Summary¹

Since the late 1960s, the survival rate in children and adolescents diagnosed with cancer has steadily improved, with a corresponding decline in the cancer-specific death rate. At the same time, while more than 85 percent of children diagnosed with cancer will now survive for more than 5 years after diagnosis, survival rates vary greatly depending on the cancer type, the stage of the cancer, and other risk factors. Although the improvements in survival are encouraging, they have come at the cost of acute, chronic, and late adverse effects precipitated by the toxicities associated with the individual or combined use of different types of treatment (e.g., surgery, radiation, chemotherapy). In some cases, the impairments resulting from cancer and its treatment are severe enough to qualify a child for U.S. Social Security Administration (SSA) disability benefits.

SSA provides disability benefits through two programs: Social Security Disability Insurance (Title II of the Social Security Act) and Supplemental Security Income (SSI) (Title XVI of the Social Security Act). Most children who qualify for SSA disability benefits do so under the SSI program. Enacted in 1972, SSI is a means-tested program based on income and financial assets that provides income assistance from U.S. Department of the Treasury general funds to adults and children with disabilities, as well as to adults aged 65 and older and individuals who are blind. In fiscal year 2019, 2,725 childhood cancer claims were allowed.

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¹ With the exception of direct quotations, this Summary does not include references. Citations to support the text and conclusions herein are provided in the body of the report.

In 2019, SSA requested that the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine convene a committee of relevant experts to provide current information and findings and conclusions regarding the diagnosis, treatment, and prognosis of selected childhood cancers, including different types of malignant solid tumors, and the effect of those cancers on children’s health and functional capacity, including the relative levels of functional limitation typically associated with the cancers and their treatment. SSA also asked the committee to provide a summary of selected treatments currently being studied in clinical trials and to identify any limitations on the availability of these treatments (other than those due to financial circumstances), such as whether treatments are available only in certain geographic areas.

STUDY APPROACH AND SCOPE

The committee relied on a number of established, comprehensive sources of information about childhood cancers that are updated regularly by various means, including ongoing literature review. These sources include the National Cancer Institute’s PDQ (Physician Data Query®); Children’s Oncology Group guidelines; and the Surveillance, Epidemiology, and End Results Program. The committee used these sources where possible because of their comprehensive evidence-based nature and regular updates, supplemented by its own literature reviews as needed. The committee drew on a variety of additional resources as well, including invited speakers with expertise in physical, neurocognitive, and psychosocial functioning as well as pain in children during and following cancer treatment. The committee also hosted a panel discussion to hear the perspectives of parents, educators, and social workers on the functional capacity of pediatric patients with cancer and survivors of childhood cancers.

Function and Disability

The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) model of disability recognizes functioning in three domains: (1) body function and structure, which encompasses physiological functions of the body, including psychological functions, as well as functioning of body structures (e.g., movement of limbs, cardiac function); (2) activities, which are actions or tasks (e.g., running, problem solving); and (3) participation, which is the performance of tasks in a societal context (e.g., participation in school or organized sports). The ICF model refers to deficits in body function and structure as impairments, deficits in completing activities as limitations, and reductions in participation

as restrictions. It should be noted that such accommodations as assistive technologies and environmental modifications are environmental contextual factors that act on the ICF domains to enhance an individual’s activity and participation.

SSA incorporates function into its definition of disability for children, considering children under age 18 to be disabled if they have a “medically determinable physical or mental impairment, which results in marked and severe functional limitations, and which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.”² SSA looks at “how appropriately, effectively, and independently” children with impairments perform their activities (everything they do at home, at school, and in the community) compared with the performance of other children their age who do not have impairments.³ In particular, SSA considers functioning in six domains: “(1) acquiring and using information, (2) attending and completing tasks, (3) interacting and relating with others, (4) moving about and manipulating objects, (5) caring for [oneself], and (6) health and physical well-being.”⁴

When SSA evaluates a child’s disability claim based on a physical or mental impairment, it follows a three-step process of disability determination. At Step 1, SSA determines whether the applicant is engaging in “substantial gainful activity.”⁵ If not, then at Step 2, SSA requires sufficient evidence to (1) establish the presence of a medically determinable physical or mental impairment(s), (2) assess the degree of functional limitation the impairment(s) imposes, and (3) project the probable duration of the impairment(s). If SSA establishes the presence of a severe medically determinable physical or mental impairment(s), it determines at Step 3 whether the impairment(s) meets or medically equals (is equivalent in severity to) the criteria in the Listing of Impairments (listings), or functionally equals (i.e., the impairment[s] results in functional limitations equivalent in severity to) the listings. The listings describe, for each of the major body systems, impairments that SSA considers severe enough to cause marked and severe functional limitations in children.

The cancer listings are unique among the listings in that they specify a duration for which a relevant impairment is considered disabling. For certain cancer listings, SSA will consider an impairment disabling for a particular period of time (e.g., at least 12 months from the date of a bone

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² 42 U.S.C. 1382c(a)(3)(C)(i).

³ 20 CFR 416.926a.

⁴ 20 CFR 416.926a.

⁵ “Substantial gainful activity” is work activity involving significant physical or mental activities for pay or profit (20 CFR 416.972). Someone earning more than a specified monthly amount ($1,260 after deduction of impairment-related work expenses for a non-blind individual in 2020) ordinarily is considered to be engaging in substantial gainful activity.

marrow transplant). For cancers without such a specified duration, SSA considers an impairment that meets or medically equals a cancer listing disabling until at least 3 years after the onset of complete remission. Following the relevant period, SSA considers any residual functional impact from the cancer or the therapy in determining whether the child will continue to be considered disabled under the SSI program rules. When a child turns age 18, SSA reviews the individual’s eligibility to continue receiving SSI benefits based on the SSA disability determination process for adults.

Timeframes of Interest

The committee recognized that high-quality cancer care spans the continuum of cancer care from diagnosis through end-of-life care. This report focuses on the acute and chronic phases of cancer care. The acute phase begins immediately after a person has been diagnosed with cancer and generally includes such up-front treatments as surgery, initial chemotherapy, and radiation therapies, as well as palliative and psychosocial care as needed by the patient. The chronic phase, which may continue for months to years following initial diagnosis, includes ongoing management of the patient with the goal of providing long-term surveillance for cancer recurrence and, in some patients, prolonged adjuvant or maintenance therapies. In addition, patients may receive palliative and psychosocial care to help them manage residual effects of the cancer and its treatment.

The committee was asked to describe “the minimum period appropriate to consider a childhood cancer disabling under SSA’s definition of disability for children.” In considering this question, the committee noted important differences between disability in children and in adults. Any interruptions to a child’s normal developmental process and experiences can have profound, and potentially lasting, functional effects. Although severe impairments acquired in adulthood also may seriously affect the individual’s function and participation in work and other daily activities, they do not interfere with the normal acquisition of cognitive and social skills that occurs during childhood and adolescence. A child’s absences from school (and other typical activities) have greater long-term impacts relative to adults’ absences from work; for children, limited functioning relative to peers has a compounding effect.

The committee identified three timeframes of interest with respect to childhood cancers and SSA’s disability determination processes. The first, which addresses the question of “the minimum period appropriate to consider a childhood cancer disabling,” is the period from the child’s cancer diagnosis through active treatment and an anticipated period of recovery

from the acute effects of treatment. During the recovery period, the child remains unlikely to be able to participate in school or other activities. This period corresponds roughly to the acute phase of the cancer care continuum. The second timeframe is the period following treatment and recovery from any acute effects of treatment, during which the child may continue to experience chronic (ongoing, persistent) effects of treatment and/or develop secondary late effects while still under the age of 18, the age at which SSA’s disability determination process shifts to that used for adults. The third timeframe is the period of adulthood (more than 18 years of age), during which individuals may continue to experience chronic effects or develop late effects of the treatment for their childhood cancer. The second and third timeframes correspond to the chronic phase of the cancer care continuum. The committee identified the period of transition from adolescence to young adulthood as particularly important for this study because of the unique issues it presents with respect to cancer treatment, functional impacts, and disability adjudication.

The committee also was asked to describe “clinical standards for identifying ‘cure’ or complete remission.” Cure is a complicated concept, and although it can be achieved in some patients, use of the term is inconsistent among researchers and clinicians. The term “long-term survivor” is preferred as it better communicates the concept that disease-free status comes with significant risk of long-term effects.

Selection of Cancer Types

The committee was asked to “provide an overview of the current status of the diagnosis, treatment, and prognosis of select childhood cancers, including different types of malignant solid tumors.” The committee understood the phrase “malignant solid tumors” to refer specifically to a category within SSA’s child cancer listings with the same label, which appears to include all types of malignant solid tumors that are not otherwise specified in the listings. The committee’s selection of cancers for discussion in this report includes not only cancer types that would be captured within SSA’s “malignant solid tumor” category but also other types of solid tumors, including those of the central nervous system (CNS), and hematologic malignancies that are specified in the cancer listings.

One of the challenges the committee faced was use of the traditional classification of tumors as “benign” and “malignant.” The distinction between these categories of tumors is often problematic in children, particularly regarding CNS tumors. Not only are these terms misleading with respect to societal understanding and misconceptions, but many of the “benign” tumors often cause long-standing and permanent late effects,

morbidities, and disability, and many can lead to a child’s death. For these reasons, the committee prefers that these terms be avoided. In CNS tumors, the terms “low grade” and “high grade” are often used instead. Many low-grade lesions, such as a low-grade glioma, are treated in the same manner as a high-grade tumor—with surgery, chemotherapy, and sometimes radiation. The committee therefore chose to include in this report some lesions that historically have been labeled “benign.” Specifically, the committee included certain lesions that often behave and are treated in the same ways as high-grade lesions and typically are not considered “benign” by the pediatric oncology community at large.

In its final selection of conditions to address in this report, the committee included conditions in three broad groups: (1) hematologic malignancies and histiocytoses, (2) CNS tumors, and (3) non-CNS solid tumors (see Box S-1).

OVERALL CONCLUSIONS

The committee formulated seven overall conclusions in six areas: (1) functional impacts of cancer and its treatment, (2) adverse effects of treatment, (3) occurrence and persistence of functional impairments, (4) transition from adolescence to adulthood, (5) participation in clinical trials, and (6) availability of pediatric cancer care providers and services.

Functional Impacts of Cancer and Its Treatment

Over the past four decades, there has been a modest yet continuous increase in the incidence of cancers occurring in children under the age of 15 years. Although there remains a group of primary and recurrent cancers for which modern, intensive multimodal therapy is not curative, such treatment has dramatically improved survival for many childhood cancers. Despite this success, however, the toxicities associated with multimodal treatment remain high. As a result, a large proportion of survivors of childhood cancer are at significantly increased risk for serious, potentially disabling, and life-threatening acute, chronic, and late adverse effects of cancer and its therapy. Chronic health problems related to cancer treatment are common among survivors, increase in prevalence with the passage of time since diagnosis, and encompass a spectrum of biomedical and psychosocial disorders and associated functional limitations. Data on historical cohorts of survivors of childhood and adolescent cancers show that the occurrence and severity of multiple chronic health conditions are substantially greater relative to individuals without a history of cancer, predisposing survivors to greater hospital-related morbidity and premature mortality compared with age- and sex-matched controls.

For these reasons, the committee drew the following overall conclusion:

1. During recent decades, the incidence of childhood cancers has increased at a modest rate, and the survival rates for many cancer types have improved. The result has been a growing number of survivors of childhood cancer who, starting from the time of diagnosis, are adversely affected by cumulative physical, cognitive, and psychosocial functional deficits, whose severity may increase over time, as a result of the cancer and its treatment.
   • Despite improved overall survival, certain specific cancers, including certain hematologic malignancies with adverse genetic features, some CNS and solid tumors with metastatic disease, or tumors that recur after primary therapy, have distinctively poor prognoses.

• The functional, social, and psychosocial impacts of all childhood cancers on both the affected children and their families are significant, beginning at the time of diagnosis, continuing through treatment, and often lasting into survivorship.
• The interruption of normal childhood during critical developmental stages by the diagnosis and treatment of a childhood cancer can be particularly debilitating and result in long-term adverse effects.
• Although many survivors of childhood cancer experience persistent adverse physical, cognitive, and psychosocial effects from the cancer and its treatment, CNS tumors and some leukemias place survivors at especially high risk for cognitive deficits, and solid tumors are often associated with physical impairments and medical complications.

Adverse Effects of Treatment

The multimodal treatment of many cancers, utilizing combinations of surgical interventions, chemotherapy, and radiation therapy, as well as immunotherapies, including chimeric antigen receptor (CAR) T cell therapy, hematopoietic stem cell transplantation, and targeted therapies, is likely to expose children with cancer diagnoses to a variety of adverse physical, functional, cognitive, and psychosocial effects. Medical side effects of therapy are common and can impact every organ system. Cognitive dysfunction is also commonly observed in survivors of childhood cancer, particularly those with a history of CNS cancer or CNS-directed therapies, including radiation and chemotherapy. In addition, anxiety, depression, and posttraumatic stress occur in a significant subset of survivors of childhood cancer, and all survivors are at risk for experiencing the effects of cancer and its treatment on psychosocial and emotional functioning. For this reason, it is important for survivors of childhood cancer to receive lifelong surveillance and appropriate interventions for treatment-related physical, cognitive, psychological, and emotional toxicities and late effects.

The age of the child at treatment is a critical factor, and other considerations can be influencing factors. For example, risk of secondary malignant neoplasms (SMN) is associated with exposure to treatments including radiotherapy and certain chemotherapy classes, but that risk can be modified by age at exposure and genetic predisposition. In addition, many of the long-term and late effects of radiation therapy, which often are permanent, depend on the age of the child at treatment, the location and volume treated, and the dose of radiation administered. Although most targeted and immunotherapies are at a relatively early stage of clinical development for pediatric cancer, they offer promise for decreasing adverse

effects. However, supportive longitudinal data are early, and in general, the survival benefits and long-term consequences of such newer therapies remain unknown.

For these reasons, the committee drew the following overall conclusion:

2. Treatment of childhood cancers generally includes individual or combined use of different modalities (e.g., surgery, radiation, chemotherapy), each of which can precipitate a range of acute, chronic, and late-occurring impairments.
   • Adverse physical, functional, cognitive, and psychosocial effects can occur regardless of treatment modality.
   • Acute effects of treatment can elicit impairment both during the treatment course and during a period of recovery following its completion.
   • The adverse effects of pediatric cancer therapy may also continue well past the end of treatment and can be cumulative and become more severe over time.
   • It is important for survivors of childhood cancer to receive lifelong surveillance and appropriate interventions for treatment-related physical, cognitive, psychological, and emotional long-term and late effects.
   • The severity of adverse effects can vary depending on cancer type; tumor location; presence of metastases; type of surgery received; treatment modality employed; duration of treatment; and such patient characteristics as age, genetics, and underlying preexisting conditions.
   • Increasing understanding of the biology and pathogenesis of cancers is resulting in a growing number of targeted treatments that hold promise for less serious acute and long-term adverse effects.

Occurrence and Persistence of Functional Impairments

Adult survivors of pediatric cancers have a real and increasing risk of experiencing disabling conditions as a result of chronic and late effects and SMN resulting from the cancer and its treatment. Despite advances in treatment protocols, as well as treatment modifications, neurologic and musculoskeletal complications and late effects continue to occur, and lead to functional impairment and participation restrictions in social contexts such as school or organized sports. Cognitive sequelae, particularly among survivors of CNS tumors or other cancers involving CNS-directed treatment, may begin at the time of diagnosis, upon initiation of treatment, or later, but

often persist and may progress in severity over time. Some may not be evident until a later developmental stage poses its functional demands. Survivors most commonly experience deficits of attention, working memory, processing speed, executive functioning, and memory that have significant negative impacts on adaptive, educational, and vocational outcomes into adulthood, resulting in persistent functional impairment and reduced independence. Certain subgroups of survivors are most likely to experience the psychosocial and emotional functioning effects of cancer and its treatment, and to a greater degree. As demands for independence increase over time, deficits in adaptive functioning are likely to become more profound and noticeable across the survivor’s lifetime. Although functional deficits resulting from cancer and its treatment can demonstrate improvement with intervention, long-term functional impairments are expected and may affect performance in the educational, vocational, social, self-care, and avocational arenas.

For these reasons, the committee drew the following overall conclusions:

3. Functional deficits resulting from cancer and its treatment can improve over time, but many may persist or worsen, or even have onset at a later time, resulting in long-term functional impairments whose effects include restrictions on participation in the educational, vocational, and avocational arenas.
   • Cognitive sequelae, especially among children treated for CNS tumors and those who receive certain types of chemotherapy, may begin at the time of diagnosis or initiation of treatment, but often persist and may progress in severity over time. Specific cognitive deficits (e.g., a decrease in processing speed related to radiation treatment) may begin well after treatment has concluded or may become evident at a later developmental stage associated with differing functional demands.
   • Long-term psychosocial effects are especially common among the following subgroups of children: those who undergo pretreatment prior to hematopoietic stem cell transplantation, those with CNS tumors, and those who experience significant physical late effects.
4. Many survivors of childhood cancer do not achieve an age-equivalent degree of independence in one or more of several domains, which may include mobility; endurance; activities of daily living; and cognitive, social, or communicative skills.
   • Although rehabilitation services may improve the level of independence with respect to functional activities among survivors

• of childhood cancers, survivors may never achieve the full level of educational and vocational participation expected for their age or developmental stage.

Transition from Adolescence to Adulthood

The transition from adolescence to adulthood at age 18 poses particular challenges for individuals diagnosed with childhood cancer in terms of (1) review of continued eligibility for those receiving SSA disability benefits and (2) continuity of cancer care and follow-up.

When children turn 18, SSA reviews their eligibility to continue receiving disability benefits using its disability determination process for adults, which differs from the process for children. Whereas the process for children comprises the three steps outlined above, the adjudication process for adults is based on medical–vocational evaluations and consists of five steps. For children, Step 3 involves a determination as to whether the child’s qualifying impairment(s) meets or medically equals criteria in SSA’s listings for children, or functionally equals the listings. SSA considers the child’s functioning compared with that of same-age children without impairments. For adults, Step 3 of the adjudication process involves a determination as to whether the adult’s qualifying impairment(s) meets or medically equals criteria in SSA’s adult listings. Although some of those listings contain functional criteria, SSA does not expressly consider whether the severity of an adult applicant’s impairment(s) “functionally equals” the listing as it does for children. Adult applicants whose impairment(s) does not meet or medically equal criteria in the listings move to Steps 4 and 5 of the determination process. At these steps SSA evaluates applicants’ residual functional capacity (RFC) and determines whether the applicants’ physical or mental RFC allows them to perform past relevant work (Step 4) or, in conjunction with such vocational factors as age, education, and work experience, including transferrable skills, to perform other work in the national economy (Step 5). Adolescents who are being reconsidered for SSA disability benefits upon turning age 18 must navigate the transition between the child determination process that incorporates functional equivalence to peers and the adult process that focuses on medical–vocational evaluations.

In addition to the differences in the disability determination processes for children and adults, there are differences in the structure of the child and adult listings for cancer. Notably, the child and adult listings differ in levels of specificity. The child cancer listings currently contain a category of “malignant solid tumors,” which appears to encompass any malignant solid tumors that are not otherwise specifically called out in the listings. In contrast, the adult cancer listings do not include a “malignant solid tumor” category, instead calling out many of those solid tumors individually (e.g.,

soft-tissue sarcoma; skeletal system sarcoma; carcinoma of the kidneys, adrenal glands, or ureters).

Maintaining continuity of cancer care is particularly challenging for individuals who were first diagnosed with cancer during adolescence, as well as for survivors of cancers diagnosed earlier in childhood. The National Cancer Institute defines the adolescent and young adult population as patients diagnosed with a first cancer between ages 15 and 39. This population experiences poorer outcomes compared with those first diagnosed as younger children and older adults. Many reasons for this disparity have been identified, including delays in diagnosis, suboptimal access and accrual to clinical trials, differences between pediatric and adult treatment protocols (i.e., whether one is treated by pediatric or adult medical oncologists), differences in access to psychosocial supports, variable adherence to prescribed treatments, and dose delays and modifications.

Regardless of age at diagnosis, it is clear that childhood cancer and its treatment often precipitate chronic and late effects that adversely impact health and functioning in adulthood. Diagnosis of medical conditions resulting from cancer treatment in childhood may require blood tests, echocardiograms, electrocardiograms, or other measures across the lifespan. Strategies exist for identifying survivors at high risk for secondary cancers and implementing surveillance methods to diagnose these cancers earlier so as to reduce morbidity and mortality. Survivors of childhood cancer also require regular, ongoing, lifelong surveillance for physical, cognitive, psychological, and emotional treatment-related toxicities and late effects, some of which may not yet be recognized, because as noted, the cognitive effects of cancer treatment not only often persist but also may progress in severity over time. However, complexities of the transition from pediatric to adult cancer care and follow-up may lead to disengagement in care, which can result in more severe adverse outcomes in adult survivors of childhood cancers.

For these reasons, the committee drew the following overall conclusion:

5. The transition from adolescence to adulthood is particularly challenging for adolescents diagnosed with cancer, as well as for survivors of childhood cancer.
   • The change in SSA’s disability determination process during the transition from adolescence to adulthood introduces challenges for determining disability and sustaining benefits across the 18-year-old threshold.
   • Complexities in the transition from pediatric to adult cancer care and follow-up may lead to disengagement in care, which can result in more severe adverse outcomes in adult survivors of childhood cancers.

• Attrition at the point of transfer from pediatric to adult cancer care cannot be explained solely by issues of access. Special support is necessary to keep survivors of childhood cancers engaged in the health care system into and through adulthood.

Participation in Clinical Trials

Clinical trials that aim to both improve survival and limit toxicity are essential to advance care and outcomes for patients with childhood cancers, and participation in such trials is considered the standard of care in pediatric oncology. Ideally, all children diagnosed with cancer should have the opportunity to enroll in a trial, which will ensure that they are receiving the most up-to-date treatments while also enabling the generation of new knowledge about how best to treat patients with particular types of cancer. With increased trial availability and continued study, for example, a decrease in side effects is anticipated from such advances as precision radiation therapy, including proton therapy. Likewise, targeted and immunotherapies offer promise for treating cancers with unmet clinical need, but further studies are necessary to understand how these novel therapies can be incorporated into the treatment of both newly diagnosed patients and patients with relapsed and refractory cancers. Continuing research on tumor biology and genomics may reveal additional therapeutic targets and treatment options. Trials to test investigational therapies for children with high-grade CNS and metastatic or relapsed non-CNS malignant solid tumors are especially needed. Studies to understand late effects of novel therapies and interventions to mitigate late effects and second cancers in hematologic malignancies are imperative because although cure rates are high in many cases, the burden of toxicities and late effects is significant.

For these reasons, the committee drew the following overall conclusion:

6. Clinical trials advance the standard of care for patients with childhood cancers and are critical to improving survival while also reducing toxicity, late effects, and subsequent neoplasms. Because of the small numbers of pediatric patients with cancer, trials would not generate meaningful results without a high rate of trial participation, which is generally considered the standard of care for childhood cancers.
   • Regulatory agencies have implemented changes to enable early access to novel therapeutic agents and to facilitate the participation of adolescents and young adults and pediatric patients with cancer in clinical trials.

• It is important to increase the participation of adolescents and young adults in clinical trials, as their participation rate is typically much lower compared with younger children.
• Increased engagement of patients, especially those from underrepresented groups, and their advocates in the development of clinical trials is important to enable representation of the patient and family perspective, including quality of life, tolerability of side effects, and goals of treatment, in the trial design.

Availability of Pediatric Cancer Care Providers and Services

High-quality pediatric cancer care requires management by a multidisciplinary team of clinicians with expertise in pediatric cancer care. Pediatric oncologists often utilize different criteria for cancer staging and risk stratification (e.g., for Hodgkin lymphoma) and different treatment protocols relative to their adult colleagues. Surgical removal of pediatric solid tumors is complex and should be done by pediatric surgical subspecialists at specialized centers. In addition, certain types of procedures (e.g., pelvic bone tumor surgical resection, treatment of neuroblastomas with vascular involvement) are available only at highly specialized centers (HSCs)—centers in which a surgeon or an interventional radiologist has received specialized training beyond the standard training for that specialty. Similarly, precision radiation therapy, including proton beam, is increasingly used to target the therapy more precisely in order to mitigate the late effects of treatment in children with cancer, especially those with CNS tumors, but it is not available at many radiation treatment centers in the United States. For these reasons, patients from less densely populated and rural environments may need to travel some distance to reach a treatment center that can provide specialized pediatric cancer care. Specialized treatment centers for pediatric cancer are available in every state, but HSCs are rare, often requiring travel to another state.

For these reasons, the committee drew the following overall conclusion:

7. The availability of and access to pediatric cancer treatments, clinical trials, follow-up care, and rehabilitation and psychological services can be limited by geography and other factors, such as the availability of experts in pediatric cancer and survivorship care, as well as specialized technology.
   • High-quality care for pediatric cancers relies on effective coordination among a highly specialized team across a broad range of disciplines.