Beth Anne Kurt, MD, Assistant Director of Clinical Services for Pediatric Hematology and Oncology
Helen DeVos Children's Hospital 

One of the success stories in oncology is the great strides we've made in managing pediatric cancer. Today, the five-year survival rate approaches 80 percent, truly an extraordinary figure. But the fact that so many kids are surviving cancer creates its own issues. For instance, what is the role of the primary care physician in caring for these patients, particularly the community pediatrician? 

Our goal at Helen DeVos Children's Hospital is to engage pediatricians as partners in patient care by encouraging continued contact with their patients as they undergo cancer treatment. We urge parents to continue bringing their child to the pediatrician for well-child visits, and for follow up of other chronic conditions not related to the cancer, such as asthma. The key, of course, is good communication between the oncologist and pediatrician. 

Once children complete their cancer treatment, it is important not only to watch for recurrence, but also potential late-term health effects from the cancer and its treatment.  We are fortunate at Helen DeVos Children's Hospital to have the Pediatric Hematology and Oncology Aftercare and Transition (ACT) clinic to perform risk-based assessments of pediatric cancer survivors and provide recommendations for follow up. Many children's hospitals throughout the country have similar programs.

However, recent studies have found that significant numbers of childhood cancer survivors do not receive the follow-up care, including screenings, they require.^1,2,3 Even if a cancer aftercare clinic is not available in your community, one valuable resource available to all primary care physicians is the Long-Term Follow-up Guidelines from the Children's Oncology Group. These guidelines, which are available online free of charge, help simplify follow up of childhood cancer survivors based on their diagnosis and treatment exposures.  

While childhood cancer survivors remain in your practice, there are certain things you should be aware of, including: 

• Cardiovascular risks in children who received anthracycline chemotherapy and/or chest irradiation require regular monitoring of cardiac health

• Breast cancer risk in girls who received chest irradiation (e.g. for Hodgkin's lymphoma)

•  A higher risk of cervical cancer in girls who have had a stem cell transplant, increasing the importance of timely HPV vaccination.⁴

• Higher rates of psychological diagnoses, including attention deficit and emotional problems, in adolescents who survived cancer.⁵

The most important thing I'd suggest is that you refer to the current guidelines from the Children's Oncology Group if a childhood cancer survivor presents with a worrisome symptom or health concern, and that you feel free to consult his or her pediatric oncologist for further guidance. 

How are you managing cancer survivors in your practice?

Beth Anne Kurt, MD, is the Assistant Director of Clinical Services at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

REFERENCES

¹Nathan PC, Greenberg ML, Ness KK et al. Medical care in long-term survivors of childhood cancer: a report from the childhood cancer survivor study.J Clin Oncol. 2008 Sep 20;26(27):4401-9.

²Klosky JL, Cash DK, Buscemi J, et al. Factors influencing long-term follow-up clinic attendance among survivors of childhood cancer. J Cancer Surviv. 2008 Dec;2(4):225-32. 

³Oeffinger KC, Mertens AC, Hudson MM, et al. Health care of young adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Ann Fam Med. 2004 Jan-Feb;2(1):61-70.

⁴Klosky JL, Gamble HL, Spunt SL, et al. Human papillomavirus vaccination in survivors of childhood cancer. Cancer. 2009 Dec 15;115(24):5627-36.

⁵Krull KR, Huang S, Gurney JG, et al. Adolescent behavior and adult health status in childhood cancer survivors. J Cancer Surviv. 2010 Sep;4(3):210-7. Epub 2010 Apr 11.