Long-term follow-up of pediatric cancer survivors: education, surveillance, and screening

Screening tool for late-effect pediatric neuro-oncological clinics: a treatment-oriented questionnaire

BACKGROUND

Many survivors of pediatric brain tumors (SPBTs) suffer from long-term late effects (LEs). Our aim was to create a practical screening tool for detecting LEs in this population. Such a screening tool will improve our ability to identify those patients who may benefit from treatment in LE clinics while focusing on individual relevant issues.

PROCEDURE

We developed the Treatment-Oriented Screening Questionnaire (TOSQ); a self-reported, risk-based questionnaire that addresses all LEs SPBTs can potentially suffer. As a basis for the TOSQ design we used the Long-Term Follow-Up Guidelines published by the Children's Oncology Group. Output includes individual recommendations for further treatment. We prospectively assessed whether the TOSQ can accurately detect treatment targets in SPBTs by comparing patient and caregiver questionnaire scores with physician evaluations. Data are presented from 41 SPBTs.

RESULTS

The TOSQ is a precise screening tool for identifying LEs in SPBTs based on the significant correlation (P < 0.05) that was found between parental scores and physician evaluations. Statistical testing proved that parents are a good source of information about child's health status, and that TOSQ accurately reflects the correlation between patient difficulties and quality of life.

CONCLUSIONS

The TOSQ is the first described screening tool for identification of LEs designed specifically for SPBTs. It is simple to use and provides a valid, comprehensive and economic assessment followed by targeted treatment plan for each patient. By repeatedly using the TOSQ over the years, we can improve our ability to detect and give focused treatment to those who require assistance.

Increasing and worsening late effects in childhood cancer survivors during follow-up

Recent advances in childhood cancer treatment have increased survival rates to 80%. Two out of three survivors experience late effects (LEs). From a group of 241 survivors previously described, 193 were followed at the long-term follow-up clinic (LTFC) of Severance Hospital in Korea; the presence of LEs was confirmed by oncologists. We reported the change in LEs during 3 yr of follow-up. The median follow-up from diagnosis was 10.4 yr (5.1-26.2 yr). Among 193 survivors, the percentage of patients with at least one LE increased from 63.2% at the initial visit to 75.1% at the most recent visit (P = 0.011). The proportion of patients having multiple LEs and grade 2 or higher LEs increased from the initial visit (P = 0.001 respectively). Forty-eight non-responders to the LTFC were older and had less frequent and severe LEs than responders at initial visit (all P < 0.05). In multivariate analysis, younger age at diagnosis, older age at initial visit, a diagnosis of a brain tumor or lymphoma, and use of radiotherapy were significant risk factors for LEs (all P < 0.05). Adverse changes in LEs were seen among the survivors, regardless of most clinical risk factors. They need to receive comprehensive, long-term follow up.

Predictors of risk-based medical follow-up: a report from the Childhood Cancer Survivor Study

PURPOSE

The purpose of this study is to conduct an intervention study designed to assess the effectiveness of using a newsletter to increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications.

METHODS

Survivors participating in the Childhood Cancer Survivor Study who were at least 25 years of age and at risk of cardiovascular disease, breast cancer, or osteoporosis related to previous cancer treatment were randomly assigned to receive a newsletter featuring brief health risk information or a newsletter including an insert providing more comprehensive health risk information. A follow-up survey distributed 24 months after the newsletter intervention assessed predictors of medical follow-up.

RESULTS

Overall, there were no differences found among the groups in terms of access to a treatment summary, medical follow-up, discussion of childhood cancer health risks, and medical screening for the targeted health behaviors. One exception, indicating borderline significance was that women at risk for osteoporosis who received the newsletter insert were more likely to have discussed their risk with a doctor than those who only received the brief information (10.1 % vs. 4.0 % p = 0.05). Discussion of breast cancer (OR = 2.15; 95 % CI = 1.74-2.66), heart disease (OR = 5.54; 95 % CI = 4.67-6.57) and osteoporosis (OR = 10.6; 95 % CI = 8.34-13.47) risk with physician significantly predicted report of undergoing screening for targeted behavior in previous 2 years as did physician access to treatment summary.

CONCLUSIONS

More detailed content in a newsletter had minimal effect on recommended screening. However, survivor's discussion of cancer-related risks with one's doctor significantly influenced participation in health screening. These results highlight the integral role of communication in health behavior.

IMPLICATIONS FOR CANCER SURVIVORS

This study is designed to assess communication strategies that increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications. The results are of great importance not only to the pediatric oncology community but also the broad range of adult oncology medical specialties who are directly involved in the long-term medical care of this ever increasing population of cancer survivors.

New health conditions identified at a regional childhood cancer survivor clinic visit

BACKGROUND

Specialty childhood cancer survivorship clinics have been established to screen for potential treatment-related effects. Given the limited empirical data regarding the merit of survivorship clinics, we assessed the frequencies of newly identified, therapy-related effects in survivors who attended Health, Education, Research, Outcomes for Survivors (HEROS) clinic at Yale during 2003-2009.

PROCEDURE

A total of 213 survivors in remission, who were diagnosed with cancer at an age ≤21 years and were ≥3 years after cancer diagnosis, underwent screening based on cancer treatment exposures according to the children's oncology group long-term follow-up guidelines. The frequencies and associated factors of newly identified health conditions were determined. Odds ratios (OR) and their 95% confidence intervals were estimated using multivariate regression models with stepwise selection.

RESULTS

Prior to the HEROS clinic visit, 49% of patients had at least one previously known late complication of therapy. After the visit, a total of 98 new health conditions were identified in 73 patients (34%). Newly identified complications in screened patients included pulmonary dysfunction (23%), endocrinopathy (19%), osteoporosis (17%), dyslipidemia (8%), neurologic impairment (4%), cardiovascular deficit (3%) and subsequent cancer (3%). Age at cancer diagnosis (OR = 1.06 [1.00-1.11]), chest irradiation (OR = 2.92 [1.58-5.40]), and history of ≥1 other treatment-related complication(s) (OR = 2.20 [1.18-4.07]) were associated with a higher likelihood of having new conditions identified.

CONCLUSION

Risk-based screening at a specialty childhood cancer survivor clinic detected a substantial number of previously unrecognized, treatment-related health complications in a group of survivors already receiving regular medical care elsewhere.

Female reproductive health after childhood, adolescent, and young adult cancers: guidelines for the assessment and management of female reproductive complications

PURPOSE

As more young female patients with cancer survive their primary disease, concerns about reproductive health related to primary therapy gain relevance. Cancer therapy can often affect reproductive organs, leading to impaired pubertal development, hormonal regulation, fertility, and sexual function, affecting quality of life.

METHODS

The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) are evidence-based recommendations for screening and management of late effects of therapeutic exposures. The guidelines are updated every 2 years by a multidisciplinary panel based on current literature review and expert consensus.

RESULTS

This review summarizes the current task force recommendations for the assessment and management of female reproductive complications after treatment for childhood, adolescent, and young adult cancers. Experimental pretreatment as well as post-treatment fertility preservation strategies, including barriers and ethical considerations, which are not included in the COG-LTFU Guidelines, are also discussed.

CONCLUSION

Ongoing research will continue to inform COG-LTFU Guideline recommendations for follow-up care of female survivors of childhood cancer to improve their health and quality of life.

Follow-up programs for childhood cancer survivors in Europe: a questionnaire survey

Background

For many childhood cancer survivors follow-up care is important long after treatment completion. We aimed to describe the availability and characteristics of long-term follow-up programs (LTFU) across Europe, their content and aims, their problems, and to assess opinions on different models of LTFU.

Methodology/Principal Findings

We asked 179 pediatric oncology institutions in 20 European countries to complete an online survey on LTFU available at their institution. Of 110 respondents (62% response), 66% reported having LTFU for pediatric survivors, 38% for adult survivors of childhood cancer. Availability varied widely across European regions, from 9% of institutions in Northern Europe reporting LTFU for adult survivors to 83% of institution on the British Isles reporting LTFU for pediatric survivors. Pediatric and adult LTFU were usually located in pediatric hospitals and run by pediatric oncologists. Content of follow-up included screening for adverse outcomes and health education. Important problems included lack of time, personnel and funding. Most institutions without LTFU reported that they would like to offer a program (86%).

Conclusion/Significance

Despite general agreement on the need of follow-up care, there is still a lack of well-organized LTFU for survivors of childhood cancer across Europe.

Evaluation of a patient information website for childhood cancer survivors

PURPOSE

Childhood cancer survivors (CCS) are in need of specialized information about late effects of treatment. In the current study, we assessed the perceived usability and satisfaction with the content of a national website with information on late effects and analyzed possible determinants related to website usability and content satisfaction.

METHODS

CCS and their parents were contacted through our local follow-up program and via online media to complete an online questionnaire regarding their baseline characteristics, medical decision style, and the usability and content of the website. Usability was evaluated using the System Usability Scale (SUS), a validated questionnaire resulting in a score from 0 to 100. For the content rating, we constructed a six-item scale resulting in a score from 1 to 5 (Cronbach's α, 0.83). Comments were analyzed qualitatively.

RESULTS

Fifty-five survivors and forty-three parents of survivors completed the questionnaire. Median age of respondents was 41 years (range, 17-58). Respondents rated the website's usability with a mean SUS score of 72.5 (95 % CI, 69.2-74.9). The mean content rating was 3.7 (95 % CI, 3.5-3.8). No determinants were significantly related to the perceived usability or content satisfaction in multivariate analyses. Qualitative analysis revealed respondents' preference for more detailed and even scientific information on late effects.

CONCLUSION

Respondents were satisfied with the usability and the contents of a website that targeted at their information needs. As knowledge about late effects is still limited among survivors, a website can be a valuable resource to improve their knowledge, promote healthy behavior, and in the end, improve their quality of life.

Male reproductive health after childhood, adolescent, and young adult cancers: a report from the Children's Oncology Group

The majority of children, adolescents, and young adults diagnosed with cancer will become long-term survivors. Although cancer therapy is associated with many adverse effects, one of the primary concerns of young male cancer survivors is reproductive health. Future fertility is often the focus of concern; however, it must be recognized that all aspects of male health, including pubertal development, testosterone production, and sexual function, can be impaired by cancer therapy. Although pretreatment strategies to preserve reproductive health have been beneficial to some male patients, many survivors remain at risk for long-term reproductive complications. Understanding risk factors and monitoring the reproductive health of young male survivors are important aspects of follow-up care. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) were created by the COG to provide recommendations for follow-up care of survivors at risk for long-term complications. The male health task force of the COG-LTFU Guidelines, composed of pediatric oncologists, endocrinologists, nurse practitioners, a urologist, and a radiation oncologist, is responsible for updating the COG-LTFU Guidelines every 2 years based on literature review and expert consensus. This review summarizes current task force recommendations for the assessment and management of male reproductive complications after treatment for childhood, adolescent, and young adult cancers. Issues related to male health that are being investigated, but currently not included in the COG-LTFU Guidelines, are also discussed. Ongoing investigation will inform future COG-LTFU Guideline recommendations for follow-up care to improve health and quality of life for male survivors.

Microdontia and hypodontia of premolars and permanent molars in childhood cancer survivors after chemotherapy

BACKGROUND

Adverse long-term general and dental health effects of cancer and cancer therapy during childhood have been reported.

AIM

To examine the association between chemotherapy before the age of 8 years and (1): microdontia; (2): hypodontia of premolars and permanent molars.

MATERIAL AND METHODS

In The Danish Registry of Childhood Cancer (DBCR), we identified 203 children who met the following inclusion criteria: (1) age below 8 years at the start of treatment; (2) age between 12 to 18 years upon dental examination; (3) had received chemotherapy The exclusion criterion was radiotherapy to the head and neck. A total of 150 children fulfilled the inclusion criteria. As controls, a random sample of 193 age-matched unexposed children was included.

RESULTS

Microdontia was found in a total of 88 teeth in 29 (19.3%) of the 150 children who had been exposed to chemotherapy, while none of the controls had microdontia of premolars or permanent molars (difference: 19.3%; 95% CL: 13.5%; 26.4%). The earlier the exposure, the more frequent was microdontia. We found a total of 27 missing premolars and permanent molars in 14 (9.3%) of the exposed children and a total of 18 missing premolars and permanent molars in 8 (4.1%) of the controls (difference: 5.2%; 95% CL: -0.1%; 11.3%).

CONCLUSION

The present study confirms findings from previous studies that chemotherapy, especially in very young children, causes microdontia and hypodontia of premolars and permanent molars.

Primary care providers as partners in long-term follow-up of pediatric cancer survivors

PURPOSE

To develop a model of shared healthcare delivery that includes primary care providers (PCP) and ensures best practice in follow-up of pediatric cancer survivors.

METHOD

Structured interviews with healthcare professionals (HCPs) were used to ascertain familiarity and confidence in providing care to survivors. Partnerships were made with HCP societies, and survivor care lectures were given at HCP meetings. HCP's preferences for ongoing continuing education (CE) opportunities were ascertained. Cancer SurvivorLink(TM), a web-based tool, was developed to allow patients to securely store their healthcare documents and share them electronically with registered HCPs. Educational material developed for Cancer SurvivorLink(TM) includes CE modules and QuickFacts--concise summaries of late effects. Website utilization was monitored utilizing Google Analytics.

RESULTS

HCPs described moderate to very low familiarity with survivor care, but high interest in online CE learning. Thirty-one lectures were given to HCP groups to increase awareness. Preferred types of ongoing CE were: lectures, online text, and video modules. CE material was developed based on feedback from HCPs and website utilizations and includes 19 QuickFacts and 5 CE modules. During the first year, the website had 471 unique visitors and 1,129 total visits. QuickFacts received 345 views with Neurocognitive, Survivor Care 101, and Endocrine being most visited, and 49 CME modules have been completed.

CONCLUSIONS

PCPs are interested in partnering in models of shared care for pediatric cancer survivors. Effective educational initiatives include lectures within HCP's professional education constructs and web-based CE opportunities. PCP involvement in survivor care alleviates some barriers to care such as geographic distance to the the cancer center and ensures that more pediatric cancer survivors receive recommended coordinated surveillance for late effects of cancer therapy.

Endocrine health problems detected in 519 patients evaluated in a pediatric cancer survivor program

CONTEXT

Many pediatric cancer survivors have endocrine conditions. Surveillance for late effects is recommended by national guidelines. Endocrine surveillance is recommended after alkylating agents, steroids, methotrexate, and radiation.

OBJECTIVE

The objective of the study was to describe the endocrine outcomes in patients followed up in a program that uses national screening guidelines.

DESIGN

The design of the study was a medical records review.

SETTING

The study was conducted in the Comprehensive Cancer Survivor Program, an academic pediatric oncology program.

PARTICIPANTS

The study included 519 pediatric and young adult survivors of noncentral nervous system childhood malignancies between January 1, 2001, and December 15, 2005.

INTERVENTION

Patients were evaluated with history, physical examinations, and evaluations recommended in the Children's Oncology Group's Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent and Young Adult Cancers.

OUTCOME MEASURES

The frequency and types of endocrine conditions were measured.

RESULTS

Four hundred eighty endocrine conditions were observed in 299 survivors (57.6% of survivors). The most common types of endocrine conditions were problems with weight and gonadal function. In a Cox regression model, stem cell transplant, radiation, and older age at cancer diagnosis were associated with higher hazard of an endocrine condition. Radiation, stem cell transplant, and sarcoma diagnosis were associated with growth problems.

CONCLUSIONS

Endocrine disorders were common after pediatric cancers. Endocrinologists should be aware of national guidelines, anticipate referral of pediatric cancer survivors, and participate in further research to optimize screening for and treatment of endocrine effects of cancer therapy.

Impact of survivorship-based research on defining clinical care guidelines

The growing number of individuals living five or more years from cancer diagnosis underscores the importance of providing guidance about potential late treatment effects to clinicians caring for long-term cancer survivors. Late treatment effects are commonly experienced by cancer survivors, increase in prevalence with aging, produce substantial morbidity, and predispose to early mortality. Findings from survivorship research permit providers to anticipate health risks among predisposed survivors and facilitate their access to interventions to prevent, detect, or rehabilitate cancer-related morbidity. This article reviews the impact that survivorship research has made in defining clinical care guidelines and the challenges that remain in developing and translating research findings into health screening recommendations that can optimize the quality and duration of survival after cancer.

Little evidence of low bone mass in acute lymphoblastic leukemia survivors

Childhood acute lymphoblastic leukemia (ALL) survivors represent a specific group at risk for many health problems, including skeletal complications and osteoporosis. The objective of this study was to assess the risk of osteoporosis associated with the prevalence of low bone mass (according to the guidelines of the Pediatric Official Positions of the International Society for Clinical Densitometry 2007) in survivors of childhood ALL. The cross-sectional study was conducted in a cohort of 69 Caucasian children and adolescents (46 boys and 23 girls) aged 12.15 ± 0.5yr diagnosed with ALL and screened up to 5 yr after cessation of the treatment. Total body bone mineral content (TB BMC, g), total body bone mineral density (TB BMD, g/cm(2)), and lumbar spine BMD (LS BMD, g/cm(2)) were determined using dual-energy X-ray absorptiometry. Time interval from the completion of the treatment to the beginning of this study (subgroup I<2 yr or subgroup II>2 yr after treatment), methotrexate (MTX) doses (subgroup I-MTX ranging from 0.5 to 1.0g/m(2); subgroup II-MTX>2.0 g/m(2)), cranial irradiation (subgroup I-without radiotherapy (RTX) and subgroup II receiving RTX of 12-18 Gy), cumulative steroid dose, and impaired endocrine function were considered as potential factors affecting bone metabolism and included in the analysis. No differences were found in bone traits (BMC, TB BMD, LS BMD) in relation to examined risk factors. In multiple regression model that included therapeutical factors, a risk group and central nervous system irradiation were of an important influence on bone mass, and risk group predicted TB BMD in small degree. Risk group and irradiation status lost their significance after the inclusion of anthropometric, age-connected, and time-connected factors. This study suggests that ALL survivors are not at increased risk for low bone mass. However, from the clinical perspective all patients after childhood ALL should be screened for clinical signs, fracture history, and lifestyle risk factors for low bone mass and osteoporosis. They should be referred to bone density evaluation only as often as may be necessary from the clinical evaluation.

The current status of follow-up services for childhood cancer survivors, are we meeting goals and expectations: a report from the Consortium for New England Childhood Cancer Survivors

BACKGROUND

National guidelines for follow-up care of childhood cancer survivors have been established. It has not been determined if pediatric oncology programs have successfully incorporated these standards for long term survivor care into clinical practice.

METHODS

To describe survivor services available in a geographically and socio-economically diverse region of the US we surveyed all 12 academic institutions with pediatric oncology programs in the New England (NE) region.

RESULTS

Participating sites diagnose a median of 34 (range 10-250) new pediatric cancers annually. The 12 institutions have 11 survivor clinics. Clinics are staffed by: pediatric oncologists (11/11); nurse practitioners (7/11); social workers/psychologists (9/11); RNs (5/11); primary care physicians (3/11); and sub-specialists (3/11). Most clinics recommend annual follow-up for all survivors (7/11); however, point of entry into survivor programs is variable. Treatment summaries and care plans are part of survivor care at each program. Almost all (10/11) refer to sub-specialists to manage late effects. Only 4 programs identified a policy for transitioning survivors to adult care (2 to adult survivor programs, 2 to adult primary-care) and 4 reported this as a problem. Two clinics had no designated funding for survivor services; 8/11 receive institutional support; 5/11 philanthropic. Five institutions conduct research in survivorship (1 government-funded, 2 philanthropy-funded, and 2 both).

CONCLUSIONS

Pediatric oncology services in the NE region are making progress toward meeting follow-up care goals for childhood cancer survivors. Funding for resource intense programs, transitioning care to adult clinical services, volume of sub-specialty referral, and participation in research are common challenges.

Survivors of childhood cancer lost to follow-up can be re-engaged into active long-term follow-up by a postal health questionnaire intervention

Lifelong long-term follow-up (LTFU) is recommended for all survivors of childhood cancer. National guidelines recommend risk-stratified levels of follow-up by a multidisciplinary team, in an age-appropriate environment. Many survivors do not participate in long-term follow-up.

OBJECTIVE

To re-engage childhood cancer survivors lost to follow-up in late effects programmes by means of postal questionnaire.

POPULATION AND METHODS

Retrospective cohort study of all children (<19 years) diagnosed with cancer in a single institution in the UK between 1971 and 2003. All lost to follow-up survivors (not seen in clinic >2 years) were sent a postal health and well-being questionnaire.

RESULTS

831 patients were diagnosed with childhood cancer between 1971 and 2003, with 575 long-term survivors (overall survival rate 69%). Information was available on 550 survivors (males 290 (53%), median age (range) at review 18.8 (5.4-44.2) years and at diagnosis 5.0 (0.0-18.8) years, and disease free survival (range) was 10.8 (1.0-37.4) years. Of the 550 survivors, 256 (46%) were lost to follow-up. 99 (39%) of lost to follow-up survivors returned completed postal questionnaires (58% female). 45% of responders reported at least one late effect, 36% mild-moderate, and 8% severe-life threatening. 19% reported two or more late effects. 74% of all childhood cancer survivors are now in active follow-up.

CONCLUSIONS

Almost half (46%) of all long-term survivors of childhood cancer are lost to follow-up, Postal follow-up is an effective means of re-engaging more than one third of survivors of childhood cancer in active long-term follow-up, half of whom had at least one late effect.

Physical and psychological outcome in long-term survivors of childhood malignant solid tumor in Japan

PURPOSE

Few studies have assessed physical and psychological status in long-term survivors of childhood solid tumors in Japan. For children with such diseases diagnosed and treated in our hospital, our purpose was to clarify the physical and psychological status of long-term survivors and their parents.

METHODS

Subjects were 56 patients who were diagnosed at our institution as having a childhood malignant solid tumor between 1982 and 2005 and had been alive for at least 5 years after treatment. Surveys were sent and returned by mail.

RESULTS

Of the 56 patients surveyed, 32 responded. The current health condition and psychosocial status of survivors were evaluated as good by their parents. However, psychological tests revealed psychosocial problems in 28.1% of the children. Severe posttraumatic stress associated with the child's disease and its treatment was present in 15.6% of the parents.

CONCLUSION

Physical status of long-term survivors of childhood malignant solid tumors was good in general. However, psychological tests revealed psychosocial problems in some of the children and posttraumatic stress in the parents. Considering the diversity of both the diseases and their clinical course, a qualitative study is warranted for further analysis.

Prospective evaluation of legal difficulties and quality of life in adult survivors of childhood cancer

BACKGROUND

Adult survivors of childhood cancer (ASCC), especially those of the central nervous system (CNS), have increased risks of educational and social difficulties. It is therefore hypothesized they are more likely to encounter legal difficulties (LDs), such as workplace discrimination and disability insurance denials, which may negatively affect their quality of life (QoL).

PROCEDURE

We developed a survey to collect information on patients' legal needs. QoL was assessed using the Functional Assessment of Cancer Therapy (FACT).

RESULTS

We prospectively approached 112 ASCC, 111 (99.1%) of whom completed the survey. The median age of respondents was 7 years at diagnosis and 31 years at survey completion. CNS tumors were the most common malignancy (32.4%). LDs were common overall (40.7%), though more prevalent in patients with CNS versus non-CNS tumors (58.6% vs. 32.3%; P = 0.023). The most prevalent LD was workplace discrimination (58.3%). On multivariate analysis, CNS tumor was the only variable significantly associated with LDs (OR = 4.49, P = 0.041). Individuals with LDs had lower QoL scores compared to those without LDs (79.96 versus 91.83 on the FACT; P =  0.005). On multivariate analysis, individuals with LDs had lower QoL scores (14.95 points lower on the FACT), which is both clinically and statistically significant (P = 0.047).

CONCLUSIONS

Legal difficulties are common in adult survivors of childhood cancer, especially those with brain tumors. Furthermore, individuals with legal difficulties have worse quality of life. Research is needed to develop effective and accessible legal resource programs.

Subclinical cardiac dysfunction and exercise performance in childhood cancer survivors

BACKGROUND

Although anthracycline cardiotoxicity is clearly related to the cumulative dose administered, subclinical cardiac dysfunction has been reported across a wide range of treatment regimens, and its clinical significance is still unclear. Purpose of this study is to investigate by exercise echocardiography for subclinical cardiac dysfunction in survivors of pediatric cancer treated with low-moderate anthracycline doses, and to evaluate whether it may alter the response of the cardiovascular system to dynamic exercise.

PROCEDURE

Post-exercise left ventricular end-systolic wall stress (ESS), left ventricular posterior wall dimension and percent thickening at end systole, and cardiopulmonary exercise test-derived indexes of cardiac function were examined in 55 apparently healthy patients (mean age 13.5 ± 2.9 years, median anthracycline cumulative dose 240 mg/m(2)) and in 63 controls.

RESULTS

Subclinical cardiac dysfunction was identified in 17 patients (30%) presenting reduced left ventricular posterior wall dimension or percent thickening, or increased values of left ventricular ESS as compared to controls (group A), while the remaining patients formed group B. Reduced oxygen consumption at peak exercise in both groups of patients was the only cardiopulmonary exercise test variable resulting significantly different between patients and controls: no differences were found among the groups of patients.

CONCLUSIONS

Our results confirm that even patients treated with a median anthracycline dose of 240 mg/m(2) (range 100-490) are at considerable risk of exhibiting subclinical cardiac dysfunction that, however, does not seem to alter the physiologic response of the cardiovascular system to dynamic exercise.

Exercise echocardiography in asymptomatic survivors of childhood cancer treated with anthracyclines: a prospective follow-up study

BACKGROUND

Exercise echocardiography reveals abnormalities in asymptomatic childhood cancer survivors who previously have been treated with anthracyclines. We determined the added value of monitoring childhood cancer survivors with exercise echocardiography compared to monitoring with resting echocardiography alone to predict anthracycline-induced cardiotoxicity. Secondary aims were to evaluate change in resting cardiac function over 10 years and to determine risk factors for late cardiotoxicity.

PROCEDURE

We invited a cohort of 110 originally asymptomatic anthracycline-treated childhood cancer survivors, who had undergone cardiac tests including exercise echocardiography 10.5 years earlier, for new cardiac evaluation. Each subject underwent a resting echocardiogram at both evaluations. At first evaluation a repeat echocardiogram was performed following peak exercise. Resting echocardiographic parameters were converted to z-character.

RESULTS

Ninety-two of 110 survivors (mean anthracycline dose 307 mg/m(2), mean follow-up time from start of treatment 8.2 years at first and 18.8 years at second evaluation) were evaluated prospectively. Mean resting fractional shortening z-character (RFSz) decreased from -0.18 to -0.93. Higher cumulative anthracycline dose was a risk factor for a lower RFSz at late follow-up (P = 0.0002). Adding exercise fractional shortening (XFS) to a model containing RFSz did not improve prediction of abnormal RFSz at late follow-up.

CONCLUSIONS

Monitoring with exercise echocardiography has no added value to monitoring with resting echocardiography alone in predicting late anthracycline-induced cardiotoxicity in childhood cancer survivors. RFSz deteriorates over time, even in originally asymptomatic patients. Previous treatment with higher cumulative anthracycline dose is the main risk factor for a lower RFSz at late follow-up.

Families of young pediatric cancer survivors: A cross-sectional survey examining physical activity behavior and health-related quality of life

The present study examined physical activity levels within young families of pediatric cancer survivors and the relationship between physical activity and health-related quality of life (HRQL). Nineteen families were recruited, including 33 parents, 17 pediatric cancer survivors, and 10 siblings. Families completed a self-report survey on background information, physical activity levels, and PedsQL generic core scale for child HRQL. Results of this cross-sectional study indicate that families were generally active, with mothers more frequently participating in overall physical activity (P < .001). Within families, parent-child physical activity levels were associated, but not survivor-sibling physical activity. Survivors and siblings did not differ in their self-reported physical activity levels or HRQL, and no association was observed between physical activity and HRQL. However, discrepancies between sibling self-report and parent proxy-reported HRQL were notable. Overall, results from this exploratory pilot work will assist in further research into physical activity behaviors and HRQL in families of pediatric cancer survivors.The nurse should consider the varied experiences of family members, particularly those of siblings, through long-term follow-up.

The Legacy of Pediatric Oncology Nursing in Advancing Survivorship Research and Clinical Care

Today, the growing population of cancer survivors, both pediatric and adult, along with the accumulated weight of data characterizing late and lingering effects of cancer and its treatment are attracting attention in the form of reports, conferences, publications and media coverage.The emphasis on survivorship research and outcomes-based clinical care began with pediatric oncology, and pediatric oncology nurses have been at the forefront of survivorship clinical care, research, and education for more than 30 years.This article highlights these contributions to the body of survivorship knowledge and quality of care, as well as areas of ongoing challenge and future directions suggested by thought leaders in our specialty. Key contributions are examined decade by decade and against the six recommendations for health care policy and practice delineated in the two recent IOM survivorship reports: evidence-based guidelines for follow-up care, standards and models of care, increasing awareness of late effects and needed follow-up care, improving professional education and training, improving access to care for survivors, and increasing research to prevent or manage late effects.

Brain Tumor Survivors Speak Out

Although progress has been made in the treatment of childhood brain tumors,work remains to understand the complexities of disease, treatment, and contextual factors that underlie individual differences in outcome. A combination of both an idiographic approach (incorporating observations made by adult survivors of childhood brain tumors) and a nomothetic approach (reviewing the literature for brain tumor survivors as well as childhood cancer survivors) is presented. Six areas of concern are reviewed from both an idiographic and nomothetic perspective, including social/emotional adjustment, insurance, neurocognitive late effects, sexuality and relationships, employment, and where survivors accessed information about their disease and treatment and possible late effects. Guidelines to assist health care professionals working with childhood brain tumor survivors are offered with the goal of improving psychosocial and neurocognitive outcomes in this population.

Differences in activities of daily living performance between long-term pediatric sarcoma survivors and a matched comparison group on standardized testing

BACKGROUND

In a cross-sectional study examining late effects of pediatric sarcoma therapy, long-term survivors were evaluated on their activities of daily living (ADL) performance.

PROCEDURE

Thirty-two persons with Ewing sarcoma family of tumors, rhabdomyosarcoma, and non-rhabdomysarcoma-soft tissue sarcoma enrolled an average of 17 years after treatment. Participants were evaluated using the Assessment of Motor and Process Skills (AMPS) 1, a standardized observational evaluation of ADL task performance. Means and 95% confidence intervals for ADL motor and ADL process ability measures were calculated for four groups: (1) sarcoma survivors, (2) "well" adults matched for age and gender, (3) "well" adults matched for gender that were 10 years older, and (4) "well" adults matched for gender that were 20 years older.

RESULTS

ADL motor ability was significantly lower for sarcoma survivors than for the age- and gender-matched comparison group (P < 0.05). There was no significant difference between ADL motor ability of sarcoma survivors and the comparison group 10 years older, but sarcoma survivors had significantly better ADL motor ability (P < 0.05) than the oldest comparison group (20 years older). Sarcoma survivors had significantly worse ADL process ability than the age-matched group (P < 0.05). There was no difference in ADL process ability between the sarcoma survivors and comparison groups that were 10 and 20 years older.

CONCLUSIONS

This first report of a clinical evaluation of ADL limitation in pediatric sarcoma survivors treated with intensive multimodal cancer therapy suggests that influences on performance of daily life activities are more common than previously reported.

The Late Effects Clinic in action: for survivors of childhood malignancy

BACKGROUND

Long-term survivors of childhood malignancy are a newly emergent patient group with a unique but wide range of survivorship issues. There are rising demands for long-term, medical follow-up and social support for this potentially vulnerable group. These demands stem from improving survival rates and the progressively increasing incidence of late physical, psychological and social sequelae. CASE-STUDIES AND DISCUSSION: The ideal method to facilitate this long-term followup is unclear, and faces the problems of health-care system limitations coupled with the paucity of outcomes-based research to guide evidence-based, clinical practice. We discuss how the Late Effects Clinic operates in our institution: optimising the involvement of the multi-disciplinary medical and allied health care teams to meet the physical and psychological needs of long-term survivors, and to assist with the social issues surrounding survivorship. This model involves a co-operative team approach, thereby alleviating the sole responsibility from general practitioners or individual physicians with a restricted realm of expertise. We present three case reports illustrating the value of a formal late effects follow-up programme, and demonstrating the integration of the Late Effects Clinic into medical practice.

Medical screening participation in the childhood cancer survivor study

BACKGROUND

Despite their risk for serious late sequelae, survivors of childhood cancer do not adhere to recommended medical screening guidelines. We identified treatment, survivor, physician, and contextual factors that may influence survivor adherence to recommended echocardiography and bone densitometry screening.

METHODS

Structural equation modeling of data from the Childhood Cancer Survivor Study; 838 participants had received a diagnosis of and were treated for pediatric cancers between 1970 and 1986.

RESULTS

Survivors at risk of cardiac sequelae (n = 316; mean [SD] age, 31.01 [7.40] years; age at diagnosis, 9.88 [5.88] years; and time since diagnosis, 21.14 [4.37] years) who reported more cancer-related visits (P = .01), having discussed heart disease with a physician (P < or = .001), with a sedentary lifestyle (P = .05), and less frequent health fears (P = .05) were most likely to follow the recommended echocardiogram schedule (R(2) = 23%). Survivors at risk of osteoporosis (n = 324; age, 30.20 [7.09] years; age at diagnosis, 9 .01 [5.51]years; and time since diagnosis, 21.20 [4.27] years) who reported more cancer-related visits (P = .05), were followed up at an oncology clinic (P = .01), had discussed osteoporosis with a physician (P < or = .001), and had a lower body mass index (P = .05) were most likely to adhere to the recommended bone density screening guidelines (R(2) = 26%). Symptoms and motivation influenced screening frequency in both models.

CONCLUSIONS

Multiple factors influence survivor adherence to screening recommendations. It is likely that tailored interventions would be more successful in encouraging recommended screening in survivors of childhood cancer than would traditional health education approaches.

Comprehensive clinical follow-up of late effects in childhood cancer survivors shows the need for early and well-timed intervention

BACKGROUND

Due to recent advances in treatment, nearly 80% of childhood cancer patients become long-term survivors. Studies on the late effects of survivors are under way worldwide. However, data on Asian survivors remain limited.

METHODS

Data on 241 survivors at the Long-term Follow-up Clinic in Severance Hospital, South Korea, were collected and late effects were confirmed by oncologists.

RESULTS

The median follow-up from diagnosis was 7.8 years. Late effects were identified in 59.8% of survivors and 23.2% had two or more late effects. Grade 3 or higher late effects were present in 10.8%. The most common late effects involved endocrine system (29.0%). Late effects were present in 95.7% of brain tumor survivors and 36.0% of Wilms' tumor survivors. Chemotherapy, hematopoietic stem-cell transplantation and radiotherapy were significant factors associated with the number and severity of late effects (P < 0.05). Brain tumor survivors had more severe late effects (P < 0.001), whereas Wilms' tumor survivors had fewer and milder late effects (P < 0.05).

CONCLUSION

The observation that over 50% of cancer survivors suffered from late effects during the short follow-up period and that a high frequency of endocrine late effects was present indicates the need for early and well-timed intervention of the survivors.

The LIVESTRONG Survivorship Center of Excellence Network

INTRODUCTION

The LIVESTRONG Survivorship Center of Excellence Network consists of eight National Cancer Institute-designated Comprehensive Cancer Centers funded by the LAF between 2004 and 2008. The Network was created to accelerate the pace of progress in addressing the needs of the growing survivor community.

METHODS

This paper will briefly describe some of the salient issues surrounding the care of cancer survivors, and examine models of survivorship care that are being developed in individual Centers of Excellence (COE) as well as in the overall Network.

RESULTS AND CONCLUSIONS

As the recommendations and policies for optimal survivorship care have to be feasible and relevant in the community setting, each COE is partnered with up to three community affiliates. Through these partnerships, the community affiliates develop survivorship initiatives at their institutions with support and guidance from their primary COE.

Cancer screening practices of adult survivors of retinoblastoma at risk of second cancers

BACKGROUND

The aim of the current study was to investigate the pattern of cancer screening behavior in adult retinoblastoma survivors, who are at high risk of developing second cancers.

METHODS

Self-reported cancer screening practices were investigated in a cohort of retinoblastoma survivors to evaluate whether they were receiving adequate screening for specific cancers and compare these rates with those of other adult survivors of childhood cancer and the general population. The prevalence of breast self-examination, clinical breast examination, mammography, Papanicolaou (Pap) test, testicular self-examination, and magnetic resonance imaging (MRI) or computed tomography (CT) scanning was determined from computer-aided telephone interviews with 836 retinoblastoma survivors aged >18 years.

RESULTS

Among female survivors, 87% had a Pap test within the past 2 years, and 76% of females age >40 years reported having a mammogram within the past 2 years; 17.4% of male survivors had performed monthly testicular self-examinations. A significantly higher proportion of hereditary compared with nonhereditary survivors reported having undergone an MRI or CT scan in the past 5 years. Higher education, greater contact with the medical care system, and having a second cancer were found to be associated positively with most screening practices. Cancer screening practices reported by retinoblastoma survivors were similar to national screening rates for breast, cervical, and testicular cancer.

CONCLUSIONS

To the authors' knowledge, the current study provides the first report of cancer screening practices of retinoblastoma survivors. Survivors of hereditary retinoblastoma should be encouraged to maintain, if not increase, their current screening practices to ensure early detection of second cancers in this high-risk population.

Bone mineral density deficits in survivors of childhood cancer: long-term follow-up guidelines and review of the literature

The development of curative therapy for most pediatric malignancies has produced a growing population of childhood cancer survivors who are at increased risk for a variety of health problems resulting from their cancer or its treatment. Because of the fact that many treatment-related sequelae may not become clinically apparent until the survivor attains maturity or begins to age, the ability of primary care providers to anticipate late effects of treatment is essential for providing timely interventions that prevent or correct these sequelae and their adverse effects on quality of life. Altered bone metabolism during treatment for childhood cancer may interfere with attainment of peak bone mass, potentially predisposing to premature onset of and more severe complications related to osteopenia and osteoporosis. Bone mineral deficits have been reported after treatment for a variety of pediatric malignancies and represent morbidity that can be reduced or prevented through lifestyle changes and attention to other common cancer-related sequelae such as hypogonadism. The Children's Oncology Group long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers provide risk-based surveillance recommendations that are based on expert opinion and review of the scientific literature for potential late effects of pediatric cancer therapy including osteopenia. This review summarizes the existing literature that has defined characteristics of cancer survivors at risk for bone mineral deficits and contributed to the surveillance and counseling recommendations outlined in the Children's Oncology group long-term follow-up guidelines.

Shared care by paediatric oncologists and family doctors for long-term follow-up of adult childhood cancer survivors: a pilot study

BACKGROUND

Since 75% of children with cancer will become long-term survivors, late effects of treatment are an ever increasing issue for patients. Paediatric oncologists generally agree that cancer survivors should be followed up for the remainder of their lives, but they might not be the most suitable health-care providers to follow up survivors into late adulthood. We designed a 3-year study to assess whether shared-care by paediatric oncologists and family doctors in the long-term follow-up of survivors of childhood cancers is feasible, whether a shared-care model is compatible with collection of data needed for registration of late effects, and how a shared-care model is assessed by survivors and family doctors.

METHODS

In 2004 and 2005, adult survivors of childhood cancers were randomly chosen from eligible patients diagnosed with childhood cancer (excluding CNS tumours) or Langerhans-cell histiocytosis between January, 1968, and December, 1997, and recalled to the long-term follow-up (LTFU) clinic at the University Medical Centre Groningen, Groningen, Netherlands, where they underwent physical and clinical assessments by an on-site family doctor (visit 1). At this visit, assessments were done according to guidelines of the UK Children's Cancer Study Group Late Effects Group, and late effects were graded by use of Common Terminology Criteria for Adverse Events (version 3). Follow-up assessments were done 1 year later in 2005 and 2006 by local family doctors (visit 2), who were asked to return data to the LTFU clinic. At this visit, the local family doctors were asked to complete a three-item questionnaire and patients were asked to complete a seven-item questionnaire about their satisfaction with the shared-care model. At the next consultation, which was planned for the end of the study (visit 3), the on-site family doctor advised patients about future follow-up on the basis of their individual risk of late effects. Main endpoints were numbers of participants, satisfaction ratings, and proportions of local family doctors who returned data that they obtained at visit 2 to the LTFU clinic.

FINDINGS

133 individuals were chosen at random from 210 enrolled adult survivors. 123 of 133 (92%) randomly selected survivors and 115 of 117 (98%) of their family doctors agreed to participate in the share-care programme. 103 of 115 (90%) family doctors returned data to the LTFU clinic at visit 2. 89 of 101 (88%) of survivors were satisfied with this shared-care model, as were 94 of 115 (82%) family doctors; 18 of 115 (16%) family doctors had no views either way; and three of 115 (3%) family doctors were dissatisfied.

INTERPRETATION

Shared-care by paediatric oncologists and family doctors is feasible for long-term follow-up of adult survivors of childhood cancers.

Wilms tumour: prognostic factors, staging, therapy and late effects

Wilms tumour is the most common malignant renal tumour in children. Dramatic improvements in survival have occurred as the result of advances in anaesthetic and surgical management, irradiation and chemotherapy. Current therapies are based on trials and studies primarily conducted by large multi-institutional cooperatives including the Société Internationale d'Oncologie Pédiatrique (SIOP) and the Children's Oncology Group (COG). The primary goals are to treat patients according to well-defined risk groups in order to achieve the highest cure rates, to decrease the frequency and intensity of acute and late toxicity and to minimize the cost of therapy. The SIOP trials and studies largely focus on the issue of preoperative therapy, whereas the COG trials and studies start with primary surgery. This paper reviews prognostic factors and staging systems for Wilms tumour and its current treatment with surgery and chemotherapy. Surgery remains a crucial part of treatment for nephroblastoma, providing local primary tumour control and adequate staging and possibly controlling the metastatic spread and central vascular extension of the disease. Partial nephrectomy, when technically feasible, seems reasonable not only in those with bilateral disease but also in those with unilateral disease where the patient has urological disorders or syndromes predisposing to malignancy. Partial nephrectomy, however, is frequently not sufficient for an anaplastic variant of tumour. The late effects for Wilms tumour and its treatment are also reviewed. The treatment of Wilms tumour has been a success story, and currently in excess of 80% of children diagnosed with Wilms tumour can look forward to long-term survival, with less than 20% experiencing serious morbidity at 20 years from diagnosis. The late complications are a consequence of the type and intensity of treatment required, which in turn reflects the nature and extent of the original tumour. Continual international trial development and participation will improve matching of treatment needs with prognosis, reducing long-term complications in the majority. The advent of molecular markers of disease severity and improved functional imaging might help.

Late effects in adult survivors of childhood cancer: the need for life-long follow-up

BACKGROUND

To assess health status and health-related quality of life (HRQoL) in childhood cancer survivors who were not involved in regular long-term follow-up.

PATIENTS AND METHODS

One hundred and twenty-three long-term survivors, median age 33 (19-50) years, follow-up 27 (9-38) years, were recalled to the long-term follow-up clinic. Most of them were treated in the period 1970-1990. Late effects were graded using the Common Terminology Criteria for Adverse Events, version 3 (CTCAEv3). HRQoL was assessed by RAND-36. Socio-economic factors were compared with data from Statistics Netherlands (CBS).

RESULTS

Grade 1-2 late effects were found in 54% of the survivors, grade 3-4 in 39%, two or more late effects in 70% and grade 2-4 previously unknown late effects in 33%. Survivors had significantly lower scores on RAND-36 compared with controls.

CONCLUSIONS

As nearly 40% of these long-term childhood cancer survivors suffer from moderate to severe late effects and 33% had previously unknown late effects it is worthwhile recalling these patients to follow-up. Where and by whom this follow-up can best be done is still a question that needs to be answered.

The willingness of general practitioners to be involved in the follow-up of adult survivors of childhood cancer

BACKGROUND

Long-term follow-up of childhood cancer survivors is mainly organised by paediatric oncologists and until now general practitioners (GPs) are rarely involved. To ensure appropriate follow-up for all survivors into adulthood, a combined effort of paediatric oncologists and general practitioners might be the solution. We investigated the willingness of GPs, who had followed a postgraduate course on late effects of cancer treatment, to participate in a shared care model for follow-up of adult childhood cancer survivors as well as what their requirements would be in case of participation.

METHODS

From the Northern Netherlands, 358 GPs participated in a postgraduate course on late effects in paediatric cancer survivors. After the course, they were asked to complete a 10-item questionnaire on motivation to participate in the regular follow-up of adult childhood cancer survivors as well as their conditions to participate.

RESULTS

The response rate was 65%. Of the responders, 97% were willing to participate in a shared care model for follow-up and 64% felt that it was their responsibility to be in charge of childhood cancer survivors. The main requirements for participation were the availability of guidelines (64%), sufficient information about the patient's medical history (37%), and short communication lines (45%). The main barriers to participate were workload (16%), lack of knowledge (15%), and lack of communication (13%).

CONCLUSION

A significant number of GPs are ready to participate in the long-term follow-up of adult childhood cancer survivors if adequate guidelines and medical information is provided and communication lines are clear.

A review of long-term follow-up for survivors of childhood cancer

Though cure from cancer is not guaranteed, children's chances of survival have increased significantly. As a result the paediatric oncology community is focused on providing appropriate follow-up care to an increasing number of young cancer survivors. How this care should be designed and delivered however remains the centre of ongoing discussion and was the focus of this review. The aims of the review were to (1) gain an understanding of current follow-up practices from studies involving health care professionals, (2) identify and evaluate studies presenting views of survivors, (3) examine commentaries on both the current and future design of long-term follow-up services and (4) evaluate existing follow-up guidelines. Empirical research, commentary papers and published guidelines were reviewed. Twenty-eight papers and five guidelines were analysed. Empirical papers were examined in relation to sample, design, findings and limitations. Commentary papers were assessed in relation to key issues about follow-up care. Guidelines were assessed on how far they were evidence-based, peer-reviewed and involved users in their development. Varying models of care were illustrated, and were dependent upon personnel and centre orientation. Variability in the level and degree to which long-term survivors were followed up was also reported. Inconsistencies in practice were noted. Nonetheless requirements for an effective service were highlighted in the majority of publications, these included communication and information. Although young people and professionals had a shared view on many aspects of follow-up care, these preferences were not consistently mirrored in service provision.

Health knowledge about symptoms of heart attack and stroke in adult survivors of childhood acute lymphoblastic leukemia

PURPOSE

Children with acute lymphoblastic leukemia (ALL), the most common pediatric malignancy, have a 5-year survival rate of better than 80%. Long-term survivors of childhood ALL, however, carry an elevated risk of early mortality from cardiac events and stroke and a disproportionately high prevalence of dyslipidemia and obesity, presumably as an adverse effect of treatment.

METHODS

As part of a clinical follow-up study of 70 young adult survivors of childhood ALL, we evaluated the degree to which this high-risk group differed in knowledge about symptoms of heart attack and stroke from that of a population-based comparison group frequency-matched by age, sex, and body mass index. Questions from the Behavioral Risk Factor Surveillance System were used to assess health knowledge.

RESULTS

Survivors of ALL scored considerably worse on symptom knowledge than did their population counterparts. The strongest association was observed for chest pain as a symptom of heart attack: ALL survivors were 14-fold more likely than the comparison group to answer the question incorrectly. Seventy-seven percent of survivors failed to identify pain in the jaw, neck, or back as a heart attack symptom.

CONCLUSIONS

These results indicate an important gap in knowledge and underscore the need for health education among survivors of childhood leukemia that includes information about symptoms of myocardial infarction and stroke.

Pediatric genitourinary tumors

PURPOSE OF REVIEW

We will review the 2005 and 2006 literature on pediatric genitourinary tumors.

RECENT FINDINGS

Survival continues to improve for primary renal, bladder/prostate and testicular tumors in childhood. The addition of more intensive chemotherapy for anaplastic histology disease, recognition of loss of heterozygosity for chromosomes 1p and 16q as an adverse prognostic factor in favorable histology Wilms' tumor, and the utilization of molecular markers to better characterize all renal tumors will better enable individualized therapy. Recognition and treatment of anaplastic histology and bilateral Wilms' tumor remains a challenge. In rhabdomyosarcoma, genitourinary site and embryonal histology confer a relatively favorable prognosis.

SUMMARY

Advances in molecular oncology, diagnostic imaging, surgical approaches and long-term follow-up of childhood cancer survivors drive risk-stratified therapy in pediatric genitourinary tumors.

Self-report of somatic symptoms in survivors of childhood cancer: effects of adaptive style

BACKGROUND

Screening for late effects in survivors of childhood cancer may be influenced by the patients' self-reporting of their somatic state. However, self report of somatic symptoms may be influenced by factors other than objectively documented physical functions. This study examined the self report of somatic symptoms in children with cancer and matched healthy control children as a function of child adaptive style.

PROCEDURE

Two groups of children age 7-18 were studied; children with cancer at least 6-month post completion of therapy (n = 120) and a group of healthy children (n = 120) matched on age, race, and gender. Children completed measures of somatic symptoms, body consciousness, and adaptive style.

RESULTS

Contrary to expectations, there were no differences between children with cancer and healthy controls in self-reported somatic symptoms, although cancer patients reported slightly lower symptomatology. In contrast, there were significant differences in self-reported somatic symptoms as a function of adaptive style. Children identified as repressors reported the lowest level of somatic symptoms and differed significantly from all other adaptive style groups.

CONCLUSION

These results do not support the prevailing hypothesis that a repressive style may be a risk factor for psychosomatic illness. However, the findings are consistent with a response bias interpretation, suggesting a general under-reporting of symptoms in repressors, including physical symptoms. These results have significant implications for health care providers and researchers following long-term survivors of childhood cancer.

Anthracycline-induced cardiotoxicity: course, pathophysiology, prevention and management

Although effective anti-neoplastic agents, anthracyclines are limited by their well recognized and pervasive cardiotoxic effects. The incidence of late progressive cardiovascular disease in long-term survivors of cancer is established and may contribute to heart failure and death. To maximize the benefits of these drugs, a high-risk population has been identified and new strategies have been investigated to minimize toxic effects, including limiting the cumulative dose, controlling the rate of administration and using liposomal preparations and novel anthracycline analogues. Dexrazoxane also shows promise as a cardioprotectant during treatment. This paper reviews these strategies, as well as medications used to manage anthracycline-induced cardiotoxicity, and functional and biochemical means of monitoring cardiotoxicity, including echocardiography, radionuclide scans and biomarker analysis. The treatment of adult cancer survivors who have had anthracycline-related cardiotoxicity has not been systematically studied. Empirically, anthracycline-associated cardiac dysfunction is treated very similarly to other forms of heart failure. These treatments include avoiding additional cardiotoxic regimens, controlling hypertension, lifestyle changes, medications and heart transplantation.

[Sequelae and quality of life in young adult survivors of childhood cancer]

PURPOSE

The long-term survival rate of childhood cancer is around 70%, but cancer- and treatment-related sequelae and the risk of a second malignancy may impair the survivors' quality of life.

METHODS

Fifty-four patients older than 18 years, treated for a cancer between 1988 and 1996, and considered as cured for at least 5 years, were asked to participate. Data on cancer, treatment and sequelae were extracted from the Rhône-Alpes childhood cancer registry and from the medical charts. Health-related quality of life was assessed with the SF-36 scale. Lifestyle, educational level, present occupation, subjective health, and worries were assessed with a detailed questionnaire.

RESULTS

Forty-three young adult patients participated (16 female, 27 male, mean age 23 [range: 18-32]). Primary cancers were leukaemias (35%), lymphomas (19%), solid tumors (34%) and central nervous system tumors (12%). Nine percent of the subjects had received cranio-spinal radiotherapy, and 14% a total body irradiation followed by bone marrow transplantation. Two patients (5%) had developed a second malignancy, 30% have an endocrine insufficiency, 14% have neurological or psychological impairment, and 21% have orthopaedic sequelae. Health-related quality of life of the population as a whole, as assessed by SF-36, is close to normative data published for healthy population of that age. Female gender, certain types of cancer (neuroblastoma, bone tumors and carcinomas), and the presence of endocrine sequelae are predictors of a worse quality of life. Only 3 patients (7%) declared having had to shorten their education because of their cancer; 63% are currently employed, 25% are students or apprentices. Worries about fertility are often mentioned; half of the subjects declare having received no formal instruction about their medical follow-up in adult age.

CONCLUSION

Although the quality of life of young adult survivors of childhood cancer as a whole does not seem very much altered, many of these survivors experience adverse sequelae warranting medical and psychological attention. Some of their preoccupations, such as worries about reproductive capacity and inheritability of their cancer, are often ignored.

Long-term effects of treatments for childhood cancers

PURPOSE OF REVIEW

The late effects of current treatments for childhood cancer increase the risk of morbidity and mortality and diminish the quality of life in long-term survivors. We selectively review the negative late cardiac, endocrine, and neurological effects of childhood cancer and its treatments and comment on current research and recommendations for the care of long-term survivors of childhood cancer.

RECENT FINDINGS

Progressive cardiotoxicity has been established. Late cardiac effects can be mitigated with the concomitant use of dexrazoxane with anthracycline. When radiotherapy is used multiple organ systems must be monitored for known late effects dependent on the location. Proper diet, physical activity, and obesity are topics that must be addressed in survivors. Late neurocognitive effects impact intelligence quotient, behavior, and achievement. Systematic follow-up with appropriate clinical screening and testing is important in diagnosing and potentially preventing late effects of cancer therapy.

SUMMARY

The new paradigm for defining successful cancer therapy is the balance between oncologic efficacy and toxicity/late effects. The complexity of late effects necessitates a multidisciplinary approach to long-term care of these patients. The high frequency, delayed onset, and potential severity of late effects demand increased and lifelong monitoring of these individuals.