Prevalence and Costs of Esophageal Strictures in the United States.

BACKGROUND & AIMS: Esophageal strictures are a leading cause of dysphagia, but data regarding the epidemiology of esophageal strictures are limited. This study aimed to investigate the prevalence, health care utilization, and financial burden of esophageal strictures in the United States. METHODS: We performed a retrospective cohort study using 2 large national insurance claims databases (MarketScan and Medicare). Using International Classification of Diseases-9 and -10 diagnostic codes, annual prevalence was calculated for both cohorts overall, and stratified by age and sex strata. Most common diagnostic and procedural codes associated with esophageal strictures were extracted and analyzed to estimate health care utilization. Direct annual medical costs of esophageal strictures were calculated. RESULTS: The annual prevalence of esophageal strictures in MarketScan in 2021 was 203.14 cases/100,000 people, whereas the annual prevalence in Medicare cohort in 2017 was 1123.47 cases/100,000. Although rates were relatively stable over time, esophageal stricture prevalence increased with advancing age. No prevalence differences were noticed between males and females. Gastroesophageal reflux disease/erosive esophagitis was the top diagnostic code associated with esophageal strictures, although an increase in the proportion of eosinophilic esophagitis codes was noted over time. Esophageal dilation codes were present in ∼50% of stricture cases. The total health care costs associated with esophageal strictures were estimated at $1.39 billion in 2017. CONCLUSIONS: Esophageal strictures are common, affecting between 1/100 and 1/1000 patients in the United States, with the highest rates seen in patients aged 75 years and older. Accordingly, strictures have a significant financial burden on the health care system, with costs greater than $1 billion annually.

Glucagon-Like Peptide-1 Receptor Agonists Do Not Increase Aspiration During Upper Endoscopy in Patients With Diabetes.

BACKGROUND & AIMS: Glucagon-like peptide-1-receptor agonists (GLP1-RAs) have been associated with greater retention of gastric contents, however, there is minimal controlled, population-based data evaluating the potential adverse effects of GLP1-RA in the periprocedural setting. We aimed to determine if there is increased risk of aspiration and aspiration-related complications after upper endoscopy in patients using GLP1-RAs. METHODS: We used a nationwide commercial administrative claims database to conduct a retrospective cohort study of patients aged 18 to 64 with type 2 diabetes who underwent outpatient upper endoscopy from 2005 to 2021. We identified 6,806,046 unique upper endoscopy procedures. We compared claims for aspiration and associated pulmonary adverse events in the 14 days after upper endoscopy between users of GLP1-RAs, dipeptidyl peptidase 4 inhibitors (DPP4is), and chronic opioids. We adjusted for age, sex, Charlson Comorbidity score, underlying respiratory disease, and gastroparesis. RESULTS: We found that pulmonary adverse events after upper endoscopy are rare, ranging from 6 to 25 events per 10,000 procedures. When comparing GLP1-RAs with DPP4i, crude relative risks of aspiration (0.67; 95% CI, 0.25-1.75), aspiration pneumonia (0.95; 95% CI, 0.40-2.29), pneumonia (1.07; 95% CI, 0.62-1.86), or respiratory failure (0.75; 95% CI, 0.38-1.48) were not higher in patients prescribed a GLP1-RA. When comparing GLP1-RAs with opioids, crude relative risks were 0.42 (95% CI, 0.15-1.16) for aspiration, 0.60 (95% CI, 0.24-1.52) for aspiration pneumonia, 0.30 (95% CI, 0.19-0.49) for pneumonia, and 0.24 (95% CI, 0.13-0.45) for respiratory failure. These results were consistent across several sensitivity analyses. CONCLUSIONS: GLP1-RA use is not associated with an increased risk of pulmonary complications after upper endoscopy compared with DPP4i use in patients with type 2 diabetes.

Efficacy and Safety of Liraglutide in Patients With an Ileal Pouch-Anal Anastomosis and Chronic High Bowel Frequency: A Placebo-Controlled, Crossover, Proof-of-Concept Study.

INTRODUCTION: After colectomy with ileoanal pouch anastomosis (IPAA), many patients develop high bowel frequency (BF) refractory to antimotility agents, despite normal IPAA morphology. Low circulating levels of glucagon-like protein-1 (GLP-1), a modulator of gastroduodenal motility, have been reported after colectomy. METHODS: Double-blind crossover study of 8 IPAA patients with refractory high BF treated with daily administration of the GLP-1 receptor agonist liraglutide or placebo. RESULTS: Liraglutide, but not placebo, reduced daily BF by more than 35% ( P < 0.03). DISCUSSION: Larger randomized controlled studies are warranted to delineate the treatment potential of GLP-1 receptor agonists in IPAA patients suffering from noninflammatory high BF.

Alpha-Gal Sensitization in a US Screening Population Is Not Associated With a Decreased Meat Intake or Gastrointestinal Symptoms.

INTRODUCTION: Patients with alpha-gal syndrome, a delayed reaction to mammalian meat, can present with isolated gastrointestinal (GI) symptoms. We aimed to estimate the frequency of alpha-gal sensitization in a Southeastern US population and determine the association between sensitization and mammalian product dietary intake or GI symptoms. METHODS: We performed a cross-sectional study of participants who underwent a screening colonoscopy at our center between 2013 and 2015. We quantified serum alpha-gal immunoglobulin E antibodies in participants who were prospectively enrolled at screening colonoscopy and compared diet intake and lower GI symptoms reported in standardized questionnaires among those with elevated versus no alpha-gal IgE antibodies. RESULTS: Alpha-gal IgE antibodies were common-31.4% of screening colonoscopy participants (127 of 404) had elevated serum alpha-gal IgE >0.1 kU/L. Alpha-gal-sensitized participants endorsed similar rates of abdominal pain compared with those without alpha-gal antibodies (33% vs 38%, adjusted odds ratio 0.9, 95% confidence interval 0.7-1.3). Mammalian meat consumption did not differ based on alpha-gal sensitization status (average 1.43 servings/d in sensitized subjects vs 1.50 in alpha-gal IgE-negative subjects, P = 0.9). Alpha-gal-sensitized participants with levels ≥10 (n = 21) were overrepresented in the lowest quartiles of mammalian meat consumption, but not among those with GI symptoms in general. Participants with high alpha-gal antibody levels >2 kU/L (n = 45) or ≥10 U/L (n = 21) did not have a reduced mean daily mammalian meat intake compared with seronegative people. DISCUSSION: Elevated alpha-gal IgE antibodies were common and not associated with a reduced mammalian meat intake, abdominal pain, or diarrhea. Seropositivity did not predict symptomatic alpha-gal sensitization in this general screening population. Other host factors likely contribute to the phenotypic expression of alpha-gal syndrome.

Adjuvant radiation therapy and health-related quality of life among older women with early-stage endometrial cancer: an analysis using the SEER-MHOS linkage.

PURPOSE: Radiation therapy (RT) has been associated with decreased health-related quality of life (HRQOL) in clinical trials of early-stage endometrial cancer (EC), but few studies have examined the association in real-world settings. We assessed HRQOL associated with adjuvant RT for older women with early-stage EC within a large U.S. population-based registry resource. METHODS: The Surveillance Epidemiology and End Results and the Medicare Health Outcomes Survey linkage (1998-2017) was used to identify women with early-stage EC aged ≥ 65 years at survey who received surgery and were diagnosed ≥ 1-year prior (n = 1,140). HRQOL was evaluated with the 36-item Short-Form Health Survey (SF-36) until 2006 and the Veterans RAND 12-Item Health Survey (VR-12) post 2006. Ordinary least squares regression was used to estimate mean difference (MD) in T scores and 95% confidence intervals (CIs) comparing treatment groups (surgery alone, adjuvant external beam radiation therapy [EBRT], or adjuvant vaginal brachytherapy [VBT]) after accounting for confounders using propensity score weighting. RESULTS: Overall, RT was not associated with physical health (MD = 0.97; 95% CI = - 1.13, 3.07) or mental health (MD = - 0.78; 95% CI = - 2.60, 1.05) relative to surgery alone. In analyses by RT type, adjuvant VBT was associated with better general health on the SF-36/VR-12 subscale (MD = 3.59; 95% CI = 0.56, 6.62) relative to surgery alone. No statistically significant associations were observed for adjuvant VBT and physical or mental health, or for adjuvant EBRT and any HRQOL domain. CONCLUSION: Older women with early-stage EC treated with adjuvant RT did not report worse physical and mental HRQOL scores compared to those treated with surgery alone, though relevant symptoms should be evaluated further to fully understand the disease and treatment specific aspects of the HRQOL.

Gastrointestinal outcomes among older women with endometrial cancer.

OBJECTIVE: Treatment for endometrial cancer may contribute to bowel dysfunction and other gastrointestinal outcomes. We investigated the risk of several gastrointestinal diagnoses among older women with endometrial cancer and matched women without a history of cancer. METHODS: Women aged 66 years and older diagnosed with endometrial cancer during 2004-2017 (N = 44,386) and matched women without a known cancer history (N = 221,219) were identified in the SEER-Medicare linked data. An index date was defined as the endometrial cancer diagnosis date in that matched set. ICD-9 and -10 diagnosis codes were used to define gastrointestinal outcomes, including constipation, abdominal pain, IBS, fecal incontinence, bowel obstruction, ileus, radiation enteritis or proctitis, colonic stricture, and vascular insufficiency of the bowel in the Medicare claims. Hazard ratios (HRs) for incident gastrointestinal diagnoses were estimated using multivariable Cox proportional hazards regression models. RESULTS: Compared to women without cancer, women with endometrial cancer had an increased risk of gastrointestinal symptoms after the index date, including constipation (HR = 2.27; 95% CI: 2.22-2.32), abdominal pain (HR = 2.94; 95% CI: 2.89-2.99), and fecal incontinence (HR = 1.96; 95% CI: 1.83-2.10). The risk of other gastrointestinal diagnoses was also higher among women with endometrial cancer (e.g., bowel obstruction: HR = 5.72; 95% CI: 5.47-5.98; ileus: HR = 7.22; 95% CI: 6.89-7.57). These associations were also apparent in sensitivity analyses limited to 1+ and 5+ years after the index date. CONCLUSIONS: Older women with endometrial cancer experience an excess risk of gastrointestinal diagnoses that may persist long after cancer diagnosis. Surveillance for these conditions may be a critical part of survivorship care.

Successful surgical correction of a cataract in a chimpanzee (Pan troglodytes) via field setting at a zoological facility.

A 41-year-old male vasectomized, zoo-housed chimpanzee (Pan troglodytes) presented with progressive visual deficits due to bilateral cataract formation. Phacoemulsification and lenticular implant were performed by a veterinary and human board-certified ophthalmologist team in a field setting. Post-operative healing occurred without complication, and the patient returned to the troop with improved vision.

Physiologic responses of Cownose Rays following freshwater dips for treatment of capsalid monogeneans.

OBJECTIVE: Two Cownose Rays Rhinoptera bonasus were presented for management of a severe capsalid monogenean infection Benedeniella posterocolpa in a mixed species habitat at an aquarium. METHODS: A series of freshwater (FW) dips were elected to mitigate parasite resistance to praziquantel due to the endemic monogenean population in the system. A pretreatment blood sample was opportunistically obtained, and subsequent samples were processed due to development of clinical signs. RESULT: While the first FW dip was tolerated well and did not induce abnormal behavior, the second led to one individual presenting with tachypnea, pallor, and lethargy. Marked hematological abnormalities requiring medical intervention occurred in both individuals after the second dip. After treatment with elasmobranch Ringer's fluid therapy, sodium bicarbonate, prednisolone acetate, and vitamin E/selenium in the more severely affected ray, and elasmobranch Ringer's alone in the second ray, hematologic derangements and symptoms resolved. Hemoconcentration, hyperproteinemia, hyperlactatemia, and hyperglycemia were attributed to a stress response. A selective loss of urea after exposure to FW resulted in decreased plasma osmolality. CONCLUSION: Given the severity of the stress response and associated complications observed, hyposalinity treatments should be utilized with caution in this species. If this therapy is employed, the clinician is advised to be prepared to administer supportive care coinciding with the FW dip if necessary.

BARIUM SULFATE GELATIN AS A NOVEL APPROACH TO FACILITATE GASTROINTESTINAL TRACT POSITIVE CONTRAST STUDIES IN A CAPTIVE HARBOR SEAL (PHOCA VITULINA) AND CALIFORNIA SEA LIONS (ZALOPHUS CALIFORNIANUS) WITHOUT RESTRAINT.

Gastrointestinal tract contrast medium studies are a valuable diagnostic modality to evaluate gastrointestinal anatomy, motility, and pathology. Four positive contrast medium studies were performed twice on a harbor seal (Phoca vitulina) and once each on two California sea lions (Zalophus californianus) to evaluate for gastrointestinal abnormalities by using barium-impregnated gelatin. Because marine mammals in human care routinely receive plain gelatin as a component of their diet and as secondary reinforcement, feeding a barium gelatin mitigates the need for tube feeding or restraint. Operant conditioning was used to position the pinnipeds for voluntary radiographs. The barium gelatin permitted adequate evaluation of gastric emptying and intestinal transit times and good evaluation of the structure of the intestinal tract. Full evaluation of gastric anatomy was limited due to the gelatin blocks not conforming to the stomach in their solid form and the barium quickly exiting the stomach as barium gelatin blocks disintegrated and because orthogonal views could not always be acquired. Even with these limitations, barium gelatin resulted in diagnostically valuable contrast imaging in a stress-free patient setting with reduced risk of aspiration and eliminated the effects that anesthesia can have on gastric motility as well as other anesthesia-associated risks.

Cardiovascular disease diagnoses among older women with endometrial cancer.

BACKGROUND: Endometrial cancer (EC) shares risk factors (e.g. obesity) with cardiovascular disease (CVD), yet little research has investigated CVD diagnoses among EC survivors. We aimed to describe the burden of CVD diagnoses among older women with EC compared to women without a cancer history. METHODS: Women aged 66+ years with an EC diagnosis during 2004-2017 (N = 44,386) and matched women without cancer (N = 221,219) were identified in the SEER-Medicare linked data. An index date was defined as the cancer diagnosis date of the EC case in that matched set. ICD-9/10 diagnosis codes were used to define CVD outcomes in the Medicare claims. Prevalent CVD was identified using diagnosis codes in the year before the index date. Hazard ratios (HRs) for incident CVD diagnoses after the index date were estimated using multivariable Cox proportional hazards regression. Women with a prevalent CVD were excluded from incidence analyses for that outcome. RESULTS: Compared to women without cancer, women with EC had a higher prevalence of CVD diagnoses at the index date. In analyses beginning follow-up at 1 year post-index date, EC survivors had an increased risk of incident CVD diagnoses including ischemic heart diseases (HR = 1.73; 95% CI: 1.69-1.78), pulmonary heart disease (HR = 1.95; 95% CI: 1.88-2.02), and diseases of the veins and lymphatics (HR = 2.71; 95% CI: 95% CI: 2.64-2.78). Risk of CVD diagnoses among women with EC was also elevated within the first year post-index date. CONCLUSIONS: Management of pre-existing CVD and monitoring for incident CVD may be critical during EC treatment and throughout long-term survivorship.

Falls, walking or balance problems, and limitations in activities of daily living (ADLs) among older endometrial cancer survivors.

PURPOSE: Functional status deficits are important quality of life concerns for older cancer survivors. We examined the prevalence of falls, walking/balance problems, and limitations in activities of daily living (ADLs) among older women with a history of endometrial cancer. METHODS: Cancer registry records from the Surveillance, Epidemiology, and End Results (SEER) program linked with Medicare Health Outcomes Survey (MHOS) data were used to identify endometrial cancer survivors aged ≥ 65 years who completed a survey ≥ 1 year after their cancer diagnosis (N = 3766), as well as an age- and race-matched group of women without a cancer history (N = 3766). We estimated prevalence ratios (PRs) to compare the prevalence of falls, walking or balance problems, and limitations in ADLs (bathing, dressing, eating, getting in/out of chairs, walking, using the toilet) between groups. RESULTS: Difficulty with walking or balance was more common among survivors than the noncancer group (43% vs 36%; PR = 1.19; 95% CI: 1.10-1.27). Fall prevalence was similar between groups (endometrial cancer: 25%; noncancer: 26%; PR = 0.98; 95% CI: 0.89-1.08). Nearly half of endometrial cancer survivors (47%) reported at least one ADL limitation, with several activities (getting in/out of a chair, walking, bathing, using the toilet) more often limited among survivors than among women without cancer. CONCLUSION: Functional impairments, especially problems with walking and/or balance, are common among older endometrial cancer survivors. Our results highlight the importance of addressing functional problems during the ongoing survivorship care of women with a history of endometrial cancer, with referral to rehabilitation or other relevant services when indicated.

BASELINE HEMATOLOGIC AND BIOCHEMICAL VALUES AND CORRELATIONS TO ENVIRONMENTAL PARAMETERS IN MANAGED JAPANESE SPIDER CRABS (MACROCHEIRA KAEMPFERI).

Although the evaluation of hematologic and biochemical parameters is a well-established diagnostic tool in vertebrate medicine, comprehensive understanding of these parameters in invertebrate species is lacking. This study provides baseline hemocyte concentrations and biochemistry values for a population of managed Japanese spider crabs (JSC; Macrocheira kaempferi) housed at six different public aquariums. The methodology for obtaining diagnostic hemolymph samples is described. Distinct hemocyte types were identified, including hyaline cells, semigranulocytes, and granulocytes, with hyaline cells as the predominant type. Correlates to exam findings and environmental parameters were evaluated and included higher absolute semigranulocyte counts (r = 0.65, P = 0.020) and triglyceride levels (r = 0.44, P = 0.014) in JSC with exoskeletal lesions; higher total protein (mean = 5.93 g/dl, P = 0.028), cholesterol (median = 18.5 mg/dl, P = 0.018), triglyceride (median = 15.5 mg/dl, P = 0.002), and amylase (median = 243 U/L, P = 0.013) in nonmolting JSC compared with JSC that have previously molted since acquisition (total protein mean = 4.83 g/dl, cholesterol median = 14 mg/dl, triglyceride median = 6.4 mg/dl, and amylase median = 131 U/L); and lower relative and absolute granulocyte counts (mean = 8.83% P = 0.030, median = 1,162 cells/µl P = 0.006, respectively) and higher albumin (median = 1.35 g/dl, P = 0.031) in JSC housed at facilities that used ozone sterilization. The data presented serve as a foundation for understanding basic clinical parameters in JSC hemolymph, as well as the potential influence of environmental stressors on those parameters.

Trends in the proportion of second or later primaries among all newly diagnosed malignant cancers.

BACKGROUND: Improvements in cancer survival mean that an increasing number of survivors may live long enough beyond their initial cancer to be diagnosed with additional independent primary cancers. The proportion of newly diagnosed cancers that are second- or higher-order primaries and how this proportion has changed over the past several decades were examined. METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) program were used to identify incident malignant primaries diagnosed between 1975 and 2017. Using the SEER sequence number, the authors tabulated the proportion of all cancers in each calendar year that were second- or higher-order primaries. The average annual percent change (AAPC) was then calculated to assess how this proportion has changed over time. RESULTS: Analyses included nearly 4.9 million incident cancers diagnosed during 1975-2017. The proportion of all cancers that were second- or higher-order increased steadily from 9.77% during 1975-1984 to 21.03% during 2015-2017, reflecting an AAPC of 2.41% (95% CI, 2.16%-2.65%). In 2015-2017, second- or higher-order cancers were most prevalent among cancers of the bladder (28.79%), followed by lung and bronchus (28.07%), melanoma (27.88%), and leukemia (26.10%). The highest AAPCs over the study period were observed for melanoma (4.05%), leukemia (3.51%), and lung and bronchus (3.36%). CONCLUSIONS: The proportion of newly diagnosed cancers that are second- or higher-order has grown rapidly over the past several decades and currently exceeds 20%. Continued monitoring of second and later primaries will be critical for anticipating the future impact on cancer treatment and survivorship care.

Material and psychological financial hardship related to employment disruption among female adolescent and young adult cancer survivors.

BACKGROUND: The importance of addressing adverse financial effects of cancer among adolescents and young adults (AYAs) is paramount as survival improves. In the current study, the authors examined whether cancer-related employment disruption was associated with financial hardship among female AYA cancer survivors in North Carolina and California. METHODS: AYA cancer survivors identified through the North Carolina Central Cancer Registry and the Kaiser Permanente Northern/Southern California tumor registries responded to an online survey. Disrupted employment was defined as reducing hours, taking temporary leave, or stopping work completely because of cancer. Financial hardship was defined as material conditions or psychological distress related to cancer. Descriptive statistics and chi-square tests were used to characterize the invited sample and survey respondents. Marginal structural binomial regression models were used to estimate prevalence differences (PDs) and 95% confidence intervals (95% CIs). RESULTS: Among 1328 women employed at the time of their diagnosis, women were a median age of 34 years at the time of diagnosis and 7 years from diagnosis at the time of the survey and approximately 32% experienced employment disruption. A substantial percentage reported financial hardship related to material conditions (27%) or psychological distress (50%). In adjusted analyses, women with disrupted employment had a 17% higher burden of material conditions (95% CI, 10%-23%) and an 8% higher burden of psychological distress (95% CI, 1%-16%) compared with those without disruption. CONCLUSIONS: Financial hardship related to employment disruption among female AYA cancer survivors can be substantial. Interventions to promote job maintenance and transition back to the workforce after treatment, as well as improved workplace accommodations and benefits, present an opportunity to improve cancer survivorship.

Primary intracranial fibrosarcoma in a southern sea otter Enhydra lutris nereis.

Southern sea otters Enhydra lutris nereis, a threatened marine mammal species, face numerous environmental and infectious disease challenges in their native habitat of coastal California, USA. However, there are few published cases describing neoplasia in sea otters despite their relatively long life span when cared for in aquarium settings. An 18 yr old neutered male southern sea otter, born and raised in human care, presented with an acute onset of seizures and dull mentation. Magnetic resonance imaging of the head revealed a large, central brain lesion. After no improvement with treatment, euthanasia was elected due to a poor prognosis. Grossly, a poorly demarcated, granular, tan mass expanded the cranial meninges in the longitudinal fissure at the level of the cruciate sulcus and extended into the underlying gray matter and superficial white matter. Histologically, the mass was composed of spindle cells, forming haphazardly arranged interlacing bundles and herringbone patterns, with a high mitotic count, moderate cellular pleomorphism, and prominent vascularization. Neoplastic cells demonstrated positive immunoreactivity for vimentin and negative immunoreactivity for smooth muscle actin, factor VIII-related antigen, S100, melan-A, E-cadherin, desmin, glial fibrillary acidic protein, and cytokeratin AE1/AE3. Based on gross, histologic, and immunohistochemical findings, the mass was most consistent with a primary intracranial fibrosarcoma (PIF). PIFs are a rare neoplasm in both humans and other animals with few reports in the veterinary literature. This is the first recorded case of a PIF in a sea otter.

DIAGNOSIS AND TREATMENT OF AN ENTEROCOCCUS FECALIS ABSCESS IN THE CRANIAL VAULT OF A SPOTTED EAGLE RAY (AETOBATUS NARINARI).

An adult female spotted eagle ray (Aetobatus narinari) presented for medical evaluation due to a swelling located on the dorsal head. Ultrasound revealed that the swelling originated from a large pocket of fluid in the cranial vault. The swelling was aspirated, and purulent discharge was obtained; Enterococcus faecalis was cultured. An incision was made over the swelling in an attempt to drain fluid but was unsuccessful. Multiple aspirates were performed to drain the abscess, and the animal was treated with oxytetracycline injections. The initial incision sloughed and resulted in a large defect in the cranium that allowed exhibit water to come into the cranial vault and come in contact with the protective membrane of the brain. Forty-two days after initial presentation, the defect in the cranium was healed; fluid from the cranial vault was sampled and appeared normal. During and after treatment, the ray exhibited no abnormal neurologic signs.

Noncancer mortality among adolescents and young adults with cancer.

BACKGROUND: Relative to the general population, cancer patients and survivors may have an elevated risk of mortality from noncancer causes, such as cardiovascular disease and infections, but few studies have examined rates of noncancer mortality among patients diagnosed as adolescents and young adults (AYAs) (ages 15-39 years). METHODS: The Surveillance, Epidemiology, and End Results database was used to identify AYA patients who were diagnosed with a first malignant cancer between 1973 and 2015. Rates of mortality from noncancer causes among AYAs with cancer were compared with those in the general US population using standardized mortality ratios (SMRs), adjusted for age, sex, race, and calendar year. RESULTS: Among 235,541 AYAs with cancer, a total of 12,948 deaths from noncancer causes occurred over 3.1 million total person-years of follow-up. Overall, noncancer mortality was significantly increased among AYAs with cancer relative to the general population (SMR, 1.84; 95% CI, 1.80-1.87). SMRs were particularly elevated for infectious diseases (SMR, 5.13; 95% CI, 4.95-5.32), cardiovascular disease (SMR, 1.55; 95% CI, 1.50-1.60), and renal diseases (SMR, 2.40; 95% CI, 2.12-2.71). These associations persisted for more than 20 years after cancer diagnosis. Cancer types associated with the highest SMRs for all noncancer mortality included leukemias (SMR, 5.26), Hodgkin lymphoma (SMR, 3.12), non-Hodgkin lymphoma (SMR, 6.33), central nervous system tumors (SMR, 3.38), head and neck cancers (SMR, 2.09), and cervical/uterine cancers (SMR, 2.03). CONCLUSIONS: AYAs with cancer have an elevated burden of mortality from noncancer causes that persists many years after cancer diagnosis, highlighting the importance of comprehensive, long-term follow-up care for noncancer conditions throughout survivorship.

Fertility-related experiences after breast cancer diagnosis in the Sister and Two Sister Studies.

BACKGROUND: Commonly used chemotherapies can be toxic to the ovaries. To the authors' knowledge, the majority of studies evaluating receipt of fertility counseling for women in their reproductive years have been performed in specific settings, thereby limiting generalizability. METHODS: A nationwide sample of US women diagnosed with breast cancer before age 45 years completed a survey assessing the prevalence of fertility counseling. Age-adjusted log-binomial regression was used to estimate prevalence ratios (PRs) and 95% CIs for fertility counseling. RESULTS: Among 432 survivors diagnosed between 2004 and 2011, 288 (67%) had not discussed the effects of treatment on fertility with a health care provider before or during treatment. Fertility discussion was associated with younger age (PR, 3.49 [95% CI, 2.66-4.58] for aged <35 years vs ≥40 years) and lower parity (PR, 1.81 [95% CI, 1.29-2.53] for parity 1 vs 2). Approximately 20% of respondents reported that they were interested in future fertility (87 of 432 respondents) at the time of their diagnosis, but not all of these individuals (66 of 87 respondents) received counseling regarding the impact of treatment on their fertility, and few (8 of 87 respondents) used fertility preservation strategies. Among 68 women with a fertility interest who provided reasons for not taking steps to preserve fertility, reasons cited included concern for an adverse impact on cancer treatment (56%), lack of knowledge (26%), decision to not have a child (24%), and cost (18%). CONCLUSIONS: Across multiple treatment settings, the majority of women of reproductive age who are diagnosed with breast cancer did not discuss fertility with a health care provider or use fertility preservation strategies. Discussing the potential impact of cancer treatment on future fertility is an important aspect of patient education.

Live birth outcomes after adolescent and young adult breast cancer.

Reproductive outcomes are an important survivorship concern for women diagnosed with cancer as adolescents and young adults (AYAs). We examined the incidence of live birth and the prevalence of adverse birth outcomes according to tumor and treatment characteristics among AYAs with breast cancer. Women diagnosed with breast cancer at ages 15-39 during 2000-2013 were identified using the North Carolina Central Cancer Registry (n = 4,978). Cancer registry records were linked to state birth certificate files from 2000 to 2014 to identify births to women with and without a breast cancer history. The breast cancer cohort was followed until live birth, death, age 46, or December 31, 2014, whichever occurred first. For each birth to breast cancer survivors (n = 338), we sampled 20 births to women without a recorded cancer diagnosis, with frequency matching on maternal age and year of delivery. The cumulative incidence of live births after breast cancer was 8% at 10 years. Births were less common among women treated with chemotherapy. Overall, the prevalence of preterm birth, low birth weight, small-for-gestational age (SGA) and Cesarean delivery did not differ substantially between births to women with and without breast cancer. However, births to women with ER-negative disease were more likely to be preterm (PR = 1.84; 95% CI: 1.11-3.06). In this population-based study, <10% of AYA breast cancer survivors had a live birth within 10 years of their diagnosis. The increase in risk of preterm delivery among ER-negative survivors in our cohort warrants further investigation in larger studies.

Conditional relative survival among long-term survivors of adolescent and young adult cancers.

BACKGROUND: Many studies have examined long-term outcomes after childhood cancer, but few address outcomes for adolescent and young adult (AYA; those aged 15-39 years) cancer survivors. Conditional survival reflects changing mortality risk with time since cancer diagnosis and is a useful measure for planning long-term follow-up care. METHODS: Using the Surveillance, Epidemiology, and End Results registry 9 database, the authors identified a cohort of AYA patients diagnosed with a first malignant cancer between 1973 and 2009 and followed through 2014. They estimated 5-year relative survival at the time of diagnosis and at each additional year survived up to 25 years after diagnosis, conditional on the individual being alive at the beginning of that year. RESULTS: A total of 205,954 AYA patients with cancer were identified. Thyroid cancer, melanoma, testicular cancer, breast cancer, lymphoma, leukemia, and central nervous system (CNS) tumors comprised 67% of all cancers. For all cancers combined, 5-year relative survival was 84.5% (95% confidence interval, 84.3%-84.7%) at 1 year after diagnosis and 94.0% (95% CI, 93.9%-94.2%) at 5 years. The relative survival first exceeded 95%, reflecting minimal excess mortality compared with the general population, at 7 years. Patients with thyroid cancer, testicular cancer, melanoma, and breast cancer reached a relative survival of >95% at the time of diagnosis and at 1, 3, and 18 years after diagnosis, respectively. Estimates for those with Hodgkin lymphoma and leukemia were >95% at 6 and 13 years, respectively, but declined to <95% at 20 years. AYA individuals with CNS tumors did not reach 95% by 25 years after diagnosis. CONCLUSIONS: For AYA survivors of breast cancer, CNS tumors, and hematologic malignancies, long-term excess mortality should be considered when planning follow-up care. Cancer 2018;124:3037-43. © 2018 American Cancer Society.