Providing Primary Care for Long-Term Survivors of Childhood Acute Lymphoblastic Leukemia

Urologic late effects

Cyclophosphamide is a long-recognized cause of hemorrhagic cystitis and a well-established bladder carcinogen. In a retrospective review¹⁵⁰ of 314 children with ALL who were treated with cyclophosphamide between 1963 and 1973, 8% developed hemorrhagic cystitis. The frequency of diagnosis was not related to age or sex, but African American children were at higher risk. Cyclophosphamide-induced hemorrhagic cystitis generally presents during therapy, with children complaining of gross hematuria or irritative voiding complaints.¹⁵¹ Concurrent treatment with oral sodium 2-mercapatoethanesulfonate appears to markedly decrease the incidence of cyclophosphamide-induced hemorrhagic cystitis.¹⁵² In a nested case-control study of survivors of non–Hodgkin’s lymphoma, Travis and colleagues¹⁵³ reported that there was a 2.4-fold increased risk of bladder cancer in patients treated with cumulative dosages of cyclophosphamide lower than 20 g. Because of the risk of chronic hemorrhagic cystitis and bladder cancer, ALL survivors treated with cyclophosphamide should have periodic screening urinalysis, and their review of systems should include voiding problems.

Alopecia

Alopecia is a bothersome late effect secondary to treatment with 24 Gy CRT for which there are no available treatments. In a retrospective study of 273 ALL survivors treated with CRT, 10% had alopecia.¹⁵⁴

Acknowledgement

Dr Oeffinger received partial support for this work through the American Academy of Family Physicians Foundation Advanced Research Training Grant and the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program.

We would like to thank Drs George Buchanan, Melissa Hudson, and Neyssa Marina for their critical review of this manuscript and Ms Laura Snell and Dr James Tysinger for their editing assistance.