Survivors Of Childhood Cancer

YOU HAVE SURVIVED! THE FUTURE?

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June 3, 1948, Sydney Farber and his colleagues reported successful use of aminopterin to induce temporary remission in children with lymphoid leukemia. Gave hope what had been a uniformly fatal disease might be amenable to treatment and, some dared to hope, cure.

• In 1970, DeVita and his colleagues showed that a combination of non– cross-reactive chemotherapeutic agents, the MOPP regimen could induce sustained remission in advanced Hodgkin's disease. • From such beginnings, an extraordinary success story unfolded, and today, more than 75% of children with cancer can be cured of their disease.

• In the United States, there are approximately 270,000 survivors of pediatric cancer, or about 1 of every 640 adults between the ages of 20 and 39 years • SGH survivors: In the last 10 years • 475 OUT OF 821 STILL ON FOLLOW UP • 87 : 10 yr survivor • 195: 5yr survivor

• Future of these survivors? • Cure may be accompanied by a host of adverse events, • Some may not appear for many years after treatment has ended

long-term health consequences 20,227 5-year survivors treated 1970 -1986. Mortality: • Second cancers (standardized mortality ratio 19.4), • Cardiac causes • Lungs (SMR, 9.2).

Study of 9535 survivors of childhood cancer, • 44% reported having at least one of below moderately or severely affected – general health, – mental health, – functional status, – limitations in activity, – cancer-related pain, and – cancer-related fear or anxiety)

Help yourself Help anyone who gives you medical care Do things that will promote your health No high risk behaviour

Help yourself from the beginning During course of treatment. • Remain positive where outcome is concerned • Be caring but firm with the child. Issues can be discussed with children but sometimes decisions have to be made for them especially when they are depressed. • Don’t spoil the child • Eat well • Education

Help yourself from the beginning

Know your disease and its treatment. • Keeping your onco book which will have your diagnosis and test results. • Know what disease you have • Know what treatment had been given and side effects of treatment • Stay in touch with the medical center or clinic where you were originally treated for cancer, at least once a year until 10 years post treatment

As the child grows • Allow them to reach for their limits – don’t curtail school activities eg camping , National service etc • Continue to instil discipline and religious values – Less problem with mental health – Less of sick role

• Treat them and siblings as equals • Education important – delinquency avoided • Tell the child about their disease once they understand usu teenage years when they start to surf the net • Making use of available resources for information and support. • Maintain a good circle of friends

As the child grows • Check with the doctor what side effects to expect • Look out for any abnormal lumps especially over sites of radiation • See a doctor immediately if there are abnormal signs and symptoms eg: bleeding from the anus, abdominal distension • Have checkups once a year, with a physical examination and

In adulthood • • • •

Pap smear once sexually active Regular breast examination Mammograms from age 40 From age 50, colonoscopy, usually every 10yrs, to screen for colorectal cancer • Prostate-specific antigen (PSA) and digital rectal examination (DRE) should be offered annually, beginning at age 50

Observe healthy lifestyle • • • • •

Exercising regularly; Diet: low-fat, high fiber diet; No excessive alcohol No tobacco No drugs

Socialize with peers

No high risk sexual behaviour

•Adopt a physically active lifestyle.

Adults: At least 30 minutes of moderate to vigorous exercise on 5 or more days of the week; 45 to 60 minutes –even better

•Children and teens: At least 60 minutes per day of moderate to vigorous exercise at least 5 days per week.

Benefits: lowering cancer risk. lower risk of heart disease, high blood pressure, diabetes, and osteoporosis (bone thinning).

Tips on how to be more active

• Use stairs not elevator. • Walk or cycle to where you want to go. • Walk to see co-workers, not phone or send email. • Dancing with your spouse or friends or in groups. • Plan active vacations rather than sitdown trips. • Join a sport- badminton, bowling, swimming • Use a stationary bicycle or treadmill when watching TV. • Plan your exercise routine to gradually

Maintain a healthy weight throughout life. • Balance calorie intake with physical activity. • Avoid excessive weight gain • Aim for and maintain a healthy weight if currently overweight or obese.

The healthiest way to reduce calories is : don’t add sugar to drinks, Reduce oil and fats, Reduce drinks and foods high in calories, fat, and/or refined sugars, but few or no nutrients. Examples: fried food, cookies, cakes, candy, ice cream, and sweetened soft drinks and alcohol.

Emphasis on plant sources; eat 5 or more servings of a variety of vegetables and fruits every day. Choose whole grains over processed (refined) grains. Limit intake of processed and red meats.

Alcohol

• Alcohol is a known cause of cancers of the mouth , pharynx (throat), larynx (voice box), esophagus, liver, breast • May also increase the risk of colon and rectum cancer • Combination of alcohol and tobacco increases the risk of some cancers far more than the effect of either drinking or smoking alone. • Women at high risk of breast cancer should not drinking any alcohol. Regular intake of even a few drinks per week is linked to a higher of breast cancer in women.

If you drink: Not > 2 drinks per day for men and 1 drink a day for women. A drink is defined as 12 ounces of beer (1can), 5 ounces of wine(1 glass), or 1.5 ounces (45mls) of 80-proof distilled spirits, eg whisky.

Common Questions About Diet and Cancer • Many stories on food and cancer • Single news reports may put too much emphasis on what the advertiser wants to promote. • Good study usually involve many people in many places, not 1 old lady telling you after taking AB vitamin, all diseases went away. • It is not advisable to change diet or activity levels based on a single study or news report.

What are antioxidants? • • • • •

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An antioxidant is a molecule capable of slowing or preventing the oxidation of other molecules. Normal body metabolism is called oxidation Oxidation reactions can produce free radicals, which start chain reactions that damage cells. Antioxidants terminate these chain reactions by removing free radical intermediates, Although oxidation reactions are crucial for life, they can also damage or kill cells; hence, plants and animals maintain complex systems of multiple types of antioxidants. Because such damage is linked with increased cancer risk, the so-called antioxidant nutrients are thought to protect against cancer. Antioxidants include vitamin C, vitamin E, carotenoids, and many other phytochemicals (chemicals from plants).

Do antioxidants reduce cancer risk? • Studies suggest that people who eat more vegetables and fruits, which are rich sources of antioxidants, may have a lower risk for some types of cancer. • Antioxidants dietary supplements are widely used hoping to maintain health and prevent diseases such as cancer and coronary heart disease. • Although some studies have suggested antioxidant supplements have health benefits, • Other large clinical trials did not detect any benefit for the formulations tested, and excess supplementation may be harmful • To reduce cancer risk, best advice is : get your antioxidants through food, not

Will eating vegetables and fruits lower cancer risk? • Eating more vegetables and fruits ⇒ ↓ risk of lung, oral, esophageal, stomach, and colon cancer. • don't know which of the many compounds in these foods are most helpful, • Best advice : eat 5 or more types of different colour vegetables and fruits each day, example: 3 types of vegetables plus 2 types of fruit.

Do vegetarian diets reduce cancer risk? • Low in saturated fats and high in fiber, vitamins, and phytochemicals. • BUT: It is not proven that a vegetarian diet has any special benefits for the prevention of cancer. • Strict vegetarian diets that avoid all animal products, including milk and eggs not good for children – not enough vitamin B12, zinc, and iron • Diets including lean meats in small to moderate amounts also healthy.

Can I get the nutritional effects of vegetables and fruits in a pill? • No. • Many healthful compounds are found in vegetables and fruits, and these compounds most likely work in together to produce their helpful effects. • The small amount of dried powder in the pills that are sold as being equivalent to vegetables and fruits often contains only a small fraction of the levels contained in the whole

• Food is the best source of vitamins and minerals. • Supplements, :helpful for some people, eg pregnant women, women of childbearing age, people with allergies, food intolerances, or other problems. • If a supplement is taken, the best choice is a balanced multivitamin/mineral supplement containing no more than 100% of the "Daily Requirement" of most nutrients

Can nutritional supplements lower cancer risk? • No proof at this time that supplements can reduce cancer risk. • Some high-dose supplements may actually increase cancer risk.

Do Vitamins lower cancer risk

Vitamin A • Vitamin A supplements, whether in the form of beta-carotene or retinol, have not been shown to lower cancer risk, and • High-dose supplements may, in fact, increase the risk for lung cancer in current and former smokers. • Retinol can cause serious problems if too much is taken. Vitamin C • Many studies have linked intake of foods rich in vitamin C to a reduced risk for cancer. • But the few studies in which vitamin C has been given as a supplement have not shown a reduced risk for cancer. Vitamin D • There is a growing body of evidence from studies that observie large groups of people (not yet tested in clinical trials) that vitamin D may have helpful effects on some types of cancer, including cancers of the colon, prostate, and breast. Vitamin E Vitamin E • vitamin E is a powerful antioxidant. • In one study, male smokers who took alpha-tocopherol had a lower risk of prostate cancer • But several other studies have not found the same link.

Can soy foods reduce cancer risk? • Women with breast cancer should take in only moderate amounts of soy foods as part of a healthy, plant-based diet. They should not ingest very high levels of soy in their diet or take concentrated sources of soy such as soycontaining pills or powders, or supplements containing high amounts of isoflavones. • Little data to show soy supplements help reduce cancer risk. High doses of soy could possibly increase the risk of estrogen-responsive cancers, such as breast or endometrial cancer.

Soy foods: good source of protein and a good alternative to meat. Contains several phytochemicals, some of which have weak estrogen activity and appear to protect against hormonedependent cancers in animal studies.

Can drinking tea reduce cancer risk? • Some research suggest tea might protect against cancer because of its antioxidant content. • In animal studies, some teas (including green tea) shown to reduce cancer risk, • But yet to be proven to reduce cancer risk in humans.

Does eating fish protect against cancer? • • • •

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Fish is a rich source of omega-3 fatty acids. Studies in animals: these fatty acids suppress cancer formation or slow down cancer growth, Limited evidence of a possible benefit in humans. Beware: some types of fish (large predatory fish such as swordfish, tilefish, shark, and king mackerel) may contain high levels of mercury, polychlorinated biphenyls (PCBs), dioxins, and other environmental pollutants. Women who are pregnant, breast-feeding, or planning to become pregnant, and young children should not eat these fish. People should vary the types of fish they eat to reduce the chance of exposure to toxins. Research has not yet shown whether taking omega-3 or fish oil supplements produces the same possible benefits as eating fish. .

Are "organic" foods more effective in lowering cancer risk? • “Organic” is the “in” word. • Plant grown without pesticides and genetic modifications. • No research exists to show such foods are more effective in reducing cancer risk than food produced by usual farms.

Do food additives cause cancer? • Many substances are added to foods to preserve them and to enhance color, flavor, and texture. • New additives must be cleared by the Food and Drug Administration (FDA) before use. • Additives are usually present in very small quantities in food, and no convincing evidence has shown that any additive at these levels causes human cancers.

Do high levels of salt in the diet increase cancer risk? • Studies in other countries link diets that contain large amounts of foods preserved by salting and pickling with an increased risk of stomach, nasopharyngeal, and throat cancer. • No evidence suggests that moderate levels of salt used in cooking or in flavoring foods affect cancer

Do irradiated foods cause cancer? • No. • Radiation is used to kill harmful organisms on foods in order to extend their "shelf life." • Radiation does not stay in the foods after treatment, and eating irradiated foods does not increase cancer risk.

Do pesticides in foods cause cancer?

Pesticides and herbicides can be toxic when used improperly No evidence shows that residues of pesticides and herbicides at the low doses found in foods increase the risk of cancer,

fruits and vegetables should be washed thoroughly before eating

Do processed meats cause cancer? • Some studies have shown eating large amounts of processed meat increased risk of colorectal and stomach cancers. • May be due to nitrites, which are added to many luncheon meats, hams, and hot dogs to maintain color and to prevent bacterial growth. • Eating processed meats and meats preserved by methods involving smoke or salt does increase exposure to potential cancer-causing agents and should be reduced as much as possible.

How does cooking meat affect cancer risk? • Adequate cooking is required to kill harmful germs in meat. • Some research suggests frying, broiling, or grilling meats at very high temperatures forms chemicals that might increase cancer risk. • These chemicals can damage DNA and cause cancer in animals, • But it is not clear how much they contribute to the increased colorectal cancer risk seen in people who eat large amounts of meat in some studies. • Techniques such as braising, steaming, poaching, stewing, and microwaving meats produce fewer of these chemicals.

How much water and other fluids should I drink? • Drinking water and other liquids may reduce the risk of bladder cancer, as water dilutes the concentration of cancer-causing agents in the urine and shortens the time in which they are in contact with the bladder lining. • Drinking at least 8 cups of liquid a day is

Avoid Carcinogens • Cancer is caused by changes (mutations) in a cell's DNA -- its genetic "blueprint". • Some of these changes may be caused by outside exposures (environmental factors.) • Substances and exposures that can lead to cancer are called carcinogens • Environmental factors include: – lifestyle factors (nutrition, tobacco use, physical activity, etc.), – naturally occurring exposures (ultraviolet light, radon, infectious agents, etc.), – medical treatments (chemotherapy, radiation, and immune system-suppressing drugs used after organ transplants, etc.), – workplace and household exposures, and – pollution.

Carcinogens may have different levels of cancer-causing potential. Risk of developing cancer depends on many factors, including how they are exposed to a carcinogen, the length and intensity of the exposure, and the person's genetic makeup.

National Toxicology Program 11th Report on Carcinogens "Known to be human carcinogens • • • • • • • • • • • • • • • • • • • • • • • • •

Aflatoxins Alcoholic beverage consumption 4-Aminobiphenyl Analgesic mixtures containing phenacetin Arsenic compounds, inorganic Asbestos Azathioprine Benzene Benzidine Beryllium and beryllium compounds 1,3-Butadiene 1,4-Butanediol dimethylsulfonate (busulfan, Myleran®) Cadmium and cadmium compounds Chlorambucil 1-(2-Chloroethyl)-3-(4-methylcyclohexyl)-1nitrosourea (MeCCNU) bis(chloromethyl) ether and technical-grade chloromethyl methyl ether Chromium hexavalent compounds Coal tar pitches Coal tars Cyclophosphamide Cyclosporin A (Ciclosporin) Diethylstilbestrol (DES) Dyes metabolized to benzidine Environmental tobacco smoke Estrogens, steroidal

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Ethylene oxide Hepatitis B virus Hepatitis C virus Human papilloma viruses: some genital-mucosal types Melphalan Methoxsalen with ultraviolet A therapy (PUVA) Mineral oils (untreated and mildly treated) Mustard gas 2-Naphthylamine Neutrons Nickel compounds Oral tobacco products Radon Silica, crystalline (respirable size) Solar radiation Soots Strong inorganic acid mists containing sulfuric acid Sunlamps or sunbeds, exposure to Tamoxifen 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD); "dioxin" Thiotepa Thorium dioxide Tobacco smoking Vinyl chloride Ultraviolet radiation, broad spectrum UV radiation Wood dust X-radiation and gamma radiation

TOBACCO and SMOKING • One of the most important carcinogen

TOBACCO and SMOKING • •

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Many kids start using tobacco by age 11. And many are addicted by age 14. Talk to your children about the risks of tobacco use when your children are 5 or 6 years old and continue through their high school years. – Tobacco use strains the heart, damages the lungs, and can cause cancer. – Smoking makes hair and clothes stink, causes bad breath, and stains teeth and fingernails. Don't use tobacco around your children, don't offer it to them, and don't leave it where they can easily get it. Talk about ways to say "no" to tobacco. Talk to your kids about the false glamorization of tobacco in the media, such as movies, TV, and magazines.

• If you use tobacco yourself and don't want your children to start, you can still influence their decisions. You can speak to your child firsthand about: – how you got started and what you thought about it at the time – how hard it is to quit – how it has affected your health – what it costs you, financially and socially • Don't smoke indoors and don't allow indoor smoking by anyone else. • Don’t smoke in the car

Infections and Cancer • Infections are linked to about 15% to 20% of cancers. – In developed countries, < 10% of all cancers are linked to infectious agents. – In developing countries, infections account for as much as 20% of all cancers. • Some infections may cause long-term inflammation, suppress a person's immune system, or directly affect a cell's DNA. Any of these pathways may lead to a higher risk of cancer. • The risk of developing a cancer is also influenced by other factors. Example, infection with Helicobacter pylori (H. pylori) bacteria may increase your risk of developing stomach cancer, but what you eat, whether or not you smoke, and other factors also influence your risk. • Although the infections that influence cancer risk are

HPV and Vaccination Human papilloma viruses (HPVs) • Spread by contact (touch), including through sex. • Very common in people who are sexually active. • No effective treatments for HPV other than removing or destroying cells that are known to be infected. • Most genital HPV infections clear with time by the body's immune system. • Certain types of HPV cause of cervical cancer, which is the second most common cancer among women but most infected never develop cancer. •

Pap smear can detect pre-cancerous changes in cells in the cervix that might be due to HPV infection, which can then be treated, if needed. This treatment can prevent the development of cancer.

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HPVs have a role in some cancers of the penis, anus, vagina, and vulva. Also been linked to cancers of the mouth, throat, head, and neck.

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•Vaccines against the types of HPV that cause cancer are now available (Gardasil®) and has been shown to help protect against infection from some of these HPV types, and is now approved for use in females aged 9 to 26, before first sexual encounter.

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Hepatitis B virus (HBV) and hepatitis C virus (HCV)and Vaccination

HBV and HCV cause viral hepatitis, a type of liver infection. Hepatitis A virus A can also cause hepatitis but only HBV and HCV can cause chronic (long-term) infections that increase a person’s chance of developing liver cancer. Liver cancers are related to HBV or HCV infection higher in Asia and Malaysia, where both the infections and liver cancer are much more common. HBV and HCV are spread much the same way as HIV -- through sharing needles, unprotected sex, or childbirth and blood transfusions, HBV is more likely to cause symptoms, such as a flu-like illness and a yellowing of the eyes and skin (jaundice). But most people recover completely from HBV infection within a few months. Only a very small percentage go on to become chronic carriers. These people have a higher risk for liver cancer. HCV, on the other hand, is less likely to cause symptoms. But most people with HCV develop chronic infections, which are more likely to

There are few drugs effective in treating hepatitis B or C, Vaccine is available to prevent HBV infection. In Malaysia, all children are vaccinated for Hep B Unfortunately, there is no vaccine to prevent HCV at this time.

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Human immunodeficiency virus (HIV)

HIV infection increases a person's risk of getting several types of cancer, especially some linked to other viruses such as HHV-8 and HPV. HIV is acquired through intimate contact with blood, vaginal secretions, breast milk, or semen from an HIV-infected person. HIV is not spread by insects, through water, or by casual contact such as talking, shaking hands, hugging, sneezing, sharing dishes, sharing a bathroom or kitchen, sharing telephones, or sharing computers. Known routes of spread include: – unprotected sex (oral, vaginal, or anal) with an HIV-infected person – injections with needles or injection equipment previously used on an HIV-infected person – prenatal and perinatal (during birth) exposure of infants from mothers with HIV – breast-feeding by mothers with HIV – transfusion of blood products containing HIV (blood has been tested since 1985)

Human immunodeficiency virus (HIV) • •

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HIV infects and destroys white blood cells known as helper T cells, which weakens the body's immune system. When the body is less able to fight off infections, other viruses such as HPV may cause more damage to the cells. This damage may trigger cancer. Many scientists believe that the immune system is also important in attacking and destroying newly formed cancers. Weak immune system may allow new cancers to survive to become a serious, lifethreatening tumor. HIV infection has been linked to a higher risk of developing of Kaposi sarcoma, invasive cervical cancer, and certain kinds of lymphoma, especially non-Hodgkin lymphoma and central nervous system lymphoma. Other forms of cancer that may be more likely to develop include: – – – – –

invasive anal cancer Hodgkin disease lung cancer cancer of the mouth and throat cancer of the testicles

Helicobacter pylori (H. pylori) • •

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Stomach cancer fourth most common cancer worldwide. Long-term infection of the stomach with H. pylori may lead to chronic inflammation and damage to the inner layer of the stomach, including ulcers. Some of these changes could lead to cancer over time, especially cancer in the lower part of the stomach. H. pylori infection is also linked with some types of lymphoma of the stomach. More than half of all cases of stomach cancer are linked to H. pylori infection. About 1 in 3 adults has evidence of infection with H. pylori, and the rate of infection is higher in older age groups. Researchers aren't exactly sure how H. pylori may be spread from one person to another. But most people who have these bacteria in their stomachs never develop cancer.

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In animals, nitrites, commonly found in cured meats, some drinking water, and certain vegetables can be converted by certain bacteria, such as H. pylori, into compounds that have been found to cause stomach cancer

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Antibiotics and other medicines can be used to treat H. pylori infections. Doctors have given antibiotics to patients who have had superficial stomach cancers removed in order to get rid of H. pylori infection. This seems to have prevented new stomach cancers in those patients.

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Cancers Caused by Radiation Therapy Ionizing radiation is an effective way to treat certain kinds of cancer. During radiation therapy, high doses of ionizing radiation are directed at the cancer, resulting in the death of the cancer cells. But, this can lead to DNA mutations in cells that survive the radiation, which can eventually lead to the development of another cancer (called a second primary cancer). When considering radiation therapy, benefits generally outweigh the risks. Some combinations of radiation therapy and chemotherapy are more risky than others. Research is needed in this area so that optimal treatment can be given that minimizes the risk of the development of secondary cancers. Following radiation therapy and/or chemotherapy.

– An increase in second primary tumors in the area being irradiated has been observed – Increased incidence of thyroid cancer and early-onset breast

Types of Cancer Associated With Ionizing Radiation •

Leukemia -major cancer to arise from high-dose radiation exposure, based on the experience of atomic blasts in Japan. Appear as early as 2 years after acute radiation exposure. Risk of developing leukemia is 5X > than in the general public. Children 2X as sensitive as adults to the leukemiacausing effects of radiation, and unborn children exposed to radiation in the uterus are even more sensitive.

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Other cancers can result from radiation exposure, may take longer to develop (usually at least 10 to 15 years). The risk for developing any type of cancer in those highly exposed to an atomic blast is about 50% higher than in those not exposed.

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The risk of developing lung cancer is 50% higher, risk for multiple myeloma is >2X the general population

Non-Ionizing Radiation • Non-ionizing radiation is low-frequency radiation that does not have enough energy to cause ionization in tissues, • Common types of non-ionizing radiation include ultraviolet rays, visible light, electromagnetic fields, infrared radiation, microwaves, and radiofrequency radiation (radio waves). • Electrical appliances, heaters, and cellular phones emit (send out) non-ionizing radiation waves. • Of all the types of non-ionizing radiation, only ultraviolet rays have been established as a cancer-causing agent.

Ultraviolet (UV) Radiation • •

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The sun is the major source of ultraviolet (UV) radiation. Most skin cancers are a direct result of sunlight exposure. Both basal cell and squamous cell cancers (the most common types of skin cancer) are found on sun-exposed parts of the body, and their occurrence is related to lifetime sun exposure. Melanoma, a potentially fatal type of skin cancer, is less dependent on sun exposure and can develop on any area of the body. Ultraviolet radiation is divided into three wavelength ranges: – UVA rays are involved in the aging of cells and produce some damage to DNA. – UVB rays are in the wavelength range mainly responsible for direct damage to the DNA, and are thought to cause most skin cancers. – UVC rays are not present in sunlight, but are present in mercury lamps.

While UVA and UVB rays make up only 1/10,000,000th of the sun's wavelengths, they are primarily responsible for the damaging effects of the sun on the skin.

Mobile Phones •

Results from the Swedish Interphone study of long-term cell phone use and Results of the long-term cohort study, which linked data on all of the 420,095 cell phone users in Denmark between 1982 and 2002 to the Danish Cancer Registry, indicate the same conclusions.

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Cell phone use, even for more than 10 years, was not associated with an increased risk of developing brain tumors or cancer overall, nor was there an association with any brain tumor subtypes or with tumors in any location within the brain.

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One cancer that has been studied extensively is acoustic neuroma, a relatively rare, slow-growing tumor of the acoustic nerve (which transmits the sensation of hearing from the ear to the brain) that occurs in less than one adult per 100,000 people per year. At least 9 epidemiological studies and one of the largest and most recent studies that analyzed data from the 5 northern European countries have looked for an association between the use of cell phones and acoustic neuroma. Conclusion: “Suggested there is no substantial risk of acoustic neuroma in the first decade after starting mobile phone use. However, an increase in risk after longer term use or after a longer lag period could not be ruled out."

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