Poor-Prognosis Metastatic Cancers in Adolescents and Young Adults: Incidence Patterns, Trends, and Disparities

Abstract

Background: For adolescents and young adults (AYAs, aged 15-39 years) with cancer, metastatic disease at diagnosis is the strongest predictor of mortality, but its associations with age and sociodemographic factors are largely unexplored.

Methods: Using Surveillance, Epidemiology, and End Results Program data from 2000 to 2016, we collected incident cases of poor-prognosis metastatic cancer (5-year survival < 50%) and compared the proportion, incidence, time trends, and incidence rate ratios for race and ethnicity, sex, and socioeconomic status among AYAs, middle-aged adults (aged 40-64 years) and older adults (aged 65-79 years).

Results: From 2000 to 2016, a total of 17 210 incident cases of poor-prognosis metastatic cancer were diagnosed in AYAs, 121 274 in middle-aged adults, and 364 228 in older adults. Compared with older patients, the proportion of AYAs having metastatic disease was equivalent or substantially lower in nearly every site except stomach and breast cancers, which were statistically significantly higher for AYAs compared with middle-aged and older adults (stomach: 57.3% vs 46.4% and 39.5%; breast: 6.6% vs 4.4% and 5.6%, respectively; 2-sided P < .001 for all comparisons). Incidence rates rose significantly faster among AYAs for breast, stomach, and kidney cancers and among AYAs and middle-aged adults for colorectal cancer. Markedly higher incidence rate ratios were noted for AYA racial and ethnic minorities with breast, stomach, and especially kidney cancer, where only non-Hispanic Black AYAs were at considerably higher risk. For most sites, incidence rate ratios were higher among male patients and individuals of low socioeconomic status across age groups.

Conclusions: For most cancers, AYAs are not more likely to present with metastases than middle-aged and older adults. Further investigation is warranted for the disproportionate rise in incidence of metastatic breast, stomach, and kidney cancer among AYAs and their excess burden among AYA racial and ethnic minorities. The rising incidence of colorectal cancer among AYAs and middle-aged adults remains an additional concern.

Figure 1.

Stage distribution by cancer site and age group: Surveillance, Epidemiology, and End Results Program (2000-2016). Asterisk (*) indicates overall χ² with 2-sided P < .001. A = adolescent and young adult; M = middle-aged adult; O = older adult; RMS = rhabdomyosarcoma; STS = soft tissue sarcoma (excluding rhabdomyosarcoma and Kaposi sarcoma).

Figure 2.

Average annual percent change of metastatic disease incidence rates by cancer site: Surveillance, Epidemiology, and End Results Program (2000-2016). Bone, rhabdomyosarcoma, and uterus not displayed because of insufficient cases (see the Methods section). Error bars indicate 95% confidence intervals. AYA = adolescent and young adult; MA = middle-aged adult; OA = older adult; STS = soft tissue sarcoma (excluding rhabdomyosarcoma and Kaposi sarcoma).

Figure 3.

Incidence rate ratios of metastatic disease by race and ethnicity and age group: Surveillance, Epidemiology, and End Results Program (2000-2016). Reference group is non-Hispanic White. Cancers with subgroup population denominators less than 50 000 not displayed to protect confidentiality. Error bars indicate 95% confidence intervals. AYA = adolescent and young adult; MA = middle-aged adult; NHAPI = non-Hispanic Asian and Pacific Islander; NHB = non-Hispanic Black; OA = older adult; STS = soft tissue sarcoma (excluding rhabdomyosarcoma and Kaposi sarcoma).

Figure 4.

Incidence rate ratios of metastatic disease by socioeconomic status (SES) and age group: Surveillance, Epidemiology, and End Results Program (2000-2016). Reference group is highest SES tertile. Error bars indicate 95% confidence intervals. AYA = adolescent and young adult; MA = middle-aged adult; OA = older adult; RMS = rhabdomyosarcoma; STS = soft tissue sarcoma (excluding rhabdomyosarcoma and Kaposi sarcoma).

Figure 5.

Incidence rate ratios of metastatic disease for male patients by age group: Surveillance, Epidemiology, and End Results Program (2000-2016). Reference group is female. Error bars indicate 95% confidence intervals. AYA = adolescent and young adult; MA = middle-aged adult; OA = older adult; RMS = rhabdomyosarcoma; STS = soft tissue sarcoma (excluding rhabdomyosarcoma and Kaposi sarcoma).