Childhood Cancer Survivors Continue to Report Poor Health

Pam Harrison

November 07, 2016

Despite the fact that more modern cancer care is significantly less intense than treatments used in the past, childhood cancer survivors undergoing treatment in a more contemporary era are no more likely to report better perceived health status than survivors from a much earlier decade.

"I was surprised by the findings because improvements in therapy and hospital care have improved survival substantially, and clinicians have been working to optimize therapy while reducing toxicities," lead author Kirsten Ness, PhD, St. Jude Children's Research Hospital, Memphis, Tennessee, told Medscape Medical News.

"But we found that self-reported health status among survivors has not improved [over earlier decades] despite evolution of treatment," she and her colleagues conclude.

The finding comes from a National Institutes of Health cross-sectional study published online November 7 in the Annals of Internal Medicine.

Dr Ness and multicenter colleagues analyzed patient reports of poor general or mental health, functional impairment, limitation of activity, and cancer-related anxiety and pain as a function of when patients were treated. The periods studied were 1970 to 1979; 1980 to 1989; and 1990 to 1999.

"Our analyses included childhood cancer survivors participating in the CCSS [Childhood Cancer Survivor Study] who were treated from 1970 to 1999 at 27 institutions in North America," the investigators write.

A total of 14,566 childhood cancer survivors (median age, 27 years) who had survived for at least 5 years after their initial diagnosis were included in the analyses.

Approximately one third of patients treated between 1970 and 1979 reported having at least one chronic health condition of grade 3 or 4, as did approximately one quarter of those treated between 1980 and 1989 and approximately one fifth of those treated between 1990 and 1999.

"Despite an overall decline in radiation exposure, reduced mean chemotherapy doses, and decreased proportions of survivors with grade 3 or 4 chronic health conditions, patient-reported health status generally did not improve across treatment decades," Dr Ness and colleagues report.

In fact, slightly more childhood cancer survivors treated in the most contemporary decade reported poor general health compared to those treated in the earliest decade (13.7% vs 11.2%).

The same was true for cancer-related anxiety, which was again higher in survivors from the most modern era of cancer care compared to those receiving treatment in the 1970s (15% vs 13.3%).

"Overall, the proportions of survivors reporting poor general health, poor mental health, functional impairment, or activity limitation or an adverse outcome in any of these 4 domains did not decrease over the 3 decades," Dr Ness and colleagues affirm.

Compared to siblings, childhood cancer survivors were also more likely to report adverse health status in any of these domains.

"Improved survival after a diagnosis of childhood cancer is a success story in modern medicine," the investigators observe.

An important reminder that the cure for cancer is not without consequences. Dr Kirsten Ness and colleagues

"Surprisingly, our data show lack of improvement in health status among childhood cancer survivors over 30 years of evolving cancer therapy — an important reminder that the cure for cancer is not without consequences," they conclude.

Perceived Ill Health

"I think one of the reasons for the contemporary cohort's perceived ill health is that more children with cancer now survive into adulthood," Dr Ness explained to Medscape Medical News.

In other words, more childhood cancer survivors who are alive now would not have survived had they been diagnosed with the same cancer in the 1970s.

This suggests that contemporary childhood cancer survivors may have been the ones with the highest-risk disease, and as a consequence, they also received the most aggressive therapy and are therefore the most likely to suffer the late consequences of intensive treatment, Dr Ness suggested.

It is also possible that patients treated in a more modern era have different expectations than people treated decades ago.

"Back in the 1970s, people might have simply said, 'I'm alive, I'm here, and I'm good with that,' " Dr Ness observed.

"Whereas more contemporary patients might have expected to be alive [at the end of treatment], but they didn't expect all of the consequences arising from it," she added.

Dr Ness pointed out that long-term follow-up of childhood cancer survivors by experts in survivorship is now more common, and late toxicities are both anticipated and planned for.

For example, at St. Jude's, after completion of treatment, childhood cancer survivors receive care at an end-of-care clinic for a period of 5 years, where they are provided with a survivorship care plan.

"The care plan tells them what their potential late effects are based on the exposures they received during treatment," Dr Ness explained.

"And I think this is fairly well done for children, not just here but in other centers as well."

An In-Depth Look

Asked by Medscape Medical News to comment on the study's findings, Jennifer Yeh, PhD, faculty member, Harvard Medical School and Boston Children's Hospital, Massachusetts, said that this well-designed study provides an in-depth look into specific domains of health status among survivors.

"It is striking that survivors fare worse in all four domains compared to siblings, and that this was consistent across 3 decades of survivors," Dr Yeh said in an email, adding that it would be interesting to know how the health status of siblings compares to that of the general population.

"Are they less well off?" she asked.

"If so, long-term family spillover effects may be another important aspect of the cancer experience for providers to be aware of and plan for," Dr Yeh suggested.

Dr Yeh and colleagues authored a study published earlier this year that found that chronic conditions were largely responsible for poorer quality of life for childhood cancer survivors in comparison with the general population (J Natl Cancer Inst. 2016;108:djw046).

The study was funded by the National Cancer Institute. The authors of the study and Dr Yeh have disclosed no relevant financial relationships.

Ann Intern Med. Published online November 7, 2016. Abstract

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