August 30, 2021
Melissa M. Hudson, M.D.,
The development of curative therapy for pediatric cancers represents a milestone in cancer advances of the last 50 years. Five-year survival rates now exceed 80% in high-income countries, with extended survival into adulthood anticipated for most children, adolescents and young adults diagnosed with cancer.
As the growing survivor population transitions from care provided at oncology centers, primary care professionals will be called on to participate in long-term follow-up care.
Thus, awareness of survivors’ physical and psychosocial morbidities is critical to assure access to care and services that address their unique health risks predisposed by cancer and its treatment.
The AAP clinical report Long-term Follow-up Care for Childhood, Adolescent and Young Adult Cancer Survivors has been updated based on the latest guidelines from the Children’s Oncology Group (COG). The report, from the Section on Hematology/Oncology, COG and the American Society of Pediatric Hematology/Oncology, is available at https://doi.org/10.1542/peds.2021-053127 and will be published in the September issue of Pediatrics.
Importance of care plan, challenges
Key facts highlighting the importance of survivorship care include the following:
Virtually all survivors experience persistent and long-term (late) effects of cancer.
Many health effects present years after cancer treatment.
Late effects contribute to excess morbidity and premature mortality.
Recognition of late effects not only has motivated changes in pediatric cancer treatment strategies but also has produced systematic efforts to characterize long-term health outcomes and develop interventions through prevention, early detection and remediation of late effects.
Complexities of planning
Factors that challenge delivery of survivorship care include the heterogeneity of pediatric cancers, diverse and evolving therapeutic approaches, and variable toxicity profiles of specific agents and modalities. In addition, risk profiles for late effects vary by patient and may be influenced by genetics, comorbid health conditions and health behaviors. Moreover, social determinants of health that affect a survivor’s access to health care and remedial resources are important to consider.
To address the multifactorial contributions to outcomes, the clinical report recommends high-quality care for all survivors. A systematic plan should address lifelong screening, surveillance and prevention that incorporates risks based on cancer therapy, genetic predispositions, lifestyle behaviors and comorbid health conditions. Foundational to risk-based care is knowledge of specific therapeutic modalities and development of a survivorship care plan.
The COG first published evidence-based screening guidelines in 2003 to facilitate systematic follow-up of pediatric cancer survivors. The Children’s Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers(COG LTFU guidelines) provide a comprehensive resource of treatment exposure-based recommendations targeted for asymptomatic survivors presenting for routine health maintenance at least two years after completing therapy. The guidelines, available at www.survivorshipguidelines.org, are updated every five years by multidisciplinary task forces that monitor the literature on late effects.
The COG LTFU guidelines address late effects from the cancer experience, transfusions, specific chemotherapeutic agents, radiation exposures, hematopoietic cell transplantation and specific surgical procedures. Each section briefly summarizes patient characteristics that have been reported to modify the risk of specific late effects and cancer- and treatment-related factors to consider in the delivery of personalized, survivor-focused care.
The clinical report offers the following guidance:
Primary health care professionals should work with the oncology subspecialist to:
develop and implement the survivorship care plan and coordinate survivorship care;
educate survivors and their families on cancer treatment-related health risks; recommended health screening and risk-reduction methods; and resources to facilitate their access to survivorship care; and
prepare survivors and their families for health care transitions.
Use the COG LTFU guidelines to develop an individualized survivorship care plan based on the survivor’s specific cancer treatment and risk of late complications.
Ensure that the survivorship care plan includes screening for potential adverse medical and psychosocial effects of the cancer experience.
Ensure that the plan addresses comorbid health conditions, familial and genetic factors, and health behaviors that affect the risk of chronic disease; and provide interventions and resources to remediate and prevent late effects of cancer and promote healthy lifestyle behaviors.