Introduction: Malignant primary bone tumors in children and young adults Paul M. Kent, MD, FAAP, Jeff Ording, BS, Elizabeth Dabrowski, MD, Karina Shah, MD, Luke Trafton Osteosarcoma, Ewing sarcoma, chondrosarcoma, and primary bone lymphoma account for greater than 95% of all primary bone tumors occurring in the first 50 years of life. These diseases are the primary focus of this review. 1 Today, most patients younger than 50 years of age with primary bone tumors are cured (Fig 1), but most are affected by some late effects of their treatment. The outlook for recurrent and metastatic bone cancer is still very poor. The need for clinical research and new treatment options is self-evident. This paper is a collaborative work from our institution's multidisciplinary sarcoma tumor board. Our pediatric and adult oncology specialists care for more than 300 patients a year in a seamless approach focusing on the disease processes without the arbitrary separation of age. Under the leadership of Dr Steven Gitelis, we have been treating adolescents and young adults (AYA, defined as individuals who are 15-39 years of age) with bone tumors using the same approach and protocols as children for the last 30 years. This successful paradigm was ahead of its time. In this review, we discuss the presentation, workup, treatment strategies, new directions, late effects, and clinical and laboratory advances in the treatment of primary malignant bone cancers in young people and the need for all patients to be given the opportunity to be treated by a multidisciplinary team and participate in clinical research. Adolescents and young adults (AYA) The NIH defines AYAs as the individuals in the age group of 15-40 years. Besides accidents and homicide, the primary cause of death in AYAs is cancer. There are 70,000 cases of cancer and 12,000 deaths a year in this age group. This is 6 times the number of cancer cases and 8 times the number of deaths compared with children under the age of 15. In the last decade, the NIH and numerous studies have demonstrated that survival and per-annum improvement seen in AYAs is significantly lower than that in younger patients, for all invasive cancers and for bone tumors specifically 2-4 (Fig 2). Biologic, clinical, and demographic data on AYAs are desperately needed to better understand this phenomenon. In recognition of this healthcare disparity, in 2006, Dr John E. Niederhuber, Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/cpcancer Curr Probl Cancer 0147-0272/$ - see front matter & 2013 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.currproblcancer.2013.07.002 Curr Probl Cancer 37 (2013) 160–166
Introduction: Malignant primary bone tumors inchildren and young adults
Paul M. Kent, MD, FAAP, Jeff Ording, BS, Elizabeth Dabrowski, MD,Karina Shah, MD, Luke Trafton
Osteosarcoma, Ewing sarcoma, chondrosarcoma, and primary bone lymphoma account forgreater than 95% of all primary bone tumors occurring in the first 50 years of life. These diseasesare the primary focus of this review.1
Today, most patients younger than 50 years of age with primary bone tumors are cured(Fig 1), but most are affected by some late effects of their treatment. The outlook for recurrentand metastatic bone cancer is still very poor. The need for clinical research and new treatmentoptions is self-evident.
This paper is a collaborative work from our institution's multidisciplinary sarcoma tumorboard. Our pediatric and adult oncology specialists care for more than 300 patients a yearin a seamless approach focusing on the disease processes without the arbitrary separationof age. Under the leadership of Dr Steven Gitelis, we have been treating adolescents andyoung adults (AYA, defined as individuals who are 15-39 years of age) with bone tumorsusing the same approach and protocols as children for the last 30 years. This successfulparadigm was ahead of its time. In this review, we discuss the presentation, workup,treatment strategies, new directions, late effects, and clinical and laboratory advances in thetreatment of primary malignant bone cancers in young people and the need for all patientsto be given the opportunity to be treated by a multidisciplinary team and participate inclinical research.
Adolescents and young adults (AYA)
The NIH defines AYAs as the individuals in the age group of 15-40 years. Besides accidentsand homicide, the primary cause of death in AYAs is cancer. There are 70,000 cases of cancer and12,000 deaths a year in this age group. This is 6 times the number of cancer cases and 8 times thenumber of deaths compared with children under the age of 15. In the last decade, the NIH andnumerous studies have demonstrated that survival and per-annum improvement seen in AYAs issignificantly lower than that in younger patients, for all invasive cancers and for bone tumorsspecifically2-4 (Fig 2).
Biologic, clinical, and demographic data on AYAs are desperately needed to better understandthis phenomenon. In recognition of this healthcare disparity, in 2006, Dr John E. Niederhuber,
72/$ - see front matter & 2013 Published by Elsevier Inc.x.doi.org/10.1016/j.currproblcancer.2013.07.002
Fig. 1. Estimated five-year survival for bone tumors age 0-44 for CS, ES and OS from 1960 to 2005. Source [1,3,5,6,24-31and additional source: Mirabello L, Troisi RJ, Savage SA. Osteosarcoma incidence and survival rates from 1973 to 2004:Data from the surveillance, epidemiology, and end results program. Cancer 2009;115:1531–43.].
Fig. 2. From 1975 to 1995 average annual percent change (AAPC) in 5-year relative survival for all invasive cancer isworse for AYA patients. Source from [1].
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the deputy director of the National Cancer Institute (NCI), directed the 242-institutionalmultinational cooperative group Children's Oncology Group (COG) to increase the eligibilityup to the age 50 years for bone tumors, sarcomas, and other cancers commonly foundin children and AYAs, as well as expand biology and epidemiology studies, and to address“…the issues facing older AYA with cancer… [and] develop strategies to improve theiroutcomes.”2
Over the last 40 years, multidisciplinary care and cooperative research has improved survivalin patients with bone tumors from 20%-25% in the 1970s to 70%-80% today.5–8 From 1975 to2000, survival for AYAs with bone tumors, similar to all invasive cancers, has improved, but notas dramatically as in non-AYAs (Fig 3).1
Adolescent and Young Adults(AYA)
Fig. 3. From 1975 to 1995 improvement in 5-year survival for all bone tumors age 0-50 from 1975 to 2000 is mostdramatic in those under 15 and those over 45. Source from [1].
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Importance of clinical research trials
Of the pediatric patients with cancer who are under the age of 15 years, 94% are treated atCOG member institutions in the US; 50%-80% are enrolled on treatment or biologic protocols, orboth, which are open at their institution, in contrast to 1%-3% of adults with cancer.9,10 In 2000,Dr Richard Padzur, FDA Director for the Division of Oncology Drugs, stated that “Because themajority of [pediatric] cancer patients receive their therapy as participants in clinical researchprotocols, participation in oncology trials has become the ‘standard of care’ in pediatriconcology,” effectively removing the distinction between “standard of care” and “clinicalresearch” for young patients with cancer.11 In addition, we know that patients who participate incooperative group clinical trials have better outcomes than those who do not.12-18
The lower survival and slower rate (or negative rate) of improvement seen in AYAs appears tocorrelate with participation in clinical research trials.9 AYAs have the lowest participation rate inclinical trials of all age groups, dramatically so for bone tumors despite its prevalence in this agerange. The prevalence seen in AYAs is approximately the same as in children (Fig 4).3,19,20 In aretrospective study, Paulessen and colleagues showed that when controlled for era, histology,age, and stage, AYAs with ES, similar to AYAs with leukemia, have lower survival when treated atadult institutions on adult protocols in comparison with pediatric protocols (10-year survival43% vs. 24%) (Fig 5).4
The reasons for these differences are not clear. It is possible that there are importantbiological and genetic differences in sarcomas and bone tumors among AYAs that we are notaware of.21 Unfortunately, AYA tumor specimens of all histologies are very poorly represented inthe US national tissue banks.21 It also plausible that AYAs benefit from being treated the same aschildren with the same diagnosis, as suggested by retrospective data.4,16-18 There is clearly aneed for rigorous research into the poor outcomes of AYAs with cancer, exactly the mission givento the COG by the NCI 7 years ago.
Collaboration for AYA
In 2000, the COG formed an AYA section, and as noted before, changed protocol eligibility toinclude AYAs. The COG teamed with the NCI, adult cooperative groups, and the American Societyof Clinical Oncology with LIVESTRONG to launch an initiative called “Focus Under Forty,” to raise
Medical Institution
Pediatric Institution
OS = 43%
Peds: age 15-20, n = 231, failed n = 120Med: age 15-20, n = 115, failed n = 82
OS = 24%
Ove
rall
Surv
ival
1.00
0.50
0.75
0.25
0.00
Fig. 5. 20 years ago, Paulessen and colleagues showed that when controlled for era, histology, age, and stage, AYAs withES, have lower survival when treated on adult protocols in comparison with pediatric protocols. Source [5].
Fig. 4. National enrollments of bone tumor clinical trials by age: 1997-2001. AYAs have the lowest participation rate inclinical trials of all age groups, dramatically so for bone tumors despite its prevalence in this age range being similar tothat in patients less then 20. Source: [19].
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awareness about this disparity, generate data, and increase participation for AYAs.2 As anexample, a new trial for ES was started that allowed the Southwest Oncology Group to enrolladult patients. Southwest Oncology Group and COG formed the Intergroup Consortium AgainstSarcoma (ICAS) with representation from each of the adult and pediatric cooperative groups inthe United States, the NCI, and Canada.20
Multidisciplinary care and research
The successes we have seen are because of hard-fought incremental survival gainsgarnered through large-scale clinical trials and commitment to enrollment in NIH
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cooperative group studies by those who treat bone cancer. New orthopedic techniques anddevices and new technologies in radiation oncology have led to better local control ofprimary tumors, fewer late effects, and better limb salvage and function, while improvementin understanding molecular pathways gives promise for the development of targeted drugdevelopment. Nevertheless, most of the advances seen in the last 50 years are the result ofrandomized clinical trials performed by American and European cooperative groups led bythe COG.6 As seen in cases of acute leukemia in children, the dramatic increases in survivalfor ES and osteosarcoma in the last 40 years have come without any new anticancerdrugs, further demonstrating the power of large carefully designed clinical trials todiscover the ideal use of chemotherapeutic agents we already have, even in very rarediseases22,23 (Fig 6).
Improved Survival in Acute LeukemiaSince 1970 is Because of Clinical Research
Fig. 6. The steady improvement survival in leukemia for children mirrors that of sarcoma. For children,there have been no new drugs added to standard therapy for bone tumors or leukemia in 40 years,demonstrating the power of large carefully designed clinical trials to discover the ideal use ofchemotherapeutic agents we already have. Source [22,23].
Fig. 7.
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Concluding thoughts
As of 2013, cancer treatment is a complex endeavor requiring experts from many fieldsworking in concert. There is a survival advantage to collaboration and to those enrolled inclinical trials. It is considered the standard of care for children, and we believe it should be thestandard of care for young adults as well. Such work ultimately benefits everyone. This work isan example of our collaboration and attempt to fulfill this mission.
We dedicate this paper to our patients and families who everyday teach us about theirdisease, but first and foremost about courage and dignity (Fig 7).
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