Multiple primary malignancies are a growing area of interest in cancer survivorship. At our institution, approximately 1 in 9 new cancer diagnoses during the 5-year study period represented second-order malignancies. Our data suggest that the VA population is at risk of developing second primary cancers. Further analysis of this population to identify unique risk factors is warranted.
Exposure to Agent Orange (AO) and the contaminating chemical 2,3,7,8-Tetrachlorodibenzodioxin (TCDD) has been associated with the development of chronic lymphocytic leukemia (CLL). Of the195 veterans diagnosed with CLL from 2001–2010 in a retrospective cohort from the Minneapolis VA, 33 (17%) were exposed to AO. Prognostic factors including Rai stage, lymphocyte doubling time and cytogenetics did not differ between exposed and unexposed patients. Exposed patients were younger at diagnosis (61 vs 72 years, p=0.001) and time to CLL treatment was shorter (9.6 vs 30.2 months, p=0.02). Overall survival did not differ between exposed and unexposed patients on Kaplan Meier analysis, but when adjusted for age, AO exposure had a hazard ratio of death of 1.8 compared to non-exposure (95% CI 0.7–4.5 p=0.24). The high estimate of the mortality hazard combined with the relatively low numbers in the exposure group suggests that further examination in a larger patient population is warranted.
Our objective was to review the utility of pretreatment comprehensive geriatric assessment (CGA) and its impact on decision making regarding choice and intensity of oncologic therapeutic regimens for older, frail, or poorfunctional-status patients, as well as using this prospective assessment to predict chemotherapy-related toxicities. Database searches were conducted in Medline, PubMed, and Ovid for clinical studies, review articles, and journal publications. Search terms included geriatric assessment, medical oncology, chemotherapy, frailty, toxicity, and functional status. Thirty-seven pertinent articles were retrieved and serve as the basis for this clinical review. Observations: CGA is an important tool for examining aspects of frailty and functional status that are not captured by traditional performance status measures. These findings may then be used in selection of appropriate therapeutic regimens for a given patient that are efficacious and tolerable. Such pretreatment assessments also have been used in predicting therapy-related toxicities. Conclusions: Frail and older patients are common in oncology practices and are at high risk for therapyrelated toxicities because of comorbidities and physiologic changes, presenting a considerable clinical challenge. CGA establishes evidence-based strategies to better assess the functional status of such patients and is predictive for chemotherapy-related toxicities in this vulnerable group. Despite publications on these measures in the oncology literature, there is limited evidence-based research to demonstrate the utility of CGA by practicing oncology providers and how to implement it into practice.
Exposure to Agent Orange (AO) has been associated with the development of chronic lymphocytic leukemia (CLL). We performed a retrospective study of 2052 Vietnam veterans identified in the National VA Tumor Registry to assess the impact of AO exposure on CLL prognosis, treatment and survival. Prognostic factors did not differ based on exposure. Veterans exposed to AO were diagnosed younger (63.2 vs. 70.5 years, p < .0001) and had longer overall survival (median not reached vs. 91 months, p < .001). This prolonged survival was in the subgroups of patients aged 60-69 years (p< .0001) and those with 11q deletion (p < .0001). Those exposed to AO were more likely to be treated with fludarabine, chlorambucil and rituximab (38 vs. 21%, p < .001) and bendamustine plus rituximab (25 vs. 18%, p = 0.039) as first line therapy. Exposure to AO was not associated with either poor prognostic factors or shortened overall survival in our large veteran population with CLL.
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