Mary Baron Nelson

Factors associated with health-related quality of life in pediatric cancer survivors†

Childhood cancer survivors are at risk for late effects of disease and treatment that may be attributed to multiple causes. This study describes health‐related quality of life (HRQOL) in childhood cancer survivors and identifies factors related to poor quality of life outcomes.

Premature carotid artery disease in pediatric cancer survivors treated with neck irradiation.

While carotid artery disease and strokes have been documented in adult cancer patients treated with neck irradiation, little information is available on pediatric patients. The purpose of this study is to determine if carotid disease is more prevalent among pediatric cancer survivors treated with neck irradiation than among healthy controls.

Premature carotid artery disease in long-term survivors of childhood cancer treated with neck irradiation: a series of 5 cases.

Background Follow-up studies find an increase in stroke and carotid artery disease incidence in adult cancer patients treated with neck irradiation. These radiation-related late effects are now being detected in young adult survivors of childhood cancer. Observations This report includes 5 pediatric cancer survivors, ages 23 to 40, who presented with advanced carotid artery stenosis 17 to 36 years after receiving neck irradiation. Radiation doses ranged from 3900 to 7350 cGy. Three of the 5 experienced a stroke. Conclusions Prevalence and risk factors associated with premature carotid artery disease after neck irradiation need to be investigated in childhood cancer survivors.

Recognizing health risks in childhood cancer survivors

Purpose To provide information about the special health needs of childhood cancer survivors through a discussion of Wilms’ tumor, a common childhood renal tumor, and case studies of two survivors of Wilms’ tumor, who encountered significant health problems as adults. This information may be generalized to many cancer survivors. Data sources Actual case studies as well as extensive review of the current literature on childhood cancer survivorship. Conclusions Adult healthcare practitioners may help to decrease morbidity of childhood cancer survivors in adulthood when they are knowledgeable about the risks of this population. Resources are readily available, both in the medical literature and on the Internet. Implications for practice With well‐established success in the treatment of childhood cancer, there are many young and middle‐aged adult survivors of the disease. However, as many as two‐thirds of survivors may have chronic long‐term effects of treatment. Most survivors eventually discontinue follow‐up with their pediatric oncologists and receive primary health care from adult providers, many of whom are unaware of survivors’ health risks. Awareness of primary care providers regarding the special health needs of childhood cancer survivors is critical to decrease morbidity and improve quality of life. The ever‐increasing number of childhood cancer survivors is creating a public health issue as they transition into adulthood.

Diffusion Tensor Imaging and Neurobehavioral Outcome in Children With Brain Tumors Treated With Chemotherapy

Background. Childhood brain tumor survivors (CBTS) often experience treatment-related neurocognitive deficits affecting quality of life (QOL), but systemic chemotherapy contributions to outcomes are unclear. Our objective was to relate brain tissue changes to neurocognitive and QOL effects after systemic myeloablative chemotherapy with autologous hematopoietic progenitor cell rescue in CBTS. Procedure. Regional brain volumes and diffusion tensor indices were correlated with neurocognitive, behavioral, and QOL measures, and compared between 8 CBTS (mean age 8.5 years, mean age at diagnosis 32 months), and 9 healthy controls (mean 9.3 years). Results. Overall QOL, school, and psychosocial functioning were significantly lower in patients (P < .05). Most patients scored within normative ranges on neurocognitive and behavioral assessment. Elevated mean diffusivity and decreased fractional anisotropy, indicating gray and white matter injury, respectively, appeared in memory and executive functioning areas. Low scores on Inhibition on the Neuropsychological Assessment–II were correlated with elevated mean diffusivity in prefrontal cortex. Conclusions. Brain injury, decreased QOL, and to a lesser extent, executive functioning deficits appear in CBTS treated with myeloablative chemotherapy and autologous hematopoietic progenitor cell rescue. Early cognitive and psychological assessment and intervention are warranted in this population.

Changes in Signal Intensity of the Dentate Nucleus and Globus Pallidus in Pediatric Patients: Impact of Brain Irradiation and Presence of Primary Brain Tumors Independent of Linear Gadolinium-based Contrast Agent Administration

Purpose To determine whether whole-brain irradiation, chemotherapy, and primary brain pathologic conditions affect magnetic resonance (MR) imaging signal changes in pediatric patients independent of the administration of gadolinium-based contrast agents (GBCAs). Materials and Methods This institutional review board-approved, HIPAA-compliant study included 144 pediatric patients who underwent intravenous GBCA-enhanced MR imaging examinations (55 patients with primary brain tumors and whole-brain irradiation, 19 with primary brain tumors and chemotherapy only, 52 with primary brain tumors without any treatment, and 18 with neuroblastoma without brain metastatic disease). The signal intensities (SIs) in the globus pallidus (GP), thalamus (T), dentate nucleus (DN), and pons (P) were measured on unenhanced T1-weighted images. GP:T and DN:P SI ratios were compared between groups by using the analysis of variance and were analyzed relative to group, total cumulative number of doses of GBCA, age, and sex by using multivariable linear models. Results DN:P ratio for the radiation therapy group was greater than that for the other groups except for the group of brain tumors treated with chemotherapy (P < .05). The number of GBCA doses was correlated with the DN:P ratio for the nontreated brain tumor group (P < .0001). The radiation therapy-treated brain tumor group demonstrated higher DN:P ratios than the nontreated brain tumor group for number of doses less than or equal to 10 (P < .0001), whereas ratios in the nontreated brain tumor group were higher than those in the radiation therapy-treated brain tumor group for doses greater than 20 (P = .05). The GP:T ratios for the brain tumor groups were greater than that for the neuroblastoma group (P = .01). Conclusion Changes in SI of the DN and GP that are independent of the administration of GBCA occur in patients with brain tumors undergoing brain irradiation, as well as in patients with untreated primary brain tumors.

Pregnancy in a Patient With a Malignant Brain Tumor Taking Temozolomide: Case Report and Review of the Literature.

Temozolomide (TMZ), an alkylating agent used in the treatment of malignant gliomas, is a pregnancy category D medication that is not advised for use in pregnant women. We report the case of a 19-year-old woman with anaplastic oligodendroglioma (high-grade glioma) who became pregnant during maintenance chemotherapy consisting of TMZ 200 mg/m2 administered 5 days monthly. The TMZ was immediately discontinued after she developed a positive pregnancy test. She delivered a full-term healthy baby boy with no prenatal or perinatal complications. Adolescents and young adults with brain tumors are often sexually active and should receive intensive and repeated anticipatory guidance regarding contraception while receiving chemotherapy. Pediatric oncology nurses are in a unique position to provide this education for patients and ensure that young women have appropriate pregnancy testing prior to chemotherapy administration.

The role of the long-term follow-up clinic in discovering new emerging late effects in adult survivors of childhood cancer.

Our understanding of late effects in long-term survivors of childhood cancer is continually evolving as significant numbers of survivors are entering middle to later adulthood. Effects of conventional treatment on premature aging are being recognized, as are long-term effects of newer therapies. Clinicians in long-term follow-up clinics are in a unique position to monitor for recognized late effects and to be alert to signs and symptoms of late effects that have not been previously reported in the pediatric cancer literature. This article presents 2 young adult survivors who displayed subtle signs of impaired cerebral blood flow due to carotid artery stenosis many years after being treated with neck irradiation. When the first patient presented nearly a decade ago in the clinic with symptoms, premature carotid artery disease was not a radiation-related late effect that had been reported previously in survivors of childhood cancer. These cases are used to illustrate the key role of long-term follow-up clinics in identifying new and emerging treatment-related late effects and underscore the importance of lifetime surveillance and the need for collaboration between pediatric and adult health care providers.

The Use of Aromatherapy to Reduce Chemotherapy-Induced Nausea in Children With Cancer: A Randomized, Double-Blind, Placebo-Controlled Trial:

Introduction: Chemotherapy-induced nausea can be distressing and difficult to manage in children with cancer. The purpose of this study was to investigate the utility of ginger aromatherapy in relieving chemotherapy-induced nausea in children with cancer. Method: This randomized, double-blind, placebo-controlled study of 49 children with cancer explored whether inhalation of the aroma of essential oil of ginger during chemotherapy decreased nausea compared with a placebo (water) or control (Johnson’s baby shampoo) measured by prechemotherapy and postchemotherapy assessment with the Pediatric Nausea Assessment Tool (PeNAT). Results: While well received, well tolerated, nontoxic, and noninvasive, ginger aromatherapy did not significantly decrease nausea in patients enrolled in this study. Among 21 patients who indicated feeling nausea prechemotherapy, 67% reported improvement, 5% worsening, and 28% no change in their postinfusion PeNAT score. We failed to detect a statistical significant difference in the change in PeNAT scores among the three groups.