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. Author manuscript; available in PMC: 2025 Sep 10.
Published before final editing as: JCO Oncol Pract. 2025 Sep 8:OP2500414. doi: 10.1200/OP-25-00414

Chronic Health Conditions and Academic Achievement: A Childhood Cancer Survivor Study Report

Lisa Bashore a,b,*, Rachel K Peterson c,d,*, Chenghong Li e, Wei Liu e, Mingjuan Wang e, Zahra M Jiwani f, Aaron J McDonald e, Philip J Lupo g, Allison King h, Deokumar Srivastava e, Wendy M Leisenring i, Rebecca M Howell j, Todd M Gibson k, Kevin Oeffinger l, Gregory T Armstrong e, W Paul Bowman a, Kevin R Krull e, Kim Edelstein m,n
PMCID: PMC12419484  NIHMSID: NIHMS2100765  PMID: 40920992

Abstract

Purpose:

To examine associations between special education, chronic health conditions (CHCs), and college graduation in survivors of childhood cancer and their siblings.

Methods:

Childhood Cancer Survivor Study participants included 23,082 five-year survivors (53.7% male; median [IQR] age at diagnosis 6(3–13) years; age at evaluation 31.0[24–39] years; treated between 1970–1999) and 5,037 siblings (47.7% male; 36.0[28–44] years at evaluation). Special education use, reasons for special education, CHCs, and college graduation, were self-reported. Primary cancer diagnosis and treatment exposures were abstracted from medical records. Comparisons between survivors and siblings were made using Chi square statistics; demographic and treatment factors associated with outcomes were examined using modified Poisson regression models.

Results:

More survivors reported special education use than siblings (26.5% vs 8.6%, RR=2.55, 95%CI=2.32–2.80). Of those survivors and siblings who had special educaton services, use was highest between kindergarten and 5th grade (64.4% of survivors and 71.9% of siblings in kindergarten-5th grade,14.4% of survivors and 12.5% of siblings in 6th-8th grade, 9.2% of survivors and 9.0% of siblings in 9th-12th grade), and primarily attributable to learning and concentration problems. Despite receiving special education, survivors were less likely to graduate college compared to siblings requiring special education (RR=0.76, 95%CI=0.66–0.88). Risk for not graduating college included history of CNS tumor (RR=1.47, 95% CI=1.40–1.55), cranial irradiation (20–29Gy, RR=1.16, 95%CI=1.09–1.25; 30–49Gy, RR=1.37, 95%CI=1.26–1.49; ≥50Gy, RR=1.35, 95%CI=1.28–1.42), or the presence of a severe, disabling or life-threatening CHC (CTCAE Grade 3–4, RR=1.15, 95%CI=1.07–1.24).

Conclusion:

Cognitive problems and CHCs increase risk for not graduating college; these problems are not alleviated by special education.

Introduction

Childhood cancer five-year survival rates have improved to >85% over several decades due to advances in primary cancer therapy and supportive care.1 However, these survivors are at increased risk for multiple chronic health conditions (CHCs) and early death as a late effect of their primary treatment.2 Treatment-related late-effects can also disrupt cognitive and academic development, resulting in increased need for special education services and limited educational attainment.3,4

Survivors who receive Central Nervous System (CNS) directed therapy,3,5–10 particularly cranial radiation therapy (CRT),3,11 experience highest risk for cognitive sequelae. Treatment-related CHCs also increase risk for cognitive decline.12 Other factors such as younger age at diagnosis and female sex moderate the treatment impact on educational attainment5,13 but do not fully explain the variability in educational outcomes for this population.

Higher education, and in particular completion of college, influences socioeconomic status, financial independence, and lifespan.14 Moreover, childhood cancer in itself is associated with financial toxicity.15 Yet, childhood cancer survivors are less likely to attend college compared to siblings.3,13,16 In addition to injury from the primary treatment exposures, the overall burden of CHCs that survivors face as they age may reduce the potential for obtaining higher education. Thus, it is important to identify the risk factors associated with failure to graduate college in order to improve long-term social attainment in survivors. However, to date these factors have not been thoroughly defined.

In this study, we examined demographic, disease, and treatment factors associated with special education use and higher educational attainment in adult survivors of childhood cancer and siblings from the Childhood Cancer Survivor Study (CCSS). We expected reduced educational attainment for survivors compared to siblings overall. We also hypothesized that specific risk factors, including younger age at diagnosis, earlier treatment era, diagnoses and/or treatments that involve the CNS, and presence and severity of CHCs would be associated with lower college completion rates.

Methods

The CCSS is a multi-institutional, retrospective cohort study with ongoing, longitudinal follow-up.17,18 Participants include 5+ year survivors of childhood cancer including CNS malignancy, leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, kidney cancer, neuroblastoma, soft tissue sarcoma, or malignant bone tumor diagnosed between 1970–99, prior to age 21 years, and treated at one of 31 collaborating institutions in North America. A randomly selected subset of survivors nominated siblings nearest in age for participation. Institutional review boards at each site approved the protocol; participants provided informed consent. Methodology and design have been previously described; details and surveys are available at http://ccss.stjude.org.18

Special education use was examined in all CCSS study participants at the baseline survey. College attainment outcomes were examined in participants at least 25 years old at last survey. Participants reporting genetic conditions associated with cognitive impairment (e.g., Down syndrome, Klinefelter syndrome, Turner syndrome) were excluded from analyses (Supplemental Figure 1).

Outcomes

Self-reported educational attainment were reported on follow-up surveys between 2001 and 2018. For special education, participants responded to a yes/no question on special education usage; those who responded “yes” identified the academic grades in which they received special education services (kindergarten-12th grade) and reasons for use (i.e., missed school, low scores on tests, problems learning or concentrating, emotional or behavioral problems). Higher educational attainment was dichotomized as college graduate (yes/no).

Risk Factors

Survivor and sibling demographic information such as sex and race/ethnicity were obtained from baseline and follow-up questionnaires. Diagnosis, age at diagnosis, and chemotherapy exposures (e.g., anthracyclines, antimetabolites, heavy metals [platinum-based], corticosteroids) were abstracted from medical records. Radiation dosimetry is briefly summarized here and described in detail in the literature.19,20 For each individual treated with CRT, records were abstracted and the maximum target dose to four anatomical segments of the brain were taken as the sum of the delivered dose from all overlapping CRT fields (covering at least 50% of a segment). The highest dose of the four segments was used in the analyses.19 Decade of diagnosis/treatment was used to account for changes in treatment and supportive care over time. Self-reported CHCs were graded according to the National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) Version 4.03.21

Data Analysis

Demographic and treatment variables were characterized using descriptive statistics. Inverse probability of sampling was used as analytic weights for varying sampling probabilities in all analyses. Modified Poisson regression models were used to examine special education and college graduation outcomes in siblings and survivors overall and by diagnosis decade (siblings were classified into decades based on the date that their sibling survivor was diagnosed).22 Relative Risk (RR) with 95% confidence intervals (CI) were reported. Modified Poisson regression analyses were also conducted among survivors for the association of diagnosis, treatment exposure, and CHCs, with adjustment for sex and age at diagnosis. Diagnosis and treatment exposures were tested in separate analyses to avoid confounding effects of diagnoses with treatments. CHCs (cardiac, endocrine, renal/gastrointestinal, neurosensory, musculoskeletal, neurological, respiratory) occurring before age 25 were included to examine college graduation outcomes in three models: (1) the number of grade 2–4 CHCs, (2) the presence of any grade 3–4 CHCs, and (3) severity (maximum grade) of any CHC. To account for the under-sampling of leukemia survivors in the CCSS expansion cohort, all statistical analyses were weighted by inverse probability of sampling. All analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC).

Results

Among 23,082 survivors, 53.7% were male (age at diagnosis, median [interquartile range, IQR] 6 [3–13] years; age at follow up evaluation 31.0 [24–39] years. Among 5,037 siblings, 47.7% were male (median age at follow up evaluation 36.0 [28–44] years). The most common cancer diagnoses included leukemia (39.1%, Table 1), CNS tumors (15.4 %), and Hodgkin lymphoma (11.4%). In the survivorship cohort, 4,053 (24.2%) had a grade 3–4 CHC; 227 (5.5%) of siblings had a grade 3–4 CHC. A diagram describing study eligibility is provided in Supplemental Figure 1.

Table 1.

Participant Demographic and Treatment Characteristics

Survivors
n=23,082		 Siblings
n=5,037
No % No %
Sex
 Male 12371 53.7 2400 47.7
 Female 10711 46.3 2631 52.3
Decade of Diagnosis of Survivor
 1970s 6037 22.9 1813 36.0
 1980s 9173 37.6 2416 48.0
 1990s 7871 39.4 808 16.0
Diagnosis Age - -
 0–4 years 9100 42.0 - -
 5–9 years 5259 23.9 - -
 10–20 years 8722 34.1 - -
 Median (IQR) 6 (3–13)
College Degree (Yes) (at least 25 yo)* 8391 50.5 2410 58.9
Age at Baseline, median (IQR) 23.0 (18–29) - 26.0 (20–33) -
Age at Follow up, median (IQR) 31.0 (24–39) - 36.0 (28–44) -
Chronic Health Conditions (CTCAEa) (before 25 years of old)*
Grade 0–2 12671 76.8 3874 94.5
Grade 3–4 4053 23.2 227 5.5
Diagnosis - -
 Leukemia 7047 39.1 - -
 Central Nervous System Tumor 4053 15.4 - -
 Hodgkin Lymphoma 2992 11.4 - -
 Wilms Tumor 2136 8.1 - -
 Bone Tumor 1964 7.5 - -
 Non-Hodgkin Lymphoma 1916 7.3 - -
 Neuroblastoma 1822 6.9 - -
 Soft Tissue Sarcoma 1152 4.4 - -
Treatment Exposures
Platinum
 Yes 2724 11.2
 No 18499 88.8 - -
 Dexamethasone +/− other steroids 2794 17.5 - -
 Other steroids but no Dexamethasone 7263 35.9 - -
 No Dexamethasone or other steroids 11166 46.6 - -
Anthracyclines mg/m2, median (IQR) 221.2 (136.4, 346.5) - -
 Methotrexate Intrathecal mg/ m2, median (IQR) 143.7 (78.0, 249.4) - -
 Methotrexate Intravenous mg/ m2, median (IQR) 4198.8 (729.3, 21079.3) - -
Cranial Radiationb
 None 14049 69.3 - -
 <20 Gy 2434 12.5 - -
 20 – 29 Gy 1590 7.5 - -
 30 – 49 Gy 586 2.6 - -
 50 Gy or higher 1931 8.1 - -
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a

National Cancer Institute’s Common Terminology Criteria for Adverse Events Version 4.03

b

Defined as maximum target dose to four anatomical segments of the brain

IQR, interquartile range; Gy, gray

Surgery to remove brain tumors was not included in this analysis due to elimination from the expansion cohort

*

Sample size is 16,724 for survivors and 4,098 for siblings, which was used for college attainment analyses.

% weighted by inverse problility of sampling to account for the under-sampling of leukemia survivors in the expansion cohort of CCSS

Special Education Use

As indicated in Table 2, a higher proportion of survivors reported special education use (n=5935, 26.4%) compared to siblings (n=431, 8.6%; RR=2.55, 95%CI=2.32–2.80). This pattern was observed across every decade of diagnosis (1970–1979: 19.4% of survivors vs. 6.6% of siblings; 1980–1989: 24.7% of survivors vs. 9.4% of siblings; 1990–1999: 32.1% of survivors vs. 10.6 % of siblings; all ps< 0.001; Table 2). Learning and concentration problems were the most commonly reported reason for special education use in both groups (survivors 71.0%; siblings 73.8%, p=.21), though survivors reported more frequent use due to lower test scores (40.4% vs 34.1%, p=.01) and missed school (21.4% vs 7.9%, p<.001) compared to siblings (Table 2). More survivors also reported longer duration of special education use (i.e., ≥8 years) compared to siblings (29.3% vs 19.5%, p<.001).

Table 2.

Grades, Duration, and Reasons for Special Education Use Across Decades Among Participants

TOTAL 1970–1979 1980–1989 1990–1999
Survivors Siblings Survivors Siblings Survivors Siblings Survivors Siblings
N % N % p N % N % p N % N % p N % N % p
Overall 5935 26.4 431 8.6 <0.001 1169 19.4 119 6.6 <0.001 2257 24.7 226 9.4 <0.001 2508 32.1 86 10.6 <0.001
Grades
 Unknown 655 12.0 28 6.5 64 5.5 11 9.2 148 7.3 14 6.2 443 17.7 3 3.5
 K-5 3796 64.4 310 71.9 722 61.8 73 61.3 1562 69.6 165 73.0 1511 61.5 72 83.7
 6–8 891 14.4 54 12.5 229 19.6 21 17.6 337 14.4 27 11.9 325 12.6 6 7.0
 9–12 593 9.2 39 9.0 0.002 154 13.2 14 11.8 0.39 210 8.7 20 8.8 0.66 229 8.2 5 5.8 <0.001
Total Duration
 Unknown 655 12.0 28 6.5 64 5.5 11 9.2 148 7.3 14 6.2 443 17.7 3 3.5
 1–3 Years 2064 33.8 225 52.2 527 45.1 70 58.8 864 37.7 119 52.7 673 36 41.9
 4–7 Years 1508 25.0 94 21.8 273 23.4 24 20.2 678 28.7 53 23.5 557 22.9 17 19.8
 8 Years or > 1708 29.3 84 19.5 <0.001 305 26.1 14 11.8 <0.001 567 26.3 40 17.7 <0.001 835 32.5 30 34.9 <0.001
Reasonsa
 Missed School 1255 21.4 34 7.9 <0.001 315 26.9 11 9.2 <0.001 494 22.2 15 6.6 <0.001 446 18.8 8 9.3 0.026
 Low Test Scores 2360 40.4 147 34.1 0.010 484 41.4 39 32.8 0.068 987 44.1 76 33.6 0.002 889 37.3 32 37.2 0.98
Learning/Concentration Problem 4230 71.0 318 73.8 0.21 822 70.3 85 71.4 0.80 1723 70.3 167 73.9 0.46 1684 67.4 66 76.7 0.069
Emotional/Behavioral Problem 724 12.6 67 15.5 0.071 112 9.6 17 14.3 0.10 277 9.6 33 14.6 0.39 335 13.6 17 19.8 0.099
Educational Attainment with Previous Special Educationb
< College Degree 2650 70.4 199 61.2 0.002 721 72.9 75 67.0 0.274 1147 71.7 93 57.8 0.001 782 67.0 31 59.6 0.267
College Degree 1107 29.4 126 38.8 <.001 263 26.6 37 33.3 464 28.2 68 42.2 380 33.0 21 40.4
Unknown 7 0.2 5 0.5 2 0.1
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Based on All Participants who responded YES to special education use

a

Reasons for special education use, participants may have responded yes to more than one reason; the total number and percentages will not add up to 6366 and 100%.

b

At least 25 years old at time of survey

Abbreviations: L/C, Learning/Concentration Problems; E/B, Emotional/Behavioral Problems

With respect to diagnosis, CNS tumor survivors were at the highest risk of special education use (RR=4.68, 95%CI=4.24–5.15) compared to siblings, though all other diagnostic groups demonstrated elevated risk as well (RRs=1.57–2.62; all ps<0.001; Supplemental Table 1). Treatment history was also associated with special education use, with those receiving over 50 Gy CRT at highest risk compared to those who did not receive CRT (RR=2.38, 95%CI=2.24–2.53; Table 3). Intrathecal methotrexate (RR=1.48, 95%CI=1.25–1.75), platinum-based therapy (RR=1.25, 95%CI=1.18–1.32), and dexamethasone (RR=1.13, 95%CI=1.05–1.23) were also associated with increased special education use (Table 3).

Table 3.

Associations between Treatment and Special Education Use and College Degree in Survivors

Special Education Use < College Degree
RR 95% CI p RR 95% CI p
None (Reference) - - - - - -
Cranial Radiation
 <20 Gy 1.25 1.15–1.37 < 0.001 1.04 0.97–1.11 0.26
 20 – 29 Gy 1.46 1.31–1.61 < 0.001 1.16 1.09–1.25 <0.001
 30 – 49 Gy 1.89 1.71–2.09 < 0.001 1.37 1.26–1.49 <0.001
 ≥ 50 Gy 2.38 2.24–2.53 < 0.001 1.35 1.28–1.42 <0.001
Chemotherapy/Steroidsa
 Intrathecal Methotrexate (gram/m2) 1.48 1.25–1.75 < 0.001 1.03 0.84–1.26 0.78
 Platinum vs No Platinum 1.25 1.18–1.32 < 0.001 1.05 0.99–1.12 0.10
 Dexamethasone 1.13 1.05–1.23 <.01 0.94 0.87–1.01 0.07
 Other Steroids* 0.92 0.86–0.99 0.02 1.06 1.02–1.12 0.01
 Anthracyclines (gram/m2) 0.84 0.70–1.02 0.08 0.91 0.81–1.04 0.16
 Intravenous Methotrexate (100 gram/m2) 1.04 0.94–1.14 0.45 1.00 0.94–1.06 1.00
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Multivariate analysis models were used for all the analyses in this table

Each model was adjusted for age at diagnosis and sex

Abbreviations: Gy, gray

a

No cranial radiation therapy

*

Not dexamethasone

Model of <College Degree included survivors who were at least 25 years old at follow up (N=16724)

Model of Special Education Use included survivors for Special Education (N = 23082)

College Graduation

Siblings reported higher rates of college graduation than survivors (58.9% vs 50.5%; Table 1). Even for those with history of special education, siblings had higher rates of college graduation compared to survivors (38.8% vs 29.4%, RR=1.32, 95%CI=1.14–1.53, p<.001; Table 2). In terms of diagnoses, CNS tumor survivors were more likely to report not graduating college (RR=1.47, 95%CI=1.40–1.55), as were all other diagnoses compared to siblings (RR’s 1.09–1.27; Supplemental Table 1). CHCs increased the risk of not graduating college. Supplemental Table 2 provides the rates of grade 2–4 CHCs by organ system in survivors. The most commonly reported grade 2–4 CHCs were endocrine (n=2830, 13.8%), neurologic (n=2555, 12.5%), and neurosensory (n=1944, 9.0%). Survivors reporting a grade 2–4 neurologic (Table 4; RR=1.27, 95%CI=1.22–1.32, p<0.001) or neurosensory CHC (RR=1.10, 95%CI=1.05–1.15, p<0.001) were at greater risk of not graduating college compared to those with grade 0–1 CHCs. Survivors with any grade 3–4 CHC were more likely to report not graduating college compared to those with a grade 0–1 CHC (RR=1.12, 95%CI=1.07–1.17, p<.001). Even after adjusting for special education use, survivors with a grade 2–4 neurological CHC, or any grade 3–4 CHC were at elevated risk of not graduating college (Table 4).

Table 4.

Association of Grade 2–4 Chronic Health Condition and <College Degree in Survivors

Unadjusted for Special Education Use Adjusted for Special Education Use
RR 95% CI p RR 95%CI p
Cardiac
< Grade 2 (Reference) - - - - - -
# of Grade 2–4 1.06 1.00–1.12 0.06 1.06 1.00 – 1.12 0.06
Endocrine
< Grade 2 (Reference) - - - - -
# of Grade 2–4 0.94 0.90 – 0.99 0.02 0.93 0.89 – 0.97 0.02
Renal/Gastrointestinal
< Grade 2 (Reference) - - - - - -
# of Grade 2–4 0.90 0.84 – 0.98 0.01 0.92 0.85 – 1.00 0.04
Neurosensory
<Grade 2 (Reference) - - - - - -
# of Grade 2–4 1.10 1.05 – 1.15 <0.001 1.04 0.99 – 1.09 01.00
Musculoskeletal
<Grade 2 (Reference) - - - - - -
# of Grade 2–4 0.98 0.92 – 1.05 0.63 0.99 0.92 – 1.06 0.77
Neurological
< Grade 2 (Reference) - - - - - -
# of Grade 2–4 1.27 1.22 – 1.32 <0.001 1.10 1.05 – 1.15 <0.001
Respiratory
< Grade 2 (Reference) - - - - - -
# of Grade 2–4 0.96 0.88 – 1.05 0.34 0.95 0.87 – 1.04 0.30
Model 2: Presence of Grade 3–4 Chronic Health Condition 1.11 1.03–1.19 .01 1.15 1.07–1.24 <.001
Model 3: Maximum Grade of any Chronic Health Conditiona
Grade 0–1 (Reference) - - - - - -
Grade 2 vs 0–1 0.95 0.90 – 0.99 0.03 0.92 0.88 – 0.92 <.01
Grade 3–4 vs 0–1 1.12 1.07 – 1.17 <0.001 1.08 1.04 – 1.13 <0.001
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Adjusted for sex and age at diagnosis

a

Represents association of the maximum number of chronic health condition and college degree

Discussion

This study provides novel information about special education use in relation to college graduation rates in a large North American cohort of childhood cancer survivors and siblings, as well as the role of CHCs on long-term educational outcomes in those survivors. Broadly, findings indicate that childhood cancer survivors demonstrate longer duration of special education use relative to siblings. Moreover, survivors have lower rates of college graduation compared to siblings who utilize special education services. This finding suggests that survivors have unique learning needs that are not being met via existing special education services.

Additional supports for cancer survivors beyond academic accommodations, such as interventions to improve cognition and academic achievement, or educational/vocational counselors who work with survivors to facilitate the transition from high school to college/work may be appropriate.23–25 It is also important to acknowledge that survivors miss significant amounts of school compared to siblings, likely secondary to medical appointments, treatment side effects, and required isolation due to immunosuppression in the acute phase of treatment, which disrupts their acquisition of academic concepts. Thus, immediate and ongoing educational supports may help to mitigate some of the direct (treatment-related factors such as CRT, chemotherapy) and indirect (i.e., school absence) impacts of cancer treatment on academic achievement.

Our study highlights the chronicity of special education use in a large cohort of childhood cancer survivors. The majority of survivors required special education services for at least four years, underscoring the enduring nature of cognitive and academic impairments that are not alleviated following the completion of treatment. Interestingly, across the three decades examined in this study, there was a steady growth in the proportion of the childhood cancer survivors who received special education services, from approximately 17% in the 1970s to nearly 48% in the 1990s. This may reflect the increased availability in, and expectations for, special education over time for students with learning problems in the general population. This time frame also coincided with the sequential reduction in CRT for some childhood cancer diagnoses to reduce treatment-related neuroendocrine and cognitive sequelae. With improvements in long-term survival, there has been increased awareness of late effects and morbidity, resulting in the utilization of special education services for pediatric survivors with the aim of improving academic and functional life outcomes.

Special education use was greatest between kindergarten and 5th grade. The median age at diagnosis among survivors in our sample was 6 years when entry into school typically begins. The implementation of special education services around the time of diagnosis is promising as cognitive sequelae can emerge within the first year of treatment.26,27 Moreover, early intervention services may mitigate cognitive and academic deficits in this population24 as well as more broadly in children with developmental conditions.28

Beyond a history of cancer, specific treatment variables contribute to reduced post-secondary attainment, including history of CNS tumor, increased CRT dose, and chemotherapy agents. Additionally, to our knowledge, this study is the first to examine the association of CHCs and educational attainment in survivors. Other studies have shown that CHCs in survivors may mediate the impact of cancer treatments on cognitive function.12,29–32 In this study, endocrine (e.g., hypothyroidism) neurological (e.g., memory, leg weakness, balance, and epilepsy), and neurosensory (e.g., hearing, blindness, double vision) impairments were the most commonly reported grade 2–4 CHCs, all of which have been shown to contribute to impaired cognitive functioning.12,29 In our study, presence of a grade 2–4 neurological or neurosensory CHC, or any grade 3–4 CHC, was associated with lower rates of college graduation. These findings highlight the contribution of specific CHCs on cognition, which affects educational attainment.29 Close monitoring of survivors with neurological or neurosensory CHCs, or any severe CHC, is warranted due to the impact of these conditions on functioning and educational attainment and may also be relevant to children without a cancer history who experience these CHCs.

These findings have important implications for oncology providers. From time of diagnosis onwards, childhood cancer survivors will require a multidisciplinary care team addressing both mortality and morbidity. At diagnosis, risk-stratified treatments should be considered for eligible patients as they reduce morbidities in certain cancers.33,34 The medical team should screen for CHCs based on the individual’s cancer history, treatment exposures, genetic predispositions, and lifestyle behaviors. While ongoing monitoring of CHCs is recommended for long-term survivors,35 less than one-quarter report a healthcare provider addressing the morbidities associated with their cancer history.36 This may reflect lack of knowledge by non-oncology physicians, as less than 15% of childhood cancer survivors receive medical care from providers with strong understanding of long-term sequelae.36 Childhood cancer survivors may have limited awareness of their cancer history,37 and would benefit from having access to documentation summarizing their cancer history through their electronic medical record or a physical document that they can bring with them to their appointments, such as the Passport for Care38 or Children’s39 Oncology Group Guidelines for Survivor Care.40 To support survivors throughout their schooling, the medical team should screen survivors (and their parents) at each clinic appointment, and at-risk survivors, as well as those with cognitive or academic concerns, referred for neuropsychological assessment to ensure that appropriate cognitive interventions are in place.41,42 Other interventions, including pharmacological and lifestyle modifications, may also ameliorate morbidities. These interventions, along with psychosocial support, should be considered on an individual basis.

Limitations of this study include the use of self-report data that are subject to reporting and recall bias, although increased rates of learning difficulties in this population have been well documented.43 We also did not have access to information about environmental influences on academic achievement outcomes such as family history of learning difficulties, socioeconomic status, or family functioning, which can be associated with learning challenges and reduced educational attainment.44,45

Conclusion

A childhood cancer diagnosis in and of itself is a risk factor for special education use and lower rates of post-secondary graduation. CNS malignancies, specific cancer treatments, and more severe CHCs increase the likelihood of these outcomes. Given that individuals who require special education services have lower rates of college degrees in the general population46 and in childhood cancer survivors, all childhood cancer survivors and their siblings should be closely monitored from time of diagnosis through high school. Findings suggest that a multi-disciplinary team comprised of oncologists (managing the cancer), special educators (remediating/intervening upon cognitive and academic impairments), neuropsychologists (documenting the cognitive sequelae and providing appropriate interventions), and primary care physicians and nurses (monitoring CHCs) are essential to support the acute and long-term needs of childhood cancer survivors.

Supplementary Material

PV Appendix Figure and Tables

Supplemental Figure 1: Consolidated Standards of Reporting Trial (CONSORT) diagram of (A) survivor and (B) sibling study participants. CCSS: Childhood Cancer Survivor Study

Supplemental Table 1: Associations between Cancer Diagnosis and Special Education Use and College Degree

Supplemental Table 2: Grades 2–4 Chronic Health Conditions by Organ System Among Survivors (N = 23,082)

Concept Summary.

Key objective:

To understand the relationship between special education use, the development of chronic health conditions, and college graduation in survivors of childhood cancer.

Knowledge generated:

Cognitive problems, treatment exposures, and treatment-related chronic health conditions increase risk for not graduating college in childhood cancer survivors; these problems are not alleviated by special education placement.

Relevance:

A multi-disciplinary team comprised of oncologists, nurses, primary care physicians, special educators, neuropsychologists, and other allied health professionals, is needed to support the acute and long-term needs of childhood cancer survivors.

Acknowledgments

The authors gratefully acknowledge the contributions of study participants and participating pediatric oncology centers.

Funding/Support:

This work was supported by the National Cancer Institute at the National Institutes of Health [CA55727, G.T. Armstrong, Principal Investigator], the Cancer Center Support (CORE) grant [CA21765, D. Srivastava, G. T. Armstrong, K. R. Krull], the American Lebanese-Syrian Associated Charities (ALSAC). K. Edelstein is supported by the Princess Margaret Cancer Foundation and the Ontario Ministry of Health and Long-Term Care.

Abbreviations:

RR

relative risk

CNS

Central Nervous System

CRT

cranial radiation therapy

CCSS

Childhood Cancer Survivor Study

CHC

chronic health conditions

Gy

gray

HL

Hodgkin Lymphoma

NHL

Non-Hodgkin’s lymphoma

MTX

Methotrexate

Footnotes

Conflict of Interest Disclosures: The authors have no conflicts of interest relevant to this article to disclose.

Clinical Trial Registration: ClinicalTrials.gov NCT01120353

Data Sharing

The Childhood Cancer Survivor Study is a US National Cancer Institute funded resource (U24 CA55727) to promote and facilitate research among long-term survivors of cancer diagnosed during childhood and adolescence. CCSS data are publicly available on dbGaP at https://www.ncbi.nlm.nih.gov/gap/ through its accession number phs001327.v2.p1. and on the St. Jude Survivorship Portal within the St. Jude Cloud at https://survivorship.stjude.cloud/. In addition, utilization of the CCSS data that leverages the expertise of CCSS Statistical and Survivorship research and resources will be considered on a case-by case basis. For this utilization, a research Application Of Intent followed by an Analysis Concept Proposal must be submitted for evaluation by the CCSS Publications Committee. Users interested in utilizing this resource are encouraged to visit http://ccss.stjude.org. Full analytical data sets associated with CCSS publications since January of 2023 are also available on the St. Jude Survivorship Portal at https://viz.stjude.cloud/community/cancer-survivorship-community~4/publications.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

PV Appendix Figure and Tables
NIHMS2100765-supplement-PV_Appendix_Figure_and_Tables.docx (16KB, docx)

Data Availability Statement

The Childhood Cancer Survivor Study is a US National Cancer Institute funded resource (U24 CA55727) to promote and facilitate research among long-term survivors of cancer diagnosed during childhood and adolescence. CCSS data are publicly available on dbGaP at https://www.ncbi.nlm.nih.gov/gap/ through its accession number phs001327.v2.p1. and on the St. Jude Survivorship Portal within the St. Jude Cloud at https://survivorship.stjude.cloud/. In addition, utilization of the CCSS data that leverages the expertise of CCSS Statistical and Survivorship research and resources will be considered on a case-by case basis. For this utilization, a research Application Of Intent followed by an Analysis Concept Proposal must be submitted for evaluation by the CCSS Publications Committee. Users interested in utilizing this resource are encouraged to visit http://ccss.stjude.org. Full analytical data sets associated with CCSS publications since January of 2023 are also available on the St. Jude Survivorship Portal at https://viz.stjude.cloud/community/cancer-survivorship-community~4/publications.

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