Chronic health conditions in adult survivors of childhood cancer

Late Mortality Among Survivors of Childhood Cancer in Canada: A Retrospective Cohort Study

BACKGROUND

Children with cancer face an increased risk of complications and death beyond the 5-year survival mark. National surveillance efforts facilitate the systematic tracking of long-term health outcomes, including treatment-related complications and late mortality, among childhood cancer survivors. We aimed to describe the population of 5-year childhood cancer survivors in Canada, quantify the risk of death among survivors relative to the general population, and identify characteristics associated with late mortality.

METHODS

This retrospective cohort study used the Canadian Cancer Registry linked to the Canadian Vital Statistics-Death database (excludes Quebec). Survivors were diagnosed with cancer before 15 years old (1992-2012) and still alive five years after diagnosis. We approximated the risk of late mortality relative to the general population using standardized mortality ratios (SMRs) and absolute excess ratios (AERs). Cumulative all-cause and cause-specific mortality and time-to-event models identified characteristics associated with late mortality.

RESULTS

Of the 10,800 5-year survivors, 405 (4%) had a late death by 2017 (median follow-up: 9.1 years). Cancer recurrence or progression caused most late deaths (64%), followed by subsequent primary neoplasms (11%) and other health-related causes (15%). Survivors had a higher risk of all-cause mortality than the general population (SMR = 9.4; 95% CI = 8.5-10.4; AER = 34.8, 95% CI = 30.8-38.8). Risk was highest in the first 5-9 years of follow-up. Cumulative mortality differed significantly by age at diagnosis, sex and cancer type.

INTERPRETATION

Our results underline the importance of long-term surveillance of childhood cancer survivors, as mortality rates remain higher than the general population for at least two decades after diagnosis.

Effectiveness of a dose-graded aerobic exercise regimen on cardiopulmonary fitness and physical performance in pediatric survivors of acute lymphoblastic leukemia: a randomized clinical trial

PURPOSE

To determine whether a 12-week supervised dose-graded aerobic exercise (D-GAE) training, when implemented in conjunction with traditional rehabilitation, could help pediatric survivors of acute lymphoblastic leukemia (ALL) enhance their cardiopulmonary capacity and improve their physical performance.

METHODS

Fifty-eight pediatric survivors of ALL (age 13.78 ± 2.47 years; boys 60.34%) were assigned at random to either undergo the D-GAE in addition to the traditional physical rehabilitation (D-GAE group; n = 29) or the traditional physical rehabilitation solely (control group; n = 29). The cardiopulmonary fitness (peak oxygen uptake (VO2peak), ventilatory equivalent (VEq/VO2), minute ventilation (VE, L/min), oxygen pulse (O2P), maximum heart rate (HRmax), 1-min heart rate recovery (HRR1), and respiratory exchange ratio (RER)) and physical performance (6-min walk test (6-MWT), timed up and down stairs (TUDS), and 4 × 10-m shuttle run test (4 × 10mSRT)) were assessed on the pre- and post-intervention occasions.

RESULTS

The mixed-model ANOVA revealed a meaningful increase of VO2peak (P = .002), VE (P = .026), O2P (P = .0009), HRmax (P = .004), and HRR1 (P = .011), and reduction of VEq/VO2 (P = .003) and RER (P = .003) in the D-GAE group compared with the control group. Besides, the analysis detected a favorable increase in the physical performance for the D-GAE group (6-MWT (P = .007), TUDS (P < .001), 4 × 10mSRT (P = .009)).

CONCLUSION

A 12-week D-GAE program in conjunction with traditional rehabilitation holds promise in enhancing cardiopulmonary fitness and improving the physical performance of pediatric survivors of ALL. Clinicians and physical rehabilitation professionals can, therefore, integrate the D-GAE into the traditional rehabilitation protocols for such a patient population to optimize their cardiopulmonary fitness and physical function, while also facilitating a gradual transition to practice and adaption.

IMPLICATIONS FOR CANCER SURVIVORS

The favorable outcomes of this study bolster the inclusion of D-GAE as a crucial element in the care and rehabilitation of pediatric survivors of ALL. By embracing these findings, healthcare professionals and oncologists can contribute to mitigating the long-term cardiopulmonary and physical complications associated with cancer treatments and fostering a state of enhanced well-being and increased physical activity among survivors.

Altered retinal vasculature in childhood cancer survivors: Data from the German CVSS-study

AIMS

Childhood cancer is a risk factor for cardiovascular diseases in later life. Retinal examination allows to non-invasively observe the vasculature of an end-organ. We observe alterations in long-term childhood cancer survivors (CCS).

METHODS

In the Cardiac and Vascular Late Sequelae in Long-Term Survivors of Childhood Cancer-Study, 1002 CCS (23-48 years) having neoplasia prior to 15 years of age were prospectively enrolled in a general and ophthalmologic examination including fundus photography. Central retinal vessel equivalents (arterial: CRAE; venous CRVE) were measured and linear regression analysis was computed to compare CCS to controls from the population-based Gutenberg Health Study (GHS) with adjustment for potential cardiovascular and ophthalmological confounders. Differences in cancer types and treatments were explored.

RESULTS

For 837 CCS (45.3% female), CRAE and CRVE were conducted. Both were smaller in CCS previously having leukaemia, central nervous system tumour, neuroblastoma, renal tumour, malignant bone tumour, soft tissue sarcoma and germ cell tumour than in GHS controls. No difference was found for CCS with prior lymphoma. Previous radiotherapy of head or neck was associated with a smaller CRVE. Higher mean arterial blood pressure and intake of antihypertensive medication were associated with smaller CRAE.

CONCLUSIONS

Retinal vasculature is altered in CCS leading to smaller retinal arteries and veins. Our finding indicates that childhood cancer and its treatment leads to systemic alterations of the microcirculation on both branches of the vasculature system. While the retinal venous vasculature is altered by radiotherapy, the lower vessel width of the arterial branch is associated with arterial hypertension.

[Organizing survivorship: transition and long-term care for childhood cancer survivors]

BACKGROUND

Survivors of childhood or adolescent cancer have high long-term survival rates due to improved therapies but often suffer from complex late and long-term effects which should be diagnosed and treated early.

OBJECTIVE

Existing models of transition and long-term follow-up care for adult survivors of childhood and adolescent cancer in Germany are presented and perspectives for care and research in this field are outlined.

RESULTS

There is potential for improvement in the area of networking of the medical disciplines involved as well as in the involvement and education of patients.

CONCLUSIONS

Nationwide harmonization and standardization of long-term follow-up care and transition is important to ensure that all childhood cancer survivors in Germany have access to care according to guideline recommendations.

Cardiovascular disease in adolescent and young adult survivors of non-Hodgkin lymphoma in Korea

PURPOSE

Long-term cardiovascular risk in adolescent and young adult (AYA) survivors of non-Hodgkin lymphoma (NHL) remains insufficiently characterized. This retrospective cohort study investigated the incidence of cardiovascular disease (CVD) among AYA survivors of NHL.

METHODS

We identified 4553 individuals aged 15-39 years diagnosed with NHL between 2006 and 2019 using the Korean National Health Insurance System database. A control group of 13,659 individuals without a history of cancer or CVD was selected using 1:3 matching based on age, sex, and residential area. The primary outcomes were major adverse cardiovascular events such as myocardial infarction, cardiomyopathy, heart failure, ischemic stroke, and hemorrhagic stroke. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazard models.

RESULTS

The mean (SD) age of the participants was 29.5 (6.8) years, and 59% were male. Over a median follow-up of 6.5 years, survivors of NHL had significantly higher risks of cardiomyopathy (HR 6.77; 95% CI 3.44-13.33), heart failure (HR 4.90; 95% CI 3.45-6.97), and hemorrhagic stroke (HR 3.14; 95% CI 1.75-5.65), compared to controls. In the subgroup analyses stratified by treatment modality, the highest risks were observed among patients who underwent hematopoietic stem cell transplantation, which involved high-dose chemotherapy with or without radiotherapy. The risk of myocardial infarction and ischemic stroke did not increase significantly.

CONCLUSION

AYA survivors of NHL had a significantly higher risk of CVD, including cardiomyopathy, heart failure, and hemorrhagic stroke, than the general population.

IMPLICATIONS FOR CANCER SURVIVORS

Long-term cardiovascular surveillance is essential for AYA survivors of NHL, particularly those receiving intensive treatment.

Fertility Preservation Discussions And Decisions: Results From a Pilot Randomized Controlled Trial Among Adolescent Males With Cancer

BACKGROUND/OBJECTIVES

The Family-centered Adolescent Sperm banking values clarification Tool (FAST) was developed to facilitate sperm banking communication and decision-making pre-cancer treatment. The FAST was tested in a pilot parallel randomized controlled trial (Fertility Preservation Discussions And Decisions: "FP-DAD"-NCT04268004), aiming to (i) assess feasibility/acceptability of FP-DAD; and (ii) examine efficacy regarding banking attempts (yes/no) and decision quality. Differences in decision quality by banking attempt were explored.

DESIGN/METHODS

Males (12-25 years, new cancer diagnosis) and caregivers were randomized to standard of care (fertility consult) or FP-DAD (fertility consult + FAST + interventionist-led discussion). One month later, FP-DAD participants completed acceptability surveys. Both arms completed the Brief Subjective Decision Quality measure. Descriptive statistics, chi-square, and independent samples t-tests/mixed-models examined relationships between variables.

RESULTS

Acceptability ratings of FP-DAD were high (88%-100%). Recruitment and participation challenges limited the final sample size (21 adolescents and 32 caregivers). Banking attempts (67% in standard of care vs. 82% in FP-DAD) did not differ by arm. While decision quality was not significantly different between groups, effect sizes were medium-large for four of six items for adolescents (d = 0.6 to -0.90) and two of six for caregivers (d = 0.36 to -0.78). Decision quality was significantly higher across several domains among those who banked.

CONCLUSIONS

FP-DAD had high acceptability, though feasibility challenges (e.g., time contraints) limited full family participation. Findings showed limited efficacy, but effect sizes suggest this may be due to sample size. Relationships between banking attempts and decision quality emphasize banking benefits. Findings will inform adaptations to the FAST for clinical implementation.

Patient Characteristics and Neighborhood-Level Social Determinants of Health Associated with Childhood Cancer Survivor Follow-Up at Urban Cancer Centers

BACKGROUND

Many childhood cancer survivors (CCS) do not receive long-term follow-up care. We investigated the association of patient characteristics and neighborhood-level social determinants of health (SDOH) with follow-up.

METHODS

CCS (N = 354) diagnosed 2013-2022 at age <18 years were identified from cancer registries at two urban hospitals. Demographics and cancer history were abstracted from the cancer registries, supplemented by electronic health record data. Vital status was ascertained from the National Death Index. Neighborhood-level SDOH was measured with social vulnerability index, childhood opportunity index, and area deprivation index. Outcomes included survivorship clinic attendance ≥ 2 years posttherapy and any ambulatory visit ≥3 and ≥5 years posttherapy at the hospitals.

RESULTS

Survivorship clinic attendance was 52% ≥2 years posttherapy. Nonattendance was associated with adolescent age at diagnosis (42% for 11-17 vs. 65% for 6-10 years; p = 0.012), non-Hispanic Black race and ethnicity versus non-Hispanic White (32 vs. 57%, p = 0.048), and central nervous system (CNS) versus hematologic cancer (19 vs. 54%, p = 0.0005). The frequency of any ambulatory visit declined from 60% ≥3 years posttherapy to 40% ≥5 years posttherapy. Although 60% of CNS cancer survivors remained in ambulatory follow-up ≥5 years posttherapy, only 19% attended survivorship clinic. In multivariate analyses, neighborhood-level SDOH measures were not associated with follow-up.

CONCLUSIONS

There was a substantial drop in follow-up among CCS from 3 to 5 years posttherapy. Future studies of follow-up should focus on engagement of CNS cancer survivors, patients diagnosed during adolescence, and minority groups.

Dosimetric comparison of intensity-modulated proton therapy and proton arc therapy for pediatric ependymoma

BACKGROUND AND PURPOSE

Proton Arc Therapy (PAT) is an emerging proton therapy treatment modality with the potential to reduce radiation exposure to healthy tissues compared to conventional Intensity-Modulated Proton Therapy (IMPT) with fewer beams. This is an attractive option for treating pediatric patients, who are vulnerable to radiation-induced side effects. There is, however, a need to investigate the redistribution of dose to the target volume and organs at risk. In this study, we therefore explored the potential of PAT in proton therapy of pediatric ependymoma.

METHODS AND MATERIALS

Three-field IMPT and PAT treatment plans for 10 pediatric ependymoma patients were optimized using the Eclipse treatment planning system. The PAT plans consisted of 8 fields, spanning 170 degrees. Both modalities were robustly optimized with a ± 2 mm isocenter shift and a ± 3% range uncertainty.

RESULTS

PAT showed improved CTV coverage compared to three-field IMPT, with a distinct increase in D98%. A clear dose reduction was found for the cochleae, with median values of 9.32 Gy(Relative Biological Effectiveness [RBE]) [0.76 - 30.40 Gy(RBE)] and 18.30 Gy(RBE) [1.24 - 29.75 Gy(RBE)] for PAT and IMPT, respectively, for the right cochlea. For the left cochlea, the respective doses were 12.34 Gy(RBE) [2.81 - 30.94 Gy(RBE)] and 18.49 Gy(RBE) [4.27 - 31.97 Gy(RBE)]. No significant difference for the brain integral dose was found between the two modalities.

INTERPRETATION

PAT can improve the dosimetric outcome of proton therapy in pediatric ependymoma patients. Organs at risk dose varied on a patient-to-patient basis; thus, individual treatment plan comparisons are recommended.

Assessing the effect of virtual navigation interventions to improve health insurance literacy and decrease financial burden in cancer survivors: The HINT II study protocol

BACKGROUND

Childhood cancer survivors often face high healthcare costs to monitor and manage new or lasting effects of their treatment. Enhancing survivors' health insurance literacy (HIL) - the knowledge, ability, and confidence in enrolling in and navigating health plans - is vital for minimizing financial burden. Few studies have assessed the effect of a health insurance navigation program on improving HIL among survivors. We present the protocol for an ongoing randomized controlled trial (RCT) assessing the effectiveness of two health insurance navigation programs (HINT-S and HINT-A) on improving HIL, financial burden, out-of-pocket costs, and healthcare utilization for adult survivors of childhood cancer.

METHODS

This three-arm RCT assesses the effectiveness of two digitally delivered health insurance navigation interventions and enhanced usual care (EUC) on improving HIL at six and 12 months in a national cohort of childhood cancer survivors. While HINT-S is composed of five synchronous, navigator-led sessions, HINT-A is an asynchronous, prerecorded set of five videos. EUC participants receive only a health insurance informational booklet. Financial burden, medical out-of-pocket costs, and healthcare utilization (receipt of preventive care, recommended screenings/vaccinations, and acute care) are assessed at 12 months. Moderators to the interventions' effectiveness will be investigated, as well as implementation outcomes (feasibility, acceptability, appropriateness, fidelity, and cost-effectiveness).

CONCLUSIONS

There is a strong need for interventions to improve cancer survivors' HIL, helping them navigate the complexity of the U.S. healthcare system. This trial will elucidate the potential effectiveness and implementation of health insurance navigation programs that may benefit many cancer survivors.

TRIAL REGISTRATION

NCT05527392.

Latent Profile Analysis of Symptom Clusters in Children and Adolescents With Malignant Tumors During Radiotherapy

BACKGROUND

Children undergoing treatment for cancer may experience a range of adverse symptoms, yet there is limited information on the symptoms they experience during radiotherapy and the potential heterogeneity among these symptoms.

OBJECTIVE

This study aimed to describe the symptom profiles of children during radiotherapy, identify subgroups of children with cancer experiencing similar symptom patterns, and evaluate differences in demographic and clinical characteristics across these subgroups.

METHODS

A total of 154 children were assessed using the Chinese version of the Memorial Symptom Assessment Scale 10-18. Latent profile analysis was used to identify distinct subgroups of patients based on symptom occurrence profiles with a prevalence greater than 40%.

RESULTS

Children experienced multiple adverse symptoms during radiotherapy. The best-fitting model identified 3 distinct symptom profiles: low symptom prevalence, high symptom prevalence, and high gastrointestinal symptom prevalence. Significant differences were observed among subgroups based on age, family income, demographic factors, and clinical characteristics, including treatment type, the number of patients currently receiving radiotherapy, radiotherapy site, and recent chemotherapy within the past week.

CONCLUSIONS

This study found that children experienced various adverse symptoms during radiotherapy, with notable heterogeneity in symptom profiles identified through latent profile analysis. Symptom prevalence varied according to demographic and clinical characteristics.

IMPLICATION FOR PRACTICE

This study highlights the need for healthcare providers to focus on different patient subgroups and provide targeted prevention and early intervention strategies for managing symptoms in children during radiotherapy.

Role of genetic modifiers on pulmonary consequences of cancer therapy in children

Childhood cancer survivors (CCS) often face late-onset adverse effects, with pulmonary complications being particularly common. In this study, we analyzed 104 CCS with pulmonary issues post-treatment using a genome-wide association study (GWAS) to identify genetic susceptibility markers. Among the cohort, 20% were diagnosed with interstitial lung disease (ILD), while other complications included pulmonary fibrosis (3%) and bronchiolitis obliterans (3%). Pulmonary function test (PFT) impairments were present in 74% of patients, with symptoms such as exertional dyspnea (14%) and chronic cough (9%). Imaging revealed bronchiectasis in 7% of patients. Although no genome-wide significant loci were identified, several loci of suggestive significance were detected, including rs6804526 (P = 6.21 × 10-5) and rs117985268 (P = 2.98 × 10-5), which are previously associated with breast cancer and respiratory failure, respectively. Additionally, copy number variation (CNV) analysis identified a 21q22.3 deletion in one patient, a region linked to lung cancer. While no genome-wide significant loci were found, these suggestive loci and CNV findings highlight potential genetic modifiers of pulmonary risk in CCS, warranting further investigation in larger cohorts to confirm these associations.

Chronic Kidney Disease or Hypertension After Childhood Cancer

Importance

Post-cancer therapy kidney outcomes, including chronic kidney disease (CKD) and hypertension, are common in childhood cancer survivors (CCS). The incidence and timing of CKD and hypertension in CCS compared with other at-risk or general populations are unclear.

Objective

To determine the association of childhood cancer treatment with post-cancer therapy CKD or hypertension.

Design, Setting, and Participants

Population-based matched cohort study of children treated for cancer between April 1993 and March 2020 in Ontario, Canada, with follow-up until March 2021. The CCS (exposed) cohort included children (≤18 years) surviving cancer. Comparator cohorts were a hospitalization cohort (children who were hospitalized) and a general pediatric population (GP) cohort (all other Ontario children). Exclusion criteria were history of previous cancer, organ transplant, CKD, dialysis, or hypertension. Matching with each of the 2 comparator cohorts was performed separately and in a 1:4 ratio by age, sex, rural vs urban status, income quintile, index year, and presence of previous hospitalization. Data were analyzed from March 2021 to August 2024.

Exposure

Treatment for cancer.

Main Outcomes and Measures

The primary outcome was the composite of CKD or hypertension, defined by administrative health care diagnosis and procedure codes. Fine and Gray subdistribution hazard modeling, accounting for competing risks (death and new cancer diagnosis or relapse) and adjusting for cardiac disease, liver disease, and diabetes, was used to determine the association of cancer treatment with outcomes.

Results

There were 10 182 CCS (median [IQR] age at diagnosis, 7 [3-13] years; 5529 male [54.3%]; median [IQR] follow-up time, 8 [2-15] years) matched to 40 728 hospitalization cohort patients (median [IQR] age at diagnosis, 7 [2-12] years; 5529 male [weighted percentage, 54.3%]; median [IQR] follow-up time, 11 [6-18] years) and 8849 CCS (median [IQR] age at diagnosis, 5 [2-11] years; 4825 male [54.5%]; median [IQR] follow-up time, 7 [2-14] years) matched to 35 307 GP cohort individuals (median [IQR] age at diagnosis, 6 [2-11] years; 4825 male [weighted percentage, 54.5%]; median [IQR] follow-up time, 10 [5-16] years). Most frequent cancer types were leukemia (2948 patients [29.0%]), central nervous system neoplasms (2123 patients [20.9%]), and lymphoma (1583 patients [15.5%]). During observation, cumulative incidence of CKD or hypertension was 20.85% (95% CI, 18.75%-23.02%) in the CCS cohort vs 16.47% (95% CI, 15.21%-17.77%) in the hospitalization cohort and 19.24% (95% CI, 15.99%-22.73%) in the CCS cohort vs 8.05% (95% CI, 6.76%-9.49%) in the GP cohort. CCS were at increased risk of CKD or hypertension compared with the hospitalization cohort (adjusted hazard ratio, 2.00; 95% CI, 1.86-2.14; P < .001) and the GP cohort (adjusted hazard ratio, 4.71; 95% CI, 4.27-5.19; P < .001).

Conclusions and Relevance

In this population-based study, CCS were at increased risk for CKD and hypertension, which are associated with mortality, suggesting that early detection and treatment of these conditions in CCS may decrease late complications and mortality.

Bone mineral status at diagnosis οf children with hematologic malignancy

Reduced bone mineral density (BMD) has been reported during and after treatment of children with hematologic malignancies. However, little is known about the skeletal status of these patients at diagnosis. The aim of this study was to evaluate the skeletal profile of newly diagnosed pediatric patients with Acute lymphoblastic leukemia (ALL), Hodgkin Lymphoma (HL), and Non-Hodgkin Lymphoma (NHL). A case-control study included 50 children with ALL, 11 with HL, and 10 with NHL and compared them to 108 sex- and age-matched controls. Patients underwent bone metabolism evaluation and dual-energy X-ray absorptiometry (DXA) scan at the time of diagnosis. Seventy-one children were evaluated (43 boys) with a median age of 8.25 years (2.16-17.33 years). Twenty-one with ALL had bone pain (16 with a limp pain) at diagnosis. More than half (59.1%) of the patients were vitamin D sufficient (25-ΟΗ-D > 20 ng/ml). Patients had lower values of serum procollagen type I C-terminal propeptide (PICP), osteocalcin (OC), and tartrate-resistant acid phosphatase (bTRAP5b) (p < 0.001) than controls. A DXA scan was performed in 45 patients. Patients with ALL and Lymphoma had lower values of Lumbar Spine (L1-L4, LS) BMD Z-score (p < 0.001, p < 0.01, respectively) while those with ALL had lower values of Total Body Less Head (ΤBLH) BMD Z-score (p = 0.003) than controls. Skeletal health is adversely affected in pediatric patients with ALL and Lymphoma at diagnosis. These observations support bone health surveillance in cancer patients and timely intervention starting at the time of diagnosis.

Accelerated Aging in Cancer and Cancer Treatment: Current Status of Biomarkers

BACKGROUND

Aging in humans is a heterogeneous process influenced by both biological and chronological factors. Biological age reflects an individual's physiological reserve and functional status. Increasing evidence suggests that cancer and its therapies accelerate biological aging. Many biomarkers have been evaluated to assess the biological age of patients with cancer. These biomarkers are emerging as potential tools to predict cancer-related toxicity and an individual's functional capacity as well as to individualize treatment.

METHODS

This review summarizes the current literature on aging biomarkers in cancer patients, with a focus on markers of cellular senescence and epigenetic modification. We evaluate the existing evidence supporting their use as predictors of toxicity in patients undergoing chemotherapy and radiation therapy.

RESULTS

Biomarkers such as interleukin-6 (IL-6), leukocyte telomere length (LTL), and DNA methylation age show potential for assessing biological age, frailty, and functional reserve. The expression of p16INK4A has demonstrated promise in predicting therapy-induced toxicity and making treating decisions. However, additional confirmatory studies are necessary to further validate these biomarkers before they can be utilized as decision aids.

CONCLUSION

Aging biomarkers hold promise for individualizing cancer therapy and predicting treatment-related toxicity. However, further studies are essential to validate their reliability and support their integration into clinical practice.

Accelerated Aging in Survivors of Childhood Cancer-Early Onset and Excess Risk of Chronic Conditions

Importance

The lifetime risk of aging-related diseases among survivors of childhood cancer, accelerated by cancer treatment exposures, is unknown. Understanding this risk can provide a more comprehensive assessment of long-term health across the lifespan of survivors and guide adult care.

Objective

To estimate the lifetime risks of 8 treatment-related cancers and cardiovascular conditions among childhood cancer survivors and compare them with the general population.

Design, Setting, Participants

Using data from the Childhood Cancer Survivor Study and national databases, this simulation modeling study projected long-term outcomes for 5-year survivors diagnosed between 1970 and 1999 based on treatment exposures and age-related risks. The general population comparator was simulated using age-, sex-, and calendar year-matched individuals who faced only age-related risks.

Exposures

Treatment era (1970s, 1980s, 1990s), original cancer diagnosis, radiation treatment for primary diagnosis (any, none).

Main Outcomes and Measures

Estimated lifetime risks of 8 health conditions (breast cancer, colorectal cancer, glial tumors, sarcomas, heart failure, coronary heart disease/myocardial infarction, stroke, and valvular disease). Risks were projected and compared with the general population, stratified by radiation exposure.

Results

In the general population, 20% developed at least 1 health condition by age 65.0 years; in 5-year survivors this threshold was reached at age 47.3 years, representing a 17.7-year (95% uncertainty interval [UI], 14.0-21.0) acceleration in disease onset. By age 65 years, 55% of survivors were projected to develop at least 1 condition, indicating a 2.7-fold (95% UI, 2.2-3.5) higher relative risk and 34.2% (95% UI, 28.3-42.5) absolute excess risk compared with the general population. Risks were higher among those treated with radiation therapy for childhood cancer (22.0 years earlier onset [95% UI, 18.0-25.0]; 37.3% excess risk [95% UI, 31.6%-44.7%]) but still elevated for those without radiation exposure (13.5 years earlier onset [95% UI, 10.0-16.0]; 31.0% excess risk [95% UI, 23.9%-40.3%]). Reaching middle age was still associated with increased health risks. Compared with the general population, survivors who reached age 40 years had a 6.2-fold higher risk (95% UI, 4.8-9.4) of developing a new condition within 10 years.

Conclusions and Relevance

This study found that survivors of childhood cancer experience accelerated onset of aging-related diseases, regardless of prior radiation exposure. These findings underscore the importance of prioritizing cancer and cardiovascular disease prevention among survivors decades earlier than for the general population.

Healthcare Professional Perspectives on Digital Health-Related Quality-of-Life Assessment in Paediatric Radiation Therapy: A Qualitative Study

INTRODUCTION

Health-related quality of life (HRQoL) is not routinely evaluated using patient-reported outcome measures (PROMs) in paediatric radiation therapy (RT). This study aimed to identify barriers and facilitators to HRQoL implementation in paediatric RT clinical practice and requirements for a digital PROM platform, from the perspectives of healthcare professionals.

METHOD

Exploratory semi-structured interviews were conducted with multidisciplinary clinicians from two hospitals providing care to paediatric RT patients. Interviews were transcribed verbatim, descriptively coded and analysed using content analysis. Consolidated Framework for Implementation Research (CFIR) was used as a theoretical framework for data collection, analysis and interpretation.

RESULTS

Nine interviews were held with nurses (n = 3), radiation therapists (n = 3), radiation oncology registrars (n = 2) and a consultant family therapist. Participants identified digital, clinical and child-friendly features to inform platform development. All participants recognised the proposed digital platform to be of value by generating new information to support patient care. The perceived alignment with clinical workflows, potential to provide staff satisfaction and individual scope to act on PROM results were key facilitators. Clinical time pressures, transient staffing and reluctance for change were identified as potential barriers. Engagement of clinical staff and training in addressing psychosocial concerns were recommended to support clinical actioning of results and foster successful clinical uptake.

CONCLUSION

This study used CFIR to systematically identify requirements for a digital platform and barriers to routine patient-reported HRQoL collection in the paediatric RT setting. The facilitators and complexities of PROM implementation can inform platform development and future implementation strategies.

Best clinical practise guidance for oral health care management of long-term childhood cancer survivors (CCS): an EAPD policy document

PURPOSE

The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help clinicians manage the oral health of long-term childhood cancer survivors.

METHODS

An expert group conducted a systematic review of the relevant literature on oral health care management of long-term childhood cancer survivors (CCS). The workshop was held during the corresponding EAPD interim seminar in Prague in May 2023. Several clinical based recommendations and statements were agreed upon, and gaps in our knowledge were identified.

RESULTS

The evidence regarding prevalence was limited to retrospective studies of moderate to good quality. Oral hygiene of CCS was worse compared to healthy individuals, showing higher values for gingival and plaque indices. Similarly, survivors had increased caries risk with higher mean dmft/DMFT and dt/DT values. The most common radiographic defects were impaired root growth in the permanent teeth and tooth agenesis. Enamel developmental defects, microdontia, and hypodontia were also commonly diagnosed. Age at start of treatment was identified as a risk factor, for the development of microdontia, tooth agenesis, and root defects in patients treated at age <3 years. The type of treatment also appeared to influence the risk, as an increased prevalence of dental caries and a higher frequency of root malformations were found in patients who had undergone concomitant radiation therapy, although evidence was limited. Treatment duration was not found to be a risk factor.

CONCLUSION

These guidelines provide recommendations for dental management for childhood cancer survivors defined as children and adolescents up to the age of 19 years, regardless of age at initial diagnosis and treatment initiation.

Late-onset epilepsy in survivors of childhood cancer outside the central nervous system: a study within the Adult Life after Childhood Cancer in Scandinavia (ALiCCS) study

PURPOSE

Although epilepsy has been reported in survivors of childhood cancer outside the central nervous system (CNS), little evidence exists on risk factors for this late complication. Our study aimed to identify risk factors of late-onset epilepsy.

METHODS

A case-cohort study was conducted within 5-year survivors of non-CNS childhood cancer from the Adult Life after Childhood Cancer in Scandinavia (ALiCCS) study, including 81 survivors diagnosed with late-onset epilepsy and a sub-cohort of 231 randomly selected survivors. Detailed treatment information was obtained from medical records. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated to assess the association between treatment-related factors and epilepsy.

RESULTS

Survivors of acute lymphoblastic leukemia (ALL) and other types of leukemia exhibited significantly higher IRRs for epilepsy compared to survivors of solid tumors (ALL: 4.4, 95% CI 2.2-8.5; other leukemia: 14.1, 95% CI 3.4-57.9). Relapse was associated with an increased IRR of epilepsy (3.5, 95% CI 1.5-8.6). Specifically, survivors of relapsed leukemia demonstrated a high IRR for epilepsy (11.4, 95% CI 3.5 - 37.3) compared to non-relapsed survivors. No association was found between epilepsy and bone marrow transplantation, radiotherapy, total body irradiation, or treatment with specific chemotherapeutic agents. Finally, survivors diagnosed after 1990 had a decreased IRR of epilepsy (0.4, 95% CI 0.2 - 0.8) compared to survivors diagnosed in 1970 - 1979.

CONCLUSION

Relapsed leukemia survivors were at increased risk for late-onset epilepsy.

IMPLICATIONS FOR CANCER SURVIVORS

Awareness of the risk of epilepsy in leukemia survivors is important, especially among those with relapse, to detect and manage epilepsy early and mitigate its impact on quality of life.

A multidisciplinary and structured approach for comprehensive evaluation of functional outcomes, adverse events, psychosocial outcomes and health-related quality of life after local therapy for bone sarcoma in children: protocol for a cross-sectional study

Introduction

Bone sarcoma patients face intensive treatment, including life-changing local therapy, which impacts both short- and long-term functioning. Moreover, bone sarcoma survivors experience the highest burden of adverse events of all childhood cancer survivors. To address these issues, we set up a structured multidisciplinary outpatient follow-up clinic for patients who completed treatment and integrated this clinic into the standard of care. This study protocol describes the methodology of a cross-sectional study that aims to systematically report the functional outcomes, adverse events, psychosocial outcomes and health-related quality of life of the cohort seen at this clinic.

Methods and analysis

Participants are recruited at the multidisciplinary follow-up clinic and their consent is obtained. Standard of care clinical assessments serve as the primary data source for this study. Furthermore, additional research assessments are performed to further expand our knowledge. Assessments are structured by standardized assessment sets that we developed based on literature review and joint national expertise in bone sarcoma care. The sets comply with international guidelines such as the World Health Organization's International Classification of Functioning, disability and health, and include a combination of patient-reported, clinician-reported and performance-based outcome measures for comprehensive representation of outcomes.

Discussion

This study will generate valuable knowledge on the functional outcomes, adverse events, psychosocial outcomes and quality of life of a national cohort of pediatric bone sarcoma patients in follow-up care. By aligning additional research assessments with standardized patient care, a comprehensive range of outcomes will be obtained while minimizing the patient's burden. Moreover, this protocol may serve as a template for clinics and research internationally, allowing for the merging of standardized outcome data in such rare disease. This will facilitate the optimization of current patient care and inform the important shared decision-making process for local treatment in future patients.

Addressing Akrasia in Childhood, Adolescent and Young Adult Cancer Survivors: Implications for Long-Term Follow-Up and Preventive Health Interventions

BACKGROUND

Childhood, adolescent, and young adult cancer survivors (CAYACS) face significant long-term health risks, yet adherence to long-term follow-up (LTFU) care remains inconsistent. This study explores the concept of akrasia (i.e., acting against one's better judgment by engaging in behaviors known to be harmful or counterproductive) to understand the psychological, cognitive, and systemic barriers influencing survivor engagement in LTFU.

METHOD

Using an ethical reflection approach based on a literature review, we discussed survivor experiences, behavioral science insights, and ethical principles to identify solutions that balance patient autonomy with supportive interventions. A narrative approach was used to summarize the key points discussed during the ethics reflection group meetings.

RESULTS

Our findings highlight key barriers such as trauma, avoidance behaviors, and cognitive constraints that contribute to non-adherence. Strategies such as shared decision-making, digital health tools, and nudge-based interventions are proposed to enhance survivor engagement. Ethical considerations emphasize the need for personalized and flexible care approaches that respect survivor agency while mitigating obstacles to adherence.

CONCLUSIONS

Addressing akrasia through ethical and behavioral frameworks could improve LTFU adherence, ultimately enhancing survivorship care and long-term health outcomes.

The Clinical Utility of Next-Generation Sequencing in Childhood and Adolescent/Young Adult Solid Tumors: A Systematic Review and Meta-Analysis

BACKGROUND

Next-generation sequencing (NGS) has emerged as a transformative tool in precision medicine, offering insights into actionable genomic alterations and informing clinical decision-making in childhood and adolescent/young adult (AYA) solid tumors.

METHODS

We conducted a systematic review and meta-analysis to assess the utility of NGS in identifying actionable genomic alterations and its impact on clinical decision-making. Studies involving patients aged 0-40 years with solid tumors were included. Data were extracted using Covidence, and pooled estimates were calculated using a random-effects model. Bias was assessed using Begg-Mazumdar, Egger, and Harbord tests.

RESULTS

Out of 13,624 references screened, 24 studies met eligibility criteria, comprising 5278 patients and 5359 samples, of which 5207 provided usable data. The pooled proportion of actionable alterations was 57.9% (95% CI: 49.0-66.5%), with minimal evidence of publication bias. Clinical decision-making outcomes were reported in 21 studies, with a pooled proportion of 22.8% (95% CI: 16.4-29.9%). Germline mutation rates, reported in 11 studies, yielded a pooled proportion of 11.2% (95% CI: 8.4-14.3%), consistent with rates typically observed in childhood cancers. Significant heterogeneity was observed across studies due to differences in sequencing methodologies, tumor types, and sampling strategies.

CONCLUSIONS

NGS demonstrates considerable potential in identifying actionable genomic targets and guiding clinical decision-making in childhood and AYA solid tumors. However, the variability in methodologies underscores the need for standardized protocols and reporting practices to enhance comparability and generalizability. This meta-analysis highlights the promise of genomic medicine while acknowledging challenges posed by heterogeneity in study designs.

Altered free fatty acids levels and the onset of metabolic syndrome in childhood cancer survivors

Childhood cancer survivors (CCS) are at increased risk for various health issues, including obesity, insulin resistance, hypertension, and dyslipidemia, resulting in the development of metabolic syndrome (MetS) later in life. It has been suggested that anticancer treatment may lead to alterations in lipid metabolism, which play a role in the pathogenesis of metabolic syndrome among CCS. The prospective study included 110 CCS, with a follow-up time of 6.39 years since the end of treatment. Fasting serum of fourteen fatty acids concentrations were measured in all children using gas-liquid chromatography. Among the study group, 41 CCS (37%) met 1 or more criteria for metabolic syndrome and exhibited higher concentrations of myristic (P = 0.002), palmitic (P = 0.003), stearic (P = 0.017), oleic (P = 0. 019), arachidonic (P = 0.002), lignoceric (P = 0.005), docosahexaenoic (P = 0.005), and total fatty acids compared to CCS without metabolic syndrome factors. Additionally, overweight or obese CCS presented higher levels of myristic (P = 0.048), palmitic (P = 0.016), oleopalmitic (P = 0.019), stearic (P = 0.024), oleic (P = 0.020), α-linoleic (P = 0.023) and behenic (P = 0.036) acids compared to survivors with a normal BMI. Childhood cancer survivors develop abnormalities in lipid metabolism, which may contribute to an earlier onset of metabolic syndrome. Additionally, overweight or obesity significantly exacerbates changes in lipid metabolism.

Assessing Pulmonary Function in Children and Adolescents After Cancer Treatment: Protocol for a Multicenter Cohort Study (Swiss Childhood Cancer Survivor Study FollowUp-Pulmo)

BACKGROUND

Childhood cancer survivors (CCS) are at risk of pulmonary dysfunction due to cancer treatments, but evidence on prevalence and risk factors remains limited. Most previous studies had small sample sizes or retrospective study designs, little information about treatments, or a lack of standardization of pulmonary function tests (PFTs) or limited their investigation to certain PFTs. Since spirometry mainly assesses the large airways but cancer therapy also affects peripheral airways, additional functional tests are needed. The nitrogen multiple breath washout test (N2MBW) is sensitive to peripheral airway damage in other patient populations, but its benefit in CCS is unknown. Therefore, comprehensive and standardized evaluation of pulmonary function after cancer treatment in childhood, using different PFTs that include N2MBW, is needed to address these knowledge gaps and provide insights into possible early stages of pulmonary dysfunction.

OBJECTIVE

In the Swiss Childhood Cancer Survivor Study (SCCSS) FollowUp-Pulmo, we will comprehensively assess lung function in children and adolescents after treatment for cancer to identify risk factors for pulmonary dysfunction, assess the ability of N2MBW to detect pulmonary dysfunction compared to other PFTs, and investigate the association of functional outcomes from PFTs with self-reported respiratory symptoms.

METHODS

SCCSS FollowUp-Pulmo is a prospective multicenter longitudinal cohort study embedded in routine clinical care that enrolls CCS aged 6-20 years for whom at least 1 year has passed since a childhood cancer diagnosis, who have completed treatment, and who attend regular pediatric oncological follow-up care. Inclusion criteria comprise any of the following: systemic anticancer treatment (chemotherapy, immunotherapy, or targeted agents), thoracic surgery, thoracic radiotherapy, or hematopoietic stem cell transplantation (HSCT). CCS undergo a standardized pulmonary assessment, including spirometry, body plethysmography, diffusing capacity of the lung for carbon monoxide (DLCO), and N2MBW, and complete a questionnaire on respiratory symptoms and lifestyle. Data from previous and subsequent routine care PFTs will be included in this study.

RESULTS

Recruitment started in June 2022 at the University Children's Hospital Bern, Switzerland. Subsequently, patient recruitment expanded to the University Children's Hospitals in Basel and Geneva, Switzerland. By October 2024, we had invited 220 patients, of which 201 have already participated in this study, resulting in a response rate of 91%. Their median age at the time of the study was 14 years (IQR 10-17), and the median time since diagnosis was 7 years (IQR 4-10). The study will continuously enroll new CCS.

CONCLUSIONS

This study will contribute to a comprehensive understanding of pulmonary function in CCS and assess related risk factors, as well as the utility of N2MBW compared to other PFTs. The results will assist in the development of more targeted screening and risk-stratified follow-up care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04732273; https://clinicaltrials.gov/study/NCT04732273.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/69743.

Direct Economic Burden of Post-Cancer Treatment Pain Among Cancer Survivors in the United States: A Population-Based Retrospective Longitudinal Study

PURPOSE

Post-cancer treatment pain (PCTP) is prevalent among cancer survivors but remains understudied. It is critical to quantify PCTP prevalence over time and to estimate the resulting short and long-term incremental healthcare expenditures (total, third-party, and out-of-pocket) and out-of-pocket burden among cancer survivors.

METHODS

A longitudinal retrospective cohort design was used. To identify cancer survivors (≥ 18 years) with PCTP, the Medical Expenditure Panel Survey (MEPS) and its supplementary Cancer Self-Administered Questionnaire (CSAQ)were used. Recycled predictions from generalised linear models (GLM) with log-link and gamma distribution were used to estimate annual incremental healthcare expenditures at different PCTP gradations over time. To account for covariate imbalance, sensitivity analysis using inverse probability weighting was conducted.

RESULTS

2125 cancer survivors had PCTP. Post-cancer treatment, 10.5%-24.2% of survivors experienced some form of chronic PCTP, whereas between 21.9%-5.1% experienced acute PCTP. Across the survivorship journey, the adjusted total annual incremental healthcare expenditures were the highest among cancer survivors with moderate chronic PCTP (< 1-year post-cancer treatment), and severe chronic PCTP, (≥ 5 years post-cancer treatment) compared to survivors with no pain, reaching respectively, $27.3 and $40.2 billion nationally. There was a significant high out-of-pocket burden among cancer survivors with severe chronic PCTP compared to those with no pain.

CONCLUSION

These findings highlight the persistent financial burden of PCTP but also the critical need for effective pain management alongside the use of patient-reported outcomes for pain among cancer survivors.

Preferences for survivorship education and delivery among Latino and non-Latino childhood cancer survivors and caregivers

PURPOSE

To assess survivor and parent perceptions of the long-term survivor visit and preferences regarding accessing health information, survivorship education, and support networks in rural and metropolitan regions of Texas.

METHODS

Leveraging the multi-institutional Survivorship and Access to Care for Latinos to Understand Disparities (SALUD) cohort, we administered a 26-item bilingual survey to adult survivors of childhood cancer and parents of younger survivors. Characteristics and responses were compared between survivors vs. parents and Latinos vs. non-Latinos using a t test or Fisher exact test. Odds ratios for the outcomes of interest were calculated with 95% confidence intervals.

RESULTS

We received 138 responses from 59 survivors and 79 parents of survivors treated at three Texas pediatric cancer hospitals/clinics. Parents were more likely than survivors to seek survivorship information from other survivors or parents of survivors (OR=6.32, 95% CI 1.78, 22.47), and non-Latinos preferred social media as an educational resource (OR=3.70, CI 1.58, 8.68). Survivors, particularly Latino survivors, preferred short videos as a mode of survivorship education delivery. Highest topic priorities for survivorship education were 'risk for second cancers' and 'diet, nutrition, and exercise.' All parents and survivors who rated survivor physical and mental health as 'fair' or 'poor' identified as Latino.

CONCLUSIONS

These results highlight differences in perceived health status between Latino and non-Latino survivors and support the development of adapted survivorship education content to address the specific needs of Latino survivors. Implications for Cancer Survivors Results of this study suggest a need for survivorship educational materials in multiple formats and that are tailored to the style, content, language preferences, and health literacy status of the target population.

Environmental health disparities in pediatric cancer: a report from the Fourth Symposium on Childhood Cancer Health Disparities

The 4th Symposium on Childhood Cancer Health Disparities was held at Texas Children's Hospital in Houston, Texas, on September 26, 2023. The symposium registered 94 attendees from different backgrounds (e.g. clinicians, epidemiologists, exposure assessment scientists, geospatial experts) with an interest in environmental health disparities of pediatric cancer susceptibility and treatment outcomes. The focus of the symposium was to provide an overview of the role of environmental risk factors in studies of pediatric cancer, introduce novel exposure assessment tools that can be applied to the field, and highlight opportunities to study the impact of environmental health disparities in pediatric cancer susceptibility and outcomes. This report summarizes the scientific content of the symposium and highlights priorities to advance the field.

Clinical outcomes of pediatric kidney replacement therapy after childhood cancer-An ESPN/ERA Registry study

Cancer and its treatment may lead to kidney injury and the need for kidney replacement therapy (KRT). We identified 287 pediatric KRT patients with a history of malignancy from the European Society for Paediatric Nephrology/European Renal Association Registry. Of these, 197 had cancer as a primary cause of KRT (group 1) and 90 had a malignancy diagnosis before KRT (group 2). Two matched controls without malignancy were randomly selected for each patient. Data were complemented with a questionnaire. Median time to kidney transplantation (KT) from KRT initiation was 2.4 (IQR: 1.5-4.7), 1.5 (IQR: 0.4-3.3), 3.6 (IQR: 1.3 to Q3 not reached), and 1.1 (IQR: 0.3-3.6) years for group 1, their controls, group 2, and their controls, respectively. Overall 10-year mortality for those on KRT was higher among cancer patients vs controls in group 1: 16% vs 9% (adjusted hazard ratio 2.02, 95% CI: 1.21-3.37) and in group 2: 23% vs 14% (adjusted hazard ratio 2.32, 95% CI: 1.11-4.85). In contrast, 10-year patient survival after the first KT was comparable to controls (93% vs 96%; 100% vs 94%, in groups 1 and 2, respectively). In summary, childhood cancer survivors' KT was delayed, and their overall mortality when on KRT was increased, but once transplanted, their long-term outcome was similar to other KT recipients.

Barriers and facilitators to the implementation of a new European eHealth solution (SurPass v2.0): the PanCareSurPass Open Space study

PURPOSE

To identify barriers and facilitators for implementing the Survivorship Passport (SurPass) v2.0 in six long-term follow-up (LTFU) care centres in Europe.

METHODS

Stakeholders including childhood cancer survivors (CCSs), healthcare providers (HCPs), managers, information and technology (IT) specialists, and others, participated in six online Open Space meetings. Topics related to Care, Ethical, Legal, Social, Economic, and Information & IT-related aspects of implementing SurPass were evaluated.

RESULTS

The study identified 115 barriers and 159 facilitators. The main barriers included the lack of standardised LTFU care in centres and network cooperation, uncertainty about SurPass accessibility, and uncertainty about how to integrate SurPass into electronic health information systems. The main facilitators included standardised and coordinated LTFU care in centres, allowing CCSs to conceal sensitive information in SurPass and (semi)automatic data transfer and filing.

CONCLUSIONS

Key barriers to SurPass implementation were identified in the areas of care, ethical considerations, and information & IT. To address these barriers and facilitate the implementation on SurPass, we have formulated 27 recommendations. Key recommendations include using the internationally developed protocols and guidelines to implement LTFU care, making clear decisions about which parties have access to SurPass data in accordance with CCSs, and facilitating (semi)automated data transfer and filing using Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR).

IMPLICATIONS FOR CANCER SURVIVORS

The findings of this study can help to implement SurPass and to ensure that cancer survivors receive high-quality LTFU care with access to the necessary information to manage their health effectively.

Diabetes Risk After Treatment for Childhood and Young Adult Cancer

OBJECTIVE

Diabetes is a potential late consequence of childhood and young adult cancer (CYAC) treatment. Causative treatments associated with diabetes have been identified in retrospective cohort studies but have not been validated in population-based cohorts. Our aim was to define the extent of diabetes risk and explore contributory factors for its development in survivors of CYAC in the U.K.

RESEARCH DESIGN AND METHODS

Cancer registration data (n = 4,238) were linked to electronic health care databases to identify cases of diabetes through clinical coding or HbA1c values. Total effect of prespecified treatment exposures on diabetes risk was estimated using flexible parametric modeling and standardized cause-specific cumulative incidence functions (CIFs).

RESULTS

After median follow-up of 14.4 years, 163 individuals (3.8%) were identified with diabetes. Total body irradiation (TBI) increases diabetes risk over time, with a 40-year CIF reaching 21.0% (95% CI 13.8-31.9) compared with 8.4% (95% CI 6.1-11.5) without TBI. Survivors treated with corticosteroids had a 7.7% increased risk at 40 years after cancer diagnosis. Hematopoietic stem cell transplant (HSCT) survivors had markedly higher risk, with a 40-year CIF of 19.6% (95% CI 13.4-28.6) versus 8.2% (95% CI 6.0-11.3) for patients who had not undergone HSCT. Among patients who received allogeneic HSCT, the 40-year CIF of diabetes was 25.7% (95% CI 17.4-38.0), compared with 7.9% (95% CI 3.3-19.1) in patients who received autologous transplants.

CONCLUSIONS

This evaluation of a hospital-based cohort of patients with CYAC identifies these patients' increased long-term risk of developing diabetes and how this varies temporally according to treatment modalities. Notable contrasts in risk by treatment were detected as early as 10 years after cancer diagnosis. Findings should inform the development of risk-stratified evidence-based screening.

DNA Damage Response and Repair Genes and Anthracycline-Induced Cardiomyopathy in Childhood Cancer Survivors: A Report From the Children's Oncology Group and the Childhood Cancer Survivor Study

BACKGROUND

Anthracyclines induce cardiotoxicity via DNA double-strand breaks and reactive oxygen species formation, resulting in cardiomyocyte dysfunction. The role of DNA damage response/repair (DDR) genes in anthracycline-induced cardiomyopathy remains unstudied.

METHODS

We conducted a gene-based and pathway-based analysis to examine the main effect and gene-anthracycline interaction effect between DDR genes and anthracycline-induced cardiomyopathy. A discovery analysis performed with a matched case-control set of anthracycline-exposed non-Hispanic White childhood cancer survivors from Children's Oncology Group-ALTE03N1 (113 cases; 226 controls) was replicated using a cohort of anthracycline-exposed non-Hispanic White childhood cancer survivors from the Childhood Cancer Survivor Study cohort (n=1658; 97 cases). Functional analyses were performed by examining the response to doxorubicin of human-induced pluripotent stem cell-derived cardiomyocytes with CRISPR/Cas9-mediated knockout of prioritized genes.

RESULTS

Successfully replicated DDR genes demonstrating main-effect association included FANCC (P=0.037) and XRCC5 (P=0.001) and demonstrated gene-anthracycline interaction included MGMT (P=0.041). Knockouts of FANCC and MGMT in human-induced pluripotent stem cell-derived cardiomyocytes demonstrated significant resistance to doxorubicin, suggesting that these genes play a role in anthracycline-induced cardiotoxicity. Successfully replicated DDR pathways demonstrating main-effect association included base excision repair (P=2.7×10-4); role of BRCA1 in DDR (P=9.2×10-5); p53 signaling (P<1×10-16); role of checkpoint kinases proteins in cell cycle checkpoint control (P<1×10-16); mismatch repair (P<10-16); and double-strand break repair by homologous recombination (P<1×10-16). Successfully replicated DDR pathways demonstrating significant interaction effects included role of BRCA1 in DDR (P=1.4×10-4); p53 signaling (P<1×10-16); the role of checkpoint kinases proteins in cell cycle checkpoint control (P<1×10-16); mismatch repair (P<1×10-16); cell cycle: G2/M DNA damage checkpoint regulation (P=0.002); double-strand break repair by homologous recombination (P=0.009); GADD45 signaling (P=4.8×10-4); and cell cycle control of chromosomal replication (P=4.5×10-4).

CONCLUSIONS

These findings provide evidence for the role of DDR genes and pathways in anthracycline-induced cardiomyopathy and provide a framework for targeted therapeutic interventions.

Children with cancer and their cardiorespiratory fitness and physical function-the long-term effects of a physical activity program during treatment: a multicenter non-randomized controlled trial

PURPOSE

We aimed to determine the effects of a classmate-supported, supervised, in-hospital physical activity program during treatment primarily on cardiorespiratory fitness and secondarily on physical function.

METHODS

A multicenter non-randomized controlled intervention study including children diagnosed with cancer, 6-18 years at diagnosis treated with chemo-/radiotherapy. The intervention comprised (i) an educational session on cancer in the child's school class; (ii) selection of two "ambassadors"-classmates who were co-admitted, supporting the child's everyday hospital life; and (iii) supervised in-hospital physical activity from diagnosis and throughout intensive treatment. One-year post-treatment, physical testing included cardiorespiratory fitness (primary outcome), Sit-to-Stand test, Timed-Up-and-Go, and Handgrip Strength.

RESULTS

The intervention group included 75 of 120 children (61% boys, 13.4 ± 3.1 years); the control groups included 33 of 58 children with cancer (58% boys, 13.5 ± 2.5 years), and 94 age- and sex-matched children without a cancer history. One-year post-treatment, cardiorespiratory fitness tended to be higher in the intervention group (37.0 ± 6.0 mL/kg/min) than in the patient control group with cancer (32.3 ± 9.7 mL/kg/min) (mean difference 4.7 [0.4 to 9.1], p = 0.034). The intervention group performed better in the secondary outcomes. Compared with community controls, both patient groups had lower cardiorespiratory fitness. The patient control group had lower Sit-to-Stand, Timed Up and Go, and Handgrip Strength, while the intervention group had strength comparable to that of the community controls.

CONCLUSIONS

Peer-supported, supervised, in-hospital physical activity during treatment may improve cardiorespiratory fitness and muscle strength 1-year post-treatment in children with cancer; however, survivors continue to have lower cardiorespiratory fitness than community controls.

IMPLICATIONS FOR CANCER SURVIVORS

Children with cancer may benefit from in-hospital physical activity in improving long-term cardiorespiratory fitness and muscle strength.

European recommendations for short-term surveillance of health problems in childhood, adolescent and young adult cancer survivors from the end of treatment to 5 years after diagnosis: a PanCare guideline

PURPOSE

Childhood, adolescent and young adult (CAYA) cancer survivors require ongoing surveillance for health problems from the end of cancer treatment throughout their lives. There is a lack of evidence-based guidelines on optimal surveillance strategies for the period from the end of treatment to 5 years after diagnosis. We aimed to address this gap by developing recommendations for short-term surveillance of health problems based on existing long-term follow-up (LTFU) care guidelines.

METHODS

The guideline working group, consisting of healthcare professionals, parents and survivor representatives from 10 countries, worked together to identify relevant health problems that may occur in survivors between the end of treatment and 5 years after diagnosis and to develop recommendations for short-term surveillance of health problems. The recommendations were drawn from existing LTFU guidelines and adapted where necessary based on clinical expertise.

RESULTS

The working group developed 44 recommendations for short-term surveillance of health problems, which were divided into four categories based on the level of surveillance required: awareness only (n = 11), awareness, history and/or physical examination without surveillance test (n = 15), awareness, history and/or physical examination with potential surveillance test (n = 1) and awareness, history and/or physical examination with surveillance test (n = 17).

CONCLUSION

The development of a guideline for short-term surveillance of health problems fills a critical gap in survivorship care for CAYA cancer survivors, providing much-needed support immediately after treatment up to 5 years after diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

This guideline will support healthcare professionals to provide appropriate follow-up care and improve the quality of life of CAYA cancer survivors.

Local Control for Pediatric Rhabdomyosarcoma of the Extremities: Is Radiotherapy Always Required After Adequate Surgical Resection? A CanSaRCC Study

OBJECTIVES

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and young adults. Typically, treatment involves a multimodal approach, with radiotherapy (RT) being a standard choice alongside surgical resection for local control, particularly in cases harboring fusions involving FOXO1. However, the long-term consequences of offering RT especially to the extremity in children can be significant including growth delay, contracture, arthritis, and secondary malignancy. Herein, we report the outcome of 10 consecutive patients with extremity RMS from two high-volume institutions who did not receive RT to primary site.

METHODS

Demographic, genetic, tumor characteristics, surgical details, post-resection overall survival and event-free survival data were retrospectively collected from the CanSaRCC (Canadian Sarcoma Research and Clinical Collaboration) database.

RESULTS

Despite the absence of adjuvant RT to the primary tumor site, 90 % of this cohort patients experienced no local failure and the single patient with local failure was subsequently salvaged with RT and further chemotherapy.

CONCLUSION

By presenting this distinctive real-world data, our aim is to illustrate that in a select high-volume pediatric sarcoma center, extremity RMS can potentially be effectively managed through surgery and chemotherapy alone.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level IV.

Treatment, toxicity, and mortality after subsequent breast cancer in female survivors of childhood cancer

Childhood cancer survivors, particularly those who received chest radiotherapy, are at high risk for developing subsequent breast cancer. Minimizing long-term toxicity risks associated with additional radiotherapy and chemotherapy is a priority, but therapeutic tradeoffs have not been comprehensively characterized and their impact on survival is unknown. In this study, 431 female childhood cancer survivors with subsequent breast cancer from a multicenter retrospective cohort study were evaluated. Compared with one-to-one matched females with first primary breast cancer, survivors are as likely to be prescribed guideline-concordant treatment (N = 344 pairs; survivors: 94%, controls: 93%), but more frequently undergo mastectomy (survivors: 81%, controls: 60%) and are less likely to be treated with anthracyclines (survivors: 47%, controls: 66%) or radiotherapy (survivors: 18%, controls: 61%). Despite this, survivors have nearly 3.5-fold (95% CI = 2.17-5.57) greater mortality risk. Here, we show survivors with subsequent breast cancer face excess mortality despite therapeutic tradeoffs and require specialized treatment guidelines.

Rurality, Cardiovascular Risk Factors, and Early Cardiovascular Disease Among Childhood, Adolescent, and Young Adult Cancer Survivors

Purpose: Cardiovascular risk factors (CVRFs) later in life potentiate risk for late cardiovascular disease (CVD) from cardiotoxic treatment among survivors. This study evaluated the association of baseline CVRFs and CVD in the early survivorship period. Methods: This analysis included patients ages 0-29 at initial diagnosis and reported in the institutional cancer registry between 2010 and 2017 (n = 1228). Patients who died within 5 years (n = 168), those not seen in the oncology clinic (n = 312), and those with CVD within one year of diagnosis (n = 17) were excluded. CVRFs (hypertension, diabetes, dyslipidemia, and obesity) within 1 year of initial diagnosis were constructed and extracted from the electronic health record based on discrete observations, ICD9/10 codes, and RxNorm codes for antihypertensives. Results: Among survivors (n = 731), 10 incident cases (1.4%) of CVD were observed between 1 and 5 years after the initial diagnosis. Public health insurance (p = 0.04) and late effects risk strata (p = 0.01) were positively associated with CVD. Among survivors with public insurance (n = 495), two additional cases of CVD were identified from claims data with an incidence of 2.4%. Survivors from rural areas had a 4.1 times greater risk of CVD compared with survivors from urban areas (95% CI: 1.1-15.3), despite adjustment for late effects risk strata. Conclusion: Clinically computable phenotypes for CVRFs among survivors through informatics methods were feasible. Although CVRFs were not associated with CVD in the early survivorship period, survivors from rural areas were more likely to develop CVD.

Use of Screening Tools to Measure Supportive Care Needs in Former Cancer Patients of Adolescent and Young Adult Age: A Systematic Review of the Literature

With the increasing number cancer survivors treated during pediatric, adolescent and young adult (AYA) ages, it has become essential to develop comprehensive long-term follow-up care tailored to each patient. The combination of being a cancer survivor and reaching AYA age at the time of long-term follow-up can make adherence to the proposed follow-up care challenging. To overcome the difficulties associated with the lack of follow-up, it is important to identify supportive care needs (SCN) for this population using effective tools. The main objective of this systematic review was to explore the screening tools for SCN used in long-term follow-up of survivors who have reached AYA age. We conducted a literature search on PubMed, Cochrane, and Science Direct for studies published since 2004. Articles were screened independently by two reviewers. Data were extracted and descriptive analyses were performed. Of the 3968 articles found, 14 met the inclusion criteria. Seven studies used tools specifically designed for the study that were not previously validated. The three tools used in the other seven studies encompassed an average of only 2.8 SCN per study. The tools currently used in clinical practice are insufficient to provide a comprehensive assessment of the SCN of AYA-aged survivors during long-term follow-up.

Influence of therapy exposures on specific late morbidities, prescription drug purchases, and mortality in aging male survivors of childhood cancer: A registry-based study

Childhood cancer treatments predispose to late health problems and premature death. Our aim was to use national registry data to study associations between cancer therapy exposures and late health outcomes in aging male childhood cancer survivors (CCS). The study comprised 200 male CCS (survival ≥5 years) treated with conventional cancer therapy at a single institution in 1964-2000 and 1000 matched population controls. Analyses involved registry-based data on prescription drug purchases, reimbursements for chronic conditions, hospital admissions, and deaths that occurred ≥5 years after the cancer diagnosis. Mean age of CCS was 45.4 years. Compared to population controls, CCS had a higher risk for hospital admissions due to cardiovascular diseases and late mortality, both of which increased after age 40 years. CCS also had a higher risk for purchases of antihypertensives and lipid-lowering drugs within the last year of the study. Heart radiation ≥10 Gy was associated with hospitalizations due to cardiovascular diseases (HR 4.14, 95%CI 1.81-9.48), purchases of antihypertensives (OR 3.05, 95%CI 1.32-7.36), and purchases of lipid-lowering drugs (OR 2.93, 95%CI 1.08-7.73). Testosterone deficiency developed typically during pediatric follow-up, and it was associated with testicular radiation ≥20 Gy (HR 41.2, 95%CI 15.4-110) but not with alkylating agents. Of patients treated with testicular radiation ≥20 Gy, 91% had purchased testosterone within the last year. Reassuringly, CCS had no excess risk for purchases of opioids, anxiolytics, antiepileptics, or antidepressants. These findings emphasize the need for risk-based follow-up. Middle-aged male CCS are at an increased risk of premature cardiovascular morbidity and excess mortality.

Long-term Follow-up for Survivors of Childhood Cancer in Saudi Arabia: A Multicenter Cross-Sectional Study

Background

With the advancement of childhood cancer therapy, long-term survivors are on the rise. Reports on childhood cancer survivors in Saudi Arabia are scarce. This study aims to assess the spectrum and burden of long-term complications among survivors of childhood cancer in Saudi Arabia.

Methods

This cross-sectional study, conducted at multiple cancer centers in Saudi Arabia, enrolled survivors who had been diagnosed with cancer before the age of 14 and had completed at least 5 years after completion of cancer therapy. The primary outcome was to estimate the prevalence of chronic health conditions (CHC) among these survivors. The secondary outcome was to assess the impact of primary cancer diagnosis and cancer therapies on the occurrence of CHC.

Results

A total of 305 survivors met the inclusion criteria as of July 2022. Females were 165 participants. The median follow-up and age at evaluation were 8.5 and 14 years, respectively. Leukemia was the most common cancer type (49.3%), followed by lymphoma (16.7%) and solid tumors (15.7%). Chemotherapy was administered to 287 survivors. Radiotherapy and surgery were used in 29.2% and 22.3% of cases, respectively. Seventy-eight percent of participants experienced at least 1 CHC, with 31.1% and 14.2% having 2 and 3 CHC, respectively. A multivariate logistic regression identified significant association between CHC and solid tumors compared to hematological malignancies (OR 2.2; 95% CI: 1.1-4.3; P = .023). Growth impairment was the most common CHC, followed by endocrinopathy. Radiotherapy was significantly associated with short stature (95% CI: 1.2-3.6; P = .008). The majority of CHC, 77.3%, were mild in severity, while 19.3% were moderate, 2.9% were severe, and .5% were life-threatening.

Conclusion

The long-term complications of childhood cancer have revealed a prevalent concern. To optimize health outcomes, it is essential to implement well-structured and long-term follow-up tailored to risk profiles, utilize cost-effective screening methods, and promote prospective clinical research and establishment of a registry.

Hypertension in Childhood Cancer Survivors: Causes, Screening, and Management

PURPOSE OF REVIEW

Survivors of childhood cancer and hematopoietic cell transplant are at risk for developing chronic health conditions, including hypertension. Studies have identified hypertension as an influential risk factor for late kidney dysfunction and cardiovascular disease in childhood cancer survivors. The overall risk of hypertension depends on the specific cancer treatment, from chemotherapy to surgery to radiation. In this report, we aim to review the main causes of hypertension in childhood cancer survivors, with a focus on newer therapies, as well as the current recommendations for screening and management of hypertension in this patient population.

RECENT FINDINGS

Novel targeted therapies and immunotherapies are being increasingly used in pediatric cancer treatment, with unclear impact on long-term health. Screening guidelines for hypertension in the survivor population have been issued by various childhood cancer cooperative groups based on best available evidence and expert opinion. Newer studies have focused on individual risk prediction, which may help improve the diagnosis and management of hypertension, particularly in higher-risk individuals. Despite the importance of hypertension as one of the few modifiable risk factors for cardiovascular and renal health, studies have yet to define optimal blood pressure targets, screening parameters, or management strategies in childhood cancer survivors. Additionally, further studies are needed to demonstrate improvement in outcomes following interventions for hypertension specifically in this patient population.

Epidemiology of multimorbidity in childhood cancer survivors: a matched cohort study of inpatient hospitalisations in Western Australia

BACKGROUND

Childhood cancer survivors (CCS) experience an elevated burden of health complications, underscoring the importance of understanding the patterns of multimorbidity to guide the management of survivors with complex medical needs.

METHODS

We examined the patterns of hospitalisations with multimorbidity in 5-year CCS (n = 2938) and age- and sex-matched non-cancer comparisons (n = 24,792) using statewide records of inpatient admissions in Western Australia from 1987 to 2019.

RESULTS

Multimorbidity rates were higher for CCS (10.6, 95%CI 10.2-10.9) than for non-cancer comparisons (3.2, 95%CI 3.2-3.3). CCS exhibited a significantly higher adjusted hazard ratio of multimorbidity, particularly when admitted for neoplasms (14.6, 95%CI 11.2-19.1), as well as blood (7.3, 95%CI 4.9-10.7), neurological and sensory (5.2, 95%CI 4.2-6.6), and cardiovascular (3.6, 95%CI 2.6-4.8) diseases. By the age of 55 years, chronic multimorbidity was more prevalent in survivors than in comparisons (14.5% vs. 5.3%). Psychiatric disorders were common comorbidities, particularly in those admitted for neurological and sensory (71.1%), endocrine (61.5%), and digestive (59.3%) diseases. Multimorbidity during hospitalisation increased the length of hospital stay (p < 0.05). Key condition clusters included (1) psychoactive substance  dependence, alcohol misuse, and other mental disorders; (2) hypertension, diabetes, kidney disease, and musculoskeletal diseases; (3) epilepsy, hypothyroidism, and other liver diseases; and (4) hypertension, kidney disease, and other liver diseases.

CONCLUSIONS

These findings suggest that exposure to cancer in childhood elevates the risk of multimorbidity. The reconfiguration of healthcare delivery to enhance personalised care and clinical integration is essential for effectively managing multimorbidity in this population.

Parental Reports on Late Effects and Follow-Up Needs: A Single-Center Assessment of Childhood Cancer Survivorship Care in Kenya

The WHO Global Initiative for Childhood Cancer will likely increase the number of childhood cancer survivors in resource-poor countries. This study explored survivorship care in Kenya through parental reports on late effects and the follow-up needs of childhood cancer survivors. Parents of Kenyan childhood cancer survivors (under 18 years old) who completed treatment for at least one year were interviewed using semi-structured questionnaires from 2021 to 2022. Parents of 54 survivors were interviewed. Survivors had solid tumors (52%) and hematological tumors (48%). Most (52%) received chemotherapy combined with either surgery or radiotherapy. Many survivors (72%) experienced symptoms according to their parents. The most prevalent symptoms were pain (37%), fatigue (26%), and ocular problems (26%). Eleven percent of parents observed limitations in the daily activities of the survivors. Parents of survivors with two or more symptoms were more likely to rate symptoms as moderate to severe (p = 0.016). Parents expressed concern about late effects (48%). Only 28% were informed about late effects at the hospital, despite 87% indicating they would have welcomed this information. Follow-up care was deemed important by 98%. Recommendations included providing education about late effects and organizing survivor meetings. Survivorship clinics should be established to ensure that follow-up information and care are accessible.

A prospective cohort study on the trajectory of health-related quality of life in adult childhood cancer survivors attending a follow-up care program

Follow-up care in adult childhood cancer survivors (ACCS) aims to screen for, prevent, and treat potential late effects. The trajectory of ACCS' health-related quality of life (HRQoL) attending follow-up care is unclear. We investigated changes in HRQoL of ACCS attending a follow-up care program. The primary outcome was the minimal clinically important decrease (MCID) in HRQoL of ≥ 5 points in the mental (MCS) and/or physical component score (PCS) of the 36-item Short Form (SF-36) between baseline and follow-up (3-months after the first visit). We compared baseline characteristics, psychological factors, satisfaction, and distress (measured using the Brief Symptom Inventory). In 47 ACCS (100%), no significant change in the overall median MCS and PCS was observed. In 14 ACCS (29.8%) a MCID in HRQoL was observed. Compared to ACCS without a MCID, they reported lower PCS (median 45.2 [31.7; 51.4] vs. 55.6 [46.1; 57.6], p = 0.007), a higher proportion of low physical health (PCS < 48; 71.4% vs. 27.3%, p = 0.009) and distress (50% vs. 18.8%, p = 0.030) at baseline. Satisfaction was high (94.9%). One in three ACCS experienced a clinically important decrease in HRQoL after follow-up care, with higher rates in those with lower physical health and higher psychological distress at baseline.

Perinatal exposure to ambient fine particle air pollution and risk of childhood ewing sarcoma in a population-based case-control study in California (1988-2015)

BACKGROUND

Incidence of childhood Ewing sarcoma, a rare cancer affecting bones and soft tissues, is increasing. Environmental exposures during the perinatal period, like air pollution, may play a role. We examined exposure to perinatal ambient fine particulate matter (PM2.5) and childhood Ewing sarcoma risk in a case-control linkage study nested within a California birth cohort.

METHODS

The study included 388 children born in California (1982-2015) and diagnosed with Ewing sarcoma at age 0-19 years (1988-2015), and 19,341 California-born cancer-free controls frequency-matched to cases on birth year (50:1 ratio). Ambient PM2.5 concentrations at the maternal residence were averaged separately over two time periods, gestation and the first year after birth, using a validated ensemble-based model (categorized as quartiles). We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between perinatal PM2.5 exposure and Ewing sarcoma risk, adjusting for sex, birth year, race, ethnicity, birth weight, and maternal education and stratifying by Hispanic ethnicity to assess potential disparities in PM2.5-related cancer risk.

RESULTS

In the overall population, perinatal ambient PM2.5 exposure was not associated with Ewing sarcoma risk when considering exposure during gestation or the year after birth. Among Hispanic children, who experienced greater air pollution exposure compared to non-Hispanic children, higher PM2.5 levels during gestation yielded elevated odds of Ewing sarcoma compared to the first quartile (Q2 OR [95% CI] = 1.53 [0.94-2.51]; Q3 = 1.56 [0.95-2.56]; Q4 = 1.39 [0.79-2.47]). Hispanic children also experienced elevated risk in relation to exposure during the year after birth.

CONCLUSION

Our results provide new suggestive evidence that ambient PM2.5 may contribute to Ewing sarcoma risk, although these findings were not statistically significant and were specific to Hispanic children. These findings require replication and underscore the need to further evaluate the potential role of ethnicity in the PM2.5-cancer relationship with genetic ancestry measures and through the lens of environmental justice.

Prevalence and Associated Factors for Depression Among Patients With Sarcoma

PURPOSE

Prevalence and risk factors for depression among patients with sarcoma and survivors of sarcoma are not well characterized.

METHODS

A sarcoma survivorship cohort was constructed from patients diagnosed between April 2022 and September 2023. Depression symptoms were assessed via the eight-item Patient-Reported Outcomes Measurement Information System-57 depression scale at enrollment. Standardized T-score levels (<50, 50-59, and ≥60) were calculated and evaluated in association with demographics, lifestyle characteristics, clinical data, and modifiable factors using multinomial logistic regression models.

RESULTS

Among 612 participants, the mean T-score was 48.3 (standard deviation, 10.0); 58.8% had a T-score <50, 27.9% scored between 50 and 59, and 13.2% scored ≥60. Participants age 18-39 years and age 40-59 years were more likely to have a T-score ≥60, with respective odds ratios (ORs) of 3.65 (95% CIs, 1.70 to 7.83) and 2.80 (1.52 to 5.17) compared with participants older than 60 years. Household incomes of $70,000-$120,000 in US dollars (USD) (OR, 0.46 [95% CI, 0.23 to 0.92]) and >$120,000 USD (OR, 0.15 [95% CI, 0.06 to 0.37]) were inversely associated with T-score ≥60 compared with household incomes <$45,000 USD. Marijuana use within the past 30 days was positively (OR, 3.48 [95% CI, 1.46 to 8.27]) associated, while regular exercise (OR, 0.43 [95% CI, 0.24 to 0.75]) and emotional support (OR, 0.37 [95% CI, 0.28 to 0.48]) were inversely associated with having T-score ≥60.

CONCLUSION

A higher prevalence of depression symptoms was notable in younger participants, marijuana users, and households with lower incomes. Regular exercise and increased emotional support were inversely associated with depression symptoms. Our study provides information for developing personalized supportive care strategies to ameliorate depression symptoms among patients with sarcoma.

Association Between Treatment of Childhood Cancer and Its Late Effects on Gonadal or Growth Function in Childhood Cancer Survivors: A Retrospective Observational Study

BACKGROUND

The late effects on childhood cancer survivors have long been recognized, but detailed studies remain limited. The current study aimed to clarify the association between childhood cancer treatment and the incidence of late effects on gonadal or growth function in Japan.

METHODS

The retrospective study included medical records of patients with childhood cancer aged up to 15 years at diagnosis, who were treated with anticancer drugs at Osaka University Hospital from January 1, 2001, to December 31, 2019, and who survived at least 5 years after diagnosis. The patients' clinical background, treatment details, and anticancer drugs used were investigated. Multivariate logistic regression analysis was performed to assess the association between childhood cancer treatment and late effects on gonadal or growth function.

RESULTS

Of the 191 eligible patients, 83 (43.5%) developed gonadal dysfunction and 38 (19.9%) developed growth dysfunction. Multivariate logistic regression analysis showed statistically significant associations of gonadal dysfunction with female sex (odds ratio [OR], 4.79; p < 0.01), autologous hematopoietic stem cell transplantation (auto-HSCT) (OR, 9.97; p < 0.01), allogeneic hematopoietic stem cell transplantation (allo-HSCT) (OR, 9.48; p < 0.01), and platinum use (OR, 4.49; p = 0.037), and of growth dysfunction with auto-HSCT (OR, 5.16; p < 0.01).

CONCLUSION

Female sex, allo-HSCT, and use of platinum are possibly associated with an increased risk of late effects on gonadal function, while auto-HSCT may pose a risk for late effects on both gonadal and growth functions. These findings should be interpreted with caution due to the limitations of the dataset and warrant further investigation to validate these associations.

Illuminating the hidden cost: A systematic review of cognitive late effects regarding cancer-related fatigue in treated paediatric brain tumors

Objective

Globally, in 2022, 30,871 children were diagnosed with CNS-tumors. Many have been treated with radiotherapy, and a significant number suffer from chronic late effects, including fatigue. This study aims to investigate previous research on the impact of cancer-related fatigue for neurocognitive function that can be related to radiotherapy in patients who have undergone primary brain radiotherapy before the age of 18.

Methods

Conducted under PRISMA-S framework, this systematic review searched MEDLINE ALL (Ovid), EMBASE (Ovid), CINAHL (EBSCO), and PsycINFO (Ovid) for relevant studies. Criteria for inclusion were children under 18 who underwent radiotherapy for primary brain cancer, focusing on late cognitive side effects, published 2000-2023.

Results

From 4,067 records, 10 studies were included, examining Proton Radiation Therapy (n = 4), X-ray Radiation Therapy (n = 3), and their comparisons (n = 3). The studies used various cognitive tests, and late effects that emerged were neurocognitive functions and disorders, intellectual functioning, specific cognitive functions and daily life, social functioning, and performance. These themes can be encompassed by cancer-related fatigue.

Conclusions

The findings underscore critical need for more in-depth research to understand the health perception variations among children post-primary brain radiotherapy. Furthermore, detailed insights of treatment specifics, disease progression, target volume sizes, and doses to surrounding organs at risk are imperative.

Prevalence of cancer survivors diagnosed during adolescence and young adulthood in the United States

BACKGROUND

Adolescent and young adult (AYA) cancer incidence rates are rising, and survivors are at risk for numerous cancer- and treatment-related consequences. Despite growing attention to this population, prevalence estimates are lacking.

OBJECTIVE

To estimate the number of individuals living in the United States with a history of cancer diagnosed during the AYA period.

METHODS

Prevalence of cancer survivors diagnosed between the ages of 15 and 39 years was estimated using data from the Surveillance, Epidemiology, and End Results (SEER) program as of January 1, 2020. Limited duration prevalence data were also used to generate complete prevalence by sex, years since diagnosis (0-<1, 1-<5, 5-<10, 10-<15, 15-<20, 20+), and attained age (15-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+) for the 15 most common AYA cancer sites.

RESULTS

There were an estimated 2 111 838 survivors of AYA cancers in the United States as of January 1, 2020. More survivors were female (66%) and long-term (>5 years from diagnosis, 83%) or very long-term survivors (>10 years from diagnosis, 68.8%). A large percentage (44%) were more than 20 years from diagnosis. The most common cancer sites among female survivors were breast (24%) and thyroid cancers (23%) and, among male survivors, testicular cancer (31%). Across the population, the highest percentage of survivors of AYA cancers were 40 to 49 years of age (25.3%).

CONCLUSION

There are more than 2.1 million cancer survivors diagnosed in the AYA period who are living in the United States; most are more than 10 years from diagnosis.

A neural network to create super-resolution MR from multiple 2D brain scans of pediatric patients

BACKGROUND

High-resolution (HR) 3D MR images provide detailed soft-tissue information that is useful in assessing long-term side-effects after treatment in childhood cancer survivors, such as morphological changes in brain structures. However, these images require long acquisition times, so routinely acquired follow-up images after treatment often consist of 2D low-resolution (LR) images (with thick slices in multiple planes).

PURPOSE

In this work, we present a super-resolution convolutional neural network, based on previous single-image MRI super-resolution work, that can reconstruct a HR image from 2D LR slices in multiple planes in order to facilitate the extraction of structural biomarkers from routine scans.

METHODS

A multilevel densely connected super-resolution convolutional neural network (mDCSRN) was adapted to take two perpendicular LR scans (e.g., coronal and axial) as tensors and reconstruct a 3D HR image. A training set of 90 HR T1 pediatric head scans from the Adolescent Brain Cognitive Development (ABCD) study was used, with 2D LR images simulated through a downsampling pipeline that introduces motion artifacts, blurring, and registration errors to make the LR scans more realistic to routinely acquired ones. The outputs of the model were compared against simple interpolation in two steps. First, the quality of the reconstructed HR images was assessed using the peak signal-to-noise ratio and structural similarity index compared to baseline. Second, the precision of structure segmentation (using the autocontouring software Limbus AI) in the reconstructed versus the baseline HR images was assessed using mean distance-to-agreement (mDTA) and 95% Hausdorff distance. Three datasets were used: 10 new ABCD images (dataset 1), 18 images from the Children's Brain Tumor Network (CBTN) study (dataset 2) and 6 "real-world" follow-up images of a pediatric head and neck cancer patient (dataset 3).

RESULTS

The proposed mDCSRN outperformed simple interpolation in terms of visual quality. Similarly, structure segmentations were closer to baseline images after 3D reconstruction. The mDTA improved to, on average (95% confidence interval), 0.7 (0.4-1.0) and 0.8 (0.7-0.9) mm for datasets 1 and 3 respectively, from the interpolation performance of 6.5 (3.6-9.5) and 1.2 (1.0-1.3) mm.

CONCLUSIONS

We demonstrate that deep learning methods can successfully reconstruct 3D HR images from 2D LR ones, potentially unlocking datasets for retrospective study and advancing research in the long-term effects of pediatric cancer. Our model outperforms standard interpolation, both in perceptual quality and for autocontouring. Further work is needed to validate it for additional structural analysis tasks.

Evaluating Feasibility of an Exercise Intervention Including Physical Assessment During the First 6 Months of Cancer Treatment in Children and Adolescents in a Randomized Controlled Trial

PURPOSE

The aim was to assess the feasibility of a randomized controlled exercise intervention, including physical assessments, in children and adolescents during the first 6 months of cancer treatment.

MATERIALS AND METHODS

A sample of children and adolescents (n = 84, 6‒17.9 years) from an ongoing trial (INTERACT: NCT04706676) was randomly assigned to an integrative neuromuscular training (INT) intervention or active control intervention during treatment. The following inter-related feasibility domains were assessed: availability, acceptance, and attrition. Further, we assessed adherence to INT and physical assessments. Adverse events related to exercise and physical assessments were also reported.

RESULTS

We found feasible rates within the availability and attrition domains. While the INT group demonstrated feasible group-level adherence rates, individual adherence to prescribed intervention demands was suboptimal. Physical assessments after 6 months of cancer treatment showed feasible rates.

CONCLUSION

This study offers insights into the feasibility of an early-initiated INT intervention designed for children and adolescents undergoing cancer treatment. To ensure an optimal frequency of exercise in future studies, a flexible approach to hospital-based INT and a structured strategy for home-based exercise should be considered. Future trials should prioritize outcomes to minimize the length and timing of assessment.