Systematic advances in risk-based therapy for childhood cancer
has been responsible for the progress in overall survival over the
past four decades; five-year survival rates now approach 80%.1 This
has resulted in a growing population of childhood cancer survivors—an
estimated 300,000 survivors in the United States.2 Demographics
of childhood cancer survivors reveal that although a third of these
individuals are less than 20 years of age, one half are between
20 and 40 years old, and the remaining one fifth are over 40 years
Cancer and its treatment during childhood can result in a variety
of long-term sequelae, such as impairment in growth and development,
endocrine dysfunction, cognitive decline, cardiopulmonary compromise, musculoskeletal
sequelae, renal compromise, gastrointestinal dysfunction, auditory
and visual impairments, as well as subsequent malignancies. It has
been demonstrated quite convincingly that one-third of the long-term
survivors report severe or life-threatening complications 30 years
from primary diagnosis.3 These sequelae are primarily related
to specific therapeutic exposures, and can reduce the overall quality
of life (QOL) of the survivors.
The health and well-being of this rapidly growing number of childhood
cancer survivors have been described fairly extensively in the literature.This
chapter reviews some of these well-described, late-occurring adverse
events in survivors of childhood cancer and what is now known about
the relationship between these events and therapeutic exposures (Table 448-1).
Table 448-1. Selected Exposure-Based Screening
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Table 448-1. Selected Exposure-Based Screening
|Category||Therapeutic Exposure||Potential Late Effect||Recommended Screening|
|Cognition||Radiation to the brain||Neurocognitive deficit||Yearly assessment of vocational/educational
|Intrathecal methotrexate||Baseline neuropsychological assessment,
repeated as clinically indicated and at key educational transition points|
|Intermediate/high dose intravenous
methotrexate or cytarabine|
|Cardiac||Anthracycline chemotherapy||Cardiomyopathy||Yearly history and physical examination|
|Chest radiation||Cardiomyopathy ||Baseline electrocardiogram|
|Atherosclerotic heart disease||Periodic
echocardiogram as indicated based on dose and age at exposure |
|Fasting glucose, lipid profile every 2 years|
|Cardiac consultation as indicated|
|Pulmonary||Nitrosureas||Interstitial pneumonitis||Yearly history and physical examination|
|Busulfan||Pulmonary fibrosis||Baseline measure of pulmonary function|
|Bleomycin||Baseline chest X-ray|
|Radiation to the lungs||Consider repeat evaluations prior to general
anesthesia and as clinically indicated|
|Endocrine||Radiation to neck/ thyroid||Hypothyroidism (primary or central)||Yearly history and physical examination|
|Radiation to the hypothalamic-pituitary axis
field||Growth hormone deficiency||Yearly thyroid function test (free T4, TSH)|
|Gonadal Function||Chemotherapy with alkylating agents ||Hypogonadism||Yearly history and physical examination
including evaluation of secondary sexual characteristics and sexual
|Surgical removal of both gonads||Infertility||Baseline (females, age 13; males,
age 14) assessment of gonadal function (LH, FSH, estradiol, or testosterone);
repeat as clinically indicated in patients with delayed puberty
or signs/symptoms of hormonal deficiency|
|Radiation involving the gonads||Premature menopause (females)|
|Second malignancies||Topoisomerase II inhibitors ||Therapy-related leukemia||Complete blood count, platelet,
differential yearly for 10 years following exposure |
|Alkylating agents||SMN in radiation field (skin, bone, ...|
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