Childhood Cancer Survivorship and Long-Term Outcomes

Spiritual Well-Being and Related Factors in Children With Cancer

Introduction: There are specific gaps that call for empirical research in the experiences of spiritual well-being among children 12 years old and younger with cancer. Understanding these relationships can help to develop holistic and family centered care in pediatric oncology wards. This study assessed the spiritual well-being of children with cancer in association with their general well-being, happiness, quality of life, pain intensity, and personal characteristics. Method: The data were collected in Lithuania between June 2020 and November 2021. Children with cancer (N = 81) who were hospitalized at pediatric oncology-hematology centers participated in the study. Inclusion criteria were age (from 5 to 12 years old), diagnosis of oncologic disease for the first time, and absence of other chronic diseases. The instruments used were: Feeling Good, Living Life; Oxford Happiness Questionnaire, Short Form; Well-Being Index; PedsQL™3.0 Cancer Module, and a Wong-Baker FACES® Pain Rating Scale. Results: Communal and personal domains of spiritual well-being had the highest scores among pediatric oncology patients while both dimensions of the transcendental domain scored lowest. Age, level of education, and family composition revealed differences in children's spiritual health, happiness, and well-being, and church attendance was significant for overall spiritual well-being and its transcendental domain on lived experience dimension. Happiness had the strongest effect on all four domains of spiritual well-being. Discussion: Children emphasized the importance of spiritual aspects to feel better to a greater extent than they experienced in their lives. Despite their young age, children were familiar with family traditions, that is, religious practice and church attendance, and followed them in a particular sociocultural context.

Childhood cancer survival in the highly vulnerable population of South Texas: A cohort study

This study examines childhood cancer survival rates and prognostic factors related to survival in the majority Hispanic population of South Texas. The population-based cohort study used Texas Cancer Registry data (1995-2017) to examine survival and prognostic factors. Cox proportional hazard models and Kaplan-Meier survival curves were used for survival analyses. The 5-year relative survival rate for 7,999 South Texas cancer patients diagnosed at 0-19 years was 80.3% for all races/ethnicities. Hispanic patients had statistically significant lower 5-year relative survival rates than non-Hispanic White (NHW) patients for male and female together diagnosed at age≥5 years. When comparing survival among Hispanic and NHW patients for the most common cancer, acute lymphocytic leukemia (ALL), the difference was most significant in the 15-19 years age range, with 47.7% Hispanic patients surviving at 5 years compared to 78.4% of NHW counterparts. The multivariable-adjusted analysis showed that males had statistically significant 13% increased mortality risk than females [hazard ratio (HR): 1.13, 95% confidence interval (CI):1.01-1.26] for all cancer types. Comparing to patients diagnosed at ages 1-4 years, patients diagnosed at age < 1 year (HR: 1.69, 95% CI: 1.36-2.09), at 10-14 year (HR: 1.42, 95% CI: 1.20-1.68), or at 15-19 years (HR: 1.40, 95% CI: 1.20-1.64) had significant increased mortality risk. Comparing to NHW patients, Hispanic patients showed 38% significantly increased mortality risk for all cancer types, 66% for ALL, and 52% for brain cancer. South Texas Hispanic patients had lower 5-year relative survival than NHW patients especially for ALL. Male gender, diagnosis at age<1 year or 10-19 years were also associated with decreased childhood cancer survival. Despite advances in treatment, Hispanic patients lag significantly behind NHW patients. Further cohort studies in South Texas are warranted to identify additional factors affecting survival and to develop interventional strategies.

Targeting Akt/PKB in pediatric tumors: A review from preclinical to clinical trials

The serine/threonine kinase Akt is a major player in the phosphoinositide 3-kinase (PI3K)/Akt/mammalian target of rapamycin (mTOR) signaling pathway, and its modulation impacts multiple cellular processes such as growth, proliferation, and survival. Several abnormalities in this pathway have been documented over the years, and these alterations were shown to have great implications in tumorigenesis and resistance to chemotherapy. Thus, multiple Akt inhibitors have been developed and tested in adult tumors, and some of them are currently undergoing phase I, II, and III clinical trials for distinct cancers that arise during adulthood. Despite that, the impact of these inhibitors is still not fully understood in pediatric tumors, and Akt-specific targeting seems to be a promising approach to treat children affected by cancers. This review summarizes recent available evidence of Akt inhibitors in pediatric cancers, from both preclinical and clinical studies. In short, we demonstrate the impact that Akt inhibition provides in tumorigenesis, and we suggest targeting the PI3K/Akt/mTOR signaling pathway, alone or in combination with other inhibitors, is a feasible tool to achieve better outcomes in pediatric tumors.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

Complex behavioral interventions targeting physical activity and dietary behaviors in pediatric oncology: A scoping review

As cancer and its treatment negatively impacts the long-term health and quality of life of survivors, there is a need to explore new avenues to prevent or minimize the impact of adverse effects in children with cancer and cancer survivors. Therefore, this scoping review aimed to report on the state of the evidence on the use and effects of complex behavioral interventions (CBI) targeting physical activity and/or dietary behaviors in pediatric oncology. Fourteen quantitative studies were included, evaluating interventions that used a combination of two or three different treatment modalities. Overall, studies demonstrated that it is feasible to implement CBI and that they can potentially improve physical activity and dietary behaviors as well as patient outcomes such as physical and psychological health. Unfortunately, due to a paucity of studies and the heterogeneity of the studies included in this review, no conclusive evidence favoring specific interventions were identified.

Sexual dysfunction in young adult survivors of childhood cancer - A population-based study

OBJECTIVE

To determine the prevalence of sexual dysfunction and to identify the factors associated with sexual dysfunction in young adult childhood cancer survivors.

METHODS

All survivors of childhood cancer (aged 19-40 years) in Sweden were invited to this population-based study, and 2546 men and women (59%) participated. Sexual function was examined with the PROMIS Sexual Function and Satisfaction Measure. Logistic regression was used to assess the differences between survivors and a general population sample (n = 819) and to identify the factors associated with sexual dysfunction in survivors.

RESULTS

Sexual dysfunction in at least one domain was reported by 57% of female and 35% of male survivors. Among females, dysfunction was most common for Sexual interest (36%), Orgasm - ability (32%) and Vulvar discomfort - labial (19%). Among males, dysfunction was most common for the domains satisfaction with sex life (20%), Sexual interest (14%) and Erectile function (9%). Compared with the general population, male survivors more frequently reported sexual dysfunction in ≥2 domains (OR = 1.67, 95% CI: 1.03-2.71), with an increased likelihood of dysfunction regarding Orgasm - ability (OR = 1.82; 95% CI: 1.01-3.28) and Erectile function (OR = 2.30; 95% CI: 1.18-4.49). Female survivors reported more dysfunction regarding Orgasm - pleasure (9% versus 5%, OR = 1.86; 95% CI: 1.11-3.13). A more intensive cancer treatment, emotional distress and body image disturbance were associated with sexual dysfunction in survivors.

CONCLUSIONS

The findings underscore the need for routine assessment of sexual health in follow-up care of childhood cancer survivors and highlight that those treated with more intensive cancer treatment and who experience concurrent psychological concerns may benefit from targeted screening and interventions.

Late mortality from other diseases following childhood cancer in Australia and the impact of intensity of treatment

BACKGROUND

People who receive treatment for cancer during childhood often experience subsequent complications of therapy, known as late effects, which can lead to an increased risk of death.

PROCEDURE

Using deidentified population-based data from the Australian Childhood Cancer Registry for children aged 0-14 diagnosed with cancer during the period 1983-2011 and who survived for a minimum of 5 years, we examined disease-related deaths (other than cancer recurrence or second primary cancers) that occurred up to 31 December 2016. Risk of death relative to the general population was approximated using standardised mortality ratios (SMRs). Treatment received was stratified according to the intensity of treatment rating, version 3 (ITR-3).

RESULTS

During the study period, 82 noncancer disease-related deaths were recorded among 13 432 childhood cancer survivors, four times higher than expected (SMR = 4.43, 95% CI = 3.57-5.50). A clear link to treatment intensity was observed, with the relative risk of noncancer disease-related mortality being twice as high for children who underwent 'most intensive' treatment (SMR = 5.94, 95% CI = 3.69-9.55) compared to the 'least intensive' treatment group (SMR = 2.98, 95% CI = 1.42-6.24; P_trend  = .01). Thirty-year cumulative mortality from noncancer disease-related deaths was estimated at 1.4% (95% CI = 1.1-1.9) after adjusting for competing causes of death such as cancer, accidents, or injuries.

CONCLUSIONS

Although childhood cancer survivors are at increased relative risk of death from noncancer diseases, particularly those who undergo more intensive treatment, the cumulative mortality within 30 years of diagnosis remains small. Knowledge of late effects can guide surveillance of survivors and treatment modification, without wanting to compromise the high rates of survival.

Comparison of blood pressure values and expression of genes associated with hypertension in children before and after hematopoietic cell transplantation

Hypertension is a well-known late effect of hematopoietic cell transplantation (HCT), but no markers predicting its development are known. Our aim was to assess short-term blood pressure (BP) values and expressions of hypertension-associated genes as possible markers of hypertension in children treated with HCT. We measured systolic blood pressure (SBP) and diastolic blood pressure (DBP), using both office procedure and ambulatory BP monitoring (ABPM) in children before HCT and after a median of 6 months after HCT. We compared the results with two control groups, one of healthy children and another of children with simple obesity. We also performed microarray analysis of hypertension-associated genes in patients treated with HCT and children with obesity. We found no significant differences in SBP and DBP in patients before and after HCT. We found significant differences in expressions of certain genes in patients treated with HCT compared with children with obesity. We concluded that BP values in short-term follow-up after HCT do not seem to be useful predictors of hypertension as a late effect of HCT. However, over expressions of certain hypertension-associated genes might be used as markers of hypertension as a late effect of HCT if this is confirmed in larger long-term studies.

Beginning Restorative Activities Very Early: Implementation of an Early Mobility Initiative in a Pediatric Onco-Critical Care Unit

Introduction

Children with underlying oncologic and hematologic diseases who require critical care services have unique risk factors for developing functional impairments from pediatric post-intensive care syndrome (PICS-p). Early mobilization and rehabilitation programs offer a promising approach for mitigating the effects of PICS-p in oncology patients but have not yet been studied in this high-risk population.

Methods

We describe the development and feasibility of implementing an early mobility quality improvement initiative in a dedicated pediatric onco-critical care unit. Our primary outcomes include the percentage of patients with consults for rehabilitation services within 72 h of admission, the percentage of patients who are mobilized within 72 h of admission, and the percentage of patients with a positive delirium screen after 48 h of admission.

Results

Between January 2019 and June 2020, we significantly increased the proportion of patients with consults ordered for rehabilitation services within 72 h of admission from 25 to 56% (p<0.001), increased the percentage of patients who were mobilized within 72 h of admission to the intensive care unit from 21 to 30% (p=0.02), and observed a decrease in patients with positive delirium screens from 43 to 37% (p=0.46). The early mobility initiative was not associated with an increase in unplanned extubations, unintentional removal of central venous catheters, or injury to patient or staff.

Conclusions

Our experience supports the safety and feasibility of early mobility initiatives in pediatric onco-critical care. Additional evaluation is needed to determine the effects of early mobilization on patient outcomes.

Exploring Differences in Perceived Satisfaction, Resilience, and Achievement Between Hispanic and Non-Hispanic White Childhood Cancer Survivors

INTRODUCTION

To address gaps in understanding disparities of posttraumatic growth among childhood cancer survivors, the aims of this study were to (1) compare satisfaction, resilience, and achievement among Hispanic and non-Hispanic White survivors; and (2) examine relationships between sociodemographic and clinical factors with satisfaction, resilience, and achievement.

METHOD

Survivors (N = 116) at Children's Hospital of Orange County After Cancer Treatment Survivorship Program completed the Child Health and Illness Profile-Adolescent Edition.

RESULTS

Resilience (p = .003) and achievement (p = .005) were lower among Hispanic survivors. Resilience was positively associated with satisfaction (p < .01) and achievement (p < .01) and achievement was positively associated with years of schooling (p < .01). No differences were found between Hispanic and non-Hispanic White satisfaction scores (p = .95).

DISCUSSION

Our findings suggest ethnic disparities in posttraumatic growth in childhood cancer survivors. Interventions aimed at promoting posttraumatic growth are vital to address these differences.

Global trends in incidence rates of childhood liver cancers: A systematic review and meta-analysis

BACKGROUND

Childhood liver cancers are relatively rare, hence inferences on incidence trends over time are limited by lack of precision in most studies.

OBJECTIVE

To conduct a systematic review and meta-analysis of published contemporary trends on childhood liver cancer incidence rates worldwide.

DATA SOURCES

PubMed, EMBASE, CINAHL, Web of Science.

STUDY SELECTION AND DATA EXTRACTION

English-language peer-reviewed articles published from 1 January 2008 to 1 December 2019 that presented quantitative estimates of incidence trends for childhood liver cancer and diagnostic subgroups. Review was conducted per PRISMA guidelines. Two authors independently extracted data and critically assessed studies.

SYNTHESIS

Random effects meta-analysis models were used to estimate pooled incidence trends by diagnostic subgroups. Heterogeneity was measured using the Q and I² statistics and publication bias evaluated using Egger's test.

RESULTS

Eighteen studies were included, all based on population-based cancer registries. Trends were reported on average for 18 years. Overall pooled estimates of the annual percentage change (APC) were 1.4 (95% confidence interval [CI] 0.5, 2.3) for childhood liver cancers, 2.8 (95% CI 1.8, 3.8) for hepatoblastoma and -3.0 (95% CI -11.0, 4.9) for hepatocellular carcinoma. Sub-group analysis by region indicated increasing trends for childhood liver cancers in North America/Europe/Australia (APC 1.7, 95% CI 0.7, 2.8) whereas corresponding trends were stable in Asia (APC 1.4, 95%CI -0.3, 2.7). Publication bias was not detected for any of these analyses. The I² statistic indicated that the heterogeneity among included studies was low for combined liver cancers, moderate for hepatoblastoma and high for hepatocellular carcinoma.

CONCLUSIONS

Incidence is increasing for childhood liver cancers and the most commonly diagnosed subgroup hepatoblastoma. Lack of knowledge of the etiology of childhood liver cancers limited the ability to understand the reasons for observed incidence trends. This review highlighted the need for ongoing monitoring of incidence trends and etiological studies.

Risk of Being Born Preterm in Offspring of Cancer Survivors: A National Cohort Study

Background: With the increased number of cancer survivors, it is necessary to explore the effect of cancer and its treatments on pregnancy outcomes, such as preterm birth, which seriously endangers the health of offspring. We aimed to explore the risk of being born preterm among offspring of cancer survivors.

Materials and Methods: This is a retrospective cohort study. All singleton live births between 1973 and 2014 in Sweden with information of birth outcomes were retrieved from the Swedish Medical Birth Register. By linking to several Swedish registers, we identified all parents of children and parental cancer diagnosis. Logistic regression was used to estimate odds ratios and 95% confidence intervals.

Results: As compared to the children without parental cancer, the risk of being born preterm was significantly higher among children of overall female cancer survivors born after cancer diagnosis with an adjusted OR of 1.48 (95 CI% = 1.39–1.59), in particular those diagnosed with childhood cancer and cancer in female genital organs. Besides, the risk might continuously decline with time at the first 8 years after maternal diagnosis. A higher risk of being born preterm was found among offspring of male survivors diagnosed with central nervous system cancer (Adjusted OR = 1.26, 95% CI = 1.04–1.53).

Conclusions: Our study provides evidence for a higher risk of being born preterm among children of female cancer survivors and male survivors with central nervous system tumor, as well as indicates that the effect on female reproductive system from cancer and related-treatments might decline with time.

HCN Channel Activity Balances Quiescence and Proliferation in Neural Stem Cells and Is a Selective Target for Neuroprotection During Cancer Treatment

Children suffering from neurologic cancers undergoing chemotherapy and radiotherapy are at high risk of reduced neurocognitive abilities likely via damage to proliferating neural stem cells (NSC). Therefore, strategies to protect NSCs are needed. We argue that induced cell-cycle arrest/quiescence in NSCs during cancer treatment can represent such a strategy. Here, we show that hyperpolarization-activated cyclic nucleotide-gated (HCN) ion channels are dynamically expressed over the cell cycle in NSCs, depolarize the membrane potential, underlie spontaneous calcium oscillations and are required to maintain NSCs in the actively proliferating pool. Hyperpolarizing pharmacologic inhibition of HCN channels during exposure to ionizing radiation protects NSCs cells in neurogenic brain regions of young mice. In contrast, brain tumor-initiating cells, which also express HCN channels, remain proliferative during HCN inhibition. IMPLICATIONS: Our finding that NSCs can be selectively rescued while cancer cells remain sensitive to the treatment, provide a foundation for reduction of cognitive impairment in children with neurologic cancers.

New approaches to therapeutic drug development for childhood cancers

PURPOSE OF REVIEW

We provide an overview of the current landscape of drug development relevant to childhood cancers. We present recent and ongoing efforts to identify therapeutic targets in pediatric cancers. We describe efforts to improve the approach to clinical trials and highlight the role regulatory changes and multistakeholder platforms play in advancing pediatric cancer drug development.

RECENT FINDINGS

Expanding knowledge of the genetic landscape of pediatric malignancies through clinical genomics studies has yielded an increasing number of potential targets for intervention. In parallel, new therapies for children with cancer have shifted from cytotoxic agents to targeted therapy, with examples of striking activity in patients with tumors driven by oncogenic kinase fusions. Innovative trial designs and recent governmental policies provide opportunities for accelerating development of targeted therapies in pediatric oncology.

SUMMARY

Novel treatment strategies in pediatric oncology increasingly utilize molecularly targeted agents either as monotherapy or in combination with conventional cytotoxic agents. The interplay between new target identification, efforts to improve clinical trial design and new government regulations relevant to pediatric cancer drug development has the potential to advance novel agents into frontline care of children with cancer.

Second primary cancers in people who had cancer as children: an Australian Childhood Cancer Registry population-based study

OBJECTIVE

To investigate the incidence of second primary cancers in people diagnosed with cancer during childhood.

DESIGN, SETTING

Retrospective, population-based study; analysis of Australian Childhood Cancer Registry data.

PARTICIPANTS

People alive at least two months after being diagnosed before the age of 15 years with a primary cancer, 1983-2013, followed until 31 December 2015 (2-33 years' follow-up).

MAIN OUTCOME MEASURES

Risks of second primary cancer compared with the general population, expressed as standardised incidence ratios (SIRs).

RESULTS

Among 18 230 people diagnosed with cancer during childhood, 388 (2%) were later diagnosed with second primary cancers; the estimated 30-year cumulative incidence of second cancers was 4.4% (95% CI, 3.8-5.0%). The risk of a new primary cancer was five times as high as for the general population (SIR, 5.13; 95% CI, 4.65-5.67). Relative risk of a second primary cancer was greatest for people who had childhood rhabdomyosarcoma (SIR, 19.9; 95% CI, 14.4-27.6). Relative risk was particularly high for children who had undergone both chemotherapy and radiotherapy (SIR, 9.80; 95% CI, 8.35-11.5). Relative risk peaked during the 5 years following the first diagnosis (2 to less than 5 years: SIR, 10.3; 95% CI, 8.20-13.0), but was still significant at 20-33 years (SIR, 2.58; 95% CI, 2.02-3.30). The most frequent second primary cancers were thyroid carcinomas (65 of 388, 17%) and acute myeloid leukaemias (57, 15%).

CONCLUSIONS

Survivors of childhood cancer remain at increased risk of a second primary cancer well into adulthood. As the late effects of cancer treatment probably contribute to this risk, treatments need to be refined and their toxicity reduced, without reducing their benefit for survival.

Risk of selected childhood cancers and parental employment in painting and printing industries: A register-based case‒control study in Denmark 1968-2015

Objectives Parental exposures and offspring's risk of cancer have been studied with inconsistent results. We investigated parental employment in painting and printing industries and risk of childhood leukemia, central nervous system (CNS) cancers, and prenatal cancers (acute lymphoblastic leukemia, Wilms tumor, medulloblastoma, neuroblastoma, retinoblastoma, and hepatoblastoma). Methods Using Danish registries, children aged ≤19 years diagnosed from 1968-2015 with leukemia (N=1999), CNS cancers (N=1111) or prenatal cancers (N=2704) were linked to parents and their employment history one year before birth to birth for fathers, and one year before birth to one year after for mothers. Twenty randomly selected controls per case were matched by age and sex. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using conditional logistic regression. Results For fathers, we found increased risks for acute myeloid leukemia (AML) consistent in painting (OR 2.26, 95% CI 1.07-4.80) and printing industries (OR 2.43, 95% CI 0.94-6.23) and these industries combined (OR 2.10, 95% CI 1.14-3.87). For mothers, increased risks of CNS cancers were found for painting industries (OR 2.34, 95% CI 1.10-4.95) and painting and printing combined (OR 1.97, 95% CI 1.08-3.64). For fathers working in combined industries, the OR for CNS was increased (OR 1.54, 95% CI 1.02-2.31), most prominently in printing industries (OR 2.09, 95% CI 1.17-3.75). Conclusion We observed increased risks of CNS tumors in offspring after parental employment in painting and printing industries. Children of fathers employed in painting and printing industries had a two-fold increase in AML.

Interest in Learning About Fertility Status Among Male Adolescent and Young Adult Survivors of Childhood Cancer

PURPOSE

As many as two-thirds of male childhood cancer survivors are at risk for fertility impairment as a consequence of treatment. Despite this, survivorship guidelines lack concrete recommendations as to when fertility status conversations should happen between patients and providers and what should be discussed. Thus, conversations may be inconsistent, or do not occur at all in survivorship. To inform recommendations for fertility-related conversations in survivorship, this pilot study aimed to better understand background (e.g., age, diagnosis and treatment intensity) and psychosocial factors (i.e., perceived barriers and perceived susceptibility) associated with survivor interest in learning about fertility status.

METHODS

Male survivors (N = 45) 15-25 years of age were recruited within 1-8 years of completing treatment. Survivors completed questionnaires based on the Health Belief Model (HBM) to assess perception of infertility risk and attitudes toward testing.

RESULTS

Most survivors (n = 31; 69%) reported they were informed of their risk for infertility by a healthcare provider before treatment, but only 31% (n = 14) of the sample banked sperm. Nearly two-thirds of survivors (n = 29; 64%) were interested in learning more about their fertility post-treatment. This interest was significantly correlated with greater perceived susceptibility to infertility by survivors, but it was not associated with other psychosocial or background factors.

CONCLUSION

Informing survivors of their personal infertility risk may increase interest in pursuing testing. Offering opportunities for fertility testing and family planning alternatives may mitigate potential psychological distress and unplanned pregnancy. While additional research is needed, future survivorship guidelines should encourage regular communication about fertility status and offer fertility testing for male survivors.

Pregnancy Among Survivors of Childhood Cancer: Cardiovascular Considerations

PURPOSE OF REVIEW

To educate clinicians on cardiovascular considerations and management strategies surrounding pregnancy in childhood cancer survivors.

RECENT FINDINGS

With advances in oncologic treatment, growing numbers of childhood cancer survivors are now able to consider pregnancy. A significant proportion of survivors have received cardiotoxic therapy, particularly anthracyclines, and/or chest radiation. Cardiomyopathy is the most common cardiac complication of cancer-directed therapy; pericardial disease, valvular disease, premature coronary artery disease, and conduction abnormalities are other potential sequelae. In female survivors of childhood malignancy, cardiac evaluation should be performed prior to pregnancy as subclinical disease has the potential to be unmasked by the hemodynamic stress of pregnancy. However, limited data exist on pregnancy outcomes after cancer survivorship. With appropriate management, maternal and fetal outcomes in pregnancy following childhood cancer are generally favorable. Further research is needed to understand the incidence of cardiac complications among childhood cancer survivors, strategies to prevent these complications, optimal cardiovascular management during pregnancy and the postpartum period, and on the impact of pregnancy itself on the natural history of treatment-related cardiotoxicity.