Montana Comprehensive Cancer Control

1
Montana Comprehensive Cancer Control

• Brian L. Abbott, M.D.
• Late Complications in Pediatric Cancer Survivors
• November 6, 2008

2
Introduction

• Cure rate for childhood cancer is around 75
• 1 in 900 adults is a childhood cancer survivor
• Tremendous need for late effects programs

3
Types of Late Effects

• Growth / endocrine
• Fertility
• Cardiac
• Pulmonary
• Renal
• Second cancers
• Psycho-social
• Economic

4
Growth Hormone Deficiency

• Biggest risk cranial radiation
• (examples A.L.L., Brain tumors, Bone marrow
  transplant)
• Lifelong GH deficiency
• short stature
• fatigue
• high cholesterol
• Screening following growth curves, somatomedin
  C, and IGF BP III
• Treatable with growth hormone injections

5
Thyroid Complications

• Toxic radiation dose for thyroid is 1000 cGy
• Example Hodgkin disease
• Hypothyroidism 67 Incidence after XRT
• Thyroid cancer 16x the general population
  (Hancock et al (NEJM, 1999) )
• Screening Thyroid levels monitored

6
Male Fertility

• Testes sensitive to both XRT and chemotherapy
  (alkylating agents such as cyclophosphamide)
• Testicular MTD
• 600 cGy (spermatogenesis)
• 2400 cGy (testosterone production)
• Recovery from alkylating agent induced
  oligospermia (low sperm counts) may take years
• More likely permanent after higher dose therapy
  (gt 7.5 gm/m2 CTX)

7
Female Fertility

• Chemotherapy and XRT may induce loss of ovarian
  function permanently
• Risk of early menopause
• Five Center Study Women treated with XRT and
  chemo for HD as children
• 42 menopause by age 31
• Compared to 5 of controls

8
Anthracycline Cardiac Damage

• Risk of heart failure
• Cumulative dose (gt450-500 mg/m2 doxorubicin)
• Age lt 4 years at administration
• Female gender
• Mediastinal / chest radiation
• Steinhertz et al reported clinical symptoms up to
  20 years following administration

9
Chemotherapy-Induced Lung Damage

• Bleomycin, BCNU, busulfan
• pulmonary fibrosis/scarring
• decrease in gas exchange ability
• Screen pulmonary function tests
• Risk reduction Discourage smoking

10
(No Transcript)
11
Neurologic Complications

• IQ impairment
• At risk populations
• Leukemia, receiving cranial XRT
• Brain tumor receiving surgery/ XRT
• Especially if under 2 years old
• Peripheral nerve damage
• From vincristine and Taxol

12
Skin Complications

• Chronic graft vs host disease of skin
• Late effect of allogeneic BMT
• Severe cases are like scleroderma
• Joint contractures, hair loss

13
Ototoxicity / Hearing Loss

• Secondary to cisplatin, which destroys hair cell
  function
• High frequency loss early on
• Later, loss in conversational range

14
Ocular Toxicities

• Cataract risk following steroids, XRT
• Sicca syndrome following B.M.T.

15
Second Cancers

• Predisposing factors
• Previous cancer therapies
• Chemotherapy
• Radiation
• Hereditary predispositions
• Up to 8-10 risk by 20 years
• Especially leukemia and breast cancer

16
Psycho-Social Complications

• Families always worried that relapse will occur
  Sword of Damocles
• Siblings may harbor resentment due to attention
  given patient
• Employment/insurance difficulties
• Loss of intimacy

17
Educational Issues

• Learning may be impaired due to radiation and
  some types of chemotherapy
• Social risk due to removal from peers and school
  environment during treatment
• Increased risk taking behavior due to feeling
  invincible (smoking)

18
Insurance Issues

• Medical expenses due to late effects
• May be medically uninsurable
• More missed days of working with loss of job and
  health insurance

19
Sohow do we address all of these issues of this
unique population???
20
Long-term follow-up clinics

• Education on survivorship issues
• Types of global evaluation
• Medical, Nursing, Social Work, Neuropsychology,
  Nutrition
• Additional evaluations depending on risk
• Dentistry, Endocrinology, Cardiology, Pulmonology

21
Thank you!

• Brian L. Abbott, M.D.
• Late Complications in Pediatric Cancer Survivors
• November 6, 2008