Analysis shows high rate of ‘significant’ health problems in childhood cancer survivors
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Roughly 500,000 people living in the United States have survived childhood cancer, a consequence of improved research, innovations and treatments.
A recent review published in Journal of the American Medical Association found that more than 95% of childhood cancer survivors will have a significant health problem by age 45 years.
“We wanted to review the literature to describe the magnitude of problems faced by childhood cancer survivors,” Smita Bhatia, MD, MPH, director of the Institute for Cancer Outcomes and Survivorship in the UAB School of Medicine, told Healio. “We wanted to understand the role of specific treatments associated with these complications and the temporal trends of the risk for those complications.”
Bhatia spoke with Healio about the most common health complications seen in childhood cancer survivors, the important role primary care can play in monitoring these patients, and how oncologists can assist in these efforts.
Healio: Why did you conduct this study?
Bhatia: We are reaching high levels of cure rates among most of the cancers that arise during childhood, and with this growing number of survivors, we need to pay increasing attention to the long-term and late effects of the treatments these individuals received. A number of studies have now shown that specific therapeutic exposures result in specific outcomes, such that by age 45, 95% of childhood cancer survivors have a significant long-term effect. For children diagnosed with cancer in the 1990s, the lifespans are shortened by about a decade. We have limited information for those diagnosed in this century.
Healio: How did you conduct the review?
Bhatia: We identified 2,468 studies and included 73 that directly addressed the issues we wanted to highlight with this review.
In addition to highlighting the magnitude of the problem and the treatment exposures associated with these complications, we wanted to provide a roadmap for how to take care of these kids in the generalist setting. We wanted to determine how adult survivors of childhood cancer should be taken care of in the community. We want to make clinicians in the community aware of these complications.
Healio: What complications did your review most commonly identify?
Bhatia: The most prevalent problems in childhood cancer survivors involve the endocrine system, presenting as hypothyroidism or growth hormone deficiencies. About 44% of our childhood cancer survivors have endocrine problems.
New cancers constitute the second most common problem. Approximately 7% of our cancer survivors develop new cancers directly related to the treatments they receive. For example, radiation to the chest in girls increases the risk for breast cancer, radiation to the neck increases the risk for thyroid cancer, and radiation to the brain increases the risk for new brain tumors.
The third most common complication is cardiovascular disease, presenting as heart failure, coronary artery disease, pericarditis, arrythmias and valvular defects.
It is important for health care professionals in the community to be aware of these complications because they develop at a much younger age than in the general population.
Healio: Were most of these complications related to radiation? What other causes did you identify?
Bhatia: While radiation is associated with an increased risk for complications, certain kinds of chemotherapies also increase the risk. For example, the anthracycline class of chemotherapies is associated with heart failure. Anthracyclines can also increase the risk for breast cancer. Alkylating agents are associated with an increased risk for colon cancer.
Healio: What did the results reveal about the risk for mental illness?
Bhatia: Anxiety and depression are common. A recent study found that the suicide rates are no different from that of the general population, except among older survivors of childhood cancer.
Healio: Can you discuss the resource for following these patients that your publication outlines?
Bhatia: Often, our childhood cancer survivors don’t remember the treatment they received, but they do remember their diagnosis accurately. We developed a diagnosis-specific roadmap for follow-up of childhood cancer survivors.
Healio: What can our oncologist readership do to help with this situation?
Bhatia: Oncologists following childhood cancer survivors should conduct risk-based surveillance for early detection of treatment-related complications. They should also develop close relationships with the survivors’ primary care providers and ensure that comorbidities such as hypertension, dyslipidemia and diabetes are managed aggressively.
Healio: Do you think younger patients being presently treated will have fewer complications due to the use of lower doses?
Bhatia: Our hope is that they will have lower risks for complications because there are clear dose-response relationships, and the oncology community has intentionally reduced the doses of the therapeutic exposures, with an eye toward diminishing the late effects.
However, there is a need to follow childhood cancer survivors treated with immunotherapy and biologic agents, where the long-term effects remain unknown.
Healio: What do you hope will be the long-term implications of these findings?
Bhatia: My hope is that this review helps the health care providers taking care of childhood cancer survivors in the community. More than that, in the oncology world and in the survivorship world, our hope is to develop effective interventions that would mitigate the risk for these complications.
Healio: Is there anything else you would like to mention?
Bhatia: I do need to acknowledge my two coauthors, Wendy Landier, PhD, CRNP, and Emily S. Tonorezos, MD, MPH. This work is never just a single-person effort.
For more information:
Smita Bhatia, MD, MPH, can be reached at The University of Alabama at Birmingham, 1600 7th Ave. South, Lowder 500, Birmingham, AL 35233; email: sbhatia@peds.uab.edu.
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