CANCER IN ADOLESCENTS AND YOUNG ADULTS

Dr. T. Sujit , DMRT

Consultant Radiation Oncologist Thanjavur Cancer Centre

CANCER IN ADOLESCENTS AND YOUNG ADULTS

Dr. T. Sujit , DMRT

Consultant Radiation Oncologist Thanjavur Cancer Centre

What is it ?

Cancer in people in the age group of 15 29 years.

Terminologies :

AYA Adolesecents & Young Adults with cancer

TYA Teenagers & Young Adults with cancer AGE - ? 15 29

- ? 15 39

Why ? - 1

PAEDIATRIC CANCERS NON EPITHELIAL TYPES

CANCER IN AYA A MIX OF BOTH

ADULT CANCERS EPITHELIAL TYPE

Why ?

-2

Uniqueness of epidemiology

Age, race, gender,

C H E N N A i

2 0 0 0 2 0 0 4

Male

female

. POPULATION BASED CANCER REGISTRY, CHENNAI Cancer Institute (WIA), Adyar, Chennai

Why ? - 3

Uniqueness of histology & tumor biology

Non-epithelial and epithelial histologies in almost equal distribution. Chennai males : nhl, brain & nervous system, hnscc,

Females : breast, cervix, nhl

US & Canada : lymphomas & leukemia,thyroid sarcomas, melanoma,

Limited response to treatment and poor prognosis suggest tumor biology is different from other age groups having the same tumors.

1. Ca nce r Epidemiology in O lde r Adole sce nts a nd Young Adults 15 to 29 Ye a r s of Age INCLUDING SEER INCIDENCE AND SURVIVAL: 1975-2000 2. POPULATION BASED CANCER REGISTRY, CHENNAI Cancer Institute (WIA), Adyar, Chennai

Uniqueness of h&n cancer in AYA

Typical age group for HNSCC : 6th - 7th decade Site : oral cavity & oropharynx , Npx, Thyroid. Usually diagnosed in advanced stage Early nodal metastases ? High grade histology

1. Verschuur HP, Irish JC, O'Sullivan B, Goh C, Gullane PJ, Pintilie M. A matched control study of treatment outcome in young patients with squamous cell carcinoma of the head and neck. Laryngoscope. Feb 1999;109(2 Pt 1):249-58 2. Veness MJ, Morgan GJ, Sathiyaseelan Y, Gebski V. Anterior tongue cancer and the incidence of cervical lymph node metastases with increasing tumour thickness: should elective treatment to the neck be standard practice in all patients?. ANZ J Surg. Mar 2005;75(3):101-5

Risk factors for HNSCC in AYA

Tobacco Alcohol Hiv Hpv

Ebv - nasopharynx
? genetic susceptibility - unproven

HPV in AYA with HNSCC

31% of oral cavity cancers in india are HPV +ve Types : 16,18, 31, 33, 35 associated with hnscc. MC type : hpv type 16 ; 90 95 % of hpv +ve tumors Hpv +ve tumors - typically small 't' size but with large ,cystic nodes

1. Impact of HPV in Oropharyngeal Cancer Journal of Oncology Volume 2011 (2011), Article ID 509036, 6 pages doi:10.1155/2011/509036 Linda Marklund and Lalle Hammarstedt Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Karolinska University Hospital, Sweden.

HPV in AYA with HNSCC

RISK FACTORS FOR HPV ASSOCIATED HNSCC:

Multiple sex partners oral & vaginal

High number of open mouth kissing partners Young age of first sexual experience
H/o genital warts

Tobacco reduces local mucosal immunity ? alcohol

HPV - carcinogenesis

Challenges in treatment of HNSCC in AYA

The improvements in outcomes for AYA lag behind those seen in cancer treatment for the very old and the very young (Levi 2003, Thomas et al. 2006) Distinct age group unique medical & psychosocial needs.
Managing chronic / delayed sequelae of treatment Probability of second primaries Socio-economic issues: marriage, fertility, career etc.

Challenges in treatment of HNSCC in AYA

SURGERY

Organ preservation Vs cure

Organ function Cosmesis Fibrosis Xerostomia

Limited neck dissections

RADIATION THERAPY

Highly conformal radiation therapy 3dcrt, imrt, tomotherapy, igrt, 3D brachytherapy Sperm banking, surrogacy

Trismus
Second primaries

CHEMOTHERAPY

fertility

Treatment of HPV +ve tumors

HPV positive tumors much more radiosensitive than HPV negative tumors

HPV infected cells not damaged as severely as cells that are repeatedly exposed to carcinogens
5 year survival for HPV + tumors = 82% 5 year survival for HPV - tumors= 32%

Smokers with a HPV+ tumor - overall worst prognosis University of Michigan Comprehensive Cancer Center

Recurrence rates :

Patients with HPV+ and current smokers = 35 % Patients with HPV+ and smoking history= 17%

Patients with HPV+ and no smoking history= 6%

Outcome & Prognosis

Distinct lack of progress in survival improvement even after 25 years in western countries

Outcome & Prognosis

Presence of co-morbidities lesser compared to other age groups Delay in diagnosis Availability of multi-modal , scientific approach Cost of diagnosis, treatment & long term follow-up.

What is needed ?

Challenge = Opportunity

Recognise as a separate entity collaborate data among institutions.

Etiologic research possibility of prevention & risk reduction.

What is needed ?

Research & Surveillance on effects of cancer diagnosis & treatment

Adverse health events

Psycho-socio-economic issues

Ongoing surveillance of incidence

Young persons more likely to adopt new habits than the old. Eg. Glue sniffing.

Awareness & screening programmes

In Conclusion

AYA most dynamic & very productive age group. Cancer in adolescents & young adults should be recognised as a separate entity. Programmes aimed at educating the public about risk factors and early diagnosis.

Multimodal approach best chances of cure

Pro-active , lifelong follow up

Need for collaborative clinical trials all aspects.