Lifetime Follow-up Care after Childhood Cancer
Abstract & Commentary
By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California. Dr. Ferris reports no financial relationship to this field of study.
Synopsis: Lifetime surveillance is required after successful treatment of childhood cancers, since up to 75% of survivors develop serious complications and other late effects.
Source: Haddy RI, Haddy TB. Lifetime follow-up care after childhood cancer. J Am Board Fam Med 2010;23:647-654.
Decreasing death rates from childhood cancers leave large numbers of adults as survivors needing monitoring for both cancer recurrence and late effects of treatment. Childhood cancers are diverse and less often are solid cancers compared to adults; present cure rates are > 80%. Most common are leukemias, brain and nervous system tumors (both malignant and non-malignant), and lymphomas. Nephroblastoma, which requires removal of the affected kidney, is the second most successfully managed malignancy of childhood; the highest cure rate is for Hodgkin lymphoma at 95.5%.
Treatment for most childhood cancers includes adjuvant radiation and chemotherapy. Since their tissues are still growing and developing, children and adolescents are especially sensitive to radiation and chemotherapy damage. For Hodgkin's lymphoma where the mantle area or chest is targeted, complications can include thyroid disease, lung and breast cancers, and pulmonary complications. Radiation to the brain can induce serious neurocognitive late effects.
Bone marrow transplantation is increasingly used and is associated with major transplant toxicities: graft rejections, graft-versus-host disease, and sequelae of prolonged immunosuppression, such as infections and septicemia. Splenectomy was utilized in the past as part of the Hodgkin's staging procedures; these patients must have early evaluation and treatment of febrile illnesses along with immunizations to protect against bacterial infections.
Late effects of childhood cancer treatment are reported in approximately 75% of survivors, with the majority related to treatment toxicity. Most common are delays in growth and development, including intellectual and sexual maturation. Decreased growth hormones can result from radiation damage to the hypothalamus, along with decreased FSH, LH, testosterone, and estradiol. Blood levels can be monitored, along with DEXA bone scans, since failure to reach peak bone mass may result in early osteoporosis. Infertility problems can also result secondary to radiation and chemotherapy with alkylating agents. Learning problems and hyperactivity have been attributed to cranial radiation, which in the past was used prophylactically for leukemias; cataracts and hearing loss can also result from chemotherapy toxicities.
Recurrence of cancer and second malignancies are the leading cause of death among survivors of more than 15 years. The excess risk for survivors continues for at least three decades, but second cancers are often successfully treated. Solid tumors may result from radiation effects, and myelodysplasia and acute myelocytic leukemia are seen from chemotherapy.
Commentary
Primary care clinicians can play a vital role in the long-term survival of childhood cancer survivors. Along with the routine health care maintenance that we provide to all patients, an awareness of major treatment toxicities and developmental effects is necessary to detect and treat problems that can significantly affect quality of life. Even the normal effects of aging, such as cardiovascular disease and osteopenia, may be accelerated or worse in these survivors due to their underlying health status. Guidelines developed by the Children's Oncology Group are a good resource for comprehensive long-term follow-up and are kept updated through a website (www.survivorshipguidelines.org).1,2
Attention to psychological well-being is particularly important, since childhood cancer survivors are more likely to report depression and even post-traumatic stress disorders compared to the general population. There may be more physical health problems resulting in lower rates of employment and even job discrimination. The primary care clinician is in a unique position to help these survivors through both empathetic support and monitoring for complications of cancer treatment and detection of new cancers.
References
1. Landier W, et al. Development of risk-based guide-lines for pediatric cancer survivors: The Children's Oncology Group Long-term Follow-up Guidelines from the Children's Oncology Group Late Effects Committee and Nursing Discipline. J Clin Oncol 2004;22:4979-4990.
2. American Academy of Pediatrics Section on Hematology/Oncology Children's Oncology Group. Long-term follow-up care for pediatric cancer survivors. Pediatrics 2009;123:906-915.
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