Reducing the global cancer burden among young adults
Authors: Tara O Henderson, Kevin C Oeffinger
Journal: The Lancet Oncology (2017)

In The Lancet Oncology, Miranda M Fidler and colleagues1Fidler MM Gupta S Soerjomataram I Ferlay J Steliarova-Foucher E Bray F Cancer incidence and mortality among young adults aged 20–39 years worldwide in 2012: a population-based study.Lancet Oncol. 2017; (published online Oct 27.)http://dx.doi.org/10.1016/S1470-2045(17)30677-0Summary Full Text Full Text PDF PubMed Scopus (301) Google Scholar provide estimates for cancer incidence and mortality among young adults (aged 20–39) worldwide. These estimates were categorised by country income and development level (Human Development Index, HDI), thus affording investigators the opportunity to compare across cancer types. This important study establishes a contemporary global burden of cancer in young adults—975 396 new cancer cases and 358 392 cancer-related deaths in 2012. The authors provide the foundation necessary for a call to action for clinicians, policy makers, and researchers focused on reducing the substantial burden that cancer afflicts upon young adults. So, what can we do? By contrast with several cancers that have a peak incidence in later adulthood, there are few opportunities for cancer screening. The notable exception is cervical cancer screening. Cervical cancer is the second most common cancer in young adults worldwide, accounting for 11·4% of cancers. Although cervical cancer is prevalent across different HDI levels, low-HDI countries are particularly vulnerable. Cervical cancer is one of the few cancers that could be largely eradicated with prevention (HPV vaccination) and screening. Unfortunately, even in very high-HDI regions, cervical cancer remains one of the top five causes of cancer death in young adults, highlighting the failures of our current policies and approaches. Other than cervical cancer, few cases of cancer in young adults can be effectively detected with screening; one exception being breast cancer screening among women with a known cancer-causing genetic mutation. Indeed, a targeted approach to surveillance for cancers in young adults is to identify individuals with a genetic predisposition. BRCA mutations predispose women to early breast and ovarian cancer. Germline TP53 mutations, also known as Li-Fraumeni syndrome, predispose patients to early breast cancer, leukaemia, sarcomas, and brain tumours. Patients with familial adenomatous polyposis (FAP) syndrome (associated with mutations in APC) develop polyps and colon cancer as early as their teens. For each of these syndromes, early cancer surveillance is recommended to detect the associated cancers early. This highlights the importance of primary care providers taking a thorough family history and promptly referring to genetic counselling, as well as potentially testing when appropriate, such that targeted screening regimens for identified cancer predisposition syndromes are initiated appropriately. Unfortunately, effective screening approaches for most other cancers prevalent among young adults, such as ovarian and testicular cancer, remain elusive. Prevention could have the greatest potential to reduce cancer incidence in young adults. HPV vaccination has the potential to substantially reduce the incidence of cervical cancer (and several other cancers such as HPV-related head and neck cancer). To reduce the incidence of Kaposi's sarcoma and liver cancer, particularly in Africa and parts of Asia, there needs to be continued focus on the prevention of HIV and hepatitis C virus (HCV) transmission. To date, in developing regions of the world, health education around condom use and safer sexual practices, has resulted in reducing the number of new HIV infections. However, the resources to administer and expand these essential programmes are limited in the low-HDI regions. By contrast, a reflection on more affluent countries is the increased incidence of melanoma in young adults, associated with tanning beds. A final approach that can reduce the cancer burden for young adults is timely and effective cancer therapy. Improvements in cure rates for young adults with cancer have lagged behind younger children and older adults.2Nass SJ Beaupin LK Demark-Wahnefried W et al.Identifying and addressing the needs of adolescents and young adults with cancer: summary of an Institute of Medicine workshop.Oncologist. 2015; 20: 186-195Crossref PubMed Scopus (172) Google Scholar Many explanations are possible for these worse outcomes, including a smaller proportion of young adult patients on clinical trials, delays in diagnosis, and biological differences in cancers between those in young adults and adults. Research in the haematological malignancies has shown that young adults have improved outcomes when they are treated on paediatric treatment regimens versus adult regimens. For example, Stock and colleagues3Stock W La M Sanford B et al.What determines the outcomes for adolescents and young adults with acute lymphoblastic leukemia treated on cooperative group protocols? A comparison of Children's Cancer Group and Cancer and Leukemia Group B studies.Blood. 2008; 112: 1646-1654Crossref PubMed Scopus (413) Google Scholar compared the outcomes of young adults treated on paediatric and adult clinical trials for acute lymphoblastic leukaemia (ALL) and noted superior outcomes among those treated on paediatric trials. Consequently, young adults are now treated according to paediatric ALL regimens. Likewise, Henderson and colleagues4Henderson TO Parsons SK Wroblewski KE et al.Outcomes in adolescents and young adults (AYA) with Hodgkin lymphoma (HL) treated on US cooperative group protocols: an adult intergroup (E2496) and children's oncology group (COG AHOD 0031) comparative analysis.Cancer. 2017; (published online Sept 13.)DOI:10.1002/cncr.30979PubMed Google Scholar reported that young adults with advanced Hodgkin's lymphoma have better outcomes when treated on a paediatric clinical trial rather than an adult trial. A concerted effort to examine the biology of other cancers in young adults and to do focused clinical trials among this age group is warranted to improve the outcomes of these patients. Lastly, this study reminds us of the future needs of the substantial population of young adults who survive cancer and their unique health-care needs. Many survivors will face lifelong risks to their physical, psychosocial, and financial health.2Nass SJ Beaupin LK Demark-Wahnefried W et al.Identifying and addressing the needs of adolescents and young adults with cancer: summary of an Institute of Medicine workshop.Oncologist. 2015; 20: 186-195Crossref PubMed Scopus (172) Google Scholar Health-care providers should be cognisant of their risks and respectful of their needs. We declare no competing interests. Cancer incidence and mortality among young adults aged 20–39 years worldwide in 2012: a population-based studyThe global cancer burden among 20–39 year-olds differs from that seen in younger or older ages and varies substantially by age, sex, development level, and geographical region. Although the cancer burden is lower in this age group than that observed in older ages, the societal and economic effects remain great given the major effects of premature morbidity and mortality. Targeted surveillance, prevention, and treatment are needed to reduce the cancer burden in this underserved age group. Full-Text PDF Open Access