title: Cause-specific late mortality among 5-year survivors of childhood cancer: the Childhood Cancer Survivor Study.
abstract: BACKGROUND
  The proportion of pediatric and adolescent cancer patients surviving 5 years has increased during the past four decades. This growing population of survivors remains at risk for disease- and treatment-associated late mortality.
  
  
  METHODS
  A total of 20 483 five-year survivors of childhood and adolescent cancer diagnosed between January 1, 1970, and December 31, 1986, and enrolled in the Childhood Cancer Survivor Study (CCSS) were included in a National Death Index search for deaths occurring between January 1, 1979, and December 31, 2002. Treatment information was abstracted from primary medical records. Survival probabilities, standardized mortality ratios (SMRs), and absolute excess risks were calculated for overall and cause-specific deaths. Diagnosis- and sex-specific survival probabilities were estimated by the product-limit method. All statistical tests were two-sided.
  
  
  RESULTS
  Among the CCSS cohort, 2821 (13.8%) 5-year survivors had died by the end of the follow-up period. The cause of death was obtained for 2534 individuals, with 57.5% of deaths attributed to recurrent disease. Estimated probability of survival 30 years from diagnosis was 82%. When compared with the US population, the absolute excess risk of death from any cause was 7.36 deaths per 1000 person-years. The overall SMR was 8.4 (95% confidence interval [CI] = 8.0 to 8.7). Increases in cause-specific mortality were seen for deaths due to subsequent malignancy (SMR = 15.2, 95% CI = 13.9 to 16.6) and cardiac (SMR = 7.0, 95% CI = 5.9 to 8.2), pulmonary (SMR = 8.8, 95% CI = 6.8 to 11.2), and other medical (SMR = 2.6, 95% CI = 2.3 to 3.0) causes. At 20 years of follow-up (25 years after first cancer diagnosis), the death rate due to a subsequent malignancy exceeded that due to all other causes.
  
  
  CONCLUSIONS
  Our extended follow-up of 5-year survivors of pediatric and adolescent cancer indicates that excess mortality persists long after diagnosis. Continued observation is needed to further define lifetime risk and to determine the potential contribution of chronic health conditions and modifiable health behaviors.
authors.affiliation: Department of Pediatrics, Emory University, 2015 Uppergate Dr, Atlanta, GA 30322, USA. amerten@emory.edu
authors.forename: Ann C
authors.initials: AC
authors.lastname: Mertens
authors.forename: Qi
authors.initials: Q
authors.lastname: Liu
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Neglia
authors.forename: Karen
authors.initials: K
authors.lastname: Wasilewski
authors.forename: Wendy
authors.initials: W
authors.lastname: Leisenring
authors.forename: Gregory T
authors.initials: GT
authors.lastname: Armstrong
authors.forename: Leslie L
authors.initials: LL
authors.lastname: Robison
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Yasui
mesh_terms: D000293:Adolescent; D000328:Adult; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D015986:Confounding Factors, Epidemiologic; D003644:Death Certificates; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009369:Neoplasms / Q000401:mortality*; D016012:Poisson Distribution; D011159:Population Surveillance; D017741:Survivors / Q000706:statistics & numerical data*; D013997:Time Factors; D014481:United States / Q000453:epidemiology