The Pediatric Perspective on Cancer Survivorship

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The Pediatric Perspective on Cancer Survivorship. Sue Lindemulder, MD, MCR Medical Director , Childhood Cancer Survivorship Program September 12, 2013. Objectives. After this presentation, participants should be able to: - PowerPoint PPT Presentation


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The Pediatric Perspective on Cancer SurvivorshipSue Lindemulder, MD, MCRMedical Director, Childhood Cancer Survivorship ProgramSeptember 12, 2013

1ObjectivesAfter this presentation, participants should be able to:Identify late effects common in children who are survivors of childhood cancer and stem cell transplantKnow how to screen patients for common late effects of treatment.Identify resources available to aid providers in screening for late effects2Background

Majority of children with cancer become long term survivorsMajority of childhood cancer survivors have late effects3

Approximately 80% will be SurvivorsChildhood Cancer Survivor StudyMulti-institutional collaborative study (26 centers)Diagnosed with cancer in childhood or adolescence and survived at least 5 yearsDiagnoses: Leukemia, Kidney, Bone, Soft Tissue Sarcoma, Neuroblastoma, Hodgkins or non-Hodgkins lymphoma, and primary CNS malignancy.Diagnoses between January 1, 1970 and December 31, 1986

5Childhood Cancer Survivor Study17,565 eligible survivors not lost to follow-up, 4855 eligible siblingsBaseline questionnaire: 24 pages with demographic variables, medical conditions, surgical procedures and other health outcomes14,362 (81.8%) survivors and 3901 (80.4%) siblings completed the questionnaire12,480 survivors had complete treatment data abstracted

6CCSS: Percentage with Late Effects

Oeffinger KC et al. 20067CCSS: Type of Late Effects

Oeffinger KC et al. 20068CCSS: Timing of Late Effects

Oeffinger KC et al. 2006

9St Jude Lifetime Cohort Study1713 participants diagnosed between 1962-2001Follow-up between Oct 1, 2007 and Oct 31, 2012Median time from Diagnosis: 25 yearsScreened per Childrens Oncology Group Long-Term Follow-Up Guidelines ( health Condition: 98.2% (97.5%-98.8%)Serious or life-threatening condition: 67.6% (65.3%-69.8%)

SJLIFE: Effect of Screening

CCSS: Survivors and Medical Care

Nathan PC et al. 2008.12Putting a Face on Survivorship


Taken from Oregonian, April 27, 2012Diagnosis: Acute lymphoblastic leukemia; Relapse (left occular & CNS) 6/7/2004 Date of Diagnosis: 1/03/2003 Date of Bone Marrow Transplant: 9/15/2004 Protocol: POG 9906; followed by relapse therapy CCG 1951 Chemotherapy exposures (cumulative dose): Anthracycline (72 mg/m2), Cytoxan (4.7 g/m2), 6-MP, Vincristine, Dexamethasone, Cytarabine, L' asparginase, Peg-Asparaginase, Methotrexate (IV, PO & IT), Ifosfamide (9 g/m2); Etopophos (allergy to Etoposide) (2.2 g/m2); Triple intrathecals x 4, Tacrolimus, Prednisone (ended 11/11/2005). Off immunosuppressives since 10/01/2006. Radiation Therapy: 2400 cGy to the left eye & 1200 cGy cranial & 1200 cGy TBI (2004) Last ECHO: (2012) FS 29%; EF 56% Last PFT: (2011) Improved from previous Surgeries: Line placement x 2 (2004 & 2005); Right hip replacement (2006); Bilateral cadaveric knee allografts (2007) Blood Products/year: 2004 on file - presumed 2003 Problem List from History: History of low shortening fraction on echo from 2004 treated with digoxin & lisinopril until 9/2004; History of hyperlipidemia; History of iatrogenic hypertension; Decreased vision left eye; Avascular necrosis; History of chronic GVHD of the skin and gut; Gonadal failure; Hypothryroid; Severe influenza requiring ICU hospitalization shortly after transplant. Neuropsych testing: (8/21/2004) (pre-transplant)- Intellectual functioning intact; normal on all examinations Cancer Treatment SummaryCardiac ToxicityLate Effect: Cardiomyopathy, Arrhythmia, Subclinical left ventricular dysfunction, Valve dysfunction. Cancers: Almost all, high doses with sarcomasChemotherapy Agents: AnthracyclinesRadiation: Total Body, Whole lung, Mantle etcRisk Factors: Obesity, Congenital Heart Disease, Isometric exercise, Smoking, Illicit drug use.

Childrens Oncology Group;

16Cardiac ToxicityPeriodic EvaluationHistory (yearly): SOB, DOE, Orthopnea, Chest pain, Palpitations, if


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