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Advances & Insights: Cancer

February 26, 2007

What the news means for you


Moscow, Jeffrey A., MD 

Jeffrey A. Moscow, MD
Pediatric oncologist 

Following up on adult survivors of childhood cancer a top priority

Childhood cancer survivors are becoming a very high-risk population as they age. The CCSS study helps create a greater awareness of the needs of this population and define the extent of their health and social problems.

“With increased intensity [of chemotherapy and radiation] comes the higher risk of complications.”

These survivors are beneficiaries as well as victims of our successes in curing childhood cancer over the last 30 years. Cancer used to be a uniformly lethal diagnosis for children, but we have more survivors today than ever. One major reason for these improved outcomes is that clinical studies have repeatedly shown the substantial benefit from increasing the intensity of chemotherapy and radiation. However, with increased intensity comes the higher risk of complications.

Each successive group of childhood survivors has grown in number, and each group has a higher risk of long-term complications because they received more intensive therapies. Cancer therapy, we have learned, is a double-edged sword.

This knowledge has already had an impact on the design of some studies for childhood cancer. In a few types of cancer where we have good survival rates, we’ve tried to reduce the intensity of some of the components of the treatment plan, such as radiation, that are most likely to cause future problems.

Danger of second cancers

Radiation therapy and certain anti-cancer drugs that are used to treat cancer can also cause cancer. Chemotherapy and radiation work by causing DNA damage that kills cancer cells. But DNA damage is also a process that can lead to cancer in normal cells decades later. This is a special problem for adult survivors of childhood cancer, many of whom had their treatments 30 years ago.

These second malignancies caused by cancer treatment are among the most serious problems faced by cancer survivors. One alarming finding of the CCSS study is that the cumulative risk of developing a second malignancy does not seem to be flattening out.

Since different treatment-related malignancies have different latency periods, when one particular type of malignancy levels off, another begins to go up. For example, among female survivors of bone marrow transplant, just as the risk of developing a second leukemia started to level off, the risk of developing breast cancer began to increase.

Other problems

Along with second malignancies, survivors are more likely to have cardiovascular and endocrine issues. Depending on what drugs children received and the age when they were treated, there can be a whole variety of other complications.

Aside from medical risks, there are social and psychological risks. Other studies have shown that adult survivors have more adverse mental health outcomes. Some have long-term learning problems and hormonal issues.  It’s also more difficult for them to get health insurance.

These challenges are compounded by the fact that adult survivors of childhood cancer do not have a natural medical “home.” Internists and adult oncologists are generally unfamiliar with childhood treatment regimens and the associated risks. Understandably, adult survivors may feel uncomfortable returning to a pediatric clinic for care. Furthermore, many do not know the details of their past treatments and their current risks. In addition, their old records may be difficult to locate.

“We plan to embark on a major effort to locate these adults and bring them in for screening and education about their past treatments and potential risks.”


Long-term follow-up care at UK

For years, UK HealthCare has offered follow-up care to survivors of childhood cancer treatment in the pediatric oncology clinic. However, we know there are hundreds of adult survivors in our communities who were treated at UK in the 1970s and 1980s and who have since been lost to follow-up.

We plan to embark on a major effort to locate these adults and bring them in for screening and education about their past treatments and potential risks. For many, it may come as a surprise that they have health problems related to the treatment they received as children.

The physicians and staff of UK HealthCare made a commitment to provide the best possible medical care to children who came through our doors decades ago, and that commitment will remain throughout their lives.

Dr. Moscow is chief of hematology-oncology at Kentucky Children’s Hospital, head of the pediatric oncology team at Markey Cancer Center and a professor of pediatrics at UK College of Medicine.

Surviving childhood cancer has its price

The survival rate of children diagnosed with cancer is an extraordinary success story in the war on cancer. Thanks to advances in treatment over the last 35 years, almost 80 percent of these children become long-term survivors. But there is a downside to this happy story: An alarming number face long-term health problems in adulthood as a result of the very treatment that saved them.

Childhood cancer survivors face long-term health problems in adulthood as a result of the very treatment that saved them.

Now, results from the largest study ever of adult survivors of childhood cancer reports that more than 62 percent have at least one chronic health condition and nearly 28 percent have a severe or life-threatening condition. The survivors are particularly vulnerable to a second malignancy, heart conditions, kidney disease, bone and muscle abnormalities, endocrine problems and sterility.

The findings are based on results from the Childhood Cancer Survivor Study (CCSS), a 26-institution study that is tracking the health outcomes of over 14,000 survivors who were diagnosed with cancer between 1970 and 1986.

The report, which appeared in the October 12, 2006, edition of the New England Journal of Medicine, is significant because there are approximately 270,000 survivors of childhood cancer today in the United States.

Survivors and siblings

The CCSS findings were based on interviews with survivors and questionnaires filled out by those survivors along with analysis of their cancer treatments. More than 10,000 adult survivors, ranging in age from 18 to 48 years, were evaluated and compared to approximately 3,000 of their siblings in roughly the same age bracket.  The survivors of childhood cancer were eight times more likely than their siblings to have severe, life-threatening, or disabling chronic health conditions.

Survivors of bone tumors, tumors of the central nervous system and Hodgkin's disease are at highest risk for long-term problems.

According to the study, the three groups at highest risk for long-term problems are survivors of bone tumors, tumors of the central nervous system and Hodgkin's disease. These groups were also more likely to have multiple conditions. For example, bone tumor survivors with multiple chronic conditions were more likely to have severe problems with bones and muscles, hearing loss, and congestive heart failure. Survivors of brain tumors were at greater risk for seizures, hormone diseases and problems with cognition; and Hodgkin's disease survivors were more likely to have second cancers and heart disease.

Women were 50 percent more likely to report a severe, life-threatening or disabling condition than male survivors. They were also at increased risk for multiple health conditions.

Treatments associated with risks

Prior to the early 1970s, most children with cancer did not survive. With significant advances in radiation and chemotherapy, the 1970s and 1980s was a time when many children were successfully treated for their cancer and became long-term survivors.

Prior to the early 1970s, most children with cancer did not survive. With significant advances in radiation and chemotherapy, the 1970s and 1980s was a time when many children were successfully treated for their cancer and became long-term survivors.

The CCSS researchers link the high incidence of long-term complications to the intensive treatment with combination chemotherapy and ionizing radiation the survivors received as children. They also report that the risks are cumulative and show no signs of leveling off.

In an editorial accompanying the study, Dr. Philip M. Rosoff points out that there have been many changes in treatment since the 1980s and doctors are more aware of the potential for late effects. However, he writes, more studies are needed because recently diagnosed patients may have not only the same, but also a different array of long-term complications.

Surveillance of survivors necessary

According to the researchers, the CCSS findings underscore a need for continued follow-up of survivors of childhood cancer, with particular attention to the risk of second cancers. Survivors should also be encouraged to exercise, maintain a healthy weight and avoid smoking.          

“It has been reported that less than 20 percent of adult survivors of childhood cancer are followed at a cancer center or by an oncologist; the likelihood of follow-up in this setting decreases even more with time,” the authors state. “For this reason, it is important for general physicians and internists to be aware of the risks facing this population.”

 

Related resources:

For more information, see:

Chronic health conditions in adult survivors of childhood cancer, New England Journal of Medicine, v. 355, no. 15, October 12, 2006, pp. 1572-82  

Focus on Research: The two-edged sword of curing childhood cancer, New England Journal of Medicine, v. 355, no. 15, October 12, 2006, pp. 1522-1523 (PDF)

Adult survivors of childhood cancers are prone to chronic health conditions, National Cancer Institute

Late effects of treatment for childhood cancer PDQ, National Cancer Institute

Facing forward: Life after cancer treatment, National Cancer Institute

Pediatric Hematology-Oncology Clinic, Kentucky Children’s Hospital, UK HealthCare

Pediatric Oncology Team, Markey Cancer Center, UK HealthCare

Division of Hematology-Oncology, Kentucky Children’s Hospital, UK HealthCare

UK HealthCare Cancer Services - Markey Cancer Center

For more information, or to make an appointment with a UK HealthCare physician, please call UK Health Connection at 1-800-333-8874. 

Page last updated: 2/21/2014 11:38:41 AM