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It doesn't stop at cure: monitoring childhood cancer survivors
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Editorial www.thelancet.com/oncology Vol 14 July 2013 671 See Review page e321 For more on the Childhood Cancer Survivor Study see https://ccss.stjude.org/ For the long-term health outcomes for childhood cancer survivors see JAMA 2013; 309: 2371–81 For the Childhood Oncology Group survivorship guidelines see http://www. survivorshipguidelines.org/ For the study on MRI monitoring of heart disease see J Cardiovasc Magn Reson 2013; 15: 48 For more on depression and anxiety in long-term cancer survivors see Articles page 721 For more on improving cancer care for children and young people see http://www. thelancet.com/series/ childhoodcancer Corbis It doesn’t stop at cure: monitoring childhood cancer survivors On June 12–13, 2013, the investigators of the Childhood Cancer Survivors Study met for their annual meeting in Memphis, TN, USA. The meeting coincided with the publication of the most comprehensive study to date on long-term health effects in childhood cancer survivors. The study included more than 1700 adults, with a median time from diagnosis of childhood cancer of 25 years, and showed that almost all participants had at least one chronic disease, including abnormal lung function, heart disease, and secondary malignancies. The investigators concluded that their findings highlight the importance of monitoring survivors of childhood cancer for long-term health problems, but are current health systems and care pathways fit for this purpose? Treatment in paediatric oncology has improved remarkably over the past half century. But, although measures are being taken to reduce long-term health risks at treatment stage, with less aggressive chemotherapy regimens and careful use of radiotherapy, there will probably always be some price to pay for cancer treatment. Robust and regular monitoring of survivors could do much to help lessen the additional social, economic, and health burdens that many will face in the years after their treatment. Although there are initiatives taken to ensure survivors of childhood cancer are monitored and offered support, these are generally institutional and regional efforts, with much of the onus put on the patient to use the resources provided, rather than health-care systems offering them proactive support. The Childhood Oncology Group have published a series of guidelines for clinicians who provide ongoing health care to survivors of childhood cancer, and recommends at least annual follow-up checks covering a range of conditions, such as growth, fertility, and secondary malignancies. Although this is a start, there are two clear areas where monitoring of childhood cancer survivors could be improved. First, robust methods for monitoring should be developed, to ensure that medical interventions can be provided as early as possible. A recent study showed a potential way to detect signs of early heart disease in childhood cancer survivors. The study investigators were able to detect early cardiac damage in patients treated with anthracyclines using MRI, even though the heart seemed functionally normal by ultrasound. Although this study was small, including just 30 patients, the development of these types of technologies could greatly facilitate the early detection of potential health problems. Furthermore, personalised screening programmes, such a breast-cancer screening for children who received chest irradiation, would be of further help to identify secondary malignancies early. Second, improvements can be made in ensuring patients receive regular follow-up appointments. Although this seems obvious, as childhood cancer survivors grow up and move on with their lives, it may not be as straightforward as visiting a family doctor once a year. Standardised record keeping and an easy way for survivors to be in control of their medical records, or improved mechanisms of ensuring records follow patients as they move from one health-care jurisdiction to another, can help prevent gaps in care over the years after cure. The establishment of specialist late-effects clinics as part of a national cancer plan can also help to ensure regular monitoring is available no matter where a childhood cancer survivor ends up. Furthermore, such clinics could ensure that those who are monitoring the survivors are highly trained and aware of the health risks that might affect cancer survivors. Besides monitoring the physical wellbeing of childhood cancer survivors, it is also important that their mental health is also attended to. Adult long-term survivors of cancer and their spouses have been shown to have higher levels of anxiety than do healthy controls. It would not be much conjecture to think that survivors of childhood cancers and their parents experience similar stresses. Personalised, web-accessible survivorship programmes may offer a way to aid in this respect, allowing an easy way to document emotions and struggles on a regular basis, rather than as a single snapshot at an annual appointment. Childhood cancer survivors are at long-term risk of substantial adverse events. Follow-up should be centred on the individual, and information should be provided to survivors to help them understand how regular check- ups can improve their long-term wellbeing and quality of life. Ultimately, what is required is a more comprehensive, proactive, and integrated follow-up care pathway for survivors of childhood cancer. Treating the patient doesn’t stop with their last cycle of therapy. ■ The Lancet Oncology
Transcript of It doesn't stop at cure: monitoring childhood cancer survivors
Editorial
www.thelancet.com/oncology Vol 14 July 2013 671
See Review page e321
For more on the Childhood Cancer Survivor Study see https://ccss.stjude.org/
For the long-term health outcomes for childhood cancer survivors see JAMA 2013; 309: 2371–81
For the Childhood Oncology Group survivorship guidelines see http://www.survivorshipguidelines.org/
For the study on MRI monitoring of heart disease see J Cardiovasc Magn Reson 2013; 15: 48
For more on depression and anxiety in long-term cancer survivors see Articles page 721
For more on improving cancer care for children and young people see http://www.thelancet.com/series/childhoodcancer
Corb
is
It doesn’t stop at cure: monitoring childhood cancer survivorsOn June 12–13, 2013, the investigators of the Childhood Cancer Survivors Study met for their annual meeting in Memphis, TN, USA. The meeting coincided with the publication of the most comprehensive study to date on long-term health eff ects in childhood cancer survivors. The study included more than 1700 adults, with a median time from diagnosis of childhood cancer of 25 years, and showed that almost all participants had at least one chronic disease, including abnormal lung function, heart disease, and secondary malignancies. The investigators concluded that their fi ndings highlight the importance of monitoring survivors of childhood cancer for long-term health problems, but are current health systems and care pathways fi t for this purpose?
Treatment in paediatric oncology has improved remarkably over the past half century. But, although measures are being taken to reduce long-term health risks at treatment stage, with less aggressive chemotherapy regimens and careful use of radiotherapy, there will probably always be some price to pay for cancer treatment. Robust and regular monitoring of survivors could do much to help lessen the additional social, economic, and health burdens that many will face in the years after their treatment.
Although there are initiatives taken to ensure survivors of childhood cancer are monitored and off ered support, these are generally institutional and regional eff orts, with much of the onus put on the patient to use the resources provided, rather than health-care systems off ering them proactive support. The Childhood Oncology Group have published a series of guidelines for clinicians who provide ongoing health care to survivors of childhood cancer, and recommends at least annual follow-up checks covering a range of conditions, such as growth, fertility, and secondary malignancies. Although this is a start, there are two clear areas where monitoring of childhood cancer survivors could be improved.
First, robust methods for monitoring should be developed, to ensure that medical interventions can be provided as early as possible. A recent study showed a potential way to detect signs of early heart disease in childhood cancer survivors. The study investigators were able to detect early cardiac damage in patients treated with anthracyclines using MRI, even though the heart seemed functionally normal by ultrasound. Although
this study was small, including just 30 patients, the development of these types of technologies could greatly facilitate the early detection of potential health problems. Furthermore, personalised screening programmes, such a breast-cancer screening for children who received chest irradiation, would be of further help to identify secondary malignancies early.
Second, improvements can be made in ensuring patients receive regular follow-up appointments. Although this seems obvious, as childhood cancer survivors grow up and move on with their lives, it may not be as straightforward as visiting a family doctor once a year. Standardised record keeping and an easy way for survivors to be in control of their medical records, or improved mechanisms of ensuring records follow patients as they move from one health-care jurisdiction to another, can help prevent gaps in care over the years after cure. The establishment of specialist late-eff ects clinics as part of a national cancer plan can also help to ensure regular monitoring is available no matter where a childhood cancer survivor ends up. Furthermore, such clinics could ensure that those who are monitoring the survivors are highly trained and aware of the health risks that might aff ect cancer survivors.
Besides monitoring the physical wellbeing of childhood cancer survivors, it is also important that their mental health is also attended to. Adult long-term survivors of cancer and their spouses have been shown to have higher levels of anxiety than do healthy controls. It would not be much conjecture to think that survivors of childhood cancers and their parents experience similar stresses. Personalised, web-accessible survivorship programmes may off er a way to aid in this respect, allowing an easy way to document emotions and struggles on a regular basis, rather than as a single snapshot at an annual appointment.
Childhood cancer survivors are at long-term risk of substantial adverse events. Follow-up should be centred on the individual, and information should be provided to survivors to help them understand how regular check-ups can improve their long-term wellbeing and quality of life. Ultimately, what is required is a more comprehensive, proactive, and integrated follow-up care pathway for survivors of childhood cancer. Treating the patient doesn’t stop with their last cycle of therapy. ■ The Lancet Oncology
