Clinician-to-Clinician Update Clinician-to-Clinician Update

Tailored Follow-Up Care Helps Pediatric Cancer Survivor Stem Health Risks

December 2017

Contributed by Lucie Turcotte, MD

Successful treatments for pediatric cancers can produce later unintended health effects, including other cancers or chronic conditions. Multidisciplinary follow-up care and new survivorship treatment and screening guidelines can help these patients manage their health risks. In this case, ongoing follow-up care allows a survivor of childhood cancer to manage new conditions and maintain her health.

Patient

A 45-year-old woman with a pediatric medical history of stage IIA nodular sclerosing Hodgkin lymphoma was seen at the University of Minnesota Health Childhood Cancer Survivor Program (CCSP) for assessment of a new palpable nodule under her right axilla.

The patient had been diagnosed with lymphoma in when she was 15 years old and received a combination of chemotherapy, including 6 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD), and mantle field radiation (2,000 cGY). Her pediatric oncologist was aware of the long-term health consequences of Hodgkin lymphoma therapy and had specifically selected this regimen, hoping to spare her long-term health issues.

Approximately 2 years after completing Hodgkin lymphoma therapy, she developed hypothyroidism and began levothyroxine replacement therapy. She was subsequently lost to oncology follow-up until she presented at age 39 years with concerns that her other health issues might be related to her history of treatment for Hodgkin lymphoma. She indicated that over the years since her pediatric cancer treatment, she had received treatment for basal cell carcinomas and had been diagnosed with pulmonary fibrosis and mitral valve prolapse.

Consultation and Management

Since resuming long-term follow-up care, she had been found to have multiple breast lumps and had undergone biopsies with benign findings 4 years and 2 years prior to her current symptoms. Unfortunately, a year prior to this visit, she again had palpable lumps in her breast. Biopsy revealed stage IA invasive ductal carcinoma of the left breast. She underwent bilateral mastectomy, a decision based on her young age, cancer treatment-related risk factors, and strong family history of breast cancer. She was also seen in the Cancer Risk Management clinic where testing for BRCA gene mutations was unrevealing.

As part of her care in the CCSP, the patient has been provided with a summary of her previous cancer therapies, which included cumulative doses of chemotherapy and cumulative dose and site of radiation, as well as a care plan for screening and follow-up recommendations.

In accordance with the Children’s Oncology Group Survivorship Guidelines and because of her previous anthracycline and radiation exposure, she now receives an echocardiogram every 2 years. Because of her history of radiation, she undergoes a carotid artery ultrasound every 2 years and annual thyroid function testing and neck exam. She has breast screening every 6 months owing to her previous mantle field radiation, alternating between having a breast MRI and mammogram performed. Annual vitamin D and lipid panel screening are also recommended in response to known risks for inferior bone health and metabolic syndrome among survivors of childhood cancer. She has received counseling on limiting alcohol intake, maintaining a healthy diet, and participating in regular physical activity.

Discussion

The patient continues to pursue ongoing counseling and screening per the above-stated recommendations. In a recent visit, she had a physical exam and ultrasound of her axilla, which fortunately is most consistent with scar tissue. Follow-up in the CCSP is recommended in 1 year.

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