Concluding Comments

Enormous progress has occurred in pediatric oncology over the past 30 years. More advanced treatment has increased survival rates in many children who would not have previously survived. The cost of this progress, however, has been significant long-term physical and psychological sequelae for these survivors and their families. How to determine who is most at risk, how to prevent these sequelae, and how to identify and treat those affected are areas of active research. In addition, clinicians are starting to understand the associations between long-term or late-onset psychological distress and both functional impairment and poor health behaviors. Interventions that address all of these components are necessary to provide these children and adolescents with the opportunity for full lives.

The manifestation of posttraumatic stress symptoms in young adults despite the apparent lack of symptoms in children or adolescents presents unanswered questions. Are the symptoms masked or prevented in younger survivors? Do they emerge in much the same way that other physical "late effects" do, or are they a response to social developmental challenges such as completing education, choosing a career path, and finding a mate? This is an area of ac tive research, with interesting implications for what is meant by "posttraumatic stress." Another relatively unexplored area is that of the psychological impact of cancer on infants and young children (Kazak and Baxt 2007). Despite the extensive research on the cognitive impact of cancer treatment on the developing brain, much less is understood about the impact of separation from parents and multiple painful procedures in preverbal children. With a growing literature on the ability of early trauma to activate genetic susceptibility to substance abuse and depression, an important goal is to reduce the trauma of lifesaving treatments to the extent possible. New evidence on the role of early painful experiences in development of hypersensitivity to pain may lead to appropriate alterations in procedures, as occurred with cranial radiation (Zeltzer et al. 2008).

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