borderline and subsequently be suited for manual labor or have no job options. Cranial boost irradiation amplifies the risk for cognitive impairment. Hearing loss can contribute to cognitive impairment and is associated with cranial radiation doses ≥30 Gy. Platinum therapy used pretransplant or for HCT conditioning (e.g. high‐risk neuroblastoma) can cause hearing loss accompanied by tinnitus and vertigo (see Table 8.1).
Glucocorticoids can cause a variety of cognitive effects including mood disturbances that can be problematic for patients. Infection with HHV6, HSV, VZV, CMV toxoplasmosis and JC virus generally needs exclusion in cases of post‐HCT cognitive decline. Underlying diseases like FA, DC, Hurler syndrome, ALD, SCID and SCD may have pretransplant neurologic deficits that may stabilize or progress after HCT (see Table 8.1 for screening advice).
Peripheral neuropathy can be a chief complaint for some survivors and etiologies frequently include pre‐HCT neurotoxic chemotherapies like vincristine, platinum agents, or brentuximab, and posttransplant CNI therapy can exacerbate. Management of painful dysesthesias can be difficult but use of gabapentin or pregabalin is often considered.
Psychological and quality of life
Pediatric HCT survivors are at risk for depression, fatigue, pain, social withdrawal, educational problems, vocational problems including unemployment and dependent living (see Table 8.1). They are less likely to report risky health behaviors (alcohol and smoking). Among autologous recipients younger age and current chronic pan were independently associated with greater depression and fatigue and among allogeneic recipients, cGVHD severity, being female, and with current pain were associated with both depression and fatigue [112].
Subsequent neoplasms (SMN)
After autologous HCT, secondary MDS/AML latently arises after DNA‐damaging chemotherapy or radiation exposures to the marrow microenvironment or in the reinfused autologous stem cells. The same may apply in allogeneic HCT if mixed donor chimerism persists and is especially concerning after HCT for WAS, DC, FA, or DBA.
Solid tumors may develop during LTFU and a study of >4900 survivors reported 22% CI of SMN at 30 years (8.1% if < age 20) [113]. This corresponds to a standardized incidence ratio (SIR) of 2.8‐fold higher than the rate for an age‐, sex‐, and calendar‐year matched SEER population; SIRs for children were 15‐fold higher at 1–10 years post‐HCT and 5‐fold higher at >30 years, thus lifetime monitoring is needed. It is noteworthy that the risk for SMN is not significantly different for 2–4.5 Gy TBI compared to chemotherapy only but still 2‐fold higher than the general population. Fractionated TBI 6–14 Gy is associated with higher rates of SMN, higher again for TBI 14.4–17.5 Gy, but not as high as for historical unfractionated TBI 6–10 Gy. The highest excess absolute risks per 1000 patient years were for breast cancer (EAR 2.2) and for oral (EAR 1.5) and skin cancers (EAR 1.5).
Certain heritable pediatric conditions have an increased risk for solid tumors independent of HCT that warrant SMN screening beyond the usual and might require relevant organ‐specific subspecialist consultation (see Table 8.1). Examples are DBA, certain phenotypes of FA, and DC. In patients with Li Fraumeni syndrome, HCT does not correct the underlying germline TP53 mutation and post‐HCT SMN risk is extremely high; cancer surveillance protocols are thus intense [114]; through age 18 years, surveillance focuses on “core” cancers: brain tumors, adrenocortical carcinoma, soft‐tissue sarcomas, bone tumors, and early onset breast cancer.
Multiple melanocytic nevi can develop after high‐dose chemotherapy exposures [115] and are best monitored periodically by a dermatologist with mole mapping. Osteochrondromas may appear incidentally on plain X‐rays after an average of 4.6 years in up to one‐quarter of children who received TBI before age 5 years; they rarely become malignant [116].
Survivorship care plans
Compliance with LTFU guidelines is suboptimal with non‐adherence by survivors and healthcare providers [9,10,117]. Young adults are most at risk, often because routine LTFU attenuates over time, possibly more at risk if their HCP perceives that the patient is doing well. Given the latency of late effects, LTFU requires education of survivors, their families, and also their pediatric and future adult HCPs. The Institute of Medicine has recommended that all survivors receive treatment summaries with individualized care plans [118]. Survivorship care plan usage appears to improve quality of life among HCT survivors [119]. There is inability of transplant centers to provide comprehensive survivorship care. More work is needed to assess the impact of models of survivor care [120, 121]. An ASTCT Practice Guidelines Committee survey found that respondents agreed that allogeneic HCT survivors have needs separate from GVHD, that complications could arise during transitions of care from pediatric to adult or from transplant center to PMD, but 55% did not have an LTFU clinic; 84% of individual practitioners prefer to provide their own survivorship care. Other barriers include a lack of expertise in sub‐specialties relevant to LTFU, logistics of the LTFU model of care, and financial issues [120]. Clearly, there is much more work to be done to optimize LTFU particularly for pediatric HCT survivors who are more prone to becoming lost to follow‐up.
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