Helena Davies

Developing strategies for long term follow up of survivors of childhood cancer

The treatment of childhood cancer has been increasingly successful over the past 30 years. Most paediatric cancers are now curable with multiagent chemotherapy in combination with surgery and radiotherapy. The overall survival five years after diagnosis is now 70% for all paediatric malignancies. The incidence is low (1200-1300 children affected each year in Britain), but with the sustained improvement in survival the number of long term survivors is increasing—about 850 additional survivors of childhood cancer each year. With this improved survival, it is important to increase our knowledge of any long term costs in the form of physical and psychosocial adverse health outcomes. This review looks at the evidence relating to long term clinical follow up after childhood cancer and considers ways to develop such follow up for the future. An awareness of the possible long term complications is important not only for optimising health care for the current survivors but also for modifying future treatment protocols to avoid therapies that are associated with unacceptable morbidity or mortality. We have summarised the evidence on selected long term complications; this evidence is inevitably based on retrospective studies. In the final section we discuss the development of a strategy for the clinical follow up of long term survivors. #### Summary points Long term follow up strategies are needed because of increasing numbers of survivors of childhood cancers Models for follow up need to be developed and formally evaluated Increasing numbers of survivors may have medical problems that will require ongoing specialist follow up The role, training programmes, and career structure of the late effects nurse practitioner needs to be developed The primary care physician may have an important role in long term follow up There is a need for prospective evaluation of new treatments and randomised studies of clinical interventions to resolve substantial uncertainties for …

Generalisability: a key to unlock professional assessment

Context  Reliability is defined as the extent to which a result reflects all possible measurements of the same construct. It is an essential measurement characteristic. Unfortunately, there are few objective tests for the most important aspects of the professional role because they are complex and intangible. In addition, professional performance varies markedly from setting to setting and case to case. Both these factors threaten reliability.

Male sex and low physical activity are associated with reduced spine bone mineral density in survivors of childhood acute lymphoblastic leukemia.

Survivors of acute lymphoblastic leukemia (ALL) are at risk of osteoporosis and obesity. We studied bone mineral density (BMD), percent of fat mass (%FM), and activity levels in survivors of ALL treated without radiotherapy. Lumbar and total areal BMD (g/cm2) and %FM were measured in 28 survivors (aged 5.7‐14.7 years) of childhood ALL by dual‐energy X‐ray absorptiometry (DXA) scan (GE Lunar, Prodigy) an average of 5 years after completion of chemotherapy (UK Medical Research Council randomized trial protocol XI [UKALL XI]). One boy fractured his arm during treatment. Apparent volumetric lumbar BMD (BMD vol; g/cm3) was calculated and %FM was adjusted for sex and age (%FM adj). Physical activity was measured by accelerometer and questionnaire. The results were compared with 28 sex‐ and age‐matched healthy controls. Total body and lumbar areal BMD (g/cm2) were not different between the ALL group and the control group. However, mean lumbar BMD vol in survivors of ALL was significantly lower than in controls (0.303 ± 0.036 g/cm3 vs. 0.323 ± 0.03 g/cm3; p < 0.01), which mostly was caused by the difference in boys (0.287 ± 0.032 g/cm3 vs. 0.312 ± 0.027 g/cm3; p < 0.05). Weekly activity score by questionnaire was significantly lower in the ALL group than in the control group (geometric mean 50 vs. geometric mean 74; p < 0.05). Male gender, low activity levels and an intravenous (iv) high dose of methotrexate were associated with low lumbar BMD vol. Patients who received an iv high dose of methotrexate (n = 18) had significantly higher %FM adj than those with intrathecal methotrexate only (n = 10; 141 ± 70% vs. 98 ± 37%; p < 0.05). In conclusion, male survivors of childhood ALL have reduced lumbar BMD vol, whereas no such difference was seen in girls. Overall, survivors of ALL were physically less active than their healthy controls and lower activity correlated with lower lumbar BMD vol and higher %FM adj.

Selecting performance assessment methods for experienced physicians

Background  While much is now known about how to assess the competence of medical practitioners in a controlled environment, less is known about how to measure the performance in practice of experienced doctors working in their own environments. The performance of doctors depends increasingly on how well they function in teams and how well the health care system around them functions.

Doctors' consultations with children and their parents: a model of competencies, outcomes and confounding influences

Context  The clinical consultation is an important aspect of the doctors role. However, there is a particular shortage of methods for assessing its quality, and its complexity makes it a considerable assessment challenge.

Leptomeningeal melanoma in childhood

Malignant melanoma (MM) is one of the least common types of childhood cancer, accounting for less than 1% of all pediatric malignancies. Neurocutaneous melanosis (NCM) is a rare phakomatosis consisting of congenital abnormal pigmentation of the skin and meninges. The meningeal lesions are particularly prone to malignant change.

Initial evaluation of the first year of the Foundation Assessment Programme

Objectives  This study represents an initial evaluation of the first year (F1) of the Foundation Assessment Programme (FAP), in line with Postgraduate Medical Education and Training Board (PMETB) assessment principles.

Pubertal growth in young adult survivors of childhood leukemia.

PURPOSE To determine the effect of cranial irradiation (18 Gy and 24 Gy) on pubertal growth in young adult survivors of childhood acute lymphoblastic leukemia (ALL). PATIENTS AND METHODS Final height (FH) and pubertal growth were retrospectively examined in 142 young adult survivors of childhood ALL. All were in first remission and had received either 18 or 24 Gy of cranial irradiation. Eighty-four children (48 girls) were treated with 24 Gy and 58 (35 girls) with 18 Gy. None had received either testicular or spinal irradiation. Timing and duration of puberty were studied in 110 patients. RESULTS Significant reduction in height standard deviation score (SDS) from diagnosis to FH was seen in both sexes and in both dose groups. In girls, in both dose groups, mean age at peak height velocity (PHV) and mean age at menarche occurred significantly earlier than in the normal population. In boys, there was a normal timing of PHV. The amplitude of PHV was significantly reduced in both sexes and in both dose groups. Parameters of pubertal duration (PHV to menarche, PHV to FH, and menarche to FH) were not significantly different from normal population values. CONCLUSION In conclusion, puberty occurred early in girls, but not in boys. Amplitude of PHV was reduced in both sexes, with no reduction in the duration of puberty. It is likely that disturbances of both timing and quality of growth during puberty contribute to the loss of standing height and body disproportion seen in these children.

Sheffield Assessment Instrument for Letters (SAIL): performance assessment using outpatient letters

Well‐designed assessments of performance are urgently required for training doctors, and to provide indicators of the quality of practice.

Multi source feedback: development and practical aspects

M ulti source feedback (MSF) is a means of assessment based on collated questionnaires from a range of co-workers and may also include patient feedback. Alternative terminology includes peer assessment, peer review or ratings and 360-degree feedback. There is a body of evidence that supports its use in a medical setting, particularly from the US and Canada and 360-degree feedback has been widely used in industry for many years. In the UK, MSF is becoming an established part of work-place based assessment for doctors in training (i.e. to inform Records of In Training Assessments (RITAs)) and as part of the evidence collected to support consultant appraisal (and potentially revalidation). Used effectively MSF has the potential to generate structured feedback, which informs educational planning by building on strengths and identifying areas for development. Sheffield Peer Review Assessment Tool (SPRAT) is an MSF tool mapped explicitly to Good Medical Practice (GMP) that is being used in a number of settings as part of overall workplace based assessment systems and also to inform consultant appraisal.