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My Patient is a Cancer Survivor: Now What? · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit depending on our topic or podcast.
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Childhood leukemia is in the news, as you may know.
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According to CNN, 15-year-old Carlo Acutis will become the Catholic Church's
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first millennial saint. He passed away from leukemia in 2006.
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Leukemia is the most common form of childhood cancer, and 80% of children will survive cancer today.
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And that's what we're talking about here on Pediatrics Now today is the crucial
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role pediatric practitioners play in caring for patients who are cancer survivors.
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I'm thrilled today because joining me here in the podcast studio is Dr. Shafka Shah.
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Dr. Shah attended medical school at Duke University and went on to residency at Emory University.
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And Dr. Shah, you have been focused on pediatric cancer for about 30 years now.
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Yes, indeed. It's incredible, the work you're doing and what your team does.
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You started out as a researcher and you were, in fact, inspired by the bravery
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of the kids you saw going through cancer?
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That's correct. I actually thought in my early days as an undergrad at Johns
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Hopkins that I would really focus on a research career.
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And I was very excited to learn about the immune system and its role in cancer
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and new treatments that were being developed, such as bone marrow transplant. planned.
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And so I really thought that it would be intriguing to work in a laboratory,
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maybe in a mouse model of leukemia.
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And I was, of course, urged by some of my faculty mentors to consider going
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over to the Children's Hospital and volunteering just to kind of get a sense
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of the type of children that might benefit from the research.
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And so I did. I volunteered really as a child life assistant for a couple of
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years at Johns Hopkins Hospital in Baltimore, Maryland.
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And I was able to meet several children that had gone through bone marrow transplants for leukemia.
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And in those days, you know, the supportive care was not as robust as it is now.
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Children really fought for their lives as they went through bone marrow transplant.
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And I remember meeting several young children that...
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Really, in my mind, were super brave. You know, they had a lot of medicines
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they had to take every day. They had to have procedures done.
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The nurses would ask them to be compliant with all the regimens to try and keep
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them as healthy as possible.
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And, you know, they couldn't see their siblings for weeks on end.
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You know, yet many of those children, they adjusted to the experience.
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And they, for the most part, were very brave, you know, for weeks as they stayed
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in the hospital undergoing the transplants.
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And so they were a big motivation for me. And I, you know, I felt that I wanted
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to be part of the clinical team taking care of them.
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And so I kind of reconfigured my rotations in my last year of,
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you know, undergrad and decided I needed to kind of get more clinical exposure
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and eventually did decide to go to medical school at that point.
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And now you're a married mother of three.
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Yes, I have three children and mine are all out of the house,
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which is great. Yes, how's that going?
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You know, you think life might be a little bit less busy when they're not under your feet all the time.
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But I still in my mind, I have to manage their schedules.
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And the summertime is a busy time if they're traveling or they're trying to
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find work across the country or across the world. old.
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You know, oftentimes we have to drive them so they'll have vehicles when they're
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in California or Baltimore.
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And so it's a busy time for my husband and myself, even though they're not in the house anymore.
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And are all three of your children in college?
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Actually, one is in college right now. She's in her third year studying engineering.
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And the middle one just graduated from college in Indiana and is going to be
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doing a master's in music and classical music performance.
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And so that's fun because we get to go see him perform from
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time to time if we if we're good at planning our call
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schedules nice and then the older one
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is living in college station now she's completed a master's
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in animal science and is trying to think about you know potentially applying
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to vet school next year so she's close to us which is nice you know if we ever
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need a little hug from her you know she's usually willing to come home for a
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good meal and she has friends in the area So we kind of entice her to come visit from time to time.
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And what an incredible program for animal science at A&M.
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It is. It's a very robust infrastructure for research in a variety of fields,
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you know, from orthopedics to cardiac health.
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She actually has been assisting in a prostate cancer research in pigs, apparently.
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There's quite a bit of animal models for human disease that are being used in
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many research studies on that campus.
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I'm amazed at how much work is going on on that campus.
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And your husband is a physician as well? He is.
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He's a urologist, so he takes care of the other end of the spectrum, I guess.
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So the older people, mostly men, but he recently just transitioned to the VA
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a year or so ago, and he enjoys that area because he's able to spend time with the veterans.
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And since he's an ex-military doc, he has, you know, things in common,
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similar jokes that they have about their superiors and deployments and such.
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So I think he's found that niche to be very suited to his personality.
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Well, and now you're, Shafka, you work at University Hospitals Pediatric Cancer
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Clinic, and you're on faculty here at the University of Texas Health Science Center.
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And as a specialist, you know more than anyone that crucial role that pediatricians
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play once their patient has been diagnosed with cancer.
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They're a cancer survivor at that moment of diagnosis.
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And it is really crucial what is done.
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But a lot of pediatricians, I mean, how are you supposed to know what to do?
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They're expected to know so much. So what would you like to say? It is very challenging.
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I mean, I think we have to admit that cancer therapy has changed quite a bit in the last 30 years.
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And it used to be we had maybe three protocols for leukemia.
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And now, you know, depending upon what type of leukemia, there may be 10,
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12 different protocols that we're using.
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And so the treatment exposures are very different. different just the type of therapies.
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There's immunotherapies now that we didn't have 10 years ago,
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and the complexity of the bone marrow transplants are, you know,
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it's another degree of complexity that's added for some patients that are really high risk.
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So even just within that one diagnosis of leukemia, you know,
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you may have a child that has very, very good outlook without a lot of long-term
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health issues, or you might have someone that had to have some immunotherapies, went on to transplant,
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maybe even had a second transplant, and they may have quite a few health problems
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that require management.
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So I think as a pediatrician, when you're seeing somebody coming in the office, you're.
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You may not be aware of what kind of complications, you know, they are at risk for.
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And so we like to provide education either at grand rounds or through even one-to-one
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phone calls with pediatricians as they accept the patients back once they're
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off treatment to really review the history of the treatment that the patient has received.
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And each patient will receive a document called a treatment summary.
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And we urge them to take that to their pediatrician's appointment so the chart
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can be complete on the end of the pediatrician about all the different exposures
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that the child was treated with.
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And it's important to document that well because there may be a need at some
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point for the child to go to see another specialist, such as endocrinologist or neurologist.
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And, you know, the way insurance companies are, you have to have documentation
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to justify those specialist referrals.
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And so the more information you have about the history of the child,
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I think we'll be better able to support the child with the type of referrals they need.
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But I definitely want to be here as a resource.
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You know, we definitely see these patients very regularly in the first five
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years of follow-up care as a new cancer survivor.
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But most patients after five years, we really are seeing only once a year.
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And so by then, the patients should really be back in their primary care home,
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either in pediatric practice or a family practice.
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And we really do need help from the primary care practice to make the referrals.
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Communicate with the schools, and to really support the parent and,
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you know, the child as they're going through their journey as a cancer survivor. Right.
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So pediatric cancer patients, cancer survivors, are at risk for age-related
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cancers that can happen much sooner?
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Right. So one way to think about all the treatments that we use to treat cancer,
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so that would be chemotherapies, radiation treatments, maybe surgeries such
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as removal of a kidney, for example.
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All of these lead to an accelerated aging process. And it's kind of interesting
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that researchers are looking at biochemical features or features of the DNA
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in patients who are long-term cancer survivors.
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And you can see the same kind of changes in their telomeres,
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for example, that you would see in like a 50-year-old.
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And so this accelerated aging process makes the cancer survivors at higher risk
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of developing things like heart problems, lung issues, kidney issues.
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Endocrine issues, diabetes, at a rate that's faster than the general population at the same age.
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And so we definitely see that patients, when they go to their primary care physicians
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and they're concerned about some of these issues, sometimes the primary care
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doctors look at them and say, well, you're only 25. five, why are you worried
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about high blood pressure?
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And, you know, that patient who's a leukemia survivor may have received a lot
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of anthracycline and their heart function is not great and they're not really
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going to tolerate high blood pressure as well as a young person who did not
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have the cancer experience.
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And so being able to provide that kind of support and making sure that the documentation
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and the chart supports the need to go to the specialist, I think helps patients
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get the appropriate assessments.
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You know, many of them, we know, at least one in four childhood cancer survivors
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will have a serious enough long-term complication that they will need ongoing
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follow-up and treatment, and it may be life-threatening if it's not managed appropriately.
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So a one-year-old girl, Sally, who she had cancer as a one-year-old,
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and she's now 12, and she's going to the pediatrician.
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Right. So I think it's kind of a unique situation when you have a very young
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child diagnosed with cancer because they really may not remember very much of the treatment,
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especially if it was the type of cancer that required a fairly brief type of
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treatment, maybe six months to a year.
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That very young child, you know, really won't recognize the nurses in the clinic.
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They, you know, they'll be kind of surprised when they see pictures of themselves
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and they hear other people talking about what happened to them when they were young.
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But usually by the time they're teenagers, they want to know more about their history.
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You know, they probably have a scar from a surgery or a port-a-calf that they
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had when they were younger.
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And so we try to have that discussion with families to try to have an open discussion
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session with the teenager to explain to them that, yes, when you were young,
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you had all these illnesses.
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You were very good about getting your treatment. Fortunately,
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it worked, and you're now a long-term survivor.
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And one way that you can kind of get some support, especially to these teenagers,
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is to allow them to maybe meet other people that have been through a similar experience.
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So when they come back to see us, we try to encourage them to go back to maybe
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one of our kids camps where other childhood cancer survivors can attend and,
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you know, really kind of meet other people and see how they're coping as they're
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becoming teenagers and having to learn about their past stories.
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And the pediatrician can be supportive of that by allowing the teenagers as
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they get older to kind of own their history for them to use the terminology.
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I had neuroblastoma when I was one years old and I got chemotherapy.
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Just talking and directing the discussion to the teenager, I think,
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is a good way that pediatricians have of engaging them directly and giving them
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ownership of their own health.
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And you, in fact, have a patient where she is going to the camp and speaking
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to other kids about her past history.
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Yes, this child actually, because she was very young, it was kind of the first
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couple times we mentioned it, I think she just really didn't know,
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and it's not something her parents talk about really very much at home.
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Maybe they talk about it behind when she's not around, you know,
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not in her, not in front of her, to try to protect her in some sense.
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But, you know, I think this year the family was open. The mother was open to,
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you know, letting her daughter go and kind of experience the world and kind
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of learn lessons from other people.
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And our camps are set up such that there's a lot of support with counselors,
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many of whom are cancer survivors themselves, and staff from the hospitals and the psychology staff.
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Child Life even has been attending recently. So we can, you know,
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allow these children to explore their feelings and let them ask questions about
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their cancer journey in a supportive environment.
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So Sally is visiting her pediatrician.
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She's 12. It's important to make sure she's up on vaccines such as HPV.
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Exactly. So one common question we get from pediatricians is,
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is it safe to give vaccines to childhood cancer survivors?
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And during pediatric residency training, they do talk quite a bit about how
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children that go through cancer therapy,
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there may be a time point where you don't give them vaccines because their immune
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system is not necessarily going to respond to the vaccine.
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And so we delay vaccination in many cases for the routine childhood vaccines
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until patients are at least six months off treatment for most of the vaccines.
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And for live virus vaccines, we'll delay for 12 months.
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And for bone marrow transplant patients, those vaccinations are actually usually
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mandated at the transplant program.
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So the pediatricians don't have to be in charge of that vaccine catch up because
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that is a little bit different type of a schedule.
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But for patients who have had routine chemo and radiation,
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they're welcome to resume vaccinations after that six-month time point for most
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of the vaccines and the 12-month month time point for the live virus vaccines.
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And one common thing we see is that since the HPV vaccine is not required for
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school attendance in many states, it is something that is kind of one of the
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last vaccines pediatricians talk about.
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And especially if they're a cancer survivor, our feelings are that they are
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at higher risk of developing new cancers because of the primary cancer's therapy.
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And so we want to do all we can to reduce the risk of a new cancer.
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And the HPV vaccine is a vaccine to prevent cancer related to the HPV virus.
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And germ cell cancers in general are on the rise, so ovarian and testicular cancer.
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So that's another place where the pediatrician, especially in the teenage years, can help.
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Usually at the annual pediatrician checkups that many kids get maybe before
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school starts or before they start going to sports camps and such,
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it's a fairly comprehensive evaluation.
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Evaluation, and that's a good opportunity to provide guidance about pubertal
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changes and to talk to girls about,
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you know, what a normal breast exam is like and to talk to boys about their testicular exams.
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And, you know, while we don't want there to be excessive anxiety on the part of the teenagers,
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I think it's really an environment where the pediatrician can kind of get the
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child used to talking about their private anatomy and to learn what's normal for them.
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We definitely have seen situations where primarily boys, you know,
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have had some changes in their testicles and have not really talked to anybody,
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either a physician or even their parents until, you know, very late in the game.
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And testicular cancer usually is one that responds very well to cancer treatments with chemotherapy.
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But if it's advanced, you obviously have to get more treatment and more side
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effects from treatment will be seen.
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Of all the tumor types, it does seem like there's increased rate incidence in
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young people of testicular cancers or germ cell tumor type cancers.
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And so I think raising awareness about doing a complete exam when and patients
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are being seen by the pediatrician, I think that will help raise awareness. And you were saying that.
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Important rapport between the adolescent and the pediatrician and the pediatrician
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being able to say, if you notice anything different down there,
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tell someone, tell your parent, tell me.
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Right. Because I think we, you know, I think there's certainly some kids that
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are on the shy side and they may not really want to talk about or raise these issues.
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But if it could be, you know, year after year, the same provider, a pediatric practice,
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you know, talking to the child directly, most children will respond to that
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and will gain some confidence with that provider and be willing to have the exams done.
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I think a lot of times we don't want the children obviously to feel nervous or anxious about it.
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And so to try to normalize the experience through the pediatric office practice, I think helps.
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And for the looking out for ovarian cancer and testicular cancer,
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That's across the board for kids who have not had cancer and cancer survivors.
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Right. Just because the incidence does seem to be increasing in the area of the germ cell tumors.
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I think just as for many years, you know, women have been taught about how to
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examine their own breasts and to know what's normal for them and to seek advice
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from their providers if something is not normal.
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I think we could do a little bit better job of educating, especially the young
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males of the world, so that that's something that doesn't get forgotten.
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You know, I think many young men, when they go off to college,
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if they're healthy, they probably don't want to see the doctor at all.
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And they're busy in their lives. They have exams. They might be on sports teams.
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And so it's the last thing they want to do.
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And, you know, it may be very hard to schedule in their busy lives.
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So before they go off to college, if they can get that kind of education from
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the pediatrician, I think that would be very valuable.
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Shafka, so back to 12-year-old Sally. So she's getting the HPV vaccine.
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What else? So she should also make sure that when she is out at the camp that she's using sunscreen.
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That's going to be important. And finding shade when possible.
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Right. Wear a hat. Exactly. So common sense, things like that are important. I mean, the other area.
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They're much at higher risk for skin cancer. Especially if they have had radiation
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treatment, their risk for skin cancer is going to be significantly higher than
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the average population.
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But honestly, across the board, all populations in the U.S.
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And Australia apparently has extremely high rate of skin cancer.
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And so I think being proactive about it and talking about how to use sunscreen,
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that you need to reapply it if you're in the water after an hour,
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wear a hat, wear sun protective clothing if you're going to be in a pool for more than an hour.
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All those things are very beneficial. And if the pediatricians can emphasize
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sun protection, I think it's just another person providing guidance rather than
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just the mother. Yes, I was going to say, and that's so hard,
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especially with my teenage kids.
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And when I say something and they were out in the sun, we were on vacation last week by the ocean.
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It was wonderful, but I still could not get, not one of them would wear a hat.
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And it was so frustrating even to walk to the water.
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But I know when they go to the pediatrician and he says something to them,
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they do tend to follow it more readily. I think so.
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And if they hear the same message year after year, I think before they go off
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to college, they'll perhaps remember a little bit of the advice.
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But I would say more and more people are going to dermatologists with unusual
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lesions and having to be biopsied. And every now and then it does show cancer,
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even in younger children.
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Melanoma, for example, is not something that we typically hear in the childhood
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population, but that also seems to be increasing.
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And that is much more aggressive skin cancer. So we really don't like,
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you know, to hear that that is a trend. But I think sun protection is something
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that we definitely could be doing a better job.
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Some countries, you go to the beach and there's people handing out free sunscreen,
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free hats, cover-ups. I love it.
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So I think, you know, getting that message through is important, starting at a young age.
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The other thing that was kind of interesting for this young girl,
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even though she was treated for just, you know, about a six-month treatment
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course, she did have trouble with development of her teeth.
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And, you know, you can imagine in the first three years of life,
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that's something that is happening for everybody.
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And that's something that we also try to emphasize is make sure you're doing
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a very good job of learning how to brush your teeth independently,
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going to the dentist regularly.
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There's definitely an increased risk of caries and needing to do extractions
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in our patient population.
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So that's something the pediatrician can also discuss with families in their
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routine clinics on an annual basis.
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Is it important for a child while he or she is going through the cancer treatment
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to also see their pediatrician regularly?
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That is a great question. I would say definitely yes.
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I would love it if that's possible. Unfortunately,
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there are barriers to that because our treatments oftentimes are so intense
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that patients may be coming to see us three, four times a week,
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and it may be hard for them to make a primary care visit.
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I think the more motivated families, they find a way to get it done.
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And they realize that, for example, if they need to go see dermatology for a
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rash, that they're going to need some referral.
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So it makes it quite a bit easier if they've already been seen in the pediatric
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practice for that referral to take place.
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I think it would be ideal if they could continue to have at least a once-a-year,
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twice-a-year visit so the primary care home understands the type of treatment
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the child is going through and can support them better once they transition
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back as a survivor off therapy.
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That's great advice. And back to the case. So 12-year-old Sally,
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she's getting the HPV vaccine. She's wearing her sunscreen.
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She's going to the dentist. She's going to the camp.
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She's talking to other kids about her story. What about nutrition?
24:43
Yeah. So that is actually something that was a big discussion for her.
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Also, she is just kind of towards the mid part of puberty. So So she's getting
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tall and she's also on a volleyball team.
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So she needs her energy.
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And sometimes, you know, when families are busy, they end up,
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you know, stopping at fast food places on their way to sports events or practices.
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Sometimes kids are needing to be in different parts of town at the same time.
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And there's a lot of begging for it.
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Yeah, they're hungry. And there may not be as many hours in the day some days
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to do homework and volleyball and dance.
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I can remember those days, how challenging it was.
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And I remember really at one point I had to tell myself, I'm not taking the
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kids to fast food anymore.
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I know they want Chick-fil-A every day, but it's... hmm.
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Probably not so healthy for them. And there's chemicals in it to make it more palatable.
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And deep fried food. I mean, it's just, it's a bad habit, you know,
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to always be relying on fast food.
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You know, food that's prepared at home tends to be more nutritional value and not as processed.
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And you found a solution by putting food in a cooler, fresh fruits.
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Right. So I really got to the point where I did not.
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I just I just felt this. Plus, it's expensive to go to all these fast food places all over town.
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And I was astounded at how much money I was spending in between the three children.
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And so, you know, of course, all three children don't like to eat the same thing
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either. Right. So, you know, you're running around. Exactly.
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It's a challenge sometimes to feed three different individual children. Yes.
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But, you know, I just told them at one point that we were just not going to do that anymore.
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I just felt like it was not sustainable for us to do that.
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And I was going to just get the cooler out and, you know, make sure we had lots
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of freeze packs in the weekend and make some sandwiches and bring lunch meat
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if they wanted a different kind of meat or string cheese, grapes.
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Grapes. I mean, easy things that you can take along.
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Grapes, they always enjoyed. Strawberries, they always enjoyed.
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So even if they didn't like my sandwiches, they could have some fruit.
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Plenty of water to stay well hydrated.
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But that would end up saving me more time. I wouldn't be like in line at the Chick-fil-A.
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That line can be super long sometimes. Yes.
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And we talked about this, but we're and kids or all of us were exposed to not
27:13
commercials about carrots or water or lettuce or grains. You know, it's this right.
27:19
It's a health industry.
27:22
You know, it's not it's not an industry that's focused necessarily on health.
27:26
It's focused on profits. So soda. Exactly.
27:30
And I think that's one thing pediatricians try their best to,
27:34
you know, to educate that there's really no nutritional value in many of the,
27:39
you know, hot chips that these kids enjoy or the sodas, you know, Dr. Pepper.
27:45
And I usually try and tell parents, you know, there's always going to be somebody's
27:49
birthday coming up or a celebration.
27:52
You know, there's going to be days where you're going to have access to,
27:56
you know, those less nutritional value foods.
27:59
And so try your best on a day-to-day basis to provide good nutrition because
28:04
you know there are going to be days where there's cake after school or somebody
28:07
wants to take everybody out for dinner after softball practice and,
28:11
you know, want your kid not to enjoy those opportunities, you know.
28:15
So I think just trying to provide some balance so that, you know,
28:19
overall you're trying to provide adequate nutrition and not just,
28:24
you know, a diet of processed foods.
28:26
Foods would your advice is it to for
28:29
the pediatric for the pediatric practitioner especially for
28:32
cancer survivors to say whenever possible
28:35
avoid fast food altogether you know
28:38
i think realistically it's very hard for people to do that so i i don't have
28:43
that as an expectation i try to kind of talk to them and ask them like what
28:47
other options do you have what other food might you like and just on you know
28:52
trying to make small changes at once you know so that does take a little bit more time.
28:57
I also encourage to tell the parents to maybe go shopping on the weekend with
29:03
a child and ask the child to pick out a food that they want to try.
29:07
And, you know, nobody wants to buy some berries the child is not going to even
29:12
eat, and then you just end up throwing away.
29:14
So, you know, if you involve the child.
29:17
In the process of choosing the food and maybe even preparing the food,
29:20
there's usually more interest.
29:22
And I think, you know, if a pediatrician could also kind of use that as a teaching
29:26
opportunity to say, you know, there's different kinds of foods.
29:30
Some are proteins and they help you build your muscles.
29:33
Some are fruits and they may have some vitamins in there.
29:36
And just to kind of explain to the child why you need a little bit of everything
29:39
in order to maintain your health, especially as you're going through these active
29:43
years and you're gaining two inches every year, through puberty,
29:48
you need some support to get through that.
29:51
And Shafka, so what else would you like the pediatrician to know?
29:56
So say Sally's being careful about not having fast food regularly.
30:03
Say maybe the family's trying to limit it to once every three months at that.
30:08
That would be awesome if they could do that. I would say once Once a week, maybe, for most kids.
30:14
So that would be ideal, right? Right. And I think just to kind of praise when
30:18
things are moving in the right direction.
30:20
You know, I think I have been found for my own children.
30:23
I would have to come to a compromise because there were just days where,
30:27
you know, that one kid just really didn't have time to come home in between
30:31
all these activities. And we were eating out.
30:34
And so, you know, just to kind of be realistic about what is likely to happen
30:38
on a week-to-week basis. But I think involving a child more as they're getting
30:43
older is really important.
30:45
And pediatricians are good at talking to kids at different developmental levels
30:49
and really getting on their level and talking to them, not just talking to the parent.
30:54
And I think most children appreciate that and they understand when they're being heard.
31:00
And I think for a cancer survivor, as they're getting to be teenagers,
31:05
using the appropriate terminology, knowing what they had,
31:08
what their treatments were like, what other doctors they need to see,
31:12
that is so important because one day that 18-year-old is going to go off to
31:17
another practice and not be seen in pediatrics, and those practices are not
31:22
going to communicate with the mother.
31:24
They want to talk to the patient directly. And so building that confidence as
31:29
the young adult is being seen in the pediatric practice in a safe environment.
31:34
Letting them understand what their history was all about so they can let their
31:39
new providers on the adult side know what's important to maintain their health.
31:44
So, for example, for Sally, is it important for the pediatric practitioner to
31:48
ask about body image issues?
31:51
There may be some physical worries there.
31:54
I think that is also important. I know in the general population,
31:58
there is definitely a concern with eating disorders and body image.
32:04
And those are seen, those problems arise more commonly in childhood cancer survivors as well.
32:10
So I think it's something that, again, if it's a pediatrician that has had a
32:15
good relationship, they might be able to have kind of a frank discussion with
32:20
the child about what's been going on with their height and their growth.
32:25
And they can kind of show the child where their growth is being compromised.
32:30
And that, you know, might make some sense to them.
32:33
I think sometimes in our clinic, we're so wrapped up with a hundred other issues.
32:38
You know, we're trying to do screening for this, screening for that,
32:42
checking your cardiac function, checking your hearing, pulmonary function.
32:47
There's a lot of assessments that we're doing in the survivorship clinic.
32:50
Sometimes the psychosocial issues get lost in the shuffle of that if we don't have time.
32:57
I mean, honestly, our staff of psychologists and social workers do try to meet with every child.
33:02
But on a given day, you know, sometimes you have to prioritize which ones have more needs than others.
33:09
And so a pediatrician that has a good relationship with a young adult,
33:13
I think, may be the first person to kind of have a frank discussion,
33:17
Maybe with a parent outside the room and be able to help support that young adult.
33:23
What if, so say Sally's blood pressure is taken and it's slightly high,
33:29
which could be the fact that she's in a doctor's office, right?
33:34
Or what would you advise there? So that's, again, a great opportunity for the
33:38
pediatrician to see that child in clinic the next week because chances are the
33:43
pediatrician's not going to be doing all the blood work or, you know, prolonged visits.
33:49
We are. So it's a bit more of a, again, a safe space for the child.
33:53
And so oftentimes the blood pressures in the pediatric offices are in the normal
33:59
range, while they might have been a little bit higher in our office.
34:03
So we probably do that at least, I don't know, two or three times a month where
34:06
we have to call the pediatric office and say, hey, do you mind letting us know
34:10
what the blood pressure is?
34:11
Especially if the child lives out of town, we're not going to bring them back
34:14
into San Antonio just to recheck the blood pressure.
34:17
So especially the pediatrician's office feels like a more comfortable space in general.
34:23
Exactly. So if her blood pressure is high, what would you recommend there?
34:28
So based on the history of the child, if we know that perhaps they had some
34:31
kidney injury or maybe they had to have one kidney removed or had exposure to
34:37
a lot of medications that maybe compromised her kidney or heart function,
34:42
we will recommend a referral to the nephrology clinic for follow-up.
34:46
You know, we can certainly do blood work to check the kidney function.
34:50
Check their urine to make sure that there's no proteinuria, make sure they're
34:54
remaining well hydrated, give that, you know, simpler advice.
34:58
But if it's significantly elevated, they need to be worked in and we contact the nephrology clinic.
35:04
You know, nowadays we have our charts that are electronic,
35:08
so we can send a message to the renal providers and they can,
35:11
you know, do a little bit of a deep dive into the patient's history and come back to us and say,
35:16
okay, we'll see them in two weeks or, oh, just check it again in three months
35:20
and let us know so we can get an assessment, usually rather quickly,
35:25
from our pediatric subspecialists here at UT Health.
35:28
Is it important to screen in the pediatric setting childhood cancer survivors for diabetes?
35:36
Now, I think really across the board, again, because we know there are so many
35:40
children that are in the overweight or obese category nationally,
35:44
not just in South Texas, but really all over the country.
35:48
We certainly try to teach the teenagers not only about their growth parameters,
35:53
the height and the weight, but also explain what the body mass index is and
35:57
show what is a normal body mass index.
36:00
It's unfortunate because many of the treatments that we use can increase the
36:05
risk for obesity in our population.
36:08
And especially if they do have some kind of physical disability and they can't
36:12
exercise as much, they may have a difficult time keeping weight off.
36:16
So that goes back again to dietary advice.
36:19
You know, if we see a trend going in the wrong direction with the BMI becoming
36:24
elevated each year, we have to be, you know, very serious about the kind of
36:28
advice that we give the families.
36:30
But we definitely know that sometimes chronic steroids that are used for treatments
36:35
will certainly make you gain weight.
36:37
And especially if you've been through a bone marrow transplant,
36:40
you might have been on steroids for a long period of time.
36:43
And then if you had brain radiation, abdominal radiation, those may be associated
36:49
with increased risk of developing overweight or obesity, and then type 2 diabetes.
36:54
Diabetes so it might be or it
36:57
is even more important for that child to
37:00
avoid sugary drinks oh yes i think
37:03
you know for the people that we see as
37:06
cancer survivors on a year-to-year basis if we have noted that their body mass
37:11
index has been you know out of range and on the high side we will do a hemoglobin
37:17
a1c to get a sense not just of what the blood sugar is that day but what you
37:23
you know, the last 10 days of blood sugar have been.
37:26
And so we educate the families about what the hemoglobin A1c is.
37:30
And fortunately, we have very good support from the endocrine team.
37:35
And we try to refer those patients with either an elevated hemoglobin A1c or
37:41
signs of acanthosis on their physical exam.
37:45
I think it's also important for the pediatrician if they notice acanthosis diagnosis
37:49
to come back and ask the parent, oh, do you know what the A1C was?
37:54
And so that would be another opportunity to provide education that we need to
37:58
stay away from excess sugar because that's just going to lead to use of these
38:05
stronger medications that we have,
38:07
whether it's metformin or insulin or some of the new agents that are on the market now for obesity.
38:14
Nobody wants to be having to check your blood sugar multiple times a day.
38:19
And so, you know, I think we have to be open with our families and say there
38:23
are some things you can do to kind of prevent Sally from going down that pathway,
38:29
and, you know, focus more on snacks.
38:32
She can have strawberries that have sugar. It's a much better way to get your
38:35
sugar in because there's fiber in the strawberries.
38:38
So it won't make your blood sugar spike like diet pepper, Dr. Pepper will. So.
38:43
Yeah. So what is, what are your thoughts about diet sodas?
38:47
So that's something that we talked to the endocrinology team about quite a bit.
38:52
And the difficulty, especially with children and diet drinks is that the diet
38:57
drinks are full of these other chemicals that are super sweet.
39:02
They're like 10, 20 times as sweet as sugar naturally is. And so it trains the
39:08
body to want more sugary foods.
39:11
So it's really not helpful if you're trying to reduce, you know,
39:16
excess sugar intake to, you know, to give a child something with,
39:20
you know, saccharin or aspartame.
39:22
I mean, all these things we can't pronounce. These additives,
39:27
you know, I think if you're an adult and that's your choice, that's your choice.
39:31
But as parents and as pediatricians, I think it's just causing more confusion
39:36
to the taste buds because they're still wanting something sweet.
39:39
So it doesn't help somebody who's trying to limit excess sugar.
39:43
And we don't really know the long-term possible effects.
39:46
Yes, there is quite a bit in the news from time to time about excess health
39:51
risks of some of these chemicals.
39:53
And I don't think they're that well studied. I wish there was perhaps more studies.
39:57
But, you know, I think trying to stick to natural foods is probably the best
40:01
advice you could give to a child or a family that you're following in the pediatric clinic.
40:08
Anything else as we're, the pediatric practitioner is trying to help Sally with life after cancer.
40:16
So I think the other important thing is as you're trying to educate the young
40:21
adult about their history, you know, I think at some point you have to, you know, issues.
40:27
May come up where you have to really make them the owner of their health, right?
40:32
And really try and have the support of the parent on the side,
40:37
but really focus more on the child and maintaining privacy.
40:42
Whether it's privacy and documentation or test results. I think we try our best
40:47
in our system to try and make sure that test results and what have you for people
40:51
over 18 are really viewed by that patient and not necessarily a parent or grandparent.
41:00
And that can become a little challenging in our patient population because the
41:04
parents, the grandparents have supported the survivor through their medical
41:08
journey through cancer, and it can be hard to let go.
41:12
But, you know, I think it's just the reality that when they graduate to the
41:18
world of adult medicine, you know, the offices are going to be contacting the survivor.
41:24
They're not going to be speaking to the grandmother or the mother any longer.
41:29
It's very rare for adult practices out there to even to give appointments,
41:36
let alone test results to relatives like that.
41:40
So to prepare the family for that transition to the adult world,
41:44
I think is super important.
41:46
And it's important that that now adult has or soon to be adult has who survived
41:52
childhood cancer to have health insurance. That is also very important.
41:56
And I think sometimes we kind of put that discussion off a little bit because
42:01
we assume that because of their cancer diagnosis that they're going to be eligible
42:05
for insurance plans longer.
42:07
But that is not really the case. And depending upon where you live in the country
42:12
and what kind of health plan the family has, depending upon if you're in school or not.
42:19
I mean, there's a lot of nuances to it, and the plans, really,
42:23
they change from year to year.
42:25
So it is hard for me, even as a health care provider with children that are under 25.
42:32
We have to look very carefully at the health plans to make sure that we can
42:37
maintain insurance as the kids are in school.
42:40
And, you know, in our office, we're blessed to have the social workers that
42:43
really know the system inside and out and can help.
42:47
As an example, this week we had a young lady who's 19 now and she thought she
42:52
had lost her insurance, but she's able to keep it until the completion of her 19th year.
42:57
So she was still able to come in for her follow-up appointments and go back
43:01
to cardiology for her checkup.
43:03
But the rules change.
43:06
It's very hard to keep track of some of these changes. And so just putting that
43:10
That bug in the ear of the parent is like, make sure you ask,
43:13
you know, your HR, you know, find out what the restrictions are and what kind of coverage.
43:19
Oftentimes dental and vision coverage is not as good once they're outside the pediatric age range.
43:26
So those are also important considerations to try to maximize the health outcomes.
43:32
Shafka, you see a lot of success stories. Is there one story you want to mention
43:38
to us to inspire us before we go?
43:41
Yeah, so I do remember when I first came here to San Antonio,
43:45
there was a young three-year-old who was diagnosed with leukemia,
43:49
and she had a very rocky first month that was in the ICU and had complications.
43:55
But she did finish her treatment for childhood of leukemia, ALL,
43:59
and comes regularly to appointments.
44:03
Either her parents, they take turns to come with her. So that's always nice
44:07
to see that the dad also comes from time to time.
44:10
And she did fairly well. She's an outgoing person. She's not shy.
44:15
She knows that she had leukemia and she has peers that know about her history.
44:21
So she's not one of those super shy people that doesn't want anyone to know
44:25
about her cancer journey.
44:27
And this year she's, she turned 18. She's actually finished her first year of
44:31
college and she came for a follow-up visit by herself.
44:35
And I was super impressed to see that, you know, number one,
44:38
that she had the knowledge.
44:40
She came back with a list of questions that she had for us as to what she needed
44:44
to do to keep herself healthy, which doctors she should go to.
44:48
And I felt great that the parents had the confidence in her to let her come
44:53
alone to a doctor's appointment in the cancer clinic.
44:57
So I was super surprised, but very thrilled that she was able to show up and
45:02
really advocate for herself.
45:04
And I think part of it is in her healthcare system, she's a military brat.
45:07
So I think they also kind of start teaching them early that,
45:12
you know, all these young people that join the military at a young age,
45:15
all of a sudden they're adults, right? They have to make their own decisions.
45:18
And And so I have a feeling maybe in her primary care home, they kind of trained
45:22
her to take ownership of her own health.
45:25
So fortunately, she's doing well in college.
45:28
I think she's aware of some of her limitations and she asks for help when she needs.
45:34
And she has good relationship with both of her parents.
45:37
And so I think she will, hopefully, I'm hoping she'll go into health care myself,
45:41
but I think she will be a success. But it was nice to see how she's really grown
45:47
up over the last 13 years.
45:49
Maybe she'll be a future pediatrician.
45:52
She could be, although I think she's looking towards social work.
45:55
I think she likes to talk to people. That's awesome.
45:59
And what would you like to say, Dr. Shah, to families whose children are cancer survivors?
46:06
I think I would say that we are here for you. I mean, I think a lot of families
46:11
will tell us that they feel like we are part of their family.
46:15
And we, most people, whether we're nurses or psychologists or physicians,
46:20
we get to know them for many, many years.
46:23
And the treatment phase is not the, you know, it's just the beginning of the journey that we have.
46:30
So we want to be here for you in good times and in bad.
46:35
So I'd love to get those pictures of high school graduations or when the babies
46:39
are coming and they have little kids themselves 20 years later.
46:44
It's great to get those pictures.
46:46
But if they, you know, if they hear like somebody in their family was diagnosed
46:49
with cancer and they're curious and they're worried now about maybe another
46:53
cancer, then, you know, we'd like to hear from them too.
46:56
We want to be here to support them for the long haul.
46:58
And it's important for their children to keep going to their regular pediatrician,
47:03
pediatric practitioner.
47:04
Yes. Yes. It's very important to kind of have that as a home base.
47:08
And we know that pediatricians are very good at talking to children one-to-one
47:12
and providing education and support so that they can transition to the adult world successfully.
47:19
And also before we wrap up, I know you were saying that it can be really important
47:22
for a pediatric practitioner to write a note once a child has finished their
47:27
cancer treatment and they're transitioning back to school.
47:31
Yeah, so that is probably one of the most important things that the family will
47:35
need is some kind of documentation for their school.
47:39
And we try to provide that, but depending upon what part of the year we're seeing
47:43
the children, they may need an updated note also from the pediatrician.
47:48
And just to explain that this is a child that's been under treatment for however
47:52
many months or years and is now in remission, doing well.
47:57
But if there are any concerns, maybe the child needs some extra time to walk in between classes.
48:03
If they have a need to maybe have extra bathroom breaks or extra water,
48:08
whatever accommodations that child might need in order to do well in a school setting.
48:14
I think it's important to kind of go ahead and put that in writing.
48:17
I hear over and over again from some parents who don't take that kind of a letter
48:23
and they just go and they ask the teachers. And teachers will forget.
48:26
They have so many other kids to watch. And unless you have something in writing,
48:31
oftentimes things won't happen.
48:33
Another thing at the school setting, if the parent has time to go and meet the
48:38
school nurse, I think that's also helpful.
48:40
Because oftentimes the school nurses get it. They know that there's going to
48:44
be some sense of nervousness when the child returns back to school after finishing cancer therapy.
48:49
And so they're going to expect maybe a few extra visits with symptoms and such.
48:54
And so that school nurse can also be a big source of support for the child going
49:00
back to school for the first time.
49:02
And Shafka, all the patients you see day in and day out. here on Pediatrics
49:09
Now, we like to promote having a life outside of medicine, doing activities
49:12
outside of medicine to recharge.
49:16
It might not be balanced because of the long schedules that all pediatricians
49:22
have and seeing so many patients.
49:23
Is there anything you want to share that you do to recharge or unplug?
49:28
Well, I do enjoy cooking, and I try to have different recipes at least once a week.
49:33
Right now, you can so easily get on the internet and find recipes from all over the world.
49:38
And so I try to challenge myself. One of my daughters is a vegetarian at this
49:43
point. So we're trying to learn some more tofu recipes.
49:46
And even my husband seems to be willing to try, you know, a meatless night here and there.
49:51
So I made some tofu with broccoli this weekend that he actually liked. That sounds good.
49:57
Did you make the sauce or do you put soy sauce on it? Yep. It's actually all those like.
50:02
Japanese or kind of Far East type of sauces, they're not hard to make.
50:08
You just need to buy the ingredients.
50:09
And fresh ginger is so delicious. Fresh ginger, garlic, some peppers usually helps also.
50:15
I try to get the low salt version of any of the sauces.
50:19
I usually don't have a very strong taste for salt.
50:22
And so I don't notice that difference. friends. So just trying to buy the low
50:27
salt options, I think, trains your mouth, your taste buds to avoid the salt content.
50:33
But I think trying to eat more vegetables is really a big focus now at the Health Science Center.
50:38
There's programs trying to encourage people to have a plant-based diet.
50:42
And so I'm trying to do that. I really, I enjoy a hamburger now and there,
50:46
but I could go a whole month without eating a burger.
50:49
My husband, no. I love vegetables.
50:53
And there's a variety of vegetables in the summertime in Texas.
50:56
I mean, there's so many different kinds of vegetables you can get in the stores
50:59
and fruits and you just have to kind of make it a habit, I think.
51:03
For us, obviously, it's easier just to grab a bag of chips, but,
51:07
you know, you can sit there and cut up that orange and it'll be a whole heck
51:10
of a lot healthier for you with all that vitamin C and fiber.
51:14
Is there anything, Shafka, that we didn't cover that you want to mention that
51:19
so we don't miss anything.
51:20
Yeah, I think, you know, just a couple other things that pediatricians are also
51:25
very good at and have to deal with.
51:27
You know, there are some trends right now. We know teenagers are experimenting
51:31
a lot with vaping and smoking different things.
51:34
And that always surprises me. But we do know that cancer survivors do experiment as well.
51:41
And I think many of us, when we first start taking care of this population,
51:45
would think that, why would you take an additional risk?
51:47
You've you've just had a bad experience with cancer diagnosis,
51:50
and now you're, you know, you're smoking, and that's going to increase your
51:54
risk for a variety of cancers.
51:56
And they are at higher risk for lung cancer, et cetera. Well,
52:00
really, many, many cancers that are associated with smoking risk.
52:03
And so it's, it's, I think it's.
52:07
Part of experimentation that young people have.
52:10
And people have this thinking that
52:13
vaping is not as bad for you or that marijuana is not as bad as smoking.
52:18
And the marijuana is more potent today, as we know. Right. So I think the pediatricians,
52:23
they understand that. They see that in their practice.
52:26
And so trying to get that message to the patients who've already had a big journey of cancer is important.
52:33
We do know teenagers, they kind of think they're invincible sometimes.
52:37
Well, I already had that cancer. I'm not going to get another cancer.
52:40
But that's probably the opposite way of thinking.
52:43
You know, what the evidence shows is that they're going to be at increased risk of cancer.
52:48
And so trying to maintain health by avoiding those exposures as much as possible.
52:53
And alcohol as well. Right. And there is a lot of information out there about
52:58
how alcohol is carcinogenic.
53:00
You know, many cancers, breast cancer, for example.
53:03
And I think, I think, you know, sometimes even adults make the wrong decisions.
53:08
And so it's, you know, I think it's understandable that a kid,
53:12
you know, going off to college for the first time will end up trying things that are not healthy.
53:16
But, you know, perhaps before they go off to college, if we can just kind of
53:20
have those open discussions as pediatricians, you know, beware your body is
53:25
not, you know, it has seen a lot of medications, a lot of treatment already.
53:29
It may not be such a smart idea to experiment with some of these things.
53:35
Do you have a quote? I love quotes. So I did find one quote from Dr.
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Hudson, who's a researcher in survivorship at St. Jude.
53:43
And she has put out a very good manuscript in a pediatric journal that is really
53:49
directed at pediatricians and the care of childhood cancer survivors.
53:53
And a lot of what I spoke about today is from that publication.
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And she had a very nice quote there that resonated with me.
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And it says that a young person and their family's lives are are forever changed
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by the diagnosis of cancer.
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And so I think that puts it in a nutshell that things will never be the same
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after that diagnosis has been made.
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And what we would like to do in the survivorship clinic and in the general peds
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clinic after treatment is done is to try to maintain the health of the cancer
54:22
survivor as best as we can.
54:24
Life after cancer, such a beautiful thing to be able to be focusing on. Yes, it is.
54:30
It certainly is. especially when they bring these cute pictures back of the
54:33
high school graduation pictures. I love those. That's amazing.
54:38
Well, Dr. Shafka Shah with the University of Texas Health Science Center and
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University Hospital, thank you so much for being here today on Pediatrics Now. It was my pleasure.
54:48
Click on the link in this podcast for free credit that may include CME,
54:52
MOC, or ethics credit, depending on our topic or podcast.
54:57
Our website is pediatricsnowpodcast.com. My email address is on there.
55:03
Please email me with episode ideas or comments.
55:08
Our sister podcast is Pediatrics Now for Parents.
55:11
That website is pediatricsnowforparents.com. You can find it wherever you get your podcasts.
55:18
This is meant to be a resource for patients. So it's meant to be one less thing
55:23
you have to say in the exam room. this Cancer Survivor Update that we just did.
55:29
We will have a special episode coming out next week for families.
55:36
I'm Holly Wayment. Thank you so much for listening. I'll see you next time.
55:42
Coming up next week, I interview a former president of the American Academy of Pediatrics.
55:48
She gives us an update on pediatric medicine.
55:52
Where are we headed? If you scroll through this Pediatrics Now news feed,
55:57
you'll find some episodes of interest.
55:59
We have some special episodes on substance use, how to get a good night's sleep.
56:05
Coming up later in July and early August, flesh-eating disease in children.
56:12
Also, diagnosis and treatment of infant skull deformities.
56:17
That's coming up soon on Pediatrics Now. now.
56:21
Cases, updates, and discussions for the busy pediatric practitioner.
56:25
Thank you so much for listening. I'm Holly Wayment.