Diminished ovarian reserve in adolescent cancer survivors treated with heavy metal chemotherapy.

The extent to which heavy metal chemotherapy results in treatment-related ovarian damage is controversial. Anti-Mullerian hormone (AMH) levels measured more than 1 year after cancer therapy completion were abstracted from the medical records of 39 female survivors of childhood cancer aged 11 years and older, whose only gonadotoxic exposure was heavy metal chemotherapy. One-fifth of survivors who received cisplatin had AMH levels indicative of diminished ovarian reserve at last measurement. There was an observed clustering of low AMH in patients diagnosed in the peripubertal age range (i.e., 10-12 years). These findings may support a small, but present, risk of gonadal damage after heavy metal chemotherapy.

Transition practices for survivors of childhood cancer: a report from the Children's Oncology Group.

PURPOSE: Pediatric healthcare systems must support childhood cancer survivors to optimize their transition to adult care. This study aimed to assess the state of healthcare transition services provided by Children's Oncology Group (COG) institutions. METHODS: A 190-question online survey was distributed to 209 COG institutions to assess survivor services, including transition practices, barriers, and implementation of services aligned with the six core elements of Health Care Transition 2.0 from the US Center for Health Care Transition Improvement. RESULTS: Representatives from 137 COG sites reported on institutional transition practices. Two-thirds (66.4%) of site discharge survivors to another institution for cancer-related follow-up care in adulthood. Transfer to primary care (33.6%) was a commonly reported model of care for young adult-aged survivors. Site transfer at ≤ 18 years (8.0%), ≤ 21 years (13.1%), ≤ 25 years (7.3%), ≥ 26 years (12.4%), or when survivors are "ready" (25.5%). Few institutions reported offering services aligned with the structured transition process from the six core elements (Median = 1, Mean = 1.56, SD = 1.54, range: 0-5). The most prevalent barriers to transitioning survivors to adult care were perceived lack of late-effects knowledge among clinicians (39.6%) and perceived lack of survivor desire to transfer care (31.9%). CONCLUSIONS: Most COG institutions transfer adult-aged survivors of childhood cancer elsewhere for survivor care, yet few programs report delivering recognized standards for quality healthcare transition programming to support survivors. IMPLICATIONS FOR CANCER SURVIVORS: Development of best practices for survivor transition is needed to help promote increased early detection and treatment of late effects among adult survivors of childhood cancer.

Cancer-Related Barriers to Health Behaviors Among Adolescent and Young Adult Survivors of Pediatric Cancer and Their Families.

Adolescent and young adult (AYA) survivors of pediatric cancer and their caregivers frequently do not meet national guidelines for physical activity (PA), nutrition, or sleep. Respondents from N = 73 AYA-aged (mean [M] = 19.0 years, range = 11-30 years) survivor families completed a survey on cancer-related barriers to health behaviors. Almost all respondents (68/73, 93.2%) endorsed ≥1 cancer-specific barrier(s) to current health behaviors (median = 5, standard deviation = 3.42, range = 0-16) in their family. Cancer-related barriers to PA, nutrition, and sleep were positively correlated (PA-nutrition: r = 0.39, p = 0.001; PA-sleep: r = 0.41, p < 0.001; nutrition-sleep: r = 0.52, p < 0.001). Wellness interventions are needed to address the unique needs of AYA-aged survivors and support multiple health behaviors simultaneously.

Feasibility of Fitbit Use in Adolescent Survivors of Pediatric Cancer: Who Consistently Uses It and for How Long?

Purpose: Wearable activity trackers with real-time feedback and goal-setting features are being incorporated into programs to increase physical activity among childhood cancer survivors. This analysis describes the adoption and use of a Fitbit® Flex™ among adolescent-aged survivors of childhood cancer without incentives, reminders, or interventions to encourage use. Procedures: Cancer survivors aged 13-18 and ≥2 years from therapy received a Fitbit Flex with instructions to wear it daily. Researchers downloaded participants' daily total steps and active minutes for 1 year. Participants were classified as consistent (≥5 days/week for >4 weeks during the first 12 weeks) or inconsistent users, and comparisons between user types were made. Longitudinal use of the Fitbit and participants' 1-year acceptability evaluations are described. Results: Overall, 67.1% (47/70) of survivors enrolled, and Fitbit data were available for 36 participants. Initially, 30.6% (11/36) were consistent users. Consistent users had lower body mass index z-scores at enrollment (0.4 ± 0.7 vs. 1.2 ± 0.9; p = 0.01), but were otherwise comparable with inconsistent users. Over time survivors' use declined; at 12 months, only one participant was using his or her Fitbit. Survivors who completed a survey (n = 22) reported their Fitbit helped them self-monitor their exercise (72.7%, 16/22) and lead a more active lifestyle (63.6%, 14/22), but found it challenging to charge and not lose, forget about, or break the device. Conclusions: In the real-world setting, only a small subset of adolescent-aged survivors will initially consistently use a Fitbit and their interest diminishes over time. To maximize engagement, interventions incorporating wearable activity trackers likely need to include additional behavior change strategies.

Changes in Opioid Prescriptions and Potential Misuse and Substance Use Disorders Among Childhood Cancer Survivors Following the 2016 Opioid Prescribing Guideline.

Importance: The Centers for Disease Control and Prevention (CDC) released an opioid-prescribing guideline in March 2016. Little is known about the guideline's potential effects on childhood cancer survivors, a population at high risk for pain. Objective: To examine changes in opioid prescriptions and potential misuse/substance use disorders (SUD) among childhood cancer survivors and peers without cancer following the guideline release. Design, Setting, and Participants: In this cohort study using the MarketScan Commercial Claims and Encounters Database, 8969 survivors who completed treatment for hematologic, central nervous system, bone, or gonadal cancers (aged ≤21 years at diagnosis) from 2009 to 2018 and 44 845 age-matched, sex-matched, and region-matched individuals without cancer were identified. With data aggregated based on the quarter-year of survivors' treatment completion, interrupted time series analyses were conducted in this cohort study to estimate the immediate (level) change and change in time trend (trend change) for each outcome after the guideline release, accounting for autocorrelation. Data were analyzed from September 2021 to April 2022. Exposures: Release of the CDC opioid-prescribing guideline. Main Outcomes and Measures: Outcomes included any opioid prescription and any indicator for potential misuse/SUD within 1 year following completion of treatment. Results: This study included 8969 childhood cancer survivors (mean [SD] age, 13.7 [6.2] years old; 3814 [42.5%] female patients) and 44 845 peers without cancer (mean [SD] age, 13.7 [6.2] years old; 19 070 [42.5%] female patients). Before the guideline release, the opioid prescription rate (21.1% vs 7.2%) and rate of potential misuse/SUD (5.6% vs 1.9%) were higher among survivors than peers without cancer. After the guideline release, the trend in opioid prescription rate declined among survivors (trend change, -1.1 percentage points [ppt]; P < .001; 95% CI, -1.5 to -0.7). Survivors also experienced an immediate level decrease (-2.1 ppt; P = .04; 95% CI, -4.2 to -0.1) and a decreasing trend (trend change, -0.4 ppt; P = .009; 95% CI, -0.6 to -0.1) in rate of potential misuse/SUD. Peers without cancer experienced decreasing trends in opioid prescription rate (trend change, -0.3 ppt; P < .001; 95% CI, -0.5 to -0.1) and rate of potential misuse/SUD (trend change, -0.1 ppt; P = .03; 95% CI, -0.1 to -0.01). By 2 years after the guideline release, relative reductions in opioid prescription rate and rate of potential misuse/SUD among survivors were 36.7% and 65.4%, respectively, with peers without cancer experiencing smaller reductions (15.9% and 29.9%). Conclusions and Relevance: In this cohort study, the opioid prescription rate and rate of potential misuse/SUD declined among both survivors and peers without cancer following the CDC guideline release, with survivors experiencing greater reductions. More research is needed to understand the guideline's potential effects on access to opioids required for pain control among childhood cancer survivors.

Early Posttherapy Opioid Prescription, Potential Misuse, and Substance Use Disorder Among Pediatric Cancer Survivors.

BACKGROUND: Pediatric cancer survivors often have pain, which may be managed with opioids. We examined the prevalence of opioid prescriptions, potential misuse, and substance use disorders (SUDs) among pediatric cancer survivors during the first year posttherapy. METHODS: Using MarketScan Commercial Database, we identified 8969 survivors (aged 21 years or younger at diagnosis) who completed cancer therapy in 2009-2018 and remained continuously enrolled for at least 1 year posttherapy and 44 845 age-, sex-, and region-matched enrollees without cancer as a comparison group. Outcomes included opioid prescriptions, any indicator of potential prescription opioid misuse, and SUDs within 1 year posttherapy. Outcomes were compared between survivors and noncancer peers in bivariate and adjusted analyses, stratified by off-therapy age (children: 0-11 years; adolescents: 12-17 years; young adults: 18-28 years). All statistical tests were 2-sided. RESULTS: A higher proportion of survivors than noncancer peers filled opioid prescriptions (children: 12.7% vs 2.0%; adolescents: 22.9% vs 7.7%; young adults: 26.0% vs 11.9%). In models adjusting for sociodemographic factors and health status, survivors remained 74.4%-404.8% more likely than noncancer peer to fill opioid prescriptions (P < .001). The prevalence of potential misuse or SUDs was low, with 1.4% of child, 4.7% of adolescent, and 9.4% of young adult survivors fulfilling at least 1 criterion; however, it was higher than noncancer peers (0.1%, 1.4%, and 4.3%, respectively). In adjusted models, the likelihood of potential misuse among survivors remained at least 2 times higher than that among noncancer peers (P < .001), and the difference in SUDs became nonstatistically significant. CONCLUSION: Statistically significantly higher rates of opioid prescriptions and potential misuse were found among pediatric cancer survivors within 1 year posttherapy as compared with peers without cancer.

Late hepatic toxicity surveillance for survivors of childhood, adolescent and young adult cancer: Recommendations from the international late effects of childhood cancer guideline harmonization group.

BACKGROUND: Survivors of childhood, adolescent and young adult (CAYA) cancer may develop treatment-induced chronic liver disease. Surveillance guidelines can improve survivors' health outcomes. However, current recommendations vary, leading to uncertainty about optimal screening. The International Late Effects of Childhood Cancer Guideline Harmonization Group has developed recommendations for the surveillance of late hepatotoxicity after CAYA cancer. METHODS: Evidence-based methods based on the GRADE framework were used in guideline development. A multidisciplinary guideline panel performed systematic literature reviews, developed evidence summaries, appraised the evidence, and formulated recommendations on the basis of evidence, clinical judgement, and consideration of benefits versus the harms of the surveillance while allowing for flexibility in implementation across different health care systems. RESULTS: The guideline strongly recommends a physical examination and measurement of serum liver enzyme concentrations (ALT, AST, gGT, ALP) once at entry into long-term follow-up for survivors treated with radiotherapy potentially exposing the liver (moderate- to high-quality evidence). For survivors treated with busulfan, thioguanine, mercaptopurine, methotrexate, dactinomycin, hematopoietic stem cell transplantation (HSCT), or hepatic surgery, or with a history of chronic viral hepatitis or sinusoidal obstruction syndrome, similar surveillance for late hepatotoxicity once at entry into LTFU is reasonable (low-quality evidence/expert opinion, moderate recommendation). For survivors who have undergone HSCT and/or received multiple red blood cell transfusions, surveillance for iron overload with serum ferritin is strongly recommended once at long-term follow-up entry. CONCLUSIONS: These evidence-based, internationally-harmonized recommendations for the surveillance of late hepatic toxicity in cancer survivors can inform clinical care and guide future research of health outcomes for CAYA cancer survivors.

Self-reported late effect symptom clusters among young pediatric cancer survivors.

PURPOSE: Most survivors of childhood cancer experience subsequent chronic conditions but little is known about concurrent symptoms. This study seeks to identify late effect symptom clusters among young pediatric cancer survivors. METHODS: Survivors ≥ 18 or parents of survivors < 18 years enrolled in an institutional cohort study indicated (yes/no) if they experienced certain symptoms after treatment. The sample was randomly divided in half for exploratory factor analyses to identify symptom clusters followed by confirmatory factor analyses. Symptoms with ≥ 10% prevalence were included. Cluster structure generalizability across subgroups was examined using congruence coefficients. RESULTS: The sample included 579 survivors (74% non-Hispanic white, 45% leukemia, 12.8 ± 4.5 years at survey, 5.9 ± 3.5 years since therapy). Respondents averaged three symptoms. Three clusters were identified: (1) gastrointestinal: abdominal pain, diarrhea, constipation, nausea, vomiting (Cronbach's α = 0.74); (2) psychological: depression, anxiety, memory problems, anger management problems, sleep problems (α = 0.71); and (3) neurologic: problems walking, numbness/tingling, fatigue, back pain, chronic pain, weakness/inability to move legs (α = 0.71). Confirmatory factor analysis confirmed the three-cluster structure (standardized root mean square residual: 0.09; parsimonious goodness of fit: 0.96; Bentler-Bonett normed fit index: 0.95). The gastrointestinal and psychological clusters were generalizable across most subgroups while the neurologic cluster varied across age and race/ethnicity subgroups. CONCLUSION: Three distinct late effect symptom clusters were identified in young childhood cancer survivors with gastrointestinal and psychological clusters remaining relatively stable across subgroups. Future studies should focus on the characteristics of patients who experience these symptoms, especially those with high symptom burden, and the synergistic impact on quality of life.

Substance use, substance use disorders, and treatment in adolescent and young adult cancer survivors-Results from a national survey.

BACKGROUND: Substance use can exacerbate cancer-related morbidity and mortality in adolescent/young adult (AYA) cancer survivors and place them at increased risk for adverse health outcomes. The objective of this study was to assess substance use, misuse, and substance use disorders [SUDs], as well as receipt of treatment for SUDs, among AYA cancer survivors. METHODS: The authors used data from the National Survey of Drug Use and Health (2015-2018) to identify a nationally representative sample of AYAs aged 12 to 34 years. Outcomes assessed past-year tobacco, alcohol, marijuana, and illicit drug use; misuse of prescription opioids; SUDs; and SUD treatment. Multiple logistic regression was estimated to compare outcomes between 832 AYAs who reported a cancer history (survivors) and 140,826 AYAs who did not, adjusting sequentially for sociodemographic characteristics and health status. RESULTS: In regressions adjusting for sociodemographic characteristics, survivors were more likely than a noncancer comparison group of peers to use alcohol (6% relative increase; P = .048) and illicit drugs (34% relative increase; P = .012), to misuse prescription opioids (59% relative increase; P < .001), and to have a marijuana (67% relative increase; P = .011), illicit drug (77% relative increase; P < .001), or prescription opioid (67% relative increase; P = .048) SUD. When further adjusting for health status, survivors were still 41% more likely (P < .001) to misuse prescription opioids than noncancer peers. Among those with SUDs, survivors were more likely than peers to receive treatment (unadjusted, 21.5% vs 8.0%; adjusted, P < .05). CONCLUSIONS: AYA survivors were as likely as or more likely than noncancer peers to report substance use problems. These findings underscore the importance of interventions to reduce substance use and improve SUD treatment among AYA cancer survivors. LAY SUMMARY: The authors assessed substance use, misuse, and substance use disorders, as well as the receipt of treatment for substance use disorders, among adolescent and young adult (AYA) cancer survivors. In a nationally representative AYA sample, cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than peers without cancer to experience substance use problems. In particular, survivors had a significantly higher rate of prescription opioid misuse than peers. However, only 1 in 5 AYA survivors who experienced substance use disorders received treatment. These findings underscore the importance of interventions toward reducing substance use and improving access to treatment among AYA survivors.

Patterns of surveillance for late effects of BCR-ABL tyrosine kinase inhibitors in survivors of pediatric Philadelphia chromosome positive leukemias.

BACKGROUND: Targeted anticancer therapies such as BCR-ABL tyrosine kinase inhibitors (TKIs) have improved outcomes for chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph + ALL). However, little is known about long-term risks of TKIs in children. Exposure-based survivorship guidelines do not include TKIs, thus surveillance practices may be variable. METHODS: We retrospectively examined surveillance for cardiac and endocrine late effects in children receiving TKIs for Ph + leukemias, diagnosed at < 21 years between 2000 and 2018. Frequency of echocardiogram (ECHO), electrocardiogram (EKG), thyroid stimulating hormone (TSH), dual-energy x-ray absorptiometry (DXA), and bone age testing were abstracted. Descriptive statistics were stratified by leukemia type. RESULTS: 66 patients (CML n = 44; Ph + ALL n = 22) met inclusion criteria. Among patients with CML, ≥1 evaluation was done: ECHO (50.0%), EKG (48.8%), TSH (43.9%), DXA (2.6%), bone age (7.4%). Among patients with Ph + ALL, ≥1 evaluation was done: ECHO (86.4%), EKG (68.2%), TSH (59.1%), DXA (63.6%), bone age (44.4%). Over a median 6.3 and 5.7 years of observation, respectively, 2% of patients with CML and 57% with Ph + ALL attended a survivorship clinic. CONCLUSIONS: Despite common exposure to TKIs in survivors of Ph + leukemias, patterns of surveillance for late effects differed in CML and Ph + ALL, with the latter receiving more surveillance likely due to concomitant chemotherapy exposures. Targeted therapies such as TKIs are revolutionizing cancer treatment, but surveillance for late effects and referral to survivorship clinics are variable despite the chronicity of exposure. Evidence based guidelines and longer follow-up are needed.

Late Effects in Survivors of Neonatal Cancer.

The current 5-year survival rate for cancer in infants is greater than 75% in developed countries. However, survivors of neonatal malignancies have an increased risk of late effects from their tumor or its treatment, which may lead to long-term morbidity and/or early mortality. This article reviews surgical approaches and chemotherapeutic agents commonly used in neonatal malignancies and their associated late effects. It also reviews the increased risk for late effects associated with radiation at a young age and hematopoietic stem cell transplantation at a young age.. It highlights the importance of survivor-specific multidisciplinary care in the long-term management of neonatal cancer survivors.

Endocrine Sequelae in Childhood Cancer Survivors.

The 5-year survival rate for childhood cancer survivors is currently greater than 80% in developed countries. However, survivors may have an increased risk of endocrine toxicities from their tumors or their treatments. Although some endocrinopathies are apparent soon after cancer therapy completion, others manifest years later; therefore, long-term surveillance is crucial. This article reviews the association between cancer treatments and endocrine late effects. It also summarizes recommendations regarding surveillance for endocrine late effects and referrals to endocrinologists based on treatment exposures. In addition, this article provides special considerations for the treatment of endocrinopathies in survivors.

Educational Intervention to Address Infertility-Related Knowledge Gaps Among Adolescent and Young Adult Survivors of Childhood Cancer.

Purpose: This study evaluates the impact of a personalized educational session on survivors' knowledge of risk for infertility and describes preferences for reproductive health care. Methods: This was a two-phase prospective study of an individualized education session for adolescent and young adult (AYA) survivors aged 18-21 years. Sessions used sex-specific visual aids (phase I) or a personalized handout (phase II). Surveys assessing knowledge of overall risk for infertility (yes/no), level of risk (none, low, moderate, or high), relative impact of treatment on the window of fertility (same/less than peers), and the need to use protection to prevent pregnancy (yes/no) were completed at baseline and 1-month follow-up. Changes in knowledge were assessed using McNemar's test. Preferences for fertility education and fertility status assessment were ascertained. Results: In phase I (n = 44), the educational intervention improved knowledge on the impact on the fertility window (from 69.7% correct responses to 90.9%; p = 0.03). In phase II (n = 54), the addition of a personalized, take-home visual aid significantly improved knowledge across all four concepts: knowledge of risk (68.4%-93.1%; p = 0.03), risk level (39.5%-86.8%; p < 0.001), impact on the fertility window (55.3%-86.8%; p = 0.003), and protection for pregnancy prevention (62.2%-81.1%; p = 0.03). Nearly all males (97%) and 66% of females preferred private sessions. The majority of survivors (73%) would like to undergo fertility status testing in the next 5 years. Conclusion: In this sample of AYA cancer survivors, individualized education sessions with personalized visual aids and assessment of survivors' understanding of information significantly improved knowledge of key reproductive health concepts.

Assessment of ovarian function in adolescents and young adults after childhood cancer treatment-How accurate are young adult/parent proxy-reported outcomes?

BACKGROUND: Providers often rely on self-reported ovarian function in adolescent and young adult (AYA)-aged childhood cancer survivors when making clinical decisions. This study described reported menstrual patterns and the agreement between respondent-reported and biochemical premature ovarian insufficiency (POI) in this population. PROCEDURE: This was a cross-sectional study of survivors (or their parent proxy) aged 13-21.9 years who received gonadotoxic therapy and were enrolled in a longitudinal health survey. Participants reported menstrual regularity, hormone-replacement therapy (HRT) use, and ovarian dysfunction. Respondent-reported POI was defined as the survivor taking HRT for ovarian failure or having been told she had ovarian failure. Biochemical POI was defined as follicle-stimulating hormone (FSH) level ≥40 mIU/mL. The agreement between respondent-reported and biochemical POI was determined using Cohen's kappa coefficient (κ) and analyzed by demographic and clinical factors. RESULTS: Among 182 AYA-aged survivors (72.5% non-Hispanic White, 46.7% leukemia survivors), 14.8% reported requiring HRT to have menses but 55.5% reported regular menses without HRT use. Among survivors with FSH measurements (n = 130), 17.7% reported POI whereas 18.5% had FSH ≥40 mIU/mL (κ = 0.66, sensitivity 70.8%, specificity 94.3%). The highest agreement between respondent-reported and biochemical POI was with young adult self-report (κ = 0.78) and survivors with >5 survivor clinic (κ = 0.83) and/or >5 endocrinologist (κ = 1.00) visits. CONCLUSIONS: The majority of AYA-aged survivors reported having regular menses without HRT support. The accuracy of respondent-reported POI increased with repeated survivor clinic or endocrinologist visits, highlighting the importance of continued education. Survivors must be informed about their ovarian function to enable them to advocate for their reproductive health.

Early Detection of Ovarian Dysfunction by Anti-Mullerian Hormone in Adolescent and Young Adult-Aged Survivors of Childhood Cancer.

PURPOSE: Current guidelines recommend screening at-risk childhood cancer survivors for ovarian dysfunction using follicle-stimulating hormone (FSH). However, FSH identifies diminished ovarian reserve (DOR), a component of ovarian dysfunction, in the later stages when fertility preservation is less likely to succeed. This analysis evaluates the utility of anti-Mullerian hormone (AMH) for the assessment of DOR in adolescent and young adult (AYA)-aged survivors of childhood cancer. METHODS: A retrospective chart review of 13- to 21-year-old female survivors who received gonadotoxic therapy and were ≥2 years off therapy was performed. Gonadotoxic treatments were categorized as low, moderate, or high risk for future infertility. Patients with AMH below the assay's age-specific normal range were identified and stratified by FSH values (normal ≤12 mIU/mL). Prevalence of low AMH and AMH-FSH subgroups was calculated and risk factors were evaluated using logistic regression. RESULTS: AMH was measured in 190 survivors who received gonadotoxic treatment; of them, 35.3% had low AMH. Among survivors who received <30 Gy cranial radiation and were not on hormone therapy (n = 141), 18.4% had normal FSH with low AMH. Stratified by future infertility risk, 10.6% of low-risk, 38.1% of moderate-risk, and 25.7% of high-risk survivors had normal FSH with low AMH (p < 0.01). Within the low-risk group, normal FSH with low AMH was significantly associated with older age at diagnosis (p = 0.02). CONCLUSION: Nearly 20% of AYA-aged at-risk survivors had low AMH and normal FSH. DOR in these patients would have been missed in standard recommended surveillance practices.

Long-term health and social function in adult survivors of paediatric astrocytoma: A report from the Childhood Cancer Survivor Study.

BACKGROUND: Although paediatric astrocytoma has an excellent 5-year survival rate, survivors remain at risk for morbidity and late mortality. This study aimed to estimate the risk of late mortality, chronic conditions, poor health status and social impairment in ageing paediatric astrocytoma survivors. METHODS: We longitudinally evaluated 1182 5-year astrocytoma survivors diagnosed between 1970 and 1986 and 4023 siblings enrolled in a retrospective cohort study. Kaplan-Meier estimates of late mortality and cumulative incidence of serious chronic conditions were estimated. Cox regression models provided hazard ratios (HRs) with 95% confidence intervals (CIs) for development of chronic conditions, and generalised linear models provided relative risks (RRs) of the poor health status and social outcomes. RESULTS: At 30 years from diagnosis, cumulative late mortality was 22.1% (CI 20.0-24.3%), primarily due to disease progression or recurrence. Compared with siblings, survivors were at increased risk of serious chronic conditions (HR 4.6, CI 3.8-5.5). Survivors reported higher rates of poor general health (RR 3.3, CI 2.8-3.8), poor mental health (RR 1.9, CI 1.7-2.1), functional impairment (RR 9.0, CI 7.7-10.5) and activity limitation (RR 3.6, CI 3.1-4.2) and lower rates of college graduation (RR 0.75, CI 0.69-0.82), marriage (RR 0.62, CI 0.58-0.66), employment (RR 0.75, CI 0.72-0.79) and household income ≥$40,000 (RR 0.68, CI 0.64-0.73). Even survivors without radiation exposure had elevated risk of chronic conditions, poor health status and social impairment compared with siblings. CONCLUSIONS: Survivors of paediatric astrocytoma are at high risk for long-term complications of their disease and its treatment. They require lifelong monitoring for late effects.

Survivor clinic attendance among pediatric- and adolescent-aged survivors of childhood cancer.

PURPOSE: Childhood cancer survivors need regular, risk-adapted, long-term survivor care. This retrospective study describes the proportion of survivors seen for an initial survivor clinic visit within a large pediatric oncology program. METHODS: Patients diagnosed with non-central nervous system childhood malignancies from 2007 to 2012 were followed from the time of survivor clinic eligibility (2 years following completion of therapy) through their initial survivor clinic visit or end of study. Demographic, cancer-related, and logistical factors related to clinic attendance were examined using Kaplan-Meier curves and Cox proportional regressions. RESULTS: Eligible survivors were 53.0% male, 51.5% non-Hispanic white, and 30.9% survivors of leukemia. Among the 866 eligible survivors for this study, 610 (70.4%) completed their initial visit. After controlling for sex and time eligible, survivors who received surgery only (aHR 0.04 (0.02, 0.08)) or radiation only (0.24 (0.15, 0.39)) and who had Medicaid (0.77 (0.64, 0.92)) were significantly less likely to have an initial visit as were those of black or other/mixed race and those who lived > 25 mi from the clinic (p < 0.01). Survivors aged 6-11 years or 12-17 years at eligibility were significantly more likely to complete an initial visit as compared to those aged 2-5 years (1.55 (1.24, 1.93) and 1.44 (1.14, 1.83), respectively). CONCLUSIONS: Nearly a third of survivors were not seen in a pediatric survivor clinic despite the importance of survivor care. These results identify populations at risk for not pursuing long-term survivorship care. IMPLICATIONS FOR CANCER SURVIVORS: Failure to transition to pediatric survivor care may lead to lifelong non-engagement and incorrect perceptions about future health.