Differential survival improvement for patients 20–29 years of age with acute lymphoblastic leukemia (2023)


Survival rates for childhood cancer have improved markedly over the last few decades with 5-year overall survival of approximately 80% [1]. However, there has been increasing concern about outcomes for adolescent and young adult (AYA) patients. The age range that defines AYA is variable but includes those aged 15–29 years [2], [3], [4]. Bleyer has emphasized that special attention to those aged 15–19 years is warranted because, in contrast to younger patients, incremental survival in this age range is poor and similar to patients aged 20–29 years [5].

We focused on acute lymphoblastic leukemia (ALL) as there is particular controversy around outcomes in the 15–19 year age group by site of care. More specifically, some [6], [7], [8], [9], [10] but not all [11] studies have reported that outcomes are better when ALL AYA patients are treated at pediatric versus adult centers. These reports tended to explain improved survival at pediatric centers based upon more aggressive treatment protocols. However, even in those treated at pediatric sites, survival was relatively poor compared with younger children [6], [7], [8], [9], [10]. Most of the studies that have evaluated outcomes of AYA ALL patients were conducted in the United States (US) or Europe [6], [7], [8], [9], [10], [11]. Whether other developed nations have different experiences is not clear.

In attempting to explain worse outcomes in AYA patients, hypotheses have included differences in treatment approaches and ability to obtain insurance and prescription drug coverage, at least in the US [12]. Little is known about whether changes in these factors over time have led to improvements in survival. Given the issues related to access to healthcare, we theorized that different patterns may be observed in the US versus a similarly developed country with universal health care such as Canada.

Consequently, the objective was to compare improvement in survival from 1986 to 2009 for ALL patients aged 1–14, 15–19 and 20–29 years at diagnosis in Ontario and the US.

Section snippets

Materials and methods

This was a population-based analysis using administrative data from Cancer Care Ontario's Ontario Cancer Registry (OCR) and the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database. Institutional review board approval was obtained from The Hospital for Sick Children and there was no requirement for informed consent.


There were 2470 patients aged 1–29 years with ALL in the OCR and 13,129 patients in SEER (Table 1). Patients aged 20–29 years comprised 9.6% of the OCR cohort and 11.1% of the SEER cohort. In both, males were significantly more common than females and income quintile (OCR) and ethnicity (SEER) were unevenly distributed by age group.

Table 2 demonstrates the unadjusted Cox proportional hazard regression analyses for different covariates by age group. Survival was incrementally worse with


In our population-based analysis of patients aged 1–29 years with ALL in Ontario, Canada and the US, we observed that survival has improved over time for patients aged 1–14 and 15–19 years in both settings. However, we observed a different survival pattern for adults aged 20–29 years with ALL. In Ontario, survival has improved by about 30% over 24 years, whereas there has been no change in survival in similarly aged US patients.

Our finding that survival has improved in the 15–19 year age group

Role of the funding source

This project had no financial or material support for the work. LS is supported by a New Investigator grant from the Canadian Institutes of Health Research [grant number 84392]. SMHA is a Research Scientist of the Canadian Cancer Society.

Conflict of interest statement

The authors have no conflicts of interest to declare.


We acknowledge support from POGO and CCO to conduct this analysis and Ms. Marie-Chantal Ethier and Ms. Tanya Hesser for their administrative support.

Contributions. All authors have contributed equally to the conception and design of the study, acquisition of data, analysis and interpretation of data, as well as drafting and critically revising the intellectual content contained within. All authors have approved the final version of the manuscript being submitted.

  • Patient reported outcome measure domains and tools used among adolescents and young adults with cancer: A scoping review

    2023, Critical Reviews in Oncology/Hematology

    Citation Excerpt :

    This group, aged 15–39 (Janssen et al., 2021), already faces challenges including balancing education and/or work, financial worries and relationship concerns such as starting or managing a young family (Janssen et al., 2021). A cancer diagnosis during this time adds further risks and concerns related to mental and physical health consequences (Gupta, 2019; Baker and Syrjala, 2018; Lewis et al., 2014; Bright et al., 2019; Kaul et al., 2016; Pole et al., 2013). AYA cancer patients experience significant and broad symptoms.

    Adolescent and young adult (AYA) cancer patients and survivors are growing and face with distinct issues from paediatric and older cancer survivors. Hence it is important the issues they encounter are measured using appropriate Patient Reported Outcome Measures (PROMs). We searched PubMed, EMBASE, CINAHL, and PsycINFO for articles including: (1) AYAs (ages 15–39), (2) Malignant neoplasms, and (3) PROMs. This resulted in 3566 unique articles, 523 were included for full text review, of which 175 were included. These studies included 203 distinct tools to measure PROMs across 31 domains. Physical function was most frequently measured domain, followed by social, emotional and mental health. The most commonly used tools were the EORTC QLQ-C30, HADS and SF-36. PROMs used in AYA cancer patients is a complex topic, this comprehensive review serves as a useful reference for researchers, clinicians and health services who want to better understand, and improve, outcomes among their patients.

  • Important factors improving outcome of young adults with acute lymphoblastic leukemia (ALL)

    2021, Best Practice and Research: Clinical Haematology

    Citation Excerpt :

    In the U.S., the 20–29 year age group has had little to no improvement in 5-year survival, at least as of 2009 (Fig. 7 red data). In the Canadian Province of Ontario, however, where the Dana Farber Cancer institute (DFCI) pediatric regimen was applied, the improvement is obvious (Fig. 8) [8]. In terms of pediatric ALL treatment regimen approaches contributing clinical trials in AYAs, the best example is CALGB 10403: A pediatric regimen for older adolescents and young adults with ALL [9].

    Four categories of important factors improving outcome of young adults and older adolescents with acute lymphoblastic leukemia (ALL) are biologic type, clinical trials, pediatric vs. adult treatment regimen, and psychosocial challenges. Overall, the outcome of ALL in the age group has improved and beginning to catch up with that in children, as exemplified by CALGB 10403, a pediatric treatment regimen. Each is dependent for optimum development, however, on progress in the others. Without adequate psychosocial support and improvement, progress in clinical trials, translational research, and pediatric regimen application is impaired. Without clinical trials, advances in translational research, optimal pediatric regimen application and adequate psychosocial research are restricted. Overall, we have improved the outcome and outlook of ALL in AYAs, as exemplified by CALGB 10403, but we and our current and future patients still have a long way to go.

  • Evaluation of the survival rate and its related factors in patients with leukemia in Kurdistan Province

    2018, Scientific Journal of Kurdistan University of Medical Sciences

  • Pediatric-inspired treatment regimens for adolescents and young adults with philadelphia chromosome–negative acute lymphoblastic leukemia: A review

    2018, JAMA Oncology

  • Adolescent and young adult (AYA) oncology in the United States: A specialty in its late adolescence

    2015, Journal of Pediatric Hematology/Oncology

  • Piecing together the puzzle of disparities in adolescents and young adults

    2015, Cancer

View all citing articles on Scopus
  • Research article

    Gene expression profiling of murine T-cell lymphoblastic lymphoma identifies deregulation of S-phase initiating genes

    Leukemia Research, Volume 37, Issue 10, 2013, pp. 1383-1390

    In a search for genes and pathways implicated in T-cell lymphoblastic lymphoma (T-LBL) development, we used a murine lymphoma model, where mice of the NMRI-inbred strain were inoculated with murine leukemia virus mutants. The resulting tumors were analyzed by integration analysis and global gene expression profiling to determine the effect of the retroviral integrations on the nearby genes, and the deregulated pathways in the tumors. Gene expression profiling identified increased expression of genes involved in the minichromosome maintenance and origin of recognition pathway as well as downregulation in negative regulators of G1/S transition, indicating increased S-phase initiation in murine T-LBLs.

  • Research article

    High electrical anisotropy in hydrochloric acid doped polyaniline/phyllosilicate nanocomposites: Effect of phyllosilicate matrix, synthesis pathway and pressure

    Applied Clay Science, Volumes 80–81, 2013, pp. 126-132

    Pressed tablets from polyaniline/phyllosilicate nanocomposites have been prepared under various conditions in order to optimize anisotropic conductivity of composite by ordering of flat phyllosilicate particles intercalated with polyaniline (PANI). Powder samples of PANI/phyllosilicate nanocomposites have been prepared using two phyllosilicates, montmorillonite and vermiculite, with a different layer charge. Two precursors were used, anilinium hydrochloride and anilinium sulfate. Prepared PANI/phyllosilicate composites were subsequently doped by hydrochloric acid via rinsing after polymerization process and for the DC conductivity measurements pressed into tablets. Applied pressure was 28MPa and 128MPa. Highly anisotropic conductivity has been achieved in pressed tablets. The in-plane conductivity for PANI/montmorillonite was 0.084S/cm, i.e., 1000× higher than in the direction perpendicular to the tablet plane. Increase of pressure up to 128MPa led to dramatic decrease of conductivity.

  • Research article

    All-trans retinoic acid and early mortality in acute promyelocytic leukemia

    Leukemia Research, Volume 37, Issue 10, 2013, pp. 1391-1392

  • Research article

    Dried blood spot sampling for detection of monoclonal immunoglobulin gene rearrangement

    Leukemia Research, Volume 37, Issue 10, 2013, pp. 1265-1270

    Molecular methods are important tools for diagnosis and monitoring of many lymphoproliferative disorders. The reliability of lymphoma diagnoses is strikingly different between developed and developing countries, partly due to lack of access to these advanced molecular analyses. To overcome these problems, we propose a new application of dried blood spots (DBS) for detecting clonal B-cell populations in peripheral blood (PB).

    We ensured that the DBS contained sufficient lymphocytes to perform a PCR-based clonality assay without producing false positives. Using the Namalwa B-cell line, we established that the assay is sensitive enough to detect 200 clonal cells in the analyzed sample. Very similar clonal results were obtained between DNA from DBS and fresh whole blood from patients with B-cell chronic lymphocytic leukemia. B-cell clonality can also be detected in DBS from African children with EBV-associated diseases.

    This is the first study demonstrating that clonality testing can be performed on DBS samples, thus improving the diagnostic and monitoring options for lymphoproliferative diseases in resource-limited settings.

  • Research article

    Does monocyte count have prognostic significance in cancer?

    Leukemia Research, Volume 37, Issue 10, 2013, pp. 1193-1194

  • Research article

    Flavopiridol: Judged by the company one keeps

    Leukemia Research, Volume 37, Issue 10, 2013, pp. 1187-1188

Copyright © 2013 Elsevier Ltd. All rights reserved.


Top Articles
Latest Posts
Article information

Author: Prof. Nancy Dach

Last Updated: 12/12/2023

Views: 5644

Rating: 4.7 / 5 (57 voted)

Reviews: 88% of readers found this page helpful

Author information

Name: Prof. Nancy Dach

Birthday: 1993-08-23

Address: 569 Waelchi Ports, South Blainebury, LA 11589

Phone: +9958996486049

Job: Sales Manager

Hobby: Web surfing, Scuba diving, Mountaineering, Writing, Sailing, Dance, Blacksmithing

Introduction: My name is Prof. Nancy Dach, I am a lively, joyous, courageous, lovely, tender, charming, open person who loves writing and wants to share my knowledge and understanding with you.