• Coronary Artery Disease : Coronary artery dis - ease (CAD) typically begins to develop about 10 years post cessation of treatment. By age 50, the cumulative incidence of CAD is about seven times that of their cancer-free siblings. Subsequent myocardial infarction increased. • Stroke : Those who received cranial radiation had an incidence of stroke eight times that of their cancer-free siblings. Overall, the incidence of stroke was 12% at a 30-year follow-up. Pulmonary Disease • Pulmonary Disease : About 16% of survivors developed restrictive lung disease and intersti- tial fibrosis with a reduced vital capacity after a follow-up of 24 years. Both chest radiation and chemotherapy were causative. Cognitive Impairment • Cognitive Impairment : Cranial radiation was causative for cognitive impairment in more than 20% of survivors at a 24-year follow-up. This usually presents with mild cognitive impairment (MCI) and can progress to more severe impair - ment of function as the person ages. Chemo brain is a cognitive impairing complication of chemotherapy. This is due to the effect of chemo - therapeutic agents, which are directly toxic to the brain. It can manifest during or after completion of treatment, initially presenting with loss of ex- ecutive cerebral function, and often irreversibly progressing to a mental state indistinguishable from Alzheimer’s disease. 7 Summary Unfortunately, cure of childhood cancer comes with the price of future, multisystem complications later in life. Despite the ominous list of complications discussed, these survivors are insurable. Doubtful any should ever be preferred risks due to long-term, unforeseen complications. The underwriter needs to be aware of these potential complications and evalu- ate the attending physician’s statement for evidence of their presence or potential for future development. Notes 1. Bhatia S et al. Clinical Care for People Who Survive Childhood Cancer- A Review, JAMA , Vol 330, September 2023. Pages 1175-1186. 2. Yeh J et al. Life Expectancy of Adult Survivors of Childhood Cancer Over 3 Decades, JAMA Oncology , 6(3), 2020, pages 350-257. 3. European Society of Medical Oncology , Dec 2017. 4. Hashmi S. Cancer Survivors Have Shorter Life Spans, News of Medical Sciences , Dec 2017. 5. Hurria A et al. Cancer Treatment as an Accelerated Aging Process: As - sessment, Biomarkers, and Interventions, American Society of Clinical Oncology , Book Vol 36, 2016, e516-522. 6. Bhaita R et al. Do Cancer and Cancer Treatments Accelerate Aging? Curr Oncol Rep , 24(11), 2022, pages 1401-1412. 7. K. What Is Chemo Brain and How Long Does It Last?, OSF Healthcare , Feb 2023.
are the type of tumor, age, and treatment used and duration of therapy. The following is a summary of long-term complica- tions post treatment: 1 Cancers • Breast Cancer : Radiation to the chest connotes a higher risk for breast cancer; the younger the age of administration, the greater the risk. The excess risk is nearly double the expected rate af- ter a 20-year follow-up. Of those who developed cancer, 18% had bilateral disease. By age 55, the cumulative incidence of breast cancer was 18%. Post-radiation cancers have a worse outcome than those arising spontaneously. Treatment with chemotherapy also induced a four times greater risk of breast cancer. The risk of breast cancer was decreased by concomitant ovarian radia- tion with cessation of ovarian function. Current recommendations recommend all women treated with chest radiation and/or chemotherapy have yearly mammograms beginning at age 25. • Thyroid Cancer : The excess risk of thyroid can - cer is about one and one-half times greater than expected. The median time for development is about 20 years post treatment. Fortunately, most of these cancers are papillary, which has the most favorable prognosis of thyroid cancers. • Sarcomas : Those treated with either radiation or chemotherapy have an excess risk for the de- velopment of a tissue sarcoma of about 16 times expected. These tumors tend to be aggressive with a poor prognosis. • Colorectal Cancer : Development of colorectal cancer post treatment is about four times ex- pected with the median time of development of about 25 years. Cardiovascular Disease • Cardiomyopathy : Several chemotherapeutic medications are directly cardiotoxic with both acute and long-term effects. The end point of a cardiomyopathy is congestive heart failure. At a mean age of 27, the prevalence of symptomatic cardiomyopathy or congestive heart failure was 16%, and 50% had asymptomatic, diminished cardiac function (i.e., lower ejection fraction). • Valvular and Pericardial Disease : The incidence of each of these was increased in those who re- ceived chest radiation. • Atherosclerosis : Incidence is directly related to the areas of radiation such as chest and head. Risk factors such as hypertension, dyslipidemia and diabetes were all elevated in survivors of a childhood cancer.
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