Correspondence
Survivors of Childhood Cancer
N Engl J Med 2007; 356:191-194January 11, 2007
- Article
To the Editor:
Oeffinger et al. (Oct. 12 issue)1 describe the late effects of the treatment of childhood cancer. Pelvic irradiation and alkylating agents increase the risks of infertility, gonadal dysfunction, and premature ovarian failure. The child's sex and age at the time of treatment influence these risks.2
Advances in the freezing of gonadal tissue and oocytes3,4 can improve the chances that a survivor of childhood cancer will become a parent. Future research by the Childhood Cancer Survivor Study (CCSS) should address the problem of infertility, which is important to survivors of childhood cancer.5
5 ReferencesTress Goodwin, M.A.
B. Elizabeth Oosterhuis, B.A.
Stanford School of Medicine, Stanford, CA 94305
tgoodwin@stanford.edu 1
Oeffinger KC ,Mertens AC ,Sklar CA , et al. Chronic health conditions in adult survivors of childhood cancer. N Engl J Med 2006;355:1572-1582
Full Text | Web of Science | Medline2
Nicholson HS ,Byrne J . Fertility and pregnancy after treatment for cancer during childhood or adolescence. Cancer 1993;71:Suppl:3392-3399
CrossRef | Web of Science | Medline3
Wallace WH ,Anderson RA ,Irvine DS . Fertility preservation for young patients with cancer: who is at risk and what can be offered? Lancet Oncol 2005;6:209-218[Erratum, Lancet Oncol 2005;6:922.]
CrossRef | Web of Science | Medline4
Meirow D ,Levron J ,Eldar-Geva T , et al. Pregnancy after transplantation of cryopreserved ovarian tissue in a patient with ovarian failure after chemotherapy. N Engl J Med 2005;353:318-321
Full Text | Web of Science | Medline5
Goodwin T ,Oosterhuis BE ,Kiernan M ,Hudson MM ,Dahl GV . Attitudes and practices of pediatric oncology providers regarding fertility issues. Pediatr Blood Cancer 2007;48:80-85
CrossRef | Web of Science | Medline
To the Editor:
Oeffinger and colleagues highlight the need to better understand adverse outcomes among patients in whom cancer is diagnosed in adolescence or young adulthood. The 5-year survival rate for these patients is stagnant as compared with that for younger and older patients.1 The incidence of bone tumors and Hodgkin's disease increases among adolescents and young adults, but it is not clear to what extent such age-dependent differences in the incidence of cancer account for an increase in chronic health conditions.2 Other age-dependent factors such as physiological development and psychosocial factors may also be associated with early and late outcomes in this population.
Brandon Hayes-Lattin, M.D.
Oregon Health and Science University Cancer Institute, Portland, OR 97239
hayeslat@ohsu.edu for the LIVESTRONG Young Adult Alliance
Dr. Hayes-Lattin reports receiving grant support from the Lance Armstrong Foundation and a financial award from Aflac Insurance.
2 References1
Closing the gap: research and care imperatives for adolescents and young adults with cancer — report of the Adolescent and Young Adult Oncology Progress Review Group. Bethesda, MD: National Cancer Institute, 2006.
2
Bleyer A, O'Leary M, Barr R, et al., eds. Cancer epidemiology in older adolescents and young adults 15 to 29 years of age, including SEER incidence and survival: 1975-2000. Bethesda, MD: National Cancer Institute, 2006.
To the Editor:
In his Perspective article (Oct. 12 issue), Rosoff1 notes that survivors of childhood cancer require monitoring for complications of their disease into adulthood. This point is also applicable to many chronic conditions as patients move from pediatric to adult-centered medical care. Currently, more than 90% of children with a chronic health condition are expected to live for more than 20 years.2
Physicians who are trained in both medicine and pediatrics have a role in the care of such patients.3,4 More than 4000 of these physicians practice in the United States. However, every year, 500,000 children with special health care needs reach the age of 18 years,5 making the care of this population too large a task for these physicians alone. Although Rosoff raises the possibility of niche fellowship training, transitional medicine deserves broader interdisciplinary attention in academic health centers. Graduate and continuing medical education programs must address this need with new curricula.
5 ReferencesNiraj Sharma, M.D., M.P.H.
University of Miami Miller School of Medicine, Miami, FL 33136
nsharma@med.miami. edu Tom Melgar, M.D.
Michigan State University Kalamazoo Center for Medical Studies, Kalamazoo, MI 49008Chad Brands, M.D.
Mayo Clinic College of Medicine, Rochester, MN 559051
Rosoff PM . The two-edged sword of curing childhood cancer. N Engl J Med 2006;355:1522-1523
Full Text | Web of Science | Medline2
Gortmaker SL ,Sappenfield W . Chronic childhood disorders: prevalence and impact. Pediatr Clin North Am 1984;31:3-18
Web of Science | Medline3
The Future of Pediatric Education II -- organizing pediatric education to fit the needs of infants, children, adolescents, and young adults in the 21st century: a collaborative project of the pediatric community. Pediatrics 2000;105:157-212
Web of Science | Medline4
Melgar T ,Chamberlain JK ,Cull WL ,Kaelber DC ,Kan BD . Training experiences of U.S. combined internal medicine and pediatrics residents. Acad Med 2006;81:440-446
CrossRef | Web of Science | Medline5
Reiss J ,Gibson R . Health care transition: destinations unknown. Pediatrics 2002;110:1307-1314
Web of Science | Medline
To the Editor:
Oeffinger et al. report that among survivors of childhood cancer, the adjusted relative risk of a chronic health condition was 3.3, but some subgroups had a relative risk of more than 10. Therefore, other survivors of cancer must have had a lower relative risk, which means that risk-adapted follow-up strategies are needed. However, Rosoff's Perspective article raises more concern about the effects and outcomes of cancer treatment than may be warranted.
In Western countries, most children with cancer are cured. For these survivors, it is important that at a certain time they are officially declared cured. They need to pursue their lives as normal people. Although they may have chronic health problems, they generally seem to rate their well-being no differently than do their peers.1 Long-term effects have to be viewed from this perspective.
1 ReferencesRiccardo Haupt, M.D.
Gaslini Children's Hospital, 16147 Genoa, Italy
riccardohaupt@ospedale-gaslini.ge. it Momcilo Jankovic, M.D.
University of Milan, Bicocca, 20052 Monza, ItalyAnjo J.P. Veerman, M.D., Ph.D.
Vrije Universiteit Medical Center, 1007 MB Amsterdam, the Netherlandsfor the International Berlin–Frankfurt–Münster Early and Late Toxicity Educational Committee
1
Langeveld NE ,Grootenhuis MA ,Voute PA ,de Haan RJ ,van den Bos C . Quality of life, self-esteem and worries in young adult survivors of childhood cancer. Psychooncology 2004;13:867-881
CrossRef | Web of Science | Medline
Author/Editor Response
We agree with Goodwin and Oosterhuis that premature ovarian failure and infertility are important problems for survivors of childhood cancer. We previously reported that in the CCSS cohort, the cumulative incidence of nonsurgical premature menopause by the age of 40 years was higher for survivors than for siblings (8.0% vs. 0.8%; relative risk, 13.21; 95% confidence interval, 3.26 to 53.51; P<0.001).1 A multiple Poisson regression model showed that risk factors for nonsurgical premature menopause included attained age, exposure to increasing doses of radiation to the ovaries, receipt of increasing doses of alkylating agents, and a diagnosis of Hodgkin's disease. For survivors who were treated with alkylating agents plus abdominopelvic irradiation, the cumulative incidence of nonsurgical premature menopause approached 30%. Although we have not yet reported on fertility rates, we have reported on pregnancy outcomes in women who have been treated for childhood cancer.2 We did not identify adverse outcomes of pregnancy for female survivors treated with most chemotherapeutic agents or radiation therapy (except pelvic irradiation, which is associated with an increased risk of low birth weight). Since concern about the outcome of future pregnancies is common among survivors, this good news should be shared with those who are pregnant or planning to become pregnant.
Hayes-Lattin asks about the association between the patient's age at the diagnosis of cancer — specifically, the adolescent period — and the incidence of chronic health conditions. As we noted in the Results section of our report, the age of the survivor at diagnosis independently modified the risk of a chronic health condition when the analysis was adjusted for age at the time of the study, sex, and race or ethnic group. Furthermore, for each cancer group, survivors who received the diagnosis at an older age were significantly more likely to report severe, life-threatening, or disabling conditions or death due to a chronic condition. These findings suggest that survivors who receive a diagnosis of cancer in their adolescent years, such as those with a bone tumor or Hodgkin's disease, are at higher risk and deserve special attention.
2 ReferencesKevin C. Oeffinger, M.D.
Charles A. Sklar, M.D.
Memorial Sloan-Kettering Cancer Center, New York, NY 10021
oeffingk@mskcc.org Leslie L. Robison, Ph.D.
St. Jude Children's Research Hospital, Memphis, TN 381051
Sklar CA ,Mertens AC ,Mitby P , et al. Premature menopause in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. J Natl Cancer Inst 2006;98:890-896
CrossRef | Web of Science | Medline2
Green DM ,Whitton JA ,Stovall M , et al. Pregnancy outcome of female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Am J Obstet Gynecol 2002;187:1070-1080
CrossRef | Web of Science | Medline
Author/Editor Response
Sharma et al. emphasize the significance of the issue that I addressed in my Perspective article. Finding physicians who are trained to provide lifetime care for the unique and growing population of survivors of childhood cancer is already a challenge, and it will only increase as more children who are cured of cancer leave the pediatric oncology clinic. It is therefore incumbent on us to find and develop the resources required to provide adequate care for them.
Although Haupt et al. attempt to present a different view of the health risks faced by adult survivors of childhood cancer, I think they downplay the significance of chronic health problems to this population as a whole. Difficulties with access to knowledgeable and qualified caregivers, as well as additional health issues, will no doubt be magnified as these patients grow older and acquire the “normal” health conditions associated with aging. Haupt et al. do, however, make a valuable point about the use of risk-adjusted assessments in gauging our level of concern about individual subgroups of survivors, as Oeffinger and his colleagues have previously described.1 Finally, Haupt and colleagues cite Langeveld et al., who reported little difference in self-esteem and other markers of overall well-being between young cancer survivors and their age-matched peers.2 However, the investigators also showed that certain subgroups of heavily treated patients clearly rated the quality of their lives differently than did their peers. Langeveld et al. also reported that these patients showed signs of long-term psychological problems such as post-traumatic stress disorder.3
3 ReferencesPhilip M. Rosoff, M.D.
Duke University School of Medicine, Durham, NC 277101
Landier W ,Bhatia S ,Eshelman DA , et al. Development of risk-based guidelines for pediatric cancer survivors: the Children's Oncology Group Long-Term Follow-Up Guidelines from the Children's Oncology Group Late Effects Committee and Nursing Discipline. J Clin Oncol 2004;22:4979-4990
CrossRef | Web of Science | Medline2
Langeveld NE ,Grootenhuis MA ,Voute PA ,de Haan RJ ,van den Bos C . Quality of life, self-esteem and worries in young adult survivors of childhood cancer. Psychooncology 2004;13:867-881
CrossRef | Web of Science | Medline3
Langeveld NE ,Grootenhuis MA ,Voute PA ,de Haan RJ . Posttraumatic stress symptoms in adult survivors of childhood cancer. Pediatr Blood Cancer 2004;42:604-610
CrossRef | Web of Science | Medline
