Cardiovascular and pulmonary Treatments that expose patients to chemotherapy, radiation to the chest, and selected targeted agents can result in cardiovascular and pulmonary late effects. Factors that increase risks for these effects include treatment for Hodgkin lymphoma as a child; age 65 years and older; and treatment with higher doses of chemotherapy, trastuzumab, or anthracyclines. Most common cardiac issues include congestive heart failure, coronary artery disease, arrhythmia, and stroke.

Chest radiotherapy, chemotherapy, chronic and long term use of prednisone, and mTOR inhibitors and many targeted therapies lead to lung problems for survivors. These manifest as a change in lung function and difficulty breathing.

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Endocrine system Exposure to radiation therapy and alkylating agents increase late effects such as menopausal symptoms in women, but navigators should remember that men who have had their testicles removed or are on antiandrogen therapy for prostate cancer are also at risk for menopausal symptoms. Other late effects include adrenal dysfunction, thyroid insufficiency, insulin resistance and diabetes, and lymphedema.

Second cancers These are classified into 2 broad categories. Treatment-related leukemias, or liquid tumors, may emerge abruptly and progress rapidly within 3 years of treatment (T-AML). Some liquid tumors emerge more slowly (5 to 12 years later), perhaps beginning as myelodysplasia (MDS), often becoming a leukemia. Alkylating agents and epipodophyllotoxins are known to increase the risk of these cancers. But radiotherapy is not likely to cause blood tumors unless the field includes the spleen or bone marrow.

Treatment-related solid tumors (second solid tumors) such as Hodgkin’s lymphoma, testicular, breast, kidney, and lung cancers, and certain tumors within the spleen or marrow are linked to radiation therapy. Secondary tumors often begin to develop approximately 15 years after treatment, and almost always in or near sites of previous radiation ports. Radiation-induced tumors are more prevalent in survivors of childhood cancers than in survivors who underwent treatment as adults.

Chemotherapy is rarely associated with secondary solid cancers, but risk is increased due to DNA damage caused by the treatment. Some targeted therapy (vemurafenib and dabrafenib, used to treat melanoma) target the BRAF protein and incur a higher risk of squamous cell carcinoma of the skin.

More recently identified late effects are cognitive effects and posttraumatic stress disorder (PTSD).

Cognitive effects As many as 75% of people with cancer experience cognitive effects during treatment; these effects persist for months after completing treatment in 35% of patients. In addition, 10% of patients experience cognitive effects as a late effect of their treatment. The extent of these symptoms often depends on age, stress level, history of depression or anxiety, coping abilities, and access to emotional and psychological resources.

Symptoms of cognitive effects include trouble concentrating, focusing, or paying attention; mental fog or disorientation; difficulty with spatial orientation; and memory loss or difficulty remembering things (especially names, dates, or phone numbers).

Factors that increase risk of cognitive symptoms include radiotherapy to the head and neck or total body irradiation; damage or disruption to areas of the brain from biopsy or tumor resection; and hormone therapy, immunotherapy, and some medications (eg, antinausea medications, antibiotics, pain medications). Infections, especially those of the brain and spinal cord and infections that cause a high fever, brain cancer, metastasis to the brain, and other symptoms related to cancer or cancer treatments can also result in cognitive issues for survivors.

Posttraumatic stress disorder PTSD is an anxiety disorder that can affect people with a history of cancer. Recent study has found that 1 in 4 women with newly diagnosed breast cancer experienced PTSD. Its triggers include diagnosis with the disease; diagnosis of an advanced cancer; undergoing painful tests and treatments; pain from the cancer or physical issues; receiving test results; prolonged hospital stays or treatment; and cancer recurrence or potential for recurrence.

Symptoms of PTSD include nightmares or flashbacks; avoidance of places, events, people, or things that bring on bad memories; strong feelings of guilt, hopelessness, or shame; trouble sleeping or concentrating; and continuous feelings of anger. Its risk factors are previous PTSD experiences or other mental health conditions prior to the cancer diagnosis, high levels of overall stress, use of avoidance strategies to cope with stress (eg, drugs or alcohol), less formal education, and low or no income. In addition, women from minority groups and single people are at higher risk of experiencing PTSD.