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PURPOSE Childhood cancer survivors (CCS) are at risk of developing subsequent malignant neoplasms (SMNs) resulting from exposure to prior therapies. CCS with underlying cancer predisposition syndromes are at additional genetic risk of SMN development. The McGill Interactive Pediatric OncoGenetic Guidelines (MIPOGG) tool identifies children with cancer at increased likelihood of having a cancer predisposition syndrome, guiding clinicians through a series of Yes or No questions that generate a recommendation for or against genetic evaluation. We evaluated MIPOGG's ability to predict SMN development in CCS. METHODS Using the provincial cancer registry (Ontario, Canada), and adopting a nested case-control approach, we identified CCS diagnosed and/or treated for a primary malignancy before age 18 years (1986-2015). CCS who developed an SMN (cases) were matched, by primary cancer and year of diagnosis, with CCS who did not develop an SMN (controls) over the same period (1:5 ratio). Potential predictors for SMN development (chemotherapy, radiation, and MIPOGG output) were applied retrospectively using clinical data pertaining to the first malignancy. Conditional logistic regression models estimated hazard ratios and 95% CIs associated with each covariate, alone and in combination, for SMN development. RESULTS Of 13,367 children with a primary cancer, 317 (2.4%) developed an SMN and were matched to 1,569 controls. A MIPOGG output recommending evaluation was significantly associated with SMN development (hazard ratio 1.53; 95% CI, 1.06 to 2.19) in a multivariable model that included primary cancer therapy exposures. MIPOGG was predictive of SMN development, showing value in nonhematologic malignancies and in CCS not exposed to radiation. CONCLUSION MIPOGG has additional value for SMN prediction beyond treatment exposures and may be beneficial in decision making for enhanced individualized SMN surveillance strategies for CCS.

Differentiated thyroid carcinoma (DTC) in children, adolescents, and young adults is associated with excellent prognosis. However, little is known about the long-term utilization of healthcare resources among survivors. The objective of this study was to compare the utilization of healthcare resources among DTC survivors to the general population, with a focus on pulmonary-related resource utilization. Population-based linked data were used to retrospectively ascertain DTC patients from the Ontario Cancer Registry, age

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) has become increasingly used as a therapeutic treatment for several pediatric conditions, however the long-term mental health sequelae remain understudied among these survivors. Our objective was to conduct a systematic literature review to determine the association between allo-HSCT and anxiety, depression, and psychological health-related quality of life (HRQOL) in pediatric allo-HSCT recipients compared to survivors of pediatric cancer or healthy children. A literature search of peer-reviewed databases was conducted. Data extraction was conducted using a standardized form. Due to the heterogeneity in studies, populations, and measurement instruments, only a qualitative synthesis was performed. A total of 24 studies met eligibility criteria. Rates of anxiety and depression were higher among survivors of pediatric allo-HSCT compared to population normal values or children treated for health conditions without allo-HSCT. Most allo-HSCT survivors self-reported psychological HRQOL within normal levels, although some studies in leukemia patients identified poorer psychological HRQOL. The presence of multiple chronic health conditions, chronic graft-versus-host-disease, and patient sex were important risk factors for worse mental health. Patients who receive allo-HSCT during childhood experience subsequent anxiety, depression, and poorer psychological HRQOL after transplant and several clinical characteristics contribute to these mental health sequelae.

Background Several known traditional cardiovascular risk factors contribute to the development of heart failure (HF); however, whether ethnicity is also an important predictor is not well established. We determined the incidence of hospitalization for HF among ethnic groups in Ontario, Canada, and examined differences in risk factor prevalence that may contribute to disparities in HF hospitalization incidence between groups. Methods and Results We conducted a retrospective observational study from 2008 to 2012 with the use of a linked cohort derived from population-based health administrative, clinical, and survey datasets. We followed 895,823 recent immigrants from 8 ethnic groups and 5.3 million long-term residents aged 40–105 years for incident HF hospitalization. Sex-stratified age-standardized HF incidence was lower among all immigrant groups than long-term residents. Among immigrants, Black men and West Asian women had the highest incidence of hospitalizations for HF (1.19 and 1.60 per 1000 person-years, respectively), and East Asians of both sexes had the lowest incidence. After adjusting for sociodemographic characteristics, comorbidities, and other risk factors, the association between ethnicity and HF hospitalization risk remained significant. Conclusions HF hospitalization incidence varies widely among ethnic immigrant groups, highlighting the importance of ethnicity as a potential independent risk factor for HF development.

Pediatric hepatic cancer is a rare malignancy, comprising only approximately 2% of all cancers diagnosed in children aged15 years. The authors sought to describe trends in pediatric hepatic cancer incidence and survival in Ontario, Canada; the United States; and Australia.Children aged15 years who were diagnosed with hepatic cancer from 1985 through 2013 were ascertained through population-based registries and followed from the time of diagnosis until December 31, 2015. Age-standardized incidence and 5-year relative survival were calculated for each jurisdiction. Multivariable flexible parametric survival models were used to explore predictors of hepatic cancer mortality.A total of 794 children were identified in Ontario (148 children), the United States (400 children), and Australia (246 children). The average annual incidence increased by 2.2% (95% CI, 0.5%-4.0%) in Australia, 2.1% (95% CI, 0.9%-3.3%) in the United States, and 1.3% (95% CI, -0.4% to 3.0%) in Ontario. The 5-year relative survival rate improved from 60% to 82% (P = .08) in Ontario and 62% to 78% (P = .02) in the United States between the diagnostic periods 1985 through 1994 and 2005 through 2013, whereas in Australia the rate remained constant (between 74% and 77%) during the study period. On multivariable analysis, there was no significant difference noted with regard to the hazard of death between jurisdictions (P = .06). Older age, the presence of metastatic disease, and being diagnosed with hepatocellular carcinoma were found to be associated with mortality.The incidence of hepatic cancer in children appears to have increased over the last 30 years in Australia and North America. Survival differences between Australia; Ontario, Canada; and the United States observed in the 1980s and 1990s were no longer apparent and only marginal geographical differences in the hazard of mortality were observed.

Videotaped information has been shown to be effective in reducing parental anxiety and facilitating knowledge transfer in various clinical settings. There is lack of literature on the use of videotaped information during the pediatric oncology initial family disclosure meeting. The purpose of this study was to deliver an informative DVD, highlighting information on childhood acute lymphoblastic leukemia (ALL), to parents of children with newly diagnosed ALL and to assess if the DVD provided increased levels of satisfaction and decreased levels of anxiety in parents around the time of diagnosis. We surveyed 24 parents of children on active treatment for ALL, diagnosed between the ages of 1 and 18 years from 2008 to 2016 at The Hospital for Sick Children, Toronto, Canada. Parents were provided a survey questionnaire assessing levels of satisfaction with information communicated by the healthcare team and anxiety following verbal disclosure and were asked to report satisfaction and anxiety levels immediately following viewing the DVD intervention. Twenty-three/24 (95.8%) parents surveyed reported seeking information from additional resources after disclosure. Of the 24 parents who watched the DVD, 12 (50.0%) watched it once, while 12 (50.0%) watched it twice or more. All parents were satisfied with DVD information, and there was a significant decrease in anxiety after viewing (P = 0.03). All 24 parents felt that the DVD was a useful educational tool. Videotaped information after verbal disclosure is an effective educational resource and is associated with reduced anxiety among parents of children with ALL.

ObjectivesThe present study evaluates the extent of association between hepatitis C virus (HCV) infection and cardiovascular disease (CVD) risk and identifies factors mediating this relationship using Bayesian network (BN) analysis.Design and settingA population-based cross-sectional survey in Canada.ParticipantsAdults from the Canadian Health Measures Survey (n=10 115) aged 30 to 74 years.Primary and secondary outcome measuresThe 10-year risk of CVD was determined using the Framingham Risk Score in HCV-positive and HCV-negative subjects. Using BN analysis, variables were modelled to calculate the probability of CVD risk in HCV infection.ResultsWhen the BN is compiled, and no variable has been instantiated, 73%, 17% and 11% of the subjects had low, moderate and high 10-year CVD risk, respectively. The conditional probability of high CVD risk increased to 13.9%±1.6% (p-16) when the HCV variable is instantiated to ‘Present’ state and decreased to 8.6%±0.2% when HCV was instantiated to ‘Absent’ (p-16). HCV cases had 1.6-fold higher prevalence of high-CVD risk compared with non-infected individuals (p=0.038). Analysis of the effect modification of the HCV-CVD relationship (using median Kullback-Leibler divergence; DKL) showed diabetes as a major effect modifier on the joint probability distribution of HCV infection and CVD risk (DKL=0.27, IQR: 0.26 to 0.27), followed by hypertension (0.24, IQR: 0.23 to 0.25), age (0.21, IQR: 0.10 to 0.38) and injection drug use (0.19, IQR: 0.06 to 0.59).ConclusionsExploring the relationship between HCV infection and CVD risk using BN modelling analysis revealed that the infection is associated with elevated CVD risk. A number of risk modifiers were identified to play a role in this relationship. Targeting these factors during the course of infection to reduce CVD risk should be studied further.

Background Due to the long-term sequelae of cranial radiotherapy (CRT), contemporary treatment protocols for children with acute lymphoblastic leukemia (ALL) aim to limit the use of prophylactic CRT. For patients with central nervous system (CNS) involvement with ALL at diagnosis, the use of CRT remains common. Children

Clinical trials on childhood acute promyelocytic leukemia (APL) report early death (ED) rates of 3-8%, but predictors of thrombohemorrhagic (TH)-ED are not well understood. In a retrospective study, we aimed to determine the incidence and predictors of TH-ED in childhood APL. Data were analyzed from children and adolescents with t(15;17)-positive APL (n = 683) who started treatment with all-trans retinoic acid (ATRA) and chemotherapy in different international studies. Demographic data; initial white blood cell (WBC), peripheral blood (PB) blast, and platelet counts; hemoglobin value; coagulation parameters; morphologic variant (M3 or M3v); and induction details were analyzed. Early death was defined as death occurring within 30 days of presentation. The incidence of ED was 4.7% (32 of 683 patients). Predictors of TH-ED were identified by univariable and multivariable Cox proportional hazard regression analyses (n = 25). In univariable analysis, high WBC (>10 × 10(9)/L) (P < 0.001) and high PB blast (>30 × 10(9)/L) (P < 0.001), M3v (P < 0.01), and black ethnicity (P < 0.001) were independent predictors of TH-ED. In multivariable analysis, high WBC count (P < 0.01) and obesity (i.e., body mass index ≥95th percentile for age) (P = 0.03) were predictors of TH-ED. Initial high WBC counts and obesity are likely predictors of TH-ED in childhood APL. The efficacy of novel drugs for APL-associated coagulopathy or of frontline arsenic trioxide and ATRA combination regimens in reducing ED rates in childhood APL remains to be established.

Hyperleukocytosis in children with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) is associated with early morbidity and mortality. The benefit from leukapheresis is controversial, and its complications are not well defined. We analyzed the frequency of early complications in children with ALL and AML presenting with white blood cell (WBC) count >100 × 10(9)/L, and the type and frequency of complications related to leukapheresis. During a 12-year period, 84 of 634 (13%) ALL and 18 of 143 (12.5%) AML patients presented with hyperleukocytosis. Leukapheresis was performed in 18 ALL and 12 AML patients. The median initial WBC was 474 × 10(9)/L in the leukapheresis group compared with 175 × 10(9)/L in the nonleukapheresis group. Neurological leukostasis occurred in 6 ALL (7.1%) and 4 AML (22.2%) patients. Pulmonary leukostasis occurred in 16 ALL (19%) and 4 AML patients (22.2%). Neurological symptoms improved in few patients after leukapheresis, except in patients with very high WBC (>650 × 10(9)/L in ALL and >400 × 10(9)/L in AML). Leukapheresis improved respiratory symptoms in some patients but caused worsening symptoms in others. Early death was associated with neurological complications, AML diagnosis, and coagulopathy. Leukapheresis did not delay initiation of chemotherapy, nor did it impact early response to chemotherapy or long-term survival. Complications included femoral vein thrombosis, electrolyte imbalances, and hemodynamic instability, which were all reversible. The role of leukapheresis as a cytoreductive procedure in childhood hyperleukocytic leukemia remains to be well defined.

Background: Acute promyelocytic leukemia (APL) is a rare subtype of childhood acute myeloid leukemia (AML). Bleeding complications occur in 80% of patients at diagnosis and contribute to a higher incidence of early death (ED) in APL compared to other AML subtypes. However, estimates of ED in pediatric APL are imprecise and factors associated with ED in children with APL are unknown. Objectives: To determine the incidence and predictors of ED, defined as death within 60 days from presentation, in childhood APL. Methods: We conducted a retrospective international analysis of children diagnosed with APL between January 1993 and December 2013. The study included 236 patients from the Italian Associazione Italiana Ematologia/Oncologia Pediatrica(AIEOP) group, 148 from the Spanish Programa de Estudio y Tratamiento de las hemopatias Malignas (PETHEMA) group, 112 from the German Berlin-Frankfurt-Munster (BFM) group, 56 from Canadian pediatric centers, 25 from the Nordic Society of Paediatric Haematology/Oncology (NOPHO), 17 from the Dutch Children's Oncology group (DCOG), 14 from St. Jude Children's Research Hospital and 14 from the Australian and New Zealand Children's Hematology-Oncology Group (ANZCHOG). Factors examined included age, sex, ethnicity, body mass index, initial white blood cell (WBC)/peripheral blood (PB) blast and platelet (PLT) counts, initial coagulation parameters, microgranular variant (M3v), intracranial hemorrhage (ICH), time from hospital admission to first all-trans retinoic acid (ATRA) dose, induction treatment including ATRA, and steroid prophylaxis in high-risk patients. All patients had a molecular and/or cytogenetic diagnosis of APL. Univariate and multivariable binary logistic regression analyses were used to determine predictors of ED. Results: The study included 622 children with APL registered on, or treated as per, each group's clinical trial. Five hundred ninety-nine (96.3%) studies included patients registered on therapeutic trials whereas 23 (3.7%) were population based. Overall, the incidence of ED was at 5.6% (35/622) and ranged from 2.5% to 16%. In univariate logistic regression analysis, initial WBC and PB blast counts were predictive of ED, with odds ratios (OR) of 1.17 (95% confidence interval, CI:1.10-1.25, P < 0.001) and 1.24 (CI: 1.10-1.41, P = 0.001), respectively. M3v APL was an independent predictor of ED, with an OR of 3.72 (CI:1.65-8.35, P = 0.001). All other predictors were not statistically significant. Twenty-two/26 patients (84.6%) with ICH had ED as opposed to 9/571 (1.6%) who did not have ICH. Use of ATRA during induction was associated with a lower proportion of ED (4.3% compared to 38% without ATRA, OR = 0.07, CI:0.03-0.19, P Conclusions: In this largest international retrospective cohort study of ED in pediatric APL to date, we found that initial WBC was significantly associated with ED. APL patients with ICH had a significantly higher probability of ED. Novel measures to reduce hemorrhagic complications should be explored as a strategy to minimize ED in children with APL, especially in high-risk APL. Optimization of the management of coagulation disorders, as well as the use of arsenic trioxide during induction treatment, are expected to reduce the risk of ED in childhood APL. Figure 1. Estimated Probability of ED at WBC counts by APL subtype Figure 1. Estimated Probability of ED at WBC counts by APL subtype Disclosures Kaspers: Janssen-Cilag: Research Funding.