Late Effects of Treatment for Childhood Cancer (PDQ®)—Patient Version - National Cancer Institute 2/7

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

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

Digestive System

KEY POINTS

• Teeth and jaws
  • Problems with the teeth and jaws are late effects that are more likely to occur after treatment for certain childhood cancers.
  • Radiation to the head and neck and certain types of chemotherapy increase the risk of late effects to the teeth and jaws.
  • Late effects that affect the teeth and jaws may cause certain health problems.
  • Possible signs and symptoms of late effects of the teeth and jaws include tooth decay (cavities) and jaw pain.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the mouth and jaws.
  • Regular dental care is very important for survivors of childhood cancer.
• Digestive tract
  • Digestive tract late effects are more likely to occur after treatment for certain childhood cancers.
  • Radiation to the bladder, prostate, or testicles and certain types of chemotherapy increase the risk of digestive tract late effects.
  • Late effects that affect the digestive tract may cause certain health problems.
  • Possible signs and symptoms of digestive tract late effects include abdominal pain and diarrhea.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the digestive tract.
• Liver and bile ducts
  • Liver and bile duct late effects are more likely to occur after treatment for certain childhood cancers.
  • Certain types of chemotherapy and radiation to the liver or bile ducts increase the risk of late effects.
  • Late effects that affect the liver and bile ducts may cause certain health problems.
  • Possible signs and symptoms of liver and bile duct late effects include abdominal pain and jaundice.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the liver and bile duct.
  • Health habits that promote a healthy liver are important for survivors of childhood cancer.
• Pancreas
  • Radiation therapy increases the risk of pancreatic late effects.
  • Late effects that affect the pancreas may cause certain health problems.
  • Possible signs and symptoms of pancreatic late effects include frequent urination and being thirsty.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the pancreas.

Teeth and jaws

Problems with the teeth and jaws are late effects that are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause the late effect of problems with teeth and jaws:

• Head and neck cancers.
• Hodgkin lymphoma.
• Neuroblastoma.
• Leukemia that spread to the brain and spinal cord.
• Nasopharyngeal cancer.
• Brain tumors.
• Cancers treated with a stem cell transplant.

Radiation to the head and neck and certain types of chemotherapy increase the risk of late effects to the teeth and jaws.

The risk of health problems that affect the teeth and jaws increases after treatment with the following:

• Radiation therapy to the head and neck.
• Total-body irradiation (TBI) as part of a stem cell transplant.
• Chemotherapy, especially with higher doses of alkylating agents such as cyclophosphamide.
• Surgery in the head and neck area.

Risk is also increased in survivors who were younger than 5 years at the time of treatment because their permanent teeth had not fully formed.

Late effects that affect the teeth and jaws may cause certain health problems.

Teeth and jaw late effects and related health problems include the following:

• Teeth that are not normal.
• Tooth decay (including cavities) and gum disease.
• Salivary glands do not make enough saliva.
• Death of the bone cells in the jaw.
• Changes in the way the face, jaw, or skull form.

Possible signs and symptoms of late effects of the teeth and jaws include tooth decay (cavities) and jaw pain.

These and other signs and symptoms may be caused by late effects of the teeth and jaws or by other conditions:

• Teeth are small or do not have a normal shape.
• Missing permanent teeth.
• Permanent teeth come in at a later than normal age.
• Teeth have less enamel than normal.
• More tooth decay (cavities) and gum disease than normal.
• Dry mouth.
• Trouble chewing, swallowing, and speaking.
• Jaw pain.
• Jaws do not open and close the way they should.

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 mouth and jaws.

These and other tests and procedures may be used to detect or diagnose late effects of the teeth and jaws:

• Dental exam and history : An exam of the teeth, mouth, and jaws to check general signs of dental health, including checking for signs of disease, such as cavities or anything that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken. This may also be called a dental check-up.
• Panorex x-ray : An x-ray of all of the teeth and their roots. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• X-ray of the jaws: An x-ray of the jaws. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the head and neck, taken from different angles. The pictures are made by a computer linked to an x-ray machine. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the head and neck. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Biopsy : The removal of bone cells from the jaw so they can be viewed under a microscope to check for signs of bone death after radiation therapy.

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

Regular dental care is very important for survivors of childhood cancer.

Doctors suggest that survivors of childhood cancer have a dental check-up and a cleaning and fluoride treatment every 6 months. Children who had radiation therapy to the oral cavity may also see an orthodontist or an otolaryngologist. If lesions are present in the mouth, a biopsy may be needed.

Digestive tract

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

Treatment for these and other childhood cancers may cause late effects of the digestive tract (esophagus, stomach, small and large intestines, rectum and anus):

• Rhabdomyosarcoma of the bladder or prostate, or near the testicles.
• Non-Hodgkin lymphoma.
• Germ cell tumors.
• Neuroblastoma.
• Wilms tumor.

Radiation to the bladder, prostate, or testicles and certain types of chemotherapy increase the risk of digestive tract late effects.

The risk of health problems that affect the digestive tract increases after treatment with the following:

• Radiation therapy to the abdomen or areas near the abdomen, such as the esophagus, bladder, prostate, or testicles, may cause digestive tract problems that begin quickly and last for a short time. In some patients, however, digestive tract problems are delayed and long-lasting. These late effects are caused by radiation therapy that damages the blood vessels. Receiving higher doses of radiation therapy or receiving chemotherapy such as dactinomycin or anthracyclines together with radiation therapy may increase this risk.
• Abdominal surgery or pelvic surgery to remove the bladder.
• Chemotherapy with alkylating agents such as cyclophosphamide, procarbazine, and ifosfamide, or with platinum agents such as cisplatin or carboplatin, or with anthracyclines such as doxorubicin, daunorubicin, idarubicin, and epirubicin.
• Stem cell transplant.

The following may also increase the risk of digestive tract late effects:

• Older age at diagnosis or when treatment begins.
• Treatment with both radiation therapy and chemotherapy.
• A history of chronic graft-versus-host disease.

Late effects that affect the digestive tract may cause certain health problems.

Digestive tract late effects and related health problems include the following:

• A narrowing of the esophagus or intestine.
• The muscles of the esophagus do not work well.
• Reflux
• Diarrhea, constipation, fecal incontinence, or blocked bowel.
• Bowel perforation (a hole in the intestine).
• Inflammation of the intestines.
• Death of part of the intestine.
• Intestine is not able to absorb nutrients from food.

Possible signs and symptoms of digestive tract late effects include abdominal pain and diarrhea.

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

• Trouble swallowing or feeling like food is stuck in the throat.
• Heartburn.
• Fever with severe pain in the abdomen and nausea.
• Pain in the abdomen.
• A change in bowel habits (constipation or diarrhea).
• Nausea and vomiting.
• Frequent gas pains, bloating, fullness, or cramps.
• Hemorrhoids.
• Reflux.

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 digestive tract.

These and other tests and procedures may be used to detect or diagnose digestive tract 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 abdominal tenderness or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam : An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum to feel for lumps or anything else that seems unusual.
• Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances 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.
• X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. An x-ray may be taken of the abdomen, kidney, ureter, or bladder to check for signs of disease.

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

Liver and bile ducts

Liver and bile duct late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause liver or bile duct late effects:

• Liver cancer.
• Wilms tumor.
• Acute lymphoblastic leukemia (ALL).
• Cancers treated with a stem cell transplant.

Certain types of chemotherapy and radiation to the liver or bile ducts increase the risk of late effects.

The risk of liver or bile duct late effects may be increased in childhood cancer survivors treated with one of the following:

• Surgery to remove part of the liver or a liver transplant.
• Chemotherapy that includes high-dose cyclophosphamide as part of a stem cell transplant.
• Chemotherapy such as 6-mercaptopurine, 6-thioguanine, and methotrexate.
• Radiation therapy to the liver and bile ducts. The risk depends on the following:
  • The dose of radiation and how much of the liver is treated.
  • Age when treated (the younger the age, the higher the risk).
  • Whether there was surgery to remove part of the liver.
  • Whether chemotherapy, such as doxorubicin or dactinomycin, was given together with radiation therapy.
• Stem cell transplant (and a history of chronic graft-versus-host disease).

Late effects that affect the liver and bile ducts may cause certain health problems.

Liver and bile duct late effects and related health problems include the following:

• Liver doesn’t work the way it should or stops working.
• Gallstones.
• Benign liver lesions.
• Hepatitis B or C infection.
• Liver damage caused by veno-occlusive disease /sinusoidal obstruction syndrome(VOD/SOS).
• Liver fibrosis (an overgrowth of connective tissue in the liver) or cirrhosis.
• Fatty liver with insulin resistance (a condition in which the body makes insulin but cannot use it well).
• Tissue and organ damage from the buildup of extra iron after having many blood transfusions.

Possible signs and symptoms of liver and bile duct late effects include abdominal pain and jaundice.

These and other signs and symptoms may be caused by liver and bile duct late effects or by other conditions:

• Weight gain or weight loss.
• Swelling of the abdomen.
• Nausea and vomiting.
• Pain in the abdomen. Pain may occur near the ribs, often on the right side, or after eating a fatty meal.
• Jaundice (yellowing of the skin and whites of the eyes).
• Light-colored bowel movements.
• Dark-colored urine.
• A lot of gas.
• Lack of appetite.
• Feeling tired or weak.

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

Sometimes there are no signs or symptoms of liver or bile duct late effects and treatment may not be needed.

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

These and other tests and procedures may be used to detect or diagnose liver or bile duct 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 studies: A procedure in which a blood sample is checked to measure the amounts of certain substances 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 For example, there may be a higher level of bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) in the body if the liver has been damaged.
• Ferritin level: A procedure in which a blood sample is checked to measure the amount of ferritin. Ferritin is a protein that binds to iron and stores it for use by the body. After a stem cell transplant, a high ferritin level may be a sign of liver disease.
• Blood studies to check how well the blood clots: A procedure in which a blood sample is checked to measure the amount of platelets in the body or how long it takes for the blood to clot.
• Hepatitis assay : A procedure in which a blood sample is checked for pieces of the hepatitis virus. The blood sample may also be used to measure how much hepatitis virus is in the blood. All patients who had a blood transfusion before 1972 should have a screening test for hepatitis B. Patients who had a blood transfusion before 1993 should have a screening test for hepatitis C.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs, such as the gall bladder, and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
• Biopsy: The removal of cells or tissues from the liver so they can be viewed under a microscope to check for signs of a fatty liver.

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

Health habits that promote a healthy liver are important for survivors of childhood cancer.

Childhood cancer survivors with liver late effects should take care to protect their health, including:

• Having a healthy weight.
• Not drinking alcohol.
• Getting vaccines for hepatitis A and hepatitis B viruses.

Pancreas

Radiation therapy increases the risk of pancreatic late effects.

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

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

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

Pancreatic late effects and related health problems include the following:

• Insulin resistance: A condition in which the body does not use insulin the way it should. Insulin is needed to help control the amount of glucose (a type of sugar) in the body. Because the insulin does not work the way it should, glucose and fat levels rise.
• Diabetes mellitus : A disease in which the body does not make enough insulin or does not use it the way it should. When there is not enough insulin, the amount of glucose in the blood increases and the kidneys make a large amount of urine.

Possible signs and symptoms of pancreatic late effects include frequent urination and being thirsty.

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

• Frequent urination.
• Feeling very thirsty.
• Feeling very hungry.
• Weight loss for no known reason.
• Feeling very tired.
• Frequent infections, especially of the skin, gums, or bladder.
• Blurred vision.
• Cuts or bruises that are slow to heal.
• Numbness or tingling in the hands or feet.

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 pancreas.

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

• Glycated hemoglobin (A1C) test: A procedure in which a sample of blood is drawn and the amount of glucose that is attached to red blood cells is measured. A higher than normal amount of glucose attached to red blood cells can be a sign of diabetes mellitus.
• Fasting blood sugar test: A test in which a blood sample is checked to measure the amount of glucose in the blood. This test is done after the patient has had nothing to eat overnight. A higher than normal amount of glucose in the blood can be a sign of diabetes mellitus.