Another possible explanation, according to Dr Ness, is that the survivors have become “medicalized”: accustomed to being the subject of follow-up studies and to responding to queries about their health.
The late-effects of treatment for childhood cancer have long been known. Compared to their siblings, survivors have a considerably higher chance of chronic health conditions. A 2014 analysis of 14,359 5-year survivors from the Childhood Cancer Survivor Study found that “the cumulative incidence of a severe, disabling, life-threatening, or fatal health condition was greater among survivors than siblings…by age 50 years.”2
Other studies found that pediatric cancer survivors have shorter life expectancies than their peers. A 2010 study found that “approximately 1 in every 4 survivors is estimated to die from late recurrence or late-effects related to secondary cancer and cardiopulmonary conditions, and another 1 in 20 from other excess risk.”3
The causes, the study continued, were frequently related to the very therapy used to combat the initial cancer.
This realization led to changes in treatment strategies to reduce toxicities. For example, pediatric oncologists reduced the use and the doses of radiation therapy and anthracyclines for treatment of acute lymphoblastic leukemia (ALL), Hodgkin lymphoma, and Wilms tumor.
“Oncologists really do and have done a fantastic job of trying to minimize toxicity, even when they designed frontline clinical trials,” said Dr Ness. “They got rid of cranial radiation for leukemia. They got rid of amputation in almost every case for kids with sarcoma…And they try to reduce the number of cardiotoxic agents children get while still achieving a cure. I think they’ve done an excellent job of trying to reduce toxicity, and I think that can probably account for the diminished number of severe, disabling, or life-threatening chronic conditions.”
Nonetheless, she said, the results of her study of self-reported health status shows the need for physicians to consider the overall well-being of pediatric cancer survivors, for life.
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“A lot of the care for survivors isn’t left in the hands of the pediatric oncologist, it’s left in the hands of the primary care provider,” she said. “Hopefully, the handoff of the child to the other providers is done with that and then there is guidance for the primary care provider to make sure that these people get appropriate follow-up.”
- Ness KK, Hudson MM, Jones KE, et al. Effect of temporal changes in therapeutic exposure on self-reported health status in childhood cancer survivors. Ann Intern Med. 2016 Nov 8. doi: 10.7326/M16-0742 [Epub ahead of print]
- Armstrong GT, Kawashima T, Leisenring W, et al. Aging and risk of severe, disabling, life-threatening, and fatal events in the childhood cancer survivor study. J Clin Oncol. 2014;32(12):1218-27. doi: 10.1200/JCO.2013.51.1055
- Yeh JM, Nekhlyudov L, Goldie SJ, Mertens AC, Diller L. A model-based estimate of cumulative excess mortality in survivors of childhood cancer. Ann Intern Med. 2010;152(7):409-17, W131-8. doi: 10.7326/0003-4819-152-7-201004060-00005