Cancer in Adolescents Cancer in Adolescents and Young Adultsand Young Adults

An International PerspectiveAn International Perspective

Ronald D. Barr MB ChB, MDProfessor of Pediatrics, Pathology and Medicine

McMaster UniversityHamilton, Ontario Canada

2010 Texas AYA Oncology Conference

Brunfelsia pauciflora

WHO ARE AYA WITH CANCER?

• Adolescents – 15 to 19 years of age• Young adults – 20 to ?

• SEER: 29• NCI/LAF/PRG: 39• Eurocare: 24

* Major resource implications

INCIDENCE OF CANCER(per million per year)

Age (years) Rate(0 – 14)15 – 1920 – 2425 – 29(40 – 44)

1502003505502,000

Communication from Charles StillerCancer Research Group

Oxford, UKDecember 2006

• Estimates from IARC database• GLOBOCAN 2002: worldwide• Annual incidence –• 15-29 years old: more than 350,000 cases• 30-39 years old: more than 650,000 cases

Challenge of AYA Oncology

Of more than 1 million new cases per year

• Many are never diagnosed• Most receive inadequate therapy

Mortality

After homicides, suicides and unintentional injury (accidents) CANCER IS THE COMMONEST

CAUSE OF DEATH IN THE 15-39 YEAR AGE GROUP IN

INDUSTRIALISED SOCIETIES

1.431.53

1.63

0.90

0.59

0.03 -0.18

0.23

0.53

1.04

1.26

1.43

1.61

1.87

1.99

1.83

1.59

1.14

0

0.5

1.0

1.5

2.0

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Change in 5-Year Relative Survival Rate of All Invasive Cancer, SEER, 1975-1997

Age at Diagnosis (Years)

Ave

rage

Ann

ual %

Cha

nge

Non-Hodgkin Lymphoma7%

HodgkinLymphoma12%

Melanoma11%

FemaleGenital10%

Testis Cancer11%Thyroid

Carcinoma10%

CNS Neoplasms6%

Soft-Tissue Sarcomas8%

Bone Tumors3%

Non-Gonadal Germ Cell Tumors 2%

Other2%

Other Carcinomas6%

Breast Cancer5%

Leukemia6%

AYA Cancers are Unique in Type and Biology

Age 15-29 Years

AAPC – Two Disease ClustersHigh survival rates: Hodgkin lymphoma, testicular tumors, thyroid cancer and melanoma• More than 40% of incident cases aged 15 – 29 years• Range of 5 year survival rates is 90 – 99%

Lower survival rates: all other diseases• Less than 60% of incident cases aged 15 – 29 years• Range of 5 year survival rates is 40 – 75%

Survival of European children and young adults with cancer diagnosed 1995-2002

Gatta G et al. Eur J Cancer 2009; 45: 992-1005

Overall 5 year survival in 23 countries for those age 15-24 years at diagnosis: 87 percent

Study sample: more than 30,000 BUT incident cases 20,000 per year

Regional variation: highest in North, lowest in East

Improvement in 5-Year Relative Survival, CanadaOntario, Canada - Courtesy of Loraine Marrett

Age at Diagnosis (Years)0 15 30 50 65 80

Are disparities in 5 year survival rates and AAPC reflections of

differences in health care systems?

Personal communicationMarch 11, 2010Barack Obama

Age at Diagnosis (Years)

Ave

rage

Ann

ual %

Cha

nge

0

1

2

0 10 20 25 30 35 40 50 60 70 805 15 90

Australia UnitedStates

Improvement in Relative Survival by Age at Diagnosis of Invasive Cancer, 1982-1997

Prepared by A. Bleyer from data provided by the Australia Institute of Health and Welfare and from U.S. SEER9

50%

60%

70%

80%

90%

0 5 10 15 20 25 30 35 40 50 60 70

Australia

Age at Diagnosis (Years)

RelativeRelative Survival, All Invasive CancerSurvival, All Invasive CancerAustralia vs. United States, 1992-1997Australia vs. United States, 1992-1997

5-Year Survival

80

5%

8%12%

8%5%

U.S.

Australia data provided by:

Chris Stevenson, AIHW

AAPC – THE INTERNATIONAL PICTUREAAPC – THE INTERNATIONAL PICTURE

Australia – David RoderCanada – Loraine MarrettEurope – Gemma GattaUnited Kingdom – Jill BirchUnited States – Archie Bleyer

Locus of Care

Determines access to age and disease appropriate

• Health care system and providers

• Infrastructure, such as physical facilities

• Treatment including clinical trials

Why does it matter?

• In Canada and the USA only 30-40% of adolescents are treated in pediatric cancer centres

• Survival advantage in some instances• Pediatric v. adult protocols e.g. A.L.L (USA, France, Italy,

the Netherlands, Denmark, UK) and soft tissue sarcomas (INT, Italy)

• Pediatric v. adult centres e.g. Ewing sarcoma (Germany)

OBSERVED CASES IN THE AIEOP CENTERS versus EXPECTED NUMBER OF CASES IN ITALY (from population-based childhood cancer registries in Italy)

A.Ferrari, A.Pession, M.Aricò,R.Rondelli, and G.Pastore

patients 0-14 years patients 15-19 years

all childhood cancers

82% 10%

LLA

98% 23%

HD

89% 9%

NHL

80% 14%

patients 0-14 years patients 15-19 years

CNS tumors

66% 14%

NBL91% 43%

renal tumors

85% 15%

bone sarcomas

93%OS 28%EW 43%

OBSERVED CASES IN THE AIEOP CENTERS versus EXPECTED NUMBER OF CASES IN ITALY

soft tissue sarcomas

RMS 97%NRSTS 74%

RMS 33%NRSTS 39%

ependymoma 35%PNET 41%

germ-cell 53%

carcinomas 1%

Age (Years)

Number of

Patientswith

Cancerin theU.S.A.

On Cooperative Group Trial

60%

2%

33% 29%

11%6%

60%

40%

50%10%

0-4 5-9 10-14 15-19

Not at NCI-Sponsored Cooperative Group Institution

At Cooperative Group Institution

20-30

The Adolescent-Young Adult

Gap in Cancer

Clinical Trials79%

92%

21%

Clinical Trial Accrual in the U.S.

0

2001-2003

Patient Age (Years)

No.

Acc

rual

s

2004-2006 decreasing

05 10 15 20 25 30 35 40 45 50 55

2,000

4,000

6,000

8,000

10,000

10 15 20 25 30

2004-2006 increasing

Courtesy of A. Bleyer. MD

No. Accruals

0-14 15-29 30-44 45-59 60-74Age (Years)

0

5,000

10,000

15,000

20,000

25,000

30,000

2000-2 2003-5

Change from 2000-2 to 2003-5

42%

-3% -4%

-40%

0%

40%

-28%-50%

9,767

3,687

7,506

28,369 28,015

7,0175,219

3,749

27,487 26,962

U.S. Cancer Patients Entered onto National Treatment Trials 2003-5 vs. 2000-2

5 10 15 20 25 30 35 40

Ave.

Ann

. Cha

nge,

5-Y

r Sur

viva

l

0%

0.5%

1.0%

1.5%

0

0%

1%

2%

1% 10%

p = .0003

Accrual Proportion (log))

Ave.

Ann

. Cha

nge,

5y

Surv

.

Age (Years)

Accr

ual P

ropo

rtion

0%

10%

20%

30%

Survival improvement is correlated with clinical trial participation

AIEOP Experience of Adolescents

• From 1989-2006 the O/E ratio was 0.10 (1.745/16,711); rising from 0.05 to 0.18

• Higher for sarcomas (bone and soft tissue) – of almost 0.50 in recent years – and lowest for gonadal tumours and carcinomas (<0.05)

• Overall enrollment on AIEOP clinical trials: 53% of children and 5.5 % of 15-19 years olds

• Enrollment on AIEOP clinical trials in AIEOP centres: 69% of children and 55% of adolescents

AYA CommitteeNCI Progress Review Group

1. Identify the characteristics that distinguish the unique cancer burden in the AYAO patient

2. Provide education, training, and communication to improve awareness, prevention, access, and quality cancer care for AYAs

3. Create the tools to study the AYA cancer problem

4. Ensure excellence in service delivery across the cancer control continuum (from prevention to end of life)

5. Strengthen and promote advocacy and support of the AYA cancer patient

Canadian National Task ForceAdolescent and Young Adult Oncology

A Conjunction of C17 and CPAC

Co-Chairs: R Barr, P Rogers, B SchacterInternational Workshop,

Toronto, March 11-13, 2010

Themes from the Workshop

Publication as a supplement to Cancer

• Awareness and advocacy• Active therapy and supportive care• Palliation and symptom management• Psychosocial needs• Survivorship• RESEARCH AND METRICS

The Adolescence of Young Adult Oncology

Albritton K, Barr R, Bleyer A.Semin Oncol 2009; 36: 478-488

• Definition of the AYA patient• Clinical trials• Health Services delivery• Oncofertility• Training• Developmental theory and psychosocial impact of cancer• Peer support and advocacy