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The increased risk for second malignancies after Hodgkin lymphoma (HL) and its treatment has been extensively documented. No study has investigated the incidence and survival implications of second primary HL after an antecedent malignancy; thus HL disease-specific survival (HL-DSS) and overall survival (OS) in this population are unknown, as are the clinical correlates of survival. We aimed to investigate this using the Surveillance, Epidemiology, and End Results (SEER) database. Materials/Methods: Patients with histologically confirmed HL diagnosed after an antecedent malignancy (HL-2, nZ821) were identified in SEER 18 registries from 2000-2014. Demographic and clinical characteristics, OS, and HL-DSS were compared to patients with a diagnosis of histologically confirmed first primary HL (HL-1, nZ31,355) from the same registries. Chi square tests and t-tests were used to compare categorical and continuous variables. Survival analyses were conducted using the Kaplan-Meier method, log-rank tests, Cox proportional hazards models, and propensity scorematched (PSM) analysis using nearest-neighbor matching with a caliper width 0.05x the logit of the standard deviation of the propensity score. Results: Hematopoietic (nZ309, 37.6%), prostate (nZ169, 20.6%) and breast (nZ77, 9.4%) malignancies were the most common antecedent malignancies in HL-2. Median latency between antecedent malignancy and HL diagnosis was 39 months. Median age at HL diagnosis for HL-1 and HL-2 were 36 and 66 years, respectively. These age distributions were significantly different (p<0.001). A smaller proportion of patients in HL-2 received combined modality therapy (chemotherapy and radiation) for HL than patients in HL-1 (14.3% vs 29.7%, p<0.001). Ann Arbor stage II patients were more frequent in HL-1 than HL-2 (39.8% vs 28.2%, p<0.001). The 5 year OS and HL-DSS rates for HL-2 vs HL-1 were 53.2% vs 82.7% and 79.1% vs 90.9%, respectively (log rank test p<0.001). With Cox regression accounting for age at and year of diagnosis, sex, race, HL histology, Ann Arbor stage, and HL therapy received, a history of antecedent malignancy was associated with an OS decrement (HR 1.27, 95%CI 1.13-1.42, p<0.001). With PSM balancing across the same co-variables a history of antecedent malignancy was associated with decrements in both HL-DSS (HR 1.48, 95%CI 1.12-1.96, p<0.01) and OS (HR 2.30, 95%CI 1.90-2.79, p<0.001). Conclusion: Second primary HL is rare compared to first primary HL. The most common malignancies preceding HL diagnosis were other hematopoietic malignancies. On PSM analysis a history of antecedent malignancy appears to adversely affect OS and DSS in those who subsequently develop HL. The HL-DSS decrement was a surprising finding, which may be related to biological differences in HL in this population, age, and/or the effect of missing co-variables known to influence survival such as performance status and specifics of treatment. Further study of this interesting subgroup of HL patients is warranted.

BackgroundMultiple national organizations recommend that cancer care providers and oncology practices be responsive to the needs of sexual and gender minority (SGM) patients. Oncology practices have attempted to incorporate this recommendation through SGM-focused cultural humility training interventions. It is unclear how best to adapt and implement such training across practices. This manuscript outlines one process for adapting a widely-used SGM training from The Fenway Institute to the context of oncology settings using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) model.MethodsWe conducted training sessions in two oncology care settings: a breast oncology center and a radiation oncology department. Subsequently, we conducted in-depth interviews with the three trainers involved in adapting The Fenway Institute's training to these two practices. Two independent investigators coded the interviews using components of the FRAME model as an analytic guide.ResultsTraining team members described the mechanisms by which FRAME adaption occurred both proactively and reactively; the importance of involving SGM-identified trainers of diverse backgrounds as well as champions from within oncology practices in which trainings were conducted; the importance of adapting both the context and content of training to be relevant to oncology audiences; and the ways in which fidelity to the core principles of improving health care for SGM patients was maintained throughout the process.DiscussionSGM cultural humility training for oncology providers and staff must undergo iterative adaptation to address the political and social context of specific practice environments and advocate for broader institutional culture change to achieve responsiveness to SGM health needs.

Purpose/Objective(s): Although rare, the incidence of bilateral testicular germ cell tumors (GCTs) has increased over time. Using the Surveillance, Epidemiology, and End Results (SEER) database, we describe the prevalence, characteristics, and outcomes of bilateral testicular GCTs, as well as the impact of prior radiotherapy on development of a metachronous GCT. Materials/Methods: A total of 757 cases of bilateral and 42,713 cases of unilateral testicular GCTs treated 1973-2013 were identified in the SEER database. Descriptive statistics are presented. Differences between unilateral and bilateral tumors were analyzed using the chi-square test. The risk of metachronous GCT was calculated using multivariable Cox proportional hazards regression models. Results: The percentage of bilaterality among all men with testicular GCTs was 1.7% (757/43,470). Of the 757 bilateral GCTs, 29% (nZ219) occurred synchronously (Table). Mean age at diagnosis was 34 years for men with unilateral GCT, 33 years for men with synchronous bilateral, and 30 and 35 years for men with asynchronous bilateral GCTs (first and second diagnoses, respectively). For asynchronous tumors, the median time between diagnoses was 5 years (range, 0.1-29.9 years). Among synchronous GCTs, 42% (92/219) were concordant seminomas, 10% (22/ 219) were concordant non-seminomas, and 48% (105/219) were discordant histologies. Among asynchronous GCTs, 42% (227/538) were concordant seminomas, 19% (104/538) were concordant non-seminomas, and 39% (206/538) were discordant histologies. Testicular cancer was the cause of death for 4.2% of men with a unilateral GCT and 1.1% of men with bilateral GCTs (p <0.001); 6 of the 8 men with bilateral GCTs who died had synchronous tumors. A second malignant neoplasm (SMN) was the cause of death for 1.1% of men with a unilateral and 2.9% of men with bilateral GCTs; among the latter, 7 of the 22 SMN deaths were in synchronous cases. Receipt of radiotherapy was not associated with the risk of developing a metachronous GCT (HR 1.00; 95% CI 0.78-1.27); however, seminoma histology of the first tumor was associated with a 36% increased risk of a metachronous GCT (HR 1.36; 95% CI 1.05-1.75). Conclusion: Among men with bilateral testicular germ cell tumors, two-thirds were diagnosed asynchronously, and most had concordant histologies between their first and second tumors. Men with bilateral testicular GCTs did not have a higher risk of death due to testicular cancer or a subsequent non-germ cell SMN than men with a unilateral testicular GCT. Receipt of radiotherapy did not increase the risk for development of a metachronous testicular GCT.

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