Central Nervous System Cancers Archives
Equitable access to care as well as improvements in cancer diagnosis and primary prevention strategies could prevent more than 2 million cancer deaths in women each year, according to a report published in The Lancet.1
Researchers studied premature cancer death in 2020 among women from 185 countries who had 36 cancer types.1,2 Of the 2.3 million women who died prematurely, an estimated 1.5 million could have avoided premature death via primary prevention or early detection strategies, and the remaining 800,000 deaths could have been prevented if women had equitable access to cancer care, according to researchers.
“[B]eing a woman impacts timely cancer care, more than being a man,” said Lancet report author Karla Unger-Saldaña, MD, of the National Cancer Institute of Mexico in Mexico City.
“[T]here are many mechanisms behind this — starting with different access to education, health literacy, cancer awareness, and gender roles that interfere with women’s ability to seek care,” she added.
Women Experience Delays in Cancer Diagnosis
“[W]omen tend to be disadvantaged from first access to care for cancer, even starting from diagnosis,” said Lancet report author Verna Vanderpuye, MD, of Korle Bu Teaching Hospital in Accra, Ghana.
Studies have suggested that several cancers tend to be diagnosed later in women than in men. Women tend to have longer times from first presentation to diagnosis for gastrointestinal, genitourinary, lung, hematologic, and other cancers.3-7
For example, in a UK study of 18,618 patients, women had delayed diagnoses of lymphoma, bladder cancer, colorectal cancer, gastric cancer, head and neck cancer, and lung cancer.7
Studies have also shown that women are more likely than men to first present with cancer symptoms at emergency rooms, with the greatest disparities seen for lung and gastrointestinal cancers.8,9
These delays in diagnosis can mean that women are diagnosed with cancer at later stages than men. Research has shown that women are diagnosed with colon, rectal, and bladder cancer at later stages than men.10-14
Delays in diagnosis may be partly explained by a lack of screening. For example, researchers found that health care providers are less likely to have discussions about lung cancer screening with women than with men.15 In addition, although screening has been shown to reduce the incidence of cervical cancer, many countries have not implemented widespread screening.16,17
How Sexism Impacts Access to Cancer Care
Sexism has been shown to impact women’s access to any type of health care, and this includes cancer care.1
“Disrespectful or even discriminatory health care resulting from health care providers’ gender biases and stereotypes” affects women’s ability to receive the care they need, Dr Unger-Saldaña noted.
Studies have shown that women’s health concerns are less likely to be taken seriously and managed appropriately than men’s.18,19 Women’s symptoms are more likely to be perceived as psychosocial, women are more likely to receive non-specific diagnoses, and they are more likely to be given prescriptions for psychoactive drugs.
A cancer-specific example of overlooking women’s health concerns is how physicians have delayed the diagnosis of breast cancer by inappropriately reassuring patients that a palpable mass is benign without performing a biopsy.20
Research has also suggested that women with cancer are more likely than their male counterparts to experience adverse events related to cancer treatment, to report inadequate pain management, and to have their sexual health concerns overlooked.21-23
“[I]n the area of breast and gynecologic cancers, only very recently have people focused on sexual health and sexual side effects of cancer treatment,” said Gita Suneja, MD, of the University of Utah in Salt Lake City, who was not involved in the Lancet report. “These are life-altering treatments that affect sexual health profoundly, yet we have long neglected women’s health and well-being.”
“Patriarchal ideas about women and women’s complaints often manifest in prevalent mistreatment, disrespect, negligence, and abuse of female patients by medical staff,” the authors of the Lancet report wrote. “These types of experiences can damage patients’ trust in health care providers and influence the patients’ willingness to participate in cancer screening or seek care for cancer symptoms.”
Another potential cause of suboptimal cancer care for women is the fact that they have been underrepresented in research, so cancers in women may not be as well understood as cancers in men.24,25 The causes of breast cancer, for example, are not well understood, despite the fact that breast cancer was the most commonly diagnosed cancer worldwide in 2020.1,26
“I think one of the key takeaways from our work was the degree to which sex and gender have not been adequately considered in cancer research, practice, and policy making,” said Lancet report author Ophira Ginsburg, MD, of the National Cancer Institute in Bethesda, Maryland. “We underestimated the massive role that gender-based and intersectional power dynamics play in the interactions of women with the cancer health system.”
Cost-Related Barriers and Intersectionality
Another barrier to optimal care that impacts women more often than men is the cost of care.1 Research has shown that women are more likely than men to have inadequate health insurance and to forgo medical care due to costs.19,27
In one study, women in Latin American countries reported that health care costs prevented them from undergoing breast cancer screening.28 In another study, women in Uganda reported that a lack of money for medical bills and transportation was the main reason they did not seek care for symptoms of breast cancer or cervical cancer.29
Women can also face barriers to care as a result of intersecting identities, such as race, ethnicity, sexual orientation, and gender identity.1 “Of course, gender intersects with other marginalized status to further complicate things,” Dr Unger-Saldaña noted.
For example, an analysis of 36 studies on access to cancer care among Indigenous people in Canada revealed that barriers to cervical cancer screening were “related to histories of trauma and abuse, including sexual and physical abuse, and residential school attendance,” as well as the inability to locate a female health care provider.30
Women belonging to sexual minority groups may also experience barriers that limit their ability to receive cancer care.1 In a US study, 29% of Black sexual minority women reported delays in breast cancer care of more than 3 months, compared with 11% of Black heterosexual women, 10% of White sexual minority women, and 5% of White heterosexual women.31
The Role of Primary Prevention Efforts
Primary prevention strategies — such as avoiding tobacco and alcohol — can prevent cancer deaths in women, but common sex-specific cancers in women are “generally not amenable to primary prevention,” the Lancet report authors noted.1 Overall, the proportion of cancers that are amenable to primary prevention strategies is greater for men than for women.
Women can benefit from interventions to reduce cancer risks, but these interventions must be gender-appropriate, according to the Lancet report authors. Women can benefit from tailored genetic testing, counseling about lifestyle changes, and HPV vaccination, for example.
Eliminating Disparities: Potential Solutions
The Lancet report authors said the report itself is a first step toward addressing disparities in cancer care.1
“The first thing is to bring the discussion to the fore,” Dr Vanderpuye said. “We need to revisit our social norms. We need to look at feminist economics.”
The report includes several recommendations for addressing disparities, such as routinely collecting and reporting data on sex, gender, and other sociodemographic factors in cancer populations; reducing exposures to known cancer risks for women; and devising strategies to increase equitable access to early cancer detection and diagnosis.
The report also recommends ensuring that health systems provide quality cancer care to women and integrating “a gender competency framework into the education and training of the cancer workforce.”
Dr Vanderpuye noted that such frameworks could “increase awareness of gender differences in cancer” and the need to prevent bias in cancer care.
Patient education is another area for improvement highlighted in the report. Educational interventions to increase women’s awareness of screening measures and cancer symptoms could lead to earlier diagnosis.
Dr Vanderpuye also suggested addressing “religious and cultural norms preventing women and girls from accessing timely care” and working to “increase enrollment of women and girls in clinical trials to direct quality care interventions.”32,33
Dr Ginsburg noted that the National Institutes of Health is offering a series of workshops on sex and gender cancer research that anyone can attend.
“This includes basic, translational, and clinical research where even sex as a biological variable has been under-examined as a factor that can influence treatment efficacy and toxicity… and the way that power dynamics influence a woman’s rights and opportunities to understand her cancer risks and to seek and obtain respectful cancer health services from primary and secondary prevention through treatment and survivorship care,” Dr Ginsburg said.
“There’s much more to be done, and we are hoping this [the Lancet report] will create a movement and generate not only interest but real-world actions to make a transformational change among our many partners, stakeholders, and those who might read the report in the future,” Dr Ginsburg said.
Disclosures: Drs Suneja, Ginsburg, and Unger-Saldaña reported having no conflicts of interest. Dr Vanderpuye and other Lancet report authors disclosed a range of affiliations that can be found in the report.
” [“post_title”]=> string(77) “Women and Cancer: Improving Diagnosis and Access to Care Could Prevent Deaths” [“post_excerpt”]=> string(176) “Sexism can prevent women from receiving equitable cancer care, according to researchers. Studies suggest that women face barriers to cancer screening, diagnosis, and treatment.” [“post_status”]=> string(7) “publish” [“comment_status”]=> string(6) “closed” [“ping_status”]=> string(6) “closed” [“post_password”]=> string(0) “” [“post_name”]=> string(59) “women-cancer-improving-diagnosis-access-care-prevent-deaths” [“to_ping”]=> string(0) “” [“pinged”]=> string(0) “” [“post_modified”]=> string(19) “2024-03-11 09:38:16” [“post_modified_gmt”]=> string(19) “2024-03-11 13:38:16” [“post_content_filtered”]=> string(0) “” [“post_parent”]=> int(0) [“guid”]=> string(46) ” [“menu_order”]=> int(0) [“post_type”]=> string(4) “post” [“post_mime_type”]=> string(0) “” [“comment_count”]=> string(1) “0” [“filter”]=> string(3) “raw” [1]=> object(WP_Post)#7189 (24) [“ID”]=> int(123281) [“post_author”]=> string(5) “45456” [“post_date”]=> string(19) “2024-03-05 10:20:00” [“post_date_gmt”]=> string(19) “2024-03-05 15:20:00” [“post_content”]=> string(8911) ”This article was updated from a prior version.
The gender pay gap among US physicians exists across specialties, with women consistently earning less than their male counterparts, recent data suggest.1
The data, released by Doximity, come from a survey of more than 190,000 US physicians over 6 years, including more than 31,000 full-time physicians in 2022.
The survey showed that men out-earned women across every medical specialty in 2022, and nearly all specialties had gender pay gaps greater than 10%. The exceptions were pediatric cardiology (with a gap of 9.2%) and nuclear medicine (with a gap of 3%).
The average annual salary for an oncologist in 2022 was $403,324 for women and $465,288 for men (a 13.3% pay gap). The average annual salary for a hematologist was $320,938 for women and $358,736 for men (a 10.5% gap). And the average annual salary for a pediatric hematologist/oncologist was $220,839 for women and $255,168 for men (a 13.5% gap).
A prior study, published in JAMA Network Open in 2022, showed similar results but revealed that the gender pay gap starts immediately after qualification and persists over time.2 In this study, female physicians earned less than their male counterparts in more than 90% of academic medical specialties, both when starting their careers and 10 years later.
This study included compensation data from 24,593 female and 29,886 male academic physicians across pediatric and adult subspecialties, both medical and surgical. The data showed that the average starting salary for women in academic medicine is 10% lower than the average starting salary for men (a median of $26,800 lower). After a decade on the job, the average salary for women is 9% lower (a median of $22,890 lower).
“We already know there are [pay] discrepancies at the moment of hiring, but women then tend to work twice as hard to get recognition, so my hope was that [the gender pay gap] was no longer there after 10 years, but the data shows that, in many cases, after 10 years, the pay discrepancies are even worse,” said Narjust Florez, MD, of the Dana-Farber Cancer Institute in Boston.
Women had a lower starting salary across 42 of the 45 subspecialties evaluated (93%). The average starting salary was $34,036 lower for women in adult hematology/oncology and $14,270 lower for women in pediatric hematology/oncology.
In contrast to the Doximity data, the JAMA Network Open study showed that women earned more than men in 3 subspecialties. They were all in pediatrics — gastroenterology, nephrology, and rheumatology. The study authors noted that pediatric specialties are a traditionally lower-paying area of medicine.
Year-10 salaries were lower for women in 43 of the 45 subspecialties (96%). The average year-10 salary was $6683 lower for women in pediatric hematology/oncology and $26,363 lower for women in adult hematology/oncology. The subspecialties in which women did not earn less than men were pediatric neurology and pediatric rheumatology.
The subspecialty with the largest pay disparity after 10 years was adult neurosurgery, with men earning about $333,000 more each year than women. Other subspecialties with large gaps at 10 years were adult cardiology and adult dermatology. The gap favoring men exceeded $100,000 annually, on average, for both of these subspecialties.
“Over the last few years, we’ve increasingly seen more objective data around all types of gender disparities in medicine,” said Pamela Kunz, MD, of Smilow Cancer Hospital and Yale Cancer Center in New Haven, Connecticut.
“Objective data is helpful, but I think that many of us in this space are starting to ask, how much more data do we need? There’s clearly a problem, and I think we need to really pivot towards focusing on the solutions,” she added.
Closing the Gap: Potential Solutions
Two interventions that could help close the gender pay gap are equalizing starting salaries and equalizing annual salary growth rates, according to the authors of the JAMA Network Open study.
They found that equalizing starting salaries for the subspecialties in which women earned less could increase women’s earning potential by a median of $250,075. Equalizing annual salary growth rates could increase a women’s earning potential by a median of $53,661.
Dr Duma noted that some institutions already equalize starting salaries. “Even when starting salaries are equal, there are many ways in which these rules can be broken,” she said. “For example, an institution may provide a signing bonus for a man and not for a woman, or more funding for research for men than women.”
“Salary often refers to base salary, and there are a lot of variable components that are missed in this,” Dr Kunz said. “Women often get asked to do more administrative tasks that may not be compensated fully, and there are differences in startup packages that are also very subjective.”
There are also nonacademic roles wherein women are less likely to be represented than men, including a presence on pharmaceutical and biotechnology advisory boards where honoraria are typically provided. Data on representation and compensation for those roles are lacking.
“Advisory boards have historically been predominantly male,” Dr Kunz said. “Roles like these not only have an impact on compensation but also have a downstream impact on opportunities to lead trials, to have podium talks, to be on other steering committees, which influence whether women get promoted and obtain leadership roles. So there is this huge domino effect.”
Additional Disparities
Dr Duma and Dr Kunz both pointed out that gender is only one variable affecting pay in academic medicine, and intersectionality involving other characteristics needs to be considered in approaches to tackle the gender pay gap.
“It’s important to recognize that women who have other underrepresented characteristics — whether it be race, age, disability — often carry an additional burden of disparities and face additional challenges,” Dr Kunz noted.
Addressing these disparities will likely require multiple approaches in parallel, but transparency about compensation is a start, the authors of the JAMA Network Open study noted. They pointed out that physician groups, including the American Medical Association and American College of Physicians, have implemented policies to promote transparency in compensation.
“As with many of the solutions around dismantling disparities, you have to be really deliberate and intentional to start trying to tackle them,” Dr Kunz said. “I think a key starting point is transparency around data and metrics for institutions and organizations; in many cases, we just don’t have access to the data.”
Disclosures: Dr Kunz and Dr Florez reported having no relevant conflicts of interest.
” [“post_title”]=> string(50) “Gender Pay Gap Persists Across Medical Specialties” [“post_excerpt”]=> string(163) “A survey of US physicians showed that men out-earned women across every medical specialty in 2022, and nearly all specialties had gender pay gaps greater than 10%.” [“post_status”]=> string(7) “publish” [“comment_status”]=> string(4) “open” [“ping_status”]=> string(4) “open” [“post_password”]=> string(0) “” [“post_name”]=> string(61) “gender-pay-gap-medicine-persists-across-specialties-over-time” [“to_ping”]=> string(0) “” [“pinged”]=> string(0) “” [“post_modified”]=> string(19) “2024-03-07 16:55:56” [“post_modified_gmt”]=> string(19) “2024-03-07 21:55:56” [“post_content_filtered”]=> string(0) “” [“post_parent”]=> int(0) [“guid”]=> string(46) ” [“menu_order”]=> int(0) [“post_type”]=> string(4) “post” [“post_mime_type”]=> string(0) “” [“comment_count”]=> string(1) “0” [“filter”]=> string(3) “raw” [2]=> object(WP_Post)#7188 (24) [“ID”]=> int(170367) [“post_author”]=> string(5) “45456” [“post_date”]=> string(19) “2024-02-28 10:30:00” [“post_date_gmt”]=> string(19) “2024-02-28 15:30:00” [“post_content”]=> string(15074) ”Research has suggested that multi-cancer early detection (MCED) tests have the potential to fulfill unmet needs in cancer diagnosis and care.1-8 However, experts say that cost-related barriers, potential regulatory roadblocks, and other issues must be addressed before MCED testing can be used more widely.
“MCEDs aim to detect multiple cancer types in asymptomatic individuals and may be especially useful for cancers that don’t have established early detection methods or screening guidelines,” said Eric Klein, MD, distinguished scientist at GRAIL in Menlo Park, California.
He added that the development of MCED tests “addresses a significant unmet need by expanding detection to include the 71% of cancers that are missed by current screening modalities for breast, cervical, colorectal, lung, and prostate cancers.”
At present, there are no MCED tests approved by the US Food and Drug Administration (FDA) or reimbursed by insurance companies, but some MCEDs can be ordered by health care providers as laboratory-developed tests (LDTs) under Clinical Laboratory Improvement Act (CLIA) regulations.9
Although there are multiple MCED tests in development, the only commercially available test is GRAIL’s Galleri, noted John B. Kisiel, MD, a gastroenterologist and professor at Mayo Clinic in Rochester, Minnesota.
Studies have suggested that Galleri can detect a cancer signal across more than 50 cancer types and predict the cancer site of origin if a signal is detected.2-4 Two other MCED tests, CancerSEEK (the precursor to Cancerguard) and SeekInCare, have been shown to detect more than 20 cancer types.5,6 And the SPOT-MAS and PanSEER tests can each detect 5 cancer types.7,8
The tests have demonstrated varied results as far as sensitivity, specificity, positive predictive value (PPV), and negative predictive value, but results with each test also vary by cancer type and disease stage.
Possible Regulatory Roadblock for MCED Testing
The evolution and availability of MCED tests may be impacted by recently proposed changes to LDT regulation.10 Historically, the FDA has regulated in vitro diagnostic (IVD) tests made outside of laboratories, but LDTs have been exempt from this oversight.
Last October, the FDA published a proposed rule that would amend its regulations to clarify that LDTs are medical devices under the Federal Food, Drug, and Cosmetic Act.The FDA would therefore phase out its general enforcement discretion approach for LDTs, and LDTs would be subjected to the same oversight as other IVD tests.
The FDA says the goal of this proposed change is to protect public health by providing greater assurance of the safety and effectiveness of LDTs, considering the rapidly increasing production and use of these tests.
Among its examples of the risks associated with LDTs, the FDA cited an article describing an oncologist’s experience with false results from the Galleri test.11 The oncologist reported 2 false positives and 28 false negatives produced by roughly 2000 Galleri tests administered over approximately 18 months. Galleri’s sensitivity was 6.7% in this case, but studies have suggested the test’s sensitivity is much higher. It was 51.5% in the CCGA study and 66.3% in the SYMPLIFY study.2,4
“Like all screening tests, MCEDs have some limitations, including false-positive and false-negative results and the potential to detect indolent cancers, and they do not detect all cancer types,” Dr Klein noted. “On the other hand, the positive predictive values of available tests are far higher than currently recommended screening tests.”
Galleri had a PPV of 38% in the PATHFINDER study, 44.4% in the CCGA study, and 75.5% in the SYMPLIFY study.2-4 Studies showed that SPOT-MAS had a PPV of 60%, CancerSEEK had a PPV of 19.4%, and SeekInCare had a PPV of 11.5%.5-7 In comparison, screening mammography for breast cancer and low-dose CT for lung cancer have demonstrated PPVs below 10%.12
If the FDA’s proposed changes are enacted, they could improve the quality and accuracy of MCED tests, having a positive impact on clinician confidence and patient outcomes, according to Julia Trosman, PhD, director and co-founder of the Center for Business Models in Healthcare in Chicago.
“Increased accuracy and the FDA stamp of approval may facilitate earlier reimbursement by both private payers and the Centers for Medicare and Medicaid Services [CMS], as we saw with tumor sequencing tests, especially if CMS and the FDA collaborate in a similar fashion as they did on the new drug application for tumor sequencing,” Dr Trosman said. A joint statement from the CMS and FDA noted that CMS supports the FDA’s proposed rule on LDTs.13
“Conversely, based on how burdensome the FDA application and process will be, the costs for labs offering MCEDs may increase, which, in turn, may be passed on to consumers paying out of pocket or insurers covering the test,” Dr Trosman said. Enactment of the rule may also lead to a reduction in the number of labs offering MCED testing, she added.
In response to a request for comment regarding the potential impact of the proposed LDT rule on Galleri specifically, a GRAIL spokesperson said, “We are actively engaging with FDA for submission of our breakthrough Galleri test under a premarket approval application. GRAIL’s clinical laboratory is regulated by governmental authorities including CMS under CLIA, and the Galleri test is approved by the New York State Department of Health.”
The FDA’s target date for the final rule on LDTs is April 2024, and the agency expects to gradually end its current enforcement approach for LDTs over a subsequent 4-year phaseout period.10,14
Other Barriers to Wider Use of MCED Testing
Cost is a major barrier to wider use of MCED testing, according to Sana Raoof, MD, PhD, a resident at Memorial Sloan Kettering Cancer Center in New York, New York.
Although people who can afford to pay out of pocket can already access MCED testing, cost represents a significant barrier to expanding MCED access to greater numbers of patients, she noted.
“There is a toss-up between waiting for more evidence of benefit vs taking an approach where we perhaps make decisions about conditional approvals and insurance coverage based on preliminary data so that all individuals may access these molecular screening tests,” Dr Raoof said. “Longer clinical trials and definitive evidence can instead be used for final approval decisions. This is one possible approach to minimize the disparity in access.”
Dr Kisiel noted that another issue, which is tied to cost, is coordinating downstream testing for patients with positive MCED test results. This “requires clinical resources and may incur additional costs, some of which may be out of pocket before MCEDs are broadly adopted,” he said.
Dr Raoof added that there is a need for guidelines outlining optimal protocols for working up a positive MCED test, and Dr Kisiel highlighted the need for guidance around counseling patients.
“It would be ideal for providers and health care systems to have a ‘playbook’ or protocol for counseling patients on MCED test expectations and results, as counseling patients on this technology requires time and may be overwhelming for busy practitioners,” Dr Kisiel said.
He also noted that more research on MCED testing is needed across various patient populations. “We do not yet fully know the performance of MCEDs in high-risk populations or how often to use them in average-risk or increased-risk patients,” Dr Kisiel said. “Additionally, there is not sufficient data to suggest that MCEDs should be used to replace standard of care cancer screening. Ongoing efforts to validate the effectiveness of MCED testing in diverse populations will also promote more widespread adoption.”
Current and Future Research on MCED Testing
Current research on MCED testing includes studies aiming to refine test performance and optimize diagnostic work-ups following positive test results, Dr Klein said. “In addition, we are engaged in implementation research to understand how best to introduce these tools into routine care and how to educate both clinicians and patients about their utility and limitations,” he added.
From Dr Raoof’s perspective, the most exciting trial in the MCED space at present is a randomized controlled trial (NHS-Galleri) investigating “whether using the methylation-based GRAIL test will reduce late-stage cancers.”15 The trial is being conducted in the UK with 140,000 asymptomatic adults aged 50 to 77 years.
According to Dr Kisiel, the focus of ongoing MCED research falls under 2 broad domains.
“Test manufacturers are likely to focus on regulatory approval and reimbursement, with questions tailored to defining the intended use population in terms of age, risk level, and other factors, and then measuring test performance in those patients,” Dr Kisiel said. Such studies will enroll large numbers of patients who will be retested annually to help determine the ideal testing frequency, he added.
“These studies will cost hundreds of millions or even billions of dollars but could help us learn the optimal pathways to cancer diagnosis or resolution of false-positive test results,” Dr Kisiel said. “These companies and academic collaborators are also modeling the potential long-term costs and cost-effectiveness of MCED testing.”
The second broad area of research may elucidate issues that could ultimately result in society endorsement and guideline adoption for MCED testing, Dr Kisiel said.
“This will require demonstration of benefits such as improved survival by down-staging cancers or even reducing mortality from specific cancers, especially those that we can’t already effectively screen for,” he explained. Research will also need to demonstrate that the broader adoption of MCED testing will not result in unnecessary invasive procedures or overdiagnosis of indolent cancers, according to Dr Kisiel.
“We hope to see that MCEDs improve access to cancer screening for underserved populations rather than increasing disparities, especially on the basis of wealth gaps,” Dr Kisiel said. He also added that patients should not avoid standard cancer screening, which can reduce mortality in colorectal, breast, cervical, and lung cancer “before we can establish that MCEDs can do the same.”
Disclosures: Dr Klein is an employee of GRAIL. Dr Raoof is a consultant to Verily, Exact Sciences, and GRAIL. Dr Kisiel is an inventor of intellectual property in the field of MCED that is licensed to Exact Sciences by Mayo Clinic, and Exact Sciences is a sponsor of his research. He may receive royalties and research funding from these relationships, both paid to Mayo Clinic. Dr Trosman disclosed NIH funding for a 2023 study on private payers’ perspectives on MCED.
” [“post_title”]=> string(58) “MCED Testing for Cancer Diagnosis: Progress and Roadblocks” [“post_excerpt”]=> string(137) “Multi-cancer early detection tests could change the way we diagnose cancers, but there are barriers preventing wider use of these tests. ” [“post_status”]=> string(7) “publish” [“comment_status”]=> string(6) “closed” [“ping_status”]=> string(6) “closed” [“post_password”]=> string(0) “” [“post_name”]=> string(49) “mced-testing-cancer-diagnosis-progress-roadblocks” [“to_ping”]=> string(0) “” [“pinged”]=> string(0) “” [“post_modified”]=> string(19) “2024-02-28 10:29:18” [“post_modified_gmt”]=> string(19) “2024-02-28 15:29:18” [“post_content_filtered”]=> string(0) “” [“post_parent”]=> int(0) [“guid”]=> string(46) ” [“menu_order”]=> int(0) [“post_type”]=> string(4) “post” [“post_mime_type”]=> string(0) “” [“comment_count”]=> string(1) “0” [“filter”]=> string(3) “raw” [3]=> object(WP_Post)#7187 (24) [“ID”]=> int(169796) [“post_author”]=> string(5) “45456” [“post_date”]=> string(19) “2024-02-16 10:45:00” [“post_date_gmt”]=> string(19) “2024-02-16 15:45:00” [“post_content”]=> string(9614) ”Childhood cancer survivors are at risk of developing second cancers and a range of chronic health problems, but a lack of awareness and infrastructure may prevent them from receiving the care they need, experts say.1,2
A recent review suggested that the most common severe or life-threatening chronic health problems related to childhood cancer and its treatment are endocrine disorders, subsequent cancers, and cardiovascular disease.1
The greatest risk of treatment-related health problems has been seen in patients who had brain cancer treated with cranial irradiation and in patients who received allogeneic hematopoietic stem cell transplants, the review suggests. Patients with the lowest risk of treatment-related health problems are those who had solid tumors that were treated with surgery alone or minimal chemotherapy.
“The findings in this paper are not surprising to those who work in childhood cancer survivorship … , but most oncologists are not specialists in survivorship,” said review author Wendy Landier, PhD, RN, of the University of Alabama at Birmingham.
“After treatment, oncologists often refer patients to survivorship clinics or primary care providers, so sometimes they’re not aware of these long-term complications that happen as children grow and develop.”
Conditions Affecting Childhood Cancer Survivors
For the review, Dr Landier and her colleagues collected and analyzed data from 73 studies published during 2000-2023.1 The data showed that childhood cancer survivors may experience anxiety, depression, and financial hardship as well as a range of long-term side effects of therapy, as outlined in the table below.
These conditions can have significant consequences on the lifespans of patients who survived childhood cancer, the review suggests. In one study cited in the review, researchers assessed the lifespans of 22,150 patients who survived 5 years or more after a childhood cancer diagnosis.3 The results showed that patients diagnosed with cancer in the 1970s had an average predicted life expectancy of 48.5 years, while those diagnosed in the 1990s had a predicted life expectancy of 57.1 years.
“The chances of childhood cancer survivors living a longer life are improving over time because the treatments in the ’70s and the ’80s were harsher than they were in the ’90s and then in the 2000s,” Dr Landier said. “For a long time now, there have been efforts to better refine treatments to spare childhood cancer survivors from short- and long-term side effects, particularly in cancers with a high survival rate, like B-cell acute lymphoblastic leukemia.”
“Another theme highlighted in this review is that risks faced after treatment for childhood cancer are not static,” said Lynda M. Vrooman, MD, of the Dana-Farber Cancer Institute and Boston Children’s Hospital.
“Risks change over time, since different medical conditions may develop at different time periods after the treatment exposure,” she explained. “For example, congestive heart failure, associated with anthracycline chemotherapy, can occur in the acute setting (while receiving therapy) but can also develop later in life as a risk that persists over time. Endocrine issues may also evolve over time.”
Recommendations and Obstacles to Care
Although an increased risk of treatment-related health conditions is inevitable for most childhood cancer survivors, healthy behaviors, such as avoiding smoking, using sun protection, and engaging in regular physical activity can help mitigate these risks, according to the review authors.1
The authors also noted that routine screenings can identify health conditions sooner, allowing for earlier interventions and better outcomes. For example, the authors recommend that childhood cancer survivors undergo yearly screenings that include a “thorough history and physical examination, general health screening (including measurement of blood pressure and body mass index), and psychosocial and mental health assessments.”
Yearly screenings should include age- and sex-appropriate preventative care recommended by the US Preventive Services Task Force as well, according to the authors.
The authors also recommend that childhood cancer survivors have dental evaluations every 6 months and that certain patients have yearly ophthalmology evaluations, echocardiograms every 5 years, and audiological evaluations every 5 years.
These recommendations may be challenging to follow, however, and some patients may not receive the long-term care they need, according to Matthew J. Ehrhardt, MD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.
“Over the last 15 to 20 years, we’ve built up a nice network of childhood cancer survivor clinics in the US, but, in most cases, childhood cancer survivors transition out of those clinics when they reach adulthood,” Dr Ehrhardt said. “At the country level, pediatric cancer survivorship clinics don’t have the capacity to see all adult survivors of childhood cancer, but adult survivorship clinics are not typically set up to transition childhood cancer survivors into adult survivorship programs. It’s a major challenge.”
“We need better systems to transition care for childhood cancer survivors either to well-equipped primary care providers that understand the challenges that these patients face or into more adult-based practices that are providing survivorship care to these patients,” Dr Ehrhardt added.
One program designed to overcome obstacles to survivorship care is “Passport for Care,” which was developed by faculty members at Texas Children’s Cancer Center and Baylor College of Medicine in Houston. Passport for Care is a free online resource for childhood cancer survivors that allows them to access information about their specific cancer type and treatment exposures as well as recommendations about long-term follow-up care.
Other resources for childhood cancer survivors can be found on institutions’ websites. For example, Lurie Children’s Hospital of Chicago and Children’s Hospital of Philadelphia both provide resources for adult survivors of childhood cancer.
Disclosures: Drs Landier, Vrooman, and Ehrhardt said they have no relevant conflicts of interest.
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