Long-term survivors of childhood cancer. The medical consequences of cure

"You can be cured, but cancer never leaves you behind": an interdisciplinary approach into the embodied cancer experiences among adult Colombian childhood/adolescent cancer survivors

PURPOSE

Childhood or adolescent cancer survivors (CACS) are an understudied population in Colombia and, in general, in Central and South America. Worldwide, studies typically focus on high-income settings while approaching CACS' experiences from a biomedical or psychological perspective. However, both perspectives miss an important aspect of survivorship after childhood or adolescent cancer: the affected individual's subjective experiences of having a disabled body. This qualitative study aimed to explore the embodied experiences of Colombian adults who survived cancer during their childhood or adolescence to better understand how CACS relate to their altered body and world.

METHODS

By integrating phenomenological insights and conducting comprehensive life-story interviews, we explored the various ways in which survivors' cancer experiences affect their bodily sense of self-from the acute phase of the disease until well into adulthood. A total of ten life-stories interviews and one focus group were carried out with seven CACS. All participants were survivors of a different type of childhood/adolescent cancer. The results were analyzed thematically, focusing on the embodied aspects of participants' experiences.

RESULTS

We developed three main themes regarding the embodied cancer experience among participating CACS: Firstly, participants' body changes because of the cancer and its treatment, which makes them aware of their body. Secondly, they adapt to this experience in different bodily ways. Finally, they carry bodily traces of their cancer experience in the present as well as into the future.

CONCLUSIONS

The CACS participating in this study report that their experience with cancer has been embodied throughout their lives, changing their sense of their body and how they relate to it, and leaving traces into the present and their imagined future.

Self-Reported Health Problems and Quality of Life in a Sample of Colombian Childhood Cancer Survivors: A Descriptive Cross-Sectional Study

Simple Summary

Childhood cancer survivors are currently an understudied population in Colombia and, in general, in South America. Indeed, the attention in this region is still largely on curative care for childhood cancers, and the group of childhood cancer survivors is not a focus point; there are no descriptions of the presence of adverse events that may have presented in the short, medium, or long term in this population This article in an observational, descriptive cross-sectional study of 122 Colombian childhood survivors who were invited to complete a self-reported study-specific online questionnaire along with the SF-36 Health Survey. The aim of this study is to describe the perceived long-term health problems and quality of life among Colombian adults who had cancer in their childhood or adolescence. This is, therefore, a first step to characterize this population and as an input for the formulation of long-term follow-up goals.

Abstract

Objectives: To describe the self-reported health problems and quality of life among adult-aged Colombian childhood and adolescent cancer survivors. Methods: This is a descriptive cross-sectional study with Colombian childhood cancer survivors (CCS) who were diagnosed before the age of 18, at the moment of study were ≥18 years, and at least 5 years had passed since diagnosis. Each participant completed a self-reported study-specific online questionnaire along with the SF-36 Health Survey to assess the prevalence of health problems and current quality of life (QoL). Data were analyzed using descriptive statistics and independent sample t-tests. Results: Out of the 122 CCS who participated, 100% reported at least one health problem, mostly gastritis, headaches, and lack of concentration, followed by obesity and fertility issues. In general, they had a good perception of their QoL, which was, on average, only diminished in the areas of vitality, emotional role functioning, and social functioning. Conclusion: Perceived health problems among the participating Colombian CCS were prevalent; most reported a good self-perceived QoL. This is the first study on understanding health problems and QoL of CCS treated in Colombia and South America. It reopens the debate on the need to carry out long-term follow-up in this population among Colombian society.

Pediatric glioblastoma target-specific efficient delivery of gemcitabine across the blood-brain barrier via carbon nitride dots

Pediatric glioblastomas are known to be one of the most dangerous and life-threatening cancers among many others regardless of the low number of cases reported. The major obstacles in the treatment of these tumors can be identified as the lack of prognosis data and the therapeutic requirement to be able to cross the blood-brain barrier (BBB). Due to this lack of data and techniques, pediatric patients could face drastic side effects over a long-time span even after survival. Therefore, in this study, the capability of non-toxic carbon nitride dots (CNDs) to selectively target pediatric glioblastoma cells was studied in vitro. Furthermore, the nanocarrier capability and efficiency of CNDs were also investigated through conjugation of a chemotherapeutic agent and transferrin (T_f) protein. Gemcitabine (GM) was introduced into the system as a chemotherapeutic agent, which has never been successfully used for the treatment of any central nervous system (CNS) cancer. More than 95% of selective damage of SJGBM2 glioma cells was observed at 1 μM of CN-GM conjugate with almost 100% viability of non-cancerous HEK293 cells, although this ability was diminished at lower concentrations. However, further conjugation of T_f to obtain CN-GM-T_f allowed the achievement of selective targeting and prominent anti-cancer activity at a 100-fold lower concentration of 10 nM. Furthermore, both conjugates were capable of effectively damaging several other brain tumor cells, which were not well responsive towards the single treatment of GM. The capability of BBB penetration of the conjugates was observed using a zebrafish model, which confirms the CNDs' competence as an excellent nanocarrier to the CNS.

Some Cancer Chemotherapy (CH) Agents May Be Associated With Tooth Agenesis, Though CH Dose, Age of CH Exposure, and Dental Development at the Time of Treatment May Be Critical Determinants

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

Adverse effects of chemotherapy on the teeth and surrounding tissues of children with cancer: A systematic review with meta-analysis. Busenhart DM, Erb J, Rigakos G, Eliades T, Papageorgiou SN. Oral Oncol 2018;83: 64-72.

SOURCE OF FUNDING

None.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data.

Scalability of cancer SurvivorLink™: A cluster randomized trial among pediatric cancer clinics

BACKGROUND

Children diagnosed with cancer are living longer and the survivor population is growing. However, most survivors develop late effects of radiation and chemotherapy shortly to years after completion of therapy, and the receipt of follow-up visits that are recommended by the Children's Oncology Group (COG) is suboptimal nationally.

AIMS

The aims of this study are to: 1) evaluate the impact of a patient-controlled electronic personal health record (ePHR) and system (SurvivorLink) on care visit attendance, risk-based surveillance, and other secondary outcomes (i.e., patient activation, quality of life (QOL)); 2) measure the use, acceptability, and perceived usefulness of, and satisfaction with SurvivorLink; and 3) assess facilitators and barriers to implementation.

METHODS

This hybrid effectiveness-implementation, clustered randomized control trial (RCT) evaluates the effect of SurvivorLink among pediatric cancer survivors and their parents on receipt of follow-up cancer care. We will recruit 20 pediatric survivor clinics with half receiving the intervention and half acting as a waitlist control. Parents of survivors and survivors will complete baseline, 3 and 12 month surveys that assess SurvivorLink use, patient self-efficacy, and intentions to return for follow-up. We will use mixed methods and multi-informant assessment to assess implementation outcomes (i.e., acceptability, feasibility, appropriateness).

DISCUSSION

New approaches are needed to facilitate the receipt of long-term follow-up care among pediatric cancer survivors. This study will assess whether SurvivorLink is effective in increasing receipt of follow-up cancer care. Moreover, it will explore the influences of context and other moderators of clinical practice change in pediatric cancer survivorship.

Physical Impairment and Social Life, Goals among Adult Long-term Survivors of Childhood Cancer: A Population-based Study from the Childhood Cancer Registry of Piedmont, Italy

Aims and Background

The study describes the health status and the attainment of life goals in the adult survivors of childhood cancer recorded at the Childhood Cancer Registry of Piedmont.

Methods and Study Design

A postal questionnaire was sent to the general practitioner of the 690 cases born before 1976 and alive in 1991 after at least 5 years from diagnosis. The answer was received for 485 (72.9%) included in the analyses. Items in the questionnaire were: sequelae related to cancer and its treatment, health-related quality of life (according to Bloom's criteria), educational level attained, and employment status.

Results

Vital and marital status were obtained for all 690 cases at the offices of the town of residence. No medical condition was reported for 309 cases (63.7%). The overall proportion with a high school or university education was compared to corresponding figures for Piedmont in 1991, adjusted by age, and was as high as in the general population. Similar results are observed for occupation. Patients of both genders were married less than expected. Patients with leukemia (112 cases), non-Hodgkin's lymphoma (34) or Hodgkin's lymphoma (52) were reported to have the highest quality of life. In contrast, patients with tumors of the central nervous system (151) had the highest frequency of sequelae and the lowest score for health-related quality of life. They also presented the lowest educational achievement, the lowest proportion of employment and, among males, the lowest frequency of marriage.

Conclusions

Our study shows a good social adjustment of adult survivors from childhood cancer, with the exception of central nervous system tumors. From the methodologic point of view, the present study shows the feasibility of surveillance surveys on health-related quality of life with the contribution of general practitioners.

Evaluation for inherited and acquired prothrombotic defects predisposing to symptomatic thromboembolism in children with acute lymphoblastic leukemia: a protocol for a prospective, observational, cohort study

BACKGROUND

Thromboembolism (TE) is a serious complication in children with acute lymphoblastic leukemia (ALL). The incidence of symptomatic thromboembolism is as high as 14% and case fatality rate of ~15%. Further, development of thromboembolism interferes with the scheduled chemotherapy with potential impact on cure rates. The exact pathogenesis of ALL-associated thromboembolism is unknown. Concomitant administration of asparaginase and steroids, two important anti-leukemic agents, is shown to increase the risk of ALL-associated TE. Dana-Farber Cancer Institute (DFCI) ALL studies reported ~10% incidence of thrombosis with significantly increased risk in older children (≥10 yrs.) and those with high-risk ALL. The majority (90%) of thromboembolic events occurred in the Consolidation phase of therapy with concomitant asparaginase and steroids when high-risk patients (including all older patients) receive higher dose steroids. Certain inherited and acquired prothrombotic defects are known to contribute to the development of TE. German investigators documented ~50% incidence of TE during therapy with concomitant asparaginase and steroids, in children with at least one prothrombotic defect. However, current evidence regarding the role of prothrombotic defects in the development of ALL-associated TE is contradictory. Although thromboprophylaxis can prevent thromboembolism, ALL and it's therapy can increase the risk of bleeding. For judicious use of thromboprophylaxis, identifying a population at high risk for TE is important. The risk factors, including prothrombotic defects, predisposing to thrombosis in children with ALL have not been defined.

METHODS

This prospective, observational cohort study aims to evaluate the prevalence of inherited prothrombotic defects in children with ALL treated on DFCI 05-01 protocol and the causal relationship of prothrombotic defects in combination with patient and disease-related factors to the development of TE. We hypothesize that the combination of prothrombotic defects and the intensive therapy with concomitant high dose steroids and asparaginase increases the risk of TE in older patients and patients with high-risk ALL.

DISCUSSION

The results of the proposed study will help design studies of prophylactic anticoagulant therapy. Thromboprophylaxis given to a targeted population will likely reduce the incidence of TE in children with ALL and ultimately improve their quality of life and prospects for cure.

Imaging of late complications of cancer therapy in children

Long-term survival after childhood cancer has improved dramatically over recent decades but survivors face lifelong risks of adverse health effects. Many of these chronic conditions are a direct result of previous therapeutic exposures. Compared to their siblings, survivors face a greater than 8-fold increase in relative risk of severe or life-threatening medical conditions; the most significant of these include second malignancies and cardiovascular and pulmonary diseases. Imaging can play a key role in identifying and characterizing such complications, which can be reasonably predicted with knowledge of the child's treatment. This article highlights the varied radiologic presentations and features seen in late cancer-therapy-related conditions.

Young Adult Cancer Survivors' Experience with Cancer Treatment and Follow-Up Care and Perceptions of Barriers to Engaging in Recommended Care

We examined correlates of low engagement in the healthcare system, experiences with survivorship care, barriers to follow-up care, and potential resources for promoting follow-up care among young adult survivors of childhood cancers. We conducted a mixed-method study involving surveys of 106 survivors of childhood cancer aged 18-34 recruited from a university-affiliated children's hospital and an NCI-designated cancer center in the Southeastern USA. Phone-based semistructured interviews were then conducted in a subset of 26. Assessments included health factors, psychosocial factors, healthcare system interaction, and interest in resources to promote engagement in healthcare. Survey participants were on average 22.14 (SD = 3.16) years old, 50.0 % female, and 77.4 % White. Overall, 46.0 % had attended survivorship clinic, 47.2 % reported receiving a treatment summary, 68.9 % had a primary care provider, and 17.0 % reported no interaction with healthcare in the past 2 years. Correlates of less than annual healthcare provider visits included being older (p = 0.003), being male (p < 0.001), lack of insurance (p = 0.002), and having had chemotherapy (p = 0.05). Participants reported varied experiences in terms of how health and treatment information was presented, from none or too little to overwhelming or anxiety-provoking amounts. Barriers to engaging in survivorship care included no/limited insurance, time, or transportation; major life changes; anxiety; and difficulty transitioning from pediatrics to adult care. Participants highlighted the need for educational and psychosocial resources, particularly technology-based resources. Multilevel interventions are needed to increase engagement in survivorship care among young adult cancer survivors. Technology-based resources addressing social support and mental well-being are intervention possibilities.

Provider advice about smoking cessation and pharmacotherapy among cancer survivors who smoke: practice guidelines are not translating

Smoking among childhood and young adult cancer survivors may increase risk for late effects of treatment, and survivors need assistance in quitting. This paper reports on the prevalence of discussions between childhood cancer survivors and their health care providers about smoking cessation and pharmacotherapy and explores factors that are associated with these discussions. This is a longitudinal study that included 329 smokers who were childhood or young adult cancer survivors, recruited from five cancer centers in the USA and Canada. Fifty-five percent of smokers reported receiving advice to quit smoking from their regular provider during the study period, and only 36 % of smokers reported discussing pharmacotherapy with their provider. Receipt of advice was associated with being female and having a heavier smoking rate. Pharmacotherapy discussions were associated with readiness to quit, heavier smoking rate, and previous provider advice to quit. Health care providers are missing key opportunities to advise cancer survivors about cessation and evidence-based interventions. Systematic efforts are needed to ensure that survivors who smoke get the treatment that they need.

Changes in health status among aging survivors of pediatric upper and lower extremity sarcoma: a report from the childhood cancer survivor study

OBJECTIVE

To evaluate health status and participation restrictions in survivors of childhood extremity sarcomas.

DESIGN

Members of the Childhood Cancer Survivor Study cohort with extremity sarcomas who completed questionnaires in 1995, 2003, or 2007 were included.

SETTING

Cohort study of survivors of extremity sarcomas.

PARTICIPANTS

Childhood extremity sarcoma survivors (N=1094; median age at diagnosis, 13y (range, 0-20y); current age, 33y (range, 10-53y); 49% male; 87.5% white; 75% had lower extremity tumors) who received their diagnosis and treatment between 1970 and 1986.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Prevalence rates for poor health status in 6 domains and 5 suboptimal social participation categories were compared by tumor location and treatment exposure with generalized estimating equations adjusted for demographic/personal factors and time/age.

RESULTS

In adjusted models, when compared with upper extremity survivors, lower extremity survivors had an increased risk of activity limitations but a lower risk of not completing college. Compared with those who did not have surgery, those with limb-sparing (LS) and upper extremity amputations (UEAs) were 1.6 times more likely to report functional impairment, while those with an above-the-knee amputation (AKA) were 1.9 times more likely to report functional impairment. Survivors treated with LS were 1.5 times more likely to report activity limitations. Survivors undergoing LS were more likely to report inactivity, incomes <$20,000, unemployment, and no college degree. Those with UEAs more likely reported inactivity, unmarried status, and no college degree. Those with AKA more likely reported no college degree. Treatment with abdominal irradiation was associated with an increased risk of poor mental health, functional impairment, and activity limitation.

CONCLUSIONS

Treatment of lower extremity sarcomas is associated with a 50% increased risk for activity limitations; upper extremity survivors are at a 10% higher risk for not completing college. The type of local control influences health status and participation restrictions. Both of these outcomes decline with age.

Do children with central venous line (CVL) dysfunction have increased risk of symptomatic thromboembolism compared to those without CVL-dysfunction, while on cancer therapy?

Background

Thromboembolism (TE) and infection are two common complications of central venous line (CVL). Thrombotic CVL-dysfunction is a common, yet less studied, complication of CVL. Two retrospective studies have reported significant association of CVL-dysfunction and TE. Recent studies indicate association of CVL-related small clot with infection. Infection is the most common cause of non-cancer related mortality in children with cancer. We and others have shown reduced overall survival (OS) in children with cancer and CVL-dysfunction compared to those without CVL-dysfunction. Despite these observations, to date there are no prospective studies to evaluate the clinical significance of CVL-dysfunction and it’s impact on the development of TE, infection, or outcome of children with cancer.

Study design

This is a prospective, analytical cohort study conducted at five tertiary care pediatric oncology centers in Ontario. Children (≤ 18 years of age) with non-central nervous system cancers and CVL will be eligible for the study. Primary outcome measure is symptomatic TE and secondary outcomes are infection, recurrence of cancer and death due to any cause. Data will be analyzed using regression analyses.

Discussion

The overall objective is to delineate the relationship between CVL-dysfunction, infection and TE. The primary aim is to evaluate the role of CVL-dysfunction as a predictor of symptomatic TE in children with cancer. We hypothesize that children with CVL-dysfunction have activation of the coagulation system resulting in an increased risk of symptomatic TE. The secondary aims are to study the impact of CVL-dysfunction on the rate of infection and the survival [OS and event free survival (EFS)] of children with cancer. We postulate that patients with CVL-dysfunction have an occult CVL-related clot which acts as a microbial focus with resultant increased risk of infection. Further, CVL-dysfunction by itself or in combination with associated complications may cause therapy delays resulting in adverse outcome.

This study will help to identify children at high risk for TE and infection. Based on the study results, we will design randomized controlled trials of prophylactic anticoagulant therapy to reduce the incidence of TE and infection. This in turn will help to improve the outcome in children with cancer.

The value of echocardiography versus cardiac troponin I levels in the early detection of anthracycline cardiotoxicity in childhood acute leukemia: prospective evaluation of a 7-year-long clinical follow-up

The present study was designed to evaluate the significance of echocardiography versus cardiac troponin I levels in early detection of anthracycline dependent cardiotoxicity in acute lymphoblastic leukemia (ALL) patients. A total of 276 pediatric ALL patients were included in the study prospectively along 3 phases of data collection lasted from 2002 to 2009; including phase I (March 2002 to February 2003; n = 25; 53.3% females), phase II (September 2003 to April 2004; n = 35; 57.1% females), and phase III (January 2005 to June 2009; n = 216; 52.7% females) with respect to cumulative anthracycline doses applied. Anthracycline was administered in accordance with berlin-Franfurt-Munich (BFM)-2000 protocol in doses of 30 to 350 mg/m(2) (in the first phase) and 30 to 240 mg/m(2) (in the following phases). Evaluation of cardiotoxicity was performed via echocardiography and measurement of cardiac troponin I levels. Patients in each phase were homogenous in terms of gender and age. Diastolic dysfunction determined via reduction E/A ratio below the cutoff value was demonstrated to deteriorate earlier than systolic functions and alteration in cardiac enzymes. Being similar between dose groups, cTnI levels were shown to rise in the presence of congestive heart failure. In conclusion, anthracycline cardiotoxicity appears to be detected in an earlier stage by using diastolic parameters compared to systolic parameters and cardiac enzymes.

Health-related Quality of Life in Children with Cancer Undergoing Treatment: A First Look at the Singapore Experience

Introduction: With intensive chemotherapy and increased survival, quality of life in our paediatric population is of increasing concern. The aim of this study was to assess the children’s quality of life during the treatment process. Materials and Methods: Patients between the ages of 7 and 18 years old who are undergoing cancer treatment in the Division of Paediatric Haematology-Oncology, Department of Paediatrics, National University Health System, were identified. The child self-reported his/her health-related quality of life (HRQOL) using the PedsQL Paediatric Quality of Life Inventory and Cancer module as a validated assessment tool. Results: Thirty-two patients were enrolled over a 3-week period in November 2007. The median age was 11 years (range, 7 to 17). There was 1 non-responder (3%). Fourteen (45%) boys and 17 (55%) girls were interviewed. There were 8 (26%) and 23 (74%) patients with solid and haematologic malignancies, respectively. For the Cognitive Problem Dimension score, 86% of patients with haematologic malignancy and 50% of those with solid malignancy scored below the 75th percentile (82), [OR 0.72 (0.01-0.8), P = 0.03]. For the Physical Health Summary score, patients with solid malignancy scored worse, 25% below the 10th percentile, as compared to 4.3% of patients with haematologic malignancy. This is reflected by a worse Pain and Hurt Dimension score for patients with solid malignancy. For the Perceived Appearance Dimension score, patients with solid malignancy (75%) scored lower than the median score (67) compared to those with haematologic malignancy (44%). Conclusions: The domains of HRQOL are affected to different extents for the patients with solid and those with haematologic malignancy. This is most likely to be due to the differences in treatment strategies and clinical course. Healthcare professionals should be aware of the effects of treatment on HRQOL and take practical steps to address these issues. Key words: Childhood cancer, Self-reported health and well-being

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

BACKGROUND

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

PROCEDURE

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

RESULTS

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

CONCLUSIONS

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

Design and recruitment of the Chicago Healthy Living Study: a study of health behaviors in a diverse cohort of adult childhood cancer survivors

BACKGROUND

Adult childhood cancer survivors are at higher risk for developing late medical effects related to their cancer treatments. Health-promoting behaviors may reduce the risk of some late effects and the severity of others. This article describes the design and recruitment of the Chicago Healthy Living Study (CHLS), an on-going study designed to examine the health behaviors and body mass index of minority adult childhood cancer survivors compared with nonminority survivors and noncancer controls.

METHODS

Survivors are identified by the hospital cancer registries at 5 treating institutions in the Chicago area; then, a multilevel recruitment plan will be implemented with the objective of enrolling 450 adult survivors of childhood cancer (150 in each racial/ethnic group). Simultaneously, 375 adult African-American, Hispanic, and non-Hispanic white noncancer controls (125 in each racial/ethnic group) living in the Chicago area will be recruited by using listed, targeted digit dialing. All participants will complete a 2-hour interview of questionnaires related to diet, physical activity, smoking, and associated mediators. Height and weight also will be measured.

CONCLUSIONS

The CHLS will provide important information on the health behaviors of adult minority childhood cancer survivors that can be used to inform the development of interventions to improve modifiable risks.

Cancer survivorship research: state of knowledge, challenges and opportunities

INTRODUCTION

Seminal advances in early detection of and treatment strategies for cancer have led to burgeoning numbers of cancer survivors. While most therapeutic modalities for cancer are beneficial and lifesaving, they are associated with adverse long-term and late sequelae.

MATERIALS AND METHODS

Literature review using MEDLINE to identify studies examining adverse medical outcomes and post-treatment follow-up care among long-term survivors. Emerging concepts in survivorship research such as definitional issues, research paradigms and methodologic concerns were also examined.

RESULTS

Long-term or late adverse sequelae are more prevalent, serious, and persistent than expected in survivors of pediatric and adult cancer, but remain understudied especially among those diagnosed as adults. Follow-up care relevant to survivorship outcomes is neither standardized nor guideline or evidence based for most adult cancers, and optimal practices have yet to be defined.

DISCUSSION

Adverse sequelae contribute to burden of illness, health care costs, and decreased length and quality of survival. To-date, very few studies have compared survivor outcomes pre-and post diagnosis. It is critical to examine under-researched questions and understudied survivor groups. Regular follow-up care and monitoring of health status post cancer treatment should 1) permit the timely diagnosis and treatment of adverse outcomes; 2) enable timely diagnosis and treatment of recurrences; 3) facilitate screening and early detection of second cancer(s); 4) allow for detection and management of co-morbidities; and 5) provide the opportunity for preventive strategies such as lifestyle changes. Research findings to-date underscore the need for continued cancer survivorship research that will: inform our understanding of the mechanisms underlying adverse sequelae; lead to the design of less toxic treatments; test the effectiveness of interventions - medical, pharmacologic, and behavioral - that reduce adverse outcomes; test models of post-treatment follow-up care; develop an evidence base for optimal follow-up care practices; and inform survivor and provider decision making.

A framework for assessment in oncology rehabilitation

Although the incidence of cancer in the United States is high, improvements in early diagnosis and treatment have significantly increased survival rates in recent years. Many survivors of cancer experience lasting, adverse effects caused by either their disease or its treatment. Physical therapy interventions, both established and new, often can reverse or ameliorate the impairments (body function and structure) found in these patients, improving their ability to carry out daily tasks and actions (activity) and to participate in life situations (participation). Measuring the efficacy of physical therapy interventions in each of these dimensions is challenging but essential for developing and delivering optimal care for these patients. This article describes the acute and long-term effects of cancer and its treatment and the use of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) as a basis for selection of assessment or outcome tools and diagnostic or screening tools in this population.

Long-term smoking cessation outcomes among childhood cancer survivors in the Partnership for Health Study

PURPOSE

Partnership for Health (PFH) was found to increase smoking cessation among smokers in the Childhood Cancer Survivors Study (CCSS) at the 8- and 12-month postbaseline follow-up. This report provides outcomes at 2 to 6 years postbaseline; the primary outcome is a four-category smoking status variable (quit at all follow-ups, quit at final follow-up only, smoker at all follow-ups, and smoker at final follow-up only); quit attempts among those who reported smoking at the final follow-up is a secondary outcome.

METHODS

PFH was a randomized control trial with two conditions, peer phone counseling (PC) and self-help (SH), that involved smokers (n = 796) enrolled in the CCSS cohort.

RESULTS

Long-term quit rates were higher in PC versus SH participants. Long-term smoking cessation outcomes were lower among those who were nicotine dependent, of lower educational levels, and among men, and were higher among those who used nicotine replacement therapy and who had higher levels of situational self-efficacy. There were no significant differences in relapse rates between conditions or in quit attempts among continued smokers.

CONCLUSION

Cessation rates continue to be significantly higher among participants in the PC condition versus SH, although the differences were not large. This article highlights differences in long-term engagement with smoking cessation among those who received the intervention.

Twenty-five-year follow-up among survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for late effects of cancer therapy. Five-year ALL survivors (< 21 years at diagnosis; n = 5760 eligible, 4151 participants), diagnosed from 1970 to 1986 were compared with the general population and a sibling cohort (n = 3899). Cumulative mortality of 5760 5-year survivors was 13% at 25 years from diagnosis. Recurrent ALL (n = 483) and second neoplasms (SNs; n = 89) were the major causes of death. Among 185 survivors, 199 SNs occurred, 53% in the CNS. Survivors reported more multiple chronic medical conditions (CMCs; odds ratio [OR], 2.8; 95% CI, 2.4-3.2) and severe or life-threatening CMCs (OR, 3.6; 95% CI, 3.0-4.5) than siblings. Cumulative incidence of severe CMCs, including death, 25 years from diagnosis was 21.3% (95% CI, 18.2-24.4; 23.3% [95% CI, 19.4-27.2] and 13.4% [95% CI, 8.4-18.4] for irradiated and nonirradiated survivors, respectively). Survivors reported more adverse general and mental health, functional impairment, and activity limitations compared with siblings (P < .001). Rates of marriage, college graduation, employment, and health insurance were all lower compared with sibling controls (P < .001). Long-term survivors of childhood ALL exhibit excess mortality and morbidity. Survivors who received radiation therapy as part of their treatment or had a leukemia relapse are at greatest risk for adverse outcomes.

Adverse Late Effects of Childhood Cancer and Its Treatment on Health and Performance

More than 12,000 newly diagnosed cases of cancer occur each year in the United States among children ages 20 years or younger, and the current 5-year survival rate is near 80%. An estimated 228,000 among adults 47 years or younger and currently living in the United States had a diagnosis of cancer during childhood or adolescence. Here, we review long-term adverse effects of childhood cancer and its treatment with an emphasis on physical performance and health. We also briefly review existing guidelines that may be used to develop appropriate exercise and diet interventions for childhood cancer survivors. We suggest that there is a need for development of evidence-based, risk-based guidelines and interventions for health promotion among long-term childhood cancer survivors, particularly for those whose physical activity limitations interfere with chances for optimizing their bodies' potential in today's society.

Chemotherapy-Induced Cognitive Impairment in Women With Breast Cancer: A Critique of the Literature

PURPOSE/OBJECTIVES

To review and critique the studies that have investigated chemotherapy-induced impairments in cognitive function in women with breast cancer.

DATA SOURCES

Published research articles and textbooks.

DATA SYNTHESIS

Although studies of breast cancer survivors have found chemotherapy-induced impairments in multiple domains of cognitive function, they are beset with conceptual and methodologic problems. Findings regarding cognitive deficits in women with breast cancer who currently are receiving chemotherapy are even less clear.

CONCLUSIONS

Although data from published studies suggest that chemotherapy-induced impairments in cognitive function do occur in some women with breast cancer, differences in time since treatment, chemotherapy regimen, menopausal status, and neuropsychological tests used limit comparisons among the various studies. Further studies need to be done before definitive conclusions can be made.

IMPLICATIONS FOR NURSING

The potential for chemotherapy-induced impairments in cognitive function may influence patients' ability to give informed consent, identify treatment toxicities, learn self-care measures, and perform self-care behaviors.

Health profiles of 814 very long-term breast cancer survivors

BACKGROUND

Information regarding the long-term health impact of cancer and cancer treatments on survivors is gradually accumulating but is generally limited to the first few years after diagnosis.

PATIENTS AND METHODS

We analyzed health information provided by 814 breast cancer survivors whose cancer was diagnosed >or= 15 years earlier and compared the information with that of female survivors of other cancers. These women were identified from a larger cohort of very long-term survivors of cancer who responded to a health survey.

RESULTS

All survivors underwent surgery as part of their cancer therapy, and 334 (41%) also received chemotherapy. Survivors of breast cancer reported significantly more arthritis/osteoporosis, cataracts, and heart problems than other cancer survivors. Those who were treated with chemotherapy reported more psychologic problems, loss of memory, and circulation problems than those who did not receive chemotherapy. A third (30.4%) of the breast cancer survivors reported that cancer had affected their health.

CONCLUSION

Very long-term survivors of breast cancer generally report good health and quality of life, as do very long-term survivors of other cancers. Nevertheless, 30.4% of breast cancer survivors report that cancer has affected their health. A number of distinctions are noted that can serve a basis for further hypothesis-driven research.

Transitioning to survivorship: a pilot study

There are no clear transition guidelines for adolescent and young adult cancer patients, their parents, and their primary care providers (PCPs) when completing active therapy and within the first few years after therapy. The purpose of this pilot study was to identify needs and concerns of recently treated adolescent cancer patients and their parents, young adult cancer survivors, and the community PCPs of adolescent patients. Four focus group interviews were conducted with survivors and parents, and 3 in-depth interviews were conducted with PCPs. All interviews were audiotaped and transcribed for content analysis. A range of needs were identified, including lack of adequate written and verbal information about their prior treatment, its potential side effects, and appropriate follow-up care. The best sources for education were identified as the primary oncologist, nurse practitioner, or nurse. At completion of treatment, parents and adult survivors felt a lack of psychosocial support. Suggestions from participants included use of informational videos for survivors, weekend education and support programs, ongoing support groups, use of the Internet, and educational newsletters. The PCPs reported a lack of general pediatric oncology knowledge and specific patient information, time constraints in their patient schedules, and having few survivors in their practices as barriers to optimal survivorship care. Further research is needed to look at the unmet educational and psychological needs of childhood cancer survivors and their parents during the critical time when they transition off treatment.

Health-Related Quality of Life for Latino Survivors of Childhood Cancer

This study compared the similarities and differences in health-related quality of life (HRQOL) among Latino and non-Latino adult long-term survivors of childhood cancer using the qualitative methodologies of focus groups and individual semistructured telephone interviews. The study also compared the sample's HRQOL, as measured by the Short-form 12 to the general, healthy United States population normative data. The data suggest that Latino survivors are reporting good HRQOL similar to the non-Latinos. The findings suggest that the paradigm of negative consequences of cure should be expanded to one, which also includes the positive impact of cure for ethnically diverse populations of childhood cancer survivors.

Smoking rates and the state of smoking interventions for children and adolescents with chronic illness

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

Factor structure of the brief symptom inventory--18 in adult survivors of childhood cancer: results from the childhood cancer survivor study

The factor structure of the Brief Symptom Inventory--18 (BSI-18; L. R. Derogatis, 2000) was investigated in a sample of adult survivors of childhood cancer enrolled in the Childhood Cancer Survivor Study (CCSS; N = 8,945). An exploratory factor analysis with a randomly chosen subsample supported a 3-factor structure closely corresponding to the 3 BSI-18 subscales: Depression, Anxiety, and Somatization. Confirmatory factor analysis with structural equation modeling validated this 3-dimensional structure in a separate subsample, though an alternative 4-factor model also fit the data. Analysis of the 3-factor model showed consistent fit in male and female participants. Compared with available community-based norms, survivors reported fewer symptoms of psychological distress. Together, results support the hypothesized 3-dimensional structure of the BSI-18 and indicate the measure may be useful in assessing psychological distress in this growing population of cancer survivors.

Health-Related Quality of Life Among Child and Adolescent Survivors of Childhood Cancer

Purpose

The main objective was to compare parent-reported health-related quality of life (HRQL) of child and adolescent survivors of childhood cancer to that of controls who had no history of cancer.

Methods

We assessed HRQL of 800 child and adolescent survivors younger than 16 years and 923 randomly selected, age- and sex-matched controls from the general population in a national multicenter retrospective cohort study using the Child Health Questionnaire parent report. Participation was 69% among survivors and 57% among controls.

Results

Survivors had means that were consistently lower than controls on the HRQL physical summary (PH; 49.9 v 55.3; P <.005), psychosocial summary (PS; 49.4 v 52.6; P < .005), and all but one of the eight subscale scores. Clinically important survivor-control differences in means on PH were found for survivors of CNS tumors, bone tumors, lymphoma, leukemia, soft tissue sarcoma and Wilms' tumor (differences: −8.7, −7.0, −6.3, −5.4, −4.4, −3.8/100, respectively); on PS, survivors of CNS tumors were most compromised (−6.1/100). Survivor-control differences in both PH and PS were also large for survivors treated with radiation only (−5.8 and −11.9/100, respectively), or radiation combined with surgery (−6.6 and −5.9/100, respectively), or radiation combined with both surgery and chemotherapy (−7.8 and −5.1/100, respectively). Cranial radiation was associated with the most compromised HRQL.

Conclusion

According to parents, HRQL for survivors was somewhat poorer, overall, than for controls. Survivors of CNS tumors, lymphoma, and leukemia and those patients treated with cranial radiation were reported to have poorest HRQL. These findings support development of guidelines for levels of follow-up care for particular groups of survivors.

A process evaluation of a telephone-based peer-delivered smoking cessation intervention for adult survivors of childhood cancer: the partnership for health study

OBJECTIVE

We report on the process evaluation of an efficacious national smoking cessation intervention for adult survivors of childhood cancer. We examine associations between intervention implementation characteristics and study outcomes, as well as participant characteristics related to level of involvement in the intervention.

METHODS

The study was conducted at the Dana-Farber Cancer Institute in Boston, Massachusetts, from 1999-2001. Participants (n = 398) were randomly assigned to receive a proactive telephone-based peer counseling intervention. They received up to 6 counseling calls, individually tailored and survivor-targeted materials, and nicotine replacement therapy (NRT) patches if they were prepared to quit smoking.

RESULTS

Forty-two percent of survivors participated in the maximum number of calls (5-6), and 29% of participants requested and received NRT. Total counseling time was an average of 51 min. Quit status at follow-up was related to intervention dose, and participants who received NRT were significantly more likely to make a 24-h quit attempt. Demographic variables (females, White), higher daily smoking rate, poorer perceived health and moderate perceived risk of smoking were significantly related to greater intervention involvement.

CONCLUSIONS

A brief peer-delivered, telephone counseling intervention is an effective way to intervene with adult survivors of childhood cancer who are smoking. Findings from the process evaluation data (call length and number, frequency, and spacing) will inform future telephone counseling cessation programs.

Health profiles of 996 melanoma survivors: the M. D. Anderson experience

BACKGROUND

The incidence and survival of melanoma are increasing, but little is known about its long-term health effects in adult survivors.

METHODS

A health survey was available from 996 melanoma survivors (577 treated with surgery alone, and 391 with combined treatments). Their medical/physiologic and psychosocial responses were analyzed and compared with those of the survivors from other cancers.

RESULTS

The melanoma survivors were 44.8 +/- 12.8 years of age at diagnosis (significantly younger than the survivors of other cancers) and 63.7 +/- 12.8 years at survey. Melanoma survivors were less likely to report that cancer had affected their health than survivors of other cancers (15.8% vs. 34.9%). The 577 individuals treated with surgery alone reported arthritis/osteoporosis, cataracts, and heart problems most frequently (less often than survivors of other cancers). The 391 individuals who had undergone combined treatments reported circulation problems and kidney problems generally as often as survivors of other cancers. Health problems were not associated with number of decades since diagnosis but with age at diagnosis, treatment modality, and family relationships.

CONCLUSION

We present information from a large cohort of long-term survivors of melanoma. As a group, they were less likely to report that cancer had affected their overall health than survivors of other cancers; a number of disease related and psychosocial factors appear to influence their health profiles.

Prevalence and Correlates of Fatigue in Long-Term Survivors of Childhood Leukemia

Purpose

To estimate the prevalence of fatigue, identify the factors associated with fatigue, and to explore the relationship between fatigue and quality of life (QOL) in long-term survivors of childhood acute lymphoblastic leukemia (ALL).

Methods

One hundred sixty-one ALL survivors diagnosed at Childrens Hospital Los Angeles (Los Angeles, CA) before age 18 years and between January 1, 1975 and December 31, 1995, participated in a structured telephone interview. Participants were aged 18 to 41 years and off treatment for an average of 14 years. Four measures of fatigue, including the Revised–Piper Fatigue Scale, were used to assess fatigue; depression was assessed using the Center for Epidemiological Studies Depression Scale. Multivariate logistic regression models were developed to identify factors associated with fatigue and depression.

Results

Prevalence of fatigue (30%) fell within the general population normal limits. Fatigue and depression were highly correlated (Pearson r = 0.75). Fatigue was associated with marriage (OR = 0.11; 95% CI, 0.02 to 0.50), having children (OR = 5.80; 95% CI, 1.30 to 25.82), sleep disturbances (OR = 6.15; 95% CI, 2.33 to 16.22), pain (OR = 5.56; 95% CI, 2.13 to 14.48), obesity (OR = 3.80; 95% CI, 1.41 to 10.26), cognitive impairment (OR = 2.56; 95% CI, 1.02 to 6.38), and exercise-induced symptoms (OR = 2.98; 95% CI, 1.11 to 8.02). Four factors associated with fatigue were also associated with depression: sleep disturbances, pain, obesity, and cognitive impairment. Fatigue was inversely related to QOL.

Conclusion

Some survivors of childhood ALL experience fatigue many years after treatment. Fatigued survivors represent a high-risk subgroup as they report more depression and poorer QOL than nonfatigued survivors and their peers.

Health-related quality of life in young survivors of childhood cancer using the Minneapolis-Manchester Quality of Life-Youth Form

OBJECTIVE

To assess the health-related quality of life (HRQL) of 8- to 12-year-old children undergoing therapy for cancer or childhood-cancer survivors by using the Minneapolis-Manchester Quality of Life-Youth Form (MMQL-YF), a comprehensive, multidimensional self-report instrument with demonstrable reliability and validity.

DESIGN, SETTING, AND PATIENTS

The MMQL-YF consists of 32 items comprising 4 scales: physical functioning, psychologic functioning, physical symptoms, and outlook on life. Scoring on the MMQL ranges from 1 to 5; 5 indicates maximal HRQL. An overall quality-of-life (QOL) score is also computed. By using a cross-sectional study design, the MMQL-YF was administered to 90 off-therapy cancer survivors, 72 children with cancer undergoing active therapy, and 481 healthy children without a history of cancer or other chronic disease.

RESULTS

Compared with healthy controls, children actively undergoing cancer treatment report low overall QOL, physical functioning, and outlook-on-life scores. However, off-therapy survivors report a superior overall QOL, compared with age-matched healthy controls.

CONCLUSIONS

Young survivors of childhood cancer report a favorable HRQL relative to healthy controls. These results are reassuring, suggesting that this group of survivors may have been too young to encounter some of the negative psychosocial impacts of cancer and its treatment.

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.

Characteristics of childhood cancer survivors predicted their successful tracing

OBJECTIVE

The Childhood Cancer Survivor Study is a retrospective cohort study that was initiated to explore late effects of childhood cancer and its therapies. We evaluated the characteristics of those requiring tracing and factors that influenced tracing success.

STUDY DESIGN AND SETTING

Medical record review identified 20,051 eligible individuals from 25 institutions in the United States and Canada. Of these, 13,021 had a current address in the medical record at the treating institution, and 7,030 had an incorrect address and required tracing by a commercial firm.

RESULTS

Tracing was successful for 4,188 persons (60%). Younger age at contact, shorter length of time since last contact, having a middle initial available, an uncommon last name, and socioeconomic factors were found to predict successful tracing. Compared to those with a current address available in medical records, subjects successfully traced were less likely to have accessed health care during the previous 2 years; and more likely to be current smokers, obese, and to report moderate to severe impairments (pain, functional status, and activity).

CONCLUSION

These findings provide an empirical basis concerning determinants and predictors of tracing success. If tracing had not been performed in this cohort, spurious associations may have been obtained for some health outcomes of interest.

Development of risk-based guidelines for pediatric cancer survivors: the Children's Oncology Group Long-Term Follow-Up Guidelines from the Children's Oncology Group Late Effects Committee and Nursing Discipline

The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers are risk-based, exposure-related clinical practice guidelines intended to promote earlier detection of and intervention for complications that may potentially arise as a result of treatment for pediatric malignancies. Developed through the collaborative efforts of the Children's Oncology Group Late Effects Committee, Nursing Discipline, and Patient Advocacy Committee, these guidelines represent a statement of consensus from a multidisciplinary panel of experts in the late effects of pediatric cancer treatment. The guidelines are both evidence-based (utilizing established associations between therapeutic exposures and late effects to identify high-risk categories) and grounded in the collective clinical experience of experts (matching the magnitude of risk with the intensity of screening recommendations). They are intended for use beginning 2 or more years following the completion of cancer therapy; however, they are not intended to provide guidance for follow-up of the survivor's primary disease. A complementary set of patient education materials ("Health Links") was developed to enhance follow-up care and broaden the application of the guidelines. The information provided in these guidelines is important for health care providers in the fields of pediatrics, oncology, internal medicine, family practice, and gynecology, as well as subspecialists in many fields. Implementation of these guidelines is intended to increase awareness of potential late effects and to standardize and enhance follow-up care provided to survivors of pediatric cancer throughout the lifespan. The Guidelines, and related Health Links, can be downloaded in their entirety at www.survivorshipguidelines.org.

Improving health care for adult survivors of childhood cancer: recommendations from a delphi panel of health policy experts

OBJECTIVES

To identify barriers to, models of care for, and initiatives to improve health care of adult survivors of childhood cancer.

METHODS

Seventeen health care policy experts were asked to respond to the three objectives through a three-iterative Delphi process.

RESULTS

Key barriers identified were that primary care physicians are unfamiliar with the health problems of survivors and survivors are often unaware of their risks. The recommended model of care would incorporate the chronic disease management model. Highest priority initiatives recommended were targeted education of primary care physicians and survivors, development and evaluation of standards of survivorship care, and a national web-based information center.

CONCLUSIONS

The insights and recommendations of the panel provide a foundation intended to improve health care of cancer survivors.

The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

The current study characterized the self-reported cancer screening practices of adult survivors of childhood cancer.

METHODS

A cohort of 9434 long-term survivors of childhood cancer and a comparison group of 2667 siblings completed a 289-item survey that included items regarding cancer-screening practices.

RESULTS

Overall, 27.3% of female respondents reported performing breast self-examination (BSE) regularly, 78.2% reported undergoing a Papanicolaou smear within the previous 3 years, 62.4% underwent a clinical breast examination (CBE) within the last year, and 20.9% had gotten a mammogram at least once in their lifetime. Approximately 17.4% of male respondents reported performing regular testicular self-examination (TSE). Women age > or =30 years who had been exposed to chest or mantle radiation therapy were more likely to report undergoing CBE (odds ratio [OR], 1.59; 95% confidence interval [95% CI], 1.32-1.92) and mammography (OR, 1.92; 95% CI, 1.47-2.56). Compared with the sibling comparison group, survivors demonstrated an increased likelihood of performing TSE (OR, 1.52; 95% CI, 1.22-1.85) or BSE (OR, 1.30; 95% CI, 1.10-1.52), of having undergone a CBE within the last year (OR, 1.18; 95% CI, 1.02-1.35), and of ever having undergone a mammogram (OR, 1.82; 95% CI, 1.52-2.17).

CONCLUSIONS

The results of the current study demonstrate that the cancer screening practices among survivors of childhood cancer are below optimal levels. Primary care physicians who include childhood cancer survivors among their patients could benefit these individuals by informing them about future cancer risks and recommending appropriate evidence-based screening.

Childhood cancer survivors--living beyond cure

Advances in diagnosis and treatment along with improved supportive care have contributed to the current survival rates for pediatric malignancies. Recent concept of a truly "cured child" in pediatric oncology envisages not only a biological cure of the disease but a child on par with peers in growth and development physically and in achievements and aspirations, both mentally and emotionally. Because of the young age of these survivors and their potential for longevity, the delayed consequences of therapy may have a serious impact on their lives and family at large than do the acute complications of the cytotoxic therapies that they had experienced. Though figures from India are not available, it has been estimated that, in USA, the prevalence of childhood cancer survivors is expected to increase from 1 in 900 persons among young adults to 1:250 persons by 2010. Although this constitutes a remarkable medical achievement, the late morbidity in this growing survivor population has become an area for concern. It is estimated that 50% of the survivors are likely to develop disabilities that alter the quality of life.

Extended follow-up of long-term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Children who survive acute lymphoblastic leukemia are at risk for leukemia-related or treatment-related complications, which can adversely affect survival and socioeconomic status. We determined the long-term survival and the rates of health insurance coverage, marriage, and employment among patients who had attained at least 10 years of event-free survival.

METHODS

A total of 856 eligible patients were treated between 1962 and 1992 in 13 consecutive clinical trials. Survival rates, the cumulative risk of a second neoplasm, and selected indicators of socioeconomic status were analyzed for the entire group and for patients who did or did not receive cranial or craniospinal radiation therapy during initial treatment.

RESULTS

Fifty-six patients had major adverse events, including 8 deaths during remission, 4 relapses, and 44 second neoplasms (41 of them radiation-related); most of the second neoplasms were benign or of a low grade of malignant potential. The risk of a second neoplasm was significantly higher in the 597 patients who received radiation therapy (irradiated group) than in the 259 patients who did not receive radiation therapy (nonirradiated group) (P=0.04; estimated cumulative risk [+/-SE] at 20 years, 20.9+/-3.9 percent vs. 0.95+/-0.9 percent). The death rate for the irradiated group slightly exceeded the expected rate in the general U.S. population (standardized mortality ratio, 1.90; 95 percent confidence interval, 1.12 to 3.00), whereas that for the nonirradiated group did not differ from the population norm (standardized mortality ratio, 1.75; 95 percent confidence interval, 0.34 to 5.00). The rates of health insurance coverage, marriage, and employment in the nonirradiated group were similar to the age- and sex-adjusted national averages. Despite having health insurance rates similar to those in the general population, men and women in the irradiated group had higher-than-average unemployment rates (15.1 percent vs. 5.4 percent and 35.4 percent vs. 5.2 percent, respectively), and women in the irradiated group were less likely to be married (35.2 percent vs. 48.8 percent).

CONCLUSIONS

Children with acute lymphoblastic leukemia who did not receive radiation therapy and who have attained 10 or more years of event-free survival can expect a normal long-term survival. Irradiation is associated with the development of second neoplasms, a slight excess in mortality, and an increased unemployment rate.