Monday, March 1, 2010

Long Term Survivors or Sufferers?

When arriving to Yousuf's regular PCP a couple weeks ago for his routine blood count, or rather a recount after the previous was too low to continue his meds, I saw a sign posted by the check-in. I can't quote it exactly but it was stating the awareness of the media's negative attention on some of the vaccines and said that Dr. Hausinger recommends all the vaccines (including H1N1 and seasonal flu) due to no scientific proof of any medical problems as a result.

Okay? No scientific proof, does that leave your heart reassured that you will walk out alright? My question is....isn't science always changing? Always evolving? It should read, "..Due to no scientific proof of any medical problems....that we KNOW of." Or, "YET." Wasn't it a part of "science" at one point to believe the world was flat? Science can only take us so far because of the fact that it hasn't stayed the same for more than a decade.

I started reading this article about long term "survivors" of childhood cancers. I thought it was interesting. I pasted the first and the last chapters. Inbetween are all the possible long term damages due to certain chemo drugs and radiation, based on studies....


The success of three decades of effective multimodality therapy for the treatment of childhood cancer has brought a cohort of maturing individuals, pursuing the normal experiences of life. Of each 1,000 twenty-year-olds, one is a survivor of childhood cancer [1]. Although the study of late effects originally arose within the realm of pediatrics, concerns may surface throughout the life cycle. Effects of therapy on the maturing organs become manifest only with the developmental process that unmasks hitherto unseen injury to immature organs. The focus of clinical trials on three- or five-year event-free survival thus does injustice to the needs of patients for support and information long after the trial endpoints are reached.

For the patient, any side effect for which he or she must compensate during life is a long-term effect. Tissue damage noted during or at the end of therapy may remain stable or become progressive. Late effects refer specifically to those unrecognized toxicities that are absent or subclinical at the end of therapy but manifest later as a result of growth, development, increased demand, or aging. Compensatory mechanisms that initially maintain the function of injured organs may fail with general organ senescence. Afflicted patients may have to undergo major adjustments to a lifestyle for which they are unprepared. The genetics of familial cancer syndromes and the mutagenic effects of therapy independently or synergistically may result in a significantly increased risk for a second malignancy. Synergistic effects of mutagenic agents (e.g., cigarette smoke) or toxins (e.g., alcohol) remain unknown.

This review will focus on types of tissue injury noted in long-term survivors. Rather than a comprehensive review of all described "late effects," the goal will be to consider types of effects and time of presentation. Stratification of effects by the time of appearance is important in considering potential causality as well as clinical screening methods. Specific organ toxicities will be presented to illustrate these points. The extent of tissue injury must be evaluated in terms of the therapies and doses given during the treatment period.

The plateau of the survival curve is most prominent in survivors of childhood malignancy since few diseases unrelated to the tumor or its therapy will result in an early death. Although the survivors of modern childhood cancer therapy are beginning to enter their fourth decade of life, it may be another two decades before the effect of aging on such individuals becomes clinically apparent. This enlarging population, as well as the similar population of young adult survivors of cancer, will require considerable attention from internists and the medical community in the decades to come.



As our patients grow, the fields of pediatric and adult oncology must grow with them. Our job is not done when the cancer cells are gone, for the years of life may present challenges that may be recognized only in the context of the original treatment plan. It must be our goal to mitigate the effects when possible, and, if not possible, to understand the effects so that future treatment regimens can be designed with fewer risks to long-term health.

Emphasis on the acute treatment phase has resulted in remarkable successes. Our discipline must now set up the mechanisms to learn where therapies have failed those who are cured of their cancers. Only by continued, systematic follow-up of large cohorts of survivors will we know the full spectrum of damage caused by cytotoxic therapy and possible interventions that may mitigate the effects. At present it is suggested that these survivors, whose bodies have been subjected to harsh cytotoxic therapies, should be encouraged to protect their bodies from further injury using the preventive approaches known to be effective for the general population. These include abstinence from tobacco, limited exposure to alcohol, sun protection, reduced fat intake, and maximal intake of fruits and vegetables. At a minimum, the surveillance techniques for detecting cancer in the general population (breast self-examination, mammography, testicular examination, examination of stools for blood, and evaluations of the rectum and colon) should be performed regularly.

A dilemma exists for the practitioner who might someday find that one in 1,000 patients is a survivor of childhood cancer. This number is too high for a practitioner to be unaware of potential problems, but far too low for him or her to maintain an adequate knowledge base to provide optimal care. Nevertheless, the trend over recent years has been to return patients to the care of primary physicians. Ongoing methods for educating both the patient and the primary caretakers must be devised. We must set up programs to evaluate the survivors every one to three years to assess and care for chronic organ damage, providing the necessary support for the primary physician. This must not replace the primary caretaker, but rather complement good primary care with that of the specialist who can anticipate potential problems specific to cytotoxic therapy.



  1. just as well the treatment plans changed recently to give one intensive block to low risk patients with A.L.L rather than two!

  2. Yeah, that's nice! But also my doctor was telling me that some of the medications increased from some years ago. She also said that they only follow patients unttil they are 18 now but by the time Yousuf reaches that age they will, more than likely, follow them their whole life. I think they should have been doing that all along! How do they truly know what a long term survivor is?