Book Review

Survivors of Childhood Cancer: Assessment and Management

N Engl J Med 1994; 331:1245November 3, 1994

Article

Survivors of Childhood Cancer: Assessment and Management
Edited by Cindy L. Schwartz, Wendy L. Hobbie, Louis S. Constine, and Kathleen S. Ruccione. 413 pp., illustrated. St. Louis, Mosby, 1994. $45. ISBN: 0-8016-6521-3

Few general physicians caring for adults under 45 years of age realize that in a given year their patient population includes as many survivors of childhood cancer as patients who will be newly diagnosed with breast or lung cancer. Schwartz et al. remind us that over 60 to 70 percent of children now survive after the diagnosis of cancer; 1 in 900 persons between 15 and 45 years of age is a survivor of childhood cancer. This book is a much-needed scholarly guide to the evaluation and care of these survivors, many of whom have complex problems.

The late effects of therapy for cancer can be classified according to the original type of cancer, specific therapies that have been administered (e.g., radiation therapy or alkylating agents), or the organ system involved. The editors grapple admirably with this problem of organization by devoting the first 80 pages of their book to tables of common treatments for each type of cancer (chapter 1) and to listings of symptoms and related organ dysfunction resulting from previous therapies (chapter 2). The first chapter is understandably incomplete (anthracyclines are not included among the drugs used for the treatment of neuroblastoma), but the charts are invaluable for internists unfamiliar with pediatric oncology. In the second chapter, the lists of a panoply of symptoms and causes are unwieldy and impractical and may be misleading. For example, the list of causes of abdominal pain does not include constipation as a possible cause, because constipation is not a dysfunction linked to previous therapy for cancer.

Each of the next 11 chapters provides an excellent, thoroughly referenced review of an organ system by experts in the field. Each begins with a thoughtful section on normal organ development and physiology, with anatomical diagrams and graphs illustrating normal as compared with pathologic development. The chapter on the central nervous system is a balanced summary of studies in this critical field, and it addresses difficult management issues, such as school intervention policies. Other outstanding chapters include those on neuroendocrine complications, ophthalmologic effects, and thyroid problems. For the physician ignorant of dental deficiencies, there is a tabular summary of normal enamel and root formation, as well as an explanation of the effect of radiation on salivary glands and taste buds, which may lead, for example, to a craving for sweets.

Radiation therapists will be pleased with the detailed reviews of data on the relation between the radiation dose and toxicity in the chapters on late effects on the lung and gonads, as well as the useful guide to an evaluation of primary and secondary amenorrhea. The chapters on late cardiac and gastrointestinal effects are equally comprehensive, but leave the reader with confusing recommendations regarding the frequency of screening tests, with no mention of cost effectiveness. Throughout, the chapter authors thoughtfully address key psychological concerns, such as body image and worries about second cancers. However, the brief chapter on survivorship does not do justice to the need for a professional overview of the psychological issues that these patients face. In contrast, a national expert covers legal issues such as employment tactics and health coverage superbly and gives readable advice for both the medical care giver and the survivor. The final sections on statistical and epidemiologic methods, educational-liaison personnel, and computerization of follow-up data are optional addenda but may be useful for those involved in establishing late-effects clinics.

Overall, this handy book has the feel and readability of a splendid pocket manual. It should become dog-eared as a comprehensive clinic reference for physicians and nurse practitioners caring for children with cancer and the growing number of adult survivors.

Cynthia S. Kretschmar, M.D.
New England Medical Center, Boston, MA 02111