Late Effects After Cancer
“Nuerocognitive Effects of Cancer Treatment in the Pediatric Population” a personal reflection by Cyndi MacKinlay
Major treatment advances for childhood cancer occurred during the 20th century. Today more than 70 percent of children are cured of their cancer. As more children survive, the impact of late effects from cancer treatment presents new challenges for caregivers. The focus for the 21st century shifts as oncologists work to cure children with cancer, while at the same time, strive to minimize late effects so that survivors may have the best opportunity for quality of life. This is challenging particularly for children treated for leukemia and CNS tumors, who are at the greatest risk for cognitive late effects from their treatment. Each year in the United States, approximately 12,500 children and adolescents are diagnosed with cancer, with leukemia and CNS tumors accounting for the largest percentage of all pediatric cancers.1
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The cognitive impact is uniquely significant in terms of its duration of impact on length cancer’s youngest patients. For example, a child diagnosed with leukemia who completes two years of therapy can face, at 7 years old, decades of cognitive impairment from his or her cancer treatment. Chemotherapy and/or radiation can result in mild to severe effects on developing brains, especially for children under 5 years of age at time of treatment. It is a devastating consequence of cancer treatment for patients and families who endure years of treatment to subsequently face this late effect of therapy.
Identification, discussion and appropriate remediation/intervention programs for at-risk children should begin at diagnosis. In this way parents can be better informed and prepared to address treatment-related cognitive deficits. Remediation/intervention programs can be introduced to patients during treatment and well before difficult learning strategies are adapted by the patient. Children may adopt ineffective learning styles in an effort to keep up with their peers in the classroom. As the academic degree of difficulty increases through grade levels, the goal of keeping up becomes more elusive and adversely impacts survivors’ self-esteem and confidence. If, however, at risk patients are provided with appropriate remediation/intervention, either during or at the conclusion of treatment, it would equip the child with the tools and skills to better manage their treatment-related cognitive impairment.
The presentations in the Neurocognitive Functioning session described a number of promising developments on the horizon. Dr. Ida Moore, of the University of Arizona, showcased Math Interventions for Children with Leukemia. In this study, children treated for acute lymphoblastic leukemia (ALL) who had declining performances in math receive 40 to 50 hours of a skill based math intervention. Early indications provided evidence of a substantial improvement in math skills. Dr. Moore’s group is pursuing the introduction of math intervention during ALL therapy and expanding enrollment to include patients treated for brain tumors. Their work is also underway to determine the mechanisms of effect of therapy on the CNS that leads to cognitive injury. It is especially significant to note that these researchers were able to capture baseline pre-treatment performance scores, something that is rarely done, and yet is so important to assessing therapy’s cognitive impact.
Dr. Raymond Mulhern, of St. Jude Children’s Hospital, presented Short-Term Efficacy of Methylphenidate (MPH) Among Survivors of Childhood Cancer for children treated for ALL and CNS tumors. MPH is a psychostimulant widely used to treat patients with attention deficit hyperactivity disorder. In children who experienced attention-related issues, use of MPH resulted in marked improvements in attention, as well as, but to a lesser extent, social behavior in this group of childhood cancer survivors. It is notable that 80 percent of participants chose to continue treatment with MPH at the end of the study. Further research will focus on dosage efficacy and side effects.
On the adult side, the Memory and Attention Adaptation Training Program (MAAT) is an intervention aimed at improving chemotherapy-related impairment. Dr. Robert Ferguson, of Dartmouth Medical School, described the advantages of a short, cognitive-behavioral intervention to address memory and attention issues in adult survivors. Participants expressed satisfaction with the intervention and improvements in a number of areas, including memory and cognitive functioning, which positively affected overall quality of life.
As a parent whose son was treated for leukemia, I sought out another NCI-funded cognitive remediation program developed by Dr. Robert Butler of the Oregon Health and Science University’s Doernbecher Children’s Hospital. My son participated in this remediation program, and I can attest to how critical such programs are to future academic and social adjustment and success of at-risk children. Dr. Butler’s multi-center study was designed for children treated for leukemia and brain tumors and works to engrain learning strategies children can employ in the classroom and in their every day lives to enhance attention, information processing, organization, and multi-tasking, and thus better their quality of life.
The emergence of cognitive remediation/intervention programs to counter cognitive late effects should become the standard of care for at-risk patients. These programs should be the rule, not the rare exception, at treating institutions. The interventions presented here are a premier example of NCI’s commitment to funding programs that allow for cancer’s youngest patients to attain and maintain academic achievement.
1. CureSearch. Available at http://www.curesearch.org/about_us/index.aspx. Accessed July 26, 2004.