Journal of Pediatric Nursing
Volume 18, Issue 2 , Pages 126-133, April 2003

Late effects of childhood cancer therapy☆☆☆

Baylor College of Medicine, Texas Children's Hospital, Texas Children's Cancer Center, Houston, TX.

Article Outline

Abstract 

One in every 900 young adults is a survivor of childhood cancer. Survivors may experience a wide variety of late effects stemming from the treatment they received. It is estimated that a significant portion of adult survivors of childhood cancer are not followed regularly in a center familiar with the late effects of their specific therapy. Therefore it is important for health care professionals in any setting to have an understanding of these possible late effects and encourage the survivor to seek appropriate follow-up. This article will provide a general overview of the potential late effects of childhood cancer therapy. Copyright 2003, Elsevier Inc. All rights reserved.

 

Entering into the 21st century, an estimated 1 in every 900 young adults between the ages of 16 and 44 years is a survivor of childhood cancer. The overall survival rate for all types of childhood cancer is now approaching 80% (Bleyer, 1997), as advancements in the treatment and cure continue to offer promising results. A survivor of childhood cancer is defined as one who has been free of disease for 5 years and off therapy for at least 2 years. These survivors may, however, experience a wide variety of late effects stemming from the treatment they received.

The consequences of therapy may be obvious or subtle and may occur months to years after the completion of treatment. In one study it was estimated that approximately 50% of all survivors will experience delayed sequelae of therapy (Oeffinger, Eshelman, Tomlinson, et al., 1998). These late effects can be caused by the cancer itself; by the treatment, which may include chemotherapy, radiation, surgery; and supportive care such as transfusions, antibiotics, and immunosuppressive therapy; or by a combination of these factors. The degree to which an individual experiences late effects is related to the location and extent of the primary disease, the type and intensity of treatment, the child's age at diagnosis, and the physiologic and developmental status of the individual at the time of diagnosis and treatment. Underlying genetic or familial predispositions may interact with treatment-related injuries and potentiate late effects (Bottomley, 1998). Any organ system may be affected. In addition to the physical issues, survivors must deal with the emotional, social, economic, and academic consequences of surviving cancer.

The importance of providing appropriate and comprehensive follow-up evaluation for this population is becoming increasingly evident (Harvey, Hobbie, Shaw, & Bottomley, 1999). Pediatric oncology centers across the country are developing programs to address the needs of the cancer survivor. However, it is estimated that a significant portion of the adult survivors of childhood cancer are not followed-up regularly in a center familiar with the potential late effects of their specific therapy (Oeffinger et al., 1998). This may be owing to a lack of understanding of potential late effects, unavailability of specialized programs in the local community, inadequacy of insurance coverage, or fear of potential findings. Therefore, it is important for health care professionals in any setting to have an understanding of these possible late effects and encourage the survivor to seek appropriate follow-up evaluation. This article provides a general overview of the potential late effects of childhood cancer therapy. Individual organ system effects are outlined, followed by a table highlighting general recommendations for follow-up evaluation as well as health maintenance suggestions.

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Neurologic 

Neurologic sequelae occur in many long-term survivors who received whole-brain irradiation, intrathecal or systemic chemotherapy such as methotrexate, or cranial surgery. The severity and incidence of neurologic late effects depends on the patient's age at diagnosis, the original disease and location, and the timing and method of central nervous system treatment. Neurocognitive deficits consist of a decline in intelligence quotient or academic achievement. Neurologic problems that may develop include seizures, leukoencephalopathy, and deficits in motor function, memory, attention, and hand eye coordination (Bottomley, 1998; Shusterman & Meadows, 2000).

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Endocrine 

Hypothalamic-pituitary and thyroid 

Endocrine dysfunction occurs from injury to the hypothalamic-pituitary axis, thyroid, or gonads, secondary to radiation, chemotherapy, or surgery. Abnormalities may include growth hormone or gonadotropin deficiency, precocious puberty, other hormone deficiencies, neurologic diabetes insipidus, thyroid dysfunction, and benign or malignant tumors of the thyroid gland or the hypothalamic-pituitary axis (Hobbie & Brophy, 1998a). Prepubertal reduction in growth velocity is seen commonly in children treated with cranial-spinal radiation (Shusterman & Meadows, 2000). A reduction in bone mineral density, a decrease in muscle mass, and an increase in adipose tissue may occur in children who received cranial irradiation therapy.

The use of growth hormone for children with documented decreased growth velocity is controversial. Benefits of its use include an increase in the growth rate and final height, an increase in bone mineral density, a decrease in adipose tissue, and an improvement in reported quality of life (Murray, Brennan, Rahim, & Shalet, 1999). Recommendations for use include initiating replacement therapy before the onset of puberty, and not earlier than 1 year after completion of cancer therapies (Hobbie & Brophy, 1998a).

Lethargy, decreased stamina, hypoglycemia, and dilutional hyponatremia may be observed in survivors who have deficient adrenocorticotropin levels. Radiation therapy may cause low gonadotropin levels, resulting in failure to progress through puberty, arrested puberty, amenorrhea, or delayed testicular or breast tissue maturation.

Hypothyroidism is the most frequently occurring thyroid disorder after cancer treatment. Primary hypothyroidism may result after radiation of 25 Gy or more to the thyroid gland. Secondary hypothyroidism may occur after radiation to the hypothalamic-pituitary axis of 50 Gy or more. Total-body irradiation used in bone marrow transplant also may cause hypothyroidism. Other thyroid disorders such as hyperthyroidism, thyriditis, thyroid nodules, and malignant tumors may occur (Gleeson & Shalet, 2001).

Gonadal 

Chemotherapy, radiation therapy, or surgical intervention can affect sexual function and fertility in men and women. Men who were treated with radiation to the pelvic area and/or received alkylating agents are susceptible to temporary or permanent azoospermia (Shusterman & Meadows, 2000). However, recovery of sperm production can occur even 5 to 10 years after treatment (Brophy & Hobbie, 1998a). Female survivors may have primary ovarian failure from chemotherapy (alkylating agents), radiation involving the abdominal or pelvic region, or surgical removal of the ovaries. The survivor may experience delayed or arrested pubertal development, delayed menarche, oligomenorrhea or amenorrhea in a postpubertal female, and early menopause. The effects of chemotherapy are dose and age related with less risk for infertility in women treated before puberty (Chiarelli, Marrett, & Darlington, 1999).

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Hearing and vision 

Hearing and visual deficits can result from neoplastic involvement of the area, chemotherapy agents, radiation therapy, or prolonged use of antimicrobials. Symptoms of auditory dysfunction include loss of high-frequency hearing, permanent hearing loss, tinnitus, vertigo, or abnormal speech development. Clinical findings can include residual fibrosis, scarring or necrosis of the ear canal, and decreased or dry cerumen. Visual abnormalities often consist of visual loss, enucleation, decreased acuity, blurred vision, cataracts, rubeosis iritis, glaucoma, retinopathy, and retinal hemorrhages. Other ophthalmologic concerns may include adhesions and scarring of the lids and decreased tear production (Nahum, Gdal-On, Kuten, Herzl, Horovitz, Weyl Ben Arush, 2001; Takeda et al., 1999).

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Head and neck 

The head and neck region may be affected directly by tumors or by treatment including chemotherapy, surgery, or radiation. Radiation effects include alterations of the bone, hair, and skin. Hair color and texture may be permanently different after treatment. Skin changes can include atrophy, dryness, telangiectasias, and hyperpigmented or hypopigmented areas. Facial asymmetry, deformities, or dental irregularities may result from bony defects (Constine, 1995). Dental sequelae includes root and crown abnormalities, enamel hypoplasia, premature apical closure, microdontia, and foreshortening or agenesis of developing teeth. Distorted taste and smell or xerostomia may be present. Intranasal scarring can result in altered mucus production or drainage with subsequent postnasal drip, chronic sinusitis, facial pain, or headache. (Dahllof, Jonsson, Ulmner, Huggare, 2001; Duggal, Curzon, Bailey, Lewis, & Prendergast, 1997).

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Cardiac 

Cardiac toxicity can develop secondary to chemotherapy, such as anthracyclines and high-dose cytoxan, mediastinal radiation therapy, or both. Myocytes are thought to be damaged permanently by radiation and chemotherapy. As the survivor ages, or additional demands are placed on cardiovascular functioning, the remaining tissue is unable to compensate. Younger children and women have an increased risk for cardiac dysfunction. Cardiomyopathy, coronary artery disease, congestive heart failure, or arrhythmias can occur within months of or years after exposure (Shusterman & Meadows, 2000).

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Respiratory 

Acute or chronic impairment of respiratory function is seen in survivors exposed to radiation therapy to the lung fields and those who received certain chemotherapeutic agents (bleomycin, busulfan, carmustine/lomustine). Radiation therapy late effects are related to cumulative dosage, the volume of lung that was irradiated, and fraction size (Brophy & Hobbie, 1998b). Young children are at the greatest risk because of the combined direct effects of treatment on their lungs and the radiation's impairment on normal growth and development of the thoracic cage, airways, and lung parenchyma. Baseline dysfunction (asthma, smoking) and concurrent infection increase the toxic effects of therapy.

Pulmonary fibrosis is the most common respiratory late effect and can occur months or even years after treatment. Mild fibrosis disease may stabilize in 1 to 2 years, and survivors can be asymptomatic. Chronic respiratory failure, dyspnea on exertion, decreased exercise tolerance, fatigue, cough, orthopnea, cyanosis, and chronic cor pulmonale are more common symptoms of severe fibrosis requiring medical intervention (Abbratt & Morgan, 2002).

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Gastrointestinal 

Radiation therapy, chemotherapy, surgical treatment, and chronic graft-versus-host disease predispose the survivor to abnormalities involving the gastrointestinal tract. Intestinal fibrosis and enteritis are most common and are related directly to radiotherapy total dose and extent of the radiation field. Severe intermittent abdominal pain, vomiting, diarrhea, constipation, dysphagia, weight loss, fatigue, obstruction, rectal pain, or bleeding may indicate intestinal fibrosis or enteritis. Adhesions, obstruction, ulcers, strictures, and malabsorption can occur and present as abdominal pain with bilious vomiting, hyperactive bowel sounds, or dysphagia. Intestinal fibrosis usually occurs within 5 years of treatment, whereas strictures have been reported as having developed as long as 20 years after therapy (Dreyer, Blatt, & Bleyer, 2002).

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Hepatic 

Abdominal radiation and certain chemotherapeutic agents can cause hepatic dysfunction and lead to the development of fibrosis or cirrhosis. Hepatic fibrosis is noted by increased transaminase and bilirubin levels, nausea, vomiting, abdominal pain, anorexia, arthralgia, jaundice, hepatomegaly, or malaise. Chronic graft-versus-host disease, cytomegalovirus, and transfusion-mediated hepatitis B or hepatitis C (primarily in children transfused before 1992) may potentiate hepatic abnormalities and lead to chronic liver damage (Strickland et al., 2000).

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Genitourinary 

Genitourinary dysfunction can present in survivors treated with surgery, chemotherapy or radiation therapy, or both. Treatment may adversely affect the kidneys, bladder, ureters, and reproductive organs. The extent of dysfunction might not be evident until a survivor reaches maturity and the affected organ is unable to compensate. Complications include glomerular dysfunction, bladder fibrosis, hemorrhagic cystitis, and renal tubular necrosis. Survivors may report hematuria, proteinuria, urgency, frequency, dysuria, hypertension, hypomagnesemia, anemia, fatigue, or growth abnormalities. Symptoms of sexual dysfunction also may present including diminished ejaculum, alteration in sexual function, and reduced or altered fertility (Dreyer, Blatt, & Bleyer, 2002).

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Musculoskeletal 

The musculoskeletal system is affected primarily by radiation therapy. The extent of damage is related directly to the radiation dose, duration of treatment, size of the radiation field, and the age of the child at the time of treatment. Patients can experience spinal abnormalities, discrepancies in limb length, exostosis, slipped capitofemoral epiphysis, pathologic fracture, avascular necrosis of the femoral head, osteoporosis, and delayed or arrested tooth development (Dreyer, Blatt, & Bleyer, 2002). Partial or complete amputation of an extremity may result in muscle group imbalance or loss of limb function.

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Hematopoietic/immunologic 

Hypoplastic or aplastic bone marrow can be a long-term effect of chemotherapy or radiation therapy. Older children and those who received high-dose chemotherapy are at the greatest risk for developing hematopoietic dysfunction (Brace-O'Neill, 1998). Decreased white blood cell production predisposes the survivor to compromised immune function increasing susceptibility to infection. Survivors who were treated with bone marrow transplantation, including total body irradiation, can have impaired cell-mediated immunity, and incomplete T-cell function up to 4 years after treatment (Brace-O'Neill, 1998).

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Second malignancies 

Second malignancies can result from exposure to previous cancer therapy or from genetic predisposition. The risk for a second cancer 20 years after a childhood cancer is estimated to be 8% to 12% (Kline, 1998). Second malignancies can present as leukemia, solid tumors, or central nervous system tumors (see Table 1).

Table 1. Second Malignancies and Associated Cancer Therapy
Risk FactorSecondary MalignancyLatent Period
Chemotherapy
EpipodophyllotoxinsMyeloid leukemia4-5 y
Etoposide, teniposide
Alkylating agentsMyeloid leukemia,3-10 y
Mechlorethamine, chlorambucil, procarbazine, carmustine, lomustine, cyclophosphamide, melphalanNon-Hodgkin's lymphoma, Hodgkin's disease
Radiation
< 6 y cranial radiationIncreased risk brain tumorsVariable
< 5 y cranial and neck radiationIncreased risk thyroid cancer
Adolescent-chest radiationIncreased risk breast cancer
General field radiationIncreased risk bone or soft-tissue sarcoma
The symptoms of leukemia include fatigue, anemia, thrombocytopenia, granulocytopenia, bone pain, bleeding, fevers, and frequent infections. Symptoms of solid tumor malignancies are fatigue, anorexia, palpable masses, bloody stools, or pain. Seizures, headaches, altered mental states, change in vision, nausea, and vomiting may indicate central nervous system tumors.

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Psychosocial 

The psychosocial impact of living with a diagnosis and history of cancer is multifaceted. Survivors may encounter academic achievement challenges, job discrimination (including military service), difficulties in obtaining or maintaining insurance, and a multitude of emotions. Studies of childhood cancer survivors have indicated that survivors live with a sense of uncertainty, a feeling that may persist throughout life (Boman & Bodegard, 2000; Newby, Brown, Pawletko, Gold, & Whitt, 2000). This may be related to fear of relapse, concerns about late effects, and anxiety related to the cancer experience as a whole. Survivors may experience significant anxiety surrounding health issues, coping skills, peer relations, or independence issues. Survivors often express concern that others may not accept them if they are aware of their previous diagnosis. For some survivors these symptoms may not surface until years after the cancer experience and can be classified as a posttraumatic stress syndrome (Rouke, Stuber, Hobbie, & Kazak, 1999).

Grief is one of the more commonly experienced emotions. Survivors experience grief over the loss of the person they were before the diagnosis; grief related to physical losses such as stamina, limb, eye, organ function, emotional losses, academic losses; and grief over the death of friends also diagnosed with cancer (Calaminus & Kiebert, 1999; Dolgin, Somer, Buchvald, & Zainzov, 1999; Rouke et al., 1999).

Let it not be thought that the cancer survivor's experience is all negative. Survivors report greater insight into themselves and others, frequently indicating that they have wisdom beyond their years, greater compassion, and heightened appreciation of life. They often describe a stronger sense of direction in their life (Bottomley & Fritsch, 1998). This life-changing event can affect an entire being, and though the physiologic late effects of childhood cancer may be more obvious, the diverse psychosocial effects should be evaluated appropriately.

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Evaluation 

A survivor of childhood cancer should have an annual history, physical, and laboratory tests specific to their disease and treatment. Further testing, scans, and laboratory studies are determined individually based on disease, previous therapy, and complications experienced. Table 2 describes therapy risks, commonly reported complaints, physical findings and recommended evaluations, nursing assessments, and interventions.

Table 2. Summary of Late Effects by Organ System
SystemRisksPotential Effects History SymptomsDiagnostic EvaluationsNursing Interventions
Central nervous systemRadiation to brain, surgical resection of brain tumor, methotrexate (high dose or intrathecal)Learning disabilities, leukoencephalopathy, poor academic performance, behavioral or attention problems, school attendance, paresthesias, tremors, gross and fine motor difficulties, seizuresNeurocognitive testing, CT, MRI, EEG as clinically indicated, audiogram, visual screenEarly childhood intervention, specialized educational programs, or tutoring
Refer: Neuropsychologic testing, neurologist, school liaison program PRN
EndocrineRadiation to the hypothalamic-pituitary-axis (HPA), thyroid, neck, spine cervical region, ovaries or testes, total body irradiationGrowth problems, hormonalimbalances: ACTH deficiency, TSH deficiency, gonadotropin deficiency or hyperprolactinemia, precocious puberty, thyroid nodules, thyroditisHeight and weight plotted on a growth curve; Tanner stage; estrogen (women), testosterone (men), coristol, or antidiuretic levels, thyroid, other hormone studies as clinically ndicated; bone age films if growth velocity is abnormalRefer: Endocrinologist PRN; growth hormone to increase growth velocity; estrogen or testosterone replacement may treat gonadotropin deficiency; hydrocortisone can manage ACTH deficiency; desmopressin can control symptoms of ADH deficiency, synthroid for hypothyroidism
Surgical resection in HPA region or thyroidectomy
Chemotherapy, alkylating agentsSymptoms of slowed growth velocity, menstrual irregularities, diabetes insipidus, hyperthyroidism, and hypothyroidism
Hearing and visualCisplatin, radiation to audiotory canal region or eye, aminoglycosides, recurrent otitis media, steroids, vision, carboplatin, uncommon cause of oxtotoxicityHigh frequency sensorineural hearing loss, abnormal speech development, cataracts; poor academic performance, headaches, blurred vision, squinting, speech problemsAudiogram baseline and as clinically indicated; visual screening yearly; neurospychologic testing as indicatedEncourage preferential seating, amplification, speech therapy, hearing aids, and glasses, tear replacement as needed
Refer: Otolaryngologist, opthamologist PRN
Dental head and neckRadiation in children <6 y Chemotherapy < 2 y ageAbnormal tooth and root development, increased caries, decreased salivary function, xerostoma, neck and jaw mobility, muscle and bone hypoplasiaRadiographic studies of irradiated areas every 3-5 y; dental evaluationEncourage routine dental examinations every 6 mo, educate survivor regarding good oral care, avoid use of tobacco products, diet low in concentrated sugar
CardiacHigh-dose cyclophosphamide, anthracycline, >300 mg/m2 or >200 mg/m2 when combined with radiation or mediastinal radiation aloneCardiomyopathy; exercise intolerance, fatigue, chest pain, dizziness, cough, dyspnea, shortness of breath, palpitations, fever, edema, hypertension or hypotension and lifestyle behaviorsCardiac evaluation with: EKG, MUGA or ECHO frequency based on cumulative dosage and resultsStrategies to decrease risk factors, weight control, reduction of saturated fat intake, avoidance of tobacco, regular exercise; some institutions encourage restriction of heavy weight lifting
Refer: Cardiologist PRN
RespiratoryRadiation to pulmonary fields, bleomycin, BCNUPneumonitis, fibrosis, tachypnea, orthopnea, frequent infections, coughPulmonary function tests baseline and every 3-5 y as clinically indicated; CT for lung volumes PRNAnnual pneumococcal and influenza vaccines, educate regarding risk for respiratory failure with high levels of oxygen if therapy included bleomycin or BCNU; encourage healthy behaviors including exercise and avoiding tobacco products
Refer: Pulmonologist, PRN
GastrointestinalRadiation to abdomen, increased risk when dactinomycin and doxorubicin given concomitantly, graft-versus host disease, abdominal surgeryFibrosis, strictures, obstruction, adhesions, malabsorption, ulcers; difficulty swallowing, heartburn, nausea, vomiting, anorexia, indigestion, diarrhea, constipation, change in bowel habits, rectal bleeding, abdominal pain, food intolerance, hemorrhoids, or jaundiceStool guaiac, HT and WT, serum chemistries, liver function tests; complete blood count with differentialEncourage healthy dietary habits; high fiber, low fat Refer: Gasteroenterologist, PRN
HepaticRadiation or surgery to hepatic area, transfusions, methotrexate, 6-MP, 6-TG, dactinomycinFibrosis, cirrhosis, hepatitis, nausea, vomiting, jaundice, abdominal pain, poor appetiteLiver function tests, hepatitis panel baseline, abdominal ultrasound as clinically indicatedEducate regarding healthy behaviors as well as avoiding alcohol or other hepatotoxic drugs Refer: Gastroenterologist
GenitourinaryRadiation to kidneys; or in combination with cisplatin, methotrexate, or nitrosoureas; enhanced effects of RT to vaginal area when given concomitantly with dactinomycin, ifosfamide; cytoxan without RT; surgical resectionUrinary tract infections, hematuria, polyuria, dysuria, urgency, frequency, enuresis, alteration in sexual function, kidney dysfunctionUrinalysis, BUN, creatinine, electrolytes, magnesium levels, baseline and then every 2-3 y; BP annuallyDietary counseling, hypertension management, kidney health; maintain adequate hydration, avoid contact sports, medical alert bracelet Refer: Urologist, nephrologist, PRN
ReproductiveRadiation to testes, to ovaries, alkylating agents, nitrosoureas, ifosfamide, and cyclophosphamide, surgery, age, thyroid dysfunctionDecreased testicular volume, poor erectile function, decreased libido, primary or secondary amenorrhea, menstrual changes, decreasing size of breasts, breast discharge, hot flashes, mood swings, headache, vaginal dryness, dyspareuniaSerum follicle-stimulating hormone, luteinizing hormone estradiol (women), sperm analysis, testosterone (men), thyroid studies; (T4, TSH, FT4), Tanner stageDiscuss potential for early menopause, decreased fertility; encourage testicular and self-breast examination symptoms and hormonal support to decrease risk for heart disease and osteoporosis Refer: Gynecologist, fertility specialist or endocrinologist, PRN
MusculoskeletalRadiation to long bones, spine or any growing bony or muscular area, amputation or limb salvageMuscle or bony asymmetry or hypoplasia, limb length discrepancy, pain, alterations in growth, gait changes, functional deficits.Bone age film; radiographs of irradiated area yearly during rapid growth, then every 5 years; standing and sitting heightEncourage physical exercise, weight control
Refer: Orthopedist, physical therapy, rehabilitation therapy, occupational therapy, PRN
Hematopoietic immunologicRadiation to marrow containing bones, total-body irradiation, high-dose chemotherapy, splenectomyFatigue, exercise-induced dyspnea, frequent infections, overwhelming bacterial infection, hypoplastic or aplastic bone marrowComplete blood count with differential; immunoglobulin levels (i.e., IgG, IgM, IgA, IgE levels) T-cell studies as clinically indicated, or if treated with bone marrow transplantation; bone marrow biopsy as clinically indicatedAsplenic individuals need prophylactic penicillin, pneumococcal vaccines annually, prompt treatment for infection; Encourage routine physical examinations
Refer: Hematologist or immunologist, PRN
*The recommendations listed under diagnostic evaluations are meant to be guidelines. It is important, when planning a survivor's follow-up evaluation to take into account the various factors that may impact frequency of testing. These factors include but are not limited to age at diagnosis, cumulative dosages of chemotherapeutic agents and radiation therapy, problems that occurred on therapy and documented problems off therapy, results of previous evaluations, physical and reported findings.

CT, computed tomography; MRI, magnetic resonance imaging; EEG, electron-EKG, electron cephalogram; PRN, as necessary; ACTH, adrenocorticotropic; EKG, electro cardiogram; MUGA, multiple gated acquisition; ECHO, echo-cardiogram; BCNU, carmustine; HT, height; WT, weight; 6-MP, meracaptopurine; BUN, blood urea nitrogen; BP, blood pressure; TSH, thyroid-stimulating hormone.

The information has been organized according to system and possible late effects. Laboratory and imaging results should be compared with baseline studies and referral to specialists familiar with the late effects of cancer therapy is recommended for any abnormal findings.

With the continued success of cancer treatments there will be an increasing number of survivors. Caring for survivors of childhood cancer is a life-long and complex process. It is important for health care providers to be aware of the potential late effects of treatment and assist the survivor to seek appropriate medical and psychosocial evaluations and follow-up evaluation. Educating the survivor regarding their potential risk for late effects is fundamental. Survivors should be encouraged to develop and maintain healthy lifestyle behaviors and participate in routine health screening programs (see Table 3).

Table 3. Promoting Health After Childhood Cancer
1. Encourage survivor to maintain life-long annual follow-up with health care provider familiar with survivor's cancer history/treatment and risk for devleoping late-effects.
2. Recommend routine cancer screening:
Females
Breast self-examinations monthly once menstruating
Clinical breast exams annually
Mammography (or other imaging studies, radionuclide scan, or sonography)
All females baseline age 35 to 40, then every 1 to 2 years until 50, then yearly
If family history of breast cancer, begin 10 years before earliest onset of breast cancer in family (but not before age 20), then every 1 to 2 years
With history of chest radiation, begin at age 25, then every 1 to 2 years
Pelvic exam with PAP smear yearly at age 18 years or older & earlier if sexually active
Males
Testicular self-examination monthly for all males 14 years or older
Both Females and Males
Serum cholesterol starting at age 25, then yearly
Rectal exam starting at age 45, then yearly
Stool for occult blood starting at age 50 (ACS recommendation)
Sigmoidoscopy starting at age 50 (ACS recommendation)
3. Encourage healthy life-style behaviors:
Use of sunscreen (SPF 15 or greater). Avoid tanning beds, excessive sun exposure
Maintain a well balanced diet including low fat, high fiber. Encourge foods rich in vitamin C (dark green leafy vegetables, citrus fruits, and orange or yellow vegetables) and A. Avoid excessive salt intake
Maintain ideal body weight
Moderate exercise 20-30 minutes at least three times weekly
Avoid use of or exposure to tobacco products (cigarette smoking, passive smoke, chewing tobacco)
Limit or avoid consumption of alcoholic beverages
Do not use controlled substances
Practice safe sex behaviors
Allow adequate time for rest
Avoid prolonged stress
Maintain routine annual visits, remain informed of late effects and advances that may reduce or prevent them
Early detection and intervention of the late effects of therapy is thought to decrease overall sequelae, improve long-term outcome, and overall quality of life.

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☆ Address correspondence and reprint requests to Sarah J. Bottomley, RN, MN, CPNP, CPON, Pediatric Nurse Practitioner, Baylor College of Medicine, Texas Children's Hospital, Texas Children's Cancer Center, 6621 Fannin St, MC 3-3320, Houston, TX 77030. E-mail: sbottomley@txccc.org.

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doi:10.1053/jpdn.2003.13

Journal of Pediatric Nursing
Volume 18, Issue 2 , Pages 126-133, April 2003

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