Watch the Cancer.Net Video: Late Effects of Childhood Cancer Treatment, with Lisa Diller, MD, adapted from this content.

This is the first article in a two-part series. It outlines risk factors for late effects of childhood cancer and types of late effects. The second article describes how to address potential late effects before, during, and after treatment.

Childhood cancer survivors are at risk for developing late effects, which are side effects that occur more than five years after treatment. These can result from both the cancer itself and the cancer treatment. Because more than 80% of children treated for cancer survive five years or more after treatment and are presumably cured, preventing and recognizing both physical and emotional late effects is an important part of cancer care.

Late effects risk

Any cancer treatment may cause late effects. Treatments such as chemotherapy, radiation therapy, and bone marrow/stem cell transplantation harm healthy cells along with the cancer cells they aim to destroy. Surgical procedures may also cause late effects. A child's risk of developing late effects depends on the type and location of cancer, the area of the body treated, the type and dose of treatment, the child's age when treated, genetics and family history, and whether other health problems existed before the cancer diagnosis.

If you are worried about any of the late effects mentioned in this article, talk with a doctor, nurse, social worker, or other member of the health care team to understand what the risks are and ways to manage them. Progress in preventing, managing, and treating late effects from childhood cancer continues to be made, and more information is available all of the time to help children and their families manage the late effects of cancer and its treatment.

Types of late effects

Late effects can be physical or emotional. Below is a listing of specific late effects of childhood cancer. Talk with your doctor before treatment begins to learn which late effects your child may experience and what can be done to lower the risks. Many of the recommendations listed here are based on guidelines from the Children's Oncology Group.

Emotional problems. No matter what age a child is during treatment, potentially long-lasting emotional effects—such as anxiety, depression, and fear of recurrence—may occur. Learn more about coping with cancer-related distress.

Second cancers. Survivors of childhood cancer have a slightly increased risk of developing a second cancer, which is a different type of cancer that appears after the original cancer diagnosis. Sometimes this is called a secondary cancer. Causes may include radiation therapy and chemotherapy. Some drugs may cause leukemia, especially drugs called alkylating agents (such as cyclophosphamide [Cytoxan, Neosar] and ifosfamide [Ifex]), epipodophyllotoxins (drugs like etoposide [Toposar, VePesid]) and anthracyclines (drugs like daunorubicin [Cerubidine, Rubidomycin] and doxorubicin [Adriamycin]). Children and adolescents treated for Hodgkin lymphoma have the highest risk for second cancers, particularly breast and thyroid cancers.

Reproductive problems and sexual development. Boys and girls are both at risk for these problems.

• In boys, radiation therapy to the brain, head, testicles, or abdomen may cause infertility (the inability to father a child), as can chemotherapy with cyclophosphamide and ifosfamide. Treatments may also change levels of testosterone (a male hormone), which can affect puberty.
• In girls, particularly those who have begun menstruation, chemotherapy and radiation therapy to the whole abdomen, pelvis, lower spine, or head can affect the ovaries, causing infertility (inability to conceive a child or maintain a pregnancy), irregular menstruation, and premature menopause. Learn more about fertility and cancer treatment.

Growth, development and endocrine (hormone problems). Cancer treatments may affect the endocrine system, a group of hormone-producing glands that control body functions, such as growth, energy, and puberty.

• Radiation therapy near the brain, eyes, or ears can affect the pituitary gland, which helps control growth. Children who haven't reached adult height may be at increased risk for growth problems. An endocrinologist (a doctor who specializes in endocrine glands and hormones) can test for problems and provide hormone treatments.
• Radiation therapy given to bone can lead to reduced or uneven growth and conditions like scoliosis (a sideways curving of the spine).
• Glucocorticoids (drugs like prednisone and dexamethasone) and methotrexate have direct effects on bone formation (mineralization), which can lead to low bone mineral density, and, when severe, osteoporosis (a disease that causes weak bones and increases risk of bone fractures). Bone strength (density) usually recovers to normal in most children after stopping these medications.

Children should receive regular check-ups to monitor their growth and development throughout puberty. Doctors often measure bone mineral density with x-ray tests; these tests help the doctor learn whether a child needs dietary supplements or specialized foods and/or physical activity to help improve bone density.

Learning and memory problems. Radiation therapy to the head may cause learning problems. Chemotherapy delivered into the spine (intrathecal therapy) may also cause learning problems. Children who were younger than age five during treatment may be at higher risk for learning disabilities and should be evaluated after treatment if they're having problems in school or at work.

Heart problems. Drugs called anthracyclines — including doxorubicin, daunorubicin, and idarubicin (Idamycin) — may cause heart problems, such as abnormal heart beat, disease of the heart muscle, and congestive heart failure. In addition, radiation therapy to the chest, spine, or upper abdomen and bone marrow/stem cell transplantation may increase the risk of heart late effects. Women and younger children are at increased risk of heart-related late effects. Survivors of childhood cancer should visit their doctor yearly for follow-up care since heart conditions often have no symptoms. An electrocardiogram (ECG or EKG) and an echocardiogram or multigated acquisition (MUGA) scan—noninvasive tests that check how the heart is functioning — should be done approximately two years after treatment is finished. The Children's Oncology Group (COG) provides clinical guidelines on how frequently a patient should continue to have these tests.

Lung and breathing problems. Certain types of chemotherapy—including bleomycin (Blenoxane), carmustine (Becenum, BiCNU, Carmubris), and lomustine (CeeNU)—may cause lung damage. Chest radiation and surgery to the chest or lungs may also cause lung problems. Children who were younger age at the time of treatment have a greater risk of lung and breathing problems. Childhood cancer survivors should have a chest x-ray and lung function tests done at least two years after treatment has ended. Talk with your doctor about how often these tests need to be repeated.

Teeth and jaw problems. Radiation therapy to the mouth, head, or neck may cause problems such as xerostomia (dry mouth) and cavities. Chemotherapy, especially when given to a child whose adult teeth haven't formed or who is younger than age five, may cause tooth development problems. Childhood cancer survivors should visit their dentist every six months for check-ups and tell the dentist about the cancer treatment they received. Talk with your child's dentist before and after treatment for guidance on reducing these potential late effects.

Digestive system. The gastrointestinal system, which helps digest and absorb food, can be affected by abdominal or pelvic surgery and radiation therapy to the neck, chest, abdomen, or pelvis. Survivors of childhood cancer should talk with their doctor if they experience abdominal pain or chronic (long-term) constipation, diarrhea, heartburn, or nausea and vomiting.

Hearing problems. Radiation therapy to the head or brain may cause hearing loss. Some chemotherapy, such as cisplatin (Platinol) or carboplatin (Paraplat, Paraplatin), may also affect hearing. Younger children are at greater risk for these problems. A child's hearing should be tested annually by an audiologist, a medical professional who identifies, treats, and manages hearing problems.

Vision and eye problems. High doses of radiation to the eye, eye socket, or brain may cause eye problems such as cataracts (a clouding of the eye lens). Radioiodine treatment for thyroid cancer may result in increased tearing, and bone marrow/stem cell transplants increase risk for dry eyes. An ophthalmologist (a doctor who specializes in diseases of the eye) should evaluate childhood cancer survivors.

More Information

Childhood Cancer Survivorship

Managing Late Effects of Childhood Cancer

Managing Side Effects

Additional Resources

Candlelighters Childhood Cancer Foundation: Late Effects

National Cancer Institute: Late Effects of Treatment for Childhood Cancer

Last Updated: October 19, 2011