Monitoring for Late Effects
The need for long-term follow-up for childhood cancer survivors is supported by the American Society of Pediatric Hematology/Oncology, the International Society of Pediatric Oncology, and the American Academy of Pediatrics. Survivors should seek care from professionals with expertise in the recognition and management of late effects.[1,2,3,4,5] Comprehensive monitoring guidelines for late effects have been developed within the Children's Oncology Group.[6]
As the number of survivors of childhood cancer is expected to increase, there is some urgency in determining where long-term follow-up should take place.[7] It will be difficult for the usual pediatric oncology clinical services to accommodate the demands of the ever-enlarging population of survivors. Transition of care from the pediatric to the adult health care setting is necessary for most childhood cancer survivors. The most important requirement in providing transition services is the coordination between primary and subspecialty, pediatric, and adult health care providers as well as between the family, healthcare, educational, vocational, and social service systems.[3,8,9]
Health-promoting behaviors should be stressed for survivors of childhood cancer, and targeted educational efforts are worthwhile.[10] Smoking, excess alcohol use, and illicit drug use increase risk of organ toxicity and, potentially, second malignant neoplasms. The impact of health behaviors on adverse health-related outcomes has not been well studied in childhood cancer survivors.
Part of long-term follow-up should also be focused on appropriate screening for educational and vocational services. A report from the Childhood Cancer Survivor Study demonstrated that childhood cancer survivors are more likely to require special education services (23%) than their siblings (8%), with survivors of central nervous system (CNS) tumors, leukemia, and Hodgkin disease at greatest risk. Similarly, survivors of CNS tumors, leukemia, neuroblastoma, and non-Hodgkin lymphoma were less likely than their siblings to complete high school or college.[11] Among adult survivors, 5.2% had never been employed, compared with 1.4% of the siblings (overall risk [OR] = 3.36). Risk was elevated for all childhood cancer diagnoses except Wilms tumor. In survivors of CNS tumors, in whom the risk was highest for unemployment, the OR was 9.10, (95% confidence interval [CI], 6.32-13.11). Compared with survivors of non-CNS tumors who received no or low doses (<30 Gy) of cranial radiation, the risk of never having been employed was 5.4 times greater among survivors of CNS tumors who had been treated with greater than 30 Gy of cranial radiation therapy (95% CI, 4.18-6.97). The risk was similarly increased for those who were treated with greater than 30 Gy of cranial radiation therapy for non-CNS tumors (OR = 4.70; 95% CI, 3.11-6.94), and to a lesser extent for survivors of CNS tumors who received less than 30 Gy of cranial radiation therapy (OR = 2.14; 95% CI, 1.36-3.24).[12]
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