Childhood Cancer Fact Library

• Cancer treatments may harm the body’s organs, tissues, or bones and cause health problems later in life. These health problems are called late effects as a result of surgery, chemotherapy, radiation therapy, and/or stem cell transplant. Late effects in childhood cancer survivors affect the body and mind. Late effects may affect organs, tissues, body function, growth and development. Other late affects are mood, feelings and actions thinking, learning, and memory as well as social and psychological adjustment. Late effects also have a risk of second cancers.⁽³⁹⁾
• The chance of having late effects increases over time. New treatments for childhood cancer have decreased the number of deaths from the primary cancer. Because childhood cancer survivors are living longer, they are having more late effects after cancer treatment. Survivors may not live as long as people who did not have cancer. The most common causes of death in childhood cancer survivors are: The primary cancer comes back or a second (different) primary cancer forms or there is heart and lung damage.⁽³⁹⁾
• Overall, children (ages 0-14) and AYA (ages 15-19) cancer survivors were 57% more likely to develop depression, 29% more likely to develop anxiety, and 56% more likely to develop psychotic disorders in the years following treatment compared to their siblings or healthy members of a control group.⁽⁸²⁾
• Adult survivors of childhood cancer have a higher risk of developing cognitive impairment later in adulthood, according to study findings published in JAMA Network Open.⁽⁸¹⁾
• Childhood cancer survivors who received radiation or certain types of chemotherapy have an increased risk of late effects to the heart and blood vessels and related health problems.⁽³⁹⁾
• NCI researchers observed that children who received radiotherapy had an increased risk of developing meningioma, cancer of the membranes that surround the brain and spinal cord (meninges).⁽⁷²⁾
• Long-term follow-up analysis of a cohort of survivors of childhood cancer treated between 1970 and 1986 has shown that these survivors remain at risk of complications and premature death as they age, with more than half of them having experienced a severe or disabling complication or even death by the time they reach age 50 years.^(63).
• Children and adolescents (ages 0 to 19) treated more recently, after 1986, may have lower risks of late effects due to modifications in treatment regimens to reduce exposure to radiotherapy, chemotherapy, and increased efforts to detect late effects, and improvements in medical care for late effects.⁽⁶³⁾
• More than 95% of childhood cancer survivors will have a significant health related issue by the time they are 45 years of age; ⁽⁴¹⁾ these health related issues are late-effects of either the cancer or more commonly, the result of its treatment.
  • 1/3 will suffer severe and chronic side effects;
  • 1/3 will suffer moderate to severe health problems; and
  • 1/3 will suffer slight to moderate side effects.⁽²⁾
• Cognitive impairment affects up to one-third of childhood cancer survivors.⁽³⁸⁾
• Long-term survivors of childhood cancer may be at elevated risk for new neurocognitive impairment and decline as they age into adulthood.⁽⁸⁶⁾
• A large follow-up study of pediatric cancer survivors found that almost 10% developed a second cancer (most commonly female breast, thyroid, and bone) over the 30-year period after the initial diagnosis.⁽³⁸⁾
• Treatment for cancer may cause infertility in childhood cancer survivors. Infertility remains one of the most common and life-altering complications experienced by adults treated for cancer during childhood.⁽⁶⁴⁾
• Having a bone marrow or stem cell transplant usually involves receiving high doses of chemotherapy and sometimes radiation to the whole body before the procedure. In most cases, this permanently stops ovaries from releasing eggs, resulting in lifelong infertility.⁽⁶⁶⁾
• Female childhood cancer survivors who were treated with chemotherapy— even if they did not receive radiation treatments to their chest — are six times more likely than the general population to be diagnosed with breast cancer later in life. For those who did receive chest radiation, that chance increases exponentially and is on par with those who have the BRCA1 or BRCA2 mutations.⁽²⁸⁾
• Childhood cancer survivors are at a 15-fold increased risk of developing Congestive Heart Failure and are at 7-fold higher risk of premature death due to cardiac causes, when compared with the general population. There is a strong dose-dependent relation between anthracycline chemotherapy exposure and CHF risk, and the risk is higher among those exposed to chest radiation.⁽³³⁾
• Children who were treated for bone cancer, brain tumors, and Hodgkin lymphoma, or who received radiation to their chest, abdomen, or pelvis, have the highest risk of serious late effects from their cancer treatment, including second cancers, joint replacement, hearing loss, and congestive heart failure.⁽³⁷⁾
• Compared with the general population, survivors of childhood and adolescent cancers have an increased risk of 6 major psychiatric disorders, including: Autism spectrum disorder (hazard ratio [HR], 10.42), ADHD (HR, 6.59), PTSD (HR, 6.10), OCD (HR, 3.37), Major depressive disorder (HR, 1.88), Bipolar disorder (HR, 2.93).⁽⁶²⁾
• Life expectancy for five-year childhood cancer survivors has steadily increased.  Life expectancy for those treated in the 70’s is only 48.5 years and survivors treated in the 80’s have a life expectancy of 53.7 years, while those treated in the 90’s rose to 57.1 years.⁽⁴¹⁾ Normal life expectancy for adults is 77.5 years.⁽⁷ⁱ⁾
• Nearly a quarter of childhood cancer survivors experience at least one debilitating neuromuscular condition 20 years post diagnosis.⁽⁴⁷⁾
• Results published in Journal of Clinical Oncologyreveal that nearly 30% of childhood cancer survivors developed pre-diabetes compared with less than 20% of patients in a matched control group. Further analysis showed that between the ages of 40 and 49 years, more than 60% of the survivor group had either pre-diabetes or diabetes.⁽⁷⁾
• Overall, survivors treated with abdominopelvic radiotherapy treatment (ART) were three times more likely to develop a subsequent colorectal cancer (CRC) than those who did not receive ART.⁽¹⁰⁾
• The North American Children’s Oncology Group has developed long-term follow up guidelines (https://www.cmaj.ca/content/cmaj/suppl/2024/03/05/196.9.E282.DC1/231358-res-4-at.pdf ) to monitor adults who had cancer as children.⁽⁸⁵⁾

• On average, in 2009 pediatric hospitalizations principally for cancer were 8 days longer and cost nearly 5 times as much as hospitalizations for other conditions (12.0 days versus 3.8 days; $40,400 versus $8,100 per stay). Costs per day were about 70 percent higher for pediatric cancer stays ($3,900 versus $2,300 per day).⁽⁵⁾
• In 2009, pediatric stays principally for cancer cost nearly one billion dollars, accounting for over 5 percent of pediatric non-newborn inpatient hospital costs.⁽⁵⁾
• One in four families lose more than 40% of their annual household income as a result of childhood cancer treatment-related work disruption, while one in three families face other work disruptions such as having to quit work or change jobs.⁽³⁶⁾
• One in five children who receive a new diagnosis of childhood cancer are already living in poverty.⁽³⁶⁾
• Parents of long-term childhood cancer survivors reported lower household income and higher risk-of-poverty. In a study group of 383 parents of long-term childhood cancer survivors, 30.4% reported lower household income and were at higher risk-of-poverty.⁽³⁵⁾ 
• A 15-year trend for clinical trials on cellular therapy for children and adolescents (ages 0-19) with cancer in the US concluded that 169 (84%) of 202 trials posted 2007-2022 also included adult populations, only 3 trials enrolled children only. There was no industry funding for CNS tumors.⁽²⁹⁾
• More than 90% of children and adolescents who are diagnosed with cancer each year in the United States are cared for at a children’s cancer center that is affiliated with the NCI-supported Children’s Oncology Group(COG).  Children’s Oncology Group is the world’s largest organization that performs clinical research to improve the care and treatment of children and adolescents with cancer.  Each year, approximately 4,000 children who are diagnosed with cancer enroll in a COG-sponsored clinical trial. COG trials are sometimes open to individuals aged 29 years or even older when the type of cancer being studied is one that occurs in children, adolescents, and young adults.⁽³⁷⁾

• Cancer is the number one cause of death by disease among children and adolescents (ages 0-19) in the United States.^(1B)
• On average, about 14% of children die within 5 years of diagnosis among those children, treated in the 70’s and 80’s, who survived to five years from diagnosis, 18% of them will die over the next 25 years. In recent decades, cancer treatments have been modified with the goal of reducing life-threatening late effects.⁽⁵⁰⁾
• 1,040 children (aged 0 -14) and 550 adolescents (aged 15-19) are expected to die from cancer in 2024 (excluding benign and borderline malignant brain tumors). ^(1B) In 2023, it is estimated that there will be 9,050 deaths due to cancer among AYAs aged 15 to 39.⁽⁴⁰⁾
• Between 1970 and 2020, patients with cancer aged 14 years and younger have experienced a 70% decline in overall cancer death rates. Adolescent patients aged 15 to 19 years experienced a 64% decrease over the same time span.^(7F)
• Between 2015 and 2019, cancer death rates decreased an average of 1.5% per year among children ages 0 to 14, while death rates for AYAs (ages 15 to 39) decreased an average of 0.9% per year.^(7G) 
• Brain cancer represents 25% of total childhood cancer deaths while leukemia accounts for 28%.^(1B)
• The median age at death for childhood brain and CNS cancers is age 9.^(7H)
• The most common causes of death in childhood cancer survivors are: The primary cancer comes back. A second (different) primary cancer forms. Heart and lung damage.⁽³⁹⁾
• Those that survive the five years have an eight times greater mortality rate due to the increased risk of liver and heart disease and increased risk for reoccurrence of the original cancer or of a secondary cancer.⁽⁸⁾
• There are 69.3 potential life years lost on average when a child dies of cancer^(7B) compared to 12 potential life years lost for adults.⁽⁷ⁱ⁾
• Survivors of hereditary retinoblastoma, a rare cancer of the eye, have a high risk of developing subsequent cancers, particularly sarcomas of the soft tissue and bone.⁽⁷³⁾
• “Despite improvements in 5-year survival, long-term survivors of childhood cancer are at four times the risk of death compared with the general, aging population.⁽⁸³⁾

• Global 5-year net childhood cancer survival is currently estimated at 37.4%.⁽⁴⁶⁾
• In 2017, childhood cancer was the sixth leading cause of total cancer burden globally and the ninth leading cause of childhood disease burden globally.⁽⁷⁰⁾
• Globally, in 2017, there were 11.5 million Disability Adjusted Life Years (DALYs) due to childhood cancer, 97.3% were attributable to Years of Life Lost (YLLs).⁽⁷⁰⁾
• More than 90% of children at risk of developing childhood cancer each year live in low income and middle-income countries.⁽³⁾
• Approximately 1 in 15 children receiving cancer treatment in low- and middle-income countries die from treatment-related complications. Although treatment-related mortality has decreased in upper–middle-income countries over time, it remains unchanged in low- and middle-income countries.⁽³¹⁾
• Approximately 90% of children with cancer live in low-income and middle-income countries (LMICs), where 5-year survival is lower than 20%.⁽³¹⁾
• In 2019, cancer was the fourth leading cause of death and tenth leading cause of Disability-Adjusted Life Years (DALYs) in adolescents and young adults (ages 15 to 39) globally.⁽⁶⁹⁾
• When the overall disease burden is studied within the age range encompassing adolescents and young adults (aged 15 years to 39 years), the global burden of cancer contributed more Disability-Adjusted Life Years (DALYs), a combination of Years of Life Lost (YLLs) and Years Lived with Disability (YLDs), to the global disease burden than some high-profile communicable diseases such as HIV/AIDS and sexually transmitted infections.⁽⁶⁹⁾
• In 2019, 43% (172,000 of 397,000) of childhood cancer cases were undiagnosed globally.⁽⁷⁸⁾
• Cancer kills more than 100,000 children (birth to 19) each year, and yet 80% of pediatric cancers are curable with currently available interventions. Notably, the majority of these deaths occur in low‐income and middle-income countries where children have poor access to health services.^(33A)
• In Europe, since 1995, a total of 16 drugs have been approved for pediatric cancers. Seven of the 16 have been approved in the first instance specifically for pediatric cancers. Nine of the 16 were first approved for adults, then later for use in pediatric cancer. Eight of the total 16 drugs affected cancers responsible for less than 6% of all European childhood cancer deaths.⁽⁷⁶⁾
• In 2018, The World Health Organization (WHO) launched the Global Initiative for Childhood Cancer with partners to provide leadership and technical assistance to support governments in building and sustaining high-quality childhood cancer programs. The goal is to achieve at least 60% survival rate globally by 2030, for all children with cancer. This represents an approximate doubling of the current cure rate and will save an additional one million lives over the next decade. The objectives are to increase capacity of countries to deliver best practices in childhood cancer care and also to prioritize childhood cancer and increase available funding at the national and global levels.⁽³⁰⁾
• Some cancers are more prevalent in developing countries. For example, Burkitt’s lymphoma is more common in East and West Africa with over 4,000 cases in East Africa and over 10,000 in West Africa while only around 20 were recorded in the UK in 2015.⁽³⁰⁾
• Because most of the world’s population is NOT covered by cancer surveillance systems or vital registration found in developed countries, and in addition, childhood cancer is rare and often presents with non-specific symptoms that mimic those of more prevalent infectious and nutritional conditions found in many low-income developing countries. Worldwide/UN-regional cancer incidence is therefore estimated using a Baseline Model (BM) method to quantify the cancer burden in children.  It is estimated that there will be 13.7 million cases of childhood cancer between 2020-2050.  Unless there are major improvements in diagnosis and treatments, of this, 45% will go undiagnosed and 11.1 million will die if no further investments in interventions are made. The vast majority, almost 85%, will be concentrated in developing countries.^(33A)
• Current projections show that Africa will account for nearly 50% of the global childhood cancer burden by 2050.⁽⁷¹⁾

• Any substance that causes cancer is known as a carcinogen. But simply because a substance has been designated as a carcinogen does not mean that the substance will necessarily cause cancer. Many factors influence whether a person exposed to a carcinogen will develop cancer, including the amount and duration of the exposure and the individual’s genetic background.⁽⁷⁹⁾
• Cancers caused by involuntary exposures to environmental carcinogens are most likely to occur in subgroups of the population, such as workers in certain industries who may be exposed to carcinogens on the job.⁽⁷⁹⁾
• Two organizations—the National Toxicology Program (NTP), an interagency program of the U.S. Department of Health and Human Services (HHS), and the International Agency for Research on Cancer (IARC), the cancer agency of the World Health Organization—have developed lists of substances that, based on the available scientific evidence, are known or are reasonably anticipated to be human carcinogens.⁽⁷⁹⁾
• The National Toxicology Program (NTP) cumulative report now includes 256 listings of substances — chemical, physical, and biological agents; mixtures; and exposure circumstances — that are known or reasonably anticipated to cause cancer in humans. The latest report, the 15th Report on Carcinogens was released on December 21, 2021. (https://ntp.niehs.nih.gov/whatwestudy/assessments/cancer/roc)⁽⁸⁰⁾
• Childhood cancer is fundamentally different to adult cancer in its biology, clinical classification, and treatment. Most childhood cancers are not caused by modifiable risk factors, public health campaigns would not have a large effect on decreasing their incidence.⁽⁵⁶⁾
• Over the past 50 years, the use of artificial chemicals in products has increased exponentially. Most of these chemicals were not tested for safety before widespread use, and the impacts of exposures are just now being realized. Children are especially vulnerable to the health impacts of chemical exposures, and these exposures are now known to be an important component of rising rates of diseases such as asthma, some cancers, and neurodevelopmental disorders in children.⁽⁷⁴⁾
• Children are at an elevated risk for chronic disease because of increased exposure to environmental toxins. The U.S. Environmental Protection Agency (EPA) (2017) identifies children as uniquely vulnerable to environmental risks because of rapidly developing brains, lungs, immune and other bodily systems with less developed natural defenses than adults, including more permeable blood-brain barriers, and metabolic and detoxification pathways that are not yet fully developed.⁽⁷⁴⁾
• Phthalates are a class of chemicals found in a variety of products. They are mixed with polyvinyl chloride and other plastics as a plasticizer that helps to make them soft and flexible. They are also added to cosmetics and other personal care products (often as a fragrance stabilizer), in medical equipment and coatings on medications, food production equipment and packaging, flooring, wall coverings, and other home products. ⁽⁷⁴⁾ In a study of 1.3 million children aged under 19 years of age, childhood phthalate exposure was associated with incidence of osteosarcoma and lymphoma.⁽⁶⁰⁾
• Pesticides are a group of chemicals intended to kill unwanted insects, plants, molds, and rodents, making them inherently toxic chemicals. Pesticides are not species-specific in their neurotoxic properties—a wanted effect on the nervous system of an insect can also be an unwanted effect on the nervous system of a child. ⁽⁷⁴⁾ Exposures to pesticides, tobacco smoke, solvents, and traffic emissions have consistently demonstrated positive associations with risk of developing childhood leukemia.⁽⁵³⁾
• Researchers found a higher level of common household pesticides in the urine of children with acute lymphoblastic leukemia. The findings should not be seen as cause-and-effect, but suggests an association between pesticide exposure and development of childhood ALL.⁽⁵⁹⁾
• The U.S. Environmental Protection Agency (EPA) reports that 75 percent of U.S. households used at least one pesticide product indoors during the past year. The EPA also states, “Exposure to pesticides may result in irritation to eye, nose and throat, damage to central nervous system, kidney and increased risk of cancer.”⁽⁵²⁾
• Exposure to toxic substances, such as industrial chemicals and radiation, can increase the risk of leukemia. People may encounter radiation during imaging tests such as MRI scans, X-rays, and CT scans. ⁽⁵⁷⁾
• Since children are more radiosensitive than adults and although CT scans are very useful clinically, potential cancer risks exist from associated ionizing radiation.⁽⁵⁴⁾
• Exposure of parents to ionizing radiation is also a possible concern in terms of the development of cancer in their future offspring. Children whose mothers had x-rays during pregnancy (that is children who were exposed before birth) and children exposed after birth to diagnostic medical radiation from computed tomography (CT) scans have been found to have a slight increase in risk of leukemia and brain tumors and possible other cancers.⁽³⁷⁾
• Risk of childhood leukemia was associated with higher crop area near mother’s homes during pregnancy; CNS tumors were associated with higher cattle density.⁽⁵¹⁾
• Intake of vitamins and folate supplementation during the preconception period or pregnancy has been demonstrated to have a protective effect.⁽⁵⁵⁾

1         American Cancer Society, Childhood and Adolescent Cancer Statistics, 2014

https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2014/special-section-cancer-in-children-and-adolescents-cancer-facts-and-figures-2014.pdf

1B        Rebecca L. Siegel MPH, Angela N. Giaquinto MSPH, Ahmedin Jemal DVM, PhD, A Cancer Journal for Clinicians, Cancer Statistics 2024,

https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21820

2      St. Jude Children’s Research Hospital, (JAMA. 2013:309 [22]: 2371-2381)

http://jama.jamanetwork.com/article.aspx?articleid=1696100

3        Lancet Oncology, Sep 2019 Volume 20 Number 9 p1211– p1225, “The global burden of childhood and adolescent cancer in 2017”

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(19)30339-0/fulltext

4     National Cancer Institute, http://www.cancer.gov/research/areas/childhood, February 8, 2024

https://www.cancer.gov/about-cancer/treatment/drugs/childhood-cancer-fda-approved-drugs

5     Agency for Healthcare Research and Quality, US Dept. of Health & Human Services, “Pediatric Cancer Hospitalizations   2009, May 2012, Rebecca Anhang Price, Ph.D., Elizabeth Stranges, M.S., and Anne Elixhauser, Ph.D.

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb132.jsp

6        American Society of Clinical Oncology

http://jco.ascopubs.org/content/28/15/2625.short

7        HemOnc today, “Survivors of childhood cancer have increased risk for prediabetes,” January 25, 2024, Josh Friedman,

https://www.healio.com/news/hematology-oncology/20240125/survivors-of-childhood-cancer-have-increased-risk-for-prediabetes

7A     National Cancer Institute,“ Age and Cancer Risk” 3/05/2021.  Source: SEER 21 2013–2017, all races, both sexes.

https://www.cancer.gov/about-cancer/causes-prevention/risk/age

7B    National Cancer Institute, SEER Cancer Statistics Review 1973-1997 (NCI 2000)

http://jnci.oxfordjournals.org/content/93/5/341.full

7C    National Cancer Institute, NIH/NCI

https://fundedresearch.cancer.gov/nciportfolio/stats.jsp

7D    National Cancer Institute, NIH/NCI

https://fundedresearch.cancer.gov/nciportfolio/about.jsp

7E     National Cancer Institute, Cancer Types, Diffuse Intrinsic Pontine Glioma (DIPG)

https://www.cancer.gov/types/brain/patient/diffuse-intrinsic-pontine-glioma

7F      Healio HemOnc Today, “Cancer death rate drops by 33%, AACR report shows,” September 13, 2023, Matthew Shinkle,

https://www.healio.com/news/hematology-oncology/20230913/aacr-report-details-33-drop-in-us-cancer-death-rate

7G     Annual Report to the Nation 2022: Overall Cancer Statistics

https://seer.cancer.gov/report_to_nation/statistics.html#new

7H      National Cancer Institute, SEER Cancer Stat Facts: Childhood Brain and Other Nervous System Cancer (Ages 0–19), “Percent of New cases by Age Group,”

https://seer.cancer.gov/statfacts/html/childbrain.html

7i       National Center for Health Statistics (NCHS): National Vital Statistics System (NVSS) “Provisional Life Expectancy Estimates 2022, Report #31, Nov. 2023

https://www.cdc.gov/nchs/data/vsrr/vsrr031.pdf

8         Journal of the National Cancer Institute, “Cause-Specific Late Mortality Among 5 Year Survivors”

http://jnci.oxfordjournals.org/content/100/19/1368.full

9       Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer   EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2018, National Cancer Institute. Bethesda, MD, Based on November 2020 SEER data submission, posted to the SEER web site, April 2021.

10     Journal of Clinical Oncology – ORIGINAL REPORTS, November 16, 2023, Volume 42, Number 3,

https://doi.org/10.1200/JCO.23.00452

11       Institute of Medicine, 2008 – Cancer Care for the Whole Patient

12       Jacobsen et al., 2012 (Journal of Clinical Oncology, 30 (11), p.1151-1153)

13       Institute of Medicine, 2008

14       Institute of Medicine 2015 – Comprehensive Care for Children with Cancer and Their Families

15       Children’s Oncology Group Long Term Follow-Up Guidelines, 2013

16       Alderfer et al., 2010 (Psycho-oncology, 19 (8), p. 789-805)

17       Alderfer et al., 2003 (Journal of Pediatric Psychology, 28 (4), p. 281-286)

18       Kazak et al., 2004 (Journal of Pediatric Psychology, 29 (3), p. 211-219)

19       Alam et al., 2012 (Death Studies, 36 (1), p. 1-22)

20     Psychosocial care addresses the effects that cancer treatment has on the mental health and emotional wellbeing of       patients, their family members, and their professional caregivers. A single profession alone does not provide     psychosocial care: Instead, every patient-healthcare provider interaction provides an opportunity to assess the    stressors and concerns of children and their family members.

21      Hawkins et al., 2017 (Journal of Clinical Oncology, 5 (1), 78-87)

22      Bona et al., 2014 (Journal of Pain Symptom Management, 47 (3), 594-600)

23      Schwartz & Brumley, 2017 (Journal of Adolescent & Young Adult Oncology, 6 (1), 142-149)

24      Alderfer et al., 2015 (Journal of Pediatric Psychology, 40 (3) 309–319)

25      Vuotto et al., 2017 (Cancer, 123 (3), 521-528)

26      Wiener et al., 2016 (Journal of Pediatric Oncology Nursing, 33(5), 378–386)

27       National Cancer Institute, “Childhood Cancer Survivor Study: An Overview,” September 7, 2023

https://www.cancer.gov/types/childhood-cancers/ccss

28       UChicago Medicine, Tara Henderson, MD, MPH, “Understanding risks for childhood cancer survivors,” 9/01/2023,

https://www.uchicagomedicine.org/forefront/cancer-articles/understanding-risks-for-childhood-cancer-survivors

29       Cho S, Miller A, Mosha M, et al. (October 28, 2023) Clinical Trials on Cellular Therapy for Children and Adolescents With Cancer: A 15-Year Trend in the United States. Cureus 15(10): e47885.  DOI: 10.7759/cureus.47885

30       World Health Organization   2021 Dec. 13, “Childhood Cancer: Key Facts,”

https://www.who.int/news-room/fact-sheets/detail/cancer-in-children

31      The Lancet Oncology, VOLUME 24, ISSUE 9, P967-977, SEPTEMBER 2023, Treatment-related mortality in children with cancer in low-income and middle-income countries: a systematic review and meta-analysis

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(23)00318-2/abstract

32      FDA Report Drug Shortages

https://www.fda.gov/drugs/drug-shortages/report-drug-shortages-root-causes-and-potential-solutions

33       Lancet Oncology. 2015 Mar; 16(3): e123–e136. doi: 10.1016/S1470- 2045(14)70409-7

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4485458/

33A      Lancet Oncology.  “Sustainable care for children with cancer.”  04/2020 Volume 21 Number 4p467-602, e180-e225:

https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(20)30022-X/abstract

34         Effect of Time from Diagnosis to Start of Radiotherapy on Children with Diffuse Intrinsic Pontine Glioma, 2014 Jan 30. Doi: 10.1002/pbc.24971 PMCID: PMC4378861NIHMSID: NIHMS667729 PMID: 24482196

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378861/

35      Household income and risk-of-poverty of parents of long-term childhood cancer survivors, Pediatric Blood Cancer, 2017 Aug; 64(8). Doi: 10.1002/pbc.26456. Epub 2017 Mar 6.

https://pubmed.ncbi.nlm.nih.gov/28266129/

36      The National Children’s Cancer Society, The Economic Impact of Childhood Cancer, November 30, 2018

Retrieved from https://policycommons.net/artifacts/1647909/the-economic-impact-of-childhood-cancer/  on 16Dec 2021.CID:20.500.12592/qp3g3v

37       The National Cancer Institute “Cancer in Children and Adolescents” 9/27/2023

https://www.cancer.gov/types/childhood-cancers/child-adolescent-cancers-fact-sheet

38      American Cancer Society, Treatment and Survivorship Statistics, 2019

https://acsjournals.onlinelibrary.wiley.com/doi/10.3322/caac.21565

39         National Cancer Institute, NIH/NCI   Late Effects of Treatment for Childhood Cancer (PDQ®)–Patient Version

https://www.cancer.gov/types/childhood-cancers/late-effects-pdq

40        National Cancer Institute, Cancer Stat Facts: Cancer Among Adolescents and Young Adults (AYAs) (Ages 15–39)

https://seer.cancer.gov/statfacts/html/aya.html

41       The ASCO Post “Many Survivors of Childhood Cancer Experience Lifelong Chronic Health Problems and Shorter Lifespans Than  Their Healthier Peers,” October 16, 2023, Jo Cavallo.

https://ascopost.com/news/october-2023/many-survivors-of-childhood-cancer-experience-lifelong-chronic-health-problems-and-shorter-lifespans-than-their-healthier-peers/

42       Food and Drug Administration, FDA, 12,27,2020, Rare Pediatric Disease (RPD) Designation and Voucher Programs

https://www.fda.gov/industry/developing-products-rare-diseases-conditions/rare-pediatric-disease-rpd-designation-and-voucher-programs

43        United States Government Accounting Offices, GAO-20-636R, Jul 31, 2020. “Survivors of Childhood Cancer: Factors Affecting Access to Follow-up Care”

https://www.gao.gov/products/gao-20-636r

44      DELETED

45        NIH/National Cancer Institute, Age-Adjusted and Age-Specific SEER Cancer Incidence Rates, 2014-2018, Table 2.1

https://seer.cancer.gov/csr/1975_2018/results_single/sect_02_table.01_2pgs.pdf

46       Lancet Oncology, Volume 20, Issue 7, July 2019, Pages 972-983, “Global childhood cancer survival estimates and priority-  setting: a simulation-based analysis,”

https://www.sciencedirect.com/science/article/abs/pii/S1470204519302736

47         Cancer Epidemiology Biomarkers, 1 August 2021, DOI:10.1158/1055-9965.EPI-21-0154

https://aacrjournals.org/cebp/article-abstract/30/8/1536/670996/Longitudinal-Evaluation-of-Neuromuscular

48         Hofmann et al. (J Clin Oncol, 2018 vol. 36(19) pp. 1963-1972)

https://pubmed.ncbi.nlm.nih.gov/29746225/

49        DELETED

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