JAMA：幼年癌症幸存者成年慢性疾病发病率高

　　据6月12日发表在《美国医学会杂志》上的一则研究披露，在一项包括了1700多名在儿童时期患过癌症的成年人的分析中，研究人员发现成年后患上一种或一种以上慢性疾病的癌症幸存者占了很高的百分比，估计这些幸存者在45岁时患上任何一种慢性疾病的累计发生率为95%。

　　根据文章的背景资料：“对儿科恶性肿瘤的根治性治疗产生了一个日益增多的成人人群，这些成人曾在七儿童时期患接受癌症治疗，而这些人有着发生健康问题的风险，而且这些风险看来会随着年龄的增加而升高。与癌症有关的毒性作用的发生率还没有得到良好的研究，而这些毒性作用通过正式的临床评估得到了系统性的确定。对得到良好描述的群组所做的持续性的临床评估对增进有关年龄增长对癌症相关性疾病及死亡影响的知识及指导研发健康筛检建议及保健干预是很重要的。”

　　孟菲斯市田纳西大学医学院，St. Jude儿童研究医院的Melissa M. Hudson, M.D.及其同事开展了一项研究，旨在通过系统性综合医学评估来确认在儿童时期患有癌症的长期存活者的一般健康状况，以及确认在接触了具有致病倾向的癌症治疗之后患上治疗并发症的发生率。对健康后果存在的确认所用的是基于对自2007年10月1日以来被纳入到St. Jude Lifetime Cohort Study的1713名成年（年龄中位数[中点]为32岁）儿童时期癌症幸存者（距诊断的中位时间为25年）的系统性接触的医学评估，并对其随访至2012年10月31日。

　　研究人员发现，肺、听觉、心脏、内分泌及神经系统功能受损最为常见（20%或以上的参与者被发现有风险）。粗略的不良健康后果发生率最高的是肺（异常肺功能，占65.2%）、听觉（听觉丧失，占62.1%）、内分泌或生殖（任何内分泌疾病，如下丘脑 - 垂体轴紊乱及男性生殖细胞功能障碍，占62.0%）、心脏（任何心脏疾病，如心瓣膜病，占56.4%），及神经认知（神经认知损害，占48.0%）功能。

　　研究人员指出：“在这一临床评估群组中，98.2%的参与者患有一种慢性疾病。在癌症诊断后，45岁时的慢性疾病总体累计发生率估计为95.5%，在35岁时为93.5%。”在45岁时，严重/致残或威胁生命的慢性疾病的估计累计发生率为80.5%。

　　“总的来说，本研究在一个于儿童时期患有癌症的长期存活者的大型系统性估计的群体中对临床确认的多器官系统致病率提供了一个大体的年龄特异性的估计。在某年轻成年人人群中普遍地患有一或多种慢性疾病的存活者百分比奇高。这些数据对如果没有得到早期发现及治疗而会有显著致病性的情况：如继发性恶性肿瘤及心脏病；以及对那些如果得到纠正可显著改善生活质量的情况：如听力丧失及视觉缺损，都凸显了临床重点监控的必要。”

Clinical Ascertainment of Health Outcomes Among Adults Treated for Childhood Cancer
Importance
Adult survivors of childhood cancer are known to be at risk for treatment-related adverse health outcomes. A large population of survivors has not been evaluated using a comprehensive systematic clinical assessment to determine the prevalence of chronic health conditions.
Objective 
To determine the prevalence of adverse health outcomes and the proportion associated with treatment-related exposures in a large cohort of adult survivors of childhood cancer.
Design, Setting, and Participants 
Presence of health outcomes was ascertained using systematic exposure–based medical assessments among 1713 adult (median age, 32 [range, 18-60] years) survivors of childhood cancer (median time from diagnosis, 25 [range, 10-47] years) enrolled in the St Jude Lifetime Cohort Study since October 1, 2007, and undergoing follow-up through October 31, 2012.
Main Outcomes and Measures 
Age-specific cumulative prevalence of adverse outcomes by organ system.
Results 
Using clinical criteria, the crude prevalence of adverse health outcomes was highest for pulmonary (abnormal pulmonary function, 65.2% [95% CI, 60.4%-69.8%]), auditory (hearing loss, 62.1% [95% CI, 55.8%-68.2%]), endocrine or reproductive (any endocrine condition, such as hypothalamic-pituitary axis disorders and male germ cell dysfunction, 62.0% [95% CI, 59.5%-64.6%]), cardiac (any cardiac condition, such as heart valve disorders, 56.4% [95% CI, 53.5%-59.2%]), and neurocognitive (neurocognitive impairment, 48.0% [95% CI, 44.9%-51.0%]) function, whereas abnormalities involving hepatic (liver dysfunction, 13.0% [95% CI, 10.8%-15.3%]), skeletal (osteoporosis, 9.6% [95% CI, 8.0%-11.5%]), renal (kidney dysfunction, 5.0% [95% CI, 4.0%-6.3%]), and hematopoietic (abnormal blood cell counts, 3.0% [95% CI, 2.1%-3.9%]) function were less common. Among survivors at risk for adverse outcomes following specific cancer treatment modalities, the estimated cumulative prevalence at age 50 years was 21.6% (95% CI, 19.3%-23.9%) for cardiomyopathy, 83.5% (95% CI, 80.2%-86.8%) for heart valve disorder, 81.3% (95% CI, 77.6%-85.0%) for pulmonary dysfunction, 76.8% (95% CI, 73.6%-80.0%) for pituitary dysfunction, 86.5% (95% CI, 82.3%-90.7%) for hearing loss, 31.9% (95% CI, 28.0%-35.8%) for primary ovarian failure, 31.1% (95% CI, 27.3%-34.9%) for Leydig cell failure, and 40.9% (95% CI, 32.0%-49.8%) for breast cancer. At age 45 years, the estimated cumulative prevalence of any chronic health condition was 95.5% (95% CI, 94.8%-98.6%) and 80.5% (95% CI, 73.0%-86.6%) for a serious/disabling or life-threatening chronic condition.
Conclusions and Relevance 
Among adult survivors of childhood cancer, the prevalence of adverse health outcomes was high, and a systematic risk-based medical assessment identified a substantial number of previously undiagnosed problems that are more prevalent in an older population. These findings underscore the importance of ongoing health monitoring for adults who survive childhood cancer.