18
Vol. 66, No. 2 2015
Northeast Florida Medicine
Pediatric Oncology
Recurrence of tumor and secondary malignancies:
Perhaps the most concerning problems seen in adult
survivors of childhood cancer are those of late disease and
secondary malignancies as a result of treatment.
19
The risk of
secondary malignancies increases over time from treatment,
with an incidence up to 20 percent by 30 years fromdiagnosis.
In general, no specific screening is recommended with the
exception of initiation of annual mammography at age 25
in women who have received mantle irradiation, and annual
blood counts in those exposed to anthracyclines. However,
all patients should have careful history and physical exam
with a low threshold for further evaluation of abnormalities.
Neuro-psychological:
Adult survivors of childhood cancer often will have long-
term cognitive, psychological and social effects from their
therapy, which can dramatically impact overall quality of
life.
20
Although there is an increasing body of literature on
this subject, much of it is based on small numbers of patients
and changing treatment paradigms such that interpretations
and recommendations for specific groups of patients are not
always available. This is particularly true for children treated
for leukemia andbrain tumors.
21
These consequences are often
related to CNS-directed therapies in children with leukemia
and especially those children with brain tumors.
22
For brain
tumors, the age of the childwhen treated, type of and location
of the tumor itself, surgical interventions, chemotherapy
given and, particularly, radiation therapy (dose-dependent)
to the CNS may introduce significant damage. In addition,
issues such as endocrinopathies, changes in body image,
depression, long periods of time missing school and lack of
age-appropriate social interactions may contribute to these
problems.Deficits have includedglobal decreases in IQ, aswell
as specificdeficits inshort and long-termmemory, visual-spatial
functioning, expressive language, fine motor skills, attention
and concentration.
23
For example, in several studies of young
children with a history of acute lymphoblastic leukemia, use
of intrathecal and higher dose systemic methotrexate has
resulted in IQ deficits even in those children who were not
exposed to irradiation.
24
These adult survivors of childhood
leukemias and brain tumors have been found to be less likely
to attend college, be fully employed and to be married than
age matched controls.
25
Pediatriconcologists havebecome increasinglyawareof these
consequences and their teams strive to provide appropriate
educational and social interactions during cancer treatment.
Efforts to modify therapy to reduce some of these late effects
have centeredaround reductions in theuse of radiation therapy
in children with leukemia and young children with brain
tumors, as well as more targeted approaches to RT, such as
IMRT and the use of proton therapy. It is hoped that these
changes in therapy will decrease exposure of the normal brain
to significant radiation exposure. Although mitigating these
outcomes, this has not completely prevented them. Thus
adult survivors of pediatric cancer must be carefully screened
for depression, fatigue, and social isolation as young adults.
26
For those young adults entering post-secondary education,
it is incumbent on educators and health care providers to
appropriately screen for subtle learningdisabilitieswhichcould
result in patients not being able to achieve their full potential.
This information must be shared with school staff to provide
appropriate disability support for these young adults.
27
Models of follow-up care
The Institute of Medicine in their 2003 publication,
“Childhood Cancer Survivorship: Improving Care and
Quality of Life” and the 2006 report “FromCancer Patient
to Cancer Survivor: Lost in Transition,” clearly point out
that adult survivors of pediatric cancer are a vulnerable
population with very special health care needs.
28,29
It is also
important to stress that young adults are at a particularly
vulnerable stage of life with transition to independence,
achievement of educational goals, the establishment of
intimate relationships and a period of increased risk taking
behavior.The Institute ofMedicine and others have provided
recommendations which include:
1. All cancer survivors must be provided with both
treatment summaries and late effect care plans as they
transition out of oncology care (pediatric oncology
care in adolescents and young adults).
2. Late effects prevention and treatment must be added
to healthcare provider educational curriculums.
3. All providers of care to cancer survivors should edu-
cate themselves on the late effects of cancer care and
provide appropriate screening and intervention to
identify and manage those complications.
4. Insurance providers must cover evidence based screen-
ings appropriate to the cancer treatment received by
the patients.
5. All providers should use appropriate evidence based
guidelines and assessment tools.
6. Counseling on maintaining a healthy lifestyle and
addressing psychosocial needs must be included in
follow-up care.
7. Models of care for cancer survivors must include
care navigation.
Fortunately, through the work of the Children’s Oncology
Group, the American Society of Pediatric Oncology nurses
and others, well documented and evidence based guidelines
for long-term management of pediatric cancer survivors
