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Surveillance and screening for new neoplasms in adult survivors of childhood cancer

Surveillance and screening for new neoplasms in adult survivors of childhood cancer A report from the Childhood Cancer Survivor Study (CCSS). Paul Nathan MD, MSc The Hospital for Sick Children Toronto, Canada. Background The childhood cancer survivor population.

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Surveillance and screening for new neoplasms in adult survivors of childhood cancer

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  1. Surveillance and screening for new neoplasms in adult survivors of childhood cancer A report from the Childhood Cancer Survivor Study (CCSS) Paul Nathan MD, MSc The Hospital for Sick Children Toronto, Canada

  2. BackgroundThe childhood cancer survivor population • 5-year cancer survival in children ~80% • Over 325,000 childhood cancer survivors alive in United States • Over 40% of survivors will develop a severe or life threatening late effect of therapy

  3. Second malignant neoplasms (SMN) in childhood cancer survivors SMN in the CCSS cohort • 30-year cumulative incidence of SMN = 9.3% • 30-year cumulative incidence of non-melanoma skin cancer = 6.9% • Leading cause of death in 20+ year survivors • Standardized incidence ratio = 9.0 • Standardized mortality ratio = 15.2 Meadows et al. JCO, 2009; Mertens et al. JNCI, 2008

  4. Study Aims • To assess adherence to published cancer surveillance guidelines by survivors at high risk for breast, colorectal or skin cancer as a result of their therapy • To compare non-high risk survivors’ adherence to national screening guidelines for breast, colorectal and cervical cancer with the general population

  5. Childhood Cancer Survivor Study • Retrospective cohort study • 26 centers: USA and Canada • Diagnosis 1970-1986 • < 21 years at diagnosis • Alive at 5 years • Selected malignancies

  6. Participating Centers Coordinating Center Contributing Institutions Resource Center

  7. Study participants

  8. Eligible n=20,602 Lost to Follow-up n=3,035 Contacted n=17,567 Declined Participation n=3,197 Participants in Baseline Survey n=14,370 Deceased Cases n=1,541 Participants in Follow-up 2000 n=10,388 Participants in Follow-up 2003 n=9,308 Exclusions n=990 Developed SMN (n=960) Race/ethnicity unknown (n=29) Other (n=1) Eligible for Current Analysis n=8,318

  9. Demographics of Study Population *Matched 1:1 by age, gender, race/ethnicity from 2003 National Health Interview Survey

  10. Cancer Diagnosis in 8,318 Survivors

  11. Specific Aim 1 Adherence to published cancer surveillance guidelines by survivors at high risk for breast, colorectal or skin cancer

  12. Risk Definitions and Recommended Surveillance

  13. Compliance with Recommended Surveillance Tests

  14. Predictors of Adherence Multivariable Logistic Regression Models • Covariates • Sex • Race/ethnicity • Age at diagnosis and interview • Employment, education, insurance • Chronic disease, mental health, physical impairment, concern about future health • Survivor or doctor has cancer treatment summary • Medical care in last 2 years, care at a cancer center

  15. Significant Predictors of Adherence Multivariable Logistic Regression Models • Colonoscopy • Older age at interview RR=1.08 (1.00-1.17) • Mammogram • Older age at interview RR=1.09 (1.04-1.13) • Care at cancer center RR=1.70 (1.04-2.76) • Skin exam • Non-white RR=0.63 (0.42-0.95) • Care at cancer center RR=1.55 (1.22-1.96) • Survivor has treatment summary RR=1.30 (1.07-1.58)

  16. Specific Aim 2 Comparison of “non-high risk” survivors vs. general population on adherence to national screening guidelines for breast, colorectal and cervical cancer

  17. US Preventive Services Task Force Cancer Screening Recommendations • Breast • Screening mammography every 1-2 years for women aged 40 and older • Colorectal • Colonoscopy at intervals of 10 years between ages of 50-75 years* • Cervix • Pap smear beginning within 3 years of onset of sexual activity or age 21 (whichever comes first) and screening at least every 3 years * OR annual fecal occult blood testing OR sigmoidoscopy every 5 years combined with fecal occult blood testing every 3 years

  18. US Preventive Services Task Force Cancer Screening Recommendations Compliance with screening Survivor Gen. Pop. Survivor Gen. Pop. Survivor Gen. Pop.

  19. Significant Predictors of Adherence Multivariable Logistic Regression Models • Breast • None • Colon • Too few survivors over 50 years to analyse in detail • Emerging evidence of increased GI malignancies in survivor cohort • Cervix • Only being “married or living as married” predicted PAP smear compliance (RR 1.17, 1.03-1.34)

  20. Conclusions (1) Adherence to Guidelines for Cancer Survivors • Rates of colonoscopy, mammography and skin exams in high-risk patients are very low. • Care at a cancer center modestly increases surveillance for breast and skin cancer. • Patients and their physicians need to be educated about recommended surveillance.

  21. Conclusions (2) Adherence to National Screening Guidelines Survivors • Cancer survivors are more likely to undergo mammograms and PAP smears than general population. • BUT: Compliance rates are very low for colonoscopy and only moderate for mammography. • Health care providers must take opportunity to promote early cancer detection strategies in survivors.

  22. Study Considerations Self-report data CCSS cohort is a select group – study may overestimate care received Cohort 1970-1986 Did not assess all screening/surveillance modalities (e.g. breast MRI, fecal occult blood)

  23. Co-Investigators • Kevin Oeffinger, Memorial Sloan-Kettering Cancer Center • Kirsten Ness, St. Jude Children’s Research Hospital • Martin Mahoney, Roswell Park Cancer Institute • Zhenghong Li, St. Jude Children’s Research Hospital • Melissa Hudson, St. Jude Children’s Research Hospital • Jennifer Ford, Memorial Sloan-Kettering Cancer Center • Wendy Landier, City of Hope • Greg Armstrong, St. Jude Children’s Research Hospital • Tara Henderson, University of Chicago • Leslie Robison, St. Jude Children’s Research Hospital

  24. CCSS Institutions • University of Minnesota • Denver Children’s Hospital • Children’s Hospital of Pittsburgh • Stanford University • Dana-Farber Cancer Institute • Children’s National Medical Center • M.D. Anderson Cancer Center • Memorial Sloan-Kettering Cancer Center • Texas Children’s Hospital • University of California, San Francisco • Seattle Children’s Hospital • Toronto Hospital for Sick Children • Children’s Medical Center of Dallas • Children’s Hospital of Columbus • Emory University • St. Jude Children’s Research Hospital • Roswell Park Cancer Center • Mayo Clinic • Children’s Health Care Minneapolis • Children’s Hospital of Philadelphia • St. Louis Children’s Hospital • Children’s Hospital of Los Angeles • UCLA Medical Center • Miller Children’s Hospital Long Beach • Children’s Hospital of Orange County • Riley Hospital for Children – Indiana Univ. • UAB/Children’s Hospital of Alabama • University of Michigan – Mott Children’s • Fred Hutchinson Cancer Research Center

  25. A Resource for Research • The Childhood Cancer Survivor Study is an NCI-funded resource to promote and facilitate research among long-term survivors of cancer diagnosed during childhood and adolescence. • Investigators interested in potential uses of this resource are encouraged to visit: • www.stjude.org/ccss

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