Abstract
Background:
There are a growing number of survivors of adolescent and young adult (AYA) cancer, however, the long-term overall survival (OS) patterns for AYA cancer survivors are underreported. The objective of this study was to assess the long-term survival of AYA cancer survivors and identify factors associated with diminished long-term survival.
Patients and Methods:
We used MD Anderson’s Tumor Registry to identify 5-year survivors of cancer diagnosed as AYAs (age 15–39 years), between the years 1970–2005, and who were alive 5 years after diagnosis. Kaplan-Meier curves were used to estimate OS rates over time, and Cox proportional hazard models were fitted to evaluate the association of covariates with OS.
Results:
We identified 16,728 5-year survivors of cancer diagnosed as AYAs with median follow-up time of 20.0 years. The 10-, 20-, and 25-year OS rates were 86% (95% confidence interval [CI], 85%−86%), 74% (95% CI, 73%−75%), and 68% (95% CI, 67%−68%), respectively, all of which were lower than the age-adjusted estimated survival rates of the general population. Long-term OS improved for AYAs diagnosed between 2000–2005 compared with the prior decades (P<.001). Older age at diagnosis, receipt of radiation, and diagnoses including central nervous system tumors and breast cancer were each associated with diminished long-term survival.
Conclusion:
AYA cancer survivors have inferior long-term survival compared with the general population. Studies investigating the prevalence and types of late treatment effects and causes of death among AYA survivors are needed to more accurately identify AYAs at highest risk for early or late mortality.
Keywords: Adolescent and Young Adult, Cancer, Survivorship, Survival, Disparities, long-term outcomes, AYA cancer
Precis
The long-term survival of AYA cancer survivors diagnosed in recent decades has improved, however remains inferior to that of the general population. AYA cancer survivors require long-term follow up to diagnose and treat late side effects of cancer treatment that may be contributing to their decreased survival.
INTRODUCTION
Approximately 75,000 adolescents and young adults (AYAs; age 15–39 years) in the United States are diagnosed with cancer each year.1, 2 Recent data suggest that these patients’ cure rates are improving, contributing to an estimated 5-year overall survival (OS) rate greater than 75%.2–4 Although the number of AYA cancer survivors continues to grow, few studies have investigated the long-term survival outcomes of this population. Comprehensive analyses of the long-term survival of AYA cancer survivors are needed to guide long-term follow-up screening for and the management of the late effects of treatment.
In contrast to the limited long-term survival data among AYA cancer survivors, long-term outcomes of childhood cancer survivors (those diagnosed before age 21 years) have been well described across multiple large cohorts.5–12 The Childhood Cancer Survivor Study (CCSS) showed that 5-year survivors of childhood cancer have a 30-year cumulative survival rate of 81.9% (95% confidence interval [CI], 81.1%−82.7%).6 As awareness of the late effects of childhood cancer treatments has increased, oncologists have refined their treatment strategies. Such refinements, including reduction of anthracycline doses and decreased use of chest radiotherapy, contributed to substantial reductions in childhood cancer survivors’ 15-year mortality rates between the 1970s and 1990s.5 Similar data for the AYA population are lacking, and whether AYA cancer survivors have had the same improvements in long-term outcomes is unknown. Prior studies assessing conditional survival in AYAs suggested both short and long-term survival may be compromised for this population.13, 14 In this large-scale, single-institution retrospective analysis, we sought to determine the long-term survival rates of AYA cancer survivors, how survival rates have changed over time, and identify factors associated with long-term survival of AYA cancer survivors.
METHODS
AYA Cancer Survivors
We used MD Anderson’s Tumor Registry to identify 16,728 AYA cancer survivors who were newly diagnosed with cancer at age 15–39 years and received treatment at MD Anderson between January 1, 1970, and December 31, 2005; who were alive at least 5 years after their initial diagnosis; and whose data were available in the registry. The study did not include patients who had more than one primary cancer (aside from superficial skin cancers) upon presentation to MD Anderson.
Follow-Up Data
All follow-up information was obtained from MD Anderson’s Tumor Registry and the Social Security Death Index. Data collected from the Tumor Registry included age at diagnosis, sex, race, cancer site and histology, disease stage at diagnosis, treatment, date of last contact, date of death, and vital status. The Tumor Registry is updated continually through letters and phone calls to patients; computer matches with kept appointments, national databases, and inpatient death identification; and notifications from MD Anderson clinical staff. All AYA cancer survivors who were lost to follow-up were reviewed with the Social Security Death Index to identify those who had died. Seven percent of patients within the Tumor Registry are lost to follow up.
Statistical Analysis
We sought to determine the long-term survival rates of AYA cancer survivors and compare them with those of the general population. In addition, we sought to determine whether the OS rates of AYA cancer survivors improved over time and whether variables including sex, race, age at diagnosis, cancer diagnosis, and treatment type were associated with differential long-term OS. OS duration was defined as the time from the date of first cancer diagnosis to the date of death or, for AYA cancer survivors alive at the time of the present study, the date of last follow-up (censored observations). Continuous variables were summarized using means, medians, standard deviations, and ranges. Categorical variables were summarized using frequencies. Kaplan-Meier survival analyses and log-rank tests were used to compare OS according to decade of diagnosis, demographic variable, and clinical variable. (Ethnicity data were not analyzed because they were not available for most survivors.) Univariable analyses and a multivariable Cox proportional hazards model were used to assess the degree to which demographic and clinical variables were associated with OS. Hazard ratios and 95% CIs were calculated. The age-adjusted expected survival probabilities of the U.S. general population were assessed using the 2014 United States Life Tables obtained from the National Vital Statistics Report.15 Instead of the cohort life table, the National Vital Statistics Reports use the period life table, which does not represent the mortality experience of an actual birth cohort but the experience of a hypothetical cohort if it experienced throughout its entire life the mortality conditions of a particular period in time.15 The reports include period tables by race, Hispanic origin and sex, containing data for every single year of age (0–100). Based on the number of individuals surviving to a specific age x and the number of individuals dying between age x and x+1 provided by the Life Tables, we estimated the cumulative survival probability for each age with the use of product-limit method, which was then adjusted using the mean age at diagnosis of the AYA cancer survivor cohort (i.e., 30 years of age). The comparison of the survival probabilities between the US general population and AYA cancer survivors was illustrated using Kaplan-Meier curves.
RESULTS
Patient Characteristics
The characteristics of the 16,728 AYA cancer survivors (9,818 females and 6,910 males) are shown in Table 1. The survivors’ median age at diagnosis was 31.0 years (range, 15.0–39.9 years). Among these survivors, 18.3%, 28.7%, 31.7%, and 21.3% were diagnosed in the 1970s, 1980s, 1990s, and early 2000s, respectively. The most prevalent cancer diagnoses were lymphoma (13.9%), breast cancer (12.0%), and cervical cancer (11.4%). Approximately 23% of the survivors received radiotherapy, and approximately 46% received chemotherapy. The survivors’ median follow-up time was 20.0 years (range, 5.0–47.4 years).
Table 1.
Survivors’ Characteristics
| Characteristic | No. (%) (N = 16,728) |
|---|---|
| Age at diagnosis, y | |
| Mean ± SD | 29.74 ± 6.74 |
| Median (range) | 31.0 (15.0–39.9) |
| 15–19 | 1,652 (9.9) |
| 20–29 | 5,691 (34.0) |
| 30–39 | 9,385 (56.1) |
| Sex | |
| Female | 9,818 (58.7) |
| Male | 6,910 (41.3%) |
| Race | |
| White | 12,884 (77.0) |
| Black | 1,316 (7.9) |
| Asian | 298 (1.8) |
| Other | 240 (1.5) |
| Missing | 1,990 (11.9) |
| Decade of diagnosis | |
| ; 1970s | 3,061 (18.3) |
| 1980s | 4,801 (28.7) |
| 1990s | 5,301 (31.7) |
| 2000s | 3,565 (21.3) |
| Histology | |
| Acute leukemia | 530 (3.2) |
| Breast cancer | 2,014 (12.0) |
| Cervical cancer | 1,915 (11.4) |
| CNS cancer | 695 (4.2) |
| Colorectal cancer | 303 (1.8) |
| Lymphoma | 2,320 (13.9) |
| Hodgkin | 1,415 (61.0) |
| Non-Hodgkin | 883 (38.1) |
| Other | 22 (0.9) |
| Melanoma | 1,856 (11.1) |
| Sarcoma | 1,391 (8.3) |
| Testicular cancer | 1,302 (7.8) |
| Thyroid | 820 (4.9) |
| Other | 3,582 (21.4) |
| SEER stage | |
| Local | 7,243 (43.3) |
| Regional | 3,889 (23.2) |
| Metastatic | 3,754 (22.4) |
| Unknown | 1,842 (11.0) |
| Treatment | |
| CT | 5,158 (30.8) |
| Surgery | 5,696 (34.1) |
| RT | 1,739 (10.4) |
| CT + surgery | 1,323 (7.9) |
| CT + RT | 864 (5.2) |
| RT + surgery | 958 (5.7) |
| CT + surgery + RT | 349 (2.1) |
| Other | 641 (3.8) |
Abbreviations: CNS, central nervous system; CT, chemotherapy; RT, radiotherapy; SD, standard deviation.
Overall Survival
The OS of the survivors compared to the age-adjusted expected survival of the general population over time is shown in Figure 1A. The survivors’ 10-, 20-, and 25-year OS rates were 86% (95% CI, 85%−86%), 74% (95% CI, 73%−75%), and 68% (95% CI, 67%−68%), respectively, and all were lower than the expected survival rates of the age-adjusted general population. The survivors’ median OS duration was 36.9 years (95% CI, 36.0–37.8 years).
Figure 1: Overall Survival of AYA Cancer Survivors.
(A) The overall survival estimate of all 5-year AYA cancer survivors was lower than that of the U.S. general population (P<.001). (B) The overall survival estimate of 5-year AYA cancer survivors diagnosed in the 2000s was higher than those of survivors diagnosed in the 1970s, 1980s, or 1990s.
Survivors’ long-term OS improved over time, with those diagnosed in the early 2000s having significantly greater survival than those diagnosed in the prior 3 decades (p<0.001) (Figure 1B). The OS rates of survivors diagnosed in the 1970s, 1980s, 1990s, and 2000s were 81% (95% CI, 80%−83%), 84% (95% CI, 83%−85%), 86% (95% CI, 85%−87%) and 92% (95% CI, 91%−93%), respectively. These differences persisted: the 25-year OS rates of the survivors diagnosed in the 1980s and 1990s (66% [95% CI, 65%−67%] and 67% [95% CI, 65%−69%], respectively), were significantly higher than that of the survivors diagnosed in the 1970s (63% [95% CI, 61%−65%]; P < .001).
Survival by Gender and Race
Similar to gender-based survival differences in the general population, female AYA cancer survivors had significantly better long-term OS than male survivors did (P = .01), however, this difference was relatively small (Figure 2A). The survivors’ long-term OS by race also followed patterns similar to those in the general population, with white survivors having a significantly higher survival rate than black survivors (P < .001) (Figure 2B). Additional analyses comparing survival among other race groups were not performed owing to low patient numbers. Analyses comparing survival among patients with different ethnicities were also not performed as this data was not available for the majority of patients.
Figure 2: Overall Survival of AYA Cancer Survivors by Race, Gender, Age at Diagnosis, and Different Ages by Decade of Diagnosis.
(A) Overall survival estimates of 5-year AYA cancer survivors by gender. The overall survival estimate for female survivors was higher than that of male survivors (P=.01). (B) Overall survival estimates of 5-year AYA cancer survivors by race. The overall survival estimate for white survivors was higher than that of black survivors (P=.01). (C) Overall survival estimates of 5-year AYA cancer survivors by age at diagnosis. AYA cancer survivors diagnosed between ages 15 and 19 and 20 and 29 had higher overall survival compares with AYAs diagnosed between ages 30 and 39 (P<.001) (D) AYA cancer survivors diagnosed between ages 15 and 19 years during the years 2000–05 had improved overall survival compared with AYA survivors diagnosed in the prior 3 decades (P<.001). (E) AYA cancer survivors diagnosed between ages 20 and 29 years during the years 2000–05 had improved overall survival compared with AYA survivors diagnosed in the prior 3 decades (P<.001). (F) AYA cancer survivors diagnosed between ages 30 and 39 years during the years 2000–05 had improved overall survival compared with AYA survivors diagnosed in the prior 3 decades (P<.001).
Survival by Age
The survivors’ OS by age at diagnosis is shown in Figure 2C. Survivors diagnosed at age 15–19 years or 20–29 years had significantly higher long-term survival rates than survivors diagnosed at age 30–39 years did (P < .001). The 25-year OS rate of survivors diagnosed at age 15–19 years (74%; 95% CI, 71%−76%) was significantly higher than those of survivors diagnosed at age 20–29 years (72%; 95% CI, 70%−73%) or age 30–39 years (64%; 95% CI, 63%−65%; P < .001).
Survivors’ survival rates by age at diagnosis stratified by decade of diagnosis are given in Figures 2D– 2F. Among survivors age 15–19 years or 20–29 years at diagnosis, the long-term OS rates of those diagnosed in the 1970s, 1980s, or 1990s did not differ significantly; however, the OS rates of those diagnosed in the early 2000s were significantly higher than diagnosed in each of the prior 3 decades (P<.001). For survivors diagnosed at age 30–39 years, the long-term OS rates increased significantly with each subsequent decade of diagnosis; for example, the 20-year OS rate of survivors diagnosed in the 1970s (62%; 95% CI, 60%−65%) was significantly lower than the estimated 20-year OS rate of those diagnosed in the 2000s (84%; 95% CI, 82%−87%; P < .001).
Survival by Cancer Type
The OS probabilities over time for survivors with the five most common AYA cancers (breast cancer, melanoma, CNS cancer, thyroid cancer, and lymphoma) are shown in Figure 3A. The groups with the lowest 25-year OS rates were CNS cancer survivors (43%; 95% CI, 38%−48%), breast cancer survivors (55%; 95% CI, 52%−58%), and Hodgkin lymphoma survivors (65%; 95% CI, 63%−68%). The OS rates of survivors diagnosed with other AYA cancers are shown in Supplemental Figure 1.
Figure 3: Overall Survival of the Survivors of the Five Most Prevalent AYA Cancer Types.
(A) Overall survival estimates of the 5-year survivors of the 5 most prevalent AYA cancer types. (B) Five-year AYA breast cancer survivors diagnosed between the years 2000–05 had improved overall survival compared with survivors diagnosed in the prior 3 decades (P<.001). (C) Five-year AYA melanoma survivors diagnosed between the years 2000–05 had improved overall survival compared with survivors diagnosed in the prior 3 decades (P<.001). (D) Five-year AYA CNS survivors diagnosed between the years 2000–05 had improved overall survival compared with survivors diagnosed in the prior 3 decades (P<.001). (E) Overall survival estimates of 5-year AYA thyroid cancer survivors by decade of diagnosis. (F) Five-year AYA lymphoma survivors diagnosed between the years 2000–05 had improved overall survival compared with survivors diagnosed in the prior 3 decades (P<.001).
The survival rates by decade of diagnosis for the survivors of cancer diagnosed as AYAs inluding breast cancer, melanoma, CNS cancer, thyroid cancer, and lymphoma are shown in Figures 3B–3F, respectively. Both breast cancer survivors and lymphoma survivors had improvements in long-term survival with each subsequent decade of diagnosis. Among AYA breast cancer survivors, the 20-year OS rate of those diagnosed in the 1970s (41%; 95% CI, 35%−46%) was significantly lower than the estimated 20-year OS rate of those diagnosed in the 2000s (83%; 95% CI, 78%−87%; P < .001). Similarly, among lymphoma survivors, the 20-year OS rate of those diagnosed in the 1970s (61%; 95% CI, 56%−65%) was significantly lower than the estimated 20-year OS rate of those diagnosed in the 2000s (82%; 95% CI, 71%−90%; P < .001). Differences in long-term survival by decade of diagnosis were not as prominent for survivors of other cancer types, although melanoma survivors diagnosed in the 2000s had a distinct survival advantage compared with those diagnosed in the previous decades, likely owing to the improved long-term survival of survivors with local disease (P < .001) (Supplemental Figure 2).
Survival by Disease Stage
Survival by SEER disease stage (local, regional, or metastatic) at diagnosis is shown in Supplemental Table 1. AYA cancer survivors who had local disease at diagnosis had the most favorable 25-year survival, whereas those with metastatic disease at diagnosis had the poorest long-term survival. Survival rates by decade of diagnosis for survivors with local, regional, or metastatic disease at diagnosis are shown in Supplemental Tables 2, 3, and 4, respectively. Survivors who had metastatic disease at diagnosis had the most pronounced improvements in survival by decade of diagnosis.
Survival by Treatment
The OS of AYA cancer survivors by radiotherapy status is shown in Figure 4. Survivors who received radiotherapy had higher 10- and 15-year OS rates than those who did not receive radiotherapy. Survivors who received radiation experienced significantly higher survival up to 23 years post diagnosis (P =.045). However, the 25-year OS rates of survivors who did not receive radiotherapy (68%; 95% CI, 67%−69%) and those who received radiation (67%; 95% CI, 65%−69%) did not differ significantly (P = .106). The 35-year survival rate of survivors who received radiotherapy was significantly lower than that of survivors who did not receive radiotherapy. OS by all treatment combinations is shown in Supplemental Table 5.
Figure 4: Overall Survival of AYA Cancer Survivors by Radiotherapy Status.
Group 1 did not receive any radiotherapy and included survivors who received chemotherapy; surgery; chemotherapy plus surgery; or other treatment. Group 2 received radiotherapy and included survivors who received radiotherapy; radiotherapy and chemotherapy; radiotherapy and surgery; or radiotherapy, chemotherapy, and surgery.
Multivariate Analysis
The results of the multivariable Cox proportional hazards model analysis identifying associations between survivors’ demographic and clinical variables and their long-term survival are provided in Supplemental Table 6. All covariates in the univariate analysis were included in the Cox proportional hazards model. Compared with a diagnosis of lymphoma, a diagnosis of breast, CNS, cervical, or colorectal cancer or sarcoma or melanoma was associated with an increased risk of diminished long-term survival. Compared with survivors who received radiotherapy alone, those who received surgery alone had a significantly lower risk of diminished long-term survival, whereas survivors who received any other treatment(s), save surgery plus radiotherapy, had a significantly higher risk of diminished long-term survival. Male survivors had a significantly higher risk of reduced long-term survival than female survivors did, and survivors who were at least 20 years old at diagnosis had a significantly higher risk than those age 15–19 years at diagnosis. Compared with survivors diagnosed in the 2000s, those diagnosed in earlier decades had a significantly increased risk of diminished long-term survival.
DISCUSSION
We found that 5-year survivors of cancer diagnosed as AYAs have worse long-term OS than the general population does. However, these survivors’ long-term survival has improved over time, with those diagnosed in the early 2000s, the most recent decade included in our analysis, showing the greatest improvements. In addition, we found that survivors’ long-term OS varied significantly according to cancer histology, age at diagnosis, sex, race, and treatment. Identification of AYA survivors at highest risk for early mortality allows targeted screening of late-effects by clinicians as well as encourages further research into the specific factors leading to increased risks.
Our finding that the long-term survival of AYA cancer survivors is significantly worse than that of the general population is consistent with the findings of the CCSS. However, compared with the long-term survival rates of the childhood cancer survivors in that study, those of the AYA cancer survivors in the present study appear to be lower at every decade after diagnosis. For example, the 10- and 20-year OS rates of the AYA cancer survivors in the present study (86% and 74%, respectively) were both lower than those of the CCSS population (94% and 88%, respectively).6 Among survivors of Hodgkin lymphoma, one of the more common cancers diagnosed in AYAs, the 25-year OS rate of the AYA cancer survivors (65%) was lower than the 30-year OS rate of the CCSS population (74%).16 These differences are likely due to a combination of treatment toxicity and the accumulation of chronic comorbidities with advancing age, conditions that manifest earlier after diagnosis among AYA cancer survivors simply because they are older than childhood cancer survivors. It is concerning that the difference in survival between AYA cancer survivors and the general population increases and becomes more pronounced over time.
Our findings show that the long-term survival of AYA cancer survivors has improved over time. However, similar to the CCSS findings, most of the survival gains by decade of diagnosis in the present study were secondary to improvements in outcomes 5–10 years after diagnosis, with less pronounced changes in mortality rates later in survivorship. Although cause-of-death data were not available for the survivors in the present study, the CCSS showed that most deaths occurring within 10 years after diagnosis were attributable to primary disease progression or disease recurrence.6 Thus, the improvements in AYA cancer survivors’ long-term survival by decade of diagnosis could have been driven by increases in primary cancer survival and influenced less by reductions in mortality due to the late effects of cancer treatment.
Though not assessed in the current analysis, it is known that long-term survivors of cancer diagnosed as AYAs are at increased risk for many chronic conditions and comorbidities; among these, cardiac and respiratory morbidity and mortality are particularly concerning.17–19 One recent study utilizing SEER data reported that AYA cancer survivors have a higher risk of death due to infection, cardiovascular disease, and renal disease.20 Among childhood cancer survivors, the risk of death due to primary cancer recurrence is high in the first 10 years after diagnosis but decreases thereafter, whereas the risk of death due to pulmonary or cardiac causes or to secondary malignancy is initially low but then increases.21, 22 An improved understanding of the ways in which causes of death among AYA cancer survivors change over time is needed to identify the main drivers of improved survival and reduce persistent disparities in long-term survival between AYA cancer survivors and the general population.
In the present study, differences in treatment-related factors likely influenced the differences in long-term survival by cancer type. For example, thyroid cancer patients do not typically receive chemotherapy or radiotherapy and are thus spared the late toxicities of these treatments. In contrast, most CNS cancer patients receive cranial radiotherapy, which increases the risk of late endocrine and cerebrovascular morbidities and subsequent neoplasms.23–25 Lymphoma patients who receive anthracycline-based chemotherapy and/or mediastinal radiotherapy are at increased risk of late cardiac morbidity.26 Breast cancer survivors are also likely to undergo chest wall radiotherapy and/or receive anthracycline-based chemotherapy and thus have an increased risk of late cardiac morbidity.27, 28
We also found differences in survival by decade of diagnosis among survivors of different types of cancer. Among AYA breast cancer and lymphoma survivors, long-term survival improved significantly with each subsequent decade of diagnosis. Among the differences in these patients’ survival rates by decade of diagnosis, differences in the 10-year survival rates were most pronounced, suggesting that the long-term improvements in survival were likely due to improvements in treating the primary disease and preventing or delaying disease progression and recurrence.29–33 In contrast, among AYA melanoma survivors, the long-term survival rates of those diagnosed in the 1970s, 1980s, or 1990s did not differ significantly, whereas those diagnosed in the 2000s had improved early survival. Importantly, compared with those diagnosed in earlier decades, melanoma survivors diagnosed in the 2000s had a higher rate of localized disease at presentation, potentially skewing outcomes, as our data showed that survivors who presented with local melanoma had significantly better survival than those who presented with regional or metastatic disease (Supplemental Figure 2). Other factors that may have contributed to these recent improvements include AYAs with melanoma having high rates of clinical trial enrollment,34; continued treatment advances, particularly the introduction of checkpoint inhibitors35; and surgical advancements.36
We found that radiotherapy conveyed a survival advantage to AYA cancer survivors only until about 25 years after diagnosis; by 35 years after diagnosis, survivors who did not receive radiotherapy had greater survival than those who did receive radiotherapy. Patients with malignancies traditionally associated with poor prognoses, such as CNS tumors, sarcomas, and breast cancer, and many with better prognoses, such as Hodgkin lymphoma, received radiation therapy, and thus further analyses within each disease group are needed to better understand the improved early survival advantage seen with radiation exposure. The dramatic decline in survival seen in patients who received radiation therapy starting 20 years post treatment is quite concerning. Thus, although radiotherapy conveyed a short-term survival benefit, the treatment’s potential late effects, including second malignancy and cardiac morbidity, likely diminished survivors’ rates/durations of long-term OS.37, 38 Oncologists caring for AYAs should consider the potential long-term impact of radiation therapy on long-term survival and health-related quality of life outcomes when deciding on initial treatment approaches.
Prior studies have reported that AYAs with cancer have experienced lower short-term (5 year) conditional survival improvements compared with older adults.39 It is not clear whether these findings will be similar 10 and 20 years post diagnosis. Further studies are needed assessing changes in conditional survival between AYAs and older adult long-term cancer survivors, with a focus on the impact of cancer subtype, treatment received, and sociodemographic factors on long-term outcomes.
The present study was not without limitations. Because this analysis included patients treated at a large academic institution with access to numerous clinical trials, some of the survival gains we observed may be delayed or unrealized in other treatment settings and the patient population may be more complex than those seen in other treatment settings. For example, MD Anderson has reported better outcomes for AYAs with acute lymphoblastic leukemia using the hyper-CVAD compared with reports for similar populations treated at other sites.40 A prior study also suggested that the socioeconomic and insurance status of AYAs treated at MD Anderson may not be fully representative of the general AYA population, as many AYAs lack insurance or are under-insured. Additional studies comparing the survival of AYA cancer survivors in the academic versus community treatment setting are warranted to determine the impact of treatment setting on long-term survival for these patients. In addition, the lack of cause-specific mortality data in the present study precluded analysis of cause of death based on diagnosis, treatment, and time from treatment, and requires further requires further exploration in follow-up studies.
In summary, our findings show that the OS rates of AYA cancer survivors were lower than the age-adjusted expected survival rates of the general population. Long-term survival among AYA survivors differs by cancer type, age at diagnosis, treatment, and decade of diagnosis. Although survivors’ short-term OS rates by decade of diagnosis have improved over time, their long-term OS rates, which were likely affected by mortality owing to the late effects of treatment, have not. To further improve the long-term survival of AYA cancer survivors, we must acquire a better understanding of the risk factors contributing to these survivors’ early mortality and then modify upfront therapy and develop risk factor-reducing interventions accordingly.
Supplementary Material
Supplemental Figure 1: Overall Survival of AYA Cancer Survivors by Histology.Overall survival estimates of all 5-year AYA cancer survivors by cancer histology.
Supplemental Figure 2: Overall Survival of AYA Melanoma Survivors by Disease Stage and Decade of Diagnosis.(A) Overall survival estimates of 5-year AYA melanoma survivors with local disease at diagnosis grouped by decade of diagnosis. (B) Overall survival estimates of 5-year AYA melanoma survivors with regional disease at diagnosis grouped by decade of diagnosis. (C) Overall survival estimates of 5-year AYA melanoma survivors with metastatic disease at diagnosis grouped by decade of diagnosis.
Funding/Support:
This work was supported by the National Cancer Institute at the National Institutes of Health [grant number P30 CA016672].
Role of the Funder/Sponsor: The funders had no role in the design of the study, conduct of the study, analysis, interpretation of data, or decision to submit the manuscript for publication.
Footnotes
Conflict of Interest Disclosures: The authors have no conflicts of interest.
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Associated Data
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Supplementary Materials
Supplemental Figure 1: Overall Survival of AYA Cancer Survivors by Histology.Overall survival estimates of all 5-year AYA cancer survivors by cancer histology.
Supplemental Figure 2: Overall Survival of AYA Melanoma Survivors by Disease Stage and Decade of Diagnosis.(A) Overall survival estimates of 5-year AYA melanoma survivors with local disease at diagnosis grouped by decade of diagnosis. (B) Overall survival estimates of 5-year AYA melanoma survivors with regional disease at diagnosis grouped by decade of diagnosis. (C) Overall survival estimates of 5-year AYA melanoma survivors with metastatic disease at diagnosis grouped by decade of diagnosis.