Patterns of care and clinical outcomes in stage IVA cervical cancer: 14-year experience from a tertiary care centre in South India

Aim: To analyse the patterns of care and clinical outcomes of patients diagnosed with cervical cancer International Federation of Gynecology and Obstetrics (FIGO) stage IVA treated at a tertiary care centre in South India. Materials and methods: The electronic medical records of 2,476 patients diagnosed with cervical cancer at a tertiary care institution between January 2005 and December 2018 were reviewed. Among them, 96 patients diagnosed with histologically proven carcinoma cervix stage IVA established by either cystoscopy or proctoscopy were included. Four patients who did not receive treatment at the study centre were excluded and 92 patients were available for final analysis. Results: The median follow-up period was 12 months (2–131 months). Of the 92 patients, 59 patients (64·13%) received radiation therapy (RT) alone, 22 patients (23·9%) received chemoradiation (CRT), three patients (3·26%) received neoadjuvant chemotherapy (NACT) followed by RT, one (1·08%) received NACT followed by CRT, four patients (4·35%) received chemotherapy alone, while three (3·26%) were offered best supportive care. The median progression-free survival (PFS) was 12 months (95% CI: 9·6–14·4 months) and median overall survival (OS) was 25 months (95% CI: 16·6–33·4 months). The 2-year and 3-year PFS was 30 and 20%, respectively, and the OS was 50 and 32%, respectively. Conclusion: The management of stage IVA cervical cancer needs to be individualised to achieve a fine balance between local control, toxicity, and quality of life. RT is the mainstay of treatment with concurrent chemotherapy in carefully selected patients. Involvement of palliative care team early in the course of treatment adds a holistic approach to the continuum of oncological care.

Patterns of Care and Outcomes in Adolescents and Young Adults with Myeloproliferative Neoplasms: A Multicenter Population-Based Study

Background: The median age at diagnosis of myeloproliferative neoplasms (MPN) is in the sixth decade, though adolescents and young adults (AYA) with MPN comprise a distinct, growing sub-population. Preliminary data has exposed a unique phenotype and clinical trajectory in these patients (Haematologica. 2019; 104(8):1580-1588; Am J Hematol. 2018; 93(12):1474-1484). Additional questions remain concerning the biological underpinnings of this population, but also, importantly, patterns of care and outcomes in the real-world setting. The objective of this study was to systematically evaluate patterns of care (diagnosis and management), as well as complications in AYA with MPN. Methods: Patients were recruited from the registry of the GQR LMC-NMP, an extensive provincial MPN network (>11 academic and community centers across Quebec). AYA were age 18-40 years at diagnosis (control population, > 40 years at diagnosis), diagnosed between 1978 and 2019 adhering to World Health Organization criteria, with exemption of bone marrow sampling in a subset. Standard risk stratification was according to MPN subtype. Conventional statistical methods were used for analyses (JMP® Pro 14.1.0 software; SAS Institute, Cary, NC, USA). Results: The AYA population consisted of 75 patients: n=15 (20%) polycythemia vera (PV), n=57 (76%) essential thrombocythemia (ET), and n=3 (4%) myelofibrosis (Table 1). Corresponding MPN subtypes in patients > 40 years were 268 (40%) PV, 347 (51%) ET, and 63 (9%) MF. Median age at diagnosis was 34 years (range 18-40) in AYA vs 64 (41-95) in the older cohort. AYA were predominantly female (68% vs 55%; p=0.03). Median platelet count at diagnosis was higher in AYA vs non-AYA (641 vs 602 x10 9/L; p=0.08), with a greater proportion of patients (21% vs 10%; p=0.04) presenting with platelets > 1000 x10 9/L. A trend towards more frequent palpable splenomegaly was observed in AYA (39% vs 25%; p=0.06). Driver mutation status in AYA vs older adults, respectively, was JAK2 (70% vs 87%) followed by CALR (28% vs 9%), MPL (2% in both), and triple negative (0% vs 2%) (p=0.001). Variant allele frequency (VAF) was significantly lower in AYA with median (range) of 20% (3-94) vs 39% (2-100) in non-AYA (p=0.02), with fewer AYA presenting VAF > 20% at diagnosis (48% vs 76%; p=0.002). Risk stratification disclosed 24% of AYA (n=14) vs 53% (n=314) of non-AYA subjects to be high risk (p<0.0001). Significantly fewer cardiovascular co-morbidities were reported in AYA (p<0.003). Regarding work-up and management, markedly more AYA patients underwent bone marrow sampling vs older patients (65% vs 50%; p=0.01). While similar rates of phlebotomy and anti-platelet administration were reported (p=0.3 and 0.2, respectively), appreciably fewer AYA patients were treated with cytoreductive agents (41% vs 72% non-AYA, p<0.0001). The nature of cytoreductive therapy varied between AYA vs older subgroups (p<0.0001 for both hydroxyurea and interferon). A greater proportion of AYA (51%) vs non-AYA (9%) were also exposed to 2+ lines of cytoreduction (p<0.0001). Similar rates of both arterial and venous thrombosis prior to/at diagnosis or post-diagnosis were found across AYA and non-AYA cohorts (p=0.9). Sites of predilection of venous events, however, were distinctive: AYA exhibited a preponderance of splanchnic vein and upper extremity thrombosis (72% and 14% respectively) vs non-AYA (20% and 7%) (p=0.03). Rates of hemorrhagic complications were significantly higher in AYA vs older adults (28% vs 16%; p=0.01), with distinctive patterns of bleeding, dominated by post-procedural/trauma/post-partum (24%) and mucocutaneous (52%) in AYA vs non-AYA (p=0.008). Kaplan-Meier survival analyses revealed proportional rates of thrombosis and hemorrhage-free survival but longer myelofibrosis-free (p=0.004) and overall survival (p=0.0006) in AYA vs older adults (Figure 1). Conclusions: AYA with MPN not only display unique clinical features but are also subject to distinct diagnostic and management practices. More rigorous investigational approaches and a propensity to address AYA with intensive cytoreductive strategies may reflect a signal of overtreatment of this population. Further, the incidence and nature of thrombotic/bleeding complications show distinctive patterns in AYA, requiring targeted vigilance and an individualized approach to monitoring and therapy. Figure 1 Figure 1. Disclosures Szuber: Novartis: Honoraria.