Problems with the teeth and jaws are late effects that are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause the late effect of problems with teeth and jaws:

• Head and neck cancers.
• Hodgkin lymphoma.
• Leukemia that spread to the brain and spinal cord.
• Nasopharyngeal cancer.
• Neuroblastoma.
• Cancers treated with a stem cell transplant.

Radiation to the head and neck and certain types of chemotherapy increase the risk of late effects to the teeth and jaws.

The risk of health problems that affect the teeth and jaws increases after treatment with the following:

• Radiation therapy to the head and neck.
• Total-body irradiation (TBI) as part of a stem cell transplant.
• Chemotherapy, especially with higher doses of alkylating agents such as cyclophosphamide.
• Surgery in the head and neck area.

Risk is also increased in survivors who were younger than 5 years at the time of treatment because their permanent teeth had not fully formed.

Late effects that affect the teeth and jaws may cause certain health problems.

Teeth and jaw late effects and related health problems include the following:

• Teeth that are not normal.
• Tooth decay (including cavities) and gum disease.
• Salivary glands do not make enough saliva.
• Death of the bone cells in the jaw.
• Changes in the way the face, jaw, or skull form.

Possible signs and symptoms of late effects of the teeth and jaws include tooth decay (cavities) and jaw pain.

These and other signs and symptoms may be caused by late effects of the teeth and jaws or by other conditions:

• Teeth are small or do not have a normal shape.
• Missing permanent teeth.
• Permanent teeth come in at a later than normal age.
• Teeth have less enamel than normal.
• More tooth decay (cavities) and gum disease than normal.
• Dry mouth.
• Trouble chewing, swallowing, and speaking.
• Jaw pain.
• Jaws do not open and close the way they should.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the mouth and jaws.

These and other tests and procedures may be used to detect or diagnose late effects of the teeth and jaws:

• Dental exam and history: An exam of the teeth, mouth, and jaws to check general signs of dental health, including checking for signs of disease, such as cavities or anything that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken. This may also be called a dental check-up.
• Panorex x-ray: An x-ray of all of the teeth and their roots. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• X-ray of the jaws: An x-ray of the jaws. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, such as the head and neck, taken from different angles. The pictures are made by a computer linked to an x-ray machine. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the head and neck. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• Biopsy: The removal of bone cells from the jaw so they can be viewed under a microscope to check for signs of bone death after radiation therapy.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of teeth and jaw late effects. If tests are needed, find out how often they should be done.

Regular dental care is very important for survivors of childhood cancer.

Doctors suggest that survivors of childhood cancer have a dental check-up and a cleaning and fluoride treatment every 6 months. Children who had radiation therapy to the oral cavity may also see an orthodontist.

Digestive tract late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause late effects of the digestive tract (esophagus, stomach, small and large intestines, rectum and anus):

• Rhabdomyosarcoma of the bladder or prostate, or near the testicles.
• Non-Hodgkin lymphoma.
• Germ cell tumors.
• Neuroblastoma.
• Wilms tumor.

Radiation to the bladder, prostate, or testicles and certain types of chemotherapy increase the risk of digestive tract late effects.

The risk of health problems that affect the digestive tract increases after treatment with the following:

• Radiation therapy to the abdomen or areas near the abdomen, such as the esophagus, bladder, prostate, or testicles, may cause digestive tract problems that begin quickly and last for a short time. In some patients, however, digestive tract problems are delayed and long-lasting. These late effects are caused by radiation therapy that damages the blood vessels. Receiving higher doses of radiation therapy or receiving chemotherapy such as dactinomycin or anthracyclines together with radiation therapy may increase this risk.
• Abdominal surgery or pelvic surgery to remove the bladder.
• Chemotherapy with alkylating agents such as cyclophosphamide, procarbazine, and ifosfamide, or with platinum agents such as cisplatin or carboplatin, or with anthracyclines such as doxorubicin, daunorubicin, idarubicin, and epirubicin.
• Stem cell transplant.

The following may also increase the risk of digestive tract late effects:

• Older age at diagnosis or when treatment begins.
• Treatment with both radiation therapy and chemotherapy.
• A history of chronic graft-versus-host disease.

Late effects that affect the digestive tract may cause certain health problems.

Digestive tract late effects and related health problems include the following:

• A narrowing of the esophagus or intestine.
• Diarrhea, constipation, or blocked bowel.
• Bowel perforation (a hole in the intestine).
• Inflammation of the intestines.
• Death of part of the intestine.
• Intestine is not able to absorb nutrients from food.

Possible signs and symptoms of digestive tract late effects include abdominal pain and diarrhea.

These and other signs and symptoms may be caused by digestive tract late effects or by other conditions:

• Trouble swallowing or feeling like food is stuck in the throat.
• Heartburn.
• Fever with severe pain in the abdomen and nausea.
• Pain in the abdomen.
• A change in bowel habits (constipation or diarrhea).
• Nausea and vomiting.
• Frequent gas pains, bloating, fullness, or cramps.
• Hemorrhoids.
• Reflux.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the digestive tract.

These and other tests and procedures may be used to detect or diagnose digestive tract late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as abdominal tenderness or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Digital rectal exam: An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum to feel for lumps or anything else that seems unusual.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. An x-ray may be taken of the abdomen, kidney, ureter, or bladder to check for signs of disease.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of digestive tract late effects. If tests are needed, find out how often they should be done.

Liver and bile duct late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause liver or bile duct late effects:

• Liver cancer.
• Wilms tumor.
• Acute lymphoblastic leukemia (ALL).
• Cancers treated with a stem cell transplant.

Certain types of chemotherapy and radiation to the liver or bile ducts increase the risk of late effects.

The risk of liver or bile duct late effects may be increased in childhood cancer survivors treated with one of the following:

• Surgery to remove part of the liver or a liver transplant.
• Chemotherapy that includes high-dose cyclophosphamide as part of a stem cell transplant.
• Chemotherapy such as 6-mercaptopurine, 6-thioguanine, and methotrexate.
• Radiation therapy to the liver and bile ducts. The risk depends on the following:

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  The dose of radiation and how much of the liver is treated.

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  Age when treated (the younger the age, the higher the risk).

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  Whether there was surgery to remove part of the liver.

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  Whether chemotherapy, such as doxorubicin or dactinomycin, was given together with radiation therapy.

• Stem cell transplant (and a history of chronic graft-versus-host disease).

Late effects that affect the liver and bile ducts may cause certain health problems.

Liver and bile duct late effects and related health problems include the following:

• Liver doesn’t work the way it should or stops working.
• Gallstones.
• Benign liver lesions.
• Hepatitis B or C infection.
• Liver damage caused by veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS).
• Liver fibrosis (an overgrowth of connective tissue in the liver) or cirrhosis.
• Fatty liver with insulin resistance (a condition in which the body makes insulin but cannot use it well).
• Tissue and organ damage from the buildup of extra iron after having many blood transfusions.

Possible signs and symptoms of liver and bile duct late effects include abdominal pain and jaundice.

These and other signs and symptoms may be caused by liver and bile duct late effects or by other conditions:

• Weight gain or weight loss.
• Swelling of the abdomen.
• Nausea and vomiting.
• Pain in the abdomen. Pain may occur near the ribs, often on the right side, or after eating a fatty meal.
• Jaundice (yellowing of the skin and whites of the eyes).
• Light-colored bowel movements.
• Dark-colored urine.
• A lot of gas.
• Lack of appetite.
• Feeling tired or weak.

Talk to your child's doctor if your child has any of these problems.

Sometimes there are no signs or symptoms of liver or bile duct late effects and treatment may not be needed.

Certain tests and procedures are used to detect (find) and diagnose health problems in the liver and bile duct.

These and other tests and procedures may be used to detect or diagnose liver or bile duct late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease For example, there may be a higher level of bilirubin in the body if the liver has been damaged.
• Ferritin level: A procedure in which a blood sample is checked to measure the amount of ferritin. Ferritin is a protein that binds to iron and stores it for use by the body. After a stem cell transplant, a high ferritin level may be a sign of liver disease.
• Blood studies to check how well the blood clots: A procedure in which a blood sample is checked to measure the amount of platelets in the body or how long it takes for the blood to clot.
• Hepatitis assay: A procedure in which a blood sample is checked for pieces of the hepatitis virus. The blood sample may also be used to measure how much hepatitis virus is in the blood. All patients who had a blood transfusion before 1972 should have a screening test for hepatitis B. Patients who had a blood transfusion before 1993 should have a screening test for hepatitis C.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs, such as the gall bladder, and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.
• Biopsy: The removal of cells or tissues from the liver so they can be viewed under a microscope to check for signs of a fatty liver.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of liver or bile duct late effects. If tests are needed, find out how often they should be done.

Health habits that promote a healthy liver are important for survivors of childhood cancer.

Childhood cancer survivors with liver late effects should take care to protect their health, including:

• Having a healthy weight.
• Not drinking alcohol.
• Getting vaccines for hepatitis A and hepatitis B viruses.

Radiation therapy increases the risk of pancreatic late effects.

The risk of pancreatic late effects may be increased in childhood cancer survivors after treatment with one of the following:

• Radiation therapy to the abdomen.
• Total-body irradiation (TBI) as part of a stem cell transplant.

Late effects that affect the pancreas may cause certain health problems.

Pancreatic late effects and related health problems include the following:

• Insulin resistance: A condition in which the body does not use insulin the way it should. Insulin is needed to help control the amount of glucose (a type of sugar) in the body. Because the insulin does not work the way it should, glucose and fat levels rise.
• Diabetes mellitus: A disease in which the body does not make enough insulin or does not use it the way it should. When there is not enough insulin, the amount of glucose in the blood increases and the kidneys make a large amount of urine.

Possible signs and symptoms of pancreatic late effects include frequent urination and being thirsty.

These and other signs and symptoms may be caused by pancreatic late effects or by other conditions:

• Frequent urination.
• Feeling very thirsty.
• Feeling very hungry.
• Weight loss for no known reason.
• Feeling very tired.
• Frequent infections, especially of the skin, gums, or bladder.
• Blurred vision.
• Cuts or bruises that are slow to heal.
• Numbness or tingling in the hands or feet.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the pancreas.

These and other tests and procedures may be used to detect or diagnose pancreatic late effects:

• Glycated hemoglobin (A1C) test: A procedure in which a sample of blood is drawn and the amount of glucose that is attached to red blood cells is measured. A higher than normal amount of glucose attached to red blood cells can be a sign of diabetes mellitus.
• Fasting blood sugar test: A test in which a blood sample is checked to measure the amount of glucose in the blood. This test is done after the patient has had nothing to eat overnight. A higher than normal amount of glucose in the blood can be a sign of diabetes mellitus.

Thyroid late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause thyroid late effects:

• Acute lymphoblastic leukemia (ALL).
• Brain tumors.
• Head and neck cancers.
• Hodgkin lymphoma.
• Neuroblastoma.
• Cancers treated with a stem cell transplant.

Radiation therapy to the head and neck increases the risk of thyroid late effects.

The risk of thyroid late effects may be increased in childhood cancer survivors after treatment with any of the following:

• Radiation therapy to the thyroid as part of radiation therapy to the head and neck or to the pituitary gland in the brain.
• Total-body irradiation (TBI) as part of a stem cell transplant.
• Chemotherapy.
• mIBG (radioactive iodine) therapy for neuroblastoma.

The risk also is increased in females, in survivors who were a young age at the time of treatment, in survivors who had a higher radiation dose, and as the time since diagnosis and treatment gets longer.

Late effects that affect the thyroid may cause certain health problems.

Thyroid late effects and related health problems include the following:

• Hypothyroidism (not enough thyroid hormone): This is the most common thyroid late effect. It usually occurs 2 to 5 years after treatment ends but may occur later. It is more common in girls than boys.
• Hyperthyroidism (too much thyroid hormone): It usually occurs 3 to 5 years after treatment ends.
• Goiter (an enlarged thyroid).
• Lumps in the thyroid: Usually occur 10 or more years after treatment ends. It is more common in girls than boys. These growths may be benign (not cancerous) or malignant (cancer).

Signs and symptoms of thyroid late effects depend on whether there is too little or too much thyroid hormone in the body.

These and other signs and symptoms may be caused by thyroid late effects or by other conditions:

Hypothyroidism (too little thyroid hormone)

• Feeling tired or weak.
• Being more sensitive to cold.
• Pale, dry skin.
• Coarse and thinning hair.
• Brittle fingernails.
• Hoarse voice.
• Puffy face.
• Muscle and joint aches and stiffness.
• Constipation.
• Menstrual periods that are heavier than normal.
• Weight gain for no known reason.
• Depression or trouble with memory or being able to concentrate.

Rarely, hypothyroidism does not cause any symptoms.

Hyperthyroidism (too much thyroid hormone)

• Feeling nervous, anxious, or moody.
• Trouble sleeping.
• Feeling tired or weak.
• Having shaky hands.
• Having a fast heartbeat.
• Having red, warm skin that may be itchy.
• Having fine, soft hair that is falling out.
• Having frequent or loose bowel movements.
• Weight loss for no known reason.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the thyroid.

These and other tests and procedures may be used to detect or diagnose thyroid late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. The blood may be checked for abnormal levels of thyroid-stimulating hormone (TSH) or free thyroxine (T4).
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later. This procedure can show the size of the thyroid and whether there are nodules (lumps) on the thyroid.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of thyroid late effects. If tests are needed, find out how often they should be done.

Neuroendocrine late effects may be caused after treatment for certain childhood cancers.

The neuroendocrine system is the nervous system and the endocrine system working together.

Treatment for these and other childhood cancers may cause neuroendocrine late effects:

• Brain and spinal cord tumors.
• Acute lymphoblastic leukemia (ALL).
• Nasopharyngeal cancer.
• Cancers treated with total-body irradiation (TBI) before a stem cell transplant.

Treatment that affects the hypothalamus or pituitary gland increases the risk of neuroendocrine system late effects.

Childhood cancer survivors have an increased risk for neuroendocrine late effects. These effects are caused by radiation therapy to the brain in the area of the hypothalamus. The hypothalamus controls the way hormones are made and released into the bloodstream by the pituitary gland. Radiation therapy may be given to treat cancer near the hypothalamus or as total-body irradiation (TBI) before a stem cell transplant. These effects are also caused by surgery in the area of the hypothalamus or pituitary gland.

Childhood cancer survivors who have neuroendocrine late effects may have low levels of any of the following hormones made in the pituitary gland and released into the blood:

• Growth hormone (GH; helps promote growth and control metabolism).
• Adrenocorticotropic hormone (ACTH; controls the making of glucocorticoids).
• Prolactin (controls the making of breast milk).
• Thyroid-stimulating hormone (TSH; controls the making of thyroid hormones).
• Luteinizing hormone (LH; controls reproduction).
• Follicle-stimulating hormone (FSH; controls reproduction).

Late effects that affect the hypothalamus may cause certain health problems.

Neuroendocrine late effects and related health problems include the following:

• Growth hormone deficiency: A low level of growth hormone is a common late effect of radiation to the brain in childhood cancer survivors. The higher the radiation dose and the longer the time since treatment, the greater the risk of this late effect. A low level of growth hormone may also occur in childhood ALL and stem cell transplant survivors who received radiation therapy to the brain and spinal cord and/or chemotherapy.
  A low level of growth hormone in childhood results in adult height that is shorter than normal. If the child's bones have not fully developed, low growth hormone levels may be treated with growth hormone replacement therapy beginning one year after the end of treatment.
• Adrenocorticotropin deficiency: A low level of adrenocorticotropic hormone is an uncommon late effect. It may occur in childhood brain tumor survivors, survivors with low growth hormone levels or central hypothyroidism, or after radiation therapy to the brain.
  Symptoms of deficiency may not be severe and may not be noticed. Signs and symptoms of adrenocorticotropin deficiency include the following:

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  Weight loss for no known reason.

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  Not feeling hungry.

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  Nausea.

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  Vomiting.

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  Low blood pressure.

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  Feeling tired.

  Low levels of adrenocorticotropin may be treated with hydrocortisone therapy.
• Hyperprolactinemia: A high level of the hormone prolactin may occur after a high dose of radiation to the brain or surgery that affects part of the pituitary gland. A high level of prolactin may cause the following:

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  Puberty at a later age than normal.

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  Flow of breast milk in a woman who is not pregnant or breast-feeding.

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  Less frequent or no menstrual periods or menstrual periods with a very light flow.

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  Hot flashes (in women).

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  Inability to become pregnant.

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  Inability to have an erection needed for sexual intercourse.

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  Lower sex drive (in men and women).

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  Osteopenia (low bone mineral density).

  Sometimes there are no signs and symptoms. Treatment is rarely needed.
• Thyroid-stimulating hormone deficiency (central hypothyroidism): A low level of thyroid hormone may occur very slowly over time after radiation therapy to the brain.
  Sometimes the symptoms of thyroid-stimulating hormone deficiency are not noticed. Low thyroid hormone levels may cause slow growth and delayed puberty, as well as other symptoms. A low level of thyroid hormone may be treated with thyroid hormone replacement therapy.
• Luteinizing hormone or follicle-stimulating hormone deficiency: Low levels of these hormones can cause different health problems. The type of problem depends on the radiation dose.
  Childhood cancer survivors who were treated with lower doses of radiation to the brain may develop central precocious puberty (a condition that causes puberty to start before age 8 years in girls and 9 years in boys). This condition may be treated with gonadotropin-releasing hormone (GnRH) agonist therapy to delay puberty and help the child's growth.
  Childhood cancer survivors who were treated with higher doses of radiation to the brain may have low levels of luteinizing hormone or follicle-stimulating hormone. This condition may be treated with sex hormone replacement therapy. The dose will depend on the child's age and whether the child has reached puberty.
• Central diabetes insipidus: Central diabetes insipidus may be caused by the absence of or low amounts of all of the hormones made in the front part of the pituitary gland and released into the blood. It may occur in childhood cancer survivors treated with surgery in the area of the hypothalamus or pituitary gland. Signs and symptoms of central diabetes insipidus may include the following:

  • Having large amounts of urine or unusually wet diapers.
  • Feeling very thirsty.
  • Headache.
  • Trouble with vision.
  • Slowed growth and development.
  • Weight loss for no known reason.
  Treatment may include hormone replacement therapy with vasopressin, the hormone that controls the amount of urine that is made in the body.

Certain tests and procedures are used to detect (find) and diagnose health problems in the neuroendocrine system.

These and other tests and procedures may be used to detect or diagnose thyroid late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry study: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Blood hormone studies: A procedure in which a blood sample is checked to measure the amounts of certain hormones released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. The blood may be checked for abnormal levels of follicle-stimulating hormone, luteinizing hormone, estradiol, testosterone, cortisol, or free thyroxine (T4).
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterol in the blood.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of neuroendocrine late effects. If tests are needed, find out how often they should be done.

Metabolic syndrome is more likely to occur after treatment for certain childhood cancers.

Metabolic syndrome is a group of medical conditions that includes having too much fat around the abdomen and at least two of the following:

• High blood pressure.
• High levels of triglycerides and low levels of high-density lipoprotein (HDL) cholesterol in the blood.
• High levels of glucose (sugar) in the blood.

Treatment for these and other childhood cancers may cause metabolic syndrome to occur later in life:

• Acute lymphoblastic leukemia (ALL).
• Cancers treated with a stem cell transplant.
• Cancers treated with radiation to the abdomen, such as Wilms tumor or neuroblastoma.

Radiation therapy increases the risk of metabolic syndrome.

The risk of metabolic syndrome may be increased in childhood cancer survivors after treatment with any of the following:

• Radiation therapy to the brain or abdomen.
• Total-body irradiation (TBI) as part of a stem cell transplant.

Certain tests and procedures are used to detect (find) and diagnose metabolic syndrome.

These and other tests and procedures may be used to detect or diagnose metabolic syndrome:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterol in the blood.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of metabolic syndrome. If tests are needed, find out how often they should be done.

Metabolic syndrome may cause heart and blood vessel disease and diabetes.

Metabolic syndrome is linked to an increased risk of heart and blood vessel disease and diabetes. Health habits that decrease these risks include:

• Having a healthy weight.
• Eating a heart-healthy diet.
• Having regular exercise.
• Not smoking.

Obesity is a late effect that is more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause obesity:

• Acute lymphoblastic leukemia (ALL).
• Brain tumors, especially craniopharyngiomas.
• Cancers treated with radiation to the brain, including total-body irradiation (TBI) as part of a stem cell transplant.

Radiation therapy to the brain increases the risk of obesity.

The risk of obesity increases after treatment with the following:

• Radiation therapy to the brain.
• Surgery that damages the hypothalamus or pituitary gland.

The following may also increase the risk of obesity:

• Being diagnosed with cancer when aged 5 to 9 years.
• Being female.
• Having growth hormone deficiency or low levels of the hormone leptin.
• Not doing enough physical activity to stay at a healthy body weight.
• Taking an antidepressant called paroxetine.

Childhood cancer survivors who get enough exercise and have a normal amount of anxiety have a lower risk of obesity.

Certain tests and procedures are used to detect (find) and diagnose obesity.

These and other tests and procedures may be used to detect or diagnose obesity:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as glucose, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
• Lipid profile studies: A procedure in which a blood sample is checked to measure the amounts of triglycerides, cholesterol, and low- and high-density lipoprotein cholesterol in the blood.

Obesity may be measured by weight, body mass index, percent of body fat, or size of the abdomen (belly fat).

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of obesity. If tests are needed, find out how often they should be done.

Bone and joint late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause bone and joint late effects:

• Acute lymphoblastic leukemia (ALL).
• Bone cancer.
• Brain and spinal cord tumors.
• Ewing sarcoma.
• Head and neck cancers.
• Neuroblastoma.
• Non-Hodgkin lymphoma.
• Osteosarcoma.
• Retinoblastoma.
• Soft tissue sarcoma.
• Wilms tumor.
• Cancers treated with a stem cell transplant.

Poor nutrition and not enough exercise may also cause bone late effects.

Surgery, chemotherapy, radiation therapy, and other treatments increase the risk of bone and joint late effects.

Possible signs and symptoms of bone and joint late effects include swelling over a bone or bone and joint pain.

These and other signs and symptoms may be caused by bone and joint late effects or by other conditions:

• Swelling over a bone or bony part of the body.
• Pain in a bone or joint.
• Redness or warmth over a bone or joint.
• Joint stiffness or trouble moving normally.
• A bone that breaks for no known reason or breaks easily.
• Short stature (being shorter than normal).
• One side of the body looks higher than the other side or the body tilts to one side.
• Always sitting or standing in a slouching position or having the appearance of a hunched back.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the bone and joint.

These and other tests and procedures may be used to detect or diagnose bone and joint late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits, past illnesses and treatments will also be taken. An exam of the bones and muscles by a specialist may also be done.
• Bone mineral density scan: An imaging test that measures bone density (the amount of bone mineral in a certain amount of bone) by passing x-rays with two different energy levels through the bone. It is used to diagnose osteoporosis (weak or thin bones that can break easily). Also called BMD scan, DEXA, DEXA scan, dual energy x-ray absorptiometric scan, dual x-ray absorptiometry, and DXA.
• X-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body, such as bones.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of bone and joint late effects. If tests are needed, find out how often they should be done.

Testicular late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause testicular late effects:

• Acute lymphoblastic leukemia (ALL).
• Germ cell tumors.
• Hodgkin lymphoma.
• Non-Hodgkin lymphoma.
• Sarcoma.
• Testicular cancer.
• Cancers treated with total-body irradiation (TBI) before a stem cell transplant.

Surgery, radiation therapy, and certain types of chemotherapy increase the risk of late effects that affect the testicles.

The risk of health problems that affect the testicles increases after treatment with one or more of the following:

• Surgery, such as the removal of a testicle, part of the prostate, or lymph nodes in the abdomen.
• Chemotherapy with alkylating agents, such as cyclophosphamide, dacarbazine, procarbazine, and ifosfamide.
• Radiation therapy to the abdomen, pelvis, or in the area of the hypothalamus in the brain.
• Total-body irradiation (TBI) before a stem cell transplant.

Late effects that affect the testicles may cause certain health problems.

Late effects of the testicles and related health problems include the following:

• Low sperm count: A zero sperm count or a low sperm count may be temporary or permanent. This depends on the radiation dose and schedule, the area of the body treated, and the age when treated.
• Infertility: The inability to father a child.
• Retrograde ejaculation: Very little or no semen comes out of the penis during orgasm.

After treatment with chemotherapy or radiation, the body’s ability to make sperm may come back over time.

Ovarian late effects are more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause ovarian late effects:

• Acute lymphoblastic leukemia (ALL).
• Germ cell tumors.
• Hodgkin lymphoma.
• Ovarian cancer.
• Wilms tumor.
• Cancers treated with total-body irradiation (TBI) before a stem cell transplant.

Radiation therapy to the abdomen and certain types of chemotherapy increase the risk of ovarian late effects.

The risk of ovarian late effects may be increased after treatment with any of the following:

• Surgery to remove one or both ovaries.
• Chemotherapy with alkylating agents, such as cyclophosphamide, mechlorethamine, cisplatin, ifosfamide, lomustine, busulfan, and especially procarbazine.
• Radiation therapy to the abdomen, pelvis, or lower back. In survivors who had radiation to the abdomen, the damage to the ovaries depends on the radiation dose, age at the time of treatment, and whether all or part of the abdomen received radiation.
• Radiation therapy to the abdomen or pelvis together with alkylating agents.
• Radiation therapy to the area near the hypothalamus in the brain.
• Total-body irradiation (TBI) before a stem cell transplant.

Late effects that affect the ovaries may cause certain health problems.

Ovarian late effects and other health related problems include the following:

• Early menopause, especially in women who had their ovaries removed or were treated with both an alkylating agent and radiation therapy to the abdomen.
• Changes in menstrual periods.
• Infertility (inability to conceive a child).
• Puberty does not begin.

After treatment with chemotherapy, the ovaries may begin to work over time.

Possible signs and symptoms of ovarian late effects include irregular or absent menstrual periods and hot flashes.

These and other signs and symptoms may be caused by ovarian late effects or by other conditions:

• Irregular or no menstrual periods.
• Hot flashes.
• Night sweats.
• Trouble sleeping.
• Mood changes.
• Lowered sex drive.
• Vaginal dryness.
• Inability to conceive a child.
• Sex traits, such as developing arm, pubic, and leg hair or having the breasts enlarge, do not occur at puberty.
• Osteoporosis (weak or thin bones that can break easily).

Talk to your child's doctor if your child has any of these problems.

Treatment for cancer may cause infertility in childhood cancer survivors.

The risk of infertility increases after treatment with the following:

• In boys, treatment with radiation therapy to the testicles.
• In girls, treatment with radiation therapy to the pelvis, including the ovaries and uterus.
• Radiation therapy to an area near the hypothalamus in the brain or lower back.
• Total-body irradiation (TBI) before a stem cell transplant.
• Chemotherapy with alkylating agents, such as cyclophosphamide, busulfan, and procarbazine.
• Surgery, such as the removal of a testicle or an ovary or lymph nodes in the abdomen.

Childhood cancer survivors may have late effects that affect pregnancy.

Late effects on pregnancy include increased risk of the following:

• High blood pressure.
• Miscarriage or stillbirth.
• Low birth-weight babies.
• Early labor and/or delivery.
• Delivery by Cesarean section.
• The fetus is not in the right position for birth (for example, the foot or buttock is in position to come out before the head).

There are methods that may be used to help childhood cancer survivors have children.

The following methods may be used so that childhood cancer survivors can have children:

• Freezing the eggs or sperm before cancer treatment in patients who have reached puberty.
• Testicular sperm extraction (the removal of a small amount of tissue containing sperm from the testicle).
• Intracytoplasmic sperm injection (an egg is fertilized with one sperm that is injected into the egg outside the body).
• In vitro fertilization (IVF) (eggs and sperm are placed together in a container, giving the sperm the chance to enter an egg).

Children of childhood cancer survivors are not affected by the parent’s previous treatment for cancer.

The children of childhood cancer survivors do not appear to have an increased risk of birth defects, genetic disease, or cancer.

Hearing problems are a late effect that is more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause hearing late effects:

• Brain tumors.
• Head and neck cancers.
• Neuroblastoma.
• Retinoblastoma.

Radiation therapy to the brain and certain types of chemotherapy increase the risk of hearing loss.

The risk of hearing loss is increased in childhood cancer survivors after treatment with the following:

• Certain types of chemotherapy, such as cisplatin or high-dose carboplatin.
• Radiation therapy to the brain.

The risk of hearing loss is greater in childhood cancer survivors who were young at the time of treatment (the younger the child, the greater the risk), were treated for a brain tumor, or received radiation therapy to the brain and chemotherapy at the same time.

Hearing loss is the most common sign of hearing late effects.

These and other signs and symptoms may be caused by hearing late effects or by other conditions:

• Hearing loss.
• Ringing in the ears.
• Feeling dizzy.
• Too much hardened wax in the ear.

Hearing loss may occur during treatment, soon after treatment ends, or several months or years after treatment ends and worsen over time. Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the ear and hearing problems.

These and other tests and procedures may be used to detect or diagnose hearing late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Otoscopic exam: An exam of the ear. An otoscope is used to look at the ear canal and the eardrum to check for signs of infection or hearing loss. Sometimes the otoscope has a plastic bulb that is squeezed to release a small puff air into the ear canal. In a healthy ear, the eardrum will move. If there is fluid behind the eardrum, it will not move.
• Hearing test: A hearing test can be done in different ways depending on the child's age. The test is done to check if the child can hear soft and loud sounds and low- and high-pitched sounds. Each ear is checked separately. The child may also be asked if he or she can hear the high-pitched hum of a tuning fork when it is placed behind the ear or on the forehead.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of hearing late effects. If tests are needed, find out how often they should be done.

Eye and vision problems are a late effect that is more likely to occur after treatment for certain childhood cancers.

Treatment for these and other childhood cancers may cause eye and vision late effects:

• Retinoblastoma, rhabdomyosarcoma, and other tumors of the eye.
• Brain tumors.
• Head and neck cancers.
• Acute lymphoblastic leukemia (ALL).
• Cancers treated with total-body irradiation (TBI) before a stem cell transplant.

Radiation therapy to the brain or head increases the risk of eye problems or vision loss.

The risk of eye problems or vision loss may be increased in childhood cancer survivors after treatment with any of the following:

• Radiation therapy to the brain, eye, or eye socket.
• Surgery to remove the eye or a tumor near the optic nerve.
• Certain types of chemotherapy, such as busulfan or corticosteroids.
• Total-body irradiation (TBI) as part of a stem cell transplant.
• Stem cell transplant (and a history of chronic graft-versus-host disease).

Late effects that affect the eye may cause certain health problems.

Eye late effects and related health problems include the following:

• Having a small eye socket that affects the shape of the child’s face as it grows.
• Loss of vision.
• Vision problems, such as cataracts or glaucoma.
• Not being able to make tears.
• Damage to the optic nerve and retina.
• Eyelid tumors.

Possible signs and symptoms of eye and vision late effects include changes in vision and dry eyes.

These and other signs and symptoms may be caused by eye and vision late effects or by other conditions:

• Changes in vision, such as:

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  Not being able to see objects that are close.

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  Not being able to see objects that are far away.

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  Double vision.

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  Cloudy or blurred vision.

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  Colors seem faded.

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  Being sensitive to light or trouble seeing at night.

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  Seeing a glare or halo around lights at night.

• Dry eyes that may feel like they are itchy, burning, or swollen, or like there is something in the eye.
• Eye pain.
• Eye redness.
• Having a growth on the eyelid.
• Drooping of the upper eyelid.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the eye and vision problems.

These and other tests and procedures may be used to detect or diagnose eye and vision late effects:

• Eye exam with dilated pupil: An exam of the eye in which the pupil is dilated (widened) with medicated eye drops to allow the doctor to look through the lens and pupil to the retina. The inside of the eye, including the retina and the optic nerve, is checked using an instrument that makes a narrow beam of light. This is sometimes called a slit-lamp exam. If there is a tumor, the doctor may take pictures over time to keep track of changes in the size of the tumor and how fast it is growing.
• Indirect ophthalmoscopy: An exam of the inside of the back of the eye using a small magnifying lens and a light.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of eye and vision late effects. If tests are needed, find out how often they should be done.

Certain types of chemotherapy increase the risk of kidney late effects.

The risk of health problems that affect the kidney increases after treatment with the following:

• Chemotherapy including cisplatin, carboplatin, ifosfamide, and methotrexate.
• Radiation therapy to the abdomen or middle of the back.
• Surgery to remove part or all of a kidney.
• Stem cell transplant.

The risk of kidney late effects is greater in childhood cancer survivors who are treated with a combination of surgery, chemotherapy, and/or radiation therapy.

The following may also increase the risk of kidney late effects:

• Having cancer in both kidneys.
• Having a genetic syndrome that increases the risk of kidney problems, such as Denys-Drash syndrome or WAGR syndrome.
• Being treated with more than one type of treatment.

Late effects that affect the kidney may cause certain health problems.

Kidney late effects or related health problems include the following:

• Damage to the parts of the kidney that filter and clean the blood.
• Damage to the parts of the kidney that remove extra water from the blood.
• Loss of electrolytes, such as magnesium, calcium, or potassium, from the body.
• Hypertension (high blood pressure).

Possible signs and symptoms of kidney late effects include problems urinating and swelling of the feet or hands.

These and other signs and symptoms may be caused by kidney late effects or by other conditions:

• Feeling the need to urinate without being able to do so.
• Frequent urination (especially at night).
• Trouble urinating.
• Feeling very tired.
• Swelling of the legs, ankles, feet, face, or hands.
• Itchy skin.
• Nausea or vomiting.
• A metal-like taste in the mouth or bad breath.
• Headache.

Sometimes there are no signs or symptoms in the early stages. Signs or symptoms may appear as damage to the kidney continues over time. Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the kidney.

These and other tests and procedures may be used to detect or diagnose kidney late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry study: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as magnesium, calcium, and potassium, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance may be a sign of kidney disease.
• Urinalysis: A test to check the color of urine and its contents, such as sugar, protein, red blood cells, and white blood cells.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs, such as the kidney, and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of kidney late effects. If tests are needed, find out how often they should be done.

Health habits that promote healthy kidneys are important for survivors of childhood cancer.

Childhood cancer survivors who had all or part of their kidney removed should talk to their doctor about the following:

• Whether it is safe to play sports that have a high risk of heavy contact or impact such as football or hockey.
• Bicycle safety and avoiding handlebar injuries.
• Wearing a seatbelt around the hips, not the waist.

Surgery to the pelvic area and certain types of chemotherapy increase the risk of bladder late effects.

The risk of health problems that affect the bladder increases after treatment with the following:

• Surgery to remove all or part of the bladder.
• Surgery to the pelvis, spine, or brain.
• Certain types of chemotherapy, such as cyclophosphamide or ifosfamide.
• Radiation therapy to areas near the bladder, pelvis, or urinary tract.
• Stem cell transplant.

Late effects that affect the bladder may cause certain health problems.

Bladder late effects and related health problems include the following:

• Hemorrhagic cystitis (inflammation of the inside of the bladder wall, which leads to bleeding).
• Thickening of the bladder wall.
• Trouble emptying the bladder.
• Incontinence.
• A blockage in the kidney, ureter, bladder, or urethra.
• Urinary tract infection (chronic).

Possible signs and symptoms of bladder late effects include changes in urination and swelling of the feet or hands.

These and other signs and symptoms may be caused by bladder late effects or by other conditions:

• Feeling the need to urinate without being able to do so.
• Frequent urination (especially at night).
• Trouble urinating.
• Feeling like the bladder does not empty completely after urination.
• Swelling of the legs, ankles, feet, face, or hands.
• Little or no bladder control.
• Blood in the urine.

Talk to your child's doctor if your child has any of these problems.

Certain tests and procedures are used to detect (find) and diagnose health problems in the bladder.

These and other tests and procedures may be used to detect or diagnose bladder late effects:

• Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Blood chemistry study: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as magnesium, calcium, and potassium, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance may be a sign of bladder problems.
• Urinalysis: A test to check the color of urine and its contents, such as sugar, protein, red blood cells, and white blood cells.
• Urine culture: A test to check for bacteria, yeast, or other microorganisms in the urine when there are symptoms of infection. Urine cultures can help identify the type of microorganism that is causing an infection. Treatment of the infection depends on the type of microorganism that is causing the infection.
• Ultrasound exam: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs, such as the bladder, and make echoes. The echoes form a picture of body tissues called a sonogram. The picture can be printed to be looked at later.

Talk to your child's doctor about whether your child needs to have tests and procedures to check for signs of bladder late effects. If tests are needed, find out how often they should be done.