Unique Challenges Faced by Vulnerable Patient Populations Children Pediatric or childhood cancers are those diagnosed from birth until the age of 14 years. In the United States in 2023, an estimated 9,910 new cases of cancer will be diagnosed among children. Thanks to major treatment advances, 85 percent of children are expected to live five years or more after a cancer diagnosis. This is a marked improvement compared to the mid-1970s, when only 42 percent of children lived beyond five years after a cancer diagnosis (587). Because childhood cancer survivors are diagnosed at a young age, they will be living longer postdiagnosis than an adult who has been diagnosed with cancer. The degree and type of late-stage side effects childhood cancer survivors develop depend on a variety of reasons, including the type and stage of cancer at the time of diagnosis, the type and dose of treatment, and the age and general health of the patient at the time of treatment. Reports indicate that 60 to 90 percent of childhood survivors develop one or more chronic health conditions following their cancer diagnosis (588,589). Pediatric patients who receive chemotherapeutics are at an increased risk of developing hearing loss, also called ototoxicity. One study found that 75 percent of children under five and 48 percent of children over five who were treated with cisplatin had hearing loss related to their treatment (590). In September 2022, FDA approved sodium thiosulfate to reduce the risk of hearing loss associated with the chemotherapeutic cisplatin in pediatric patients one month and older. Sodium thiosulfate reduced the risk of cisplatin-associated hearing loss by almost 60 percent compared to those who did not receive the drug (591). By preventing ototoxicity, this approval will help many pediatric cancer survivors experience a better quality of life. Pediatric cancer survivors are also more susceptible to premature aging. According to one study, daily functional limitations, psychosocial symptoms, and health conditions of a 30-year-old cancer survivor are similar to those of a 63-year-old healthy individual (593). While premature aging and cancer is an emerging research area, new evidence implicates changes in the epigenome that occur after treatment with cancer therapies as a contributing factor. In one study that evaluated changes in the epigenome of adult survivors of childhood cancers, researchers identified epigenetic patterns that are normally found in much older individuals. These changes were directly associated with the development of early-onset obesity, chronic health conditions, and higher risk of dying within 5 years (594). The quality of mental health among survivors of childhood cancers is also concerning. When compared to their healthy siblings, young adult survivors of childhood cancers reported increased loneliness that subsequently increased anxiety, depression, and the likelihood of smoking. Long-term followup with these patients found higher levels of suicidal thoughts, and heavy/risky alcohol consumption (569). This population is also more susceptible to major mental health illnesses, including autism, attention deficit disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and posttraumatic stress disorder, with the greatest number of mental health illnesses experienced by survivors of brain and lymphatic/ hematopoietic tissue cancers (595). Adolescents and Young Adults Adolescent and young adult (AYA) cancer survivors are those diagnosed between the ages of 15 and 39. Based on estimates of new cancer cases in 2023, 4.4 percent of all new cases will be in AYA and 85.8 percent of AYAs diagnosed with cancer will live 5 years or more after their diagnosis (596). This population group faces unique personal, social, and emotional challenges. Many AYA survivors experience long-term side effects and are at a two- to three-fold higher risk of premature ovarian failure, chronic liver disease, renal failure and cardiovascular disease compared to those with no diagnosis of cancer (597). Between 44 and 86 percent of AYA survivors have concerns regarding how treatments for cancer, including surgery, radiotherapy, and cytotoxic chemotherapy, may lead to infertility, which is the inability to conceive a child (598). The possibility of impaired reproductive abilities may lead some patients to store reproductive material through the process of fertility preservation (see Sidebar 43, p. 137). Participation in fertility preservation and the type of preservation should be decided by the individual after discussions with his or her health care providers. 35 percent of cancer caregivers reported that they stopped working to provide care to someone diagnosed with cancer (586). 5-year survivors of childhood cancer reduced their risk of health-related mortality by 20 to 30 percent when adhering to a healthy lifestyle (592). AACR Cancer Progress Report 2023 Supporting Cancer Patients and Survivors 136
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