Survival rates among AYAs with certain cancers show little to no improvement
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Although 5-year survival rates have increased for multiple cancer types among adolescents and young adults, little or no improvement has been observed for some common malignancies in this population, according to findings published in Cancer.
Investigators at NCI called for a focused response and more research to address the latter trend, most apparent with breast cancer, gynecologic cancers and sarcomas.
“As SEER cancer data collection expands over time, including more years of diagnosis, we are able to piece together a larger part of the cancer survival story for the adolescent and young adult [AYA] population in the United States,” Denise Riedel Lewis, PhD, MPH, chair of the SEER Rapid Response Surveillance Studies committee in the division of cancer control and population sciences at NCI, said in a press release. “These results will help refocus our research efforts on [AYA] cancer survivorship.”
Lewis and colleagues used data from the SEER database and National Center for Health Statistics to analyze incidence, mortality and survival rates from 1975 to 2016 for nine cancer types with the highest mortality rates among AYAs aged 15 to 39 years. Researchers modeled relative survival trends using JPSurv, a new Joinpoint regression program designed specifically for survival data.
Results showed significant improvement in 5-year relative survival for brain and other nervous system tumors, colon and rectal cancer, lung and bronchial cancer, acute myeloid leukemia and non-Hodgkin lymphoma. Investigators attributed progress in these cancers to new prevention options, advances in diagnosis and treatment, and containment of risk factors such as HIV/AIDS and HPV, among other factors.
However, Lewis and colleagues found limited or no improvement in survival for female breast cancer, cervical cancer, ovarian cancer, and bone and joint sarcomas.
Survival rates have plateaued among AYAs with female breast cancer, which had the highest incidence and mortality rates among this population. Results of the trend analysis showed 5-year relative survival increased from 1985 through 2007, by an annual rate of 0.66 percentage points, and stabilized after 2007. Although mortality declined from 1986 to 2012, it has increased since 2012.
Among AYAs with cervical cancer, the 5-year relative survival rate exceeded 80% in 1975 and held steady through 2011. Disease burden decreased after 2005 due to declining incidence and a flat mortality rate.
Five-year relative survival for ovarian cancer rose slightly — by 0.24 percentage points — during the period analyzed, with incidence remaining stable since 1996 following large declines in 1993 and 1996. Mortality declined, as well.
For bone, joint and soft tissue sarcomas, 5-year relative survival increased by 0.82 percentage points from 1975 to 1989 before leveling off. Increased incidence between 1975 and 2016 and a flat mortality rate indicated an increased disease burden, Lewis and colleagues wrote.
Additional research is needed in cancers that have shown little or no improvement, according to the investigators.
“Substantial concern remains regarding the high number of breast cancers coupled with declining survival rates, the increases in colorectal cancer incidence, and the slow progress for sarcomas and AML, which suggest investigations of biological differences among AYA patients and efforts to further improve treatment in this group,” they wrote.
Perspective
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Michael E. Roth, MD
Although it is encouraging that survival outcomes have improved for AYAs diagnosed with some cancer subtypes, the report by Lewis and colleagues highlights that further efforts are needed to address the stagnation in survival for many AYA malignancies. Lack of progress for young adult patients with bone, breast, colorectal and other cancers is of great concern, and we need to understand why — despite advances in genomics and the development of targeted and cellular therapies — these patients are not having more rapid improvements in their cure rates.
Much of the progress in cancer care and outcomes over the last 7 decades has been achieved through clinical trials. Unfortunately, few AYAs participate in cancer clinical trials.
AYAs have unique cancer biology, tolerate cancer treatment differently than older and younger patients, and have distinct psychosocial needs, all of which likely impact survival outcomes. The development of AYA cancer trials is the best path forward to achieve more rapid and sustained gains in survival. The restructuring of NCI’s National Clinical Trials Network fostered the development of AYA cancer clinical trials developed jointly between medical and pediatric oncology. These trials seek to identify the optimal treatment approaches specifically for AYAs. Because cancer is more common among older adults, trials for patients with malignancies such as breast cancer and colorectal cancer often include relatively few AYAs compared with the total number of patients enrolled on the study. This limits the ability to determine whether the studied treatments are more effective in the AYA population. Powered AYA study endpoints are needed in these trials.
We also need to understand and target disparities within the AYA cancer population that contribute to the stagnation in survival. Relatively few cancer care delivery studies have assessed the impact of factors such as socioeconomic and insurance status, location of care and adherence to care on outcomes of AYAs with cancer. Fewer studies have assessed interventions to address these important aspects of care. In order to improve survival rates, it is essential that AYAs have access to the treatments identified to be most effective in the location where they receive their cancer care, which for the majority of AYAs is in the community setting.
Increased attention over the past 2 decades to disparities in outcomes among AYAs with cancer has led to improvements in survival for some cancers; however, additional focused efforts are needed to make further gains. The development of AYA cancer clinical trials aimed at identifying optimal treatment approaches, studying AYA cancer biology and improving cancer care delivery will allow us to make more rapid progress.
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