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CLINICIAN'S CORNER
Medical Assessment of Adverse Health Outcomes in Long-term Survivors of Childhood Cancer
Maud M. Geenen, MD;
Mathilde C. Cardous-Ubbink, MSc;
Leontien C. M. Kremer, MD, PhD;
Cor van den Bos, MD, PhD;
Helena J. H. van der Pal, MD;
Richard C. Heinen, MSc;
Monique W. M. Jaspers, PhD, MSc;
Caro C. E. Koning, MD, PhD;
Foppe Oldenburger, MD;
Nelia E. Langeveld, PhD, RN;
Augustinus A. M. Hart, MSc;
Piet J. M. Bakker, MD, PhD;
Huib N. Caron, MD, PhD;
Flora E. van Leeuwen, PhD, MSc
JAMA. 2007;297:2705-2715.
Context Improved survival of children with cancer has been accompanied by multiple treatment-related complications. However, most studies in survivors of childhood cancer focused on only 1 late effect.
Objective To assess the total burden of adverse health outcomes (clinical or subclinical disorders ["adverse events"]) following childhood cancer in a large cohort of childhood cancer survivors with long-term and complete medical follow-up.
Design, Setting, and Population Retrospective cohort study of 1362 five-year survivors of childhood cancer treated in a single institution in the Netherlands between 1966 and 1996. All survivors were invited to a late-effects clinic for medical assessment of adverse events. Adverse events occurring before January 2004 were graded for severity in a standardized manner.
Main Outcome Measures Treatment-specific prevalence of adverse events (according to severity) at end of follow-up and relative risk of high or severe burden of disease ( 2 severe or 1 life-threatening or disabling adverse events) associated with various treatments.
Results Medical follow-up was complete for 94.3% of survivors (median follow-up, 17.0 years). The median attained age at end of follow-up was 24.4 years. Almost 75% of survivors had 1 or more adverse events, and 24.6% had 5 or more adverse events. Furthermore, 40% of survivors had at least 1 severe or life-threatening or disabling adverse event. A high or severe burden of adverse events was observed in 55% of survivors who received radiotherapy only and 15% of survivors treated with chemotherapy only, compared with 25% of survivors who had surgery only (adjusted relative risks, 2.18 [95% confidence interval, 1.62–2.95] and 0.65 [95% confidence interval, 0.46–0.90], respectively). A high or severe burden of adverse events was most often observed in survivors of bone tumors (64%) and least often in survivors of leukemia or Wilms tumor (12% each).
Conclusions In young adulthood, a substantial proportion of childhood cancer survivors already has a high or severe burden of disease, particularly after radiotherapy. This underscores the need for lifelong risk-stratified medical surveillance of childhood cancer survivors.
Author Affiliations: Late Effects Study Group and Outpatient Clinic/Polikliniek Late Effecten Kindertumoren (PLEK) (Drs Geenen, Kremer, van den Bos, van der Pal, Koning, Bakker, Caron, and van Leeuwen and Ms Cardous-Ubbink and Mr Heinen) and Department of Pediatric Oncology (Drs Kremer, van der Bos, Langeveld, and Caron), Emma Children's Hospital/Academic Medical Center; Departments of Medical Oncology (Drs Geenen, van der Pal, and Bakker), Medical Informatics (Dr Jaspers), and Radiotherapy (Drs Oldenburger and Koning), Academic Medical Center; and Departments of Radiotherapy (Mr Hart) and Epidemiology (Dr van Leeuwen), the Netherlands Cancer Institute, Amsterdam, the Netherlands.
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