Case-linked analysis of clinical trial enrollment among adolescents and young adults at a National Cancer Institute-designated comprehensive cancer center.

BACKGROUND: Poor accrual to cancer clinical trials may contribute to the lower improvement in survival observed for adolescents and young adults (AYAs) (those aged 15-39 years) with cancer. This has been difficult to quantify without reliable mechanisms to link incident cases with study enrollments. Using unique resources available at their National Cancer Institute-designated comprehensive cancer center, the authors compared the percentage of AYAs, children, and older adults enrolled onto cancer clinical trials and determined predictors of enrollment. METHODS: Patients diagnosed with cancer from January 2008 through December 2012 at 1 pediatric and 2 adult University of Southern California hospitals were identified through the California Cancer Registry and individually linked to institutional trial enrollment databases. The availability of clinical trials was assessed. RESULTS: Across the center, the enrollment percentage for AYAs (6%) was equal to that of older adults (6%), but was less than that for children (22%) (P < .01). Within the children's hospital, the AYA enrollment percentage was also less than that for children (15% vs 23%, respectively; P<.01). On multivariate analysis, diagnosis and site of care were found to be predictive of AYA enrollment onto therapeutic and nontherapeutic studies. Hispanic and Asian/Pacific Islander individuals were more likely to enroll onto nontherapeutic studies compared with non-Hispanic whites, but no racial/ethnic difference was observed for therapeutic studies. CONCLUSIONS: In the current study, the percentages of AYAs and older adults enrolled onto therapeutic trials were low but similar. Diagnosis, site of care, and race/ethnicity appear to be predictive of enrollment. Prospective mechanisms must be instituted to capture reasons for nonenrollment of AYAs and develop corrective interventions.

Significant response to oral Etoposide in the treatment of an unresectable cardiac sarcoma.

Primary cardiac sarcomas are rare and carry a poor prognosis. The standard of care is complete resection. Outcomes for patients without complete resection are dismal, and the benefit of adjuvant therapy is uncertain. A 9-year-old girl presented with a large right-sided cardiac mass. After biopsy, the tumor was classified as an undifferentiated sarcoma. Resection was not feasible due to apparent invasion of the right ventricle and atrioventricular groove. Treatment with oral etoposide resulted in a 97% reduction in tumor volume and allowed for complete resection of residual tumor. She is alive with no evidence of disease 25 months from diagnosis.

Severe thrombocytopenia in a child secondary to passive platelet antibody transfer from a plasma transfusion.

Although rare, passive transfer of platelet antibodies through blood products can result in thrombocytopenia, acute transfusion reactions, and death. We report a case of severe alloimmune thrombocytopenia from a plasma transfusion. A postliver transplant patient with a normal platelet count received fresh frozen plasma before liver biopsy. Postbiopsy, she developed cardiorespiratory distress, petechiae, and severe thrombocytopenia (platelet count 2000/µL). Her platelet count recovered to normal after 1 week. This diagnosis should be considered whenever an unexpected drop in the platelet count occurs after a plasma-rich transfusion. Conservative transfusion practices and more targeted donor screening may prevent similar events.

Lack of impact on polyp detection by fellow involvement during colonoscopy: a meta-analysis.

BACKGROUND: Conflicting data regarding the impact of fellow involvement during colonoscopy on the adenoma detection rate (ADR) and polyp detection rate (PDR) have been reported in the literature. AIMS: Our aim was to perform a meta-analysis to determine the impact of fellow participation during colonoscopy on the ADR and PDR. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, pertinent articles that reported ADR and/or PDR between attending physicians alone compared to gastroenterology fellows with attending physicians were obtained through database searches. Data was abstracted and pooled using a random effects model. The quality of each included study was ascertained using a modified version of the Quality Assessment of Diagnostic Accuracy Studies tool, and potential publication bias was assessed. RESULTS: A total of 14 articles that included 21,504 colonoscopies met the inclusion criteria. The overall PDR and ADR were 44.4 and 30.8%, respectively. No significant differences were found between participant characteristics and colonoscopies performed with or without fellow participation. No significant differences were found in the relative rate of ADR (1.04, 95% CI 0.94-1.15) or PDR (1.03, 95% CI 0.93-1.14) with or without a fellow. An important limitation is that none of the included studies randomized fellow involvement. CONCLUSIONS: Involvement of a fellow during colonoscopy did not affect adenoma and polyp detection rates.

Patterns of Cancer Care and Association with Survival among Younger Adolescents and Young Adults: A Population-Based Retrospective Cohort Study.

BACKGROUND: Younger adolescents and young adults (AYA) may receive care from either adult or pediatric oncologists. We explored patterns of care in this population and whether survival is associated with provider type. METHODS: Utilizing the California Cancer Registry, we examined a cohort of 9,993 AYAs diagnosed with cancer aged 15 to 24 years from 1999 to 2008. Provider type (adult/pediatric) was determined by individual physician identifiers. For provider type, multivariable logistic regression models were adjusted for age, sex, race/ethnicity, socioeconomic status, diagnosis, and stage. For observed survival, Cox proportional hazard models were additionally adjusted for provider type. ORs and HR with 95% confidence intervals (95% CI) were determined. RESULTS: Most patients saw adult providers (87.3% overall; 72.7% aged 15-19 years). Patients with acute leukemia, sarcoma, and central nervous system (CNS) malignancies more often saw pediatric providers [OR (95% CI) adult versus pediatric 0.48 (0.39-0.59), 0.74 (0.60-0.92), 0.76 (0.60-0.96), respectively]; those with germ cell tumors and other cancers, including carcinomas, more often saw adult providers [2.26 (1.72-2.98), 1.79 (1.41-2.27), respectively]. In aggregate and for most cancers individually, there was no survival difference by provider type [overall HR (95% CI) 1.00 (0.86-1.18)]. Higher survival was associated with pediatric providers for CNS malignancies [1.63 (1.12-2.37)] and rhabdomyosarcoma [2.22 (1.03-4.76)], and with adult providers for non-Hodgkin lymphoma [0.61 (0.39-0.96)]. CONCLUSIONS: Most AYAs 15 to 24 years old are treated by medical oncologists. In general, survival was not associated with provider type. IMPACT: Current patterns of care for this population support increased collaboration between medical and pediatric oncology, including joint clinical trials.