National Cancer Institute


Posted Date: Jan 26, 2016

Expert-reviewed information summary about the health problems that continue or appear after cancer treatment has ended.

This PDQ cancer information summary has current information about the late effects of treatment for childhood cancer. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change. The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Pediatric Treatment Editorial Board.

Late Effects of Childhood Cancer Treatment

Late Effects of Treatment for Childhood Cancer

General Information about Late Effects

Key Points for this Section

  • Late effects are health problems that occur months or years after treatment has ended.
  • Late effects in childhood cancer survivors affect the body and mind.
  • There are three important factors that affect the risk of late effects.
  • The chance of having late effects increases over time.
  • Regular follow-up care is very important for survivors of childhood cancer.
  • Good health habits are also important for survivors of childhood cancer.

Late effects are health problems that occur months or years after treatment has ended.

The treatment of cancer may cause health problems for childhood cancer survivors months or years after successful treatment has ended. Cancer treatments may harm the body's organs, tissues, or bones and cause health problems later in life. These health problems are called late effects.

Treatments that may cause late effects include the following:

Doctors are studying the late effects caused by cancer treatment. They are working to improve cancer treatments and stop or lessen late effects. While most late effects are not life-threatening, they may cause serious problems that affect health and quality of life.

Late effects in childhood cancer survivors affect the body and mind.

Late effects in childhood cancer survivors may affect the following:

  • Organs, tissues, and body function.
  • Growth and development.
  • Mood, feelings, and actions.
  • Thinking, learning, and memory.
  • Social and psychological adjustment.
  • Risk of second cancers.

There are three important factors that affect the risk of late effects.

Many childhood cancer survivors will have late effects. The risk of late effects depends on factors related to the tumor, treatment, and patient. These include the following:

  • Tumor-related factors Type of cancer.Where the tumor is in the body.How the tumor affects the way tissues and organs work.
  • Treatment-related factors Type of surgery.Chemotherapy type, dose, and schedule.Type of radiation therapy, part of the body treated, and dose.Stem cell transplant.Use of two or more types of treatment at the same time.Blood product transfusion.Chronic graft-versus-host disease.
  • Patient-related factorsThe child's gender. Health problems the child had before being diagnosed with cancer.The child’s age and developmental stage when diagnosed and treated.Length of time since diagnosis and treatment.Changes in hormone levels.The ability of healthy tissue affected by cancer treatment to repair itself.Certain changes in the child's genes.Family history of cancer or other conditions.Health habits.

The chance of having late effects increases over time.

New treatments for childhood cancer have decreased the number of deaths from the primary cancer. Because childhood cancer survivors are living longer, they are having more late effects after cancer treatment. Survivors may not live as long as people who did not have cancer. The most common causes of death in childhood cancer survivors are:

  • The primary cancer comes back.
  • A second (different) primary cancer forms.
  • Heart and lung damage.

Studies of the causes of late effects have led to changes in treatment. This has improved the quality of life for cancer survivors and helps prevent illness and death from late effects.

Regular follow-up care is very important for survivors of childhood cancer.

Regular follow-up by health professionals who are trained to find and treat late effects is important for the long-term health of childhood cancer survivors. Follow-up care will be different for each person who has been treated for cancer. The type of care will depend on the type of cancer, the type of treatment, genetic factors, and the person's general health and health habits. Follow-up care includes checking for signs and symptoms of late effects and health education on how to prevent or lessen late effects.

It is important that childhood cancer survivors have an exam at least once a year. The exams should be done by a health professional who knows the survivor's risk for late effects and can recognize the early signs of late effects. Blood and imaging tests may also be done.

Long-term follow-up may improve the health and quality of life for cancer survivors. It also helps doctors study the late effects of cancer treatments so that safer therapies for newly diagnosed children may be developed.

Good health habits are also important for survivors of childhood cancer.

The quality of life for cancer survivors may be improved by behaviors that promote health and well-being. These include a healthy diet, exercise, and regular medical and dental checkups. These self-care behaviors are especially important for cancer survivors because of their risk of health problems related to treatment. Healthy behaviors may make late effects less severe and lower the risk of other diseases.

Avoiding behaviors that are damaging to health is also important. Smoking, excess alcohol use, illegal drug use, being exposed to sunlight, or not being physically active may worsen organ damage related to treatment and may increase the risk of second cancers.

Second Cancers

Key Points for this Section

  • Childhood cancer survivors have an increased risk of a second cancer later in life.
  • Certain genetic patterns or syndromes may increase the risk of a second cancer.
  • Patients who have been treated for cancer need regular screening tests to check for a second cancer.
  • The kind of test used to screen for a second cancer depends in part on the kind of cancer treatment the patient had in the past.

Childhood cancer survivors have an increased risk of a second cancer later in life.

A different primary cancer that occurs at least two months after cancer treatment ends is called a second cancer. A second cancer may occur months or years after treatment is completed. The type of second cancer that occurs depends in part on the original type of cancer and the cancer treatment. Benign tumors (not cancer) may also occur.

Second cancers that occur after cancer treatment include the following:

Solid tumors that may appear more than 10 years after primary cancer diagnosis and treatment include the following:

Myelodysplastic syndrome and acute myeloid leukemia may appear less than 10 years after a primary cancer diagnosis of Hodgkin lymphoma, acute lymphoblastic leukemia, or sarcoma and treatment with chemotherapy that included the following:

Certain genetic patterns or syndromes may increase the risk of a second cancer.

Some childhood cancer survivors may have an increased risk of developing a second cancer because they have a family history of cancer or an inherited cancer syndrome such as Li-Fraumeni syndrome. Problems with the way DNA is repaired in cells and the way anticancer drugs are used by the body may also affect the risk of second cancers.

Patients who have been treated for cancer need regular screening tests to check for a second cancer.

It is important for patients who have been treated for cancer to be checked for a second cancer before symptoms appear. This is called screening for a second cancer and may help find a second cancer at an early stage. When abnormal tissue or cancer is found early, it may be easier to treat. By the time symptoms appear, cancer may have begun to spread.

It is important to remember that your child's doctor does not necessarily think your child has cancer if he or she suggests a screening test. Screening tests are given when your child has no cancer symptoms. If a screening test result is abnormal, your child may need to have more tests done to find out if he or she has a second cancer. These are called diagnostic tests.

The kind of test used to screen for a second cancer depends in part on the kind of cancer treatment the patient had in the past.

All patients who have been treated for cancer should have a physical exam and medical history done once a year. A physical exam of the body is done to check general signs of health, including checking for signs of disease, such as lumps, changes in the skin, or anything else that seems unusual. A medical history is taken to learn about the patient’s health habits and past illnesses and treatments.

If the patient received radiation therapy, the following tests and procedures may be used to check for skin, breast, or colorectal cancer:

  • Skin exam: A doctor or nurse checks the skin for bumps or spots that look abnormal in color, size, shape, or texture, especially in the area where radiation was given. It is suggested that a skin exam be done once a year to check for signs of skin cancer.
  • Breast self-exam: An exam of the breast by the patient. The patient carefully feels the breasts and under the arms for lumps or anything else that seems unusual. It is suggested that women treated with a higher dose of radiation therapy to the chest do a monthly breast self-exam beginning at puberty until age 25 years. Women who were treated with a lower dose of radiation to the chest may not need to begin checking for breast cancer at puberty. Talk to your doctor about when you should begin breast self-exams.
  • Clinical breast exam (CBE): An exam of the breast by a doctor or other health professional. The doctor will carefully feel the breasts and under the arms for lumps or anything else that seems unusual. It is suggested that women treated with a higher dose of radiation therapy to the chest have a clinical breast exam every year beginning at puberty until age 25 years. After age 25 years or 8 years after radiation treatments end (whichever is first), clinical breast exams are done every 6 months. Women who were treated with a lower dose of radiation to the chest may not need to begin checking for breast cancer at puberty. Talk to your doctor about when you should begin clinical breast exams.
  • Mammogram: An x-ray of the breast. A mammogram may be done in women who had a higher dose of radiation to the chest and who do not have dense breasts. It is suggested that these women have a mammogram once a year starting 8 years after treatment or at age 25 years, whichever is later. Talk to your doctor about when you should begin to have mammograms to check for breast cancer.
  • Breast MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of the breast. This procedure is also called nuclear magnetic resonance imaging (NMRI). An MRI may be done in women who had a higher dose of radiation to the chest and who have dense breasts. It is suggested that these women have an MRI once a year starting 8 years after treatment or at age 25 years, whichever is later. If you had radiation to the chest, talk to your doctor about whether you need an MRI of the breast to check for breast cancer.
  • Colonoscopy: A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer. A colonoscope is inserted through the rectum into the colon. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer. It is suggested that childhood cancer survivors who had a higher dose of radiation to the abdomen, pelvis, or spine have a colonoscopy every 5 years. This begins at age 35 years or 10 years after treatment ended, whichever is later. If you had radiation to the abdomen, pelvis, or spine, talk to your doctor about when you should begin to have a colonoscopies to check for colorectal cancer.

Cardiovascular System

Key Points for this Section

  • Heart and blood vessel late effects are more likely to occur after treatment for certain childhood cancers.
  • Radiation to the chest and certain types of chemotherapy increase the risk of heart and blood vessel late effects.
  • Late effects that affect the heart and blood vessels may cause certain health problems.
  • Possible signs and symptoms of heart and blood vessel late effects include trouble breathing and chest pain.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the heart and blood vessels.
  • Health habits that promote a healthy heart and blood vessels are important for survivors of childhood cancer.

Heart and blood vessel late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause heart and blood vessel late effects:

Radiation to the chest and certain types of chemotherapy increase the risk of heart and blood vessel late effects.

The risk of health problems involving the heart and blood vessels increases after treatment with the following:

Childhood cancer survivors who were treated with radiation to the heart or blood vessels and certain types of chemotherapy are at greatest risk.

New treatments that decrease the amount of radiation given and use lower doses of chemotherapy may lessen the risk of heart and blood vessel late effects compared with older treatments.

The following may also increase the risk of heart and blood vessel late effects:

Late effects that affect the heart and blood vessels may cause certain health problems.

Childhood cancer survivors who received radiation or certain types of chemotherapy have an increased risk of late effects to the heart and blood vessels and related health problems. These include the following:

Possible signs and symptoms of heart and blood vessel late effects include trouble breathing and chest pain.

These and other signs and symptoms may be caused by heart and blood vessel late effects or by other conditions:

  • Trouble breathing, especially when lying down.
  • Heartbeat that is too slow, too fast, or different from the heart's normal rhythm.
  • Chest pain.
  • Swelling of the feet, ankles, legs, or abdomen.
  • When exposed to cold or having strong emotions, the fingers, toes, ears, or nose become white and then turn blue. When this happens to the fingers, there may also be pain and tingling.
  • Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body).
  • Sudden confusion or trouble speaking or understanding speech.
  • Sudden trouble seeing with one or both eyes.
  • Sudden trouble walking or feeling dizzy.
  • Sudden loss of balance or coordination.
  • Sudden severe headache 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 heart and blood vessels.

These and other tests and procedures may be used to detect or diagnose heart and blood vessel late effects:

  • Physical exam and history: An exam of the body to check general signs of health, including checking the heart for signs of disease, such as abnormal heart beat, high blood pressure, or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Electrocardiogram (EKG): A recording of the heart's electrical activity to check its rate and rhythm. A number of small pads (electrodes) are placed on the patient’s chest, arms, and legs, and are connected by wires to the EKG machine. Heart activity is then recorded as a line graph on paper. Electrical activity that is faster or slower than normal may be a sign of heart disease or damage.
  • Echocardiogram: A procedure in which high-energy sound waves ( ultrasound) are bounced off the heart and nearby tissues or organs and make echoes. A moving picture is made of the heart and heart valves as blood is pumped through the heart.
  • Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs such as the heart and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
  • 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 heart and blood vessel late effects. If tests are needed, find out how often they should be done.

Health habits that promote a healthy heart and blood vessels are important for survivors of childhood cancer.

Childhood cancer survivors with heart and blood vessel late effects should take care to protect their health, including:

  • Having a healthy weight.
  • Eating a heart-healthy diet.
  • Having regular exercise.
  • Talking to their doctor before starting an intense exercise program.
  • Not smoking.

Central Nervous System

Key Points for this Section

  • Brain and spinal cord late effects are more likely to occur after treatment for certain childhood cancers.
  • Radiation to the brain increases the risk of brain and spinal cord late effects.
  • Late effects that affect the brain and spinal cord may cause certain health problems.
  • Possible signs and symptoms of brain and spinal cord late effects include headaches, loss of coordination, and seizures.
  • Certain tests and procedures are used to detect (find) and diagnose health problems in the brain and spinal cord.
  • Survivors of childhood cancer may have anxiety and depression related to their cancer.
  • Some childhood cancer survivors have post-traumatic stress disorder.
  • Adolescents who are diagnosed with cancer may have social problems later in life.

Brain and spinal cord late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause brain and spinal cord late effects:

Radiation to the brain increases the risk of brain and spinal cord late effects.

The risk of health problems that affect the brain or spinal cord increases after treatment with the following:

When radiation to the brain and intrathecal chemotherapy are given at the same time, the risk of late effects is higher.

The following may also increase the risk of brain and spinal cord late effects:

  • Being about 5 years old or younger at the time of treatment.
  • Being female.
  • Having hydrocephalus and a shunt placed to removed the extra fluid from the ventricles.
  • Having hearing loss.
  • Having cerebellar mutism following surgery to remove the brain tumor. Cerebellar mutism includes not being able to speak, loss of coordination and balance, mood swings, being irritable, and having a high-pitched cry.
  • Having a personal history of stroke.

Central nervous system late effects are also affected by where the tumor has formed in the brain and spinal cord.

Late effects that affect the brain and spinal cord may cause certain health problems.

Childhood cancer survivors who received radiation, certain types of chemotherapy, or surgery to the brain or spinal cord have an increased risk of late effects to the brain and spinal cord and related health problems. These include the following:

  • Headaches.
  • Loss of coordination and balance.
  • Seizures.
  • Loss of the myelin sheath that covers nerve fibers in the brain.
  • Movement disorders that affect the legs and eyes or the ability to speak and swallow.
  • Nerve damage in the hands or feet.
  • Stroke.
  • Hydrocephalus.
  • Loss of bladder and/or bowel control.
  • Cavernomas (clusters of abnormal blood vessels).
  • Back pain.

Survivors may also have late effects that affect thinking, learning, memory, emotions, and behavior.

New ways of using more targeted and lower doses of radiation to the brain may lessen the risk of brain and spinal cord late effects.

Possible signs and symptoms of brain and spinal cord late effects include headaches, loss of coordination, and seizures.

These signs and symptoms may be caused by brain and spinal cord late effects or by other conditions:

  • Headache that may go away after vomiting.
  • Seizures.
  • Loss of balance, lack of coordination, or trouble walking.
  • Trouble speaking or swallowing.
  • Trouble with having the eyes work together.
  • Numbness, tingling, or weakness in the hands or feet.
  • Being unable to bend the ankle to lift the foot up.
  • Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body).
  • Unusual sleepiness or change in activity level.
  • Unusual changes in personality or behavior.
  • A change in bowel habits or trouble urinating.
  • Increase in head size (in infants).
  • Sudden confusion or trouble speaking or understanding speech.
  • Sudden trouble seeing with one or both eyes.
  • Sudden severe headache for no known reason.

Other signs and symptoms include the following:

  • Problems with memory.
  • Problems with paying attention.
  • Trouble with solving problems.
  • Trouble with organizing thoughts and tasks.
  • Slower ability to learn and use new information.
  • Trouble learning to read, write, or do math.
  • Trouble coordinating movement between the eyes, hands, and other muscles.
  • Delays in normal development.
  • Social withdrawal or trouble getting along with others.

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 brain and spinal cord.

These and other tests and procedures may be used to detect or diagnose brain and spinal cord 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.
  • Neurological exam: A series of questions and tests to check the brain, spinal cord, and nerve function. The exam checks a person’s mental status, coordination, and ability to walk normally, and how well the muscles, senses, and reflexes work. This may also be called a neuro exam or a neurologic exam. In some cases, a more complete exam may be done by a neurologist or neurosurgeon.
  • Neuropsychological assessment: A series of tests to examine the patient's mental processes and behavior. Areas that are checked usually include: Knowing who and where you are and what day it is.Ability to learn and remember new information. Intelligence.Ability to solve problems.Use of spoken and written language.Eye-hand coordination.Ability to organize information and tasks.

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

Survivors of childhood cancer may have anxiety and depression related to their cancer.

Survivors of childhood cancer may have anxiety and depression related to physical changes, having pain, the way they look, or the fear of cancer coming back. This may cause problems with personal relationships, education, employment, and health, and cause thoughts of suicide. Survivors with these problems may be less likely to live on their own as adults.

Follow-up exams for childhood cancer survivors should include screening and treatment for possible psychological distress, such as anxiety, depression, and thoughts of suicide.

Some childhood cancer survivors have post-traumatic stress disorder.

Being diagnosed and treated for a life-threatening disease may be traumatic. This trauma may cause post-traumatic stress disorder (PTSD). PTSD is defined as having

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