MDNews - Central Pennsylvania

Two-thirds of the patients in the study received treatment in an adult cancer center, and of that number, only 33 percent received pediatric regimens in those facilities. Nearly 87 percent of younger AYAs — patients age 15–18 — were treated in a pediatric setting. However, only 16 percent of 19- to 24-year-old patients received care in pediatric cancer centers, and more than 98 percent of 25- to 39-year-old patients were treated in adult cancer centers. Patients treated in pediatric settings as well as those treated in National Cancer Institute (NCI)-designated Comprehensive Cancer Centers or Children's Oncology Group (COG) centers enjoyed sizable advantages in overall survivability, with hazard ratios of 0.53 for pediatric settings and 0.80 for the latter two settings. The data showed a positive trend that may indicate greater recognition in the medical community of the importance of referring AYAs to pediatric cancer centers: The percentage of AYAs who received care in such centers increased by more than seven points during the study period. WHAT SETS PEDIATRIC CENTERS APART? To the study's authors, pediatric cancer centers' expertise is key. "[ALL] is the bread and butter of pediatric oncologists," says Dr. Muffl y, lead author. "Would you rather go to a surgeon who performs two heart transplants a year or 150?" "There's a standard of care given at [pediatric cancer centers] that's elevated compared to other centers," Dr. Alvarez says. "[T]here's more ability to administer chemotherapy per the protocol, enroll patients on [new] protocols, and have social services and things like that, that AYAs might need." The fi ndings echo those of a 2017 study by a group that included Julie Wolfson, MD, MSHS, Assistant Professor of Pediatrics and a member of the Institute for Cancer Outcomes and Survivorship at the University of Alabama at Birmingham. Using data from Los Angeles County, California, that group found that 15- to 29-year-old ALL patients treated in specialized cancer centers enjoyed much higher survival rates than peers who did not visit such centers. The reasons for that advantage are likely multifactorial and include supportive care, a multidisciplinary approach to care, clinical trial enrollment and the dual presence of clinical work and research, according to Dr. Wolfson, who treats patients at Children's of Alabama. She says compliance is likely a key factor in the advantage patients in the pediatric model hold. "The internal medicine model is very individualistic, [whereas] the pediatric model is more of a paternalistic model where the system will not let you fall off ," Dr. Wolfson says. "From many diff erent angles, the system is reminding you, supporting you and helping you to stay on time. Adherence on the patient's part to staying on schedule is probably enhanced ... in a pediatric model due to the diff erences in the ways we operate." Dr. Muffl y says referring clinicians must carefully assess which care setting will give their patients the best opportunity to do well. ALL is extremely rare in adults and potentially curable, she says, but management of the disease is evolving rapidly. "When you see a patient with ALL, strong consideration should be [given to] where they would receive the most up-to-date, compre- hensive care in 2018," Dr. Muffl y says. n Additional Angles to Explore FOR LORI MUFFLY, MD, MS, Clinical Assistant Professor of Medicine–Blood and Marrow Transplantation at Stanford University, and Elysia Alvarez, MD, MPH, Assistant Professor of Clinical Pediatrics at the University of California, Davis, the effect of care setting on outcomes for adolescents and young adults with acute lymphoblastic leukemia is still shrouded in questions. "We're putting together a bunch of ideas, trying to attack this from every angle, trying to fi gure out how you can take these [study fi ndings] to a policy level," Dr. Muffl y says. "One idea we've been talking about is doing some studies of both providers and patients to fi gure out how these patients get where they get [for treatment]." Dr. Alvarez says it will be important to pinpoint factors that account for differ- ences in outcomes between pediatric and adult cancer centers. "We're looking at identifying those factors more closely to see if there are things we could potentially educate other types of centers or community hospitals about to improve outcomes at those places," she says. "I think this work can be translated to other cancers, as well." M D N E W S . C O M /// M D N E W S C E N T R A L P E N N S Y LVA N I A ■ 2 018 1 5

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