Monitoring Survivors of Childhood Cancers for Late Effects of Treatment
A Conversation With Smita Bhatia, MD, MPH
Jamie H. Von Roenn, MD
Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science, and Professional Development Department.
This past January, ASCO held its inaugural Cancer Survivorship Symposium, which brought together the fields of medical oncology and primary care to address the critical need for coordinated care for cancer survivors. Among the presenters at the symposium was Smita Bhatia, MD, MPH, who gave the keynote address on the science of cancer survivorship, including the substantial burden of long-term complications from treatment and increased risk of early death that survivors of childhood cancers often face.
Dr. Bhatia’s interest in cancer outcomes across all diagnoses and age groups and her research investigating the health challenges that survivors of childhood cancers encounter and identifying survivors at highest risk of treatment-related health complications have led to the discovery of the increased risk of radiation-related breast cancer among women exposed to chest radiation during adolescence for the treatment of Hodgkin lymphoma. The findings from her research have resulted in a reduction in the amount of radiation teenage girls and young adults are now exposed to during radiotherapy and also led to modifications of other cancer therapies, including stem cell mobilization for transplantation.
Dr. Bhatia’s scientific efforts during nearly 2 decades at the City of Hope Comprehensive Cancer Center in Duarte, California, led to the establishment of multidisciplinary survivorship clinics for cancer survivors in institutions nationwide and the development of comprehensive follow-up care plans for all cancer survivors. She is now Vice Chair for Outcomes in the Department of Pediatrics and Director of the Institute for Cancer Outcomes and Survivorship at the University of Alabama at Birmingham (UAB) School of Medicine, and Associate Director for Cancer Outcomes Research at the UAB Comprehensive Cancer Center.
Dr. Bhatia is a long-time ASCO member and has served on the ASCO Board of Directors, Cancer Survivorship Committee, Cancer Prevention Committee, and the Journal of Clinical Oncology Editorial Board. She is also a member of the American Society for Clinical Investigation and the Association of American Physicians.
In 1996, Dr. Bhatia received a Young Investigator Award from the Conquer Cancer Foundation of ASCO. She is also the recipient of the Frank H. Oski Lectureship Award from the American Society of Pediatric Hematology/Oncology.
Today, Dr. Bhatia is leading several ongoing collaborative research efforts in childhood cancer survivorship.1 The ASCO Post talked with Dr. Bhatia about key findings from her current research, the increased risk of secondary cancers and other major health problems encountered by survivors of childhood cancers, the importance of collaborative teamwork between oncologists and primary care providers, and the role genetics may play in susceptibility to treatment-related adverse outcomes.
What is your research showing regarding the risk of shorter life spans, secondary cancers, and other diseases that survivors of childhood cancer face as a result of their cancer and treatment?
Smita Bhatia, MD, MPH
I want to preface my answer by saying that when we conduct survivorship research, especially investigations into treatment-related complications such as second cancers, which occur several years after treatment is completed, we are referring to cohorts of patients who were treated long ago. Those treatments may not be the treatments we use today.
The burden of morbidity that our cancer survivors carry is substantial. This is illustrated very well by a landmark paper published several years ago, which showed that about 40% of childhood cancer survivors have life-threatening complications 30 years out from their cancer diagnosis.2 These findings indicate the need for lifelong monitoring and surveillance of our childhood cancer survivors.
But who assumes the responsibility of lifelong care for the survivors? Primary care providers are reluctant to take on the responsibility of caring for survivors of childhood cancers, who often have complex medical issues. So should the responsibility of caring for these survivors fall to the pediatric oncologist or medical oncologist, who are already overwhelmed providing acute care to newly diagnosed patients with cancer?
Solving this dilemma has resulted in the development of multidisciplinary survivorship clinics, which are often led by nurse practitioners. Health promotion and risk-based anticipatory screening for early detection of long-term complications are the main focuses of such clinics.
This model of care is based on the Children’s Oncology Group Long-Term Follow-up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers (available at survivorshipguidelines.org) and can be implemented in every survivorship program throughout the United States.
Contributors to Risk
Are there childhood cancers that present a greater risk for late effects than others because of their treatment requirements?
The observation that not all patients develop a complication when exposed to treatment suggests that genetics may play a role in the development of these complications.— Smita Bhatia, MD, MPH
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More often than not, it is not the type of cancer but the treatment that results in the long-term complications. Of course, specific types of cancer and treatments are highly correlated. Further, the age at which the child receives the treatment is correlated with cancer type. Thus, it is hard to tease apart the cancer type and treatment exposures in determining the cause of complications.
That said, the observation that not all patients develop a complication when exposed to treatment suggests that genetics may play a role in the development of these complications. There are several initiatives underway that are examining the role of genetics in the development of long-term treatment-related complications in childhood cancer survivors.
Role of Prevention
Are there preventive strategies for patients who have gone through anthracycline-based treatment and are at risk for heart disease?
Currently, the major recommended preventive strategy is the scheduling of periodic cardiac evaluations to screen for early detection of heart failure. Saro H. Armenian, DO, MPH [Director of the Childhood Cancer Survivorship Clinic at City of Hope Comprehensive Cancer Center] is leading a large study to understand whether certain medicines can actually reverse the heart failure.
Several studies have identified a variety of demographic (young age and female sex) and clinical (higher dose of anthracyclines, chest radiation, hypertension, and diabetes) factors that contribute to the risk of heart failure in childhood cancer survivors. These findings may help identify which patients are most vulnerable to late effects of this type.
How can ASCO help educate primary care physicians about the long-term consequences of cancer treatment so they are aware of the necessity for close monitoring and early screening in childhood cancer survivors?
Primary care physicians are seeing survivors of childhood cancer as adults, and it is important that they become educated about the health issues they face. The ASCO Cancer Survivorship Committee continues to develop recommendations for the management of survivors of adult-onset cancer.
ASCO launched the Cancer Survivorship Symposium this year, which is a collaborative effort among ASCO, the American Academy of Family Physicians, and the American College of Physicians, to provide clinicians across disciplines with the information needed to guide the best care for survivors of cancer. The next Cancer Survivorship Symposium is scheduled for January 27–28, 2017, in San Diego, California.
Having this type of ongoing communication between oncology professionals and primary care providers will help improve care coordination and outcomes for cancer survivors. ■
Disclosure: Dr. Bhatia reported no potential conflicts of interest.