1. The Pediatric Perspective on Cancer Survivorship Sue Lindemulder, MD, MCR Medical Director, Childhood Cancer Survivorship Program September 12, 2013

2. Objectives After this presentation, participants should be able to: Identify late effects common in children who are survivors of childhood cancer and stem cell transplant Know how to screen patients for common late effects of treatment. Identify resources available to aid providers in screening for late effects

3. Background Majority of children with cancer become long term survivors Majority of childhood cancer survivors have late effects

4. Approximately 80% will be Survivors

5. Childhood Cancer Survivor Study Multi-institutional collaborative study (26 centers) Diagnosed with cancer in childhood or adolescence and survived at least 5 years Diagnoses: Leukemia, Kidney, Bone, Soft Tissue Sarcoma, Neuroblastoma, Hodgkin’s or non- Hodgkin’s lymphoma, and primary CNS malignancy. Diagnoses between January 1, 1970 and December 31, 1986

6. Childhood Cancer Survivor Study 17,565 eligible survivors not lost to follow-up, 4855 eligible siblings Baseline questionnaire: 24 pages with demographic variables, medical conditions, surgical procedures and other health outcomes 14,362 (81.8%) survivors and 3901 (80.4%) siblings completed the questionnaire 12,480 survivors had complete treatment data abstracted

7. CCSS: Percentage with Late Effects Oeffinger KC et al. 2006

8. CCSS: Type of Late Effects Oeffinger KC et al. 2006

9. CCSS: Timing of Late Effects Oeffinger KC et al. 2006

10. St Jude Lifetime Cohort Study 1713 participants diagnosed between 1962-2001 Follow-up between Oct 1, 2007 and Oct 31, 2012 Median time from Diagnosis: 25 years Screened per Children’s Oncology Group Long- Term Follow-Up Guidelines (www.survivorshipguidelines.org) Chronic health Condition: 98.2% (97.5%-98.8%) Serious or life-threatening condition: 67.6% (65.3%-69.8%)

11. SJLIFE: Effect of Screening

12. CCSS: Survivors and Medical Care Nathan PC et al. 2008.

13. Putting a Face on Survivorship

14. Taken from Oregonian, April 27, 2012

15. Diagnosis: Acute lymphoblastic leukemia; Relapse (left occular & CNS) 6/7/2004 Date of Diagnosis: 1/03/2003 Date of Bone Marrow Transplant: 9/15/2004 Protocol: POG 9906; followed by relapse therapy CCG 1951 Chemotherapy exposures (cumulative dose): Anthracycline (72 mg/m2), Cytoxan (4.7 g/m2), 6-MP, Vincristine, Dexamethasone, Cytarabine, L' asparginase, Peg-Asparaginase, Methotrexate (IV, PO & IT), Ifosfamide (9 g/m2); Etopophos (allergy to Etoposide) (2.2 g/m2); Triple intrathecals x 4, Tacrolimus, Prednisone (ended 11/11/2005). Off immunosuppressives since 10/01/2006. Radiation Therapy: 2400 cGy to the left eye & 1200 cGy cranial & 1200 cGy TBI (2004) Last ECHO: (2012) FS 29%; EF 56% Last PFT: (2011) Improved from previous Surgeries: Line placement x 2 (2004 & 2005); Right hip replacement (2006); Bilateral cadaveric knee allografts (2007) Blood Products/year: 2004 on file - presumed 2003 Problem List from History: History of low shortening fraction on echo from 2004 treated with digoxin & lisinopril until 9/2004; History of hyperlipidemia; History of iatrogenic hypertension; Decreased vision left eye; Avascular necrosis; History of chronic GVHD of the skin and gut; Gonadal failure; Hypothryroid; Severe influenza requiring ICU hospitalization shortly after transplant. Neuropsych testing: (8/21/2004) (pre-transplant)- Intellectual functioning intact; normal on all examinations Cancer Treatment Summary

16. Cardiac Toxicity Late Effect: Cardiomyopathy, Arrhythmia, Subclinical left ventricular dysfunction, Valve dysfunction. Cancers: Almost all, high doses with sarcomas Chemotherapy Agents: Anthracyclines Radiation: Total Body, Whole lung, Mantle etc Risk Factors: Obesity, Congenital Heart Disease, Isometric exercise, Smoking, Illicit drug use. Children’s Oncology Group; www.survivorshipguidelines.org

17. Cardiac Toxicity Periodic Evaluation History (yearly): SOB, DOE, Orthopnea, Chest pain, Palpitations, if <25 yrs abdominal symptoms Physical (yearly): Cardiac murmur, S3/S4, Increased P2 sound, Pericardial rub, Rales, JVD Screening ECHO or MUGA baseline at entry into LTFU then at intervals. EKG baseline at entry into LTFU then as clinically indicated Children’s Oncology Group; www.survivorshipguidelines.org

18. Cardiac Toxicity Screening Guidelines Age at TreatmentRadiation with Potential Impact to the Heart Anthracycline DoseRecommended Frequency < 1 year oldYesAnyEvery year No <200 mg/m2Every 2 years ≥200 mg/m2Every year 1-4 years oldYesAnyEvery year No <100 mg/m2Every 5 years ≥100 to <300 mg/m2Every 2 years ≥300 mg/m2Every year ≥5 years oldYes<300 mg/m2Every 2 years ≥300 mg/m2Every year No<200mg/m2Every 5 years ≥200 to <300 mg/m2Every 2 years ≥300 mg/m2Every year Any age with decrease in serial function Every year Children’s Oncology Group; www.survivorshipguidelines.org

19. Pulmonary Toxicity Late Effect: Pulmonary fibrosis, interstitial pneumonitis Cancers: Hodgkin’s, germ cell tumors, BMT Chemotherapy Agents: Bleomycin, Busulfan Radiation: Whole lung, Total Body, Mediastinal etc Other: Chronic GVHD Risk Factors: Younger age at tx, higher doses, radiation dose ≥ 10Gy, smoking Children’s Oncology Group; www.survivorshipguidelines.org

20. Pulmonary Toxicity Periodic Evaluation History (yearly): Cough, SOB, DOE, Wheezing Physical (yearly): Pulmonary exam Screening Chest x-ray and Pulmonary function testing (including DLCO and spirometry): Baseline at entry into long term follow-up. Repeat as clinically indicated if abnormal or if progressive dysfunction. Children’s Oncology Group; www.survivorshipguidelines.org

21. Meet Jessica

22. Jessica’s Cancer Treatment Summary Diagnosis: Philadelphia + acute biphenotypic leukemia diagnosed at age 11; 2 x relapsed on therapy 10/14/1993 after two courses (paused for infection) & 1/1994 (after 2 courses of salvage therapy). Date of Diagnosis: 5/1993 Date of Bone Marrow Transplant: 3/27/1994 Chemotherapy exposures (cumulative dose): Anthracycline (430 mg/m2), Cytoxan (2 gram/m2), Vincristine (12mg/m2), Steroids (prednisone and dexamethasone), Cytarabine (10.3 gram/m2), Asparginase, 6-mercaptopurine, 6-thioguanine, Etoposide (800 mg/m2), Fludarabine (41mg/m2) and Intrathecal methotrexate and cytarabine. BMT preparative chemotherapy: Thiotepa (900 mg/m2) and Etoposide (1.5 gram/m2). Radiation Therapy: Cranial 1800 cGy (1993); TBI 1200 cGy (1994) Surgeries: Thyroid cyst removed (1984); Cholecystectomy; Appendectomy (1995); multiple central lines; Bilateral hip total arthoplasty (2007); Left knee total arthroplasty (2007); Manipulation of left knee arthoplasty (2008). Fracture repair & plating of right distal radius (2009); Multiple dental extractions (2012 & 2013) Blood Product Exposure/year: 1993 On therapy complications: Multiple episodes of sepsis and bacteremia, clostridium cellulitis of hip, leg, and perineum, veno-occlusive disease, septic arthritis, acute graft-versus-host disease, multiple compression fractures of the spine, hepatic abscesses, GI bleed, seizures. Off therapy complications: Chronic graft-versus-host disease, osteonecrosis of bilateral hips and left knee, fracture of right wrist, hyperlipidemia, ovarian failure (OCPs to be prescribed once triglycerides are controled), growth failure without GH treatment, sub clinical hypothyroidism, vitamin D deficiency, cholecystitis, osteoporosis, dry eye, diabetes type 2 (controled) and excessive dental caries. Alteration in body image

23. Bone Toxicity Late Effect: Reduced Bone Mineral Density, Osteonecrosis Cancers: ALL, osteosarcoma Chemotherapy Agents: Steroids, HD Methotrexate Radiation: Any Other: Bone marrow transplant Risk Factor: Younger age, lower weight, growth hormone deficiency, hypogonadism/delayed puberty, inadequate vitamin D or calcium intake, smoking Children’s Oncology Group; www.survivorshipguidelines.org

24. Bone Toxicity Periodic Evaluation History (yearly): Fracture history, joint pain Physical (yearly): No specific Screening Bone Density Evaluation: Baseline at long term follow-up and than as clinically indicated (baseline is age dependent). Vitamin D levels Children’s Oncology Group; www.survivorshipguidelines.org

25. Endocrine Toxicity: Thyroid Late Effect: Hypothyroidism, Thyroid nodules, Thyroid cancer Cancers: Hodgkin’s, Brain tumors, BMT Chemotherapy Agents: None Radiation: Cranial, Spine, Supraclavicular, Chest, Mantle, Mediastinal, Total Body Risk Factors: Female, Radiation doses ≥ 10 Gy, Thyroid directly in field Children’s Oncology Group; www.survivorshipguidelines.org

26. Endocrine Toxicity: Thyroid Periodic Evaluation History (yearly): Fatigue, Weight gain, Cold intolerance, Constipation, Dry skin, Brittle Hair, Depressed mood. Physical (yearly): Height, Weight, Hair and skin, thyroid exam Screening TSH and free F4 yearly. May need more frequently during periods of rapid growth Children’s Oncology Group; www.survivorshipguidelines.org

27. Meet Brady

28. Brady’s Cancer Treatment Summary Diagnosis: Stage IV Adrenal Neuroblastoma (Age 3 years) Date of Diagnosis: 11/1993 Date of Bone Marrow Transplant: Auto, July 1994 (CHLA) Protocol: CCG 3891 Regimen: B - Bone marrow transplant Chemotherapy exposures (cumulative dose): Carboplatin (1 g/m2); Cisplatin (300 mg/m2); Etoposide (1.64 g/m2); Doxorubicin (150 mg/m2); Cyclophosphamide (9 g/m2); Melphalan (210 mg/m2); Retinoic Acid. Radiation Therapy: 999 cGy TBI (1994); 2000 cGy to the sphenoid sinus, right shoulder, right hip, right tibia, left tibia (1994); 1000 cGy to the abdomen (1994); MIBG 330 mCU (8/1995). Surgeries: Subtotal resection of left adrenal mass (1994); Left sphenoid sinus sinusotomy (1994); Line placement x 2 (1994 & 1995); Resection of anterior abdominal wall fibromatosis (1995); Resection of chest wall keloid and detached retina repair (1997); Left cataract removal and lens implant (2003); YAG laser capsulotomy left eye (2004); Left tonsillectomy (path of mass = lymphoid follicular hyperplasia) and right tonsil biopsy (2005); Bilateral tibia-fibula osteotomy (2006). Blood Products/year: None on file, presume 1993 Problem List from History: Hypothyroid; Short Stature; Gonadal failure; Cataracts and retinal detachment. Neuropsych testing: (2001) Intellectually in the "bright normal to superior range". Susceptible to distraction.

29. Brady’s Growth Chart

30. Growth Abnormalities Late Effect: Growth Abnormalities (isolated limb or global) Chemotherapy Agents: ? intrathecals Radiation: Cranial, Spine, Total Body, any bone Risk Factors: Younger age, higher radiation doses Children’s Oncology Group; www.survivorshipguidelines.org

31. Growth Abnormalities Periodic Evaluation History (every 6 months until growth complete): Assessment of nutritional status Physical (every 6 months until sexually mature): Height, Weight, BMI and Tanner Stage Screening Plot and follow growth curves carefully. If there is one risk factor and cross one height percentile line refer to endocrine. Children’s Oncology Group; www.survivorshipguidelines.org

32. Warning! Decreased Velocity!

33. Eye Toxicity Late Effect: Cataracts Cancers: ALL, BMT, Brain tumors Chemotherapy Agents: Busulfan, Steroids Radiation: Cranial, Total Body Risk Factors: Radiation dose ≥10 Gy. TBI ≥ 5 Gy. Combination therapy. Children’s Oncology Group; www.survivorshipguidelines.org

34. Eye Toxicity Periodic Evaluation History (yearly): Visual changes (decreased acuity, halos, diplopia) Physical (yearly): Eye exam (visual acuity, fundoscopic exam for lens opacity) Screening Yearly evaluation by ophthalmologist for those who received TBI or ≥ 30 Gy radiation Evaluation every 3 years for everyone else Children’s Oncology Group; www.survivorshipguidelines.org

35. Meet Leah

36. Leah’s Cancer Treatment Summary Diagnosis: Acute lymphoblastic leukemia, high risk for age, slow early response, diagnosed at 11 years old, finished planned chemo 5/2003; Myelodysplastic syndrome with monosomy 7 diagnosed August 2003. Date of Diagnosis: 1/2001 Date of Bone Marrow Transplant: 11/2003 – MUD marrow Chemotherapy exposures (cumulative dose): Anthracycline (300 mg/m2); cytoxan (10 grams/m2); including SCT dose); thiopurines, vincristine, steroids, cytarabine, asparaginase, methotrexate, Busulfan (16 mg/kg); fludarabine (160 mg/m2). Grade 1 GVHD off immunosuppression since Oct 2004; Radiation Therapy: Cranial prophylaxis 1800 cGy Surgeries: Central line x 2, Cholecystectomy (2003), Sinus irrigation (2004) Blood Products/year: 2001 Problem List from History: Ovarian failure; Acne; Gastroesophageal reflux; Recurrent vaginal yeast infections. Neuropsych testing: (7/2009) FS IQ 107; Attention issues

37. Endocrine Toxicity: Gonadal Function Late Effect: Delayed puberty, oligo/ azospermia, premature menopause, infertility Cancers: Sarcomas, Hodgkin’s, BMT Chemotherapy Agents: Alkylating agents Radiation: Cranial, radiation to ovary or testes Risk Factors: Higher cumulative doses of alkylators combine with radiation, smoking Children’s Oncology Group; www.survivorshipguidelines.org

38. Endocrine Toxicity: Gonadal Function Periodic Evaluation History (yearly): Puberty (onset, tempo), Sexual function, Medications impacting sexual function Physical (yearly): Tanner Staging, Testicular volume until sexually mature for boys Screening FSH, LH, Estradiol/Testosterone: At age 13 (girls)/14 (boys) and as indicated for signs of gonadal deficiency. Sexual function. Semen analysis Children’s Oncology Group; www.survivorshipguidelines.org

39. Neurocognitive Function Late Effect: Deficits in executive function, attention, memory, processing speed, visual-motor integration Chemotherapy agents: Cytarabine (high dose), Methotrexate (IT and high dose), Radiation: Cranial, Total Body Risk Factors: Younger age, female, CNS leukemia/ lymphoma, CNS-directed therapy, Radiation Children’s Oncology Group; www.survivorshipguidelines.org

40. Neurocognitive Function Periodic Evaluation History (yearly): Educational and/or vocational progress Screening Referral for formal neuropsychological evaluation: Baseline at entry into long term follow-up then as indicated Children’s Oncology Group; www.survivorshipguidelines.org

41. Risk for All?

42. Second Cancers AML/MDS: – Chemotherapy Agents: Anthracyclines, Etoposide – Other: Bone marrow transplant Skin Cancer: – Radiation: Skin in any field Soft Tissue Cancer (Bone, Brain, Thyroid, Breast, GI, Muscle): – Radiation: Any tissue in the field Children’s Oncology Group; www.survivorshipguidelines.org

43. When are they at Risk? Robison LL et al. 2009

44. Does the Risk Ever End? Robison LL et al. 2009

45. Second Cancers: Screening AML: CBC every year for 10 years (ongoing for BMT) Skin Cancer: Yearly dermatologic exam Soft Tissue Cancer: Yearly exam Breast Cancer: Mammogram beginning 8 years after radiation or at age 25 years (later date). Breast MRI yearly in addition to mammography. Colorectal Cancer: Colonscopy every 5 years (minimum) beginning at 10 years after radiation or age 35 years (later date). Children’s Oncology Group; www.survivorshipguidelines.org

46. Tools to Assist Medical Providers

47. Tools for Providers and Patients Comprehensive Survivorship Program Access to risk-based recommendations Access to multi-disciplinary consultation and instruction regarding issues Education regarding future screening Communication with providers

48. Doernbecher Childhood Cancer Survivorship Program Multi-disciplinary clinics on Fridays – Program Coordinator: Kitt Swartz – Medical Director: Sue Lindemulder – Nurse Practitioner: Kelly Anderson – Psychologist: Michael Harris & Debbie Dwelle – Social Worker: Sue Best – Educational Specialist: Kerri Russell – Dental Support: Dental residents – Neuro-oncologist: Stacy Nicholson – Orthopedic Surgeons: Ivan Krajbich and James Hayden – Oncology Nurse: Katie Loomis

51. Conclusions Most children will survive their cancer. Survivors are at risk for medical and psychosocial late effects and need lifelong monitoring Education for patients and providers with regard to screening for late effects is important to maintain future health There are many tools and resources to assist with the care of these patients

52. Thank you for Your Attention!

53. References Chow EF et al. Risk of Thyroid Dysfunction and Subsequent Thyroid Cancer Among Survivors of Acute Lymphoblastic Leukemia: A report from the Childhood Cancer Survivor Study. Pediatr Blood Cancer (2009). 53: 432-437. Hudson MM et al. Clinical Ascertainment of Health Outcomes Among Adults Treated for Childhood Cancer. JAMA (2013). 309(22): 2371-2381. Nathan PC et al. Medical Care in Long-Term Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol (2008). 26(27): 4401- 4409. Oeffinger KC et al. Chronic Health Conditions in Adult Survivors of Childhood Cancer. NEJM (2006). 355(15): 1572-1582. Robison LL et al. Treatment-associated subsequent neoplasms among long-term survivors of childhood cancer: The Childhood Cancer Survivor Study experience. Pediatr Radiol (2009). 39(Suppl 1): S32-S37.