ORLANDO, FL—The number of cancer survivors in the US is now approximately 9.8 million, a statistic that is a testament to the tremendous progress that has been made in treating cancer. One age group, however, seems to have fallen through the cracks—people diagnosed between the ages of 20 and 50.
Archie Bleyer, MD, made these remarks during a “Meet the Expert” session for the media held here at the ASCO Annual Meeting. Dr. Bleyer recently left the University of Texas M. D. Anderson Cancer Center to join St. Charles Cancer Treatment Center in Bend, Oregon, where he is Medical Advisor and continues as Director of Aflac Research Projects in Adolescent & Young Adult Oncology for the Children's Oncology Group.
This age group represents 16% of all patients diagnosed with cancer between 1996 and 2000, he noted. “Our national progress against cancer in children is well known. We've done very well with children under the age of 15 [an arbitrary cut-off for designating someone a child].” The five-year survival rate in children under 15 improved from 58% in 1975 to 80% in 1997, an average annual change of 1.68%.
The group of patients diagnosed with cancer between the ages of 50 and 80 years has benefited even more than children from advances in diagnosis and treatment. “Less well known is the remarkable improvements in prolonging survival in adults, especially those between the ages of 50 and 80,” Dr. Bleyer continued. “This group of patients enjoys improved prolongation of five-year survival compared with that experienced by children. Progress against cancer in most adults has been underestimated.”
Patients diagnosed with cancer between the ages of 60 and 80 years represent 50% of all cancers diagnosed in the US, and the average annual improvement in five-year survival for this group is 2.12%. Those aged 50 to 85 at the time of diagnosis represent 70% of all cancers, and the average annual improvement in that group is 1.86%.
Progress in adults is attributable to many factors, including earlier detection, improved ability to conduct basic and translational research, improved technology, treatment innovations, and improvements in supportive care, Dr. Bleyer said.
But for patients age 20 to 50 at the time of diagnosis, he said, “we have seen no progress over the past 24 years in prolonging five-year survival. This is an orphaned group.”
The reasons for this poor performance appear to be multifactorial. Some of them relate to lack of health insurance. People between the ages of 18 and 30 are the least likely to be insured, Dr. Bleyer noted, and many children lose insurance when they leave home and aren't likely to get health insurance until they reach age 40, mainly because they can't afford it.
Uninsured patients between the ages of 15 and 29 have been reported to have the longest time to diagnosis of cancer compared with people who are insured through their workplace and those who are self-insured.
“These patients are also harder to treat, because they have more advanced cancers,” he noted.
‘Hole in Our Training’
Another factor that may contribute to the gap in progress for those age 20 to 50 is that there is no specific medical discipline for young adult oncology. This lack of certification reflects “a hole in our training,” he noted.
“We have pediatric oncology and adult oncology, but no oncology for those whose ages are in between.”
The lack of early detection in this age group is a major problem, Dr. Bleyer said, noting that college medical staffs don't check students for cancer because they are not trained properly.
“When cancer is present, they aren't educated about how to detect it,” he said. Also, this age group may not seek medical advice because they are embarrassed about breast or testicular masses.
Monitoring for Late Effects of Cancer
Dr. Bleyer also discussed the treatment of people who develop cancer as children and then have difficulty finding experts to treat them as they reach young adulthood.
This group of patients is at risk for recurrences, second cancers, and delayed side effects from chemotherapy and radiation. Many parents still bring their sons and daughters who developed childhood cancer and are now 25 or 30 years old to children's clinics because there is nowhere else to go, he noted.
“There is no national system organized to deal with this group of cancer survivors. Less than 20% of survivors of childhood cancer are followed after age 30.”
Dr. Bleyer said that the Children's Oncology Group (COG) has tried to remedy the situation by developing risk-based guidelines, now available online at www.survivorshipguidelines.org
“These guidelines help generalists and specialists assess risks in survivors of childhood cancer. They are the best current resource in learning how to help a child with cancer,” he noted.
Perhaps some of these unmet needs will be met by ASCO's new Survivorship Task Force, which will identify and manage a range of initiatives to improve the quality of care for cancer survivors, he said.
ASCO also plans to develop Clinical Practice Guidelines for physicians on issues related to late effects of cancer treatment, secondary cancers, and psychosocial issues for survivors.