Langerhans cell histiocytosis: NACHO update on progress, chaos, and opportunity on the path to rational cures

Langerhans cell histiocytosis (LCH) is a myeloid neoplastic disorder characterized by lesions with CD1a-positive/Langerin (CD207)-positive histiocytes and inflammatory infiltrate that can cause local tissue damage and systemic inflammation. Clinical presentations range from single lesions with minimal impact to life-threatening disseminated disease. Therapy for systemic LCH has been established through serial trials empirically testing different chemotherapy agents and durations of therapy. However, fewer than 50% of patients who have disseminated disease are cured with the current standard-of-care vinblastine/prednisone/(mercaptopurine), and treatment failure is associated with long-term morbidity, including the risk of LCH-associated neurodegeneration. Historically, the nature of LCH-whether a reactive condition versus a neoplastic/malignant condition-was uncertain. Over the past 15 years, seminal discoveries have broadly defined LCH pathogenesis; specifically, activating mitogen-activated protein kinase pathway mutations (most frequently, BRAFV600E) in myeloid precursors drive lesion formation. LCH therefore is a clonal neoplastic disorder, although secondary inflammatory features contribute to the disease. These paradigm-changing insights offer a promise of rational cures for patients based on individual mutations, clonal reservoirs, and extent of disease. However, the pace of clinical trial development behind lags the kinetics of translational discovery. In this review, the authors discuss the current understanding of LCH biology, clinical characteristics, therapeutic strategies, and opportunities to improve outcomes for every patient through coordinated agent prioritization and clinical trial efforts.

Vaccination practices of pediatric oncologists from eight states

BACKGROUND

Vaccinations are a vital part of routine childhood and adolescent preventive care. We sought to identify current oncology provider practices, barriers, and attitudes towards vaccinating childhood and adolescent cancer patients and survivors.

METHODS

We conducted a one-time online survey distributed from March-October 2018 to pediatric oncologists at nine institutions across the United States (N = 111, 68.8% participation rate). The survey included 32 items about vaccination practices, barriers to post-treatment vaccination, availability of vaccinations in oncology clinic, familiarity with vaccine guidelines, and attitudes toward vaccination responsibilities. Descriptive statistics were calculated in STATA 14.2.

RESULTS

Participants were 54.0% female and 82.9% white, with 12.6% specializing in Bone Marrow Transplants. Influenza was the most commonly resumed vaccine after treatment (7030%). About 50%-60% were familiar with vaccine guidelines for immunocompromised patients. More than half (62.7%) recommended that patients restart most immunizations 6 months to 1 year after chemotherapy. Common barriers to providers recommending vaccinations included not having previous vaccine records for patients (56.8%) or lacking time to ascertain which vaccines are needed (32.4%). Of participants, 66.7% stated that vaccination should be managed by primary care providers, but with guidance from oncologists.

CONCLUSIONS

Many pediatric oncologists report being unfamiliar with vaccine guidelines for immunocompromised patients and almost all report barriers in supporting patients regarding vaccines after cancer treatment. Our findings show that further research and interventions are needed to help bridge oncology care and primary care regarding immunizations after treatment.

Children's Oncology Group's 2023 blueprint for research: Non-Hodgkin lymphoma

Pediatric non-Hodgkin lymphoma (NHL) includes over 30 histologies (many with subtypes), with approximately 800 cases per year in the United States. Improvements in survival in NHL over the past 5 decades align with the overall success of the cooperative trial model with dramatic improvements in outcomes. As an example, survival for advanced Burkitt lymphoma is now >95%. Major remaining challenges include survival for relapsed and refractory disease and long-term morbidity in NHL survivors. Langerhans cell histiocytosis (LCH) was added to the NHL Committee portfolio in recognition of LCH as a neoplastic disorder and the tremendous unmet need for improved outcomes. The goal of the Children' Oncology Group NHL Committee is to identify optimal cures for every child and young adult with NHL (and LCH). Further advances will require creative solutions, including engineering study groups to combine rare populations, biology-based eligibility, alternative endpoints, facilitating international collaborations, and coordinated correlative biology.

A phase II trial of nifurtimox combined with topotecan and cyclophosphamide for refractory or relapsed neuroblastoma and medulloblastoma

Children with relapsed/refractory (R/R) neuroblastoma (NB) and medulloblastoma (MB) have poor outcomes. We evaluated the efficacy of nifurtimox (Nfx) in a clinical trial for children with R/R NB and MB. Subjects were divided into three strata: first relapse NB, multiply R/R NB, and R/R MB. All patients received Nfx (30 mg/kg/day divided TID daily), Topotecan (0.75 mg/m² /dose, days 1-5) and Cyclophosphamide (250 mg/m² /dose, days 1-5) every 3 weeks. Response was assessed after every two courses using International Neuroblastoma Response Criteria and Response Evaluation Criteria in Solid Tumors (RECIST) criteria. One hundred and twelve eligible patients were enrolled with 110 evaluable for safety and 76 evaluable for response. In stratum 1, there was a 53.9% response rate (CR + PR), and a 69.3% total benefit rate (CR + PR + SD), with an average time on therapy of 165.2 days. In stratum 2, there was a 16.3% response rate, and a 72.1% total benefit rate, and an average time on study of 158.4 days. In stratum 3, there was a 20% response rate and a 65% total benefit rate, an average time on therapy of 105.0 days. The most common side effects included bone marrow suppression and reversible neurologic complications. The combination of Nfx, topotecan and cyclophosphamide was tolerated, and the objective response rate plus SD of 69.8% in these heavily pretreated populations suggests that this combination is an effective option for patients with R/R NB and MB. Although few objective responses were observed, the high percentage of stabilization of disease and prolonged response rate in patients with multiply relapsed disease shows this combination therapy warrants further testing.

A qualitative inquiry of communication based barriers to the diagnosis of pediatric cancer: Perceptions of primarily Spanish-speaking caregivers

BACKGROUND

Primarily Spanish-speaking cancer patients and caregivers often experience non-congruence with healthcare providers about beliefs, values, and knowledge of cancer. Our goal was to describe how communication related to the diagnosis of cancer was influenced by culture and language among primarily Spanish-speaking caregivers of pediatric cancer patients.

METHODS

Caregivers participated in three focus groups about their experiences with their child's diagnosis, communication issues, and understanding of their child's diagnosis and treatment plan. Focus groups were audio recorded, transcribed, and qualitatively analyzed using interpretive description.

RESULTS

Three themes emerged: 1) Negative experiences and barriers during the cancer diagnosis and treatment, 2) Miscommunication and system complexity, and 3) Language barriers throughout the diagnostic process. Due to barriers and negative experiences, some caregivers reported that their child's diagnosis was delayed, that providers sometimes used dehumanizing language, and that they were confused about diagnostic testing and treatment.

CONCLUSION

Cultural and linguistic disparities in pediatric oncology must be systematically addressed at the provider, clinic, and system level.

PRACTICE IMPLICATIONS

High-quality cancer care delivered by oncologists and cancer care teams should include cultural humility when discussing the cancer diagnosis and prognosis.

Two Clonally Distinct B-Cell Lymphomas Reveal the Diagnosis of XLP1 in a Male Child and His Asymptomatic Male Relatives: Case Report and Review of the Literature

X-linked lymphoproliferative disease type 1 (XLP1) is a primary immunodeficiency disorder caused by pathogenic variants in the SH2D1A gene (SH2 domain containing protein 1A). Patients with XLP1 may present acutely with fulminant infectious mononucleosis, hemophagocytic lymphohistiocytosis, and/or B-cell non-Hodgkin lymphoma (B-NHL). We report a boy who developed 2 clonally distinct B-NHL 4 years apart and was found to have previously unrecognized XLP1. The report highlights the importance of clonal analysis and XLP1 testing in males with presumed late recurrences of B-NHL, and the role of allogeneic stem cell transplant (allo-SCT) in XLP1 patients and their affected male relatives.

Molecular and phenotypic diversity of CBL-mutated juvenile myelomonocytic leukemia

Mutations in the CBL gene were first identified in adults with various myeloid malignancies. Some patients with juvenile myelomonocytic leukemia (JMML) were also noted to harbor mutations in CBL, but were found to have generally less aggressive disease courses compared to patients with other forms of Ras pathway-mutant JMML. Importantly, and in contrast to most reports in adults, the majority of CBL mutations in JMML patients are germline with acquired uniparental disomy occurring in affected marrow cells. Here, we systematically studied a large cohort of 33 JMML patients with CBL mutations and found that this disease is highly diverse in presentation and overall outcome. Moreover, we discovered somatically acquired CBL mutations in 15% of pediatric patients who presented with more aggressive disease. Neither clinical features nor methylation profiling were able to distinguish patients with somatic CBL mutations from those with germline CBL mutations, highlighting the need for germline testing. Overall, we demonstrate that disease courses are quite heterogeneous even among patients with germline CBL mutations. Prospective clinical trials are warranted to find ideal treatment strategies for this diverse cohort of patients.

BRAF V600E mutation in Juvenile Xanthogranuloma family neoplasms of the central nervous system (CNS-JXG): a revised diagnostic algorithm to include pediatric Erdheim-Chester disease

The family of juvenile xanthogranuloma family neoplasms (JXG) with ERK-pathway mutations are now classified within the "L" (Langerhans) group, which includes Langerhans cell histiocytosis (LCH) and Erdheim Chester disease (ECD). Although the BRAF V600E mutation constitutes the majority of molecular alterations in ECD and LCH, only three reported JXG neoplasms, all in male pediatric patients with localized central nervous system (CNS) involvement, are known to harbor the BRAF mutation. This retrospective case series seeks to redefine the clinicopathologic spectrum of pediatric CNS-JXG family neoplasms in the post-BRAF era, with a revised diagnostic algorithm to include pediatric ECD. Twenty-two CNS-JXG family lesions were retrieved from consult files with 64% (n = 14) having informative BRAF V600E mutational testing (molecular and/or VE1 immunohistochemistry). Of these, 71% (n = 10) were pediatric cases (≤18 years) and half (n = 5) harbored the BRAF V600E mutation. As compared to the BRAF wild-type cohort (WT), the BRAF V600E cohort had a similar mean age at diagnosis [BRAF V600E: 7 years (3-12 y), vs. WT: 7.6 years (1-18 y)] but demonstrated a stronger male/female ratio (BRAF V600E: 4 vs WT: 0.67), and had both more multifocal CNS disease ( BRAFV600E: 80% vs WT: 20%) and systemic disease (BRAF V600E: 40% vs WT: none). Radiographic features of CNS-JXG varied but typically included enhancing CNS mass lesion(s) with associated white matter changes in a subset of BRAF V600E neoplasms. After clinical-radiographic correlation, pediatric ECD was diagnosed in the BRAF V600E cohort. Treatment options varied, including surgical resection, chemotherapy, and targeted therapy with BRAF-inhibitor dabrafenib in one mutated case. BRAF V600E CNS-JXG neoplasms appear associated with male gender and aggressive disease presentation including pediatric ECD. We propose a revised diagnostic algorithm for CNS-JXG that includes an initial morphologic diagnosis with a final integrated diagnosis after clinical-radiographic and molecular correlation, in order to identify cases of pediatric ECD. Future studies with long-term follow-up are required to determine if pediatric BRAF V600E positive CNS-JXG neoplasms are a distinct entity in the L-group histiocytosis category or represent an expanded pediatric spectrum of ECD.

HPV vaccination knowledge, intentions, and practices among caregivers of childhood cancer survivors

The HPV vaccine is an important vaccine for childhood cancer survivors because of their risks of second cancers, yet few survivors receive it. We examined HPV vaccine knowledge among caregivers of childhood cancer survivors, whether their child had received the vaccine, and their intentions to vaccinate. Eligible participants were caregivers (mostly parents) whose child finished cancer treatment at Primary Children’s Hospital in Salt Lake City, Utah 3 to 36 months prior to the start of the study (N = 145). Additional analyses were done among caregivers whose child was age-eligible for the HPV vaccine (ages 11 and up; N = 61). We ran descriptive statistics and fit multivariable generalized linear models to identify factors associated with intention to vaccinate and HPV vaccination uptake. Among caregivers whose child had not yet gotten the HPV vaccine, approximately 30% stated they were not likely to get the vaccine for their child and the most commonly cited reason was not enough information (25.2%). Provider discussion about vaccines and side effects (relative risk (RR) = 1.85, 95% CI 1.16–2.94), along with recommendations regarding vaccines after cancer treatment (RR = 1.35, 95% CI 1.06–1.72), led to greater caregiver intention to get the HPV vaccine for their child with cancer. Approximately 40% of age-eligible survivors had gotten at least one dose of the HPV vaccine. Our findings demonstrate a need for oncology-focused interventions to educate families of childhood cancer survivors about the importance of the HPV vaccine after cancer therapy.

Caregiver Intention To Restart Vaccinations After Childhood Cancer Treatment

Timely vaccination after childhood cancer treatment is vital for protecting against vaccine-preventable diseases during survivorship. However, caregiver intention for restarting vaccinations, such as getting catch-up or booster vaccines, after cancer treatment is unknown. Methods: We surveyed primary caregivers ages 18 or older with a child who had completed cancer treatment in the prior 3–24 months (N = 129; participation rate = 60.3%). Participants were asked about demographics, their child's vaccination status, and healthcare factors (e.g., provider recommendations, barriers). We examined the influence of whether the oncology care team recommended catch-up or booster vaccines on caregiver intention to restart vaccines using multivariable generalized linear models. Vaccine barriers were examined by intention in chi- square tests. Results: Caregivers were primarily aged 30–49 years (82.0%), mothers (81.2%), college graduates (44.8%), married (89.1%), and Non-Hispanic (90.3%). In total, 67% of caregivers intended to restart vaccines for their child and 49.6% reported that they had a discussion with the cancer care team about catch-up or booster vaccines. Caregivers who discussed vaccines with their child's cancer care team were much more likely to report intention to restart vaccination (Relative Risk (RR) = 1.82, 95% CI 1.37–2.45). The most common barrier to restarting vaccines after cancer was not knowing which vaccines to get, which was common across both groups (intend to restart = 31% vs. did not intend = 40.5%, P = 0.29). Of caregivers, 93.1% who intended to restart vaccines felt vaccines were safe compared to 79.5% of those who did not (P = 0.02). Conclusions: Caregivers of childhood cancer survivors need guidance for restarting vaccinations after cancer treatment, including information on safety and which vaccines their child needs. Provider recommendations positively influence caregiver's intention to restart vaccines. Clinical guidelines are needed to support providers in making tailored vaccination recommendations after cancer treatment.

Severe Sepsis-Associated Morbidity and Mortality among Critically Ill Children with Cancer

Severe sepsis (SS) in pediatric oncology patients is a leading cause of morbidity and mortality. We investigated the incidence of and risk factors for morbidity and mortality among children diagnosed with cancer from 2008 to 2012, and admitted with SS during the 3 years following cancer diagnosis. A total of 1,002 children with cancer were included, 8% of whom required pediatric intensive care unit (PICU) admission with SS. Death and/or multiple organ dysfunction syndrome occurred in 34 out of 99 PICU encounters (34%). Lactate level and history of stem-cell transplantation were significantly associated with the development of death and/or organ dysfunction ( p  < 0.05).

A retrospective analysis of treatment-related hospitalization costs of pediatric, adolescent, and young adult acute lymphoblastic leukemia

This retrospective study examined the longitudinal hospital outcomes (costs adjusted for inflation, hospital days, and admissions) associated with the treatment of pediatric, adolescent, and young adult acute lymphoblastic leukemia (ALL). Patients between one and 26 years of age with newly diagnosed ALL, who were treated at Primary Children's Hospital (PCH) in Salt Lake City, Utah were included. Treatment and hospitalization data were retrieved from system-wide cancer registry and enterprise data warehouse. PCH is a member of the Children's Oncology Group (COG) and patients were treated on, or according to, active COG protocols. Treatment-related hospital costs of ALL were examined by computing the average annual growth rates (AAGR). Longitudinal regressions identified patient characteristics associated with costs. A total of 505 patients (46.9% female) were included. The majority of patients had B-cell lineage ALL, 6.7% had T-ALL, and the median age at diagnosis was 4 years. Per-patient, first-year ALL hospitalization costs at PCH rose from $24,197 in 1998 to $37,924 in 2012. The AAGRs were 6.1, 13.0, and 7.6% for total, pharmacy, and room and care costs, respectively. Average days (AAGR = 5.2%) and admissions (AAGR = 3.8%) also demonstrated an increasing trend. High-risk patients had 47% higher costs per 6-month period in the first 5 years from diagnosis than standard-risk patients (P < 0.001). Similarly, relapsed ALL and stem cell transplantations were associated with significantly higher costs than nonrelapsed and no transplantations, respectively (P < 0.001). Increasing treatment-related costs of ALL demonstrate an area for further investigation. Value-based interventions such as identifying low-risk fever and neutropenia patients and managing them in outpatient settings should be evaluated for reducing the hospital burden of ALL.

Healthcare utilization and quality among survivors of adolescent and young adult cancer

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Background: To evaluate perceived health care quality among a national sample of survivors of adolescent and young adult (AYA) cancer relative to individuals from the general population. Methods: Using the Medical Expenditure Panel Surveys from 2008-2012, we identified 1,163 survivors diagnosed with cancer ages 15-39 who were at least five years from diagnosis and currently ages of 20-64. A comparison group with no history of cancer was created via propensity score matching on sex, age at study, race/ethnicity, census-region, and survey year. Participants with one or more health care visit in the past 12 months were asked to rate health care quality from all providers (0 = worst to 10 = best), which we categorized as low (0-4), moderate (5-7) and high (8-10). Among survivors, we identified factors such insurance and health status associated with health care quality using ordinal logistic regression. Results: Mean time since diagnosis was 18.3 years. A total of 18% of survivors of AYA cancer reported no health care visits in the previous 12 months compared to 25% of the comparison group (p < 0.001). Survivors rated their health care quality lower than the comparison group (low/moderate: 30.8% vs. 22.5%, respectively, p = 0.003). Among survivors, those who were publicly insured (odds ratio (OR) = 0.62, 95% confidence interval (CI): 0.39-0.97, p = 0.04) and uninsured (OR = 0.25, 95% CI: 0.13-0.48, p < 0.001) were more likely to provide lower health care quality ratings than privately insured survivors. Survivors in fair/poor health also reported poorer quality compared to those in excellent/very good/good health (OR = 0.43, 95% CI, p < 0.001). Conclusions: Survivors of AYA cancer reported greater health care use and poorer health care quality compared to individuals without cancer. Our results call for targeted interventions to meet AYA cancer survivors’ health care needs and expectations.

Statewide Longitudinal Hospital Use and Charges for Pediatric and Adolescent Patients With Cancer

PURPOSE

We investigated longitudinal hospitalization outcomes (total charges, hospital days and admissions) among pediatric and adolescent patients with cancer compared with individuals from the general population without cancer using a novel and efficient three-step regression procedure.

METHODS

The statewide Utah Population Database, with linkages to the Utah Cancer Registry, was used to identify 1,651 patients who were diagnosed with cancer from 1996 to 2009 at ages 0 to 21 years. A comparison group of 4,953 same-sex and -age individuals was generated from birth certificates. Claims-based hospitalization data from 1996 to 2012 were retrieved from the Utah Department of Health. Using the regression method, we estimated survival (differences due to survival) and intensity (differences due to resource accumulation) effects of the cancer diagnosis on hospitalization outcomes within 10 years after diagnosis.

RESULTS

At 10 years after diagnosis, on average, patients with cancer incurred $51,723 (95% CI, $48,100 to $58,284) more in charges, spent 30 additional days (95% CI, 27.7 to 36.1 days) in the hospital, and had 5.7 (95% CI, 5.4 to 6.4) more admissions than the comparison group. Our analyses showed that the highest hospitalization burden occurred during the first 4 years of diagnosis. Patients with leukemia incurred the greatest hospitalization burden throughout the 10 years from diagnosis. Intensity effects explained the majority of differences in hospital outcomes.

CONCLUSION

Our results suggest that children and adolescents who were diagnosed with cancer in 2014 in the United States will incur over $800 million more in hospital charges than individuals without cancer by 2024. Interventions to reduce this burden should be explored in conjunction with improving health and survival outcomes.

Financial Burden of Pediatric Cancer for Patients and Their Families

PURPOSE

Cancer treatment may cause financial stress for pediatric oncology patients and their families. We evaluated pediatric cancer caregivers' perceived financial burden related to socioeconomic factors (eg, parental employment) and health care use factors (eg, unexpected hospitalizations).

METHODS

A single-site, cross-sectional survey of primary caretakers of patients with childhood cancer was performed from July 2010 to July 2012. Eligible patients were treated at a pediatric cancer hospital, diagnosed at age ≤ 21 years and were ≤ 5 years from diagnosis (N = 254). Financial burden was rated on a visual analog scale of 0 to 100. Multivariable linear regression models were used to calculate coefficients and 95% CIs of financial burden by time since diagnosis.

RESULTS

Mean age at diagnosis was 6.8 years (SD = 5.5 years), and average time since diagnosis was 1.6 years (SD = 1.4 years). The most common diagnosis was leukemia (41.9%). When adjusted for sex, age at diagnosis, insurance status, and rural residence, caregivers whose child was 1 to 5 years from diagnosis with ≥ 5 unexpected hospitalizations experienced 24.9 (95% CI, 9.1 to 40.7; P < .01) points higher financial burden than those with no unexpected hospitalizations. In addition, when compared with families without employment disruptions, families of children 1 to 5 years from diagnosis in which a caregiver had quit or changed jobs reported 13.4 (95% CI, 3.2 to 23.6; P = .01) points higher financial burden.

CONCLUSIONS

Efforts to reduce unexpected hospitalizations and employment disruptions by providing more comprehensive supportive care for pediatric patients with cancer could help ease families' financial burden.

Treatment-related costs of pediatric acute lymphoblastic leukemia

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Background: Few studies have examined costs of pediatric cancer care and we lack a clear understanding of cost trends. In this study, we examined longitudinal treatment- and patient-related hospitalization costs within 5 years of diagnosis of acute lymphoblastic leukemia (ALL), the most common childhood cancer in the United States. Methods: We used data on N=555 patients diagnosed with pediatric ALL from 1998 to 2013 identified through the Intermountain Healthcare System in UT. The majority of these patients (>95%) were diagnosed and treated at the Primary Children’s Hospital (PCH) in Salt Lake City, UT. PCH encompasses the largest coverage area in the continental U.S. served by a single children’s hospital. We computed the average annual per patient hospitalization cost (aggregate and by components such as room, care and nursing cost, pharmacy cost, therapy and diagnostics costs). We used the generalized estimating equations (GEE) regression framework to identify patient characteristics (sex, age, race, rural/urban residence, insurance, high vs. standard risk, relapse, bone marrow transplant (BMT), and year of diagnosis) associated with hospital-related treatment costs (total cost per encounter). Results: Annual average cost of per patient hospitalization increased by 26% from 1998-2005 to 2006-2013. Most of this increase was driven by annual increases in room, care and nursing costs (increased by 29%) and pharmacy cost (increased by 79%). Our GEE models indicated the greatest costs among relapsed patients (average difference (δ) =$15,507 vs. those without relapse), BMT patients (δ=$15,184 vs. no transplant) and patients older than 10 years at diagnosis (δ=$8,539 vs. patients younger than 10 years at diagnosis). Publically insured patients had per encounter hospitalization costs that were greater (δ=$931) than privately insured. Conclusions: Average annual cost of hospitalization for pediatric ALL care has increased over the past fifteen years. Management of room, care and nursing, and pharmacy costs need to be considered in efforts to address the cost burden. In addition, patient-centered strategies to manage higher costs, such as better management of patients who are older at diagnosis or publically insured, may be warranted.

A population-based study of childhood cancer survivors' body mass index

Background. Population-based studies are needed to estimate the prevalence of underweight or overweight/obese childhood cancer survivors. Procedure. Adult survivors (diagnosed ≤20 years) were identified from the linked Utah Cancer Registry and Utah Population Database. We included survivors currently aged ≥20 years and ≥5 years from diagnosis (N = 1060), and a comparison cohort selected on birth year and sex (N = 5410). BMI was calculated from driver license data available from 2000 to 2010. Multivariable generalized linear regression models were used to calculate prevalence relative risks (RR) and 95% confidence intervals (95% CI) of BMI outcomes for survivors and the comparison cohort. Results. Average time since diagnosis was 18.5 years (SD = 7.8), and mean age at BMI for both groups was 30.5 (survivors SD = 7.7, comparison SD = 8.0). Considering all diagnoses, survivors were not at higher risk for being underweight or overweight/obese than the comparison. Male central nervous system tumor survivors were overweight (RR = 1.12, 95% CI 1.01-1.23) more often than the comparison. Female survivors, who were diagnosed at age 10 and under, had a 10% higher risk of being obese than survivors diagnosed at ages 16-20 (P < 0.05). Conclusion. While certain groups of childhood cancer survivors are at risk for being overweight/obese, in general they do not differ from population estimates.

The financial burden of unexpected hospitalizations for childhood cancer patients and their families

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Background: Complications of therapy, such as infection, pain, or dehydration, may cause financial stress for childhood cancer patients due to unexpected hospitalizations. Treatment for childhood cancer is typically provided at tertiary health care centers, requiring rural patients to travel long distances for care. We evaluated the perceived financial burden of unanticipated hospitalizations, insurance, and rurality on childhood cancer patients and their families. Methods: A single-site, cross-sectional survey of primary caretakers of childhood cancer patients was performed from July 2010-July 2012. Eligible patients were treated at a pediatric cancer hospital, diagnosed age ≤21 years and were ≤5 years from diagnosis (N=310). Financial burden was rated on a visual analog scale of 0-100. Multivariable linear regression models were used to calculate coefficients and 95% Confidence Intervals (CI) of financial burden by number of unexpected hospitalizations (0, 1-4, ≥5) and time since diagnosis. Results: The average age at diagnosis was 7.0 (SD 5.6) years. The most common diagnosis was leukemia (47.4%). The mean number of unexpected hospitalizations was 4.2 (SD 7.3). Patients did not differ on number of unexpected hospitalizations by current age, gender, race/ethnicity, or household income. In multivariable analyses, patients 1-5 years past diagnosis with ≥5 unexpected hospitalizations reported financial burden was 22.6 (95% CI 6.2-39.1, p=0.007) points higher than those with no hospitalization and 13.7 (95% CI 2.8-23.6 p=0.007) points higher than those with 1-4 hospitalizations. Patients <1 year from diagnosis did not differ. While type of insurance (public vs. private) did not impact burden, rural patients reported 15.0 (95% CI 6.8-23.2, p<0.001) points higher financial burden than urban patients. Conclusions: A high number of unexpected hospitalizations and rural residence were associated with greater financial burden for families of childhood cancer patients. Efforts to reduce unexpected admissions by managing side effects in outpatient visits, utilizing home health nurses and collaborating with local primary care physicians for remote patients could help ease the financial burden.

A comparison of central lines in pediatric oncology patients: Early removal and patient centered outcomes

BACKGROUND

While there is increasing evidence supporting the choice of subcutaneous ports (SPs) over external venous catheters (EVCs) in pediatric oncology patients, prior conflicting studies exist and little data have been gathered as to which type of central line is preferred from the patient/family perspective.

PROCEDURE

We performed a single institution, 10 years, retrospective analysis of central lines in pediatric oncology patients (n = 878) to evaluate unplanned early removal and cause of removal while simultaneously obtaining a cross sectional survey of 143 of the primary caretakers/parents of these patients to evaluate their overall satisfaction with the line.

RESULTS

EVCs have significantly higher odds of unplanned early removal in comparison to SPs (6.7% of SPs vs. 27.3% of EVCs, odds ratio (OR) = 6.3, P < 0.0001 when controlling for age and diagnosis) secondary to increased infection, malfunction and patient preference. Patients with SPs felt like their central line was easier to care for, had less daily impact in their life, and were overall more satisfied with their central line compared to patients with EVCs, even when controlling for early removal (P < 0.0001 for all). SP patients were much more likely to state that they would choose the same type of line again (OR = 15, P < 0.0001) than EVC patients.

CONCLUSION

SPs demonstrated lower removal rates and greater patient satisfaction than EVCs. These data should be considered when choosing a central line for pediatric cancer patients.

Endoscopy in the diagnosis of intestinal graft-versus-host disease: is lower endoscopy with biopsy as effective in diagnosis as upper endoscopy combined with lower endoscopy?

BACKGROUND

Graft-versus-host disease (GvHD) causes morbidity and mortality in recipients of hematopoietic stem cell transplantation (SCT). This study assessed the distribution of GvHD in gastrointestinal (GI) biopsies from the upper and lower GI tract in pediatric patients who had undergone SCT and evaluated if there was correlation between biopsy findings and possible extra-intestinal manifestations of GvHD.

PROCEDURE

We performed a retrospective chart review for all patients diagnosed with GvHD, who underwent both upper and lower endoscopy. We also reviewed pathology and clinical reports to determine which biopsy sites were diagnostic of GvHD and to evaluate for the possible presence of extra-intestinal manifestations GvHD at the time of biopsy.

RESULTS

Twenty patients were identified who had undergone both upper and lower endoscopy for evaluation of GvHD. Patients with GvHD diagnosed on upper endoscopy also had GvHD identified in the sigmoid colon region 100% of the time (positive predictive value [PPV] = 1). In patients that were found to have underlying liver disease, GvHD was diagnosed in the sigmoid colon region 90% of the time (PPV = 0.9).

CONCLUSION

Use of sigmoid biopsy for GvHD diagnosis is effective, safe, and less expensive compared to other endoscopic interventions.

Macrophage activation syndrome in children with systemic lupus erythematosus and children with juvenile idiopathic arthritis

OBJECTIVE

To describe patient demographics, interventions, and outcomes in hospitalized children with macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis (JIA).

METHODS

We performed a retrospective cohort study using data recorded in the Pediatric Health Information System (PHIS) database from October 1, 2006 to September 30, 2010. Participants had International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for MAS and either SLE or JIA. The primary outcome was hospital mortality (for the index admission). Secondary outcomes included intensive care unit (ICU) admission, critical care interventions, and medication use.

RESULTS

A total of 121 children at 28 children's hospitals met the inclusion criteria, including 19 children with SLE and 102 children with JIA. The index admission mortality rate was 7% (8 of 121 patients). ICU admission (33%), mechanical ventilation (26%), and inotrope/vasopressor therapy (26%) were common. Compared to children with JIA, those with SLE had a similar mortality rate (6% versus 11%, respectively; exact P = 0.6). More patients with SLE than those with JIA received ICU care (63% versus 27%; P = 0.002), received mechanical ventilation (53% versus 21%; P = 0.003), and had cardiovascular dysfunction (47% versus 23% received inotrope/vasopressor therapy; P = 0.02). Children with SLE and those with JIA received cyclosporine at similar rates, but more children with SLE received cyclophosphamide and mycophenolate mofetil, and more children with JIA received interleukin-1 antagonists.

CONCLUSION

Organ system dysfunction is common in children with rheumatic diseases complicated by MAS, and more organ system support is required in children with underlying SLE than in children with JIA. Current treatment of pediatric MAS varies based on the underlying rheumatic disease.

Congenital and childhood myeloproliferative disorders with eosinophilia responsive to imatinib

Eosinophilia is seen in several myeloproliferative disorders (MPD). A subset of MPD involves the platelet-derived growth factor receptor beta (PDGFRB) gene. Imatinib mesylate has been efficacious in treating some of these MPDs. Here we describe two patients with MPD with eosinophilia and PDGFRB rearrangements, one of which was congenital. Both patients were treated with single agent imatinib and continue to be in clinical, hematologic, and cytogenetic remission despite weaning doses. No definite guidelines currently exist regarding the exact dosing and duration of imatinib therapy for these patients.

Abstract A39: Health care barriers for rural and urban adult survivors of child and adolescent cancer

Introduction: By 30 years after diagnosis, 73% of child and adolescent cancer survivors develop at least one chronic health condition. However, there is little information on the health care needs of rural adults treated for child and adolescent cancer and whether they lack access to care to identify and manage chronic health problems. We explored health care barriers of rural and urban adult survivors of childhood and adolescent cancer.

Methods: We performed semi-structured interviews with 36 adult survivors (currently ages 19-56; mean=41.3 years) identified by Utah Cancer SEER Registry. Eligible survivors were diagnosed before age 21 from 1973-2005. We randomly selected participants from gender, age (18-29, 30-45, and 46-60), and rural/urban strata (rural defined as living in a county with less than 75% of population in an urban area [population ≥2,500]). Interviews were performed from April-June 2012. We asked survivors questions about their health insurance coverage, current use of health care, and barriers to accessing care, and whether they discussed their cancer history with their current provider. Interviews were recorded, transcribed, and analyzed for themes using NVivo 9. Themes were compared by urban and rural status.

Results: Half of participants were male and 90% (N=34) were white. The average age at diagnosis was 12.6 years (SD=6.7). The most common cancers were gonad/germ cell (N=8; 22%), leukemia (N=7; 19%), and lymphoma (N=6, 17%). A total of 15 survivors were rural and 21 urban. The majority of both urban and rural survivors were insured.

Common themes among both rural and urban survivors included: general satisfaction about the services covered by their health insurers, concern about increasing insurance costs, and a history of being denied insurance in the past due to their cancer. Most survivors had a primary health care provider; however, urban survivors described seeing specialty providers more often than rural survivors. About half of survivors discussed their cancer diagnosis and treatment with their current primary care provider. Barriers to discussing their cancer history with providers included a belief that their cancer was in the past so there was no need to discuss it with providers, an impression that their providers did not think their cancer history was worth discussing, and a belief that health problems would have already emerged because their cancer diagnosis and treatment occurred years ago.

Health care barriers described only by rural survivors included: difficulty finding quality health care for specific health problems, limitations in finding providers that were familiar with cancer survivors, and having to drive long distances to see providers. Interestingly, most rural survivors were willing to travel long distances to get the care they needed.

Conclusions: Survivors were generally satisfied with their health insurance, but were concerned about future coverage. Despite access to primary care providers, many survivors are unaware of their health risks and do not discuss their cancer history with their providers. Rural survivors lack access to providers who are knowledgeable about cancer and specialty care to screen for specific health conditions. Both rural and urban child and adolescent cancer survivors and their health care providers require education about the risk of late effects from childhood cancer.

Citation Format: Anne C. Kirchhoff, Echo L. Warner, Elyse R. Park, Roberto E. Montenegro, Jennifer Wright, Antoinette M. Stroup, Mark Fluchel, Anita Y. Kinney. Health care barriers for rural and urban adult survivors of child and adolescent cancer. [abstract]. In: Proceedings of the Fifth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2012 Oct 27-30; San Diego, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2012;21(10 Suppl):Abstract nr A39.

Limitations in health care access and utilization among long-term survivors of adolescent and young adult cancer

BACKGROUND

Health care outcomes for long-term survivors of adolescent and young adult (AYA) cancer were compared with young adults without a cancer history, using the 2009 Behavioral Risk Factor Surveillance System data.

METHODS

Eligible participants were 20 to 39 years of age. There were N = 979 who self-reported a cancer diagnosis between the ages of 15 to 34 years and were at least 5 years from diagnosis (excluding nonmelanoma skin cancer). The remaining 67,216 participants with no cancer history were used as controls. Using multivariable regressions, relative risks and 95% confidence intervals were generated to examine the relationship of survivor status on indicators of poor health care (uninsured, no personal health care provider, no routine care, and avoiding seeing a doctor due to cost). Adjusted proportions were calculated by demographic groups. Results are weighted by Behavioral Risk Factor Surveillance System survey design.

RESULTS

Although the proportion uninsured did not differ (21% of survivors vs 23% of controls), AYA survivors reported forgoing care due to cost at higher levels than controls (relative risk = 1.67, 95% CI = 1.44-1.94). Cost barriers were particularly high for survivors aged 20 to 29 years (44% vs 16% of controls; P < .001) and female survivors (35% vs 18% of controls; P < .001). Survivors reporting poorer health had more cost barriers. Moreover, uninsured survivors tended to report lower use of health care than did controls.

CONCLUSIONS

AYA cancer survivors may forgo health care due to cost barriers, potentially inhibiting the early detection of late effects. Expanding health insurance coverage for young cancer survivors may be insufficient without adequate strategies to reduce their medical cost burdens.

Natural killer cell lymphoma in a pediatric patient with inflammatory bowel disease

Tumor necrosis factor α (TNF-α) antibody agents are an effective therapy for the treatment of inflammatory bowel disease (IBD); however, because of the potential for immune suppression with these drugs, TNF-α antibody agents can increase the risk of malignancy. We report here the case of an 11-year-old boy who presented with bowel obstruction. He also had a history of periodic fever, aphthous stomatitis, and cervical adenitis (PFAPA). Intestinal inflammation continued and impaired his quality of life; he was diagnosed with IBD of an undetermined type (IBD-U). Symptoms improved with infliximab, but he developed elevated transaminase levels with hepatosplenomegaly 1 year after scheduled infusions. Skin biopsy revealed an atypical lymphoid infiltrate consistent with an Epstein-Barr virus (EBV)-positive natural killer (NK)/T-cell lymphoma with associated hemophagocytic lymphohistiocytosis. Bone marrow biopsy revealed a similar EBV-positive lymphoid infiltrate consistent with an NK/T-cell lymphoma. EBV-positive tissue was present in gastrointestinal biopsies. Flow-cytometric analysis revealed an atypical, clonal NK-cell population, and biopsy specimens from several tissue sites tested positive for CD3, CD56, and CD30. The patient died soon after the diagnosis was made. This patient developed an EBV-driven malignancy while receiving infliximab. All patients with IBD who receive infliximab should be monitored for malignancy, especially young patients. This case underscores the need for future studies to better understand the biology of lymphoproliferative disorders.

Self and proxy-reported health status and health-related quality of life in survivors of childhood cancer in Uruguay

BACKGROUND

The incidence of cancer in children in Uruguay is similar to that in industrialized societies but the survival rate is half as great. This study assesses another important measure of treatment effectiveness: the health-related quality of life (HRQL) of survivors.

METHODS

All new patients diagnosed in a 3-year period were eligible if free of disease for at least 2 years after therapy and at least 7 years of age at the time of study. A sample of convenient subjects for comparison was obtained from schools and clinics for well children. During a 7-month period, Spanish language interviewer-administered questionnaires were used to collect Health Utilities Index data from survivors and the comparison group (self-reports), and from proxies (parents, physicians, and teachers).

RESULTS

Of 113 eligible survivors, 95 (84%) participated together with 96 "control" subjects. Control subjects have a higher mean HRQL utility score than survivors (P < 0.001). The mean score for survivors of acute lymphoblastic leukemia (ALL): 0.72 (n = 49) is higher than the score for survivors of brain tumors: 0.60 (n = 20), as expected. Inter-rater agreement is highest between survivors and parents, and lowest between controls and physicians or teachers.

CONCLUSIONS

The burden of morbidity in survivors of childhood cancer in Uruguay is considerable and greater than that in a comparative group of healthy children. Survivors of ALL have better HRQL than survivors of brain tumors, mirroring experience elsewhere. The level of inter-rater agreement is related to the degree of familiarity of the pair-members of respondents with each other.

Childhood cancer in Uruguay: 1992-1994. Incidence and mortality

BACKGROUND

The referral of all children with cancer in Uruguay to a single center affords the opportunity to generate population-based incidence and mortality rates in this developing country in Latin America.

PROCEDURE

All incident cases of cancer in children, 0-14 years of age, were ascertained from a combination of three sources for the period January 1992-December 1994. Diagnoses were grouped according to the International Classification of Childhood Cancer. Information on the size and age distribution of the total population was obtained from national census records. Follow-up was undertaken until December 1999 to afford a minimum interval of 5 years and the determination of mortality rates.

RESULTS

The average annual incidence was 133.6 cases of cancer per million children per year and the disease distribution was similar to that in industrialized countries, with the exception of a higher rate and younger age distribution for the Hodgkin disease. The overall age-standardized mortality rate from cancer in childhood, at 6.5 per 100,000, was approximately twice that in the United States and Canada.

CONCLUSIONS

Basic indicators of development suggest that Uruguay is more akin to the countries of North America and Western Europe than to those in the developing world. An opportunity has been identified to improve the outcome for children with cancer in this country.