Armstrong Gregory T, Ross Jordan D
St. Jude Children's Research Hospital.
The University of Tennessee Health Science Center College of Medicine.
Prog Pediatr Cardiol. 2014 Sep 1;36(1-2):19-26. doi: 10.1016/j.ppedcard.2014.09.003.
The survival rate for childhood cancer is steadily improving, and the current estimate for the prevalence of childhood cancer survivors in the United States is 420,000. With this encouraging trend and the aging of this population, there is an ever-increasing responsibility to identify adult survivors of childhood cancer with adverse health outcomes related to cancer treatment across the span of their lives. To accomplish this, large cohort studies have been developed to follow survivors longitudinally. Compared to siblings, survivors have a higher cumulative incidence of morbidity and mortality, and this gap in incidence only widens with age. One of the most significant late toxicities in survivors is late onset cardiotoxicity, largely due to anthracycline and chest-directed radiation exposure. Survivors also have an increased prevalence of traditional cardiovascular risk factors as they age, which potentiates the risk for major cardiac events. Prevention is essential. Minimizing anthracycline dose exposure in pediatric cancer patients is a primary method of cardioprotection. Dexrazoxane and enalapril have also been studied as primary (pre-exposure) and secondary (post-exposure) cardioprotecant agents, respectively. Additionally, the Children's Oncology Group has published exposure-driven, risk-based screening guidelines for long-term follow-up, which may be a cost-effective way to identify subclinical cardiac disease before progression to clinical presentation. Ongoing research is needed to determine the most effective diagnostic modality for screening (e.g. echocardiography), and the most effective intervention strategies to improve long-term outcomes.
儿童癌症的生存率正在稳步提高，目前美国儿童癌症幸存者的患病率估计为42万。随着这一令人鼓舞的趋势以及这一人群的老龄化，识别出在其一生中有与癌症治疗相关的不良健康后果的成年期儿童癌症幸存者的责任日益重大。为了实现这一目标，已经开展了大型队列研究来对幸存者进行纵向跟踪。与兄弟姐妹相比，幸存者的发病率和死亡率累积发生率更高，而且这种发病率差距只会随着年龄的增长而扩大。幸存者中最显著的晚期毒性之一是迟发性心脏毒性，这主要是由于蒽环类药物和胸部定向放疗暴露所致。随着年龄的增长，幸存者患传统心血管危险因素的患病率也会增加，这会增加发生重大心脏事件的风险。预防至关重要。尽量减少儿科癌症患者的蒽环类药物剂量暴露是心脏保护的主要方法。右丙亚胺和依那普利也分别作为主要（暴露前）和次要（暴露后）心脏保护剂进行了研究。此外，儿童肿瘤学组已经发布了基于暴露驱动、风险的长期随访筛查指南，这可能是在进展为临床表现之前识别亚临床心脏病的一种具有成本效益的方法。需要进行持续研究以确定最有效的筛查诊断方式（如超声心动图）以及改善长期结局的最有效干预策略。
