RT May Affect Scholastic Performance in Pediatric Brain Tumor Survivors

CancerNetwork® spoke with Raymond B. Mailhot, MD, MPH, an associate professor in the Department of Radiation Oncology at the University of Florida College of Medicine, about the rationale behind assessing radiation dosing and subsequent scholastic performance in survivors of pediatric brain tumors in a retrospective analysis study. Study findings were presented at the 2024 American Society of Radiation Oncology (ASTRO) Annual Meeting.¹

Mailhot began by explaining that the rationale for the study arose out of discussions he held with the parents of children with brain tumors who sought information about how treatment with radiation would impact their academic performance. He further explained the impact of education as a social determinant of health, with negative consequences including poverty, worse health, and incarceration, which may occur as a result of unsatisfactory scholastic performance. He then highlighted measures that correlate with lower educational outcomes, including lower grades, frequent absence, and quarterly suspension.

Mailhot subsequently touched upon survivorship among pediatric patients who received radiotherapy for brain tumors, emphasizing neuropsychological testing to inform Individualized Education Programs, which are not universally accessible for this group. He concluded by referencing a 2020 study that cited barriers to accessing neuropsychological appointments, which he stated was an important gap in practice.²

Transcript:

What led to this work was born out of conversations with families and their children who [have] cancer. A part of our job as physicians is to always go over the benefits and risks of treatment. One of the dreaded consequences that can occur for children who receive radiation to their brain is that there can be decreases or decrements in their IQ. For me, that has always been—speaking personally––a difficult subject to discuss because of [how abstract it can be].

I could cite a change in IQ of 8 points, but I would want to be more tangible in my discussion with families. [An explanation families may] appreciate more is, “What will it look like for my child to perform in school?” Education is a social determinant of health, so if people do not graduate high school, or if they perform poorly in school, that is associated with worse health, a chance of not generating as much income later in life, a higher risk of incarceration, and a higher chance of poverty. There is a real tie between education and health.

At the same time, baseline statistics that are called Early Warning Indicators for American children in public schools [show] that in the sixth grade, if a child has a “D” or “F” in English or math, they have an attendance rate of less than 90%, or if they have more than 1 suspension per quarter, that sixth grader has a 25% chance of graduating high school. If that sixth grader is Black, Hispanic, or poor, that goes down to a 10% chance of graduating high school.

In conversations––specifically with one family in which the child had essentially been a recent immigrant to the United States­­, so they were also learning English at the same time—and in discussing the treatment with the family, it became very evident to me….that this child has a lot on their plate. The prognosis associated with their brain tumor is very high. The overall survival for germinoma is greater than 95%.

There is a real important emphasis on how this looks for the next steps of children. Classical survivorship for these [children], meaning what follow up should look like, involves neuropsychological testing, which involves things like IQ tests or academic tests that a neuropsychologist can then use to inform schools like [Individualized Education Programs], but that is not universally accessible.

A study published in [2022] demonstrated that of 185 surveyed parents of childhood cancer survivors, a majority of them were unable to get that neuropsychological appointment, citing things like a lack of referral, distance, and lack of insurance coverage. Even though this is a standard that I recommend, the important gap in practice is that not all children have access to it.

References

1. Mailhot Vega R, Indelicato DJ, Bradley JA, et al. Establishing the association between OAR dose and post-therapy scholastic performance in pediatric brain tumor survivors. Presented at: ASTRO 2024 Annual Meeting. September 29-October 2, 2024. Washington, DC. Abstract 172
2. Devine KA, Christen S, Mulder RL, et al. Recommendations for the surveillance of education and employment outcomes in survivors of childhood, adolescent, and young adult cancer: A report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Cancer. 2022;128(13):2405-2419. doi:10.1002/cncr.34215