The price of surviving childhood cancer

Surviving cancer is challenging enough, but now a recent report highlights the fact that survivors face double the chronic health challenges of the general population as a result of curative cancer therapies.

In The Lancet, researchers at St. Jude Children’s Research Hospital in Memphis, Tennessee, surveyed children who survived 10 years or longer beyond an initial childhood cancer diagnosis.

Of the more than 5000 patients studied, 54.5% were still alive at the time of the report. The researchers also evaluated chronic health conditions faced by these patients after treatment, grading those conditions by severity. They found that by age 50 years, childhood cancer survivors on average faced 17.1 chronic health conditions-4.7 of which were severe, disabling, or life threatening. In comparison, the general population faced 9.2 chronic health conditions by age 50 years, with 2.3 of those being severe.

The study highlights the fact that although childhood cancer cure rates are increasing, cures come at a price. Lead author Nickhill Bhakta, MD, MPH, an assistant faculty member of the St. Jude Department of Global Pediatric Medicine, says more than 80% of children with cancer now have an over-10-year survival rate, but 30-year-old survivors are faced with chronic health conditions similar to a 60-year-old in the general population. Part of the problem is that the treatment methods that help cure cancer-particularly chemotherapy and radiation-damage other healthy tissue in addition to cancerous cells, leading to long-term comorbidities.

“Managing pediatric cancer survivors in a busy practice is not easy. It has been well documented that pediatric cancer survivors, as a group, experience more chronic health conditions compared to the general population. It has also been postulated that this excess morbidity or illness corresponds to an early aging process potentially as a result of the types of chemotherapy and radiation that they experience in order to cure their cancer,” Bhakta says.

He says the study highlights the fact that all survivors are not the same, and that the development of chronic conditions varies substantially based on age, type of cancer, treatments, and when they were treated. “This is important as we cannot just apply a single method that effectively manages everyone. Quality care delivery is hard and takes a lot of work,” he says.

Second, Bhakta says survivors represent a vulnerable population with a greater number of chronic health conditions compared to the general population. “This increased risk of illness occurs at all ages, not just right after they are cured. I would strongly encourage pediatricians to engage their pediatric oncology colleagues to identify specialists with late-effects experience to help comanage their patients and ensure adherence to the late-effect guidelines produced by the Children’s Oncology Group,” he adds.

Primary care providers play an important role in the management of pediatric cancer patients, Bhakta says, because they often have the first opportunity to identify chronic health conditions in survivors.

“Hopefully the data and visualizations from this paper can help pediatricians quickly review the types of chronic health conditions they should diligently monitor and follow,” Bhakta says. “However, there are 2 key ways that pediatricians can improve the health of survivors. First, being aware and adhering to the Children’s Oncology Group late-effect guidelines is critical. This requires a basic knowledge of their patient’s treatment and type of cancer. As not all patients know this information, open communication with late-effect clinics and their clinical oncology colleagues in the treating section is the second key factor.”

However, because primary care providers see patients more than specialists, they may be better suited to recognize new chronic conditions early and offer appropriate intervention for improved long-term outcomes.

“Right now, most people use the words ‘childhood cancer survivor’ as a generic term to apply to a really diverse and complex population. This paper illuminates 2 things: first that these survivors have substantial early chronic disease that is distinct from that seen in the aging population, and [second] that there are major differences from survivor to survivor depending on their primary cancer subtype and treatment exposures,” Bhakta says. “Because the nuance here is critical, early referral and integration with late-effects clinics would help primary care providers manage these patients optimally in their clinical practice.”

The paper suggests that specialized, integrated care-particularly medical homes with multiple practices-is most beneficial to managing this patient population because they have the capability to address multiple medical issues along with psychosocial needs. The study also highlights the need to find ways to mitigate the chronic effects of cancer treatment.

"We wanted to get a very big picture of what the landscape of chronic health conditions looks like," Bhakta says. "It has multiple ramifications on how we do things, it affects how we screen patients and how we treat patients who've already been cured. We are doing such a good job at treating pediatric cancers, we can now look at whether we really need to use as much of these medicines to still get the same effect."