text:
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Fortunately, cancer in children and adolescents is rare, although the overall incidence of childhood cancer has been slowly increasing since 1975.[1] Children and adolescents with cancer are usually referred to medical centers that have a multidisciplinary team of cancer specialists with experience treating the cancers that occur during childhood and adolescence. This multidisciplinary team approach incorporates the skills of the following health care professionals and others to ensure that children receive treatment, supportive care, and rehabilitation that will enable them to achieve optimal survival and quality of life:
(Refer to the PDQ summaries on Supportive and Palliative Care for specific information about supportive care for children and adolescents with cancer.)
Guidelines for pediatric cancer centers and their role in the treatment of pediatric patients with cancer have been outlined by the American Academy of Pediatrics.[2] At these pediatric cancer centers, clinical trials are available for most types of cancer that occur in children and adolescents, and the opportunity to participate in these trials is offered to most patients and families. Clinical trials for children and adolescents with cancer are generally designed to compare potentially better therapy with therapy that is currently accepted as standard. Most of the progress made in identifying curative therapies for childhood cancers has been achieved through clinical trials. Information about ongoing clinical trials is available from the NCI Web site.
Dramatic improvements in survival have been achieved for children and adolescents with cancer.[1,3,4] Between 1975 and 2010, childhood cancer mortality decreased by more than 50%.[1,3,4] Childhood and adolescent cancer survivors require close follow-up since cancer therapy side effects may persist or develop months or years after treatment. (Refer to the PDQ summary on Late Effects of Treatment for Childhood Cancer for specific information about the incidence, type, and monitoring of late effects in childhood and adolescent cancer survivors.)
Neuroblastoma is the most common extracranial solid tumor in childhood. More than 650 cases are diagnosed each year in North America.[5,6] The prevalence is about 1 case per 7,000 live births; the incidence is about 10.54 cases per 1 million per year in children younger than 15 years. About 37% are diagnosed as infants, and 90% are younger than 5 years at diagnosis, with a median age at diagnosis of 19 months.[7]
While there is no racial variation in incidence, there are racial differences in tumor biology, with African Americans more likely to have high-risk disease and fatal outcome.[8,9]
Population-based studies of screening for infants with neuroblastoma have demonstrated that spontaneous regression of neuroblastoma without clinical detection in the first year of life is at least as prevalent as clinically detected neuroblastoma.[10,11,12]
Neuroblastoma originates in the adrenal medulla or the paraspinal sites where sympathetic nervous system tissue is present.
Risk Factors
Little is known about the events that predispose to the development of neuroblastoma. Parental exposures have not been definitively linked to neuroblastoma.
Germline deletion at the 1p36 or 11q14-23 locus is associated with neuroblastoma, and the same deletions are found somatically in sporadic neuroblastomas.[13,14]
About 1% to 2% of patients with neuroblastoma have a family history of neuroblastoma. These children are on average younger (9 months at diagnosis), and about 20% have multifocal primary neuroblastomas. The primary cause of familial neuroblastoma is a germline mutation in the ALK gene.[15] Familial neuroblastoma is rarely associated with congenital central hypoventilation syndrome (Ondine's curse), which is caused by a germline mutation of the PHOX2B gene.[16]
Biologic and Molecular Features
Biological subtypes
On the basis of biologic factors and an improved understanding of the molecular development of the neural crest cells that give rise to neuroblastoma, neuroblastic tumors have been categorized into the following three biological types:
These specific genetic changes may be combined with traditional clinical factors such as patient age and tumor stage to refine neuroblastoma risk classes.
Children whose tumors have lost a copy of 11q are older at diagnosis, and their tumors contain more segmental chromosome changes in gene copy number compared with children whose tumors show MYCN amplification.[19,20] Moreover, segmental chromosome changes not detected at diagnosis may be found in neuroblastomas at relapse. This suggests that clinically important tumor progression is associated with accumulation of segmental chromosomal alterations.[21]
Molecular features
Approximately 6% to 10% of sporadic neuroblastomas carry somatic ALK-activating mutations, and an additional 3% to 4% have a high frequency of ALK gene amplification. The mutations result in constitutive phosphorylation of ALK, leading to dysregulation of cell signaling and uncontrolled proliferation of the ALK-mutant neuroblasts. Thus, inhibition of ALK kinase is a potential target for treatment of neuroblastoma, especially in children whose tumors harbor an ALK mutation or ALK gene amplification.[22]
Genome-wide association studies in children with neuroblastoma have found common single-nucleotide polymorphisms (SNPs) associated with a modest susceptibility to develop high-risk neuroblastoma.[23,24] Other SNPs are associated with susceptibility to develop low-risk neuroblastoma.[24] SNPs associated with race predict a higher incidence of neuroblastoma and worse outcome.[25]
Large genomic studies have found few recurrent gene mutations in patients with neuroblastoma, including ALK (9.2%), PTPN11 (2.9%), ATRX (2.5%; 7.1% focal deletions), MYCN (1.7%), and NRAS (0.8%).[19,21,26,27]ATRX is involved in epigenetic gene silencing and telomere length. ATRX mutation without MYCN amplification is associated with older age at diagnosis in adolescents and young adults with metastatic neuroblastoma.[28] It is unclear whether an ATRX mutation is an independent prognostic risk factor.
Neuroblastoma Screening
Current data do not support neuroblastoma screening. Screening at the ages of 3 weeks, 6 months, or 1 year caused no reduction in the incidence of advanced-stage neuroblastoma with unfavorable biological characteristics in older children, nor did it reduce the number of deaths from neuroblastoma in infants screened at any age.[11,12] No public health benefits have been shown from screening infants for neuroblastoma at these ages. (Refer to the PDQ summary on Neuroblastoma Screening for more information.)
Evidence (against neuroblastoma screening):
Clinical Presentation
The most common presentation of neuroblastoma is an abdominal mass. The most frequent signs and symptoms of neuroblastoma are due to tumor mass and metastases. They include the following:
The clinical characteristics of neuroblastoma in adolescents are similar to those observed in children. The only exception is that bone marrow involvement occurs less frequently in adolescents, and there is a greater frequency of metastases in unusual sites such as lung or brain.[32]
Opsoclonus/myoclonus syndrome
Paraneoplastic neurologic findings, including cerebellar ataxia or opsoclonus/myoclonus, are rare in children with neuroblastoma.[33] Opsoclonus/myoclonus syndrome is frequently associated with pervasive and permanent neurologic and cognitive deficits, including psychomotor retardation. Neurologic dysfunction is most often a presenting symptom but may arise long after removal of the tumor.[34,35,36]
Patients who present with opsoclonus/myoclonus syndrome often have neuroblastomas with favorable biological features and are likely to survive, though tumor-related deaths have been reported.[34]
The opsoclonus/myoclonus syndrome appears to be caused by an immunologic mechanism that is not yet fully defined.[34,37] The primary tumor is typically diffusely infiltrated with lymphocytes.[38]
Some patients may clinically respond to removal of the neuroblastoma, but improvement may be slow and partial; symptomatic treatment is often necessary. Adrenocorticotropic hormone or corticosteroid treatment is thought to be effective, but some patients do not respond to corticosteroids.[35,37] Various drugs, plasmapheresis, intravenous gamma globulin, and rituximab have been reported to be effective in selected cases.[35,39,40,41] The long-term neurologic outcome may be superior in patients treated with chemotherapy, possibly because of its immunosuppressive effects.[33,39]
Diagnostic evaluation of neuroblastoma includes the following:
Serum catecholamines are not routinely used in the diagnosis of neuroblastoma except in unusual circumstances.
In rare cases, neuroblastoma can be discovered prenatally by fetal ultrasonography.[43] There is controversy about the need for immediate diagnostic biopsy in infants aged 6 months and younger with suspected neuroblastoma tumors that are likely to spontaneously regress. Biopsy was not required for infants entered into a COG study of expectant observation of small adrenal masses in neonates, and 81% avoided undergoing any surgery at all.[44] In a German clinical trial, 25 infants aged 3 months and younger with presumed neuroblastoma were observed without biopsy for periods of 1 to 18 months before biopsy or resection. There were no apparent ill effects of the delay.[45]
The diagnosis of neuroblastoma requires the involvement of pathologists who are familiar with childhood tumors. Some neuroblastomas cannot be differentiated, via conventional light microscopy, from other small round blue cell tumors of childhood, such as lymphomas, primitive neuroectodermal tumors, and rhabdomyosarcomas.
The minimum criterion for a diagnosis of neuroblastoma, as established by international agreement, is that diagnosis must be based on one of the following:
Prognostic Factors
Between 1975 and 2002, the 5-year survival rate for neuroblastoma in the United States has remained stable at approximately 87% for children younger than 1 year and has increased from 37% to 65% in children aged 1 to 14 years.[1] The 5-year overall survival for all infants and children with neuroblastoma has increased from 46% when diagnosed between 1974 and 1989, to 71% when diagnosed between 1999 and 2005;[47] however, this single number can be misleading because of the extremely heterogeneous prognosis based on the neuroblastoma patient's age, stage, and biology. (Refer to the Cellular Classification of Neuroblastic Tumors section of this summary for more information.) Approximately 70% of patients with neuroblastoma have metastatic disease at diagnosis.
The prognosis for patients with neuroblastoma is related to the following:[48,49,50,51]
Some of these prognostic factors have been combined to create risk groups to help define treatment. (Refer to the International Neuroblastoma Risk Group Staging System section and the Children's Oncology Group Neuroblastoma Risk Grouping section of this summary for more information.)
Age at diagnosis
The effect of age at diagnosis on 5-year survival is profound. The 5-year survival stratified by age is as follows:[47]
Children of any age with localized neuroblastoma and infants aged 18 months and younger with advanced disease and favorable disease characteristics have a high likelihood of long-term, disease-free survival.[52] The prognosis of fetal and neonatal neuroblastoma are similar to that of older infants with neuroblastoma and similar biological features.[53] Older children with advanced-stage disease, however, have a significantly decreased chance for cure, despite intensive therapy.
Adolescents and young adults
Neuroblastoma has a worse long-term prognosis in an adolescent older than 12 years or in an adult compared with a child, regardless of stage or site and, in many cases, a more prolonged course when treated with standard doses of chemotherapy. Aggressive chemotherapy and surgery have been shown to achieve a minimal disease state in more than 50% of these patients.[32,54,55] Other modalities, such as local radiation therapy and the use of agents with confirmed activity, may improve the poor prognosis for adolescents and adults.[54,55]
Clinical stage of disease
Neuroblastoma tumors have been clinically staged using surgical and pathological data according to the International Neuroblastoma Staging System (INSS). Stage of disease is correlated with outcome.
Studies of children with stage 1 and 2 neuroblastoma with favorable biologic features report an EFS rate of almost 100%, compared with an event-free survival (EFS) rate of about 50% for those who have unfavorable biological features (i.e., INPC and MYCN gene amplification).[56,57,58] Infants aged 1 year and younger have a greater than 80% cure rate, while older children have a cure rate of 50% to 70% with current, relatively intensive therapy.[59,60,61,62]
Survival of patients with INSS stage 4 disease is strongly dependent on age. Children younger than 1 year at diagnosis have a good chance of long-term survival (i.e., a 5-year disease-free survival rate of 50%–80%),[63,64] with outcome particularly dependent on MYCN amplification and tumor cell ploidy. Hyperdiploidy confers a favorable prognosis while diploidy predicts early treatment failure.[60,65] Infants aged 18 months and younger at diagnosis with INSS stage 4 neuroblastoma who do not have MYCN gene amplification are categorized as intermediate risk.[7,66,67,68]
Site of primary tumor
Site of primary tumor is not an independent prognostic factor. Multifocal (multiple primaries) neuroblastoma occurs rarely, usually in infants, and generally has a good prognosis.[69] Familial neuroblastoma and germline ALK gene mutation should be considered in patients with multiple primary neuroblastomas.
Tumor histology
Neuroblastoma tumor histology has a significant impact on prognosis and risk group assignment (refer to the Cellular Classification of Neuroblastic Tumors section and Table 4 of this summary for more information).
Histologic characteristics considered prognostically favorable include the following:
Histologic characteristics considered prognostically unfavorable include the following:
Regional lymph node involvement
In metastatic neuroblastoma, the presence of cancer in the lymph nodes on the same side of the body as the primary tumor has no effect on prognosis. However, when lymph nodes with metastatic neuroblastoma cross the midline and are on the opposite sides of the body from the primary tumor, the patient is upstaged (refer to the Stage Information for Neuroblastoma section of this summary for more information) and a poorer prognosis is conferred.
Response to treatment
Response to treatment has been associated with outcome. The persistence of neuroblastoma cells in bone marrow after induction chemotherapy, for example, is associated with a poor prognosis, which may be assessed by sensitive minimal residual disease techniques.[72,73,74] The degree of tumor volume reduction predicts response in high-risk patients, as does a decrease in mitosis and an increase in histologic differentiation.[75,76] Similarly, the persistence of mIBG-avid tumor after completion of induction therapy predicts a poor prognosis.[77]
Biological features
A number of biologic variables have been studied in children with this tumor:[78]
The degree of expression of the MYCN gene in the tumor does not predict prognosis.[82] However, high overall MYCN-dependent gene expression and low expression of sympathetic neuron late differentiation genes both predict a poor outcome of neuroblastomas otherwise considered to be at low or intermediate risk of recurrence.[83]
Other biological prognostic factors that have been extensively investigated include tumor cell telomere length, telomerase activity, and telomerase ribonucleic acid;[85,86] urinary VMA, HVA, and their ratio;[87]MRP1;[88] GABAergic receptor profile;[89] dopamine; CD44 expression; TrkA gene expression; and serum neuron-specific enolase level, serum lactic dehydrogenase level, and serum ferritin level.[78] These factors are currently not in use for stratification on clinical trials.
Spontaneous Regression of Neuroblastoma
The phenomenon of spontaneous regression has been well described in infants with neuroblastoma, especially in infants with the 4S pattern of metastatic spread.[90] (Refer to the Stage Information for Neuroblastoma section of this summary for more information.)
Spontaneous regression generally occurs only in tumors with the following features:[91]
Additional features associated with spontaneous regression include the lack of telomerase expression,[92,93] the expression of Ha-ras,[94] and the expression of the neurotrophin receptor TrkA, a nerve growth factor receptor.[95]
Studies have suggested that selected infants who appear to have asymptomatic, small, low-stage adrenal neuroblastoma detected by screening or during prenatal or incidental ultrasound examination, often have tumors that spontaneously regress and may be observed safely without surgical intervention or tissue diagnosis.[96,97,98]
Evidence (observation):
Neuroblastomas are classified as one of the small, round, blue cell tumors of childhood. They are a heterogenous group of tumors composed of cellular aggregates with different degrees of differentiation, from mature ganglioneuromas to less mature ganglioneuroblastomas to immature neuroblastomas, reflecting the varying malignant potential of these tumors.[1]
There are two cellular classification systems for neuroblastoma.
Favorable and unfavorable prognoses are defined on the basis of these histologic parameters and patient age. The prognostic significance of this classification system, and of related systems using similar criteria, has been confirmed in several studies.[2,3,4]
In the future, the INPC system is likely to be replaced by a system that does not include patient age as a part of cellular classification.
Because patient age is used in all risk stratification systems, a cellular classification system that did not employ patient age was desirable, and underlying histologic criteria, rather than INPC or Shimada Classification, was used in the final decision tree. Histologic findings discriminated prognostic groups most clearly in two subsets of patients, as shown in Table 2.
Staging Evaluation
A thorough evaluation for metastatic disease is performed before therapy initiation. The following studies are typically performed:[1]
Metaiodobenzylguanidine (mIBG) scan
Before resection of the primary tumor, bone involvement is assessed by mIBG scan, which is applicable to all sites of disease, and by technetium-99 scan if the results of the mIBG scan are negative or unavailable.[2,3] Approximately 90% of neuroblastomas will be mIBG avid. It has a sensitivity and specificity of 90% to 99% and is equally distributed between primary and metastatic sites.[4] Although iodine 123 (123 I) has a shorter half-life, it is preferred over131 I because of its lower radiation dose, better quality images, less thyroid toxicity, and lower cost.
Imaging with 123 I-mIBG is optimal for identifying soft tissue and bony metastases and is superior to 18F-fluorodeoxyglucose positron emission tomography–computerized tomography (PET-CT) in a prospective comparison.[5] Baseline mIBG scans performed at diagnosis provide an excellent method for monitoring disease response and performing posttherapy surveillance.[6]
A retrospective analysis of paired mIBG and PET scans in 60 newly diagnosed neuroblastoma patients demonstrated that for International Neuroblastoma Staging System (INSS) stages 1 and 2 patients, PET was superior at determining the extent of primary disease and more sensitive for detection of residual masses. In contrast, for stage 4 disease, 123 I-mIBG imaging was superior for the detection of bone marrow and bony metastases.[7]
Curie score and SIOPEN score
Multiple groups have investigated a semi-quantitative scoring method to evaluate disease extent and prognostic value. The most common scoring methods in use for evaluation of disease extent and response are the Curie and the International Society of Paediatric Oncology European Neuroblastoma Group (SIOPEN) methods.
Other staging tests and procedures
Other tests and procedures used to stage neuroblastoma include the following:
International Neuroblastoma Staging Systems
International Neuroblastoma Staging System (INSS)
The INSS has replaced the previously used Evans and Pediatric Oncology Group (POG) staging systems. The INSS is described in Table 3 and represents the first step in harmonizing risk stratification worldwide. The INSS is a postoperative staging system that was developed in 1988 and used the extent of surgical resection to stage patients. This led to variability in stage assignments in different countries, and INSS staging was also affected by access to experienced pediatric surgeons. As a result of further advances in the understanding of neuroblastoma biology and genetics, a new risk classification system was developed that incorporates newer biological factors into the INSS and reaches consensus on the criteria for defining each of these guidelines.
INSS combines certain features of the previously used Evans and POG systems [1,13] and has identified distinct prognostic groups (refer to Table 3).[1,13,14,15]
Controversy exists regarding the INSS staging system and the treatment of several small subsets of patients.[16,17,18] Risk group assignment and recommended treatment are expected to evolve as additional outcome data are analyzed. For example, the risk group for INSS stage 4, including patients aged 12 to 18 months, changed in 2005 for patients with MYCN-nonamplified status.[19,20,21]
International Neuroblastoma Risk Group Staging System (INRGSS)
The INRGSS is a preoperative staging system that was developed specifically for the INRG cellular classification system. The extent of disease is determined by the presence or absence of image-defined risk factors (IDRFs) and/or metastatic tumor at the time of diagnosis, before any treatment. IDRFs are surgical risk factors, detected by imaging, that make total tumor excision risky or difficult at the time of diagnosis.
The INRGSS simplifies stages into L1, L2, M or MS (refer to Table 4 for more information). Localized tumors are classified as stage L1 or L2 disease on the basis of whether one or more of the 20 IDRFs are present.[22] For example, in the case of spinal cord compression, an IDRF is present when more than one-third of the spinal canal in the axial plane is invaded, when the leptomeningeal spaces are not visible, or when the spinal cord magnetic resonance signal intensity is abnormal. By combining the INRGSS, preoperative imaging and biological factors, each patient has a risk stage defined that predicts outcome and dictates the appropriate treatment approach to be followed. The INRGSS has predictive value for lower stage patients, with stage L1 having a 5-year EFS of 90%, compared with 78% for L2.[22]
Most international protocols have begun to incorporate collection and use of IDRF in risk stratification and assignment of therapy.[23,24] It is anticipated that the use of standardized nomenclature will contribute substantially to more uniform staging and thereby facilitate comparisons of clinical trials conducted in different parts of the world.
Because most children with neuroblastoma in North America are treated according to the Children's Oncology Group (COG) risk-group assignment, the treatments described in this summary are based on COG risk group assignment. Each child is assigned to a low-risk, intermediate-risk, or high-risk group (refer to Tables 6, 7, and 8 for more information) based on the following:[1,2,3,4,5,6]
Other biological factors that influence treatment selection include unbalanced 11q loss of heterozygosity and loss of heterozygosity for chromosome 1p.[7,8]
The treatment of neuroblastoma has evolved over the past 60 years. Generally, treatment is based on whether the tumor is low, intermediate, or high risk:
Children's Oncology Group (COG) Neuroblastoma Risk Grouping
The treatment section of this document is organized to correspond with the COG risk-based treatment plan that assigns all patients to a low-, intermediate-, or high-risk group. This risk-based schema is based on the following factors:
Table 6 (in the Treatment of Low-Risk Neuroblastoma section), Table 7 (in the Treatment of Intermediate-Risk Neuroblastoma section), and Table 8 (in the Treatment of High-Risk Neuroblastoma section) describe the risk group assignment criteria used to assign treatment in the COG-P9641 and COG-A3961 studies.
Assessment of risk for low-stage MYCN-amplified neuroblastoma is controversial because it is so rare. A study of 87 INSS stage 1 and 2 patients pooled from several clinical trial groups demonstrated no effect of age, stage, or initial treatment on outcome. The event-free survival (EFS) rate was 53% and the overall survival (OS) rate was 72%. Survival was superior in patients whose tumors were hyperdiploid, rather than diploid (EFS, 82% ± 20% vs. 37% ± 21%; OS, 94% ± 11% vs. 54% ± 15%).[9] The overall EFS and OS for infants with stage 4 and 4S disease and MYCN-amplification was only 30% at 2 to 5 years after treatment in a European study.[10]
Description of International Neuroblastoma Response Criteria
Before therapy can be stopped after the initially planned number of cycles, certain response criteria, depending on treatment group, must be met. These criteria are defined as follows:[11,12]
In patients without metastatic disease, the standard of care is to perform an initial surgery to accomplish the following:
The COG reported that expectant observation in infants younger than 6 months with small adrenal masses resulted in an excellent EFS and OS while avoiding surgical intervention in a large majority of patients.[13]
Whether there is any advantage to gross-total resection of the primary tumor mass after chemotherapy in stage 4 patients older than 18 months is controversial.[14,15,16,17]
Radiation Therapy
In the completed COG treatment plan, radiation therapy for patients with low-risk or intermediate-risk neuroblastoma was reserved for symptomatic life-threatening or organ-threatening tumor bulk that did not respond rapidly enough to chemotherapy. Common situations in which radiation therapy is used in these patients include the following:
Treatment of Spinal Cord Compression
Spinal cord compression is considered a medical emergency. Immediate treatment is given because neurologic recovery is more likely when symptoms are present for a relatively short period of time before diagnosis and treatment. Recovery also depends on the severity of neurologic defects (weakness vs. paralysis). Neurologic outcome appears to be similar whether cord compression is treated with chemotherapy, radiation therapy, or surgery, although radiation therapy is used less frequently than in the past.
The completed COG low-risk and intermediate-risk neuroblastoma clinical trials recommended immediate chemotherapy for cord compression in patients grouped as low risk or intermediate risk.[18,19,20]
Children with severe spinal cord compression that does not promptly improve or those with worsening symptoms may benefit from neurosurgical intervention. Laminectomy may result in later kyphoscoliosis and may not eliminate the need for chemotherapy.[18,19,20] It was thought that osteoplastic laminotomy, a procedure that does not remove bone, would result in less spinal deformity. Osteoplastic laminotomy may be associated with a lower incidence of progressive spinal deformity requiring fusion but there is no evidence that functional deficit is improved with laminoplasty.[21]
Surveillance During and After Treatment
Surveillance studies during and after treatment are able to detect asymptomatic and unsuspected relapse in a substantial portion of patients. In an overall surveillance plan, one of the most reliable tests to detect disease progression or recurrence is the 123 I-metaiodobenzylguanidine scan.[22,23]
Low-risk neuroblastoma represents nearly one-half of all newly diagnosed patients. The success of prior Children's Oncology Group (COG) clinical trials has contributed to the continued reduction in therapy for select patients with neuroblastoma.
The COG low-risk group assignment criteria are described in Table 6.
(Refer to the Treatment of Stage 4S Neuroblastoma section of this summary for more information about the treatment of stage 4S neuroblastoma.)
Standard Treatment Options for Low-Risk Neuroblastoma
For patients with localized disease that appears to be resectable based on the absence of image-defined risk factors (L1), the tumor should be resected by an experienced surgeon. If the biology is confirmed to be favorable, residual disease is not considered a risk factor for relapse. Several studies have shown that patients with favorable biology and residual disease have excellent outcomes with event-free survival (EFS) in excess of 90% and overall survival (OS) of 99% to 100%.[1,2]
Standard treatment options for low-risk neuroblastoma include the following:
Treatment for patients categorized as low risk (refer to Table 6) may be surgery alone, which is curative for most patients with low-risk neuroblastoma. Patients need not undergo complete resection of disease to be cured by surgery alone.[2]
There is controversy about the need to attempt resection, whether at the time of diagnosis or later, in asymptomatic infants aged 12 months or younger with apparent stage 2B and 3 MYCN-nonamplified disease. In a German clinical trial, some of these patients were observed after biopsy or partial resection without chemotherapy or radiation, and many did not progress locally and never received additional resection.[3]
Observation without biopsy
Studies suggest that selected small adrenal masses, presumed to be neuroblastoma, detected in infants younger than 6 months by screening or incidental ultrasound may safely be observed without obtaining a definitive histologic diagnosis and without surgical intervention, thus avoiding potential complications of surgery in the newborn.[4]
Evidence (observation without biopsy):
Results from the COG-P9641 study showed that surgery alone, even without complete resection, can cure nearly all patients with stage 1 neuroblastoma, and the vast majority of patients with asymptomatic, favorable biology, INSS stage 2A and 2B disease.[2] The use of chemotherapy may be restricted to specific situations (e.g., children with MYCN-amplified stage 1 and 2 neuroblastoma and children with MYCN-nonamplified stage 2B neuroblastoma who are older than 18 months or who have unfavorable histology or diploid disease). These children have a less favorable outcome than other low-risk patients.[2,5]
Chemotherapy is also reserved for patients who are symptomatic, such as from spinal cord compression or, in stage 4S, respiratory compromise secondary to hepatic infiltration. The chemotherapy consists of carboplatin, cyclophosphamide, doxorubicin, and etoposide. The cumulative chemotherapy dose of each agent is kept low to minimize permanent injury (COG-P9641).[2]
Evidence (chemotherapy):
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with neuroblastoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
The Children's Oncology Group (COG) intermediate-risk group assignment criteria are described in Table 7.
Standard Treatment Options for Intermediate-Risk Neuroblastoma
Standard treatment options for intermediate-risk neuroblastoma include the following:
Surgery and chemotherapy
Patients categorized as intermediate risk have been successfully treated with surgery and four to eight cycles of chemotherapy (carboplatin, cyclophosphamide, doxorubicin, and etoposide; the cumulative dose of each agent is kept low to minimize permanent injury from the chemotherapy regimen) (COG-A3961). As a rule, patients whose tumors had unfavorable biology received eight cycles of chemotherapy, compared with four cycles for patients whose tumors had favorable biology. The COG-A3961 phase III trial demonstrated that therapy could be significantly reduced for patients with intermediate-risk neuroblastoma while maintaining outstanding survival.[4]
Whether initial chemotherapy is indicated for all intermediate-risk infants with localized neuroblastoma is controversial.
Evidence (surgery and chemotherapy):
In cases of abdominal neuroblastoma thought to involve the kidney, nephrectomy is not undertaken before a trial of chemotherapy has been given.[8]
Surgery and observation in infants
The need for chemotherapy in all asymptomatic infants with stage 3 or 4 disease is somewhat controversial, as some studies have shown favorable outcomes with surgery and observation as described below.[7]
Evidence (surgery and observation in infants):
Radiation therapy
Radiation therapy is reserved for patients with the following:
The Children's Oncology Group (COG) high-risk group assignment criteria are described in Table 8.
Approximately 8% to 10% of infants with stage 4S disease will have MYCN-amplified tumors and are usually treated on high-risk protocols. The overall event-free survival (EFS) and overall survival (OS) for infants with stage 4 and 4S disease and MYCN-amplification were only 30% at 2 to 5 years posttreatment in a European study.[1]
For children with high-risk neuroblastoma, long-term survival with current treatments is about 54%.[2] Children with aggressively treated, high-risk neuroblastoma may develop late recurrences, some more than 5 years after completion of therapy.[3,4]
Standard Treatment Options for High-Risk Neuroblastoma
Outcomes for patients with high-risk neuroblastoma remain poor despite recent improvements in survival in randomized trials.
The standard treatment option for high-risk neuroblastoma is the following:
Chemotherapy, surgery, SCT, radiation therapy, isotretinoin (cis -retinoic acid), anti-GD2 antibody ch14.18, and interleukin-2/GM-CSF
Treatment for patients with high-risk disease is generally divided into the following three phases:
Induction phase
The backbone of the most commonly used induction therapy includes dose-intensive cycles of cisplatin and etoposide alternating with vincristine, cyclophosphamide, and doxorubicin.[5] Topotecan was added to this regimen based on the anti-neuroblastoma activity seen in relapsed patients.[6] Response to therapy at the end of induction chemotherapy correlates with EFS at the completion of high-risk therapy.[7] After a response to chemotherapy, resection of the primary tumor is usually attempted.
Consolidation phase
The consolidation phase of high-risk regimens involves myeloablative chemotherapy and HSCT, which attempts to eradicate minimal residual disease using lethal doses of chemotherapy and autologous stem cells collected during induction chemotherapy to repopulate the bone marrow. Several large randomized controlled studies have shown an improvement in 3-year EFS for HSCT (31% to 47%) versus conventional chemotherapy (22% to 31%).[8,9,10] Previously, total-body irradiation had been used in HSCT conditioning regimens. Most current protocols use either carboplatin/etoposide/melphalan or busulfan/melphalan as conditioning for HSCT. Two or more sequential cycles of myeloablative chemotherapy and stem cell rescue given in a tandem fashion has been shown to be feasible for patients with high-risk neuroblastoma.[11,12]
A randomized clinical study (COG-ANBL0532) testing the efficacy of two cycles versus one cycle of myeloablative chemotherapy with stem cell rescue has been completed. (Refer to the Autologous Hematopoietic Cell Transplantation section in the PDQ summary on Childhood Hematopoietic Cell Transplantation for more information about transplantation.)
Radiation to the primary tumor site (whether or not a complete excision was obtained) and persistently metaiodobenzylguanidine-positive bony metastatic sites is often performed before, during, or after myeloablative therapy. The optimal dose of radiation therapy has not been determined. Radiation of metastatic disease sites is determined on an individual case basis.
Preliminary outcomes for proton radiation therapy of high-risk neuroblastoma primary tumors have been published.[13]
Maintenance phase
Differentiation therapy is used to treat potential minimal residual disease following HSCT.[14] After recovery from myeloablative chemotherapy and stem cell rescue, patients are treated with the differentiating agent oral isotretinoin for 6 months. Immunotherapy is given along with differentiated therapy in the post-HSCT differentiation therapy regimen. Antibodies developed to target GD2, present on the surface of neuroblastoma cells, are used. For high risk-patients in remission following HSCT, chimeric anti-GD2 antibody ch14.18 combined with GM-CSF and interleukin-2 are given in concert with isotretinoin and have been shown to improve EFS.[15,16]
Evidence (all treatments):
Local control (surgery and radiation therapy)
The potential benefit of aggressive surgical approaches in high-risk patients with metastatic disease to achieve complete tumor resection, either at the time of diagnosis or following chemotherapy, has not been unequivocally demonstrated.
Treatment Options Under Clinical Evaluation
The following are examples of national and/or institutional clinical trials that are currently being conducted. Information about ongoing clinical trials is available from the NCI Web site.
Most cases of stage 4S neuroblastoma do not require therapy. However, if bulk disease is causing organ compromise and risk of death, low-dose to moderate-dose chemotherapy and/or radiation therapy is used. Eight percent to 10% of these patients will have MYCN amplification and are treated with high-risk protocols.[1] (Refer to the Treatment of High-Risk Neuroblastoma section of this summary for more information about the treatment of stage 4S high-risk neuroblastoma.)
Treatment Options for Stage 4S Neuroblastoma
There is no standard approach to the treatment of stage 4S neuroblastoma.
Treatment options for stage 4S neuroblastoma include the following:
Resection of primary tumor is not associated with improved outcome.[2,3,4]
Observation with supportive care (asymptomatic patients)
The treatment of children with stage 4S disease is dependent on clinical presentation.[2,3] Most patients do not require therapy unless bulk disease is causing organ compromise and risk of death.
Chemotherapy (symptomatic patients)
Infants diagnosed with International Neuroblastoma Staging System (INSS) stage 4S neuroblastoma, particularly those with hepatomegaly or those younger than 2 months, have the potential for rapid clinical deterioration and may benefit from early initiation of therapy. It has been difficult to identify infants with stage 4S disease who will benefit from chemotherapy. Several clinical trials have evaluated the presence of symptoms in patients with 4S disease, including the following:
Various chemotherapy regimens (cyclophosphamide alone, carboplatin/etoposide, cyclophosphamide/doxorubicin/vincristine) have been used to treat symptomatic patients. The approach is to administer the chemotherapy only as long as symptoms persist in order to avoid toxicity, which contributes to lower survival. Additionally, lower doses of chemotherapy are often recommended for very young or low-weight infants along with granulocyte colony-stimulating factors after each cycle of chemotherapy.
Evidence (chemotherapy for symptomatic patients):
Tumor growth due to maturation should be differentiated from tumor progression by performing a biopsy and reviewing histology. Patients may have persistent maturing disease with metaiodobenzylguanidine (mIBG) uptake that does not affect outcome.[1] When neuroblastoma recurs in a child originally diagnosed with high-risk disease, the prognosis is usually poor despite additional intensive therapy.[2,3,4,5] However, it is often possible to gain many additional months of life for these patients with alternative chemotherapy regimens.[6,7] Clinical trials are appropriate for these patients and may be offered. Information about ongoing clinical trials is available from the NCI Web site.
Prognostic Factors for Recurrent Neuroblastoma
The International Neuroblastoma Risk Group Project performed a decision-tree analysis of clinical and biological characteristics (defined at diagnosis) associated with survival after relapse in 2,266 patients with neuroblastoma entered on large clinical trials in well-established clinical trials groups around the world.[2]
Significant prognostic factors determined at diagnosis for postrelapse survival include the following:[2]
The Children's Oncology Group (COG) experience with recurrence in low-risk and intermediate-risk neuroblastoma is that the majority of recurrences can be salvaged. The COG reported a 3-year event free survival (EFS) of 88% and an OS of 96% in intermediate-risk patients and a 5-year EFS of 89% and OS of 97% in low-risk patients.[8,9] Moreover, in most patients originally diagnosed with low-risk or intermediate-risk disease, local recurrence or recurrence in the 4S pattern may be treated successfully without hematopoietic stem cell transplantation.
Recurrent Neuroblastoma in Patients Initially Classified as Low Risk
Locoregional recurrence
Standard treatment options for locoregional recurrent neuroblastoma initially classified as low risk include the following:
Surgery followed by observation or chemotherapy
Local or regional recurrent cancer is resected if possible.
Those with favorable biology and regional recurrence more than 3 months after completion of planned treatment are observed if resection of the recurrence is total or near total (?90% resection). Those with favorable biology and a less than near-total resection are treated with chemotherapy.
Infants younger than 1 year at the time of locoregional recurrence whose tumors have any unfavorable biologic properties are observed if resection is total or near total. If the resection is less than near total, these same infants are treated with chemotherapy.
Chemotherapy may consist of moderate doses of carboplatin, cyclophosphamide, doxorubicin, and etoposide. The cumulative dose of each agent is kept low to minimize permanent injury from the chemotherapy regimen as used in prior COG trials (COG-P9641 and COG-A3961). Older children with local recurrence with either unfavorable International Neuroblastoma Pathology Classification at diagnosis or MYCN gene amplification have a poor prognosis and are treated with aggressive combination chemotherapy, offered palliative care, or offered entry onto a clinical trial.
Evidence (surgery alone or chemotherapy with or without surgery):
Metastatic recurrence
Standard treatment options for metastatic recurrent neuroblastoma initially classified as low risk include the following:
Metastatic recurrent or progressive neuroblastoma in an infant initially categorized as low risk and younger than 1 year at recurrence may be treated according to tumor biology as defined in the prior COG trials (COG-P9641 and COG-A3961):
Chemotherapy may consist of moderate doses of carboplatin, cyclophosphamide, doxorubicin, and etoposide. The cumulative dose of each agent is kept low to minimize permanent injury from the chemotherapy regimen, as used in prior COG trials (COG-P9641 and COG-A3961).
Any child initially categorized as low risk who is older than 1 year at the time of metastatic recurrent or progressive disease and whose recurrence is not in the stage 4S pattern usually has a poor prognosis.
Recurrent Neuroblastoma in Patients Initially Classified as Intermediate Risk
The standard treatment options for locoregional and metastatic recurrence in patients with intermediate-risk neuroblastoma are derived from the results of the COG-A3961 trial. Among 479 patients with intermediate-risk neuroblastoma treated on the COG-A3961 clinical trial, 42 patients developed disease progression. The rate was 10% of those with favorable biology and 17% of those with unfavorable biology. Thirty patients had locoregional recurrence, 11 had metastatic recurrence, and one had both types of recurrent disease. Six of the 42 patients died of disease, while 36 patients were salvaged. Thus, most patients with intermediate-risk neuroblastoma and disease progression may be salvaged.[8]
Standard treatment options for locoregional recurrent neuroblastoma initially classified as intermediate risk include the following:
The current standard of care is based on the experience from the COG Intermediate-Risk treatment plan (COG-A3961). Locoregional recurrence of neuroblastoma with favorable biology that occurs more than 3 months after completion of chemotherapy may be treated surgically. If resection is less than near total, then additional chemotherapy may be given. Chemotherapy may consist of moderate doses of carboplatin, cyclophosphamide, doxorubicin, and etoposide. The cumulative dose of each agent is kept low to minimize permanent injury from the chemotherapy regimen, as used in a prior COG trial (COG-A3961).
Standard treatment options for metastatic recurrent neuroblastoma initially classified as intermediate risk include the following:
If the recurrence is metastatic and/or occurs while on chemotherapy or within 3 months of completing chemotherapy and/or the original tumor histology was unfavorable, the prognosis is poor and the patient is treated with an aggressive regimen of combination chemotherapy or entered on a clinical trial.
Recurrent Neuroblastoma in Patients Initially Classified as High Risk
Any recurrence in patients initially classified as high risk signifies a very poor prognosis.[2] Clinical trials may be offered. Palliative care should be considered as part of the patient's treatment plan.
Treatment options for recurrent or refractory neuroblastoma in patients initially classified as high risk include the following:
It is not known whether one therapeutic approach is superior to another.
Evidence (second autologous SCT following retrieval chemotherapy):
Evidence (131 I-mIBG):
Recurrent Neuroblastoma in the Central Nervous System
Central nervous system (CNS) involvement, although rare at initial presentation, may occur in 5% to 10% of patients with recurrent neuroblastoma. Because upfront treatment for newly diagnosed patients does not adequately treat the CNS, the CNS has emerged as a sanctuary site leading to relapse.[22,23] CNS relapses are almost always fatal, with a median time to death of 6 months.
Current treatment approaches generally include eradicating bulky and microscopic residual disease in the CNS and minimal residual systemic disease that may herald further relapses. Neurosurgical interventions serve to decrease edema, control hemorrhage, and remove bulky tumor before starting therapy. Compartmental radioimmunotherapy using intrathecal radioiodinated monoclonal antibodies has been tested in patients with recurrent metastatic CNS neuroblastoma after surgery, craniospinal radiation therapy, and chemotherapy.[7]
Treatment Options Under Clinical Evaluation for Recurrent or Refractory Neuroblastoma
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent neuroblastoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Treatment of High-Risk Neuroblastoma
Revised text about the Children's Oncology Group (COG) ANBL12P1 trial to state that the International Society of Paediatric Oncology European Neuroblastoma Group published a comparison of the conditioning regimen busulfan/melphalan (BuMel) versus carboplatin/etoposide/melphalan, and BuMel showed better survival outcomes. Also added text to state that the outcome of this trial will influence the choice of preparative regimens used in upcoming COG high-risk neuroblastoma trials.
Added text about the COG-ANBL09P1 trial as a treatment option under clinical evaluation.
This summary is written and maintained by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of neuroblastoma. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Neuroblastoma Treatment are:
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Pediatric Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Neuroblastoma Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/neuroblastoma/HealthProfessional. Accessed <MM/DD/YYYY>.
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
Based on the strength of the available evidence, treatment options may be described as either "standard" or "under clinical evaluation." These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.
Contact Us
More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.
Call 1-800-4-CANCER
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.
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The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.
Write to us
For more information from the NCI, please write to this address:
Search the NCI Web site
The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.
There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.
Find Publications
The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
Last Revised: 2014-01-14
This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use.
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Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.


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Understanding Vitiligo
Recently, it was announced that Chantelle Brown-Young, one of the Black female contestants in this summer's edition of America's Next Top Model, has vitiligo. But what exactly is this skin condition? Read more about what vitiligo is and how it affects African-Americans.— Kellee Terrell
(Photo: Chantelle Brown-Young via Instagram)
Health Rewind: Exercise Reduces Our Risk of Breast Cancer08/17/2014
What to Say to Depressed Loved Ones08/13/2014
Ebola: What You Need to Know08/07/2014
Rewind: Obamacare, Young People and Mental Health Care08/07/2014
The 411 on Herpes08/06/2014
Celebs Who Have Suffered From Mental Health Issues08/04/2014
7 Tips for Choosing a Better Breakfast Cereal08/04/2014
Outbreak: Eight of the Biggest Global Health Scares07/31/2014
Health Rewind: Prison Rates Among Women Are Skyrocketing07/31/2014
10 Healthy Foods to Have in Your Kitchen07/28/2014
Does Maintaining Weight Lower Depression Black Women?07/25/2014
Nine Celebrities Who Survived Childhood Sexual Abuse07/23/2014
The 411 on Crohn's Disease07/17/2014
Health Rewind: Blacks Want Genetic Testing for Alcoholism?07/16/2014
Health Rewind: Linking Black Students to Mental Health Care07/09/2014
Lean Lies: Don't Believe These Weight Loss Myths07/08/2014
The 411 on Measles07/07/2014
Health Rewind: Black Men Still Behind in Health Coverage07/03/2014
Why Access to Birth Control Matters to Black Women07/01/2014
The 411 on Buying Organic Food06/26/2014
Health Rewind: CDC Lays Out New Graphic Anti-Smoking Ads06/25/2014
June 19 Is World Sickle Cell Day: Get The Facts06/19/2014
Health Rewind: Young Americans Are Healthier Under Obamacare06/18/2014
Sun and Shape: The 411 on Exercising Outside06/17/2014
The 411 on Alzheimer's Disease06/13/2014
Health Rewind: New African-American Breast Cancer Initiative06/12/2014
Everything You Need to Know About LGBT Health06/10/2014
Health Rewind: B. Smith Has Alzheimer's06/06/2014
Lessons From the Red Carpet: How Celebs Stay Healthy06/05/2014
Health Rewind: New Survey on Black Women, Fitness and Hair05/30/2014
Summer Skin Care: What You Need to Know05/29/2014
Have You Tried the African-American Heritage Diet?05/29/2014
The 411 on Teen Pregnancy05/27/2014
Health Rewind: Halle Berry on Motherhood and Breastfeeding05/21/2014
Getting Your Body Back After Baby05/21/2014
The 411 on PrEP for HIV Intervention05/19/2014

subset: commoncrawl


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In Minecraft, I have a graphical glitch where there are small purple and sometimes blue static squares all over my Minecraft screen. How could I fix this? They are roughly the size of the on-screen Minecraft blocks and they jitter left and right ect. and it makes it very hard to play.
Thank you!


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You are here:
One good thing is leading to another as Oxfam helps farmers like Susanna in Liberia reclaim swamp land to grow rice.
How you're helping change lives
Education can lift communities like Ameera's out of poverty, forever. We lobby governments, build schools, train teachers - whatever it takes.
Since 2008, UK aid has helped pay for more midwives in Ghana - that's more Cecilias saving countless mothers from dying in childbirth.
Good sanitation and better prospects go hand in hand. Teams like Som's help families stay free of disease and facing a brighter future.
Help change lives for good
Clean water on tap, a cow or two, desks for a school... a little help from Oxfam is often all people need to transform their communities forever. See the impact of our work.
We work on long-term projects with communities determined to shape a better future for themselves.
Where we work
We respond fast in emergencies, and stay to help people rebuild their lives.
Emergency response
In a world rich in resources, poverty isn't inevitable - it's an injustice which we must overcome.
Issues we work on
You're changing lives. Here's how.
Take a peek at the latest edition of Inside Oxfam and discover how we help communities bounce back from disaster. There are some inspiring and uplifting stories such as Chiawa's: she's one of a group of 20 farmers who - with investment and training provided by Oxfam - grow bananas so good they have won awards
Inside Oxfam: Inspiring videos and stories.
3.9 million
people reached by health promotion activities
people benefiting from support to improve their crops, goods or services
1.4 million
people benefiting from improved sanitation facilities
We publish outstanding analysis informed by our work and experience in the field.
Policy & Practice website
We work with the private sector to promote fairer markets and ethical practices.
Working with business
How your company can partner with Oxfam
Two thirds of poor people are women. We put their rights at the heart of our work.
Oxfam and gender equality
goes directly to emergency,
development and
campaigning work
is spent on
support costs
is invested to generate
future revenue
Where your money goes
© 2015. Oxfam is a registered charity in England and Wales (no 202918) and Scotland (SC039042).
Oxfam GB is a member of the international confederation Oxfam.


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Peyton Manning is incredible. I love watching a great player, when his team is on the downward slope. It's really then that you get to see their greatness.
Anyway, go ahead guys. I just needed to say that.
Peyton Manning is incredible. I love watching a great player, when his team is on the downward slope. It's really then that you get to see their greatness.
Anyway, go ahead guys. I just needed to say that.
Though it wasn't pretty, Minaj was really teaching a lesson in civility.
Nicki Minaj didn't, in the end, say much to Miley Cyrus at all. If you only read the comments that lit up the Internet at last night's MTV Video Music Awards, you might think she was kidding, or got cut off, when she "called out" the former Disney star who was hosting: "And now, back to this bitch that had a lot to say about me the other day in the press. Miley, what's good?"
But to really understand the moment, you need to watch the tape.
To summarize: When Minaj's "Anaconda" won the award for Best Hip-Hop Video, she took to the stage in a slow shuffle, shook her booty with presenter Rebel Wilson, and then gave an acceptance speech in which she switched vocal personas as amusingly as she does in her best raps—street-preacher-like when telling women "don't you be out here depending on these little snotty-nosed boys"; sweetness and light when thanking her fans and pastor. Then a wave of nausea seemed to come over her, and she turned her gaze toward Cyrus. To me, the look on her face, not the words that she said, was the news of the night:
The neurologist leaves behind a body of work that reveals a lifetime of asking difficult questions with empathy.
Oliver Sacks always seemed propelled by joyful curiosity. The neurologist's writing is infused with this quality—equal parts buoyancy and diligence, the exuberant asking of difficult questions.
More specifically, Sacks had a fascination with ways of seeing and hearing and thinking. Which is another way of exploring experiences of living. He focused on modes of perception that are delightful not only because they are subjective, but precisely because they are very often faulty.
To say Sacks had a gift for this method of exploration is an understatement. He was a master at connecting curiosity to observation, and observation to emotion. Sacks died on Sunday after receiving a terminal cancer diagnosis earlier this year. He was 82.
In the name of emotional well-being, college students are increasingly demanding protection from words and ideas they don't like. Here's why that's disastrous for education—and mental health.
Something strange is happening at America's colleges and universities. A movement is arising, undirected and driven largely by students, to scrub campuses clean of words, ideas, and subjects that might cause discomfort or give offense. Last December, Jeannie Suk wrote in an online article for The New Yorker about law students asking her fellow professors at Harvard not to teach rape law—or, in one case, even use the word violate (as in "that violates the law") lest it cause students distress. In February, Laura Kipnis, a professor at Northwestern University, wrote an essay in The Chronicle of Higher Education describing a new campus politics of sexual paranoia—and was then subjected to a long investigation after students who were offended by the article and by a tweet she'd sent filed Title IX complaints against her. In June, a professor protecting himself with a pseudonym wrote an essay for Vox describing how gingerly he now has to teach. "I'm a Liberal Professor, and My Liberal Students Terrify Me," the headline said. A number of popular comedians, including Chris Rock, have stopped performing on college campuses (see Caitlin Flanagan's article in this month's issue). Jerry Seinfeld and Bill Maher have publicly condemned the oversensitivity of college students, saying too many of them can't take a joke.
Can the sleek F-35 match the rugged dependability of the aging A-10? The Pentagon plans to find out.
If you're the Pentagon, how do you choose between an aging, but dependable, fighter jet and a brand new aircraft that you're not quite sure is up to the job? You have them fight it out, naturally.
That's essentially what the Air Force said it would do when it announced that starting in 2018, it would pit the A-10 "Warthog" against the F-35 Joint Strike Fighter in a series of tests to see if the new F-35s can adequately replace the A-10s, which the military wants to retire. A 40-year-old platform, the A-10 has been described by Martin Dempsey, the joint chiefs chairman, as "the ugliest, most beautiful aircraft on the planet." It may be old, but as a certain Irish actor would say, it has a very particular set of skills: The A-10 excels at providing what's known as "close-air support," flying low and slow to provide ideal cover protection for U.S. troops fighting in ground combat. That capability is prized not only by the military, but also by a pair of key Republican lawmakers who oversee its budget, Senators John McCain and Kelly Ayotte.
Thicker ink, fewer smudges, and more strained hands: an Object Lesson
Recently, Bic launched a campaign to "save handwriting." Named "Fight for Your Write," it includes a pledge to "encourage the act of handwriting" in the pledge-taker's home and community, and emphasizes putting more of the company's ballpoints into classrooms.
As a teacher, I couldn't help but wonder how anyone could think there's a shortage. I find ballpoint pens all over the place: on classroom floors, behind desks. Dozens of castaways collect in cups on every teacher's desk. They're so ubiquitous that the word "ballpoint" is rarely used; they're just "pens." But despite its popularity, the ballpoint pen is relatively new in the history of handwriting, and its influence on popular handwriting is more complicated than the Bic campaign would imply.
Nervous Democrats are looking for alternatives as Hillary Clinton falters. But is the VP the right person for the job?
"I think panic is the operative mode for the Democratic Party," David Axelrod, who has been on the receiving end of panic mode many times over the years, told me this week. I had asked Obama's political guru how bad the current panic was for Hillary Clinton—bad enough for the party to seek an alternative? Bad enough, perhaps, to create an opening for Joe Biden?
Axelrod didn't think so. "I think it's indisputable she's had a rocky few months," he said. "But if you look at her support among Democrats, and the resources she brings, she's still very strong—I think she's going to be the nominee."
Not everyone is so sure. Public opinion has turned starkly negative on Clinton in recent months, as she has struggled to put the scandal over her use of email as secretary of state to rest. In a poll released this week, the word most commonly summoned when people were asked about her was "liar."
In 1901, William McKinley, 25th president of the United States, was struck down by an assassin's bullet six months into his second term. There are towns and monuments and geographic features across America bearing his name—tribute to the fallen leader from a nation wracked by grief. Mount McKinley is not one of them.
The Alaskan peak, tallest in the U.S., will henceforth be known by its Athabaskan name Denali, as my colleague Krishnadev Noted this morning. But why was it ever known as Mount McKinley to begin with?
Grasses—green, neatly trimmed, symbols of civic virtue—shaped the national landscape. They have now outlived their purpose.
The hashtag #droughtshaming—which primarily exists, as its name suggests, to publicly decry people who have failed to do their part to conserve water during California's latest drought—has claimed many victims. Anonymous lawn-waterers. Anonymous sidewalk-washers. The city of Beverly Hills. The tag's most high-profile shamee thus far, however, has been the actor Tom Selleck. Who was sued earlier this summer by Ventura County's Calleguas Municipal Water District for the alleged theft of hydrant water, supposedly used to nourish his 60-acre ranch. Which includes, this being California, an avocado farm, and also an expansive lawn.
The case was settled out of court on terms that remain undisclosed, and everyone has since moved on with their lives. What's remarkable about the whole thing, though—well, besides the fact that Magnum P.I. has apparently become, in his semi-retirement, a gentleman farmer—is how much of a shift all the Selleck-shaming represents, as a civic impulse. For much of American history, the healthy lawn—green, lush, neatly shorn—has been a symbol not just of prosperity, individual and communal, but of something deeper: shared ideals, collective responsibility, the assorted conveniences of conformity. Lawns, originally designed to connect homes even as they enforced the distance between them, are shared domestic spaces. They are also socially regulated spaces. "When smiling lawns and tasteful cottages begin to embellish a country," Andrew Jackson Downing, one of the nation's first landscaper-philosophers, put it, "we know that order and culture are established."
Residents of Newtok, Alaska, voted to relocate as erosion destroyed their land. That was the easy part.
NEWTOK, Alaska—Two decades ago, the people of this tiny village came to terms with what had become increasingly obvious: They could no longer fight back the rising waters.
Their homes perched on a low-lying, treeless tuft of land between two rivers on Alaska's west coast, residents saw the water creeping closer every year, gobbling up fields where they used to pick berries and hunt moose. Paul and Teresa Charles watched from their blue home on stilts on Newtok's southern side as the Ninglick River inched closer and closer, bringing with it the salt waters of the Bering Sea.
"Sometimes, we lose 100 feet a year," Paul Charles told me, over a bowl of moose soup.
Many communities across the world are trying to stay put as the climate changes, installing expensive levees and dikes and pumps, but not Newtok, a settlement of about 350 members of the Yupik people. In 1996, the village decided that fighting Mother Nature was fruitless, and they voted to move to a new piece of land nine miles away, elevated on bedrock.
The Islamic State is no mere collection of psychopaths. It is a religious group with carefully considered beliefs, among them that it is a key agent of the coming apocalypse. Here's what that means for its strategy—and for how to stop it.
What is the Islamic State?
Where did it come from, and what are its intentions? The simplicity of these questions can be deceiving, and few Western leaders seem to know the answers. In December, The New York Times published confidential comments by Major General Michael K. Nagata, the Special Operations commander for the United States in the Middle East, admitting that he had hardly begun figuring out the Islamic State's appeal. "We have not defeated the idea," he said. "We do not even understand the idea." In the past year, President Obama has referred to the Islamic State, variously, as "not Islamic" and as al-Qaeda's "jayvee team," statements that reflected confusion about the group, and may have contributed to significant strategic errors.
How an Instagram hashtag inspired a movement
Why aren't more people doing basic skin-cancer screening?
A rock monster tries to save a village from destruction.


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Published: 05 June 2013
It was the final flight for Tidy Northern Ireland's 2013 Big Spring Clean at Belfast International Airport, as the campaign draws to a close for this year.
Airport staff from HR, Marketing and Operations joined together to create a litter pick. 11 bags of rubbish were collected from the landside cargo area. Items found were mostly of paper and plastic origin and unusually a football was found.
Event organiser, PR Manager Deborah Harris, Belfast International Airport –
"Working with Tidy NI has been a great experience. As an airport we recognise and accept our responsibility to minimise the environmental impacts of our business activities and initiatives such as the Big Spring Clean-up are an excellent way for all members of staff to get involved."
Tidy Northern Ireland Campaign Manager Lynsey McCloskey said
"This was a fantastic clean-up effort by Belfast International Airport and I applaud the staff who took time out of their busy day to be part of something BIG - Tidy Northern Ireland's Big Spring Clean campaign. This is the landing point for many of Northern Ireland's visitors travelling from near and far so it is very fitting that the clean-up took place here today. A tidy Northern Ireland will encourage tourism and improve the environment we live in for everybody."
The Big Spring Clean campaign and the Belfast International Airport litter pick have both been supported by Antrim Borough Council.
Mayor of Antrim Councillor Roy Thompson said
"I am delighted that Belfast International Airport has taken the initiative to carry out a litter pick and I support them wholeheartedly in their efforts. It would be fantastic if, after the area has been cleaned up, those who drop the litter realise how much cleaner and attractive the area looks and put a stop to their anti-social actions."


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Bar Code Equipment › Hand Held Computer › LXE Hand Held Computer › LXE Tecton › LXE MX7T2B1B1B0US4D
Wi-Fi (802.11a/b/g), Short Range 1D Laser Scanner, Windows CE 6.0, Bluetooth, 256MB/256MB, 55 key Alphanumeric Keypad, ANSI. Includes Battery, Stylus, and Hand Strap. Interface cables and charging cradle sold separately.
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With natural handgrip ergonomics and a sleek design for an industrial tool, the LXE Tecton delivers its enhanced performance across a wide array of supply chain tasks. The successor to LXE's highly successful MX7, the Tecton features multi-range scanning capabilities that enable bar code reads from four inches to 40 feet, so operators can perform warehouse moves ranging from receiving to full pallet put-aways with the same version of the computer. Scan-intensive picking can be enabled with the Tecton's available easy-grip removable handle with two-finger trigger, and every Tecton comes with LXE's ToughTalk technology for voice-driven processes. Tecton also features a scan vibration signal that can be used to verify successful scans, and multiple built-in data-entry options.
Full specifications (PDF)
Manufacturer part number: MX7T2B1B1B0US4D


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I'm building a LEGO model and planning on lighting it with a bank of 5 battery operated LEDs. I know sunlight negatively affects several LEGO colors. Will a bright LED harm the elements in my MOC the same way sunlight would?
Take the 2-minute tour ×
LEGO® Answers is a question and answer site for LEGO® and building block enthusiasts. It's 100% free, no registration required.
Ultra-violet radiation is emitted primarily by sunlight, mercury lamps, black lights.
LEDs emitting visible light will not produce a significant amount of UV radiation required to discolour LEGO bricks. However, LEDs can be manufactured to emit UV light,


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User Tip: If you're unsure of your vehicle type, you may skip the machine type selection box.
Select type, make, model and year above
"Customer service is priority #1 at Rocky Mountain ATV/MC. We value our customers and strive to be the best shopping experience- when you buy from us, you are buying lifetime service."
-Dan Thomas, CEO and Founder
We take pride in offering no hassle returns. In the event of a return, please call, email or chat with us to receive a solution to the problem. For apparel that doesn't fit quite right, Click here to see our Fit Guaranteed Program.
We will stand behind all products we sell with regards to manufacturing defects in workmanship and material. Most products are limited to the manufacturer's warranty. However, we will do everything in our power to take care of the problem.
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Comments On Jan 30, 2015:Quality seat.. Little on the high side $$$ dollar wise. Fit good and is holding up well.
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Comments On Jul 17, 2014:I bought this to replace a tall seat. Love it and it also had the KTM logo on it!
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Comments On May 06, 2014:has taken a ton of abuse and will last forever, but it is rough on the body
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Comments On Mar 19, 2014:The seat foam is way better than stock. If you are concerned about firmness, it breaks in after a ride or so. If you are sitting all day than that might be the reason for saddle soreness. The cover material is durable and the seat fits perfect. I see others had problems with fitment but I would have to believe that it may be the bike and not the seat... also make sure to tighten the bolt towards the back first so you don't get a gap between the seat and the back fender.
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Comments On Mar 10, 2014:Purchased since I needed new cover and new seat bed on my ol 98 YZ 250. The fit is fine - the bed fits good. The gripper cover is great. But the foam is way harder than stock. I had to remove it and put the stock seat back on. The seat is well made and the quality looks good, but the comfort factory is a 0.
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Comments On Mar 05, 2014:BOUGHT THE SEAT A LITTLE SKETCHED OUT A BUDDY OF MINE GOT ONE FOR HIS RM AND HE HATES IT AND IT IS CRAZY STIFF. I GOT MINE AND RODE THE NEXT DAY IN SOME ROUGH DESERT AND IT WAS MUCH BETTER THAN MY PREVIOUS SEAT.
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Comments On Aug 07, 2013:It fits well and is a low profile seat, but if you plan on sitting on it all day then get on the pegs and ride it's not for a day cruise. Ride on Honda!
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Comments On May 19, 2013:At first my son thought that this seat was too stiff, but after riding a couple of practices, he believes that it allows him to maintain better body position in turns improving his overall performance. Definitely recommend.
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Comments On Mar 27, 2013:Made well but kind of hard
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Comments On Mar 02, 2013:this seat is super hard, i bought it cuz stock yz seats are too hard, and this one was just as hard if not harder.
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It isn't GTFO HERE!!!
ugh! Another mistake
ShakeandBake would gladly clean up your mess. You want me to bring him on as a co-owner with you? Hahahahaha
Better make them, and make them quick. Season starts in a week from tomorrow.
aaaaand my team just got even worse. I thought Brown would at least last make it to week 4.
Wow, that's gonna be such a pansy avatar for...hey, maybe 7-16 weeks.
BnR gets a huge break with Wilson, though. Makes his Bradshaw and Jones picks...bad...they're still really bad.
I'm an Arian Foster injury away from having a top 10 back, at least.


text: Weekly Tournament Results for 5/22/12 The La Mirada Disc Golf Club hosted their weekly disc golf tournament on Tuesday, May 22nd at 5:00pm. We had a good turnout with 30 players in four (4) divisions. Open (1), Advanced (11), Intermediate (7) and Novice (11). In the Open division it was "Super" Dave Bretado who took 1st place, beating himself with a score of 47. He takes back his $12. Joel Hall commented that the rest of the regular Open players are tired of playing for 2nd place. To that I say, fine, then get more Open players to come play against you! Read more about Weekly Tournament Results for 5/22/12Log in to post comments


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Shurtape CP-106 Economy Grade Masking Tape is an economy grade high adhesion crepe paper masking tape with thermoplastic rubber adhesive. Designed for general purpose packaging, bundling, holding, splicing, masking and labeling for home, school and industry. Offers a patented thermoplastic adhesive that allows a 100% surface contact area to the substrate with clean removal properties. Economical, but with good performance on variety of substrates. Has excellent quick stick and holding power on cardboard plus good low temperature properties. Shurtape CP 106 has higher adhesion than Shurtape CP 105 and is a favorite among sub and sandwich shops. Also used to mask windows.
(1 to 71 rolls)
(72 to 359 rolls)
(360 to 719 rolls)
(>= 720 rolls)
* see individual roll price to left
(1 to 47 rolls)
(48 to 239 rolls)
(240 to 479 rolls)
(>= 480 rolls)
(1 to 35 rolls)
(36 to 179 rolls)
(180 to 359 rolls)
(>= 360 rolls)
(1 to 23 rolls)
(24 to 119 rolls)
(120 to 239 rolls)
(>= 240 rolls)
(1 to 15 rolls)
(16 to 79 rolls)
(80 to 159 rolls)
(>= 160 rolls)
Offers the widest range of application flexibility available. Exhibits excellent processing performance whether manually or automatically applied. Has superior tensile strength, adhesion properties and holding force which ensures consistent, reliable seals. Hot melt adhesive will bond faster to a surface which is referred to as quick-grab or quick-stick. It typically has higher tack (will feel stickier to the touch), but is also softer. It has lower heat resistance, shear resistance, and sometimes UV resistance than an acrylic adhesive. NOTE: it is called hot melt because the adhesive is applied hot by the manufacturer and then hardens as it cools (you do not need to apply heat to the tape yourself).
Properties are similar to that of hot melt rubber, but natural rubber often holds where other adhesives won't (recycled fibers, dust, cold, heat and heavy loads). It provides good overall adhesion and moisture resistance.
Offer excellent performance, especially for applications in temperatures less than 40°F and greater then 120°F. It provides excellent clarity, has high shear strength, is usually more permanent/durable even when exposed to moisture, and it ages well over extended periods in fluorescent and sunlight. Since it remains clear for the life of the application and does not yellow over time it is ideal for applications such as sealing white cartons. While it has good initial adhesion it does take 24-48 hours to cure and to achieve its maximum bond strength (has gradual adhesion buildup). Another difference between hot melt rubber and acrylic adhesive is if you fold tape over making the two adhesive sides touch the acrylic adhesive will remain attached to the carrier (e.g. paper, film) while a hot melt adhesive will stick to itself and pull off of the carrier. It is the best choice for clarity, UV resistance and aging characteristics.
Is great for extreme temperature applications since silicone adhesive can work in continuous operating temperatures from -100°F to 500°F. They also exhibit good chemical resistance, retain electrical properties, and remove cleanly with little or no residue.
Zinc oxide based adhesive formula is a skin-friendly adhesive which is commonly used on sports medicine tapes.
Examples: 1/16 inch = 62.5 mils; 1/32 inch = 31.25 mils
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Adobe Acrobat X Pro Upgrade -WinItem#: A38-11234X | Model#: 65096935
Currently Out Of Stock!
Acrobat X Pro Upgrade -Win Product Details
Adobe Acrobat X Pro Software - Upgrade
You can use Adobe Acrobat X Pro software to deliver high-impact communications that combine audio, video, interactive media, and a wide variety of file types into a polished, professional PDF portfolio. Get feedback faster through easy-to-manage electronic reviews. Create and distribute fillable PDF forms to collect critical data. Apply passwords and permissions to protect your work.
What It Is And Why You Need It:
- Convert or scan to PDF
- Export and edit PDF files
- Combine files from multiple applications
- Increase productivity and process consistency Streamline online document reviews
- Collect data with fillable PDF forms
- Protect PDF files and documents
Category: Creativity application
Subcategory: Creativity - desktop publishing
Language(s): Universal English
License Type: Version upgrade package
License Qty: 1 user
License Pricing: Standard
Upgrade from: Adobe Acrobat Professional v. 7 ¦ Adobe Acrobat Professional v. 8 ¦ Adobe Acrobat Pro v. 9
Platform: Windows
Distribution Media: DVD-ROM
Package Type: Retail
System Requirements
OS Required: Microsoft Windows XP Home Edition, Microsoft Windows XP Professional, Microsoft Windows Server 2003, Microsoft Windows Server 2008 R2, Microsoft Windows 7 Starter, Microsoft Windows 7 Home Premium (32/64 bits), Microsoft Windows Server 2008, Microsoft Windows Server 2003 x64 Edition SP2, Microsoft Windows Server 2008 x64 Edition, Microsoft Windows
Software Requirements: Internet Explorer 8.0, Internet Explorer 7, Mozilla Firefox 3.5, Mozilla Firefox 3.6
Peripheral / Interface Devices: DVD-ROM, 1024 x 576 monitor resolution
System Requirements Details: Microsoft Windows - 1.3 GHz - RAM 512 MB - HD 1.9 GB
Manufactured by: Adobe
Warranty provided by: Adobe
Mfg Part No: 65096935
UPC No: 883919195971
Box Size: ( Length:8, Width:8, Depth:2)
Shipping Weight: 0.4500 pound(s)
Dimensional Weight: 1pounds
What is Dimensional weight?
Click here for full warranty and support information
- Limited Warranty: A full text version of the limited warranty
may be obtained by mailing a self addressed, stamped envelope to the
address below and requesting the warranty for item number: A38-11234X
Warranty Information
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Miami, FL. 33144
- Adobe logos are registered trademarks of Adobe. All others trademarks and copyrights mentioned herein are the property of their respective owners.


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Introducing a new way to navigate by topics. Access the latest news, data, publications and more around topics of interest.
Our population statistics cover age, sex, race, Hispanic origin, migration, ancestry, language use, veterans, as well as population estimates and projections.
The U.S. Census Bureau is the official source of statistical data tracking the national economy.
Business is a large part of America's diverse economy. This section provides key information about businesses in your community.
This section provides information on a range of educational topics, from educational attainment and school enrollment to school districts, costs and financing.
We measure the state of the nations workforce, including employment and unemployment levels, weeks and hours worked, occupations, and commuting.
Our statistics highlight trends in household and family composition, describe characteristics of the residents of housing units, and show how they are related.
Health statistics on insurance coverage, disability, fertility and other health issues are increasingly important in measuring the nation's overall well-being.
We measure the housing and construction industry, track homeownership rates, and produce statistics on the physical and financial characteristics of our homes.
Income is the gauge many use to determine the well-being of the U.S. population. Survey and census questions cover poverty, income, and wealth.
The U.S. Census Bureau is the official source for U.S. export and import statistics and regulations governing the reporting of exports from the U.S.
The U.S. Census Bureau provides data for the Federal, state and local governments as well as voting, redistricting, apportionment and congressional affairs.
Search an alphabetical index of keywords and phrases to access Census Bureau statistics, publications, products, services, data, and data tools.
Geography provides the framework for Census Bureau survey design, sample selection, data collection, tabulation, and dissemination.
Geography is central to the work of the Bureau, providing the framework for survey design, sample selection, data collection, tabulation, and dissemination.
Find resources on how to use geographic data and products with statistical data, educational blog postings, and presentations.
The Geographic Support System Initiative will integrate improved address coverage, spatial feature updates, and enhanced quality assessment and measurement.
Work with interactive mapping tools from across the Census Bureau.
Find geographic data and products such as Shapefiles, KMLs, TIGERweb, boundary files, geographic relationship files, and reference and thematic maps.
Metropolitan and micropolitan areas are geographic entities used by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics.
Find information about specific partnership programs and learn more about our partnerships with other organizations.
Definitions of geographic terms, why geographic areas are defined, and how the Census Bureau defines geographic areas.
We conduct research on geographic topics such as how to define geographic areas and how geography changes over time.
Visit our library of Census Bureau multimedia files. Collection formats include audio, video, mobile apps, images, and publications.
Official audio files from the Census Bureau, including "Profile America," a daily series of bite-sized statistics, placing current data in a historical context.
Infographics include information on the Census Bureau's history of data collection, our nation's veterans and the American Community Survey.
Stock photos that illustrate official Census Bureau operations and activities.
Read briefs and reports from Census Bureau experts.
Watch Census Bureau vignettes, testimonials, and video files.
Read research analyses from Census Bureau experts.
Access data through products and tools including data visualizations, mobile apps, interactive web apps and other software.
Find information using interactive applications to get statistics from multiple surveys.
Developer portal to access services and documentation for the Census Bureau's APIs.
Explore Census Bureau data on your mobile device with interactive tools.
Find a multitude of DVDs, CDs and publications in print by topic.
These external sites provide more data.
Download extraction tools to help you get the in-depth data you need.
Learn more about our data from this collection of e-tutorials, presentations, webinars and other training materials. Sign up for training sessions.
Explore Census data with interactive visualizations covering a broad range of topics.
Learn how we serve the public as the most reliable source of data about the nation's people and economy.
Information about the U.S. Census Bureau.
Information about what we do at the U.S. Census Bureau.
Our researchers explore innovative ways to conduct surveys, increase respondent participation, reduce costs, and improve accuracy.
Our surveys provide periodic and comprehensive statistics about the nation, critical for government programs, policies, and decisionmaking.
Learn about other opportunities to collaborate with us.
Explore the rich historical background of an organization with roots almost as old as the nation.
Explore prospective positions available at the U.S. Census Bureau.
Information about the current field vacancies available at the U.S. Census Bureau Regional Offices.
Discover the latest in Census Bureau data releases, reports, and events.
The Census Bureau's Director writes on how we measure America's people, places and economy.
Find interesting and quirky statistics regarding national celebrations and major events.
Profile America is a daily, 60-second feature that uses interesting vignettes for that day to highlight information collected by the Census Bureau.
Find media toolkits, advisories, and all the latest Census news.
See what's coming up in releases and reports.
Contact: Public Information Office
The U.S. Census Bureau today released estimates from the American Community Survey, the most detailed portrait of America's towns and neighborhoods — even for the smallest communities within a metro area — for the combined years from 2007 to 2011. The American Community Survey permits communities to observe the composition of their population, from preschool to the oldest ages and milestones in between, including college, work and marriage.
Wide variation exists in the languages spoken at home, educational attainment, the share of persons working in manufacturing, marital status and living arrangements, and many other measures across the Detroit metropolitan area.
"The American Community Survey provides the only statistics on school enrollment, jobs, housing and many other measures for all towns and neighborhoods," said Thomas Mesenbourg, the Census Bureau's acting director. "The results are used by everyone from retailers, homebuilders and police departments, to town and city planners. The numbers permit them to examine demographic patterns within metropolitan areas."
Selected highlights from the 2007-2011 estimates show the wide variation in conditions within the Detroit metro area:
More information about the social, economic and housing characteristics of cities and towns in the Detroit area, as well as information on other geographies, can be found on the Census Bureau's American FactFinder website.
The American Community Survey five-year estimates are available for all states, counties, places, congressional districts, census tracts and block groups. Today's release marks the first time since the 2000 Census that statistics for ZIP Code tabulation areas — a close approximation of the U.S. Postal Service's ZIP Code areas — have been released on such a wide range of topics.


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- Independent
- The Enterprise
- The Recorder
A group of Girl Scouts was the target of an attempted robbery Sunday evening.
Around 6 p.m. March 24, Charles County sheriff's officers went to the 3200 block of Plaza Way in Waldorf after someone called to report a strong-arm robbery.
Diane Richardson, spokeswoman for the sheriff's office, said a man and woman were arguing near a group of Girl Scouts who were selling cookies outside a business. The girls were between the ages of 8 and 17.
The woman approached the Scouts and their troop leader and pushed the cookies off the table. The man, later identified as James Ernest Wright, 48, attempted to grab a donation box from the table, Richardson said.
She said the troop leader grabbed an envelope of cash from the box to keep the man from getting it. Wright then pushed the troop leader in an attempt to grab the envelope. Richardson said Wright fled without the envelope. The woman ran away, too.
Police would not say how much money was in the envelope.
Before police got to the scene, Richardson said, an off-duty Department of Defense officer, also the father of one of the Girl Scouts, was in the area and was alerted by the troop members of the situation.
The father located Wright, and soon after, sheriff's officers arrived and helped apprehend Wright, who also had lunged at the father.
Wright was charged with second-degree assault, theft and robbery and was being held at the Charles County jail. The woman was not located.


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Summertime is almost here. The smell of barbecue is in the air. Children are out of school, and it's the perfect time to plan a getaway.
Summer is all about having fun, and throwing back a few cold ones is a common way to beat the heat. The Critical Days of Summer Campaign, from Memorial Day to Labor Day, has been around for more than 20 years. One of the campaign's goals is to raise awareness of the hazards of alcohol.
"The Air Force has created this campaign to bring emphasis on these critical days and also to prepare Airmen at all levels to handle the hazards and challenges we find throughout the summer," said Ben Bruce, 56th Fighter Wing Ground Safety manager.
U.S. Air Force statistics show that summer injuries increase with the use of alcohol.
"We find in a lot of our other activities, whether barbecuing or off-duty recreation, a lot of injuries hinge around the use of alcohol," Bruce said. "We have a big chunk of our young Airmen moving through the system who are that age and engaged in high-risk activities. You put alcohol in the mix you've got a dangerous situation."
Statistics show that junior Airmen and officers are more often involved in alcohol-related incidents.
"Between ages 18 and 26, most of us are 10-feet tall and bulletproof," Bruce said. "The challenge is balancing that natural aggression and desire to push the limits by learning boundaries and using alcohol responsibly."
Airmen and family members can better prepare themselves this summer by having a plan and knowing their limits before they begin any activity.
"We recommend the zero, zero, one, three plan," Bruce said. "Zero underage drinking, zero DUIs, one drink an hour, three drinks maximum. That goes for the standard beer, shot of whiskey or a glass of wine.
"It's a good tool to use," he said. "It prevents you from being irresponsible and certainly from binge drinking, which is a serious concern. You want to stay well below that .08 limit, and the best way to do that is the zero, zero, one three plan. Anything other than that and you're rolling the dice."
The critical days of summer campaign is about promoting a culture of responsibility while enjoying summertime activities.
"Everybody needs to take responsibility for themselves," said Capt. Julie Beyer, 56th Fighter Wing Staff Judge Advocate military justice chief. "As a culture we should be looking out for each other. If you're going to be drinking, know that there is assistance through Airmen Against Drunk Driving, taxis, having a designated driver or calling a friend to come get you. Just make the choice and have a plan in place."
Another goal during the critical days of summer is to promote responsibility through the ranks to curb incidents involving alcohol.
"The most important people are the immediate supervisors of the Airmen," Bruce said. "They are the most influential. It starts with the front-line supervisor. When they get involved good things happen."
DUIs increase during the summer, however those numbers have been declining the last three years with the help of front-line supervisors, Bruce said.
"There were 19 DUIs last year and five so far this year; however, if we don't curb them, we are on track to repeat those numbers," he said.
Though the goal of the critical days of summer campaign is to keep Airmen and their families safe during the summer, that doesn't mean it can't be fun.
"We are not prohibitionist in the safety business," Bruce said. "We don't want to make you stop using alcohol. We just want you to use it responsibly. That will eliminate a lot of things like underage drinking, DUIs and binge drinking."