Long-term auditory complications after childhood cancer: A report from the Swiss Childhood Cancer Survivor Study

A Health Service Research Study on a Low-Threshold Hearing Screening Program for Childhood Cancer Survivors in Switzerland: Protocol for the HEAR Study

BACKGROUND

Hearing loss is a common late effect in childhood cancer survivors, caused by ototoxic cancer treatments, such as platinum chemotherapy, cranial radiation with doses of ≥30 Gray, and surgery involving the auditory system. Early recognition of hearing loss as part of follow-up care allows for therapeutic support to mitigate consequences. However, hearing tests are usually only repeated in childhood cancer survivors with abnormal hearing during or right after treatment ends, leaving hearing loss undetected in childhood cancer survivors with late onset or when missed during cancer treatment. Further, general follow-up care attendance may be low after childhood cancer survivors transition to adult care, contributing to missing hearing screening posttherapy. Low attendance may be attributed to childhood cancer survivors finding follow-up care burdensome and time-consuming, lacking awareness of their risk for certain late effects, or the absence of suitable interdisciplinary follow-up clinics. A low-threshold, easily accessible screening program requiring minimal participant effort may address these barriers and improve access to hearing loss screening for childhood cancer survivors.

OBJECTIVE

The HEAR study aims to develop, conduct, and evaluate the feasibility of a low-threshold, community-based screening program for hearing loss in childhood cancer survivors, using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, a tool to plan and evaluate health interventions. Within the screening program, participating childhood cancer survivors completed a standardized hearing assessment at a local Swiss hearing aid provider's shop. This approach provides low-threshold access to detect hearing loss as it is easily and conveniently accessible for everyone.

METHODS

Eligible childhood cancer survivors were identified through the Childhood Cancer Registry Switzerland and included those diagnosed with cancer between 1976 and 2019 before 21 years and who were ≥2 years post diagnosis. We invited eligible childhood cancer survivors by post. Participants scheduled a hearing test appointment at a hearing aid shop. They completed a baseline questionnaire before the hearing test, and 2 follow-up questionnaires afterward to assess program feasibility and participant experiences. Semistructured interviews with participants, hearing aid shop staff, and group discussions with health care professionals will provide qualitative insights. The RE-AIM framework will guide the program evaluation using the quantitative and qualitative data collected.

RESULTS

As of February 2025, all participants have been recruited, and all steps of the study up to the group discussions and the RE-AIM evaluation have been completed.

CONCLUSIONS

The HEAR study introduces a novel, simple, and low-threshold approach to screening for hearing loss after cancer treatment through hearing aid shops located in the community and close to participants' homes. This approach has the potential to supplement existing follow-up care programs by reducing the burden of hearing screening for adult childhood cancer survivors and reaching those who might otherwise be lost to follow-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06036407; https://clinicaltrials.gov/study/NCT06036407.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63627.

Dental Health of Childhood Cancer Survivors-A Report From the Swiss Childhood Cancer Survivor Study (SCCSS)

BACKGROUND

Cancer and its treatments can affect dental health of childhood cancer survivors. We aimed to evaluate the prevalence of dental problems in survivors, compare them to their siblings, and investigate cancer-related risk factors.

METHODS

As part of the population-based Swiss Childhood Cancer Survivor Study, we sent questionnaires inquiring about dental problems to survivors aged 5-19 years and their siblings. We retrieved cancer-relevant information from the Swiss Childhood Cancer Registry and used logistic regressions to compare dental problems between survivors and siblings and to investigate cancer-related risk factors.

RESULTS

We included 735 survivors and 144 siblings. Almost half of survivors and siblings reported at least one dental problem. Compared to siblings, CCS might be more likely to have hypo- or microdontia (odds ratio [OR] 1.7; 95% CI: 0.9-3.2) and enamel hypoplasia (2.2; 0.8-6.0), but seem to be similarly likely to have cavities or cavity-related tooth loss (0.8; 0.6-1.3). Chemotherapy was associated with enamel hypoplasia (3.0; 1.2-10.4), cavities or cavity-related tooth loss (1.5; 1.0-2.3), and gum problems during (23.0; 9.4-76.2) and after (4.6; 2.0-13.5) treatment. Hematopoietic stem cell transplantation (HSCT) was related to hypo- or microdontia (5.4; 2.6-10.7), cavities or cavity-related tooth loss (2.1; 1.2-3.6), and gum problems during treatment (2.0; 1.2-3.6). For hypo- or microdontia and cavities, associations with treatment were driven by patients diagnosed before the age of 5 years.

CONCLUSION

Childhood cancer survivors treated with chemotherapy or HSCT, especially at a young age, might be more likely to have dental problems. Regular dental check-ups guided by healthcare teams and dental hygiene habits can mitigate risks and promote survivor's long-term dental health.

Awareness about the risk of hearing loss after ototoxic treatments in Swiss childhood cancer survivors

OBJECTIVES

The International Guideline Harmonization Group recommends childhood cancer survivors (CCS) exposed to ototoxic treatments be aware of the risk of hearing loss. We assessed awareness among adult CCS.

METHODS

We identified adults diagnosed with cancer < 20 years who received ototoxic treatments through the Swiss Childhood Cancer Registry (ChCR) and invited them to the HEAR-study. Participants completed a questionnaire and underwent pure-tone audiometry. Cancer and treatment data were obtained from the ChCR. We used logistic regression to explore factors influencing awareness.

RESULTS

Of 424 invited, 105 CCS participated (25 %). Fifty-seven percent did not remember receiving information on hearing loss prior to the study. CCS who remembered being informed were more likely diagnosed after 1995 (OR: 4.5, 95 % CI: 1.3-15.4), reported hearing problems (10.9, 2.6-45.1) and other late effects (4.1, 1.3-13.2), and treated with platinum chemotherapy only (10.8, 2.2-53.2) versus cranial radiotherapy only. 44 % of participants presented clinically relevant hearing loss.

CONCLUSIONS

Over half of CCS exposed to ototoxic treatments were unaware of their risk of hearing loss.

PRACTICE IMPLICATIONS

Educating CCS about potential late effects of ototoxic treatments is important to allow early diagnosis and treatment, especially for those who had cancer longer ago and those exposed to cranial radiation.

Late effects of the treatment of childhood cancer

Excellent progress has been made in the last few decades in the cure rates of pediatric malignancies, with more than 80% of children with cancer who have access to contemporary treatment being cured. However, the therapies responsible for this survival can also produce adverse physical and psychological long-term outcomes, referred to as late effects, which appear months to years after the completion of cancer treatment. Research has shown that 60% to 90% of childhood cancer survivors (CCSs) develop one or more chronic health conditions, and 20% to 80% of survivors experience severe or life-threatening complications during adulthood. Therefore, understanding the late side effects of such treatments is important to improve the health and quality of life of the growing population of CCSs.

Auditory complications among childhood cancer survivors and health-related quality of life: a PanCareLIFE study

PURPOSE

Auditory complications are potential side effects from childhood cancer treatment. Yet, limited evidence exists about the impact of auditory complications-particularly tinnitus-on health-related quality of life (HRQoL) among childhood cancer survivors (CCS). We determined the prevalence of hearing loss and tinnitus in the European PanCareLIFE cohort of CCS and examined its effect on HRQoL.

METHODS

We included CCS from four European countries who were diagnosed at age ≤ 18 years; survived ≥ 5 years; and aged 25-44 years at study. We assessed HRQoL (Short Form 36), hearing loss, and tinnitus using questionnaires. We used multivariable linear regression to examine associations between these two auditory complications and HRQoL adjusting for socio-demographic and clinical factors.

RESULTS

Our study population consisted of 6,318 CCS (53% female; median age at cancer diagnosis 9 years interquartile range [IQR] 5-13 years) with median age at survey of 31 years (IQR 28-35 years). Prevalence was 7.5% (476/6,318; confidence interval [CI]: 6.9-8.2) for hearing loss and 7.6% (127/1,668; CI: 6.4-9.0) for tinnitus. CCS with hearing loss had impaired physical (coefficient [coef.] -4.3, CI: -7.0 to -1.6) and mental (coef. -3.2, CI: -5.5 to -0.8) HRQoL when compared with CCS with normal hearing. Tinnitus was associated with impaired physical (coef. -8.2, CI: -11.8 to -4.7) and mental (coef. -5.9, CI: -8.8 to -3.1) HRQoL.

CONCLUSION

We observed reduced HRQoL among CCS with hearing loss and tinnitus. Our findings indicate timely treatment of hearing loss and tinnitus may contribute to quality of life of survivors.

IMPLICATIONS FOR CANCER SURVIVORS

CCS who experience auditory complications should be counseled about possible therapeutic and supportive measures during follow-up care.

Schools' need for information from the healthcare system when balancing between educational demands and the requirements of the child diagnosed with cancer: A qualitative study

PURPOSE

To improve patient care by describing teachers' and school leaders' experiences in teaching children diagnosed with cancer, to better understand which information would be beneficial for schools to receive from the healthcare system.

METHODS

This qualitative study was based on semi-structured interviews with 15 teachers and six school leaders in primary, secondary, and high schools in Sweden (student ages 6-18). The data was analyzed with thematic analysis.

RESULTS

Three main themes were revealed: a different diagnosis from other diagnoses, meaning that the respondents in this study perceived the information about a cancer diagnosis differently compared to other diagnoses due to the uncertain outcome of the child's condition and survival; a balancing act, including a need to balance schools' educational demands with the child's needs; and a desire for more information, especially pedagogical and school-related information.

CONCLUSIONS

The emotional impact on teachers of teaching a child with cancer is significant, and the medical information provided by consultant nurses from the hospitals was very appreciated and helpful. However, educators also highlighted their need for pedagogical information. This information would preferably come from a person specialized in special educational needs for children with cancer, for example, a teacher or a special education teacher from the hospital school or the oncological team.

Remote Field Application of Digital Technology for Hearing Assessments in a Cohort of Pediatric Germ Cell Tumor Survivors

BACKGROUND

Childhood cancer survivors treated with platinum-based chemotherapy are at risk of treatment-induced hearing loss. Accurate evaluation of hearing thresholds has historically been limited to clinical audiometry, which is logistically challenging and expensive to include in epidemiologic studies. We evaluated the feasibility of using a remote, tablet-based hearing assessment in a cohort of pediatric germ cell tumor survivors treated with platinum-based chemotherapy.

METHODS

Survivors from the GCT Outcomes and Late effects Data (GOLD) study were recruited to the pilot study (n = 100). Study personnel conducted remote hearing assessments of standard and extended high frequency thresholds using validated tablet-based audiometry (SHOEBOX, Inc.). T tests and Wilcoxon rank-sum tests evaluated differences in assessment characteristics between children and adults. Agreement between self-reported and measured hearing loss was calculated using Cohen κ.

RESULTS

We were able to reach 136/168 (81%) eligible participants, of which 100 (74%) agreed to participate. Successful completion of the remote hearing assessment was high [97%; 20 children (ages 7-17), 77 adults (ages 18-31)]. The mean assessment length was 37.6 minutes, and the mean turnaround time was 8.3 days. We observed hearing loss at standard frequencies in 21% of participants. Agreement between self-reported and measured hearing loss was significant (P value = 1.41 × 10-7), with 83.5% concordance.

CONCLUSIONS

Hearing loss measured using the remote assessment aligns with self-reporting and rates of hearing loss reported in the literature for this population.

IMPACT

Remote application of tablet-based audiometry is a feasible and efficacious method for measuring hearing in epidemiologic studies with participants spread across large geographic areas.

Evaluation of Metabolic and Cardiovascular Risk Measured by Laboratory Biomarkers and Cardiopulmonary Exercise Test in Children and Adolescents Recovered from Brain Tumors: The CARMEP Study

In recent decades, the improvement of treatments and the adoption of therapeutic protocols of international cooperation has led to an improvement in the survival of children affected by brain tumors. However, in parallel with the increase in survival, long-term side effects related to treatments have been observed over time, including the activation of chronic inflammatory processes and metabolic alterations, which can facilitate the onset of metabolic syndrome and increased cardiovascular risk. The aim of this study was to find possible statistically significant differences in the serum concentrations of early biomarkers of metabolic syndrome and in the results of cardiopulmonary exercise testing between survivors of childhood brain tumors and healthy controls. This is a prospective and observational study conducted on a group of 14 male patients who survived childhood brain tumors compared with the same number of healthy controls. The concentrations of early metabolic syndrome biomarkers [adiponectin, leptin, TNF-α, IL-1, IL-6, IL-10, endothelin-1, apolipoprotein B, and lipoprotein (a)] were measured and a cardiopulmonary exercise test (CPET) was performed. Results: Childhood brain tumor survivors performed worse on average than controls on the CPET. Furthermore, they showed higher endothelin-1 values than controls (p = 0.025). The CPET results showed an inverse correlation with leptin. The differences found highlight the greater cardiovascular risk of brain tumor survivors, and radiotherapy could be implicated in the genesis of this greater cardiovascular risk.

The Incidence and Risk Factors of Cisplatin and Carboplatin Ototoxicity in Pediatric Oncology Patients at Tertiary Oncology Center

Pediatric cancers are relatively rare diseases when considering all types of cancer. Platinum-based chemotherapeutic agents are potent agents against a variety of pediatric malignancies. An important adverse effect of platinum-based agents is the occurrence of hearing loss. This hearing loss can pose a challenge to detect especially if the child is in his early of life. It will also significantly affect the child development of social, pedagogical, and personal dimensions. It is integral to identify incidence of platinum-based ototoxicity and risk factors that increase the likelihood of developing hearing loss in cancer children. We performed a retrospective chart review of 123 pediatric patients who had completed cisplatin and carboplatin therapy for a variety of malignancies. Patients were diagnosed at Princess Nourah Oncology Centre between January 2011 and December 2016, were less than 14 years old at diagnosis. Audiograms were scored using the International Society of Pediatric Oncology (SIOP) Boston Scale (0-4), a validated grading system for cisplatin-related hearing loss. Ototoxicity was reported in 16 patients out of 123 with a rate of 13%. The incidence of ototoxicity was highest in CNS tumors such as medulloblastoma (37.5%) and optic glioma (25%). Males were at greater risk for developing hearing loss than females. Cumulative cisplatin dose and addition radiation therapy were also identified as risk factors for development of ototoxicity (P = 0.008). Nature and location of cancer, gender, cumulative dose, and addition of radiation therapy are important clinical biomarkers of cisplatin ototoxicity.

Severity of hearing loss after platinum chemotherapy in childhood cancer survivors

BACKGROUND

Hearing loss is a potential side effect from childhood cancer treatment. We described the severity of hearing loss assessed by audiometry in a representative national cohort of childhood cancer survivors (CCS) and identified clinical risk factors.

PROCEDURE

We included all CCS from the Swiss Childhood Cancer Registry who were diagnosed ≤18 age and treated with platinum-based chemotherapy between 1990 and 2014. We extracted audiograms, treatment-related information, and demographic data from medical records. Two reviewers independently assessed the severity of hearing loss at latest follow-up using the Münster Ototoxicity Scale. We used ordered logistic regression to identify clinical risk factors for severity of hearing loss.

RESULTS

We analyzed data from 270 CCS. Median time from cancer diagnosis to last audiogram was 5 years (interquartile range 2.5-8.1 years). We found 53 (20%) CCS with mild, 78 (29%) with moderate, and 75 (28%) with severe hearing loss. Higher severity grades were associated with (a) younger age at cancer diagnosis (odds ratio [OR] 5.4, 95% confidence interval [CI]: 2.5-12.0 for <5 years); (b) treatment in earlier years (OR 4.8, 95% CI: 2.1-11.0 for 1990-1995); (c) higher cumulative cisplatin doses (OR 13.5, 95% CI: 4.7-38.8 for >450 mg/m² ); (d) concomitant cranial radiation therapy (CRT) (OR 4.4, 95% CI: 2.5-7.8); and (e) hematopoietic stem cell transplantation (HSCT) (OR 2.7, 95% CI: 1.0-7.2).

CONCLUSION

Three of four CCS treated with platinum-based chemotherapy experienced some degree of hearing loss. We recommend closely monitoring patient's hearing function if treated at a young age with high cumulative cisplatin doses, and concomitant CRT as part of long-term care.

A prospective study on prevalence and determinants of ototoxicity during treatment of childhood cancer: protocol for the SOUND study (Preprint)

Background

Some children with central nervous system (CNS) and solid tumors are at risk to develop ototoxicity during treatment. Up to now, several risk factors have been identified that may contribute to ototoxicity, such as platinum derivates, cranial irradiation, and brain surgery. Comedication, like antibiotics and diuretics, is known to enhance ototoxicity, but their independent influence has not been investigated in childhood cancer patients. Recommendations for hearing loss screening are missing or vary highly across treatment protocols. Additionally, adherence to existing screening guidelines is not always optimal. Currently, knowledge is lacking on the prevalence of ototoxicity.

Objective

The aim of the Study on Prevalence and Determinants of Ototoxicity During Treatment of Childhood Cancer (SOUND) is to determine the feasibility of audiological testing and to determine the prevalence and determinants of ototoxicity during treatment for childhood cancer in a national cohort of patients with solid and CNS tumors.

Methods

The SOUND study is a prospective cohort study in the national childhood cancer center in the Netherlands. The study aims to include all children aged 0 to 19 years with a newly diagnosed CNS or solid tumor. Part of these patients will get audiological examination as part of their standard of care (stratum 1). Patients in which audiological examination is not the standard of care will be invited for inclusion in stratum 2. Age-dependent audiological assessments will be pursued before the start of treatment and within 3 months after the end of treatment. Apart from hearing loss, we will investigate the feasibility to screen patients for tinnitus and vertigo prevalence after cancer treatment. This study will also determine the independent contribution of antibiotics and diuretics on ototoxicity.

Results

This study was approved by the Medical Research Ethics Committee Utrecht (Identifier 20-417/M). Currently, we are in the process of recruitment for this study.

Conclusions

The SOUND study will raise awareness about the presence of ototoxicity during the treatment of children with CNS or solid tumors. It will give insight into the prevalence and independent clinical and cotreatment-related determinants of ototoxicity. This is important for the identification of future high-risk patients. Thereby, the study will provide a basis for the selection of patients who will benefit from innovative otoprotective intervention trials during childhood cancer treatment that are currently being prepared.

Trial Registration

Netherlands Trial Register NL8881; https://www.trialregister.nl/trial/8881

International Registered Report Identifier (IRRID)

DERR1-10.2196/34297

Long-term morbidity and mortality in 2-year hepatoblastoma survivors treated with SIOPEL risk-adapted strategies

BACKGROUND AND AIMS

Prognosis of hepatoblastoma patients has increased with cisplatin-based chemotherapy and high-quality resection including liver transplant. Consequently current risk-adapted therapeutic strategy aims to reduce long-term side effects in patients with standard risk disease.

METHODS

We report long-term mortality and morbidity data concerning 151 2-year hepatoblastoma survivors treated with SIOPEL risk-adapted strategies (sex-ratio M/F = 1.6, median age at diagnosis = 2.6 years [range 0-17.7], median year at diagnosis = 2008 [1994-2017]). Fifty-three patients had loco-regional risk factors VPEFR, 12 were PRETEXT-IV and 30 were metastatic. All received cisplatin and 84 anthracyclines. Twelve had liver transplant. To assess hearing, renal and cardiac functions, audiograms were performed in 116/151 patients (76.8%), glomerular filtration rate in 113/151 (74.8%) and cardiac ultrasound in 65/84 (77.4%) anthracycline-exposed patients.

RESULTS

With a median follow-up of 9.4 years (range 2.1-25.8), four late relapses, one second malignancy (Acute Myeloid Leukemia AML-M5) and two deaths (one from hepatoblastoma, one from AML) occurred. The 10-years event free survival and overall survival probabilities were 95.5% (95% CI 91.9-99.1) and 98.7% (95% CI 96.8-100), respectively. Sixty-eight non-oncologic health-events included 57 cases of hearing loss (including 25 Brock 3-4), three liver cirrhosis, three pre-operative portal cavernoma, two focal nodular hyperplasia, two grade-1 chronic kidney diseases and one asymptomatic cardiac dysfunction were reported. Ototoxicity was significantly associated with cisplatin cumulative dose (OR = 2.07, 95% CI 1.32-3.24, p = 0.001) and carboplatin exposure (OR = 3.14, 95% CI 1.30-7.58, p = 0.01) in multivariable analysis adjusted for sex and age at diagnosis.

CONCLUSIONS

With current risk-adapted strategies, hepatoblastoma is a highly curable disease, with very rare relapses, and few late effects except hearing loss which remains a serious condition in these very young patients.

Provider Documentation of Tinnitus in Childhood Cancer Survivors

Tinnitus is a known complication of treatment for childhood cancer and potentially reduces the quality of life for childhood cancer survivors (CCS). Although current guidelines recommend annual surveillance in CCS at risk for tinnitus, current screening practices among pediatric oncology survivorship providers are unknown. The authors performed a retrospective cohort study to assess the adequacy of current tinnitus screening in survivorship care. The 5.6% prevalence of tinnitus reported by the Childhood Cancer Survivorship Study, the largest ongoing follow-up cohort of CCS, served as the baseline for comparison for our rate of documented positive screening for tinnitus. Survivorship providers identified tinnitus in 3 of 624 (0.48%) eligible CCS, which was significantly lower than the prevalence in the Childhood Cancer Survivorship Study (P<0.0001). Survivorship providers documented any screening for tinnitus (positive or negative) in 15 of 624 (2.4%) CCS. Screening practices significantly differed by ototoxic exposure history and age at follow-up. This study demonstrates that screening and detection of tinnitus are underdocumented by survivorship providers, raising concern for inadequate screening practices. Improved screening may facilitate the recognition and treatment of this late effect, improving the quality of life for CCS.

Long-term follow-up of high-risk neuroblastoma survivors treated with high-dose chemotherapy and stem cell transplantation rescue

Intensive treatments including high-dose chemotherapy (HDC) with autologous stem cell rescue have improved high-risk neuroblastoma (HRNB) survival. We report the long-term health status of 145 HRNB survivors, alive and disease-free 5 years post HDC. Median follow-up was 15 years (range = 5-34). Six patients experienced late relapses, 11 developed second malignant neoplasms (SMNs), and 9 died. Event-free and overall survivals 20 years post HDC were 82% (95% CI = 70%-90%) and 89% (78%-95%), respectively. Compared with the French general population, the standardized mortality ratio was 19 (95% CI = 8.7-36.1; p < 0.0001) and the absolute excess risk was 37.6 (19.2-73.5). Late effects were observed in 135/145 patients (median = 3 events/patient); 103 had at least one severe event. SMNs arose at a median of 20 years post HDC and included carcinoma (n = 5), sarcoma (2), acute myeloid leukemia (2), melanoma (1), and malignant glioma (1). Non-oncologic health events included dental maldevelopment (60%), severe hearing loss (20% cumulative probability at 15 years), hepatic focal nodular hyperplasia (14%), thyroid (11%), cardiac (8%), and renal (7%) diseases and growth retardation (height-for-age z-score ≤ -2 for 21%). Gonadal insufficiency was near-universal after busulfan (40/43 females, 33/35 males). Severe late effects are frequent and progressive in HRNB survivors needing systematic very long-term follow-up.

Late Effects in Childhood Cancer Survivors: Early Studies, Survivor Cohorts, and Significant Contributions to the Field of Late Effects

With improvement in cure of childhood cancer came the responsibility to investigate the long-term morbidity and mortality associated with the treatments accountable for this increase in survival. Several large cohorts of childhood cancer survivors have been established throughout Europe and North America to facilitate research on long-term complications of cancer treatment. The cohorts have made significant contributions to the understanding of early mortality, somatic late complications, and psychosocial outcomes among childhood cancer survivors, which has been translated into the design of new treatment protocols for pediatric cancers, with the goal to reduce the potential risk and severity of late effects.

Risk factors associated with tinnitus in 2948 Dutch survivors of childhood cancer: a Dutch LATER questionnaire study

Background

Tinnitus is a serious late effect of childhood cancer treatment. The aim of this study was to determine the occurrence and risk factors for tinnitus in a national cohort of childhood cancer survivors (CCS).

Methods

Data were collected within the national Dutch Childhood Oncology Group - Long-Term Effects after Childhood Cancer (DCOG-LATER) cohort by a self-reported health questionnaire among 5327 Dutch CCS treated between 1963 and 2002. Siblings (N = 1663) were invited to complete the same questionnaire. Relevant patient characteristics and treatment factors were obtained from the Dutch LATER database. The occurrence of tinnitus in survivors was compared to siblings. To study the effect of risk factors, multivariate logistic regression models were estimated.

Results

In total, 2948 CCS and 1055 siblings completed the tinnitus item. Tinnitus was reported in 9.5% of survivors and in 3.7% of siblings (odds ratio [OR] 3.0, 95% confidence interval [CI] 2.9-3.1). Risk factors associated with tinnitus in CCS were total cumulative dose cisplatin ≥400 mg/m² (OR 2.4, 95% CI 1.4-4.0), age at diagnosis (≥10 years: OR 2.1, 95% CI 1.6-2.8), cranial irradiation/total body irradiation (TBI; OR 1.9, 95% CI 1.5-2.5), and neuro/ear, nose, throat (ENT) surgery (OR 1.8, 95% CI 1.1-2.9). Fifty-one percent of CCS with tinnitus had received treatment with either cisplatin, cranial irradiation/TBI, and/or neuro/ENT surgery.

Conclusions

Tinnitus in CCS was present nearly 3 times more often than in siblings. Awareness in CCS previously treated with cisplatin, cranial irradiation/TBI, and/or neuro/ENT surgery is warranted. As only half of affected CCS had a history of these treatments, it seems that other factors might be associated with tinnitus occurrence in this population.

Childhood cancer: Survival, treatment modalities, late effects and improvements over time

Since the 1960s, paediatric oncologists have gradually become better organised in large study groups and participation in clinical trials is today considered as the standard of care, with most children with cancer in Europe and North America being enrolled on available treatment protocols. Chemotherapy is nowadays the main element of therapy, but irradiation is still required for some patients. With the advent of multimodality therapy and supportive care, five-year cancer survival exceeds 80 % in most European and North American countries today. The substantial improvements in survival led to a constantly growing population of childhood cancer survivors. Concerns regarding the risk of late effects of the intensive cancer treatment at a young age, together with increasing numbers of survivors, have directed attention towards survivorship research. Survivors of childhood cancer are at longstanding risk of various severe somatic and mental health conditions attributable to the cancer and its treatment, as well as adverse social and socioeconomic consequences, and diminished psychological well-being and quality of life. It is, however, important to stress that some survivors have no or very mild adverse health conditions. Nevertheless, joint efforts are warranted for the care and long-term follow-up of childhood cancer patients. With this article, we provide a comprehensive overview of improvements in survival and treatment modalities over time, as well as the related somatic and mental late effects, and social and socioeconomic difficulties that these children might encounter later in life.

Nationwide, population-based study of school grades in practical and aesthetic subjects of children treated for brain tumour

BACKGROUND

Children treated for brain tumour (hereafter termed paediatric brain tumour survivors (PBTS)) often need extra support in school because of late-appearing side effects after their treatment. We explored how this group of children perform in the five practical and aesthetic (PRAEST) subjects: home and consumer studies, physical education and health, art, crafts and music.

METHODS

In this nationwide population-based study of data from the Swedish Childhood Cancer Registry and Statistics Sweden, we included 475 children born between 1988 and 1996, diagnosed with a brain tumour before their 15th birthday. We compared their grades in PRAEST subjects with those of 2197 matched controls. We also investigated if there were any differences between girls and boys, children diagnosed at different ages, and children with high-grade or low-grade tumours.

RESULTS

The odds for failing a subject were two to three times higher for girls treated for a brain tumour compared with their controls in all five PRAEST subjects, whereas there were no significant differences between the boys and their controls in any subject. PBTS had lower average grades from year 9 in all PRAEST subjects, and girls differed from their controls in all five subjects, while boys differed in physical education and health and music. PBTS treated for high-grade tumours neither did have significantly different average grades nor did they fail a subject to a significantly higher extent than PBTS treated for low-grade tumours.

CONCLUSIONS

Children treated for a brain tumour, especially girls, are at risk of lower average grades or failing PRAEST subjects. All children treated for brain tumour may need extra support as these subjects are important for their well-being and future skills.

Platinum-drugs Ototoxicity in Pediatric Patients With Brain Tumors: A 10-Year Review

PURPOSE

Platinum-derived chemotherapy is one of the cornerstones in the treatment of central nervous system tumors in children. We aimed to assess the incidence of hearing loss in children after the exposure to platinum drugs.

MATERIAL AND METHODS

Retrospective study of prospectively collected data on children consecutively diagnosed with brain tumors and treated with platinum derivatives at a tertiary referral hospital between January 2006 and December 2015. We analyzed multiples variables, such as: age at diagnosis, tumor location, hydrocephalus, platinum drug type, radiotherapy, and follow-up time. The final sample size was 51 patients.

RESULTS

The median age at diagnosis was 6 years. The median overall follow-up time was 75 months. The incidence of ototoxicity was 23.5%. Rates of hearing loss with carboplatinum were lower than with cisplatinum. A statistically significant association occurred between the presence of hydrocephalus, radiotherapy exposure, infratentorial tumor location, and ototoxicity after treatment with platinum derivatives.

CONCLUSIONS

Childhood central nervous system tumors nowadays exhibit improved cure and survival rates. However, the ototoxicity resulting from the chemotherapy treatment may accompany patients for the rest of their lives. This study reveals that this occurrence is not negligible, and the association of radiotherapy and the presence of hydrocephalus can be potentiating factors.

Genetic Determinants of Ototoxicity During and After Childhood Cancer Treatment: Protocol for the PanCareLIFE Study

Background

Survival rates after childhood cancer now reach nearly 80% in developed countries. However, treatments that lead to survival and cure can cause serious adverse effects with lifelong negative impacts on survivor quality of life. Hearing impairment is a common adverse effect in children treated with cisplatin-based chemotherapy or cranial radiotherapy. Ototoxicity can extend from high-tone hearing impairment to involvement of speech frequencies. Hearing impairment can impede speech and language and neurocognitive development. Although treatment-related risk factors for hearing loss following childhood cancer treatment have been identified, the individual variability in toxicity of adverse effects after similar treatment between childhood cancer patients suggests a role for genetic susceptibility. Currently, 12 candidate gene approach studies have been performed to identify polymorphisms predisposing to platinum-induced ototoxicity in children being treated for cancer. However, results were inconsistent and most studies were underpowered and/or lacked replication.

Objective

We describe the design of the PanCareLIFE consortium’s work packages that address the genetic susceptibility of platinum-induced ototoxicity.

Methods

As a part of the PanCareLIFE study within the framework of the PanCare consortium, we addressed genetic susceptibility of treatment-induced ototoxicity during and after childhood cancer treatment in a large European cohort by a candidate gene approach and a genome-wide association screening.

Results

This study included 1124 survivors treated with cisplatin, carboplatin, or cranial radiotherapy for childhood cancer, resulting in the largest clinical European cohort assembled for this late effect to date. Within this large cohort we defined a group of 598 cisplatin-treated childhood cancer patients not confounded by cranial radiotherapy. The PanCareLIFE initiative provided, for the first time, a unique opportunity to confirm already identified determinants for hearing impairment during childhood cancer using a candidate gene approach and set up the first international genome-wide association study of cisplatin-induced direct ototoxicity in childhood cancer patients to identify novel allelic variants. Results will be validated in an independent replication cohort. Patient recruitment started in January 2015 and final inclusion was October 2017. We are currently performing the analyses and the first results are expected by the end of 2019 or the beginning of 2020. 

Conclusions

Genetic factors identified as part of this pan-European project, PanCareLIFE, may contribute to future risk prediction models that can be incorporated in future clinical trials of platinum-based therapies for cancer and may help with the development of prevention strategies.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11868

A comparison of the Muenster, SIOP Boston, Brock, Chang and CTCAEv4.03 ototoxicity grading scales applied to 3,799 audiograms of childhood cancer patients treated with platinum-based chemotherapy

Childhood cancer patients treated with platinums often develop hearing loss and the degree is classified according to different scales globally. Our objective was to compare concordance between five well-known ototoxicity scales used for childhood cancer patients. Audiometric test results (n = 654) were evaluated longitudinally and graded according Brock, Chang, International Society of Pediatric Oncology (SIOP) Boston, Muenster scales and the U.S. National Cancer Institute Common Technology Criteria for Adverse Events (CTCAE) version 4.03. Adverse effects of grade 2, 3 and 4 are considered to reflect a degree of hearing loss sufficient to interfere with day-to-day communication (> = Chang grade 2a; > = Muenster grade 2b). We term this "deleterious hearing loss". A total number of 3,799 audiograms were evaluated. The prevalence of deleterious hearing loss according to the last available audiogram of each patient was 59.3% (388/654) according to Muenster, 48.2% (315/653) according to SIOP, 40.5% (265/652) according to Brock, 40.3% (263/652) according to Chang, and 57.5% (300/522) according to CTCAEv4.03. Overall concordance between the scales ranged from ĸ = 0.636 (Muenster vs. Chang) to ĸ = 0.975 (Brock vs. Chang). Muenster detected hearing loss the earliest in time, followed by Chang, SIOP and Brock. Generally good concordance between the scales was observed but there is still diversity in definitions of functional outcomes, such as differences in distribution levels of severity of hearing loss, and additional intermediate scales taking into account losses <40 dB as well. Regardless of the scale used, hearing function decreases over time and therefore, close monitoring of hearing function at baseline and with each cycle of platinum therapy should be conducted.

Tinnitus during and after childhood cancer: A systematic review

BACKGROUND

Tinnitus can occur during and after treatment for childhood cancer. Studies on the occurrence of, and risk factors for tinnitus during and after childhood cancer treatment are scarce. The aim of this study is to get insight into the frequency and risk factors of tinnitus during and after childhood cancer therapy, based on a review of all previously reported literature.

MATERIALS AND METHODS

Systematic electronic literature searches that combined childhood cancer with different treatments and tinnitus terms were performed in the databases EMBASE, Medline, Cochrane, Web of Science, and Google Scholar. Studies were included based on reporting the frequency of tinnitus during and/or after childhood cancer, with 75% of participants being under the age of 25 at time of diagnosis, diagnosed with any type of childhood malignancy and treated with any type of chemotherapy and/or radiotherapy. A risk of bias assessment per research question was performed.

RESULTS

Tinnitus incidence rates were reported up to 15.9 (95% CI 11.8-21.4) during therapy and up to 5.4 (95% CI 4.3-6.9) more than 5 years after diagnosis. The relative risk of developing tinnitus as compared to siblings during and after childhood cancer therapy were reported up to 17.2 (95% CI 11.8-25.0) during therapy and up to 3.7 (95% CI 2.7-5.1) more than 5 years after diagnosis. Independent risk factors for tinnitus development included high dose cranial radiation and platinum based chemotherapy.

CONCLUSION

The frequency of and risk to develop tinnitus seems to be higher in childhood cancer patients and survivors as compared to the normal population. Regular tinnitus screening before, during and after therapy with standardized questionnaires for early detection seems therefore reasonable in order to identify high-risk patients and eventually develop successful clinical preventive, supportive and management strategies.

PanCareLIFE: The scientific basis for a European project to improve long-term care regarding fertility, ototoxicity and health-related quality of life after cancer occurring among children and adolescents

AIMS

Survival after cancer diagnosed during childhood or adolescence continues to improve with new treatments and supportive therapies. Optimal long-term care requires that risks to vulnerable organs are clearly defined and translated into guidelines that are implemented into practice. PanCareLIFE is a pan-European consortium that addresses survivorship issues comprising fertility, hearing impairment and quality of life. This article describes the scientific basis of PanCareLIFE's studies.

METHODS

PanCareLIFE involves 17 partner institutions from eight European countries, with additional 11 data providers from five other countries. Study designs and methods include molecular genetic, cohort and case-control studies, a longitudinal study and an intervention study. Ethics and data protection issues have been taken into account from the beginning.

RESULTS

PanCareLIFE will investigate the way that treatment impairs female fertility, by evaluating anti-Müllerian hormone levels and the underlying genetic susceptibility to loss of fertility. For our fertility studies, more than 6000 survivors have completed questionnaires, more than 1500 provided serum samples and more than 400 case-control triads have been identified. Fertility preservation guidelines for boys and girls will be developed. More than 2000 survivors have contributed audiograms for the ototoxicity study. Almost 1000 samples were sent for genetic analysis related to ototoxicity and gonadal reserve. The SF-36 questionnaire will measure quality of life in more than 10,000 survivors.

CONCLUSIONS

The large number of subjects enrolled in PanCareLIFE and the detailed information accumulated will allow in-depth evaluation of important outcomes. Fertility preservation guidelines will help patients and their families make informed decisions and contribute to their long-term well-being.

Hearing Loss in Adult Survivors of Childhood Cancer Treated with Radiotherapy

The ototoxic effects of radiotherapy have been poorly characterized. We examined adult survivors of childhood cancer who were treated with radiotherapy, which included the head, before the age of 22 years and between 1952 and 2016. Those who received platinum chemotherapy were excluded. Demographic, diagnosis, and treatment outcomes were captured. Audiograms were graded using the Chang and International Society of Paediatric Oncology ototoxicity (SIOP) scales. Among 276 patients with a history of radiation to sites that included the brain, orbit, nasopharynx, and total body irradiation, the median age at treatment was 10.1 years and 59% were male. Of 51 survivors who had post-treatment audiograms, 19 demonstrated severe hearing impairment according to both the Chang and SIOP scales after a median follow-up of 16.6 years. Of those with severe impairment, 10 were using hearing aids. Among the 23 patients with more than one audiogram, five had normal hearing on the first audiogram but hearing loss upon subsequent study. Ototoxic effects of radiotherapy are present in a significant portion of survivors, but impairment may present over time, and our results suggest that many are not being screened. Further, among patients with severe hearing loss, use of hearing aids is not universal. Expansion of access to audiology testing and hearing interventions may be warranted.

Audiological monitoring in Swiss childhood cancer patients

BACKGROUND

Full audiological monitoring is the best strategy to detect hearing loss early and to provide timely intervention in the absence of a clinical method of otoprotection. Full monitoring requires audiological evaluation before, and then during and after ototoxic cancer treatment. In a worldwide context of monitoring protocols that vary substantially, we analyzed the audiological monitoring of childhood cancer patients over the last decade across treatment centers in Switzerland.

PROCEDURE

We retrospectively searched for audiological evaluations in all nine Swiss Pediatric Oncology Centers. We analyzed proportions of patients who had audiological monitoring and described type and timing of monitoring. We determined predictors of audiological monitoring using multivariable logistic regression and described time trends.

RESULTS

We included 185 patients from the Swiss Childhood Cancer Registry diagnosed from 2005 to 2013 who had platinum chemotherapy and/or cranial radiation ≥30 Gray and who were alive at time of study. Less than half of children, 43%, had full audiological monitoring (before, during, and after treatment), while 72% were tested after cancer treatment. Nonstudy patients were less likely to have had monitoring in all phases of cancer treatment. Patients who received treatment with cisplatin or both platinum chemotherapy and cranial radiation were more likely to have had monitoring after treatment. Monitoring during and after treatment increased over the study period, but monitoring before treatment was insufficient in all time periods.

CONCLUSIONS

Our population-based study indicates that audiological monitoring is insufficient in Switzerland, particularly for nonstudy patients. Clinicians must become more aware of the importance of full audiological monitoring.

Overweight in childhood cancer survivors: the Swiss Childhood Cancer Survivor Study

Background

An increased risk of becoming overweight has been reported for childhood cancer survivors (CCSs), in particular leukemia survivors, although the evidence is inconclusive.

Objective

We assessed the prevalence of overweight in CCSs, with a focus on leukemia survivors, compared it with their peers, and determined potential risk factors.

Design

As part of the Swiss Childhood Cancer Survivor Study, we sent a questionnaire between 2007 and 2013 to all Swiss resident CCSs aged <21 y at diagnosis who had survived ≥5 y. We calculated body mass index (BMI) from medical records at diagnosis and self-reported heights and weights at survey. We calculated BMI z scores by using Swiss references for children and compared overweight prevalence in CCSs, their siblings, and the general population with the use of the Swiss Health Survey (SHS) and assessed risk factors for being overweight by using multivariable logistic regression.

Results

The study included 2365 CCSs, 819 siblings, and 9591 SHS participants. At survey, at an average of 15 y after diagnosis, the prevalence of overweight in CCSs overall (26%) and in leukemia survivors (26%) was similar to that in siblings (22%) and the general population (25%). Risk factors for being overweight in CCSs were male sex (OR: 1.8; 95% CI: 1.5, 2.1), both young (OR for ages 5-14 y: 1.6; 95% CI: 1.2, 2.3) and older (range-OR for ages 25-29 y: 1.7; 95% CI: 1.2, 2.4; OR for ages 40-45 y: 4.0; 95% CI: 2.5, 6.5) age at study, lower education (OR: 1.4; 95% CI: 1.1, 1.8), migration background (OR: 1.3; 95% CI: 1.1, 1.7), and no sports participation (OR: 1.4; 95% CI: 1.1, 1.7). Risk factors for overweight were similar in peers. CCSs treated with cranial radiotherapy (≥20 Gy) were more likely to be overweight than their peers (OR: 1.6; 95% CI: 1.2, 2.2).

Conclusions

The prevalence of and risk factors for being overweight are similar in long-term CCSs and their peers. This suggests that prevention methods can be the same as in the general population. An important exception is CCSs treated with cranial radiotherapy ≥20 Gy who may need extra attention during follow-up care. This study was registered at clinicaltrials.gov as NCT03297034.

Profound hearing loss following surgery in pediatric patients with posterior fossa low-grade glioma

Background

Hearing loss may occur in patients with posterior fossa low-grade glioma who undergo surgery.

Methods

We retrospectively reviewed 217 patients with posterior fossa low-grade glioma, including 115 for whom results of hearing tests performed after surgery and before chemotherapy or radiation therapy were available. We explored the association of UHL with age at diagnosis, sex, race, tumor location, extent of resection, posterior fossa syndrome, ventriculoperitoneal shunt placement, and histology.

Results

Of the 115 patients, 15 (13.0%: 11 male, 6 black, 8 white, 1 multiracial; median age 7 years [range, 1.3-17.2 years]) had profound UHL after surgery alone or before receiving ototoxic therapy. Median age at tumor diagnosis was 6.8 years (range, 0.7-14.1 years), and median age at surgery was 6.8 years (range, 0.7-14.1 years). Patients with UHL had pathology characteristic of pilocytic astrocytoma (n = 10), ganglioglioma (n = 4), or low-grade astrocytoma (n = 1). Of these 15 patients, 4 underwent biopsy, 1 underwent gross total resection, 1 underwent near-total resection, and 9 underwent subtotal resection. UHL was more frequent in black patients than in white patients (OR 7.3, P = .007) and less frequent in patients who underwent gross total resection or near-total resection than in those who underwent subtotal resection (OR 0.11, P = .02).

Conclusions

Children undergoing surgery for posterior fossa low-grade glioma are at risk for UHL, which may be related to race or extent of resection. These patients should receive postoperative audiologic testing, as earlier intervention may improve outcomes.

Validation of questionnaire-reported hearing with medical records: A report from the Swiss Childhood Cancer Survivor Study

BACKGROUND

Hearing loss is a potential late effect after childhood cancer. Questionnaires are often used to assess hearing in large cohorts of childhood cancer survivors and it is important to know if they can provide valid measures of hearing loss. We therefore assessed agreement and validity of questionnaire-reported hearing in childhood cancer survivors using medical records as reference.

PROCEDURE

In this validation study, we studied 361 survivors of childhood cancer from the Swiss Childhood Cancer Survivor Study (SCCSS) who had been diagnosed after 1989 and had been exposed to ototoxic cancer treatment. Questionnaire-reported hearing was compared to the information in medical records. Hearing loss was defined as ≥ grade 1 according to the SIOP Boston Ototoxicity Scale. We assessed agreement and validity of questionnaire-reported hearing overall and stratified by questionnaire respondents (survivor or parent), sociodemographic characteristics, time between follow-up and questionnaire and severity of hearing loss.

RESULTS

Questionnaire reports agreed with medical records in 85% of respondents (kappa 0.62), normal hearing was correctly assessed in 92% of those with normal hearing (n = 249), and hearing loss was correctly assessed in 69% of those with hearing loss (n = 112). Sensitivity of the questionnaires was 92%, 74%, and 39% for assessment of severe, moderate and mild bilateral hearing loss; and 50%, 33% and 10% for severe, moderate and mild unilateral hearing loss, respectively. Results did not differ by sociodemographic characteristics of the respondents, and survivor- and parent-reports were equally valid.

CONCLUSIONS

Questionnaires are a useful tool to assess hearing in large cohorts of childhood cancer survivors, but underestimate mild and unilateral hearing loss. Further research should investigate whether the addition of questions with higher sensitivity for mild degrees of hearing loss could improve the results.