Cognitive Outcomes Following Contemporary Treatment Without Cranial Irradiation for Childhood Acute Lymphoblastic Leukemia
Cognitive Outcomes Following Contemporary Treatment Without Cranial Irradiation for Childhood Acute Lymphoblastic Leukemia
复制标题
DOI：
10.1093/jnci/djs344
复制
发表时间：
2012-09-01
影响因子：
10.3
通讯作者：
Pui, C. H.
中科院分区：
文献类型：
--
作者：
Conklin, H. M.;Krull, K. R.;Pui, C. H.
急性淋巴细胞性白血病(ALL)的治疗包括在高达20%的高危儿童中使用预防性头颅照射，尽管这种治疗方式存在已知的认知风险。圣裘德ALL全面治疗研究第15期的患者在完成巩固治疗后120周(n=243)使用综合认知电池进行了评估，该研究省略了所有患者的预防性头颅照射。(2)以标准化样本为基础，比较ALL患者组中表现低于平均水平者的百分比和期望率。采用单变量Logistic回归估计化疗强度(治疗组)、确诊时年龄和性别对表现低于平均水平的概率的影响。所有的统计测试都是双面的。总体而言，ALL组在持续注意力的一项指标上表现低于平均水平的风险在统计学上显著更高(67.31%，比遗漏错误的标准均值低1个SD以上，P<；.001)，但在智力功能、学术技能或记忆力方面没有。接受高强度化疗的患者与接受低强度治疗的患者相比，在处理速度(27.14%比6.25%，P=0.009)和学习能力(数学推理：18.60%比3.90%，P=0.008；单词阅读：20.00%比2.60%，P=0.007；拼写：27.91%比3.90%(P=.001)，父母报告的多动症(23.00%比9.84%，P=.018)和学习问题(35.00%比16.39%，P=.005)。确诊时的年龄和性别与认知能力低于平均水平的风险都不相关。接受颅脑照射可能有助于保持整体认知能力，但单用化疗并不是没有风险。护理者教育和干预措施的发展应同时解决早期注意力缺陷和认知迟发效应。
Treatment of acute lymphoblastic leukemia (ALL) has included the use of prophylactic cranial irradiation in up to 20% of children with high-risk disease despite known cognitive risks of this treatment modality.Patients enrolled on the St Jude ALL Total Therapy Study XV, which omitted prophylactic cranial irradiation in all patients, were assessed 120 weeks after completion of consolidation therapy (n = 243) using a comprehensive cognitive battery. (2) analysis was used to compare the percentage of below-average performers among the entire ALL patient group to the expected rate based on the normative sample. Univariate logistic regression was used to estimate the effect of intensity of chemotherapy (treatment arm), age at diagnosis, and sex on the probability of below-average performance. All statistical tests were two-sided.Overall, the ALL group had a statistically significantly higher risk for below-average performance on a measure of sustained attention (67.31% more than 1 SD below the normative mean for omission errors, P < .001) but not on measures of intellectual functioning, academic skills, or memory. Patients given higher intensity chemotherapy were at greater risk for below-average performance compared with those given lower intensity therapy on measures of processing speed (27.14% vs 6.25%, P = .009) and academic abilities (Math Reasoning: 18.60% vs 3.90%, P = .008; Word Reading: 20.00% vs 2.60%, P = .007; Spelling: 27.91% vs 3.90%, P = .001) and had higher parent-reported hyperactivity (23.00% vs 9.84%, P = .018) and learning problems (35.00% vs 16.39%, P = .005). Neither age at diagnosis nor sex was associated with risk for below-average cognitive performance.Omitting cranial irradiation may help preserve global cognitive abilities, but treatment with chemotherapy alone is not without risks. Caregiver education and development of interventions should address both early attention deficits and cognitive late effects.