Late effects of treatments for childhood bone cancer

Recovering from childhood bone cancer and adjusting to life after treatment is different for each child. Recovery can depend on the stage of the disease, the type and dose of treatment, the child’s age at the 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 late side effects.

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

Bone problems

Children who received treatment for bone cancer have a higher risk for bone problems. Children who are treated when they are younger than 6 years of age or while they are undergoing a growth spurt have a greater risk for late effects. The following are the most common bone problems that can develop.

Bone fracture may occur in children who receive a bone allograft after limb-sparing surgery. A bone graft can take 6–8 months to heal. Sometimes the replaced or reconstructed bone may not heal properly, causing non-union of the bone. Fractures can occur if there is excessive activity on a bone allograft. If there is a non-union of a bone graft, the metal implant will eventually break causing a fracture. The child may need more surgery for additional bone grafting if non-union occurs.

Differences in the length of limbs can occur in children treated for bone cancer. Bones constantly grow throughout childhood and adolescence until the skeleton is mature and adult height is reached. The area on each bone where growth occurs is called the growth plate, or epiphyseal plate. Bone cancer often develops near the growth plate, so this area is usually removed during surgery to remove the tumour. As a result, the reconstructed bone cannot grow as it normally would. The other limb continues to grow normally, which leads to the limbs being different lengths. Additional surgeries and other procedures may be needed to help the treated bone grow or to make the limbs the same length.

Problems with an internal prosthesis include the prosthesis breaking or becoming loose. These problems can happen as children grow or if they are active. The child may need to have more surgery to tighten or replace part of the implant.

Stiffening of a joint can occur after limb-sparing surgery because it can cause stiffening or shrinking of muscles, tendons and ligaments around the joint. Follow-up with physical or occupational therapy and keeping active can help to prevent stiffening of the joint.

Infection can be a problem in some cases. The bone graft or internal prosthesis can sometimes become infected after limb-sparing surgery. Antibiotics may be given to lessen the chance of infection if the child has a low neutrophil count (called neutropenia). Neutrophils help defend the body against bacteria, viruses and types of fungus. Doctors may need to remove and replace an internal prosthesis if it becomes infected.

Osteoporosis is a condition in which the bones become weak and brittle. Radiation therapy can affect bone formation, which can lead to osteoporosis. Certain chemotherapy drugs, such as methotrexate, can also cause osteoporosis. Osteoporosis can lead to stress fracture or weakness in a bone graft.

Find out more about bone and muscle problems.

Phantom limb pain

Sometimes children who have an arm or leg amputated believe that they can feel pain or other sensations in the limb that has been removed. This is called phantom limb pain. Symptoms of phantom limb pain can include pain, burning, throbbing or itching.

Phantom limb pain usually occurs 1–4 weeks after surgery and usually becomes more tolerable during the first year when the child becomes a regular prosthetic wearer. For some children, phantom pain can become a long-term problem.

Medication can often help phantom limb pain.

Find out more about pain.

Heart problems

Certain chemotherapy drugs used to treat childhood bone cancer, such as doxorubicin (Adriamycin), can have late effects on the heart. These late effects include problems with heart muscle function, such as left ventricular dysfunction or cardiomyopathy. Chemotherapy for childhood bone cancer can also lead to abnormal heart rhythms, or arrhythmias.

Girls have a greater risk of developing heart problems after chemotherapy with doxorubicin for bone cancer. Other risk factors for heart problems after treatment with doxorubicin include:

  • larger total, or cumulative, dose of doxorubicin
  • radiation therapy to the chest
  • radiation to the left side of the abdomen

Find out more about heart problems.

Hearing problems

Certain chemotherapy drugs used to treat childhood bone cancer, such as cisplatin (Platinol AQ), can damage the inner ear. This damage is usually permanent. It can lead to hearing loss (usually high frequency sounds) or balance changes. Hearing damage can also affect a child’s social, emotional and intellectual development.

Find out more about hearing problems.

Lung problems

Radiation therapy to the chest can cause pneumonitis and pulmonary fibrosis especially when combined with drugs such as cyclophosphamide (Cytoxan, Procytox).

Find out more about lung problems.

Reproductive system problems

Some chemotherapy drugs used to treat childhood bone cancer, such as cyclophosphamide and ifosfamide (Ifex), can affect the eggs in ovaries and sperm in testicles. Sometimes children treated for bone cancer may be infertile when they are adults.

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

Social, emotional and other issues

Childhood bone cancer usually develops during the teenage years, which can be a very sensitive time in a child’s life. It can have a strong impact on how a child looks, how they feel about their bodies (called body image) and how they see themselves (called self-esteem). Most children feel the greatest effects in the first year after diagnosis, but these effects can last a long time in some people.

Having bone cancer can affect school, work, sports or other activities. It is common to have concerns, fears and anxiety about changes in appearance and body function. It is important for the child to attend school as much as possible. This can help with keeping a daily routine and keeping friends informed and in the picture.

Talk to your child’s healthcare team about support services available in your community. Some treatment centres may have programs to introduce children who have just been diagnosed with bone cancer to children who have completed treatment. Seeing another person who has had bone cancer can be helpful.

Second cancers

Childhood bone cancer survivors have a higher risk of developing a second cancer. The benefit of treating a child’s cancer usually far outweighs the risk of developing a second cancer from treatment. Every attempt is made to lower the risk as much as possible. Treatment plans try to reduce the amount of radiation that is given or to delay it until the child is older and their healthy cells can better tolerate the effects of radiation. Limiting the dose or using other drugs (called chemoprotectants) can help prevent or lessen some of the toxic effects of chemotherapy.

The risk of a second cancer is different for each child, depending on their cancer diagnosis and treatment received.

Certain chemotherapy drugs, such as etoposide (Vepesid), can increase the risk of developing acute myelogenous leukemia (AML) or a myelodysplastic syndrome (MDS).

Children treated for bone cancer also have a higher risk of developing solid tumours, such as sarcomas. The risk varies depending on the treatments the child received, but it is mostly related to radiation. The risk may be even higher if chemotherapy is given with radiation therapy.

Find out more about second cancers.

Questions to ask about late effects and supportive care after treatment

To make the decisions that are right for your child, find out more about late effects of childhood cancer and ask your child’s healthcare team questions about supportive care after treatment.

Expert review and references