ASCO 2009:兒童癌症倖存者—後來的生活...


  June 16, 2009 (佛州奧蘭多) — 根據發表於美國臨床腫瘤協會第45屆年會的研究結果,兒童癌症倖存者即便處於高風險,由於他們在童年時接受了放射線的顧慮,因此接受建議的癌症篩檢者很少。
  
  發表者表示,這篇與另一篇討論這些存活者的創傷後壓力異常(posttraumatic stress disorder,PTSD)比率增加的報告,是這群人容易發生的一項標記。
  
  主要作者、多倫多兒童醫院腫瘤科的Paul Nathan醫師在會議中的記者會表示,對於這些存活者來說,癌症篩檢與及早偵測特別重要。理由之一是,二度的惡性腫瘤是兒童癌症倖存者在20多年後成年時的最主要致死原因。
  
  Nathan醫師表示,有其他癌症高風險的成年存活者,他們因為在年輕時接受過放射線治療,乳房攝影、大腸鏡檢查與皮膚檢查的比率相當低。特別的是,高風險存活者之中,只有11.5%有適當的大腸鏡檢查(之前5年內有1次檢查),26.7%有過皮膚檢查,46.3%有適當的乳房攝影(之前2年內有1次檢查)。
  
  芝加哥西北大學老年醫學與經濟學名譽教授Charles Bennett博士形容這是個不及格的比率,Bennett博士在會議中討論此篇研究。
  
  新研究屬於國家癌症中心資助的綜合長期追蹤大型研究「Childhood Cancer Survivor Study (CCSS) 」的一部份。
  
  【非高風險存活者接受篩檢的情況稍微好一些】
  CCSS研究中回答有關篩檢調查的8,318名存活者有多數是高風險者。
  
  風險分類是根據童年時的放射線曝露程度。童年時腹部、脊椎或骨盆接受超過30 Gy者視為大腸直腸癌高風險,胸部接受超過20 Gy者視為乳癌高風險。童年時任何程度的放射線曝露都視為成年時皮膚癌的高風險。
  
  在CCSS研究中,前述類別之外者視為非高風險存活者。
  
  非高風險存活者接受建議篩檢的比率高於一般族群,乳房攝影分別為67%與58%、子宮頸抹片為82%與70%。兩組的大腸鏡檢查比率相同(約24%)。
  
  Nathan醫師表示,CCSS調查回覆對象平均年紀約為 31歲;他指出,這個世代是經過篩選的一組,因此篩檢比率可能低估了。
  
  【誰對這些存活者負責?】
  Nathan醫師指出,CCSS的篩檢分析產生其他令人失望的訊息。他表示,成年時在癌症中心接受照護僅適度增加了乳癌和皮膚癌的存活。
  
  參與討論的Bennett博士問道,誰應該注意這些兒童癌症倖存者—一般醫療醫師或腫瘤科醫師:「這是個新的問題。誰對這些存活者負責?」
  
  Bennett博士認為,一般醫療醫師和腫瘤科醫師兩者都需負責照護。不過,他也指出,兒童癌症倖存者是特別案例,因為他們可能轉診給新的醫師,而成年存活者一般不會轉診。
  
  【PTSD預測因子】
  同樣於會議中發表、來自CCSS資料的另一篇研究中,研究者發現,兒童癌症倖存者發生PTSD的機會是其兄弟姊妹的四倍多。
  
  主要作者、加州大學洛杉磯分校David Geffen醫學院精神科名譽教授Margaret Stuber醫師指出,不過,此發生率(9%) 其實並不高 。她在記者會中表示,好消息是,超過90%的兒童癌症倖存者沒有PTSD,即使他們經歷過相當難熬的時期。
  
  Stuber醫師認為,一般醫療醫師和腫瘤科醫師都應對存活者的PTSD風險有所警覺。她表示,應將評估PTSD納入兒童癌症倖存者的長期健康篩檢。
  
  Stuber醫師等人在CCSS對存活者(n= 6542人)與兄弟姊妹(n= 368人)的分析中,發現9%的存活者與2%的兄弟姊妹有PTSD。四歲前有診斷的倖存者以及那些頭部接受放射線治療者的PTSD風險增加。
  
  PTSD在那些接受密切治療如截肢、放射線或多種療法者中比較常見。
  
  就社會經濟層面來說,PTSD與未婚、大學以下學歷、年收入少於20,000美金、受雇工作有關。Stuber醫師表示,還不清楚是PTSD影響這些因素,還是這些因素造成發生PTSD。
  
  研究者宣告沒有相關財務關係。
  
  美國臨床腫瘤協會(ASCO)第45屆年會:摘要CRA6501 與CRA10002。發表於2009年6月1日。
  

ASCO 2009: Childhood Survivors of Cancer -- Life Later On . . .

By Nick Mulcahy
Medscape Medical News

June 16, 2009 (Orlando, Florida) — Low percentages of survivors of childhood cancer undergo recommended screening for cancers, even when they are at high risk because they received radiation during childhood, according to study results presented here at the American Society of Clinical Oncology 45th Annual Meeting.

This report and another on the increased rate of posttraumatic stress disorder (PTSD) in these survivors serve as a reminder of the vulnerabilities of this population, suggested meeting presenters.

Cancer screening and early detection are especially important in these survivors, Paul Nathan, MD, a staff oncologist at the Hospital for Sick Children in Toronto, Ontario, and the lead author of a new study of cancer screening in survivors, said at a press conference at the meeting. One reason for this is the fact that a second malignant neoplasm is the leading cause of death in adults who have survived childhood cancer for 20 years or more, he continued.

In adult survivors at high risk for another cancer because they received radiation treatment in their youth, the rates of mammography, colonoscopy, and skin exams are "very low," said Dr. Nathan.

Specifically, among high-risk survivors, only 11.5% had appropriate colonoscopy (1 procedure in the previous 5 years), only 26.7% had ever had a skin exam, and only 46.3% had appropriate mammography (1 within the previous 2 years).

"This is not a passing grade," said Charles Bennett, MD, PhD, the AC Buehler Professor of Geriatrics and Economics at Northwestern University in Chicago, Illinois, about the low rates. Dr. Bennett acted as a discussant of the study at the meeting.

The new study is part of the larger Childhood Cancer Survivor Study (CCSS), a comprehensive long-term follow-up study funded by the National Cancer Institute.

Nonhigh-Risk Survivors Fare Better in Receiving Screening

The majority of the 8318 survivors in the CCSS who answered a screening survey were at high risk for a second cancer.

The categorization of risk is made on the basis of radiation exposure during childhood. Adults who received more than 30?Gy to the abdomen, spine, or pelvis as children are considered high risk for colorectal cancer, and those who received more than 20?Gy to the chest are considered high risk for breast cancer. Any kind of childhood radiation exposure creates a high risk for skin cancer as an adult.

In the CCSS, nonhigh-risk survivors fell outside these parameters.

The nonhigh risk survivors underwent recommended screening at higher percentages than the general population for mammography (67% vs 58%, respectively) and pap smears (82% vs 70%). The 2 groups had colonoscopy at the same rate (about 24%).

The average age of the survey respondents in the CCSS was about 31 years, said Dr. Nathan. The cohort is a select group and thus the rates of screening are probably underestimates, he added.

Who Is Responsible for These Survivors?

The screening analysis from the CCSS produced other disappointing news, Dr. Nathan reported. Receiving care as an adult at a cancer center only "modestly increases surveillance for breast and skin cancer," he said.

Discussant Dr. Bennett asked who should be looking after childhood cancer survivors — primary-care physicians or oncologists: "This is a new paradigm. Who is responsible for survivors?"

Dr. Bennett suggested that both primary-care physicians and oncologists need to take responsibility. However, he also pointed that childhood survivors are a special case insofar as they have to transition to new physicians, whereas adult survivors of cancer generally do not.

PTSD Predictors

In another study derived from the CCSS data and presented at the meeting, investigators found that childhood survivors are 4 times more likely than their siblings to suffer from PTSD.

However, the incidence — 9% — was not high, noted lead author Margaret Stuber, MD, from the Jane and Marc Nathanson Professor of Psychiatry at the University of California, Los Angeles David Geffen School of Medicine.

"The good news is that more than 90% of survivors of childhood cancer don't have PTSD, even though they went through a very difficult experience," she announced at the press conference.

Both primary-care providers and oncologists should be aware of the risk for PTSD in survivors, suggested Dr. Stuber. "Assessment for PTSD should be considered part of the long-term health screening for childhood cancer survivors," she said.

In a CCSS analysis of survivors (n?= 6542) and siblings (n?= 368), Dr. Stuber and colleagues found that 9% of survivors and 2% of their siblings had PTSD. Survivors who had been diagnosed before the age of 4 years and those treated with radiation to the head were at increased risk for PTSD.

PTSD was also more likely among those who had undergone intense treatments, such as amputation, radiation, or multiple modalities.

In terms of socioeconomics, PTSD was associated with being unmarried, having less than a college education, earning less than $20,000 per year, and being employed. Dr. Stuber admitted that it was not clear whether PTSD influenced these factors or these factors contributed to the onset of PTSD.

The researchers have disclosed no relevant financial relationships.

American Society of Clinical Oncology (ASCO) 45th Annual Meeting: Abstracts CRA6501 and CRA10002. Presented June 1, 2009.

    
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