Final height and body mass index among adult survivors of childhood brain cancer: childhood cancer survivor study

Obesity and craniopharyngioma

An epidemic of pediatric obesity has occurred across the world in recent years. There are subgroups within the population at high-risk of becoming obese and especially of having experience of precocious cardiovascular and metabolic co-morbidities of obesity. One of these subgroups comprises patients treated for childhood cancers and namely survivors of craniopharyngioma. The high incidence of obesity in this group makes these patients an important disease model to better understand the metabolic disturbances and the mechanisms of weight gain among cancer survivors. The hypothalamic-pituitary axis damage secondary to cancer therapies or to primary tumor location affect long-term outcomes. Nevertheless, the aetiology of obesity in craniopharyngioma is not yet fully understood. The present review has the aim of summarizing the published data and examining the most accepted mechanisms and main predisposing factors related to weight gain in this particular population.

Gonadotropin-dependent precocious puberty: neoplastic causes and endocrine considerations

Premature activation of the hypothalamic-pituitary-gonadal (HPG) axis manifests as gonadotropin-dependent precocious puberty. The mechanisms behind HPG activation are complex and a clear etiology for early activation is often not elucidated. Though collectively uncommon, the neoplastic and developmental causes of gonadotropin-dependent precocious puberty are very important to consider, as a delay in diagnosis may lead to adverse patient outcomes. The intent of the current paper is to review the neoplastic and developmental causes of gonadotropin-dependent precocious puberty. We discuss the common CNS lesions and human chorionic gonadotropin-secreting tumors that cause sexual precocity, review the relationship between therapeutic radiation and gonadotropin-dependent precocious puberty, and finally, provide an overview of the therapies available for height preservation in this unique patient population.

Increased prevalence of risk factors for cardiovascular disease in long-term survivors of acute lymphoblastic leukemia and Wilms tumor treated with radiotherapy

BACKGROUND

Only a few studies have assessed cardiovascular risk factors (CRFs) in childhood cancer survivors. We determined the prevalence of CRFs in long-term survivors of acute lymphoblastic leukemia (ALL) and Wilms tumor.

PROCEDURE

Adult survivors of ALL and Wilms tumor treated with radiotherapy and chemotherapy (RT + CT) or treated with chemotherapy alone (CT) were compared with sibling controls. CRFs (hypertension, diabetes mellitus, hypercholesterolemia, obesity, renal insufficiency) and hormonal deficiencies were assessed in each participant. Multivariate logistic regression analysis was used to evaluate the association between CRFs and treatment.

RESULTS

Seventy-nine ALL, 62 Wilms tumor survivors, and 69 control subjects (mean ages 24.5, 25.9, and 26 years, respectively) were enrolled. Mean follow-up time since cancer treatment was 20.8 years. In the Wilms RT + CT group significantly more survivors had hypertension (21.6% vs. 1.4%, P < 0.001) and renal insufficiency (8.1% vs. 0%, P = 0.016) compared to controls. There were also more patients with multiple CRFs in the Wilms RT + CT group (16.2% vs. 2.9% in controls, P = 0.019). Almost 15% of ALL RT + CT survivors had growth hormone deficiency. Hypogonadism was seen in 18.9% of survivors in the Wilms RT + CT group. We observed no significant differences between CT-treated survivors of both malignancies and controls. The adjusted odds ratio for the occurrence of at least one CRF was 2.6 increased for survivors following abdominal radiotherapy. Treatment with CT alone was not associated with the occurrence of multiple CRFs.

CONCLUSIONS

Long-term survivors of ALL and Wilms tumor have unfavorable CRFs due to previous RT not CT.

Body weight, social competence, and cognitive functioning in survivors of childhood brain tumors

BACKGROUND

The purpose of the following article was to examine: (a) body mass index (BMI) in survivors of childhood brain tumors; (b) the association of BMI with social competence and cognitive functioning; and (c) congruency in reporting of survivors' social competence by the survivors, parents, and teachers.

PROCEDURE

Fifty-four survivors of childhood brain tumors (32 males) 8-18 years participated. BMI-for-age percentiles and BMI Z-scores (SDS) were calculated and survivors were categorized as underweight, normal, overweight, or obese, using established criteria. Informants completed measures of social competence and internalizing behaviors. Survivors also completed a test of self-perception and cognitive functioning (IQ).

RESULTS

Survivors were more underweight (15% vs. 4%), and less overweight (17% vs. 31%) than population norms (chi(2) = 38.62, P < 0.001). Parents perceived lower social competence in survivors that were underweight, had lower verbal IQ, and higher internalizing behaviors (P < 0.05). A significant interaction between BMI-for-age and IQ on self-perception of close friendships suggested that survivors with lower weight and lower IQ perceived having fewer close friendships (P < 0.05). Congruency among the three informants was moderate.

CONCLUSIONS

Survivors of childhood brain tumors are at increased risk for underweight. Underweight status is related to lower parent reported social competence and survivors' self-perception of fewer close friendships in the presence of low IQ.

Characteristics and determinants of adiposity in pediatric cancer survivors

BACKGROUND

Adiposity and the diseases associated with it, including cardiovascular disease, are emerging long-term complications of pediatric cancer survivors. Direct evaluations of adiposity and comparisons to contemporary controls that can differentiate recent trends in obesity from cancer-related treatments and sequelae are limited.

METHODS

We evaluated demographic, treatment, lifestyle, and endocrine factors at the time of dual-energy X-ray absorptiometry testing in 170 non-Hispanic white survivors and 71 sibling controls, and compared three measures of adiposity [body mass index (BMI), total body fat, and trunk fat]. For the survivors alone, we determined factors independently associated with BMI and body fat.

RESULTS

Survivors were at 12 years since diagnosis; 58% had leukemia or lymphoma. BMI did not differ between groups. Among males, body fat was greater in survivors than in controls (25.8% versus 20.7%; P = 0.007), as was trunk fat (26.7% versus 21.3%; P = 0.008). Total or trunk fat did not differ among females. Cholesterol, triglycerides, low-density lipoprotein cholesterol, and television viewing hours were higher among male survivors than in controls. Independent factors associated with higher BMI and total and trunk fat included any cranial radiation and television viewing hours, whereas prior treatment with cyclophosphamide was associated with lower BMI and body fat measures.

CONCLUSIONS

Compared with siblings, male survivors have greater body fat and metabolic risks. Cranial irradiation and television hours are important risk factors for adiposity in pediatric cancer survivors.

IMPACT

Pediatric cancer survivors should be carefully monitored for cardiovascular risk factors and sedentary lifestyles.

Long-term survivors of childhood central nervous system malignancies: the experience of the Childhood Cancer Survivor Study

In the last four decades, advances in neurosurgical technique, delivery of radiation therapy (RT), supportive care, and use of chemotherapy have improved 5-year survival for children with central nervous system (CNS) malignancies. Currently, in the United States 74% of children will become 5-year survivors of their primary CNS malignancy. This improved outcome has resulted in a new and growing population of childhood cancer survivors. Surgery, RT and chemotherapy, while essential components of primary treatment for most childhood CNS malignancies, have also been associated with risk of long-term morbidity and late mortality. The Childhood Cancer Survivor Study, a retrospective cohort of over 14,000 survivors of childhood cancer diagnosed between 1970 and 1986, has been an important resource for quantification of associations between these therapeutic modalities and risk of long-term adverse health and quality of life outcomes. CNS malignancy survivors are at significant risk for late mortality, development of second neoplasms, as well as increased risk for multiple endocrinopathies and adverse neurologic health conditions. Importantly, the CCSS has identified a number of dose-response relationships between RT and development of subsequent malignant neoplasms of the central nervous system, abnormal timing of menarche and neurocognitive function. Ongoing study of childhood cancer survivors is needed to establish long-term risks and evaluate impact of newer techniques such as conformal RT or proton beam delivery that limit RT exposure and may reduce long-term effects.

Childhood medulloblastoma: current status of biology and treatment

Medulloblastoma, a primitive neuro-ectodermal tumour that arises in the posterior fossa, is the most common malignant brain tumour occurring in childhood. Over the past half century, the long-term survival for children with medulloblastoma has improved remarkably from a certain fatal diagnosis to a cancer that is often curable. Although overall survival for children with non-disseminated and non-anaplastic medulloblastoma can approach 80%, the current multidisciplinary therapeutic approach is not without long-term sequelae. Chemotherapy has improved the long-term survival and allowed for reductions in the amount of radiation given, thereby reducing some of the long-term toxicities. In this review, we describe the current understanding of the basic biology of medulloblastoma and report on the current active chemotherapeutic agents utilized in medulloblastoma therapy. Ultimately, our understanding of the basic biology of medulloblastoma may lead to further advances in therapy by providing targets that are more specific and potentially less toxic.

The metabolic syndrome in adult survivors of childhood cancer, a review

The number of adult survivors of childhood cancer in the general population has increased. As reports on the prevalence of the metabolic syndrome in adult survivors of childhood cancer are scarce, we reviewed the available literature on the components of the metabolic syndrome in adult survivors of childhood cancer. Although there is a lack of studies estimating the prevalence of metabolic syndrome directly, especially prevalence of insulin resistance, obesity, and dyslipidemia is increased in certain groups. Therefore, adult survivors of childhood cancer are at increased risk of developing cerebrovascular and cardiovascular diseases. Accordingly, it is important to identify the predisposing factors of the metabolic syndrome in cohorts of survivors, to introduce medical interventions, and to subsequently decrease the risk of cerebrovascular and cardiovascular events.

Survivorship: childhood cancer survivors

Late effects of therapy for childhood cancer are frequent and serious. Fortunately, many late effects are also modifiable. Proactive and anticipatory risk-based care can reduce the frequency and severity of treatment-related morbidity. The primary care clinician should be an integral component in risk-based care of survivors. Continued communication between the "late effects" staff at the cancer center and the primary care clinician is essential for optimum care of this high-risk population.

Cardiovascular risk factors in adult survivors of pediatric cancer--a report from the childhood cancer survivor study

BACKGROUND

Childhood cancer survivors are at higher risk of morbidity and mortality from cardiovascular disease compared with the general population.

METHODS

Eight thousand five hundred ninety-nine survivors (52% male) and 2,936 siblings (46% male) from the Childhood Cancer Survivor Study, a retrospectively ascertained, prospectively followed study of persons who survived 5 years after childhood cancer diagnosed from 1970 to 1986, were evaluated for body mass index of > or =30 kg/m(2) based on self-reported heights and weights and self-reported use of medications for hypertension, dyslipidemia, and impaired glucose metabolism. The presence of three or more of the above constituted Cardiovascular Risk Factor Cluster (CVRFC), a surrogate for Metabolic Syndrome.

RESULTS

Survivors were more likely than siblings to take medications for hypertension [odds ratio (OR), 1.9; 95% confidence interval (95% CI), 1.6-2.2], dyslipidemia (OR, 1.6; 95% CI, 1.3-2.0) or diabetes (OR, 1.7; 95% CI, 1.2-2.3). Among these young adults (mean age of 32 years for survivors and 33 years for siblings), survivors were not more likely than siblings to be obese or have CVRFC. In a multivariable logistic regression analysis, factors associated with having CVRFC included older age at interview [> or =40 versus <30 years of age (OR, 8.2; 95% CI, 3.5-19.9)], exposure to total body irradiation (OR, 5.5; 95% CI, 1.5-15.8) or radiation to the chest and abdomen (OR, 2.3; 95% CI, 1.2-2.4), and physical inactivity (OR, 1.7; 95% CI, 1.1-2.6).

CONCLUSIONS

Among adult survivors of pediatric cancer, older attained age, exposure to total body irradiation or abdominal plus chest radiation, and a sedentary life-style are associated with CVRFC.

Cardiac outcomes in a cohort of adult survivors of childhood and adolescent cancer: retrospective analysis of the Childhood Cancer Survivor Study cohort

OBJECTIVES

To assess the incidence of and risks for congestive heart failure, myocardial infarction, pericardial disease, and valvular abnormalities among adult survivors of childhood and adolescent cancers.

DESIGN

Retrospective cohort study.

SETTING

26 institutions that participated in the Childhood Cancer Survivor Study.

PARTICIPANTS

14,358 five year survivors of cancer diagnosed under the age of 21 with leukaemia, brain cancer, Hodgkin's lymphoma, non-Hodgkin's lymphoma, kidney cancer, neuroblastoma, soft tissue sarcoma, or bone cancer between 1970 and 1986. Comparison group included 3899 siblings of cancer survivors.

MAIN OUTCOME MEASURES

Participants or their parents (in participants aged less than 18 years) completed a questionnaire collecting information on demographic characteristics, height, weight, health habits, medical conditions, and surgical procedures occurring since diagnosis. The main outcome measures were the incidence of and risk factors for congestive heart failure, myocardial infarction, pericardial disease, and valvular abnormalities in survivors of cancer compared with siblings.

RESULTS

Survivors of cancer were significantly more likely than siblings to report congestive heart failure (hazard ratio (HR) 5.9, 95% confidence interval 3.4 to 9.6; P<0.001), myocardial infarction (HR 5.0, 95% CI 2.3 to 10.4; P<0.001), pericardial disease (HR 6.3, 95% CI 3.3 to 11.9; P<0.001), or valvular abnormalities (HR 4.8, 95% CI 3.0 to 7.6; P<0.001). Exposure to 250 mg/m(2) or more of anthracyclines increased the relative hazard of congestive heart failure, pericardial disease, and valvular abnormalities by two to five times compared with survivors who had not been exposed to anthracyclines. Cardiac radiation exposure of 1500 centigray or more increased the relative hazard of congestive heart failure, myocardial infarction, pericardial disease, and valvular abnormalities by twofold to sixfold compared to non-irradiated survivors. The cumulative incidence of adverse cardiac outcomes in cancer survivors continued to increase up to 30 years after diagnosis.

CONCLUSION

Survivors of childhood and adolescent cancer are at substantial risk for cardiovascular disease. Healthcare professionals must be aware of these risks when caring for this growing population.

Late effects of therapy for pediatric brain tumor survivors

Approximately 2 of every 3 of all pediatric patients with brain tumors will be long-term survivors. However, there is a steep cost for pediatric brain tumor survivors, and the group as a whole faces significantly more late effects than many other survivors of pediatric cancers. Most of these effects can be attributed to direct neurologic damage to the developing brain caused by the tumor and its removal, the long-term toxicity of chemotherapy, or the effects of irradiation on the central nervous system. The late effects experienced by childhood brain tumor survivors involve multiple domains. This article will review the significant late effects that occur within the medical, neurocognitive, psychosocial, and economic domains of the survivorship experience. We conclude by discussing how the late effects in different domains often coexist and can create a complex set of obstacles that pose significant challenges for a survivor of a pediatric brain tumor on a daily basis.

Chronic health conditions in childhood cancer survivors: is it all treatment-related--or do genetics play a role?

BACKGROUND

High-intensity, risk-based therapeutic strategies for childhood cancer have resulted in long-term survival rates that now approach 80%. However, the growing population of survivors is at a substantial risk for treatment-related complications that can significantly impact quantity and quality of survival. It is increasingly recognized that many of these complications result from complex interactions between therapeutic exposures and genetic susceptibility.

OBJECTIVE

This review is designed to increase general clinician awareness of the ongoing efforts by investigators to understand the interactions between therapeutic exposures and genetic susceptibility to therapy-related complications.

RESULTS

Most studies have relied on a biologically plausible candidate gene approach to evaluate genetic susceptibility. This has resulted in the identification of unique genetic polymorphisms that could alter metabolic pathways of therapeutic agents associated with specific adverse events. We highlight some of these findings and discuss their implications for future prevention strategies, as well as their role in elucidating the pathophysiology of these complex diseases.

CONCLUSION

Research exploring the role of genetic susceptibility in the development of therapy-related adverse outcomes is still in its infancy. There is a need for continued efforts to study these outcomes in the context of complex gene-gene and gene-environment interactions unique to cancer survivors. A better understanding of the pathogenesis of these outcomes will help develop effective targeted prevention strategies.

Diabetes mellitus in long-term survivors of childhood cancer. Increased risk associated with radiation therapy: a report for the childhood cancer survivor study

BACKGROUND

Childhood cancer survivors are at increased risk of morbidity and mortality. To further characterize this risk, this study aimed to compare the prevalence of diabetes mellitus (DM) in childhood cancer survivors and their siblings.

METHODS

Participants included 8599 survivors in the Childhood Cancer Survivor Study (CCSS), a retrospectively ascertained North American cohort of long-term survivors who were diagnosed between 1970 and 1986 as well as 2936 randomly selected siblings of the survivors. The main outcome was self-reported DM.

RESULTS

The mean ages of the survivors and the siblings were 31.5 years (age range, 17.0-54.1 years) and 33.4 years (age range, 9.6-58.4 years), respectively. Diabetes mellitus was reported in 2.5% of the survivors and 1.7% of the siblings. After adjustment for body mass index, age, sex, race/ethnicity, household income, and insurance, the survivors were 1.8 times more likely than the siblings to report DM (95% confidence interval [CI], 1.3-2.5; P < .001), with survivors who received total body irradiation (odds ratio [OR], 12.6; 95% CI, 6.2-25.3; P < .001), abdominal irradiation (OR, 3.4; 95% CI, 2.3-5.0; P < .001), and cranial irradiation (OR, 1.6; 95% CI 1.0-2.3; P = .03) at increased risk. In adjusted models, an increased risk of DM was associated with total body irradiation (OR, 7.2; 95% CI, 3.4-15.0; P < .001), abdominal irradiation (OR, 2.7; 95% CI, 1.9-3.8; P < .001), use of alkylating agents (OR, 1.7; 95% CI, 1.2-2.3; P < .01), and younger age at diagnosis (0-4 years; OR, 2.4; 95% CI, 1.3-4.6; P < .01).

CONCLUSION

Childhood cancer survivors treated with total body or abdominal irradiation have an increased risk of diabetes that appears unrelated to body mass index or physical inactivity.

Long-term outcomes among adult survivors of childhood central nervous system malignancies in the Childhood Cancer Survivor Study

BACKGROUND

Adult survivors of childhood central nervous system (CNS) malignancies are at high risk for long-term morbidity and late mortality. However, patterns of late mortality, the long-term risks of subsequent neoplasms and debilitating medical conditions, and sociodemographic outcomes have not been comprehensively characterized for individual diagnostic and treatment groups.

METHODS

We collected information on treatment, mortality, chronic medical conditions, and neurocognitive functioning of adult 5-year survivors of CNS malignancies diagnosed between 1970 and 1986 within the Childhood Cancer Survivor Study. Using competing risk framework, we calculated cumulative mortality according to cause of death and cumulative incidence of subsequent neoplasms according to exposure and dose of cranial radiation therapy (RT). Neurocognitive impairment and socioeconomic outcomes were assessed with respect to dose of CNS radiotherapy to specific brain regions. Cumulative incidence of chronic medical conditions was compared between survivors and siblings using Cox regression models. All tests of statistical significance were two-sided.

RESULTS

Among all eligible 5-year survivors (n = 2821), cumulative late mortality at 30 years was 25.8% (95% confidence interval [CI] = 23.4% to 28.3%), due primarily to recurrence and/or progression of primary disease. Patients who received cranial RT of 50 Gy or more (n = 813) had a cumulative incidence of a subsequent neoplasm within the CNS of 7.1% (95% CI = 4.5% to 9.6%) at 25 years from diagnosis compared with 1.0% (95% CI = 0% to 2.3%) for patients who had no RT. Survivors had higher risk than siblings of developing new endocrine, neurological, or sensory complications 5 or more years after diagnosis. Neurocognitive impairment was high and proportional to radiation dose for specific tumor types. There was a dose-dependent association between RT to the frontal and/or temporal lobes and lower rates of employment, and marriage.

CONCLUSIONS

Survivors of childhood CNS malignancies are at high risk for late mortality and for developing subsequent neoplasms and chronic medical conditions. Care providers should be informed of these risks so they can provide risk-directed care and develop screening guidelines.

Survival and late effects on development of patients with infantile brain tumor

BACKGROUND

Most infants with brain tumor may have a poor prognosis. The aim of the present study was to retrospectively analyze the survival and outcome with regard to mental and physical development in 11 subjects with brain tumor; these tumors were diagnosed when the patients were under 1 year of age.

METHODS

The histological diagnoses of these tumors were astrocytoma, n = 3; pineocytoma, n = 2; teratoma, n = 1; ependymoma, n = 1; atypical teratoid/rhabdoid tumor, n = 1; glioblastoma, n = 1; medulloblastoma, n = 1; and choroid plexus papilloma, n = 1. Surgical resection was performed in eight patients, and adjuvant chemotherapy was administered to all except one patient with choroid plexus papilloma. Radiotherapy was additionally performed for four of the 10 chemotherapy patients.

RESULTS

Six patients survived. Among the surviving patients, five were under no treatment for 50-167 months after the diagnosis (median duration, 89 months), while one received chemotherapy for 20 months. Five patients exhibited mental retardation, and one patient experienced normal development after surgical removal of his choroid plexus papilloma. Diencephalic syndrome developed in one patient with pilomyxoid astrocytoma that necessitated hormone replacement therapy, and bodyweight over +2 SD was observed in two patients. The remaining five patients died 11-111 months after diagnosis (median duration, 24 months).

CONCLUSION

The prognosis of infantile brain tumor with regard to mortality and developmental outcome remains poor. Furthermore, survivors require comprehensive medical and social support for an extended period.

The Childhood Cancer Survivor Study: a National Cancer Institute-supported resource for outcome and intervention research

Survival for childhood cancer has increased dramatically over the last 40 years with 5-year survival rates now approaching 80%. For many diagnostic groups, rapid increases in survival began in the 1970s with the broader introduction of multimodality approaches, often including combination chemotherapy with or without radiation therapy. With this increase in rates of survivorship has come the recognition that survivors are at risk for adverse health and quality-of-life outcomes, with risk being influenced by host-, disease-, and treatment-related factors. In 1994, the US National Cancer Institute funded the Childhood Cancer Survivor Study, a multi-institutional research initiative designed to establish a large and extensively characterized cohort of more than 14,000 5-year survivors of childhood and adolescent cancer diagnosed between 1970 and 1986. This ongoing study, which reflects the single most comprehensive body of information ever assembled on childhood and adolescent cancer survivors, provides a dynamic framework and resource to investigate current and future questions about childhood cancer survivors.

Physical performance limitations in the Childhood Cancer Survivor Study cohort

Physical performance limitations are one of the potential long-term consequences following diagnosis and treatment for childhood cancer. The purpose of this review is to describe the risk factors for and the participation restrictions that result from physical performance limitations among childhood cancer survivors who participated in the Childhood Cancer Survivor Study (CCSS). Articles previously published from the CCSS cohort related to physical performance limitations were reviewed and the results summarized. Our review showed that physical performance limitations are prevalent among childhood cancer survivors and may increase as they age. Host-based risk factors for physical disability include an original diagnosis of bone tumor, brain tumor, or Hodgkin's disease; female sex; and an income less than $20,000 per year. Treatment-based risk factors include radiation and treatment with a combination of alkylating agents and anthracyclines. Musculoskeletal, neurologic, cardiac, pulmonary, sensory, and endocrine organ system dysfunction also increase the risk of developing a physical performance limitation. In summary, monitoring of physical performance limitations in an aging cohort of childhood cancer survivors is important and will help determine the impact of physical performance limitations on morbidity, mortality, and caregiver burden. In addition, in developing restorative and preventive interventions for childhood cancer survivors, we must take into account the special needs of survivors with physical disability to optimize their health and enhance participation in daily living activities.

High-risk populations identified in Childhood Cancer Survivor Study investigations: implications for risk-based surveillance

Childhood cancer survivors often experience complications related to cancer and its treatment that may adversely affect quality of life and increase the risk of premature death. The purpose of this manuscript is to review how data derived from Childhood Cancer Survivor Study (CCSS) investigations have facilitated identification of childhood cancer survivor populations at high risk for specific organ toxicity and secondary carcinogenesis and how this has informed clinical screening practices. Articles previously published that used the resource of the CCSS to identify risk factors for specific organ toxicity and subsequent cancers were reviewed and results summarized. CCSS investigations have characterized specific groups to be at highest risk of morbidity related to endocrine and reproductive dysfunction, pulmonary toxicity, cerebrovascular injury, neurologic and neurosensory sequelae, and subsequent neoplasms. Factors influencing risk for specific outcomes related to the individual survivor (eg, sex, race/ethnicity, age at diagnosis, attained age), sociodemographic status (eg, education, household income, health insurance) and cancer history (eg, diagnosis, treatment, time from diagnosis) have been consistently identified. These CCSS investigations that clarify risk for treatment complications related to specific treatment modalities, cumulative dose exposures, and sociodemographic factors identify profiles of survivors at high risk for cancer-related morbidity who deserve heightened surveillance to optimize outcomes after treatment for childhood cancer.

Adiposity in childhood cancer survivors: insights into obesity physiopathology

As childhood cancer treatment has become more effective, survival rates have improved, and a number of complications have been described while many of these patients reach adulthood. Obesity is a well-recognized late effect, and its metabolic effects may lead to cardiovascular disease. Currently, studies concerning overweight have focused on acute lymphocytic leukemia and brain tumors, since they are at risk for hypothalamic-pituitary axis damage secondary to cancer therapies (cranial irradiation, chemotherapy, and brain surgery) or to primary tumor location. Obesity and cancer have metabolic syndrome features in common. Thus, it remains controversial if overweight is a cause or consequence of cancer, and to date additional mechanisms involving adipose tissue and hypothalamic derangements have been considered, comprising premature adiposity rebound, hyperinsulinemia, leptin regulation, and the role of peroxisome proliferator-activated receptor γ. Overall, further research is still necessary to better understand the relationship between adipogenesis and hypothalamic control deregulation following cancer therapy.

Blockade of estrogen receptor signaling inhibits growth and migration of medulloblastoma

Medulloblastoma (MD) is the most common malignant brain tumor in children. These invasive neuroectodermal tumors arise from cerebellar granule cell-like precursors. In the developing cerebellum, estrogen influences growth and viability of granule cell precursors that transiently express elevated levels estrogen receptor-beta (ERbeta) during differentiation. Immunoanalysis revealed that ERbeta was expressed in the maturing human cerebellum, in all 22 primary MD tumors analyzed, and in two MD-derived cell lines (D283Med and Daoy). Very low levels of ERalpha-like proteins were detected in each cell line and 41% of tumor samples. Physiological concentrations of the 17beta-estradiol- or the ERbeta-selective agonist 2,3-bis(4-hydroxyphenyl)-propionitrile diarylpropionitrile dose-dependently increased MD growth and cellular migration. In contrast, the ERalpha-selective agonist (4-propyl-[1H]pyrazole-1,3,5-triyl) trisphenol did not influence MD growth. Similar to previous studies in normal cerebellar granule cell precursors, these studies demonstrate that the physiological actions of estrogens in MD are mediated by ERbeta. Preclinical studies assessing the therapeutic efficacy of antiestrogen chemotherapeutics for treating human MD were performed. It was found that pharmacological inhibition of ER-mediated signaling with the ER antagonist drug Faslodex (ICI182,780) blocked all estrogen-mediated effects in both cell culture and xenograft models of human MD. These studies have revealed that functional ERbeta expression is a fundamental aspect of MD biology and has defined antiestrogen therapy as a potentially efficacious clinical approach to improve the long-term outcomes for MD patients.

Growth effects of methylphenidate among childhood cancer survivors: a 12-month case-matched open-label study

BACKGROUND

To investigate the effect of stimulant medication [methylphenidate (MPH)] on growth patterns among survivors of childhood cancer (acute lymphoblastic leukemia or brain tumor).

PROCEDURE

Using a case-matched comparison design, childhood cancer survivors participating in a 12-month open-label MPH trial (n = 51) were compared with childhood cancer survivors not taking MPH (n = 51). Measures of body mass index (BMI), height, and weight were obtained at hospital visits and corrected for gender and age using Centers for Disease Control normative data.

RESULTS

Significant deceleration of BMI and weight, but not height, was observed during the 12-month MPH trial for those children taking MPH.

CONCLUSIONS

Childhood cancer survivors taking MPH experience significant, though modest, deceleration of BMI and weight across the first year of MPH intervention. The absence of height deceleration, and the presence of only modest BMI and weight deceleration, suggests that MPH is reasonably well tolerated by childhood cancer survivors with respect to growth. Such findings are encouraging in light of increasing evidence that MPH mitigates some of the cognitive late-effects of cancer treatments. Nevertheless, on a case-by-case basis, clinicians should balance the intended benefits of MPH with potential growth effects in this vulnerable population.

Pediatric obesity in acute and critical care

Pediatric obesity has reached epidemic proportions in the United States. Significant obesity-related comorbidities are being noted at earlier ages and often have implications for the acute and critically ill child. This article will review the latest in epidemiologic trends of pediatric obesity and examine how it affects multisystem body organs. The latest data evaluating the specific effects of obesity on acute and critically ill children will be reviewed. Available nonpharmacologic, pharmacologic, and surgical strategies to combat pediatric obesity will be discussed.

Endocrine outcomes for children with embryonal brain tumors after risk-adapted craniospinal and conformal primary-site irradiation and high-dose chemotherapy with stem-cell rescue on the SJMB-96 trial

PURPOSE

To estimate the cumulative incidence of specific hormone deficiencies and the influence of hypothalamic-pituitary (HP) axis radiation dose in a cohort of children with embryonal brain tumors treated with risk-adapted craniospinal irradiation (CSI), conformal primary site irradiation, and high-dose chemotherapy.

PATIENTS AND METHODS

Clinical data and HP axis radiation dosimetry data were obtained from 88 eligible children. All patients received regular endocrine follow-up that included screening tests of thyroid function and stimulation testing for growth hormone deficiency (GHD), and adrenocorticotropin hormone deficiency.

RESULTS

The cumulative incidence of GHD, thyroid-stimulating hormone (TSH) deficiency, adrenocorticotropic hormone deficiency, and primary hypothyroidism at 4 years from diagnosis was 93% +/- 4%, 23% +/- 8%, 38% +/- 6%, and 65% +/- 7%, respectively. Radiation dosimetry to the HP axis was associated only with the development of TSH deficiency; the 4-year cumulative incidence was 44% +/- 19% and 11% +/- 8% (P = .014) for those receiving more or less than the median dose to the hypothalamus (>or= 42 v < 42 Gy), respectively. The median dose of CSI for the average-risk (AR) patients was 23.4 and 39.6 Gy (36 to 40.5 Gy) for the high-risk patients. The estimated mean decline in height Z-score after radiation therapy was greater in high-risk patients (-0.65 units/yr) when compared with AR patients (-0.54 units/yr; P = .039).

CONCLUSION

Pediatric patients with CNS embryonal tumors are at high risk for treatment-related hormone deficiencies. GHD and primary hypothyroidism were diagnosed in a majority of subjects relatively soon after the completion of therapy. Radiation dose to the hypothalamus in excess of 42 Gy was associated with an increase in the risk of developing TSH deficiency.

Fatigue and sleep disturbance in adult survivors of childhood cancer: a report from the childhood cancer survivor study (CCSS)

STUDY OBJECTIVE

To examine the prevalence of and risk factors for fatigue and sleep disturbance among adult survivors of childhood cancer.

DESIGN

Retrospective cohort of childhood cancer survivors.

SETTING

Twenty-six academic institutions treating childhood cancer.

PARTICIPANTS

Two thousand six hundred forty-five survivors of childhood acute lymphocytic leukemia, central nervous system tumors, Hodgkin lymphoma, soft-tissue sarcomas, or bone tumors diagnosed before age 21, surviving at least 5 years from diagnosis, and a 500-sibling comparison group.

MEASUREMENTS

Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale.

RESULTS

Significant differences were found between survivors and siblings on the Functional Assessment of Chronic Illness Therapy-Fatigue (40.8 vs 42.0, P < 0.02), Pittsburgh Sleep Quality Index (6.1 vs 5.5, P < 0.004), and Epworth Sleepiness Scale (6.2 vs 5.4, P < 0.001). Nineteen percent of survivors were in the most fatigued range, 16.7% reported disrupted sleep, and 14% increased daytime sleepiness. Survivors with a history of radiation therapy were more likely to be fatigued (odds ratio 1.7, 95% confidence interval 1.3-2.3), yet without significantly different mean scores. Female sex, congestive heart failure, pulmonary fibrosis, depression, and being unmarried significantly predicted more fatigue, whereas obesity and an infant in the house predicted more daytime sleepiness. Similar sociodemographic predictors were also identified among the siblings.

CONCLUSION

Because of the large sample size, we detected more objectively reported fatigue, sleep disturbance, and daytime sleepiness among adult survivors of childhood cancer. However, the clinical significance of these differences is questionable. Predictors of fatigue and poor sleep were similar in both survivors and the siblings.

Medulloblastoma in childhood: new biological advances

Medulloblastoma is the most common embryonal tumour in children. Patients with medulloblastoma are currently staged as average-risk or poor-risk on the basis of clinical findings. With current multimodality therapy, nearly 90% of children with average-risk, non-disseminated medulloblastoma have 5-year event-free survival, and those with high-risk disease have a 60-65% survival rate; however, the outcome for younger children, particularly infants, is worse. Children who survive medulloblastoma are at risk of long-term sequelae related to the neurological effects of the tumour, surgery, or radiotherapy, and the additive effects of chemotherapy. Molecular biology has changed our understanding of medulloblastoma and has implications for diagnostic stratification and treatment. As newer biological agents are translated from the lab to the bedside, clinicians need to understand the fundamental signalling pathways that are targeted during therapy. Greater understanding of the molecular biology of medulloblastoma is needed so that more children can be cured or have an improved quality of life.

Long-Term Health Status Among Survivors of Childhood Cancer: Does Sex Matter?

Increasing numbers of children diagnosed with cancer will survive their primary malignancy. Within this growing population of long-term survivors, considerable effort has been put forth to identify treatment-related risks for adverse health-related outcomes, such as exposure to alkylating agents, anthracyclines, radiotherapy, and surgery. Patient sex has been identified as a risk factor for numerous long-term adverse outcomes, with female sex more commonly associated with higher risks. In this article, we review the literature, which generally supports associations between female sex and cognitive dysfunction after cranial irradiation, cardiovascular outcomes, obesity, radiation-associated differences in pubertal timing, development of primary hypothyroidism, breast cancer as a second malignant neoplasm and suggests an increased prevalence for the development of osteonecrosis among females. Results of this review support future investigations to further define sex as a risk factor for other common treatment-specific exposures and outcomes. Additionally, research should focus on understanding the underlying biologic and physiological basis of these sex-specific risks. Historically, evidence from both basic science and clinical research has been used to develop risk-stratified therapy, allowing reduction of toxic therapies to low-risk patients without compromising overall survival. With greater knowledge of sex-specific risks, the potential application of sex-specific therapy designed to avoid poor long-term adverse outcomes may become a viable strategy.

Changes in body composition after childhood cancer treatment: Impact on future health status—A review

PURPOSE

To describe data on changes in body composition in childhood cancer survivors. Underlying mechanisms in development of obesity are addressed, in order to discuss intervention strategies.

METHODS

A systematic literature search was undertaken with a number of search terms.

RESULTS

Female survivors of ALL and brain tumours, especially if treated with cranial irradiation, showed a higher prevalence of obesity compared with the general population, while survivors of other malignancies had a higher prevalence of underweight. Influences of corticosteroid treatment and cytostatics on body composition are uncertain. Diminished physical activity, early adiposity rebound (<5 years of age) and/or hypothalamic involvement of tumour or treatment, and subsequent growth hormone deficiency, may play a role in the development of obesity in childhood cancer survivors.

CONCLUSION

Longitudinal prospective studies in more extensive cohorts are necessary to estimate actual prevalence and facilitate the unravelling of the underlying mechanisms in change of body composition.

Hypertension and prehypertension in long-term survivors of childhood and adolescent cancer

BACKGROUND

Hypertension as a late effect following childhood and adolescent cancer has received little attention. Since obesity, a known risk factor for hypertension, is increased following some childhood cancers, it seems likely that significant numbers of survivors would have hypertension.

PROCEDURES

The records of patients seen in the Long Term Follow Up Clinic of Children's National Medical Center were examined for a single institution, retrospective study of blood pressure in survivors of childhood and adolescent cancer. Of 103 consecutive survivors who attended the clinic from January 1 through June 30, 2004, 51 (49.5%) were female and 52 (50.5%) were male. Their mean age was 14.6 years. Systolic and diastolic blood pressures for children and adolescents under 18 years of age were evaluated for hypertension and prehypertensive according to standards for age, sex, and height. Blood pressures for adults 18 years of age and older were evaluated according to standard adult values. Children and adolescents were evaluated for obesity and overweight according to body mass index (BMI) standards for age and sex. Adults were evaluated according to standard adult values.

RESULTS

Twenty-nine patients (28.2%) were hypertensive or prehypertensive, and 74 (71.8%) were normal. Thirty-eight patients (36.9%) were obese or overweight, and 65 (63.1%) were non-obese. Most Wilms tumor patients, 7 of 10 (70.0%), had hypertension or prehypertension, but only 4 of 10 (40.0%) were obese or overweight.

CONCLUSION

Careful follow-up of their blood pressure status is warranted for long-term survivors of childhood and adolescent cancer, especially for those with an initial diagnosis of Wilms tumor.

Genetic susceptibility and body mass in childhood cancer survivors

Childhood cancer survivors are at increased risk of many long-term treatment-related sequel such as second cancers, cardiovascular disease, and pulmonary complications. Certain treatments seem to influence the risk of becoming overweight, obese, or underweight, and abnormal body mass index (BMI) is associated with increased morbidity and mortality. Because BMI is modifiable, it is important to identify treatment and patient-related factors contributing to altered BMI. New research areas include exploring how genetic susceptibility through population polymorphism may contribute to BMI. Illuminating potential gene-environment interactions that influence obesity and underweight might be more readily accomplished in a study of high-risk individuals (i.e., childhood cancer survivors) with well-characterized exposures. The new Childhood Cancer Research Network in the Children's Oncology Group, when fully implemented, should make it less difficult in the future to recruit the large numbers of patients needed for such studies.

Late-Occurring Stroke Among Long-Term Survivors of Childhood Leukemia and Brain Tumors: A Report From the Childhood Cancer Survivor Study

Purpose

This report examines the incidence of and risk factors for strokes that occur in ≥ 5-year survivors of childhood leukemia and brain tumors.

Patients and Methods

The rate of first occurrence of self-reported late-occurring strokes was determined for leukemia survivors (n = 4,828), brain tumor survivors (n = 1,871), and a comparison group of a random sample of cancer survivor siblings (n = 3,846). Relative risks (RRs) and 95% confidence intervals (CIs) of stroke by treatment exposures were examined by multivariate analyses.

Results

Thirty-seven leukemia survivors and 63 brain tumor survivors reported a late-occurring stroke. The rate of late-occurring stroke for leukemia survivors was 57.9 per 100,000 person-years (95% CI, 41.2 to 78.7). The RR of stroke for leukemia survivors compared with the sibling comparison group was 6.4 (95% CI, 3.0 to 13.8; P < .0001). The rate of late-occurring stroke for brain tumor survivors was 267.6 per 100,000 person-years (95% CI, 206.8 to 339.2). The RR of stroke for brain tumor survivors compared with the sibling comparison group was 29.0 (95% CI, 13.8 to 60.6; P < .0001). Mean cranial radiation therapy (CRT) dose of ≥ 30 Gy was associated with an increased risk in both leukemia and brain tumor survivors in a dose-dependent fashion, with the highest risk after doses of ≥ 50 Gy CRT.

Conclusion

Survivors of childhood leukemia and brain tumors, particularly those with brain tumors treated with CRT at doses of greater than 30 Gy, are at an increased risk of stroke.

The prevalence of overweight and obesity in pediatric survivors of cancer

OBJECTIVE

To compare the prevalence of overweight in a cohort of pediatric survivors of cancer with that in the general population.

STUDY DESIGN

We reviewed the charts of 441 cancer survivors followed at a Canadian tertiary care pediatric hospital and calculated their most recent body mass index. We compared this cohort with population data generated from the Canadian Community Health Survey.

RESULTS

At a median age of 14.7 years (range, 3.4 to 19.5 years) and a median time from diagnosis of 9.7 years (range, 3.4 to 19.2 years), 140 of 441 patients (31.7%) were overweight or obese. Only 12 of the 441 patients (2.7%) were underweight. Males age 6 to 11 years (odds ratio [OR] = 2.29; 95% confidence interval [CI] = 1.36 to 3.86; P < .001) and male survivors of acute lymphoblastic leukemia (OR = 1.55; 95% CI = 1.03 to 2.52; P = .04) were more likely to be overweight than the general population. No other age or diagnostic group had an increased risk of overweight.

CONCLUSIONS

The prevalence of overweight was not increased in this cohort compared with the general population. However, almost 1/3 of these patients are overweight, necessitating a clinical and research focus on preventing and combating overweight in childhood cancer survivors.

Surviving childhood cancer: the impact on life

With modern therapies, most children diagnosed with cancer are expected to reach adulthood. Therefore, there are large and ever-increasing numbers of children and young adults in our population who are survivors of childhood cancer. Many of the therapies responsible for improved cancer survival rates can also damage normal cells and tissues. As more children survive cancer, the physical and emotional costs of enduring cancer therapy become increasingly important. Although most childhood cancer survivors are now expected to survive, they remain at risk for relapse, second malignant neoplasms, organ dysfunction, and a negative psychologic impact. Individual risk is quite variable and is dependent on multiple factors including the type and site of cancer, the therapy utilized, and the individual's constitution. The risks are likely to change as we learn more about the specific long-term effects of cancer therapy, develop more refined and targeted therapies, and develop and apply more effective preventative strategies or therapeutic interventions. Guidelines for long-term follow-up have been established and are available to help facilitate appropriate monitoring of and care for potential late effects.

Quality of Life Among Long-Term Adolescent and Adult Survivors of Childhood Cancer

Purpose

We assessed effects of childhood or adolescent cancer on quality of life among adolescent and adult cancer survivors, a group who are thought to be at particular risk for adverse late effects.

Patients and Methods

We studied 1,334 survivors and 1,477 age- and sex-matched, general population controls from across Canada using a mailed questionnaire which included the Short Form-36 (SF-36) and measures of self-esteem, optimism, and life satisfaction. General linear models and logistic regression were used. Survivor-control differences corresponding to an effect size (ES) ≥ 0.5 were considered clinically important.

Results

Participants were age 15 years to 37 years. Most survivors (83.8%) were diagnosed ≥ 10 years earlier. Fewer survivors (62.1%) than controls (71.1%) reported very good or excellent general health (adjusted odds ratio, 0.6; 95% CI, 0.5 to 0.7). However, quality of life differences between survivors and controls were small, and for the most part probably not clinically important. Three clinical characteristics—having had CNS or bone cancer, more than one treatment series, and ≥ two organs with a dysfunction at treatment end—were independently associated with poorer quality of life in the physical dimensions. Only survivors with ≥ two organs with dysfunction (8.7%) reported poorer quality of life in both physical and psychosocial domains, with several clinically important ES. The largest ES for the SF-36 physical summary scores were found in the 8% of survivors with two or three of these characteristics simultaneously, compared with those survivors who had none (−0.79 and −1.13, respectively).

Conclusion

Overall, a sizeable majority of adolescent and adult long-term survivors of childhood cancer in Canada appear to have adapted well.

Obesity in pediatric oncology

Today's obesity pandemic began in the United States, spread to Western Europe and other developed regions, and is emerging in developing countries. Its influences on outcomes of childhood cancer are unknown. A recent Children's Oncology Group symposium considered epidemiology of obesity, pharmacology of chemotherapy and outcomes in obese adults with cancer, excess mortality in obese pediatric patients with acute myeloid leukemia (AML), and complications in obese survivors. The salient points are summarized herein. Body mass index (BMI) is the accepted index of weight for height and age. In the US, obesity prevalence (BMI > 95th centile) is increasing in all pediatric age groups and accelerating fastest among black and Hispanic adolescents. Pharmacologic investigations are few and limited: half-life, volume of distribution, and clearance in obese patients vary between drugs. Obese adults with solid tumors generally experience less toxicity, suggesting underdosing. For patients undergoing bone marrow transplantation, obese adults generally experience greater toxicity. In pediatric acute myeloblastic leukemia, obese patients have greater treatment-related mortality (TRM), similar toxicity and relapse rates, and inferior survival compared with patients who are not obese. An excess of female survivors of childhood leukemia who received cranial irradiation are obese. Ongoing treatment effects of childhood cancer may predispose to a sedentary lifestyle. These findings call for measures to prevent obesity, retrospective and prospective studies of chemotherapy pharmacology of analyzed according to BMI and outcomes, additional studies of the obesity impact on outcomes in pediatric cancer, and promotion of a healthy lifestyle among survivors.

Seqüelas endócrinas da radioterapia no tratamento do câncer na infância e adolescência

A radioterapia resulta em endocrinopatias, osteoporose, obesidade e seqüelas neurológicas em pacientes tratados por câncer. A deficiência de GH é a complicação mais freqüente no eixo hipotálamo-hipofisário. A freqüência, prazo de surgimento e gravidade da deficiência de GH dependem da dose recebida durante a irradiação craniana, mas idade à radioterapia e fracionamento da dose também são variáveis importantes. Outras anormalidades do eixo hipotálamo-hipofisário são igualmente dose-dependentes. Baixas doses de irradiação induzem puberdade precoce ou avançada, enquanto altas doses provocam deficiência gonadotrópica. Complicações endócrinas secundárias à irradiação periférica, como distúrbios gonadais ou tireoidianos são descritos. Mesmo com secreção normal de GH, o crescimento pode ser comprometido por lesões ósseas após irradiação corporal total ou crânio-espinhal. Resultados melhores sobre a estatura final têm sido obtidos com reposição de GH em associação com o tratamento da puberdade precoce ou avançada. O objetivo desta revisão é a abordagem das seqüelas endócrinas tardias da radioterapia.

Retrospective family study of childhood medulloblastoma

Medulloblastoma is the most common malignant central nervous system tumor of childhood and can occur sporadically or in association with inherited cancer susceptibility syndromes such as the nevoid basal cell carcinoma syndrome (NBCCS). To determine whether an association existed between the risk of developing medulloblastoma and undiagnosed syndromes, we retrospectively reviewed clinical data on 33 patients with medulloblastoma from a single institution and compared them with their unaffected relatives (n = 46). Six patients had tumors showing desmoplastic histology. Two of the six met diagnostic criteria for NBCCS. One NBCCS patient had a missense mutation of patched-1 (PTCH1); the other had no identifiable PTCH1 mutation. Two patients with isolated desmoplastic medulloblastoma had an insertion and splice site mutation, respectively, in suppressor of fused (SUFU). All patients with nondesmoplastic medulloblastoma histology received molecular testing for SUFU. None of these patients had an identifiable mutation in PTCH1 or SUFU. We performed a clinical evaluation for Greig cephalopolysyndactyly syndrome (GCPS) in four medulloblastoma families, who exhibited macrocephaly as the only finding consistent with the diagnosis of GCPS. Molecular analysis of GLI3 in these four families was negative. There was a paucity of clinical findings among the majority of medulloblastoma patients in this study group to suggest a definable cancer genetic syndrome. We conclude that clinically recognizable syndromes are uncommon among patients with medulloblastoma, however, PTCH1 and SUFU mutations are present at a low but significant frequency.

Cardiac changes associated with growth hormone therapy among children treated with anthracyclines

OBJECTIVE

The objective was to assess the cardiac effects of growth hormone (GH) therapy. Anthracycline-treated childhood cancer survivors frequently have reduced left ventricular (LV) wall thickness and contractility, and GH therapy may affect these factors.

METHODS

We examined serial cardiac findings for 34 anthracycline-treated childhood cancer survivors with several years of GH therapy and baseline cardiac z scores similar to those of a comparison group (86 similar cancer survivors without GH therapy).

RESULTS

LV contractility was decreased among GH-treated patients before, during, and after GH therapy (-1.08 SD below the age-adjusted population mean before therapy and -1.88 SD 4 years after therapy ceased, with each value depressed below normal). Contractility was higher in the control group than in the GH-treated group, with this difference being nearly significant. The GH-treated children had thinner LV walls before GH therapy (-1.38 SD). Wall thickness increased during GH therapy (from -1.38 SD to -1.09 SD after 3 years of GH therapy), but the effect was lost shortly after GH therapy ended and thickness diminished over time (-1.50 SD at 1 year after therapy and -1.96 SD at 4 years). During GH therapy, the wall thickness for the GH-treated group was greater than that for the control group; however, by 4 years after therapy, there was no difference between the GH-treated group and the control group.

CONCLUSIONS

GH therapy among anthracycline-treated survivors of childhood cancer increased LV wall thickness, but the effect was lost after therapy was discontinued. The therapy did not affect the progressive LV dysfunction.

Body mass index in long-term adult survivors of childhood cancer: a report of the Childhood Cancer Survivor Study

BACKGROUND

The goals of the current study were to determine the distribution of body mass index (BMI) of survivors of common pediatric malignancies and to identify factors associated with abnormal BMI.

METHODS

The Childhood Cancer Survivor Study (CCSS) is a multicenter cohort study of >/= 5-year survivors of pediatric cancer diagnosed between 1970 and 1986. Self-reported heights and weights were used to calculate BMI for 7195 adult survivors, compared with population-based, age-specific, and gender-specific norms from the 1995 National Health Interview Survey. Underweight was defined as a BMI < 18.5 kg/m(2) and obese as BMI >/= 30 kg/m(2).

RESULTS

Survivors of leukemia were more likely to be obese (females: odds ratio [OR] = 1.5; 95% confidence interval [CI], 1.2-1.8; males: OR = 1.2; 95% CI, 1.0-1.5). Survivors more likely to be underweight included female and male survivors of Hodgkin disease (OR = 1.7; 95% CI, 1.3-2.3 and OR = 3.5; 95% CI, 2.3-5.3) and Wilms tumor (OR = 1.8; 95% CI, 1.2-2.8 and OR = 5.5; 95% CI, 3.1-9.7), female survivors of bone carcinoma without amputation (OR = 1.9; 95% CI, 1.2-2.9), and male survivors of leukemia (OR = 2.4; 95% CI, 1.6-3.6), brain tumors (OR = 2.7; 95% CI, 1.6-4.4), non-Hodgkin lymphoma (OR = 3.1; 95% CI, 1.9-5.2), neuroblastoma (OR = 4.9; 95% CI, 2.48-10.0), and soft tissue sarcoma (OR = 3.5; 95% CI, 2.0-6.0). In females, treatment with total body irradiation, alkylating agents, and anthracyclines and in males, treatment with abdominal radiation, younger age at treatment, and treatment with anthracyclines and alkylating agents were associated with being underweight. Underweight survivors were more likely to report adverse health and major medical conditions.

CONCLUSIONS

A significant proportion of childhood survivors of cancer are underweight as adults and the impact of this on the general health of survivors will need to be addressed further.

Long-term endocrine effects of cancer treatment: experience of the Royal Children's Hospital, Melbourne

OBJECTIVES

To evaluate the frequency and degree of severity of endocrine late effects in patients treated for childhood cancer and to assess the value of the late effects clinic for continued monitoring of these patients.

METHOD

Data was collected on all patients who attended the late effects clinic at the Royal Children's Hospital (RCH) between 1998-2003. Endocrine function was assessed by clinical and biochemical evaluation at the time of presentation and at ongoing intervals of 3-12 months as clinically indicated.

RESULTS

A total of 249 children attended the late effects clinic. Two hundred and thirty five endocrine diagnoses were made in 155 (62%) patients, of whom 63 patients had multiple endocrinopathies.

CONCLUSION

Our audit supports the need for ongoing prospective surveillance in survivors of childhood cancer. Appropriate and timely interventions in such patients can help to reduce morbidity and improve quality of life.

Long-term outcomes of adult survivors of childhood cancer

During the past 30 years, changes in the treatment of children and adolescents with cancer have led to substantial improvements in survival. Although treatment-related factors have been shown to impact subsequent health status and quality of life, there is limited information on survivors who are now two or more decades after treatment. The Childhood Cancer Survivor Study (CCSS) was established as a resource for investigating the long-term outcomes of a cohort of 5-year survivors of childhood and adolescent cancer, diagnosed between 1970-1986. The CCSS cohort has more than 14,000 active participants, including survivors of leukemia, brain tumors, Hodgkin disease, non-Hodgkin lymphoma, Wilms tumor, neuroblastoma, soft-tissue sarcoma, and bone tumors. Study participants, extensively characterized by their cancer therapy, have provided self-reported sociodemographic- and health-related information. Although the survivor population has been found to be at significantly increased risk of several adverse outcomes, such as late mortality, second cancers, pulmonary complications, pregnancy loss, low birth weight of offspring, and decreased education, the overall proportion of survivors affected is relatively small. Subgroups at high risk of adverse outcomes, defined by treatment-related, demographic, or medical factors, can be identified. The ongoing evaluation of large and diverse cohorts of cancer survivors will aid in further identifying individuals who should be the target of innovative intervention strategies.