Page 15 - Delaware Medical Journal - November/December 2020
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ORIGINAL RESEARCH
TABLE 1-1: NUMBER OF ALL-SITE CANCER CASES, BY SEX AND RACE/ETHNICITY; DELAWARE AND COUNTIES, 2011-2015
All Races
Non-Hispanic Caucasian
Non-Hispanic African American
Hispanic
All
Male
Female
All
Male
Female
All
Male
Female
All
Male
Female
Delaware
1,114
395
719
730
274
456
237
62
175
97
47
50
Kent
242
82
160
164
58
106
58
--
44
15
--
--
New Castle
689
242
447
438
163
275
154
39
115
62
29
33
Sussex
182
70
112
127
52
75
25
--
16
20
--
--
Source: Delaware Department of Social Services, Division of Public Health, Delaware Cancer Registry, 2018.
central nervous system (CNS) tumors,
and lymphomas. Traditionally, AYA patients 18 years of age and older are treated on adult regimens.4 With regard
to acute lymphoblastic leukemia (ALL), adult regimens typically consist of myelosuppressive agents, resulting in a year event-free survival (EFS) is 30% to 45% for AYA patients.5 On the other hand, pediatric regimens focus on the Berlin- Frankfurt-Munster backbone of ALL therapy, with a prolonged maintenance therapy.5 Patients fare better on this pediatric patients is ~90%.5 Retrospective studies from North American and European groups suggest that AYAs have superior outcomes when treated with approaching over 70%.4 Despite these improved outcomes, AYAs should still be recognized as a distinct subset of patients, as the biology of the leukemia often has more high-risk features compared to pediatric patients. Therefore, while they may fare better on the pediatric regimen, efforts need to continuously be made
approaches.
Similarly, data from national cancer registries suggest that AYAs with acute myeloid leukemia (AML) have superior overall survival compared to their older counterparts, but inferior survival compared to children.4,6 Thus, one may presume that AYAs should be treated on pediatric regimens. However, most
pediatric protocols consist of intensive chemotherapy and include greater anthracycline exposure than the adult regimens, along with the use of multi- agent consolidation. While AYAs have been noted to have decreased incidence
of relapse when treated on pediatric
AML protocols, this intensive treatment regimen contributes to treatment-related mortality. Furthermore, it is important
to note that the biology of AML changes with age, therefore further underscoring the biologic differences in this patient population.6 Better understanding of these age-related variations may contribute to improved outcomes in the future. Overall, AYAs may have improved outcomes
when treated with a mix of elements from pediatric and adult regimens.6 Once again, the AYA population cannot simply be lumped into the pediatric or adult groups;
such that regimens target their unique characteristics.
CNS Tumors and Lymphoma
CNS tumors and lymphomas in the AYA population are also associated with poorer outcomes compared to children. With regard to CNS tumors, patients require complex, evidence-based care to achieve the best outcomes. A study done by Wolfson et al. compared outcomes between children and AYAs with CNS tumors from 1998 to 2008.7 The authors found that care at an NCI-Designated Cancer Center (NCICCC)/Children’s Oncology Group (COG) site improved outcomes in AYAs with World Health
Organization (WHO) grade II CNS tumors compared to children.7 This
is in part due to the multidisciplinary coordination of care present at NCICCC/ COG sites.7 Overall, the survival trends
of AYA patients with lymphoma lag behind their pediatric counterparts. In a study done by Henderson et al. in 2017, outcomes of AYA patients with Hodgkin lymphoma were analyzed when treated on a pediatric versus an adult protocol. The free survival rate was 85% when treated on a pediatric regimen, compared to 68% when treated on an adult regimen.8
Barriers to AYA Care
providers has been noted to be a 9 This underscores the need for health care professionals to have knowledge about the disparities that AYAs face and the tools to provide well-rounded care to this vulnerable population. Furthermore, there is an overall lack of societal and government awareness of 9 Fardell et al. proposes recommendations for AYA models of care. These include access to treatment with AYA cancer experts who are knowledgeable about age-appropriate clinical trials, regular of AYA oncology, and educational lectures and training for hospital
staff to help build expertise on AYA oncology.9 Additional recommendations
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