are responsible for coordinate regulation of operons encoding replication, transfer, and stable inheritance functions. Overexpression of incC alone caused rapid displacement of RK2. Using two different reporter systems, we show that incC modulates the action of KorB. Using promoter fusions to the reporter gene xylE, we show that incC potentiates the repression of transcription by korB. This modulation of korB activity was only observed with incC1, which encodes the full-length IncC (364 amino acids [aa]), whereas no effect was observed with incC2, which encodes a polypeptide of 259 aa that lacks the N-terminal 105 aa. Using bacterial extracts with IncC1 and IncC2 or IncC1 purified through the use of a His6 tail and Ni-agarose chromatography, we showed that IncC1 potentiates the binding of KorB to DNA at representative KorB operators. The ability of IncC to stabilize KorB-DNA complexes suggests that these two proteins work together in the global regulation of many operons on the IncP-1 genomes, as well in plasmid partitioning.

Trihalomethanes in public water supplies and adverse birth outcomes

We conducted a retrospective cohort study to evaluate the relation between the level of total trihalomethanes in drinking water and adverse birth outcomes. The study population comprised women residing in an area with municipal surface water who had a singleton birth in Nova Scotia between January 1, 1988, and December 31, 1995, or a pregnancy termination for a major fetal anomaly. We found little association between trihalomethane level and the outcomes related to fetal weight or gestational age, but we found an elevated relative risk for stillbirths for average trihalomethane levels during pregnancy of 100 microg/liter or greater (adjusted relative risk = 1.66; 95% confidence interval = 1.09-2.52) relative to women exposed to trihalomethane levels of 0-49 microg/liter. We saw little evidence of an elevated prevalence or dose-response pattern for congenital anomalies, with the possible exception of chromosomal abnormalities (adjusted prevalence ratio = 1.38 and 95% confidence interval = 0.73-2.59 for women exposed to trihalomethane levels of 100 microg/liter or greater).