Childhood Cancer Survivorship Improving Care and Quality of Life (2003) / Chapter Skim
Currently Skimming:
4. Late Effects of Childhood Cancer
4. Late Effects of Childhood Cancer
Pages 49-89
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 49... ...
Chemotherapy, radiation therapy, and surgery may all cause late effects involving any organ or system of the body. Effects of surgery with 49
|
From page 50... ...
These late effects include cognitive impairment, fertility problems, alterations in growth and development, organ system damage, chronic hepatitis, and second malignant neoplasms (DeLaat and Lampkin, 1992; Donaldson, 1993; Dreyer et al., 2002; Friedman and Meadows, 2002; Marina, 1997; Meister and Meadows, 1993; Neglia and Nesbit, 1993; Schwartz, 1995~. Survivors frequently have more than one late effect, with perhaps as many as a quarter of survivors experiencing one that is severe or life-threatening (Garre et al., 1994; Oeffinger et al., 2000; Stevens et al., 1998~.
|
From page 51... ...
Despite the relatively high prevalence of late effects, recent evidence suggests that survivors of chilc~hooci cancer view themselves as being in relatively good health. Only 11 percent of 9,434 members of the CCSS cohort reported that they were in fair or poor general health when recently surveyed (Kevin Oeffinger, personal communication to Maria Hewitt, August 16, 20021.
|
From page 52... ...
L `` , SoftTissue Sarcoma ~ ~ ·._ _. :_ - - - :_.- — Bone ~ ;.; i ._ j 10 16 20 25 Years since diaq~osis FIGURE 4.2 Mortality, by cancer type (Childhood Cancer Survivor Study)
|
From page 53... ...
LATE EFFECTS OF CHILDHO OD CANCER TABLE 4.1 Causes of Death in the Childhood Cancer Survivor Study Cohort 53 Cause of death Number of deaths Percent of deaths Total Recurrence Treatment-related consequences Subsequent neoplasm Cardiac Pulmonary Other sequelae Non-treatment related External causes Medical conditions 1,848 1,246 394 235 83 33 43 208 94 114 100.0 67.4 21.3 12.7 4.5 1.8 2.3 11.3 5.1 6.2 SOURCE: Adapted from Mertens et al., 2001. O _ ~ O o Lid 0 _ rid ~ O cn — ah o .~ cot o cot .> 0 _ f , ~ RecurrencelOripinal ~~ r Extelna Pulmonary ~ 10 15 20 Years since diagnosis FIGURE 4.3 Cumulative cause-specific mortality (Childhood Cancer Survivor Study)
|
From page 54... ...
NEUROCOGNITIVE LATE EFFECTS Cognitive impairment is one of the most clebilitating late effects among children whose cancer (or its treatment) involveci the central nervous system.
|
From page 55... ...
· Weakness, fatigue · Obesity · Osteoporosis · Avascular necrosis of bone · Dental problems · Kidney damage · Hepatitis C · Infertility · Vision problems · Second cancers Salivary gland malfunctioning (effect of jawbone irradiation) Lung damage Heart problems Infertility Hepatitis C Second cancers (e.g., breast cancer in females)
|
From page 56... ...
For children with CNS tumors or acute lymphocytic leukemia (ALL) , the severity of cognitive impairment following radiation therapy has been associated with the dose of radiation that is administered.
|
From page 57... ...
Studies of cognitive late effects in children treated for ALL and CNS tumors suggest that nonverbal abilities are most impaired, including shortterm memory, processing speed, visual-motor integration, sequencing ability, and attention and concentration. These effects are common to other types of acquired brain injury.
|
From page 58... ...
, and when enrolled, spent a longer time in these programs than did their siblings (Table 4.3~. Cancer survivors were also at higher risk of missing school for long periods and repeating a year of school.
|
From page 59... ...
PSYCHOSOCIAL AND BEHAVIORAL LATE EFFECTS "The experience of completing cancer treatment has two faces one of celebration and hope, one of uncertainty and fear" (Haase and Rostad, 1994, p.
|
From page 60... ...
60 CHILDHO OD CANCER SUR VIVORSHIP TABLE 4.3 Enrollment in Special Education Programs Among Survivors of Childhood Acute Lymphoblastic Leukemia Relative to Sibling Controls, by Time from Diagnosisa Before diagnosis After diagnosis From die Educational Outcome Event rateb RRc Event rateb RRc Event rat Special education Total 3.8 1.4 9.5 3.4~ 5.5 Age at diagnosis, y 0-5 12.3 4.5~ 8.1 26 7.7 2.8 ~ 4.9 Cranial radiation, Gy None 5.8 2.1 0 18 7.2 2.6~ 1.4 24 11.4 4.1~ 10.8 Intrathecal methotrexate, mg None 11.5 4.1 ~ 16.2 <83 11.2 4.1 ~ 4.9 283 5.5 2.0~ 3.0 Learning disabled Total 5.1 1.4 13.3 3.6~ 13.2 Age at diagnosis, y 0-5 17.5 4.7~ 24.7 26 10.8 2.9~ 0.9 Cranial radiation, Gy None 6.0 1.6 0 18 5.4 1.4 4.4 24 19.6 5.3~ 25.0 Intrathecal methotrexate, mg None 12.5 3.3 ~ 10.8 <83 18.2 4.9~ 21.8 283 6.9 1.9 6.1 Gifted and talented Total 7.0 1.0 7.0 1.0 11.3 Age at diagnosis, y 0-5 4.2 0.6 4.1 26 8.9 1.2 12.8 Cranial radiation, Gy None 5.7 0.8 17.5 18 8.5 1.2 15.2 24 6.2 0.9 6.2 Intrathecal methotrexate, mg None 8.0 1.1 10.8 <83 5.2 0.7 10.0 283 9.1 1.3 12.7 aOnly survivors diagnosed before 18 years of age were considered. bEvents per 1,000 person-years.
|
From page 61... ...
LATE EFFECTS OF CHILDHO OD CANCER o Sibling 61 From diagnosis through 2 y after diagnosis After 3 y from diagnosis RRc Event rateb RRc Event rated RRc 3.4 4.5 2.8 2.
|
From page 62... ...
Preliminary results of a study of marriage among members of the Childhood Cancer Survivor Study suggest that adult survivors of childhood cancer marry at lower rates than expected, especially survivors of CNS tumors (Rauck et al., 1999~. Psychosocial interventions to address these concerns can include psychological, emotional, peer, or education support; social skills training; adjustment counseling; family counseling; therapeutic play; cognitive-behavioral interventions; and group or individual psychotherapy (Cohen and Walco, 1999; Kazak et al., 1999; Schwartz, 1999; Van Dongen-Melman, 2000; Walker, 1989~.
|
From page 63... ...
have led the authors to theorize that psychosocial distress results from limited educational and employment opportunities that are secondary to late effects of chemotherapy and cancer-related social disruptions at critical developmental life stages (Zebrack et al., 2002~. Other investigators examining outcomes among cancer survivors have suggested that increased anxiety and depression in children who have had treatment for childhood cancer may be a consequence of perceived or real academic underachievement (Brouwers et al., 2002~.
|
From page 64... ...
. Childhood cancer survivors, particularly if they are male, with high rates of anxiety, depression, or self-esteem deficits, limited vocational potential, and physical health or functioning deficits may be especially likely to engage in risk-taking behaviors.
|
From page 65... ...
Preliminary results from studies of smoking cessation interventions among childhood cancer survivors show success in helping smokers to quit (Emmons et al., 2002~. HEART AND LUNG LATE EFFECTS Childhood cancer survivors with a history of exposure to certain chemotherapeutic agents (i.e., anthracyclines, notably daunomycin and doxorubicin)
|
From page 66... ...
Further longitudinal studies will be needed to ascertain their long-term protective action. Most survivors who develop echocardiographic evidence of left ventricular dysfunction after treatment with an anthracycline will likely remain asymptomatic, but longitudinal studies suggest that a significant proportion of those treated will experience progressive changes and may develop congestive heart failure (Grenier and Lipshultz, 1998; Lipshultz et al., 1995~.
|
From page 67... ...
Little is known of the effects of lower dose radiation therapy currently in use (from 15 to 25 Gy)
|
From page 68... ...
A recent study, for example, found an increased risk of second malignant neoplasms in childhood cancer survivors who had received growth hormone therapy for growth hormone deficiency following cranial irradiation for childhood cancer (Sklar et al., 2002~. Other studies of more heterogeneous populations have not identified an increased risk of leukemia among patients treated with growth hormone, an unknown number of whom were childhood cancer survivors (Fradkin et al., 1993~.
|
From page 69... ...
Obesity Adult survivors of childhood acute lymphoblastic leukemia, particularly females treated at a younger age and previously treated with cranial radiotherapy with cumulative doses of 20 Gy or more have been found to be at a marked increased risk for obesity (Didi et al., 1995; Schell et al., 1992; Van Dongen-Melman et al., 1995; Zee and Chen, 1986~. Adult survivors were at two to three times the risk for obesity, relative to sibling controls (i.e., the age- and race-adjusted odds ratio (OR)
|
From page 70... ...
have also been used to avoid reproductive late effects. Males can become infertile following treatment with chemotherapy and radiation, but usually maintain normal hormonal production.
|
From page 71... ...
Decreased bone mineral density is a multifactorial disorder that is being recognized with increased frequency among survivors of brain tumors (Barr et al., 1998) , acute lymphoblastic leukemia (Aisenberg et al., 1998; Arikoski et al., 1998; Nysom et al., 1998)
|
From page 72... ...
SECOND MALIGNANCIES The cumulative risk of second malignant cancers 20 years following primary treatment for childhood cancer varies between 3 and 10 percent and is 5 to 20 times greater than that expected in the general population. Radiation therapy is associated with the development of thyroid cancer, breast cancer, melanoma and other skin cancers, brain tumors, and bone and soft tissue sarcomas.
|
From page 73... ...
Doses of radiation used in the treatment of childhood cancers, such as Hodgkin's and non-Hodgkin's lymphomas, soft tissue sarcoma, and Wilms' tumor, are associated with an increased risk for basal cell carcinoma and squamous cell carcinoma (Meadows et al., 1985; Olsen et al., 1993; Swerdiow et al., 1997~. Although some follow-up studies of cancer patients have demonstrated an increased risk for malignant melanoma, it is not clear how much, if any, of the excess risk is due to radiation therapy (Shore, 2001~.
|
From page 74... ...
, aminoglycoside antibiotics, and some antifungal agents, such as amphotericin B can cause renal failure or damage. Other renal late effects occur secondary to radiation exposure.
|
From page 75... ...
The aminoglycoside antibiotics may also produce ototoxicity. Immune Function Radiation, chemotherapy, bone marrow transplantation, and removal (or irradiation)
|
From page 76... ...
Only through longterm follow-up of adult survivors will the impact of these types of late effects on the aging process become evident. SUMMARY AND CONCLUSIONS Complications, disabilities, or adverse outcomes that are the result of the disease process, the treatment, or both, are generally referred to as "late effects." Estimates are that as many as two-thirds of survivors will experience a late effect, with perhaps a quarter of survivors experiencing one that is severe or life-threatening.
|
From page 77... ...
Preliminary evidence suggests that there are ways to intervene with tailored smoking cessation interventions in this high-risk population. Other commonly reported late effects include late-onset cardiac and pulmonary disease among childhood cancer survivors with a history of exposure to certain chemotherapeutic agents (i.e., anthracyclines, notably daunorubicin and doxorubicin)
|
From page 78... ...
1998. Reduced bone mineral density in long-term survivors of childhood acute lymphoblastic leukemia.
|
From page 79... ...
1995. High incidence of obesity in young adults after treatment of acute lymphoblastic leukemia in childhood.
|
From page 80... ...
2002. Predictors of smoking initiation and cessation among childhood cancer survivors: a report from the childhood cancer survivor study.
|
From page 81... ...
2003. Endocrine and cardiovascular late effects among adult survivors of childhood brain tumors.
|
From page 82... ...
1990. Growth failure and growth hormone deficiency in children after bone marrow transplantation for leukemia.
|
From page 83... ...
1996. Birth defects in offspring of adult survivors of childhood acute lymphoblastic leukemia.
|
From page 84... ...
1985. Second malignant neoplasms in children: an update from the Late Effects Study Group.
|
From page 85... ...
2001. Cardiovascular risk factors in young adult survivors of childhood acute lymphoblastic leukemia.
|
From page 86... ...
1991. Growth hormone treatment of growth failure secondary to total body irradiation and bone marrow transplantation.
|
From page 87... ...
2000. Risk factors for nephrotoxicity after ifosfamide treatment in children: a UKCCSG Late Effects Group study.
|
From page 88... ...
Ward, JD.2000. Pediatric cancer survivors: assessment of late effects.
|
From page 89... ...
1997. Comparison of psychologic outcome in adult survivors of childhood acute lymphoblastic leukemia versus sibling controls: a cooperative Children's Cancer Group and National Institutes of Health study.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.