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SurvivorshipAwaiting clinical review

Survivorship and late effects

About 1 in 640 young US adults is a childhood cancer survivor — you will meet them in primary care, and the exposure history is the exam.

Survivors with a chronic condition by age 45
~80%
Anthracycline echo surveillance
Risk-based, per COG LTFU guidelines
Chest radiation breast screening
Begin at 25 y or 8 y post-radiation

Map exposure to organ risk

  • Anthracyclines → cardiomyopathy (dose-dependent, higher risk with younger age at treatment and chest radiation).
  • Alkylating agents (cyclophosphamide, ifosfamide) → gonadal failure and infertility; ifosfamide also causes Fanconi-like tubulopathy.
  • Cisplatin → sensorineural hearing loss and nephrotoxicity; carboplatin is less ototoxic.
  • Bleomycin → pulmonary fibrosis; relevant to anesthesia oxygen strategy years later.
  • Cranial radiation → neurocognitive deficits, growth hormone deficiency, hypothyroidism, secondary meningioma.
  • Chest radiation → breast cancer risk (screen early with MRI plus mammography), premature coronary disease.
  • Epipodophyllotoxins (etoposide) → secondary AML with KMT2A rearrangement, short latency.

What a survivorship visit contains

  • A treatment summary the patient can hand to any clinician: diagnosis, agents, cumulative doses, radiation fields and doses, surgeries.
  • Risk-based screening from the COG Long-Term Follow-Up Guidelines rather than one-size-fits-all testing.
  • Fertility counseling, mental health screening, school and vocational support.
  • Transition planning to adult primary care with explicit handoff of the exposure history.

Do not miss

  • New exertional dyspnea or reduced exercise tolerance in an anthracycline-exposed survivor is heart failure until echocardiography says otherwise.

Pearls

  • Ask every young adult with an unexplained cardiomyopathy whether they had cancer as a child.

  • Secondary AML after etoposide appears in 1–3 years; after alkylators it appears later with monosomy 5/7.

  • The treatment summary is the single most valuable document you can generate for a survivor.

On the ward

  1. 1During discharge planning, confirm that the cumulative anthracycline dose is recorded in the chart summary.
  2. 2Ask about fertility preservation before therapy starts — it cannot be retrofitted.
  3. 3Flag hearing screening for any child receiving cisplatin.

2 vignette questions on this topic.

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Sources

  • Children's Oncology Group — Protocol families and risk stratification frameworks used across US pediatric centers.
  • NCCN Guidelines (Pediatric) — US consensus guidance on treatment and supportive care pathways.