A 16-year-old boy with a history of leukemia at age 12 years complains of right hip pain of several months' duration. A 34-year-old woman who had Hodgkin lymphoma at age 14 years comes in for a routine physical. A 24-year-old woman who was treated for osteosarcoma of the left distal femur as a teenager presents with new-onset dyspnea. How would these patients' history of childhood cancer guide your approach?
Progress in the treatment of childhood cancer over the past several decades represents one of the greatest success stories in modern medicine (Figure). Cure rates now approach 80%.1 The population of long-term survivors of childhood cancer has steadily increased to more than 270,000 in the United States.2 However, their cure has come with a cost: most childhood cancer survivors experience health problems related to their chemotherapy, radiotherapy, or surgery.
In this article we provide an overview of the physical and psychological disorders that survivors of childhood cancer may encounter. On page 443, we present 3 cases that illustrate specific challenges often faced by survivors, and we outline monitoring strategies that can help you minimize the long-term adverse effects of cancer treatments.
LONG-TERM PHYSICAL SEQUELAE OF CANCER THERAPIES
Among children treated from the 1970s through the 1990s, a chronic disease will develop in about 75% by 40 years of age; a serious health problem will develop in over 40%; and many will have multiple conditions.3,4 (Examples of late effects of radiation therapy and chemotherapy are listed in the Table.) The risk of morbidity increases with age; many sequelae of cancer therapy do not become apparent until 10 or 20 years after treatment. Almost 1 in 2 long-term survivors will have significantly diminished health status.5 In addition, the risk of premature death secondary to another cancer or heart or lung disease is significantly increased.6 However, the risk of morbidity, diminished health status, and premature mortality can be reduced by longitudinal health care that incorporates targeted strategies for prevention, early detection, counseling, and education.
PSYCHOLOGICAL IMPACT OF CHILDHOOD CANCER AND ITS TREATMENT
Similar to the medical sequelae, the psychological impact of cancer during childhood depends in part on a number of disease-, treatment-, and demographic-related factors. Survivors of disease or therapy that involved the CNS are at the greatest risk for psychosocial morbidity, including learning disabilities, social and behavioral adjustment difficulties, and limited capacity for independent living in adulthood. Long-term survivors of bone tumors, sarcomas, and Hodgkin lymphoma show higher levels of cancer-related anxiety and fears than do other groups, possibly because these illnesses are usually diagnosed during adolescence and young adulthood—at a developmental stage of heightened awareness and sensitivity.
Although the prevalence of clinical psychiatric disease in survivors is similar to that in the general population, survivors are twice as likely to have symptoms of moderate depression, anxiety, or somatization. A small but significant subgroup of survivors experience distress many years following treatment completion, with 25% to 30% estimated to be at increased risk for long-term adjustment problems. Lower socioeconomic status, female sex, and lower educational attainment predict adaptation difficulties among long-term survivors—much as these factors do in the general population.
1. Ries LAG, Melbert D, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2004. Bethesda, MD: National Cancer Institute. http://seer.cancer.gov/csr/1975_2004/. Accessed March 27, 2008.
2. Hewitt M, Weiner SL, Simone JV, eds. Childhood Cancer Survivorship: Improving Care and Quality of Life. Washington, DC: National Academies Press; 2003.
3. Oeffinger KC, Mertens AC, Sklar CA, et al; Childhood Cancer Survivor Study. Chronic health conditions in adult survivors of childhood cancer. N Engl
J Med. 2006;355:1572-1582.
4. Geenen MM, Cardous-Ubbink MC, Kremer LC, et al. Medical assessment of adverse health outcomes in long-term survivors of childhood cancer. JAMA. 2007;297:2705-2715.
5. Hudson MM, Mertens AC, Yasui Y, et al. Health status of adult long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. JAMA. 2003;290:1583-1592.
6. Mertens AC, Yasui Y, Neglia JP, et al. Late mortality experience in five-year survivors of childhood and adolescent cancer: the Childhood Cancer Survivor Study. J Clin Oncol. 2001;19:3163-3172.
7. Aziz NM, Oeffinger KC, Brooks S, Turoff AJ. Comprehensive long-term follow-up programs for pediatric cancer survivors. Cancer. 2006;107:841-848.
8. Landier W, Bhatia S, Eshelman DA, et al. 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. J Clin Oncol. 2004;22:4979-4990.
9. Ries LAG, Percy CL, Bunin GR. Introduction. In: Ries LAG, Smith MA, Gurney JG, et al, eds. Cancer Incidence and Survival Among Children and Adolescents: United States SEER Program 1975-1995. Bethesda, MD: National Cancer Institute, SEER Program; 1999. NIH publication 99-4649.