Recent research shows improvement in long-term survival rates for childhood cancer patients, but also highlights the challenges that remain for many of the almost 400,000 survivors in the United States. Among these survivors are women facing gynecological health issues from the late effects of their treatment. What follows are several areas of concern that gynecologists and obstetricians should consider when treating women who had cancer as girls.
1. Treatment summary. An adult woman who had cancer during childhood should have a written summary of treatments she received. Certain commonly utilized treatments for childhood cancer — including radiation to the chest or pelvis, anthracycline exposure, bone marrow transplant and high-dose alkylating agents — have gynecological or obstetric late effects. If the patient doesn’t have a summary, she should try to get one from the institution that treated her. Otherwise, academic medical centers that treat childhood cancer patients often have dedicated survivorship programs that can construct a summary. In addition, some community-based medical or radiation oncologists will see a patient for a survivorship visit. The provision of a “treatment summary and survivorship care plan” is increasingly a part of the standard of care for survivors, but many long-term survivors have never received one.
2. Ovarian function and fertility. Women treated with high-dose alkylating agents are at risk of primary ovarian failure, early menopause and/or infertility. Women at risk for early menopause who were previously exposed to alkylating agents may be menstruating regularly, but consideration of risk for early menopause will contribute to their management, both in counseling regarding timing of pregnancy as well as in consideration of egg preservation. Research that my colleagues and I published in Lancet Oncology found that many survivors of childhood cancer who eventually became pregnant took longer to conceive than other women of the same age, supporting the concept that menstruating survivors have ovarian damage. Survivors of childhood cancer should be referred to a fertility specialist after no more than six months of trying unsuccessfully to get pregnant. Earlier referral is indicated when the patient has a history of pelvic radiation or high cumulative doses of alkylating agents, as were delivered in survivors of many pediatric solid tumors.
3. Pregnancy. Female survivors are at risk of cardiotoxicity if their treatment included anthracyclines, and this risk may increase during pregnancy. Anthracyclines are associated with late onset ventricular dysfunction, which can be asymptomatic and observed on echocardiogram. Risk factors for late congestive heart failure include a history of CHF during cancer treatment, young age at exposure, total dose of anthracyclines and radiation to the chest. Exposure to anthracyclines and/or chest radiation has been associated with development of heart disease during pregnancy or in the peripartum period. Evaluation of heart-disease risk based upon exposure might include echocardiography prior to pregnancy, as well as evaluation by a cardiologist or high-risk obstetric practice with expertise in cancer patients.
4. Breast health. Women with a history of chest radiation in childhood or early adolescence are at very high risk of developing breast cancer, similar to the risk seen in BRCA1 and BRCA2 carriers. These patients should start mammography and breast MRI screening at age 25, or 8 years after exposure, whichever is later. An ongoing study is looking at tamoxifen to prevent radiation-induced breast cancer, but this is not yet standard of care. The role of prophylactic mastectomy is not well studied in this group of patients, but risk of bilateral breast cancer is elevated in this group, suggesting that this may be a reasonable intervention. Because the risk is so high, consultation with a physician in a breast cancer prevention program is one resource that might be considered.
5. Bone health. Women who were treated for childhood cancer may have had poor bone mineralization during adolescence. Reasons for this might include inadequate calcium intake, lack of exercise and sun exposure during their illness and inadequate estrogen production during or after therapy. They may be at risk for osteopenia and osteoporosis even if they are menstruating or receiving estrogen replacement therapy. These patients should have an early assessment of bone health.
For more information, here are peer-reviewed guidelines based on specific childhood exposures during pediatric cancer treatment.
Lisa Diller is chief medical officer, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and director, David B. Perini Jr. Quality of Life Clinic.
