Introduction
Cancer is a
serious global public health issue, accounting for the third leading cause of
mortality worldwide, with one in every seven deaths in 2021. While cancer
usually affects the elderly, it is extremely rare in adolescents and young
adults (AYAs), accounting for approximately 5% of all cases (1). According to
the National Cancer Institute, cancer in AYAs refers to instances diagnosed
between the ages of 15 and 39. This age group is distinct from others in terms
of cancer types, risk factors, tumour biology, prognosis, and survival. Tumours
in AYAs differ molecularly from those in younger (<10 years) and older age
groups (>40 years), indicating potential differences in aetiology and
treatment effectiveness (2). Furthermore, they face a variety of
complex, age-related challenges, such as fertility preservation, long-term
adverse effects, socioeconomic burden, and issues related to mental health
(3,4).
The global burden of AYA cancer is increasing, with considerable
geographical variations in incidence and mortality. According to the recent
Global Burden of Disease (GBD) report, 1.19 million new cancer diagnoses and
396,000 cancer deaths occurred in AYAs worldwide (5). Cancer was the fourth
highest cause of mortality and the tenth leading cause of disease burden among
this age group, accounting for 23.5 million disability-adjusted life years,
according to the Global Cancer Observatory (GLOBOCAN) 2022 (6). However, in recent years, paediatric and adult
oncology populations have observed substantial improvements in survival rates,
although AYA populations have benefited less. Such improved survival rates have
been attained through improved care coordination, drug discovery, clinical
trial enrolment, and the rapid incorporation of novel therapeutic agents into
standard-of-care therapy (7).
Although the World Health Organisation (WHO) states that adolescents
(10-19 years old) are at the lowest risk of death, this has not been true for
adolescent malignancies (8,9). The remarkable survival improvements in young
haematological malignancies and sarcomas have not been extended to the AYA
population. Similarly, advancements in adult colorectal and breast malignancies
do not appear to improve results in the AYA population (9). Differences in
tumour biology may contribute to the limited therapeutic benefit seen in AYAs
despite systemic treatment advances (10). The AYA group has a reduced
likelihood of enrolling in clinical trials, a higher risk of non-adherence to
therapy, and a poorer psychosocial impact due to cancer diagnosis and
infertility. This study analysed the epidemiological patterns and outcomes of
solid organ cancers in the AYA age group at a tertiary care centre in Southern
India.
Materials and methods
This retrospective analysis was carried out
in the Oncology department at a tertiary hospital in South India after
obtaining approval from the Institutional Ethics Committee, MS Ramaiah Medical
College, Bengaluru, India with reference no. MSRMC/EC/SP-11/07-2022. The
medical records of all patients aged between 10 and 39 years diagnosed with a
non-haematological malignancy were retrieved. Informed consent was obtained
before inclusion in the study. Data was collected between January 2019 and
December 2021 from an electronic cloud-based database where physical medical
records were reviewed for missing data. The date of censoring is May 2022.
Those medical records with insufficient information or poor follow-up were
excluded from the analysis. Demographic characteristics, disease and
therapy-related details, applicability of genetic testing, completion of
planned therapy, and access to insurance were collected. The diagnosis was classified according
to the site of cancer.
The primary end point was to find the distribution
patterns and outcomes of solid organ cancers in the AYA age group. The
secondary endpoints were to compare this with the available data in Indian and
Western literature.
Descriptive statistics were used to summarise
patient and tumour characteristics. Survival analysis was represented using
Kaplan-Meier curves, and patients were censored at last follow-up. The P value
of less than 0.05 was considered significant. All the analyses were carried out
using SPSS software version 18.0.
Results
In this study, a total of 519 patients aged
less than 40 years were analysed during the study period; of these,
non-haematological cancers comprised nearly 20% of the population (N = 100). A
majority of the patients were in the 31-39 age group of 84% followed by the
21-30 age group of 14%. There was a female preponderance (61%) noted in this
study. About 36% of the AYA patients are in stage 3, followed by stage 4 (29%),
stage 2 (23%) and stage 1 (8%) as enumerated in Table 1. Also, 82% patients
were treated with curative intent.
Table 1. Patient characteristics.
|
Variables |
Outcome (Died=Yes) |
Total, N (%) |
P Value |
|
|
Yes |
No |
|||
|
Age (in Years) |
||||
|
10-20 |
0(0%) |
2(2.1%) |
2(2%) |
0.710 |
|
21-30 |
1(25%) |
13(13.5%) |
14(14%) |
|
|
31-39 |
3(75%) |
81(84.4%) |
84(84%) |
|
|
Gender |
||||
|
Male |
1(25%) |
38(39.6%) |
39(39%) |
0.654 |
|
Female |
3(75%) |
58(60.4%) |
61(61%) |
|
|
Stage
of tumour |
||||
|
Stage I |
0(0%) |
8(8.3%) |
8(8%) |
0.452 |
|
Stage II |
0(0%) |
23(24%) |
23(23%) |
|
|
Stage III |
1(25%) |
35(36.5%) |
36(36%) |
|
|
Stage IV |
3(75%) |
26(27.1%) |
29(29%) |
|
|
NA |
0(0%) |
4(4.2%) |
4(4%) |
|
|
Curative treatment |
||||
|
Yes |
2(50%) |
80(83.3%) |
82(82%) |
0.147 |
|
No |
2(50%) |
16(16.7%) |
18(18%) |
|
The three most common cancers observed were
breast cancer (32%), gastrointestinal cancer (20%), and head and neck cancer
(19%). Gastrointestinal cancers were mainly colorectal (60%) and gastric (20%)
in origin. Nearly half of the patients with Head and Neck Cancer had oral
cavity involvement (52%). Nasopharyngeal cancers were the second most prevalent
(N=6) in this subgroup. Cervical cancer was the most common gynaecological
cancer (61%) identified in this study. Only 30% of those diagnosed with gynaecological
cancer had ovarian cancer. Three of the four patients with genitourinary
cancers had renal cell carcinoma, with just one patient diagnosed with
testicular NSGCT. Sarcoma was diagnosed in only 4%, exhibiting varied histology
as listed in Table 2.
Table 2. Distribution of cancer among the study
subjects.
|
Diagnosis |
N (%) |
|
Breast |
|
|
Invasive
ductal carcinoma |
32(32%) |
|
Invasive
lobular carcinoma |
0(0%) |
|
Gastrointestinal Tract |
|
|
Esophagus
squamous cell carcinoma |
1(1%) |
|
Esophagus
adenocarcinoma |
1(1%) |
|
Stomach |
4(4%) |
|
Pancreatic
carcinoma |
2(2%) |
|
Colorectal
carcinoma |
12(12%) |
|
Head and Neck |
|
|
Oral
cavity- buccal mucosa |
10(10%) |
|
Hard
palate |
1(1%) |
|
Tongue |
1(1%) |
|
Oropharynx |
0(0%) |
|
Larynx |
1(1%) |
|
Nasopharynx |
6(6%) |
|
Gynecology |
|
|
Endometrium |
1(1%) |
|
Cervix |
8(8%) |
|
Ovary |
4(4%) |
|
Gestational
trophoblastic neoplasia risk |
0(0%) |
|
Central Nervous System |
|
|
Anaplastic
oligodendroglioma |
6(6%) |
|
Glioblastoma |
2(2%) |
|
Anaplastic
astrocytoma |
1(1%) |
|
Genitourinary Tract |
|
|
Renal
cell carcinoma |
3(3%) |
|
Bladder |
0(0%) |
|
Testicular
seminoma |
0(0%) |
|
Testicular
non-seminoma |
1(1%) |
|
Sarcoma |
|
|
Osteosarcoma |
1(1%) |
|
Chondrosarcoma |
0(0%) |
|
Soft
tissue- synovial cell sarcoma |
1(1%) |
|
Gastrointestinal
stromal tumour |
1(1%) |
|
Primitive
neuro-ectodermal tumours |
1(1%) |
|
Thorax |
|
|
Small-cell
lung carcinoma |
0(0%) |
|
Non-small
cell lung carcinoma |
2(2%) |
All patients were offered therapy, and 73%
completed the prescribed treatment. The reasons for treatment discontinuation
in 27% of patients were unavailable. About 80% of the patients underwent
first-line therapy, while 13% received second-line therapy. Additionally, 54%
of the patients did not have any identifiable hereditary cancer syndrome. Of
the 46% of patients who required genetic testing, only 25 (54%) underwent the
necessary testing, as shown in Table 3.
At a median follow-up of 18 months, 15% of
patients experienced disease relapse. The median overall survival for the two
most common cancers was 25.3 months for breast cancer (Figure 1) and 15.5
months for gastrointestinal cancer (Figure 2).
Table 3. Distribution of genetic testing and treatment
characteristics of study subjects.
|
Variables |
Outcome (Died=Yes) |
Total |
P Value |
|
|
Yes |
No |
|||
|
Treatment completed |
||||
|
Yes |
2(50%) |
71(74%) |
73(73%) |
0.571 |
|
No |
2(50%) |
25(26%) |
27(27%) |
|
|
Relapse |
||||
|
Yes |
1(25%) |
14(14.6%) |
15(15%) |
1.000 |
|
No |
3(75%) |
82(85.4%) |
85(85%) |
|
|
Median line of therapy |
||||
|
1 |
3(75%) |
77(80.2%) |
80(80%) |
0.072 |
|
2 |
0(0%) |
13(13.5%) |
13(13%) |
|
|
3 |
0(0%) |
6(6.3%) |
6(6%) |
|
|
4 |
1(25%) |
0(0%) |
1(1%) |
|
|
Genetic test applicable |
||||
|
Yes |
2(50%) |
44(45.8%) |
46(46%) |
1.000 |
|
No |
2(50%) |
52(54.2%) |
54(54%) |
|
|
Genetic testing done |
||||
|
Yes |
1(25%) |
24(25%) |
25(25%) |
1.000 |
|
No |
3(75%) |
72(75%) |
75(75%) |
|
Figure 1. Kaplan-Meier curve
of OS of AYA patients with breast cancer. Median OS: 25.3 months. OS, overall
survival; AYAs, adolescents and young adults.
Figure 2. Kaplan-Meier curve
of OS of AYA patients. Median OS: 15.5 months. OS, overall survival; AYAs,
adolescents and young adults.
The overall median survival was 20 months,
with a 96% survival rate at 2 years, as shown in Figure 3.
Figure 3. Kaplan-Meier curve
of OS of AYA patients with gastrointestinal
cancer. Median OS: 20 months. OS, overall
survival; AYAs, adolescents and young adults.
Discussion
The present study was an outcome analysis of solid organ cancers in the
AYA population. There were published data from India that have largely been
hospital-based and predominantly from the Northern region (11-13). Given the
country’s diverse ethnicity, geography and evolving lifestyle, this study is
pertinent in describing non-haematological cancers in the AYA population
residing in southern India. A recent study analysed data from 28
population-based registries (PBCR) and 58 hospital-based registries (HBCR) and
published a comprehensive cancer incidence in adolescents and young adults.
Similar to this study, cancer incidence was reported to be female
predominant, which contrasts with the findings of hospital-based studies
published from Northern India (11, 12).
All the published studies concur that the highest incidence was seen in
the fourth decade. Likewise, more than 80% of our patients were in
the 31-39 years age group. Similar to previously published studies, we found
breast cancer to be the most common cancer subtype (11-14). In addition, there
was a higher proportion of gastrointestinal cancers (20%), mainly colorectal
cancers. The statistics are comparable to those published by Singh et al. in
2016, perhaps reflective of a greater proportion of the older AYA population
reported in both studies (13). However, a study mapping the epidemiology of the
AYA population in the same geographical location in 2010 reported a low
incidence of GI cancers (10%), with only 3% being of colorectal origin. The
increase in the proportion of colorectal cancer to 60% of all GI cancers seen
in our study may be attributable to diet and lifestyle changes on colorectal
cancer (15). Consistent with previously published studies, the majority of our
patients have locally advanced tumours (11, 13, 14).
Metastatic or incurable cancers were reported in 29% of patients, which
was higher than that reported by Mathur et al. (14), though lower
than that reported by a hospital-based study from our neighbouring Bangladesh
(39.5%) (16). Despite presentation with advanced cancers, survival of “adult”
type cancers remains superior in the AYA population, with a 95% survival in our
cohort at a median follow-up of 18 months. We also report a higher proportion
of compliance with therapy, which perhaps translates to a 2-year survival rate
of 95%, in a major improvement of the 50% survival rate reported in a previous
study (12).
Genetic counselling and testing were mandated according to NCCN
guidelines in 46% of our population; however, only 25% underwent the necessary
testing. Barriers to genetic testing were not explored in this study, although
a study focusing on breast cancer patients alone identified financial
constraints and fear of emotional burden as primary reasons (17).To our knowledge, this is the first study to report on the
acceptance of genetic testing within the AYA population.
In this study, the median overall survival for the two most common
cancers was 25.3 months for breast cancer and 15.5 months for gastrointestinal
cancer. The overall median survival was 20 months, and the 2-year survival rate
was 96%. Similarly, Sundar et al. emphasised that AYA patients benefit from
several durable responses lasting more than 2 years (18).
The present study has several strengths, such as the limited number of
studies on AYAs in South India and its analysis of the survival of the study
participants. However, there were certain limitations, like a small sample size
and retrospective data collection. The major findings from our study show that
breast, colorectal, and head and neck cancers are the most frequent. Consistent
with prior studies, the majority are diagnosed at advanced stages. We endorse
the implementation of screening recommendations for the AYA population.
Additionally, awareness campaigns focused on cancer diagnosis and preventive
lifestyle modifications, including tobacco and smoking cessation, should be
extended to the AYA group. Government and public insurance schemes are pivotal
in providing quality cancer care for most of our patients. Future studies
focusing on quality of life, psycho-oncology, and oncofertility
in the Indian AYA population will shed light on largely unexplored areas.
Conclusion
This study evaluating non-haematological cancers in the AYA population found
breast, colorectal and head and neck cancers to be most frequent. The majority
have excellent survival beyond 2 years despite an advanced stage at
presentation. We also found a low rate of acceptance for genetic testing and
counselling. Notably, solid tumours were increasingly
seen in AYA cancer patients, and this could influence the choice of novel
therapy options.
Author contribution
SP, PJ, SM performed Conceptualization, Methodology, Writing, Original
Draft and Investigation. VVM, SKD performed Supervision and
Writing - Review & Editing. SP, SM performed Data Collection,
Software and Formal analysis. All authors reviewed the manuscript.
Conflicts of interest
There are no conflicts of interest.
Funding
There is no funding.
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