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CHAPTER 8 Long‐term follow‐up of children
Paul A. Carpenter
Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
Introduction
More than half a million HCT survivors are estimated by 2030 due to improvements in HLA‐typing and supportive care [1]. Unfortunately, among HCT‐recipients who survive at 2 years without recurrence of their original disease indication for transplant, there is a four‐ to nine‐fold increased mortality rate for 5‐year survivors relative to an age and sex‐matched general population [2–5].
This can be attributed to an increased cumulative incidence (CI) of chronic health conditions among HCT survivors; in one study 66% had at least one chronic health condition and the 10‐year CI for severe/life‐threatening conditions or death as result was 35% (95%CI, 32–39%). HCT survivors were 3.5 times as likely as siblings to develop a severe/life‐threatening condition, this was amplified further among those survivors with chronic graft‐versus‐host‐disease (cGVHD) [6].
All HCT late effects result from varying degree of interaction between underlying diagnosis, pre‐HCT exposures to chemotherapy and radiation, and post‐HCT complications including GVHD, immunodeficiency and medications (Figure 8.1). Risks for late effects are modified by other intrinsic and extrinsic factors like age, sex, genetics, underlying disease, social factors, comorbidities and lifestyle which can do so in a positive or negative manner.
The cGVHD burden cannot be overemphasized given its potential for protean manifestations over several years, especially with morbid forms that can include tissue sclerosis, joint contractures, bronchiolitis obliterans and failure thrive. Given that clinical immunologic tolerance may take years rather than months [7,8], toxicities arising from immunosuppressive therapies (IST) as well as medications used to treat side effects of IST can contribute to chronic health conditions per se, for example, hypertension, dyslipidemia, and chronic renal insufficiency to name a few.
Therefore, there is an increased focus on late complications that cause morbidity, mortality and quality‐of‐life impairments. Early detection and preventive efforts aim to recognize and mitigate patient‐, disease‐, or BMT‐related risk