Canadian patterns of practice for intracranial germ cell tumors in adolescents and young adults.

INTRODUCTION: The study objectives were to describe patterns of practice for intracranial germ cell tumors (IGCT) in adolescents and young adults (AYA) and to determine factors associated with practice patterns. METHODS: A survey was written containing questions on the management of two 17-year old males, one with localized pineal germinoma and the other with localized pineal non-germinomatous germ cell tumor (NGGCT). An invitation to participate anonymously in the survey was e-mailed to 119 oncologists who treat brain tumors across Canada. RESULTS: Seventy-two (61%) of the 119 oncologists participated in the study. For the germinoma case, the most common treatment approaches were whole ventricular radiotherapy (WVRT) and chemotherapy (CH) (56%), WVRT alone (15%), and craniospinal radiotherapy (CSRT) alone (10%); for physicians recommending WVRT + CH, most frequently selected whole ventricular doses were 24 Gy (57%) and 18 Gy (20%). Chemotherapy was included in the treatment of germinoma by 96% of pediatric physicians vs. 54% of adult physicians (P = 0.001). The most common treatment approaches for NGGCT were CSRT + CH (44%), WVRT + CH (21%), and pineal gland RT + CH (15%). The selection of craniospinal vs. smaller-volume RT was not associated with the physicians' specialty, percentage of practice treating brain tumors, number of IGCTs seen, or size of institution. CONCLUSIONS: There is wide variation in the management of IGCT in AYA across Canada. A 17-year old male with a localized pineal germinoma is highly likely to receive chemotherapy if managed by a pediatric oncologist, while the same patient is much less likely to receive chemotherapy if managed by an adult oncologist.

Colorectal Polyps in Childhood Cancer Survivors Treated with Radiation Therapy.

BACKGROUND: Cancer survivors treated with abdominal or pelvic radiation therapy (RT) for childhood cancer have an increased risk of colorectal cancer. However, clinical guidelines are inconsistent on recommendations regarding the early initiation of screening in these patients due to the lack of supporting evidence that these patients pass through a pre-invasive phase, in which adenomatous polyps can be detected and removed. AIMS: To determine the prevalence of adenomatous polyps in cancer survivors treated with RT for childhood cancer; the prevalence in average-risk patients aged 17-49; and the prevalence in average-risk patients aged 50-75. METHODS: We conducted a retrospective study comparing the prevalence of adenomatous polyps among three patient groups: childhood cancer survivors aged 17-49 with prior RT who underwent colonoscopy screening from 2006 to 2017; age- and gender-matched patients in the average-risk population; and average-risk patients aged 50-75. RESULTS: One hundred and forty-five patients were included in the study. The proportion of patients with adenomatous polyps in the cancer survivor group was significantly higher than that in the age- and gender-matched average-risk group (58.6 vs 17.2%, p = 0.00) and higher than the average-risk group aged 50-75 (58.6 vs 27.6%, p = 0.009). The prevalence of adenomas with high-risk features was higher in the survivor group compared to patients aged 50-75 (20.7 vs 3.5%, p = 0.015). CONCLUSIONS: Cancer survivors treated with RT for childhood cancer have a higher prevalence of adenomatous polyps compared to the average-risk population. These findings support the early initiation of colonoscopy screening 10 years after radiation therapy, even in patients who have received RT doses below 30 Gy.

Follow-up patterns of cancer survivors: a survey of Canadian radiation oncologists.

PURPOSE: With continual advancements in cancer care, improved outcomes, and increasing survivors, survivorship has become an important area of research. This project seeks to determine the current status of follow-up care in oncology. METHODS: An electronic survey was sent to the Canadian Association of Radiation Oncology members. Based on brief clinical scenarios pertaining to various survivor populations, questions were posed to determine routine follow-up practices. RESULTS: One hundred eleven radiation oncologists (RO) responded (44% response rate); 29% were female, 43% were in practice <10 years, and most of Canada was represented. Most worked in centers with >10 oncologists (69%) and saw >200 new consults per year (78%). Only 10% reported not following their patients routinely, mainly in those with breast cancer. Most would follow their central nervous system, gastrointestinal, head and neck, gynecologic, and genitourinary patients. Lack of resources and a belief that follow-up by family physicians (FPs) is equally effective were the top reasons for not following. Treatment toxicity and possibility of further treatment were the most common reasons for routine follow-up. The majority (55%) would follow patients for <5 years, with 36% for 5-10 years, and a minority (9%) for longer than 10 years; 54% would not change the frequency of follow-up, but 39% would decrease and only 7% would increase follow-up. Some felt transferring more care to other health professionals would require additional training and more guidelines. Survivorship care plans are underutilized. CONCLUSIONS: Transfer of follow-up care to FPs is desired and feasible. This would allow for more comprehensive medical care and improve access to care for newly diagnosed patients. The development and usage of survivorship care plans would improve this care. IMPLICATIONS FOR CANCER SURVIVORS: Survivors may be increasingly followed by family physicians. Better coordination between oncologists and family physicians, including the use of survivorship care plans, may facilitate this transition.

Oncologists' view of informed consent and shared decision making in paediatric radiation oncology.

BACKGROUND AND PURPOSE: Cure rates of paediatric malignancies have dramatically improved with therapy intensification, at the cost of late treatment side effects. A survey was developed, centred around medulloblastoma scenarios, in order to explore paediatric oncology physicians' views on discussing late effects and involving parents in treatment decisions. MATERIALS AND METHODS: Participants were 59 paediatric radiation and medical oncologists or fellows from USA (22), Canada (18), Europe (16), Australia (2), and Asia (1). RESULTS: Ninety-five percent of respondents indicated late effects discussion prior to multimodality treatment was important. Of those who supported it, 100%, 83%, 64%, and 48% thought discussing cognitive impairment, infertility, stroke, and seizures as potential late effects was important, respectively. Only 71% of respondents believed parents should be involved in treatment decisions, which did not significantly vary by respondent age, country, specialty, gender, or years in practice. CONCLUSIONS: The majority of oncologists who treat children believe discussing late effects with parents is important. However, there is mixed opinion on which late effects should be discussed and whether parents should be involved in deciding which treatments should be pursued. Research into perceived barriers to shared decision making and effective methods of improving the informed consent process in paediatric malignancies is needed.

Educational outcomes among survivors of childhood cancer in British Columbia, Canada: report of the Childhood/Adolescent/Young Adult Cancer Survivors (CAYACS) Program.

BACKGROUND: Increased survival of patients with childhood cancer has resulted in a growing population of survivors within the education system, many of whom may experience educational difficulties. The current study provides a comprehensive assessment of survivors' educational achievements. METHODS: Seven hundred eighty-two childhood cancer survivors from the British Columbia (BC) Cancer Registry who attended BC schools from 1995 to 2004, were compared with a randomly selected comparison group of 8386 BC school children. Grade repetition, standard Foundation Skills Assessments (FSA), graduation-year examinations, and special education designations were compared, and factors that affected survivors' educational outcomes were identified. RESULTS: Survivors of central nervous system tumors had statistically significant FSA deficits in numeracy and reading (adjusted odds ratios from 0.2 to 0.5 in various grades); leukemia survivors also had lower FSA scores, although most differences were not statistically significant. Other survivors demonstrated no significant differences in FSA scores. Survivors were significantly more likely than controls to receive special education (32.5% vs 14.1%). Females and those who had received radiation treatment (particularly cranial radiation) were at increased risk for poor educational outcomes. CONCLUSIONS: The current results have implications for the management of survivors in the education system to maximize their educational experience.

Mortality among 5-year survivors of cancer diagnosed during childhood or adolescence in British Columbia, Canada.

BACKGROUND: Ongoing monitoring of late mortality among survivors of a childhood or adolescent cancer is essential to appropriately evaluate risk in more recent cohorts and with longer follow-up. We examined overall and cause-specific mortality in a population-based cohort of 2,354 individuals diagnosed with a cancer or tumor prior to 20 years of age between 1970 and 1995 in British Columbia (BC), Canada who survived at least 5 years. PROCEDURE: Late deaths in a survivor cohort ascertained from the BC Cancer Registry were identified using death registrations. Standardized mortality ratios, absolute excess risk of death, and cumulative risk of death were determined. Demographic, temporal, and disease-related factors in risk of late mortality were also assessed. RESULTS: After 24,491 person-years of follow-up, there were 181 deaths, 139 of which were cancer related. Excess risk of late mortality among survivors was 7 deaths per 1,000 person-years at risk (AER = 6.6). Standardized mortality ratio (SMR) was ninefold higher relative to the underlying BC population (SMR = 9.1, 95% CI, 7.8-10.5), and was greatest for those with a recurrence within 5 years of diagnosis, and for those diagnosed with acute lymphoblastic leukemia and nervous system tumors. Absolute excess risk of late death was significantly higher for males and for those diagnosed prior to 1980, but did not vary according to age at diagnosis. Relative mortality was significantly increased due to cancer-related causes of death (SMR = 81.7, 95% CI, 68.6-95.8), as well as circulatory (SMR = 9.7, 95% CI, 4.2-19.1) and respiratory (SMR = 16.8, 95% CI, 4.6-43.0) diseases. CONCLUSIONS: In this population-based cohort with long follow-up, there continues to be excess late mortality among childhood and adolescent cancer survivors due to both cancer and non-cancer causes, even among more recently diagnosed survivors.

Risk of a second malignant neoplasm among 5-year survivors of cancer in childhood and adolescence in British Columbia, Canada.

BACKGROUND: We examined second malignancies, a recognized late effect of therapy among survivors of childhood and adolescent cancer, among a recent, population-based cohort of 2,322 5-year survivors diagnosed before 20 years of age in British Columbia (BC), Canada between 1970 and 1995. PROCEDURE: Survivors and second malignancies were identified from the BC Cancer Registry. Risk of second malignancy was evaluated using standardized incidence ratios (SIRs), absolute excess risk (AER), and cumulative risk. The effect of demographic, temporal, and disease-related characteristics on risk was assessed. RESULTS: Fifty-five second malignancies were observed after 26,071 person-years of follow-up. Relative rate of developing a second malignancy among survivors was 5 times higher than expected (SIR = 5.0, 95% CI, 3.8-6.5), and absolute excess risk was 1.7 deaths per 1,000 person-years. Cumulative incidence of a second malignancy was 5.1% at 25 years after diagnosis of the first cancer. SIRs and absolute excess risk of subsequent cancer was higher among females (SIR = 5.9, 95% CI, 4.5-8.3 and AER = 2.66). While relative risk of second cancer was higher for those diagnosed before 10 years of age (SIR = 10.6, 95% CI, 7.1-16.0), absolute excess risk was slightly higher for those diagnosed after 10 years of age. SIRs were significantly elevated for all follow-up periods, but absolute excess risk of a second cancer was highest among patients surviving more than 15 years. CONCLUSIONS: Increased risk of a subsequent neoplasm is evident among childhood cancer survivors diagnosed in more recent periods than has been previously reported, continues years after diagnosis, and varies according to several risk factors. Continued surveillance is essential to quantify and characterize long-term and changing risks for appropriate follow-up.