Many Younger Patients Receive Inappropriate First-Line Care

Nearly one-third of adolescent and young adult patients diagnosed with cancer do not receive appropriate therapy, according to recent research published in the Journal of the National Cancer Institute.

The study highlights inconsistencies in treatment for younger patients, which could potentially lead to lower survival rates and toxicities – particularly for the 44 percent of patients with acute lymphocytic leukemia (ALL) who fail to receive appropriate care.

“There has been little improvement in the survival of adolescent and young adult cancer patients relative to other age groups in recent decades, raising the question of whether such patients receive appropriate initial treatment,” said Arnold Potosky, MD, first author of the paper and director of Health Services Research at Georgetown University Medical Center in Washington, DC.

To investigate whether initial cancer treatment could be a factor in these lagging results, Dr. Potosky and authors reviewed registry data, patient surveys, and detailed medical records of a population-based sample of 504 adolescents and young adults (age range, 15-39 years). Patients had ALL, Hodgkin or non-Hodgkin lymphoma, germ cell cancer, or sarcoma. “Appropriate” treatment was defined as the most favorable treatment modality based on cancer type, tumor node metastasis staging, and other pathologic or histological characteristics.

Approximately 75 percent of young cancer patients in this sample received appropriate treatment; this number dropped to 68 percent when male patients with stage I germ cell cancer were excluded – all of whom received appropriate treatment.

Rates of appropriate treatment varied across cancer type:

  • 79 percent in sarcoma
  • 73 percent of non-Hodgkin lymphoma
  • 58 percent in Hodgkin lymphoma
  • 56 percent in ALL

Among the 27 ALL patients in the study population, the most common factor in inappropriate treatment was failure to receive cyclophosphamide or high-dose cytarabine as part of consolidation or maintenance therapy.

Physicians may be inadvertently providing inappropriate care because of their desire to balance benefit of these combination chemotherapy regimens against potential toxicity, the investigators suggested.

Multivariable analysis showed that only two factors were significantly associated with the likelihood of receiving appropriate treatment: cancer type (p<0.01) and clinical trial participation (p=0.04), with patients participating in research having 2.6-times greater odds of receiving appropriate treatment (95% CI 1.1-6.4).

Despite this benefit, only 7 percent of patients were confirmed to be participating in clinical research – although 13 percent of patients self-reported participation. While the number of patients in the current study is small, the results shine a light on the appropriateness of therapy in younger cancer patients who fall between the cracks of pediatric and medical oncology. Future studies need to look at the impact of inappropriate initial treatment on subsequent patient outcomes, including survival, symptoms, and quality of life, Dr. Potosky concluded.


    Potosky AL, Harlan LC, ALbritton K, et al. Use of appropriate initial treatment among adolescents and young adults with cancer. J Natl Cancer Inst. 2014;106:dju300.