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The Young Adult Cured of Cancer in Childhood. Melissa M. Hudson, M.D. After Completion of Therapy Clinic St. Jude Children’s Research Hospital. Long-Term Survival. Health & Resilience. Transition of Care After Pediatric Cancer. Cancer Diagnosis. Primary Prevention

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The Young Adult Cured of Cancer in Childhood

Melissa M. Hudson, M.D.

After Completion of Therapy Clinic

St. Jude Children’s Research Hospital

transition of care after pediatric cancer



Health &


Transition of Care After Pediatric Cancer



Primary Prevention

Risk-adapted therapy

Favorable: Reduce therapy

Unfavorable: Intensify therapy

Secondary Prevention

Health education

Cancer screening

Therapeutic interventions


Health Care


Health Care

optimal care after cancer
Optimal Care After Cancer
  • Longitudinal care from diagnosis to death.
  • Comprehensive care including preventive measures to reduce morbidity and mortality.
  • Coordination of care by provider knowledgeable about cancer-related risks working with multidisciplinary team.
  • Health care sensitive to cultural and spiritual values and issues of the cancer experience
challenges to providing care
Challenges to Providing Care
  • Evolving therapies and late effects.
  • Long latency to evaluate health outcomes.
  • Multiple factors contributing to cancer-related health risks.
  • Unknown effects of aging on many treatment sequelae.
  • Lack of consensus regarding screening guidelines and risk reduction methods.
challenges to providing care1
Challenges to Providing Care
  • Transitioning from oncology to primary care.
  • Transitioning from pediatric to adult care.
  • Lack of knowledge by primary care providers:
    • Cancer-related health risks
    • Risk-reduction methods.
  • Lack of support from healthcare system for specialized survivor care, e.g., long-term follow-up programs.
goals of after therapy care
Goals of After Therapy Care
  • To maintain cancer-free survival.
  • To detect cancer-related complications at early stages.
  • To prevent, reduce, or correct cancer-related complications.
  • To optimize health and resilience.
prevention of morbidity
Prevention of Morbidity
  • Identify factors predisposing to cancer-related morbidity.
  • Identify factors modifying cancer-related health risks.
  • Provide interventions to prevent, reduce, correct cancer-related morbidity.
factors contributing to morbidity
Factors Contributing to Morbidity




Host Factors

BRCA, ATM, p53




























Vital Organ Toxicity



risk based care
Risk-Based Care
  • Screening/prevention plan that integrates cancer experience with health care needs.
  • Considers risk for morbidity related to:
    • Host: sex, race, age at diagnosis & follow-up
    • Cancer: location, treatment modalities
    • Genetic/familial predispositions
    • Lifestyle habits
    • Co-morbid health conditions
case study adult survivor
Case Study: Adult Survivor
  • 25 year-old female patient diagnosed with Hodgkin’s disease at age 15 years
  • Combined modality treatment with COPP/ABV and mantle (21 Gy) radiation
  • Family history: Mother - breast cancer at 42 years; Father - angioplasty at 44 years
  • Social history: cigarette smoking, tanning bed use; drinks alcohol socially; noncompliant with breast cancer surveillance
review risk factors
Review Risk Factors
  • Host: female, pubertal status during treatment, 10 years after therapy
  • Treatment: alkylating agents, anthracycline, bleomycin, chest radiation
  • Familial: pre-menopausal breast cancer, early-onset coronary artery disease
  • Lifestyle: tobacco, tanning, alcohol
assess late effects risks
Assess Late Effects Risks
  • Dental: xerostomia, accelerated dental decay
  • Thyroid: hypothyroidism, thyroid nodules
  • Cardiac: cardiomyopathy, atherosclerosis
  • Pulmonary: restrictive lung disease
  • Gonadal: infertility, early menopause
  • Second malignancy, especially breast cancer
counsel to promote health
Counsel to Promote Health
  • Inform of potential health risks.
  • Address increased vulnerability
  • Provide personalized risk information
  • Establish priority health goals.
  • Discuss benefits of protective behaviors.
  • Discuss barriers to/personal costs
  • Provide follow-up counseling.
educate about risks
Educate About Risks
  • Cancer diagnosis and treatment
  • Cancer-related health risks
  • Behavioral factors affecting risk
  • Risk reduction strategies
address increased vulnerability
Address Increased Vulnerability
  • Sociodemographic factors
  • Cancer treatment modalities
  • Family history/genetic predisposition
  • Maladaptive behaviors
  • Unknown impact of aging
personalize health education
Personalize Health Education
  • Predisposing cancer treatments:

Radiation, Adriamycin, bleomycin, alkylators

  • Predisposing family history

First-degree relative with breast cancer

First-degree relative with early onset CAD

  • Maladaptive lifestyles

Smoking, tanning, alcohol use

Address also: diet, weight control, exercise

  • Need for early breast cancer surveillance.
encourage health goals
Encourage Health Goals
  • Stop smoking.
  • Use sun protection measures.
  • Eat a healthy diet.
  • Limit alcohol intake.
  • Adopt a physically active lifestyle.
  • Maintain a healthful weight.
  • Pursue early breast cancer screening.
discuss benefits
Discuss Benefits

Smoking cessation

  • Reduce risk of heart and lung disease.
  • Reduce risk of tobacco-related cancers.

Sun protection

  • Reduce risk of premature skin aging.
  • Reduce risk of skin cancer.
discuss benefits1
Discuss Benefits

Healthy diet and physical activity

  • Reduce risk of cardiovascular disease.
  • Reduce risk of breast, colon, uterine and other cancers.

Limit alcohol consumption

  • Reduce risk of liver disease.
  • Reduce risk of mouth, pharynx, larynx, esophagus, liver, and breast cancer.
discuss benefits2
Discuss Benefits

Regular screening examinations

  • Early detection of health problems
  • Prevention of health problems
  • Early intervention to reduce morbidity
address barriers
Address Barriers
  • Appreciate that barriers may be personal, familial, social, economic in etiology.
    • Fear/discomfort with breast screening
    • Insurance denial of clinician/imaging screening
  • Provide information to facilitate behavioral change.
    • Patient education about breast screening
    • Clinician communication with primary care providers or insurance company
health behavior counseling
Health Behavior Counseling
  • Discuss alternative behaviors and choices.
  • Anticipate reactions/responses by family and peers.
  • Challenge survivor (and family) to commit to healthier lifestyle.
  • Provide follow-up counseling.
barriers to risk based care
Barriers to Risk-Based Care
  • Clinic environment: work flow impeded with time-consuming counseling
  • Clinical staff: time constraints with patient care and lack of knowledge about cancer-related health risks
  • Survivors/Family: lack of interest or resistance to counseling efforts
requisites for success
Requisites for Success
  • Dedicated time/day for survivor follow-up
  • Dedicated staff with interest in late effects
    • Specialty or advance practice nurse most commonly utilized
  • Multidisciplinary participation
    • Oncologists - Nurse
    • Psychologist - Social worker
    • Allied and subspecialty care providers
for comprehensive risk based screening recommendations and patient education materials
For Comprehensive Risk-BasedScreening Recommendations and Patient Education Materials

For complete recommendations:

Children’s Oncology Group

Long-Term Follow-Up Screening Guidelines

advice to survivors
Advice to Survivors
  • Know about cancer/cancer-related health risks.
  • Keep a record of medical events.
  • Share record with all providers.
  • Pursue routine medical evaluations.
  • Review lifestyle for methods of risk reduction.
  • Keep informed about late effects research.
taming anxiety about late effects
Taming Anxiety About Late Effects
  • Serious late effects occur in a minority.
  • Late effects are possible only when cancer therapy is successful.
  • Research can reduce and prevent late effects.
  • Knowledge of factors predisposing to late effects can reduce their incidence.