More children with cancer are being cured (overall survival is now ~80%) but at what cost? Although very few new chemotherapeutic agents have been introduced into the treatment of childhood cancer in recent years, significant progress has been made in understanding the childs response to treatment. Many patients are now risk stratified not only based on stage or subtype of disease, but also on response to initial therapy. This has allowed the identification of those patients who will be cured with relatively mild chemotherapy (and therefore minimal or no late effects) and conversely those who require very intensive treatment with potentially very significant long-term problems.
The pattern of late effects experienced by survivors is changing fewer having the predictable risks of radiotherapy, which can now be omitted in many settings. Conversely others with high risk disease, will have less predictable, but not necessarily less significant, late complications of intensive chemotherapy often in addition to radiotherapy. Survival rates for children with brain tumours are also improving. Here there has not been the same fall in the use of radiotherapy but an increase in chemotherapy, which potentially will lead to additional late sequelae or morbidity.
So there are challenges for the oncologist in taking decisions that will minimise late effects (whilst maximising chances of cure) and also decisions to be made about which patients should be followed into the long-term how often and by whom. Is survival from cancer a chronic disease, or can patients move on?