21 Year Data for Cancer Survivors

Most pediatric gastroenterologists see many children with pediatric cancers, so it is gratifying to see data showing improving long-term outcomes (GT Armstrong et al. NEJM 2016; 374: 833-42).  In addition, pediatric oncology serves as a model for improving therapy by enrolling virtually all of its patients in research protocols.

The authors evaluated late mortality among 34,033 patients in the Childhood Cancer Survivor Study.  All of these patients had survived at least 5 years after childhood cancer. During the study which had a median followup of 21 years, there were 3958 deaths and 1618 (41%) of these were attributable to health-related causes, including subsequent neoplasms (n=746), cardiac (n=241), and pulmonary (n=137).

The improvement in treatment regimens have included reductions in radiotherapy and anthracycline exposure.  The graph below shows survival rates 20 years after being cancer-free (15 years after being cancer-free for 5 years).

My take: This study confirms that these improved regimens have long-lasting effects on mortality.  Through cooperative research, we can do better in oncology and in all of pediatrics.

Incidence of death from any cause from patients treated between 1970-1999.

Incidence of death from any cause from patients treated between 1970-1999.

How Common are Clostridium difficile infections?

In 2011, Clostridium difficile was estimated, by a recent report from the CDC (NEJM 2015; 372: 825-34) to result in 453,000 infections in the U.S. based on surveillance data from 10 geographic regions.

Other key findings:

  • Approximately 29,000 deaths were attributed to Clostridium difficile infections
  • 65.8% of cases were health care associated.
  • 24.2% had onset in the hospital
  • Increased risk was particularly notable among the elderly, with an rate ratio of 8.65 in those 65 years of age or older
  • The aggressive NAP1 strain was evident in 30.7% of health-care associated infections compared with 18.8% of community-associated infections

Related posts:

Note to blog followers: Yesterday’s blog was retitled to “Radiologic Image for St. Patrick’s Day” rather than “Endoscopic Image for St. Patrick’s Day”

Lost Decade from Smoking

A recent study (NEJM 2015; 372; 631-40) showed that smoking is more deadly than previously estimated.  Key points:

  • Deaths per year due to smoking: a new analysis suggests the true figure may be closer to 575,000.  That equates to 1 death in every 5 in the United States.
  • Smoking is thought to shorten life expectancy by more than one decade!
  • The 21 causes of death that have been officially blamed on smoking accounted for only 83% of the actual deaths among smokers

Here’s a link to a summary of the article:  Cigarette Smoking is Even More Deadly Than You Thought (from LA Times)

Related blog post:

From NPR: Enormous Ice Formations at Niagara Falls:

From NPR

From NPR

Current Mortality from Being Born Premature

A recent study (Patel RM et al. NEJM 2015; 372: 331-40) provides prospectively collected data on 6075 deaths among 22,248 live births with gestational ages 22-29 weeks from the U.S NICHD Neonatal Research Network. between 2000 thru 2011:

Key findings:

  • Improved death rate in most recent period of study:  number of deaths per 1000 live births was 275  (2000-2003), 285 (2004-2007), 258 (2008-2011)
  • While there were fewer pulmonary deaths with time, the deaths attributed to necrotizing enterocolitis increased: number of deaths per 1000 live births was 23 (2000-2003), 29 (2004-2007), 30 (2008-2011).  Necrotizing enterocolitis was the leading cause of death between 15-60 days of life (Figure 1).
  • Overall, 40.4% of deaths occurred within 12 hours after birth.  Only 17.3% occurred after 28 days of life.
  • For the entire study period, the rate of death (per thousand) was associated with gestational age: 949 (22 weeks), 730 (23 weeks), 427 (24 weeks), 258 (25 weeks), 157 (26 weeks), 115 (27 weeks), 78 (28 weeks)
  • The authors speculate that the overall reduction in death rate is likely related to more aggressive respiratory care (for bronchopulmonary dysplasia); one marker of this was increased usage of high-frequency ventilation.

Bottomline: While there has been improvement, being born premature is associated with high mortality.

A Leading Cause of Mortality in U.S….

Being uninsured.  A recent article in Annals of Intern Medicine (2014; 160: 585-93) explored the reduction in mortality associated with expansion of Medicaid.

Key result: “Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (−2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults).”  The control group consisted of similar patients from other states.

An editorial (advbd.co/1lWHfsu) on this subject (from Atul Gawande retweet), notes the following: “The takeaway: Every 830 additional people who got insurance under Massachusetts’ health reforms prevented roughly one death….

A 2012 Urban Institute report estimated that 15.1 million uninsured adults could gain coverage if every state expanded Medicaid. Using the 830 figure from the Massachusetts study, and acknowledging that the state’s coverage wasn’t exactly equivalent to Medicaid, that would translate to 18,193 deaths prevented per year.

For a sense of comparison—that would make the Medicaid coverage gap the number five leading cause of preventable death in the United States

1 “Medicaid Coverage Gap” based on 2012 estimate; other causes based on 2010 data.

Bottomline: Not having health insurance can be very bad for your health.

Related blog post:

45,000 Unnecessary Deaths Per Year | gutsandgrowth

Second-Guessing Aggressive Medical Treatment in Pediatrics

An excerpt of a review of a recent study (Inflamm Bowel Dis. 2014;20:291-300.) from Healio Gastro, http://bit.ly/1njexRZ.  This study was briefly referenced at the bottom of a previous blog post (UC SUCCESS | gutsandgrowth).

Mortality and malignancy, the most serious complications of pediatric inflammatory bowel disease, were relatively rare and linked most commonly with aggressive treatment rather than the condition itself, according to recent study data.

In a multinational retrospective study, researchers surveyed all pediatric gastroenterologists in 20 European countries and Israel on cancer and/or mortality among their pediatric patients with inflammatory bowel disease (PIBD) from 2006 to 2011.

Among 44 children diagnosed with IBD (median age at diagnosis, 10 years; 26 boys), 18 cases of cancer were identified and/or 31 patients died. Twelve cancer patients had Crohn’s disease, and 19 patients who died had ulcerative colitis (UC). The most common cancers were hematopoietic tumors (n=11). Mortality was attributed to infections (n=14) and other causes, including cancer (n=5), uncontrollable disease activity related to IBD (n=4) and procedural complications (n=3).

“Cancer and mortality in PIBD are rare, but cumulative rates are not insignificant,” the researchers wrote. “…. At least six lymphomas were likely treatment-associated by virtue of their phenotype.”

Researchers said that aggressive therapy with immunosuppressants and biologics has become common among PIBD patients because their disease is often more severe than that found in adults with IBD…

“Nine out of 19 patients with UC died because of an infectious complication. These fatalities may have been prevented by earlier surgical intervention when intensified medical treatment is ineffective.”

Bottomline: Making a colectomy decision is quite difficult when medical therapies may be effective.  Recent guidelines using PUCAI scores may assist physicians in identifying medical failures more quickly.


Male Vulnerability Factor?

A recent study examined mortality data from 1999-2008, comparing male deaths to female deaths (Pediatrics 2013; 132: 631-38) –thanks to Ben Gold for this reference.

Here’s a link to the abstract:  Pediatric Mortality in Males Versus Females in the  – Pediatrics

This study reviewed mortality data, including data from the CDC’s WONDER (wide-ranging online data for epidemiologic research) system .

Key Findings:

  • Males had higher relative risk of dying in all age groups with a relative risk of 1.44.
  • Males had higher mortality rates in 17 of 19 major ICD-10 categories (including cancer), thus this does not appear to be simply a matter of more accidents.
  • Even between 15-19 years when accidental and nonaccidental trauma were excluded males continue to demonstrate an increased relative risk of death.

While this study is limited by relying on the accuracy of coding for underlying cause of death, it supports the idea that males have a higher mortality throughout their lifespan.