Childhood Cancer: Late Effects of Cancer Treatment

What are late effects?

Today, because of advances in treatment, about 8 out of 10 children treated for cancer survive at least 5 years, and most of these children are cured. But the treatments that allow these children to live can also cause health problems.

Most side effects appear during or just after treatment and go away a short time later. But some problems may not go away or may not show up until months or years after treatment. These problems are called late effects. Because childhood cancer survivors are living longer, their long-term health and these late effects have become a focus of care and research.

Just as the treatment of childhood cancer requires a very specialized approach, so does aftercare and watching for late effects. Late effects can involve more than one part of the body (or more than one organ system) and can range from mild to severe.

Careful follow-up after cancer treatment allows doctors to find and treat the late effects as early as possible. The follow-up schedule depends on the type of cancer the child had, the treatments used, and the risk of late effects from those treatments.

Who is at risk for late effects?

Each child getting cancer treatment is unique. And the treatments used vary from child to child and from one type of cancer to another. Late effects will also vary, and depend mostly on the type of treatment used and the doses given. Other things that can affect a child's risk include:

• The type of cancer
• Where the cancer was in the body
• How old the child was when treated
• The child's overall health before the cancer
• The child's genetic make-up (inherited risk for certain health problems)

What causes late effects?

Most late effects are caused by chemotherapy or radiation. Major surgery may also lead to late effects, but this is less common. Late effects are caused by the damage that cancer treatment causes to healthy cells in the body. Cancer treatments like radiation therapy, chemotherapy, or stem cell transplants kill cells that grow quickly, such as cancer cells. But in a child, many healthy cells in organs throughout the body are growing fast, too. Treatment can damage these cells and keep them from growing and developing the way they should.

Healthy cells that aren't fed the way they should be, ongoing cell injury, death of healthy cells, and scar tissue formation may all be causes of late effects.

Chemotherapy

Chemotherapy (often called “chemo”) drugs kill cancer cells. But they damage normal cells, too, which can cause short-term and long-term side effects. These side effects depend on the type and dose of drugs, as well as how often and how long they are given. For example, side effects are likely to be more severe with high-dose chemotherapy followed by a stem cell transplant.

Chemotherapy drugs attack cells that are quickly growing and dividing. The drugs work because cancer cells grow and divide faster than most normal cells. But some normal cells also divide quickly, such as the cells in the bone marrow that make new blood cells, the cells lining the inside of the mouth and stomach, and the hair follicle cells. These dividing cells are the ones most damaged by chemotherapy. This may cause side effects during treatment, such as low blood cell counts, nausea, diarrhea, or hair loss. These short-term side effects usually go away over time after treatment is over.

Late effects, on the other hand, may happen many years later. A child's whole body is growing. This means that many different kinds of healthy, normal cells are dividing faster than they would be in an adult. Some types of chemotherapy can damage these cells and keep them from growing and developing the way they should.

Radiation therapy

Radiation treatment uses high-energy rays (such as x-rays) to kill cancer cells and shrink tumors. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly into or next to the tumor (internal or implant radiation). Radiation treatment may be used to reduce the size of a cancer before surgery, kill any cancer cells that may be left behind after surgery, or, in some cases it may be the main treatment. As with chemotherapy, radiation therapy can affect normal cells as well as cancer cells.

A child's risk of late effects from radiation depends on a number of factors, including:

• The dose of radiation. Higher doses are often linked to greater risk.
• The area of the body that is being treated. Some organs and parts of the body are more likely to be affected by radiation than others.
• The child's age. Younger children's bodies tend to be more sensitive to the effects of radiation.
• The child's genetic makeup. Some children may be at greater risk for side effects. For example, the bodies of children with the hereditary form of retinoblastoma (an eye cancer) are more sensitive to the effects of radiation.

Surgery

Surgery is an important part of treatment for many cancers. As with other types of treatment, the possible long-term effects of surgery depend on a number of different factors.

The type of cancer and its location in the body help determine the extent of the surgery needed. In some cases, surgery may be fairly minor and may leave nothing more than a scar. Other situations may need to be more extensive and require removing part or all of an organ, or even a limb. Doctors do their best to limit the effects of surgery by striking a balance between ensuring all of the cancer is taken out and removing as little healthy body tissue as possible.

The child's age can also be important. Younger children, whose bodies are still growing quickly, may be more affected by some operations than older children who are already at or near their full body size.

Treatment effects on certain parts of the body

Below are some of the more common possible late effects of cancer treatment. This is by no means a complete list. Depending on the type of treatment and other factors, other long-term effects can occur as well. If your child is being treated for cancer or if you were treated as a child, it's important to speak with the health care team to learn more about the possible late effects based on the specifics of your situation.

Brain

Some treatments may be used for tumors in the brain or to try to prevent cancer from spreading there. Children who are most likely to have late effects in the brain are those with brain tumors or with acute lymphocytic leukemia (ALL), but children with other cancers may be affected as well. Treatments that can affect the brain include surgery, radiation therapy, and chemotherapy.

Normal brain cells grow quickly in the first several years of life, making them very sensitive to radiation. This is why doctors try to avoid using radiation therapy to the head or to postpone it in children younger than 3 years old to limit damage that might affect brain development. But even in older children, radiation may cause problems such as learning disabilities. Doctors try to use as little radiation as possible, but this needs to be balanced with the risk of the cancer growing or returning, as radiation therapy may be lifesaving in some cases.

Some types of chemotherapy, given either into a vein (intravenous, or IV chemo) or directly into the spinal column (intrathecal chemo), can also cause learning disabilities in children. These problems are more common if higher doses of certain chemotherapy drugs are used, and if the child is younger at the time of treatment. Learning disabilities are more common in children who get both chemo and radiation to the brain.

The learning problems, often called cognitive impairments, usually show up within a few years of treatment. They may be seen as:

• Lower IQ scores, which can vary depending on how intense the treatment is
• Lower academic achievement test scores
• Problems in memory and attention
• Poor hand-eye coordination
• Slowed development over time
• Behavior problems

Non-verbal skills like math are more likely to be affected than language skills like reading or spelling, but nearly any area of brain development can be affected.

Other late effects that may show up, depending on the type of treatment used, include things like seizures and headaches. Treatments that affect the brain can also lead to other effects in the body. For example, radiation therapy can also affect the pituitary gland, which is found at the base of the brain. Symptoms of pituitary problems can include fatigue, listlessness, poor appetite, cold intolerance, and constipation, which may point to low levels of certain hormones. Other problems can include delayed growth and/or sexual maturation, which are described below.

Eyesight

Cancer treatment can affect vision in a number of ways, and is more likely if the tumor was in or near the eye. Vision problems after treatment are most common with retinoblastomas, which are childhood cancers that start in the back of the eye. In many cases, the vision in the eye has already been destroyed by the tumor at the time of diagnosis. Surgery may be needed to remove the affected eye. If this is done, an artificial eye is put in to take the place of the eyeball.

Radiation therapy to the eye can sometimes damage inner parts of the eye, which can lead to vision problems. Radiation in the area of the eye can also sometimes cause cataracts (clouding of the lens of the eye) over time. Radiation treatment to the bones near the eye may also slow bone growth, which can change the shape of the child's face as it grows.

Certain chemo drugs can be toxic to the eye and may lead to problems like blurred vision, double vision, and glaucoma. Many times, these effects go away over time.

Children who have had a stem cell transplant may be at higher risk for some eye problems if they develop chronic graft-versus-host-disease. This is a condition in which the new immune system attacks cells in the eye.

Other late effects on the eye may include:

• Dry eye
• Watery eye
• Eye irritation (feels like something is in the eye)
• Discolored sclera (white part of the eye may be a different color)
• Poor vision
• Light sensitivity
• Poor night vision
• Tumors on the eyelid
• Drooping eyelid

Your child's vision will be checked during treatment so that, if possible, the treatment plan can be changed if there are signs of vision loss. After treatment, eye exams will be done regularly to help find problems. Over time, treatments such as cataract removal or eyeglasses may be needed.

Hearing

Certain chemo drugs and antibiotics may cause hearing loss (especially with high-pitched sounds). Radiation given to the brain or ear can also lead to hearing loss, as can surgery in these areas. This risk may be increased in children who are young at the time of treatment. Other late effects may include:

• Ringing in the ears
• Trouble hearing words when background noise levels are high
• Dizziness
• Hard, crusty earwax

If your child is getting treatment that may affect hearing, the cancer care team will likely check your child's hearing during treatment. This may allow for early changes in treatment if hearing loss becomes a concern.

After treatment, regular hearing tests will help find any problems. It is important to find and address any hearing issues as soon as possible. Younger children with hearing loss may have problems with language development. Older children may have problems in school or in social situations. Some children might need hearing aids or may need to use other resources to help them communicate effectively.

Growth and development

Slowed growth during childhood cancer treatment is a common problem. A certain amount of catch-up growth may occur after treatment, but in some children, short stature (height) is permanent.

Chemotherapy may contribute to a slow-down in growth. When chemo is given alone, without radiation, the change in growth rate is most often short-term. Over time many patients catch up to a normal growth pattern after treatment. But certain chemotherapy drugs, when given in high enough doses, have more lasting effects. And some of the long-term effects of intensive chemotherapy without radiation are still unclear.

Many of the late effects on growth and development are linked to radiation therapy. Radiation has a direct effect on the growth of bones that are in the area that is being treated (see "Muscle and bone").

Radiation (and sometimes surgery) in the head and neck area can also affect overall growth and development in the body. Treating this area can damage the pituitary gland, which is the main gland of the endocrine system.

The endocrine system is a group of glands that help regulate many important body functions, including growth, metabolism, puberty, and responses to stress. Endocrine glands include the pituitary, thyroid, adrenals, testicles (in boys), and ovaries (in girls). These glands work by releasing hormones into the bloodstream, which can then affect cells throughout the body. For example, the pituitary releases growth hormone, which stimulates body growth in children. Hormones from the ovaries and testicles affect sexual maturation and fertility.

The hormone changes that result from damage to endocrine glands such as the pituitary can slow the child's growth, and may affect bones, height, and full maturity. Again, very young children are most likely to be affected. The slowing of growth is usually seen within 5 years of treatment.

Treatment with growth hormone may reverse some of these effects if the pituitary gland is damaged. But growth hormone treatment has its own risks. The choice to use growth hormone replacement should be made with your child's doctor, and you should fully discuss its possible side effects.

Thyroid

The thyroid gland, found at the base of the neck, is an important part of the endocrine system. Hormones from the thyroid affect growth and development in children, as well as help regulate the body's metabolism.

Thyroid function may be affected by radiation therapy or surgery in the head and neck area, or by total body irradiation, which may be used as part of a stem cell transplant. Treatments may damage the thyroid directly, or they may damage the pituitary, which in turn affects thyroid function.

Low thyroid function (hypothyroidism) occurs when the thyroid no longer makes enough thyroid hormone. It can cause extreme tiredness, dry skin, unexplained weight gain, constipation, slowed bone growth, and thinning hair. Thyroid hormone replacement can be given in the form of daily pills, if needed.

An overactive thyroid (hyperthyroidism), is less likely, but it can happen. Signs of this include nervousness, weight loss, trouble sleeping, diarrhea, and enlarged thyroid gland (goiter). If treatment is needed, radiation or surgery may be used to lower thyroid hormone levels.

Regular thyroid blood tests can help detect these problems early, often before symptoms appear. Testing may be needed for more than 10 years after radiation treatment. In fact, thyroid problems have been found more than 20 years after treatment.

Muscle and bone

Radiation treatment can have serious effects on the proper growth of bone and muscle in young people. Very young children have a lot of growing to do, and radiation can slow the growth of any given area. Bones, soft tissue, muscle, and blood vessels are very sensitive to radiation during times of rapid growth. Young children and children going through a growth spurt at puberty are at great risk for late effects.

Along with stunted bone growth, other late effects related to bone and muscle can include:

• Unequal growth of body parts (the treated side doesn't grow the same way as the untreated side)
• Bone pain
• Joint stiffness
• Gait changes (changes in the way the child walks)
• Weak bones that can break easily (osteoporosis)
• Decreased calcium in the bones

Surgery for some types of childhood cancers can have obvious effects on muscle and bone growth in certain parts of the body. This is most likely with cancers that start in bones (such as osteosarcomas or Ewing tumors) or muscles (such as rhabdomyosarcomas).

Some problems in bone growth can be due to damage to the endocrine system (see the section "Growth and development," above).

Sexual development and fertility

Males

In males, the testicles have 2 main functions. They make male hormones (such as testosterone), which influence sexual development and help the body maintain bone and muscle strength. The testicles also make sperm, which are needed to father children.

Both radiation therapy and chemo can reduce sperm production and may also affect sexual development. In general, the cells in the testicles that make sperm are more likely to be damaged by cancer treatments than are the cells that make hormones. The effects may be short-term or permanent, depending on the intensity of the treatment.

Radiation therapy aimed at the testicles can affect sperm-producing cells. It may also damage the cells that make hormones if given at higher doses. Radiation aimed at structures in the abdomen (belly) or pelvis may also have this effect. In some cases the testicles may be shielded or moved out of the radiation field during treatment to try to prevent this.

Sex hormone levels in the body are also influenced by the pituitary gland, so radiation therapy to the head area can affect these as well.

High doses of certain chemotherapy drugs are more likely to affect the cells that make sperm, but very high doses can also affect the cells that make hormones.

Treatments that affect sperm production can alter the patient's ability to father children. For some, this may be only temporary, but for others it may be long lasting or even permanent. It is important to think about this before starting cancer treatment in the older child. For boys who have gone through puberty, sperm banking (collecting and freezing sperm samples) may be an option that can allow them to father children later in life. This is less of a risk in young males who are treated before puberty.

The effects of treatments that alter testosterone levels can include failure to complete puberty, delayed or accelerated puberty, decreased sexual desire, and impotence (being unable to get and keep an erection). Doctors may prescribe testosterone in the form of injections, patches, or gels applied to the skin to help treat this.

Females

In females, organs important for sexual development and pregnancy include the ovaries and the uterus (womb). The ovaries, which are in the lower abdomen, make female hormones (such as estrogen and progesterone). These hormones influence sexual development (including menstrual periods and fertility) and play a major role in keeping the heart, bones, and other parts of the body healthy. The ovaries also contain eggs (ova), which are needed to have children. The uterus serves as a place for babies to grow during pregnancy. Either of these organs can be affected by cancer treatments.

The ovaries can be affected by both chemotherapy and radiation therapy. For parents, it's important to discuss the possible long-term effects with your child's health care team before treatment. The degree of problems mostly depends on the intensity of treatment and the girl's age and stage of puberty at the time of treatment. Girls who have not yet been through puberty are less affected. Protecting the ovaries is a major concern when treating the nearby areas with radiation.

Radiation treatment to the abdomen or pelvis can directly damage the ovaries. Radiation to the head can also affect the pituitary gland, which in turn can interfere with the hormones needed for the ovaries to work as they should.

High doses of certain chemotherapy drugs can damage the ovaries. In girls who are already menstruating, this can cause a stoppage of menstrual periods, which may be temporary or more long lasting. Other chemo drugs (or lower doses of chemo) may not cause problems.

Girls who get treatments that affect the ovaries are at risk for early or delayed puberty and start of menstruation, irregular menstrual periods, early menopause, and reduced fertility, as well as other health problems. Doctors may recommend hormone replacement therapy to help with some of these issues if they remain after cancer treatment.

The uterus can be affected, too, especially if radiation is given to the abdomen. Late affects can include a uterus that is smaller than normal or which may not stretch as it should. This can increase the risk of miscarriage, low birth-weight babies, and premature birth.

Reproduction

Many survivors of childhood cancer may be concerned about their ability to have a child. Most survivors of childhood cancer can go on to have healthy children, though there may be some risks.

Some men who were treated for cancer as children may have decreased fertility. In women, problems that could affect fertility include irregular menstrual periods, early menopause, changes in the uterus, and other treatment-related issues that could affect pregnancy outcomes. The causes of some of these problems are discussed above. Problems can vary greatly from patient to patient, and careful monitoring for any problems both during and after treatment is important.

For some who are treated for cancer as children, there may be ways to help preserve fertility or increase the chances of having their own children later in life. As mentioned above, sperm banking before treatment may be an option for some older boys. Some women who want to have children may be encouraged to try and get pregnant early in their childbearing years to improve the chances of success. Researchers are also studying newer ways of preserving or restoring fertility in children who were treated for cancer. For more information about some of these approaches, see our document, Fertility and Cancer. It has more on reproductive options and a section on children with cancer.

Studies continue to look at the possible risk of congenital (inborn) abnormalities in the children of cancer survivors. Most studies thus far have not shown a link, but treatments given today may use different drugs or doses not yet proven safe to future offspring.

Heart/cardiovascular system

Heart disease can be a serious late effect of certain cancer treatments. The actual damage to the heart may occur during treatment, but the effects may not show up until many years, or even decades later.

A class of chemotherapy drugs called anthracyclines, which are used to treat many childhood cancers, can damage the heart muscle or affect its rhythm. The amount of damage is related to the total dose of the drug given and child's age at the time of treatment. Doctors try to limit the doses of these drugs as much as possible while still giving high enough doses to treat the cancer effectively. Studies are now being done to see if certain drugs shown to help protect the heart in adults during anthracycline chemotherapy may also help children.

Radiation therapy to the chest or spine, or in the form of total body irradiation can also damage the heart muscle or cause problems with its rhythm. Radiation can also damage the heart valves or the blood vessels (coronary arteries) that supply the heart muscle with oxygen. The total dose and type of radiation and the age of the patient at the time of treatment affect this risk.

Most people who get these treatments do not develop significant heart problems. This is especially true in children being treated today, as modern approaches have reduced treatment doses and lowered the risk. Problems are more likely in people who received more intensive treatment, but doctors can't always predict who will or won't have problems. When these treatments do affect the heart, the damage does not usually show up right away, but it may raise the risk of heart problems later in life.

Careful monitoring for heart problems is very important in the years after treatment because often there are no symptoms. Special tests, such as an echocardiogram (an ultrasound of the heart), can help show hidden problems. With routine physical exams and testing, heart problems may be found early and treated, if necessary.

Heart disease remains one of the leading killers among all Americans, so doing things to help keep the heart healthy – like not smoking, maintaining a healthy weight, eating well, and getting regular physical activity – is important for everyone. But it is especially important in people treated for childhood cancers. Some people may need to be careful with certain physical activities, so talk with your doctor first if you are planning on starting an exercise program or increasing your current level of activity.

Lungs

Certain cancer treatments can affect the lungs.

Lung problems can occur in children who have had radiation therapy to the chest or total body irradiation. The risk of problems depends on the dose of radiation, the amount of lungs that get radiation, and the age of the patient. The use of certain chemotherapy drugs at the time of radiation may also increase the risk. Possible late effects include:

• Decreased lung volume (lungs can't hold as much air)
• Shortness of breath, which may be worse with exercise
• Chronic (ongoing) dry cough
• Lung tissue that becomes scarred and thickened (called pulmonary fibrosis), which may limit the lungs' ability to expand
• Inflamed lung tissue, which can cause trouble breathing (called pneumonitis)
• Increased risk of lung infections
• Increased risk for lung cancer later in life

Certain chemo drugs, such as bleomycin, may also cause lung problems, especially fibrosis and pneumonitis. The risk of problems increases with higher drug doses.

Some people who get these treatments may have no noticeable symptoms, but for others, problems may start as soon as within the first 1 to 2 years after treatment.

People who have received these treatments need careful follow-up with a doctor, especially during the first few years after treatment. Special tests such as chest x-rays or pulmonary function tests may be done on a regular basis in those with strong risk factors. For some, seeing a pulmonologist (lung doctor) may be helpful.

Keeping the lungs healthy is important for everyone, but it is especially important in people who have received these treatments for childhood cancers. The best way to help keep the lungs healthy is to avoid smoking or being around tobacco smoke. If you do smoke and want help quitting, call the American Cancer Society at 1-800-227-2345.

Teeth

Chemotherapy or radiation therapy in an area that involves the teeth and jaw can lead to late effects, mostly in children who are treated before age 5. But older children may have problems too. Late effects of these treatments can include:

• Small teeth
• Missing teeth or delayed tooth development
• Tooth enamel is not normal (teeth may be discolored or not have a normal shape)
• Increased risk of cavities
• Roots of teeth are shorter than they should be, which can lead to early loss of teeth

Radiation in the area around the mouth can also affect the salivary glands, which can lead to decreased saliva and dry mouth. This can cause tooth decay and gum disease.

Regular dental exams are important to find problems early and reduce the risk of infection, decay, and tooth loss.

Second cancers

Childhood cancer survivors have a small increase in risk of developing a second cancer during their lifetime. This risk is not the same for all survivors. Many factors affect risk, such as the type of the first cancer, type of treatments given, child's age at the time of treatment, and genetics. For example, those survivors who had radiation treatment tend to show a higher risk of second cancers in the areas that were treated. You can get more information on this in our document, Second Cancers Caused by Cancer Treatment.

As childhood cancer survivors live longer into adulthood, they are also at higher risk of developing other cancers usually seen in adults, such as prostate, breast, or colon cancer. As these children grow up and age, things like genetics, diet, activity level, overall health, body weight, exposure to viruses, and environmental exposures all play a part in their cancer risk.

It is important to remember and keep detailed records of the cancer treatments that were used during childhood. Sharing this information can help people and their doctors decide what tests they might need to help find certain cancers early, when treatment is most likely to be effective.

Emotional issues

Emotional issues may come up, too, and can affect all levels of maturity. As with other late effects, factors such as the child's age at diagnosis and the extent of treatment may play a role here.

During treatment, families tend to focus on the daily aspects of getting through it and beating the cancer. But once treatment is finished, a number of emotional concerns may arise. Some of these may last a long time. They can include things like:

• Dealing with physical changes that result from the cancer or its treatment
• Worries about the cancer returning or new health problems developing
• Feelings of resentment for having had cancer or having to go through treatment when others do not
• Concerns about being treated differently or discriminated against (by friends, classmates, coworkers, employers, etc.)
• Concerns about dating, marrying, and having a family later in life

No one would choose to have cancer, but for many childhood cancer survivors, the experience can eventually be a positive one, allowing for clearer setting of priorities and helping to establish strong self-values. Other survivors may have a harder time recovering, adjusting to life after cancer, and moving on. It is normal to have some anxiety or other emotional reactions after treatment, but feeling overly worried, depressed, or angry can affect many aspects of a young person's growth. It can get in the way of relationships, school, work, and other aspects of life. With support from family, other survivors, mental health professionals, and others, many people who have survived cancer can thrive in spite of the challenges they've had to face.

Long-term follow-up guidelines

In an effort to increase awareness of late effects and improve follow-up care of childhood cancer survivors throughout their lives, the Children's Oncology Group has developed long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. These guidelines can help you know what to watch for, what type of screening should be done, and how late effects may be treated. You can learn more about the guidelines and download them for free at the CureSearch Web site: www.survivorshipguidelines.org. The guidelines are written for health care professionals. There are patient versions of some of the guidelines available as well (as "Health Links") on the site as well, but we urge you to review them with a doctor.

Follow-up is key

After treatment, the main concerns for most families are the immediate and long-term effects of the cancer and its treatment, and concerns about possible cancer recurrence. It is certainly understandable to want to put the cancer and its treatment behind you and to get back to a life that doesn't revolve around cancer. But it's important to realize that follow-up care is a central part of this process that offers the best chance for recovery and long-term survival.

For many years after treatment of childhood cancer, regular follow-up exams will be very important. The doctors will watch for signs that the cancer has come back, as well as for short-term and long-term effects of treatment. These effects vary with each patient and with each type of treatment.

For the rest of the childhood cancer survivor's life, doctors should watch for things like pain, tiredness, and anxiety, as well as other possible signs of late effects. Physical and emotional effects may linger.

For parents, it is important to know what kind of treatment your child had and what impact this treatment might have on his life as he grows up. Ask your child's doctor to help you stay aware of what long-term effects might occur based on the treatments your child had. And be sure your adult child knows the details of his childhood cancer so he can share that information with his doctors. If you do not have a copy of this information, contact the doctor who treated the child. If treatment was given at a hospital or clinic, you will need to contact them, too. These records are usually destroyed at some point, and may not be available more than a few years after treatment. There are certain pieces of information that you and your child should have, even into adulthood, including:

• A copy of the pathology report from any biopsies or surgeries.
• If there was surgery, a copy of the operative report(s).
• If there were hospitalizations, a copy of the discharge summaries doctors prepare when patients are sent home.
• If there was chemotherapy treatment for the cancer, a list of the final doses of each drug. Certain drugs may have specific long-term side effects. If you can get a list of these from the pediatric oncologist, it might help any new doctors your child has.
• If there was radiation therapy, a final summary of the dose and field.

For all survivors, while late effects may lead to problems, they are the result of life-saving treatment. Researchers will continue to search for ways to reduce long-term effects. For now, the gift of life may involve having to cope with some of the late effects of cancer treatment.