Late Effects of Treatment for Childhood Cancer (PDQ®)—Patient Version - National Cancer Institute 3/7

Late Effects of Treatment for Childhood Cancer (PDQ®)—Patient Version - National Cancer Institute

Late Effects of Treatment for Childhood Cancer (PDQ®)–Patient Version

Endocrine System

KEY POINTS

• Thyroid gland
  • Thyroid late effects are more likely to occur after treatment for certain childhood cancers.
  • Radiation therapy to the head and neck increases the risk of thyroid late effects.
  • Late effects that affect the thyroid may cause certain health problems.
  • Signs and symptoms of thyroid late effects depend on whether there is too little or too much thyroid hormone in the body.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the thyroid.
• Pituitary gland
  • Neuroendocrine late effects may be caused after treatment for certain childhood cancers.
  • Treatment that affects the hypothalamus or pituitary gland increases the risk of neuroendocrine system late effects.
  • Late effects that affect the hypothalamus may cause certain health problems.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the neuroendocrine system.
• Testicles and ovaries
• Metabolic syndrome
  • Metabolic syndrome is more likely to occur after treatment for certain childhood cancers.
  • Radiation therapy increases the risk of metabolic syndrome.
  • Certain tests and procedures are used to detect (find) and diagnose metabolic syndrome.
  • Metabolic syndrome may cause heart and blood vessel disease and diabetes.
• Weight
  • Being underweight, overweight, or obese is a late effect that is more likely to occur after treatment for certain childhood cancers.
  • Radiation therapy increases the risk of being underweight, overweight, or obese.
  • Certain tests and procedures are used to detect (find) and diagnose a change in weight.

Thyroid gland

Thyroid late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause thyroid late effects:

• Acute lymphoblastic leukemia (ALL).
• Brain tumors.
• Head and neck cancers.
• Hodgkin lymphoma.
• Neuroblastoma.
• Cancers treated with a stem cell transplant.

Radiation therapy to the head and neck increases the risk of thyroid late effects.

The risk of thyroid late effects may be increased in childhood cancer survivors after treatment with any of the following:

• Radiation therapy to the thyroid as part of radiation therapy to the head and neck or to the pituitary gland in the brain.
• Total-body irradiation (TBI) as part of a stem cell transplant.
• MIBG (radioactive iodine) therapy for neuroblastoma.

The risk also is increased in females, in survivors who were a young age at the time of treatment, in survivors who had a higher radiation dose, and as the time since diagnosisand treatment gets longer.

Late effects that affect the thyroid may cause certain health problems.

Thyroid late effects and related health problems include the following:

• Hypothyroidism (not enough thyroid hormone): This is the most common thyroid late effect. It usually occurs 2 to 5 years after treatment ends but may occur later. It is more common in girls than boys.
• Hyperthyroidism (too much thyroid hormone): It usually occurs 3 to 5 years after treatment ends.
• Goiter (an enlarged thyroid).
• Lumps in the thyroid: Usually occur 10 or more years after treatment ends. It is more common in girls than boys. These growths may be benign (not cancerous) or malignant (cancer).

Signs and symptoms of thyroid late effects depend on whether there is too little or too much thyroid hormone in the body.

These and other signs and symptoms may be caused by thyroid late effects or by other conditions:

Hypothyroidism (too little thyroid hormone)

• Feeling tired or weak.
• Being more sensitive to cold.
• Pale, dry skin.
• Coarse and thinning hair.
• Brittle fingernails.
• Hoarse voice.
• Puffy face.
• Muscle and joint aches and stiffness.
• Constipation.
• Menstrual periods that are heavier than normal.
• Weight gain for no known reason.
• Depression or trouble with memory or being able to concentrate.

Rarely, hypothyroidism does not cause any symptoms.

Hyperthyroidism (too much thyroid hormone)

• Feeling nervous, anxious, or moody.
• Trouble sleeping.
• Feeling tired or weak.
• Having shaky hands.
• Having a fast heartbeat.
• Having red, warm skin that may be itchy.
• Having fine, soft hair that is falling out.
• Having frequent or loose bowel movements.
• Weight loss for no known reason.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the thyroid.

These and other tests and procedures may be used to detect or diagnose thyroid late effects:

• Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. The blood may be checked for abnormallevels of thyroid-stimulating hormone (TSH) or free thyroxine (T4).
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later. This procedure can show the size of the thyroid and whether there are nodules (lumps) on the thyroid.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of thyroid late effects. If tests are needed, find out how often they should be done.

Pituitary gland

Neuroendocrine late effects may be caused after treatment for certain childhood cancers.

The neuroendocrine system is the nervous system and the endocrine system working together.

Treatment for these and other childhood cancers may cause neuroendocrine late effects:

• Brain and spinal cord tumors.
• Acute lymphoblastic leukemia (ALL).
• Nasopharyngeal cancer.
• Cancers treated with total-body irradiation (TBI) before a stem cell transplant.

Treatment that affects the hypothalamus or pituitary gland increases the risk of neuroendocrine system late effects.

Childhood cancer survivors have an increased risk for neuroendocrine late effects. These effects are caused by radiation therapy to the brain in the area of the hypothalamus. The hypothalamus controls the way hormones are made and released into the bloodstream by the pituitary gland. Radiation therapy may be given to treat cancer near the hypothalamus or as total-body irradiation (TBI) before a stem cell transplant. These effects are also caused by surgery in the area of the hypothalamus, pituitary gland, or optic pathways.

Childhood cancer survivors who have neuroendocrine late effects may have low levels of any of the following hormones made in the pituitary gland and released into the blood:

• Growth hormone (GH; helps promote growth and control metabolism).
• Adrenocorticotropic hormone (ACTH; controls the making of glucocorticoids).
• Prolactin (controls the making of breast milk).
• Thyroid-stimulating hormone (TSH; controls the making of thyroid hormones).
• Luteinizing hormone (LH; controls reproduction).
• Follicle-stimulating hormone (FSH; controls reproduction).

Late effects that affect the hypothalamus may cause certain health problems.

Neuroendocrine late effects and related health problems include the following:

• Growth hormone deficiency : A low level of growth hormone is a common late effect of radiation to the brain in childhood cancer survivors. The higher the radiation dose and the longer the time since treatment, the greater the risk of this late effect. A low level of growth hormone may also occur in childhood ALL and stem cell transplant survivors who received radiation therapy to the brain and spinal cord and/or chemotherapy.
  A low level of growth hormone in childhood results in adult height that is shorter than normal. If the child's bones have not fully developed, low growth hormone levels may be treated with growth hormone replacement therapy beginning one year after the end of treatment.
• Adrenocorticotropin deficiency: A low level of adrenocorticotropic hormone is an uncommon late effect. It may occur in childhood brain tumor survivors, survivors with low growth hormone levels or central hypothyroidism, or after radiation therapy to the brain.
  Symptoms of deficiency may not be severe and may not be noticed. Signs and symptoms of adrenocorticotropin deficiency include the following:
  • Weight loss for no known reason.
  • Not feeling hungry.
  • Nausea.
  • Vomiting.
  • Low blood pressure.
  • Feeling tired.
  Low levels of adrenocorticotropin may be treated with hydrocortisone therapy.
• Hyperprolactinemia: A high level of the hormone prolactin may occur after a high dose of radiation to the brain or surgery that affects part of the pituitary gland. A high level of prolactin may cause the following:
  • Puberty at a later age than normal.
  • Flow of breast milk in a woman who is not pregnant or breast-feeding.
  • Less frequent or no menstrual periods or menstrual periods with a very light flow.
  • Hot flashes (in women).
  • Inability to become pregnant.
  • Inability to have an erection needed for sexual intercourse.
  • Lower sex drive (in men and women).
  • Osteopenia (low bone mineral density).
  Sometimes there are no signs and symptoms. Treatment is rarely needed.
• Thyroid-stimulating hormone deficiency (central hypothyroidism): A low level of thyroid hormone may occur very slowly over time after radiation therapy to the brain.
  Sometimes the symptoms of thyroid-stimulating hormone deficiency are not noticed. Low thyroid hormone levels may cause slow growth and delayed puberty, as well as other symptoms. A low level of thyroid hormone may be treated with thyroid hormone replacement therapy.
• Luteinizing hormone or follicle-stimulating hormone deficiency: Low levels of these hormones can cause different health problems. The type of problem depends on the radiation dose.
  Childhood cancer survivors who were treated with lower doses of radiation to the brain may develop central precocious puberty (a condition that causes puberty to start before age 8 years in girls and 9 years in boys). This condition may be treated with gonadotropin-releasing hormone (GnRH) agonist therapy to delay puberty and help the child's growth. Hydrocephalus may also increase the risk of this late effect.
  Childhood cancer survivors who were treated with higher doses of radiation to the brain may have low levels of luteinizing hormone or follicle-stimulating hormone. This condition may be treated with sex hormone replacement therapy. The dose will depend on the child's age and whether the child has reached puberty.
• Central diabetes insipidus : Central diabetes insipidus may be caused by the absence of or low amounts of all of the hormones made in the front part of the pituitary gland and released into the blood. It may occur in childhood cancer survivors treated with surgery in the area of the hypothalamus or pituitary gland. Signs and symptoms of central diabetes insipidus may include the following:
  • Having large amounts of urine or unusually wet diapers.
  • Feeling very thirsty.
  • Headache.
  • Trouble with vision.
  • Slowed growth and development.
  • Weight loss for no known reason.
  Treatment may include hormone replacement therapy with vasopressin, the hormone that controls the amount of urine that is made in the body.

Certain tests and procedures are used to detect (find) and diagnose health problems in the neuroendocrine system.

These and other tests and procedures may be used to detect or diagnose thyroid late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry study : A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. The blood may be checked for abnormal levels of follicle-stimulating hormone, luteinizing hormone, estradiol, testosterone, cortisol, or free thyroxine (T4).
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterol in the blood.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of neuroendocrine late effects. If tests are needed, find out how often they should be done.

Testicles and ovaries

See the Reproductive System section of this summary for information about late effects in the testicles and ovaries.

Metabolic syndrome

Metabolic syndrome is more likely to occur after treatment for certain childhood cancers.

Metabolic syndrome is a group of medical conditions that includes having too much fat around the abdomen and at least two of the following:

• High blood pressure.
• High levels of triglycerides and low levels of high-density lipoprotein (HDL) cholesterol in the blood.
• High levels of glucose (sugar) in the blood.

Treatment for these and other childhood cancers may cause metabolic syndrome to occur later in life:

• Acute lymphoblastic leukemia (ALL).
• Cancers treated with a stem cell transplant.
• Cancers treated with radiation to the abdomen, such as Wilms tumor or neuroblastoma.

Radiation therapy increases the risk of metabolic syndrome.

The risk of metabolic syndrome may be increased in childhood cancer survivors after treatment with any of the following:

• Radiation therapy to the brain or abdomen.
• Total-body irradiation (TBI) as part of a stem cell transplant.

Certain tests and procedures are used to detect (find) and diagnose metabolic syndrome.

These and other tests and procedures may be used to detect or diagnose metabolic syndrome:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterol in the blood.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of metabolic syndrome. If tests are needed, find out how often they should be done.

Metabolic syndrome may cause heart and blood vessel disease and diabetes.

Metabolic syndrome is linked to an increased risk of heart and blood vessel disease and diabetes. Health habits that decrease these risks include:

• Having a healthy weight.
• Eating a heart-healthy diet.
• Having regular exercise.
• Not smoking.

Weight

Being underweight, overweight, or obese is a late effect that is more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause a change in weight:

• Acute lymphoblastic leukemia (ALL).
• Brain tumors, especially craniopharyngiomas.
• Cancers treated with radiation to the brain, including total-body irradiation (TBI) as part of a stem cell transplant.

Radiation therapy increases the risk of being underweight, overweight, or obese.

The risk of being underweight increases after treatment with the following:

• Total-body irradiation (TBI) for females.
• Radiation therapy to the abdomen for males.
• Certain types of chemotherapy (alkylating agents and anthracyclines).

The risk of obesity increases after treatment with the following:

• Radiation therapy to the brain.
• Surgery that damages the hypothalamus or pituitary gland, such as surgery to remove a craniopharyngioma brain tumor.

The following may also increase the risk of obesity:

• Being diagnosed with cancer when aged 5 to 9 years.
• Being female.
• Having growth hormone deficiency or low levels of the hormone leptin.
• Not doing enough physical activity to stay at a healthy body weight.
• Taking an antidepressant called paroxetine.

Childhood cancer survivors who get enough exercise and have a normal amount of anxietyhave a lower risk of obesity.

Certain tests and procedures are used to detect (find) and diagnose a change in weight.

These and other tests and procedures may be used to detect or diagnose a change in weight:

• Physical exam and history: An exam of the body to check general signs of health, including weight or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterol in the blood.

Being underweight, overweight, or obese may be measured by weight, body mass index, percent of body fat, or size of the abdomen (belly fat).

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of a change in weight. If tests are needed, find out how often they should be done.