Unmet Survivorship Care Needs of Adolescent and Young Adult Cancer Survivors

Jensen and coauthors1 present the first large-scale, population-based report of endocrine late effects among adolescent and young adult (AYA) cancer survivors. Including all Danish cancer survivors diagnosed at ages 15 to 39 years, between 1976 and 2009, the authors identified 32 548 one-year cancer survivors and compared their risk of endocrine diseases with 188 728 cancer-free individuals matched by year of birth and sex. This study demonstrated a 73% higher relative risk of endocrine disease among AYA cancer survivors than the general population. The complications with the highest absolute excess risks were thyroid disease, testicular dysfunction, and diabetes mellitus, with the highest at-risk groups for complications being survivors of leukemia, Hodgkin lymphoma, and brain cancer. An increased incidence of endocrine late effects was noted in those treated at younger ages, presumably related to the diseases with the highest complication rates being more prevalent at younger ages. The authors conclude that these results demonstrate a need for counseling and follow-up to enhance prevention and surveillance for endocrine complications of therapy in AYA survivors. While the choice to limit the definition of endocrinopathy to one that required contact with a hospital was only mentioned briefly by the authors in the limitations section, it is an important area for discussion with regard to methodology. As conditions such as hypothyroidism and type 2 diabetes mellitus are commonly seen by primary care providers, many additional cases likely were diagnosed outside the hospital setting, and thus the reported prevalence of these late effects in this study is likely to be a significant underestimate of the actual risk. Based on what is known about late effects from the pediatric oncology literature, having AYA cancer survivors present to the hospital with these common and anticipatable late effects, so severe that many required hospitalization, is another indication of the need for surveillance programming. It is widely recognized that provision of cancer care for AYAs requires understanding and considerations that are distinct from those in children and older adults, and that there is a lack of evidence about late effects specific to this group.2 High-quality articles are beginning to emerge examining some of the most common and devastating late effects of cancer therapy, including cardiac dysfunction and secondary malignancies, creating a body of evidence to which this article contributes. While there are considerations such as sexuality, oncofertility, and transition that are particularly important to the AYA group, many of the specific late effects noted in the article by Jensen et al, as well as their predisposing factors, including treatment-related risk factors, are analogous to those in the childhood cancer group. A recent Lancet Diabetes and Endocrinology series summarized the evidence for the agentand dose-specific endocrine risks of cancer therapy.3 Cranial radiotherapy has been demonstrated to predispose to hypothalamic and pituitary dysfunction, explaining the findings by Jensen et al of multiple endocrine risks among brain cancer survivors, most notably a 112-fold relative risk of pituitary hypofunction.1 Similarly, neck and chest radiotherapy, a mainstay of Hodgkin lymphoma treatment, has been demonstrated to predispose to thyroid dysfunction with an absolute excess risk of 362 per 100 000 person-years noted in the Danish cohort study.1 While it is important to determine whether AYA cancer survivors are at any additional specific risk of late effects, a lack of strong evidence in this group should not be used to dismiss the need for appropriate surveillance informed by the pediatric literature. + Related article