Prevalence of Late Effects in Childhood Cancer Survivors

60% to more than 90% of survivors develop one or more chronic health conditions.

20% to 80% of survivors experience severe or life-threatening complications during adulthood.

Morbidity accumulation is accelerated in young adult survivors of childhood cancer, compared with that of siblings and the general population. Accumulation of chronic diseases predicts risk of early mortality.[19]

Survivors at the age of 18 years experienced an average of 22.3 disabling conditions per 100 individuals versus 3.5 in controls, and 128.7 lower-severity conditions (at risk of progressing to higher-grade disabling conditions) versus 12.4 in controls.

Survivors at the age of 26 years experienced an average of 40.3 disabling conditions per 100 individuals versus 5.7 in controls, and 240.5 lower-severity conditions versus 51.3 in controls.

The cumulative burden of disabling, disease-specific conditions at the ages of 18 and 26 years was most notable for survivors of bone tumors (musculoskeletal: 99.9 and 121.70, respectively), soft tissue sarcomas (musculoskeletal: 49.5 and 54.1, respectively), and central nervous system (CNS) tumors (neurological: 24.7 and 36.8, respectively).

The cumulative burden of lower-severity conditions (potentially amenable to intervention) at the ages of 18 and 26 years was most notable for neurological conditions across most cancer subgroups, with the highest cumulative burden in CNS tumor survivors (95.2 and 162.3, respectively).

These findings highlight the importance of optimizing access to health care and health insurance as survivors age and can no longer participate in pediatric health care systems.

Age and follow-up time of the cohorts studied.

Methods and consistency of assessment (e.g., self-reported vs. risk-based medical evaluations).

Treatment intensity and treatment era.

Cancer treatment did not account for disparities in mortality, chronic health conditions, or subsequent neoplasms observed among the groups.

Differences in socioeconomic status and cardiovascular risk factors affected risk. All-cause mortality was higher among non-Hispanic Black participants than among other groups, but this difference disappeared after adjustment for socioeconomic status.

Risk of developing diabetes was elevated among racial and ethnic minority groups even after adjustment for socioeconomic and obesity status.

Non-Hispanic Black patients had a higher likelihood of reporting cardiac conditions, but this risk diminished after adjusting for cardiovascular risk factors.

Nonmelanoma skin cancer was not reported by non-Hispanic Black participants, a finding that has been replicated by other studies.[24] Hispanic participants had a lower risk of nonmelanoma skin cancer than non-Hispanic White participants.

With the exception of survivors requiring intensive multimodality therapy for refractory/relapsed malignancies, life-threatening treatment effects are relatively uncommon after contemporary therapy in early follow-up (up to 10 years after diagnosis).

However, survivors still frequently experience life-altering morbidity related to effects of cancer treatment on endocrine, reproductive, musculoskeletal, and neurological function.

The 20-year cumulative incidence of at least one grade 3 to 5 chronic condition decreased significantly, from 33.2% for survivors diagnosed between 1970 and 1979, to 29.3% for those diagnosed between 1980 and 1989, to 27.5% for those diagnosed between 1990 and 1999, compared with a 4.6% incidence in a sibling cohort.

The overall decrease in incidence of chronic conditions across the three treatment decades was, in part, because of a substantial reduction of endocrinopathies, subsequent malignant neoplasms (SMNs), musculoskeletal conditions, and gastrointestinal conditions, whereas the cumulative incidence of hearing loss increased during this time.

Declines in morbidity were not uniform across the diagnosis groups or condition types because of differences in treatment and survival patterns over time. For more information, see Figure 2.

Despite declines in chronic health conditions over time, self-reported health status has not improved in more recent treatment eras. This finding may be because of the survival of children with higher-risk disease who would have previously died of cancer, or an enhanced awareness of and surveillance for late effects among more recently treated survivors.[27]