Late effects for neuroblastoma

Recovering from neuroblastoma and adjusting to life after treatment is different for each child. Recovery depends on the stage of the disease, the type and dose of treatment, the child's age at time of treatment and many other factors. The end of cancer treatment may bring mixed emotions. Even though treatment has ended, there may be other issues to deal with, such as coping with long-term side effects.

The healthcare team can suggest ways to help your child with the following.

Learning problems can develop in children treated with high-dose chemotherapy. Generally, learning difficulties are mild and do not cause any major disability. Children who are under the age of 5 during treatment may be at a higher risk for learning problems.

Find out more about learning difficulties.

Certain chemotherapy drugs, such as cisplatin and carboplatin, may cause hearing loss when they are given to very young children. This may lead to other concerns, such as delayed language development and impaired social development. Hearing tests are usually done at the end of treatment and then once a year to monitor the child's hearing. If necessary, the child may need a hearing aid or speech therapy.

Find out more about hearing problems.

Children who receive radiation therapy to the neck area have a higher risk for developing hypothyroidism, hyperthyroidism and thyroid nodules. Hypothyroidism is lowered thyroid function. Hyperthyroidism is increased thyroid function. Thyroid nodules are growths on the thyroid that can sometimes cause hyperthyroidism.

Find out more about thyroid problems.

Radiation therapy to the chest can have late effects on the heart, including scarring of the heart muscle. Certain chemotherapy drugs used to treat neuroblastoma, such as doxorubicin, can also affect the heart. Heart problems can include:

• inflammation or scarring of the protective covering of the heart (called pericarditis)
• hardening or narrowing of the heart arteries (called coronary artery disease)
• scarring or weakening of the heart muscle (called cardiomyopathy)
• abnormal heartbeat (called arrhythmia)
• inability of the heart to pump blood properly (called congestive heart failure)

The healthcare team will carefully monitor children receiving radiation therapy or chemotherapy for neuroblastoma for any signs of heart damage. They will do regular physical exams and tests, such as echocardiograms (an ultrasound of the heart), electrocardiograms (ECG) and blood pressure monitoring. These exams and tests help doctors find heart problems early and determine if treatment is necessary.

Find out more about heart problems.

Some chemotherapy drugs, particularly cyclophosphamide and ifosfamide (Ifex), can cause bladder problems such as hemorrhagic cystitis. Hemorrhagic cystitis is when the bladder becomes inflamed and bleeds. It usually occurs right away or a few weeks after chemotherapy. Sometimes it occurs years after chemotherapy.

Find out more about bladder problems.

Kidney problems may be a concern for children who have a stem cell transplant or cisplatin as part of the chemotherapy regimen. Regular follow-up visits will let the doctor check how well the kidneys are working. Specific blood and urine tests are done to check if the kidneys are working properly or if the child needs further testing or treatment. Sometimes electrolyte supplements (with magnesium, calcium, potassium or phosphate) are given, at least on a temporary basis.

Find out more about kidney problems.

Children treated with radiation therapy for neuroblastoma have a higher risk of developing problems with their bones and muscles. Radiation therapy to the spine can result in a shorter overall height. Radiation therapy to the chest and neck area can cause narrow shoulders, a narrower neck and a poorly developed chest. The doctor will monitor the child's height and weight at each follow-up visit. Some children may need artificial (synthetic) growth hormone replacements if their growth is affected.

Find out more about bone and muscle problems.

Radiation therapy and some chemotherapy drugs used to treat neuroblastoma can cause reproductive system problems. These problems include early or delayed puberty in boys and girls. Children treated for neuroblastoma may be infertile when they are adults. Girls treated with alkylating agents may have premature menopause as women. The higher the total dose of chemotherapy, the greater the risk of damage. High doses of chemotherapy used in preparation for a stem cell transplant increase the risk of reproductive system problems.

Girls who receive radiation therapy to the pelvis may also have fertility problems later in life. These problems may include the ovaries not working properly or problems with pregnancy, such as premature delivery. The doctor will monitor the child's sexual development at each follow-up visit. If it appears that puberty is delayed, hormone replacement therapy may be needed so that sexual development can occur.

Infertility is very common in children with high-risk neuroblastoma who have a stem cell transplant.

Find out more about male reproductive system problems and female reproductive system problems.

Neuroblastoma survivors have a higher risk of developing a second cancer. This risk may be due to treatments, such as chemotherapy or radiation therapy. Children treated for cancer today have a lower risk of developing a second cancer than they did in the past. New chemotherapy combinations, lower doses of chemotherapy and lower doses of radiation that are more accurately targeted to the tumour have lowered the risk of a second cancer.

Chemotherapy with alkylating agents and etoposide can raise the risk of developing acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS).

Children treated for neuroblastoma may also have a higher risk of developing solid tumours. The risk of developing secondary solid tumours varies depending on the treatment given. They are mostly related to radiation therapy. The risk of developing a solid tumour may be further increased if chemotherapy is given with radiation therapy.

The Children’s Oncology Group (COG) follow-up guidelines recommend that children with neuroblastoma have early screening for secondary cancer as part of their supportive care. For example, the COG recommends that girls who received radiation to the chest have mammography 8 years after their treatment or by the age of 25 years, whichever is later.

Find out more about second cancers and the Children’s Oncology Group (COG) long-term follow-up guidelines.