The+Work-In-Progress+Page

=What long-term health risks do childhood brain tumor survivors face? =

We became interested in this topic after discovering the besides leukemia, brain tumors are the most common type of cancer found intoc children. Every year, about 2,000 children under age twenty are diagnosed with brain cell malignancies [21] ; luckily, about 60% of them survive. Because there are so many different types of brain cells, there are similarly many different types of brain tumors, each with different natures. From there, we decided to explore the various effects that either the tumor or treatment of a tumor might have on a patient long-term considering that children are more likely to have brain tumors than adults, but their cells are also more prone to damage. Our research focused on identifying the most import factors that influence these long-term consequences. We explored the different treatment types--surgery, radiation, and chemotherapy--as well as the specific risks themselves, including learning problems, loss of brain function, new tumor development and effects to the endocrine system. After evaluating many factors, including age, location, treatment type, and dosage, among others, we concluded acknowledgment of all factors was necessary in the decision-making process by doctors of how to best proceed with treatment.

Understanding the Brain
Before we can understand the impact of brain cancer, we must first understand the significance of the brain itself. The human brain is the main organ of the central nervous system and responsible for regulating the body's actions and reactions. It is divided into three main parts: 1) the cerebral cortex, 2) the brain stem, and 3) the cerebellum, all of which are responsible for controlling different functions in the body.

The Cerebral Cortex
The cerebral cortex is most generlaly associated with learning, memory, and a level of thinking unique to humans. It is comprised of four different lobes: 1) the frontal, 2) the parietal, 3) the occipital, and 4) the temporal lobes. The **frontal lobe** is most commonly attributed with conciousness and one's mood. It allows us to understand what we are doing in our environment and initiate both activity and an emotional response. It is also the site of habits and motor activity memory. It also has a role in language, being the lobe responsible for assigning meaning to words. The **parietal lobe** is the location of touch perception and where we integrate a variety of sensory stimuli. It also controls voluntary movement and our ability to manipulate objects. The **﻿occiptal lobe** is primarily responsible for vision. Finally, the **temporal lobe** is responsible for the scent and sound senses. It also plays a role in memory acquisition and the mental categorization of objects. Lastly, it controls visual perception. [11]

The Brain Stem
The brain stem controls the activity involved in the startle response and autonomic nervous system, including breathing, swallowing, heart rate, reflexes to visual and auditory stimuli, sweating, digestion, temperature, and blood pressure. More generally, it controls the processes that occur independently of brain function. It also controls our ability to sleep. [11]

The Cerebellum
The cerebellum controls the coordination of voluntary movement and maintains our sense of balance and equilibrium. [11]

What are brain tumors?
A brain tumor is any abnormal growth of cells located withing the brain, brainstem, or the central spinal canal, more specifically known as an intracranial solid neoplasm [21]. These tumors can be both benign, meaning it has remained localized, and malignant, meaning it has metastisized from its original location to other parts of the brain; however, a tumor's threat level is determined less by its cancerous behavior and more so by other factors, including type of tumor, location, size, development, age of the patient, etc. While adults usally have brain tumors in the front two-thirds of the the brain, primary tumors in children are ususally located in the posterior cranial fossa, which contains the cerebellum and brain stem. [21] Childhood brain cancer is quiet diverse because it can arise in many different type of the developing cells in the brain; the different types are classed by morphology [21]. According to Children's Hospital Boston, currently ranked third in the nation for Top Ranked Pediatric Hospitals for Cancer, there are many different types of primary brain tumors in children [13][20][29]. They list: Medulloblastomas, which are located in the middle of the cerebellum, account for the greatest portion of brain tumors at about 15 to 20%.
 * choroid plexus tumor
 * craniopharyngioma
 * dysembryoplastic neuroepithelial tumor
 * germ cell tumors
 * low and high-grade gliomas, including epndymomas, astrocytomas, oligodendrogliomas
 * medulloblastoma
 * meningioma
 * primitive neuroectodermal tumors
 * rhabdoid tumor

**What are typical brain tumor symptoms?**
Brain tumor symptoms vary amongst the different types considering they ﻿ impact ﻿ ﻿ brain function in ﻿different manners. Brain tumors are usually only discovered after a child starts to display symtpms. Since diagnostic tools like x-ray radiation are not normally directed at the skull for safety reasons, they will not usually be found in routine check-ups and will have to have progressed to advanced symptoms [21]. There are a number of generalized symptoms that are common among the many types of brain tumors. It is important, however, in recognizing that symptoms in children may not be as easy as in adults because they are not always able to express what is wrong [1] [[|28]]. The appearance of these systems may encourage further diagnostic testing that may reveal the presence and nature of a primary tumor. These tests include neurological (which tests eye movement, hearing, sensation, muscle movement, sense of smell, balance/coordination, and memory) and psychological evaluations. [[|23]] These are usually supplemented by imaging techniques like magnetic resonance imaging (MRI), which is most common method and usually used for tumors near bones, in the brainstem, or that are low-grade; computed tomography (CT), which is not as sensitive, but uses less radiation; and positron emossion tomography (PET), which measures brain activity and is used in conjunction with MRI. Spinal taps may also indicate the presence of tumor cells in the spinal cord; furthermore, the more invasive biopsy procedure can provide information on the cell type of a tumor and where it originated.
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">**﻿Headaches**, while most likely due to other conditions, should not be ignored, particularly if the pain becomes chronic. Persistent and long-lasting headaches are common in patients with brain tumors; typically, these will become more frequent and severe over time.
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">Up to half of people with brain tumors have **seizures**.
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">A child who seems to be sleeping more then usual, seems less energetic and fatigued during the daytime may be exhibiting signs of a brain tumor. Fever, weight loss, and general malaise be also be early symptoms
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; line-height: 18pt;">Overall c**ognitive decline** may also be a symptom of a brain tumor**.** Children with brain tumors might show a greater difficulty at remembering things, as well as processing information and reacting appropriately.This might cause a child take longer to complete tasks than normal.
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif; line-height: 18pt;">Mild to severe **personality changes** may become apparent

<span style="font-family: Arial,Helvetica,sans-serif;">Treatment Options
<span style="font-family: Arial,Helvetica,sans-serif;">﻿<span style="font-family: Arial,Helvetica,sans-serif;">Generally speaking, cancers that occur in childhood respond to treatment well. About 60% of the children diagnosed with a brain tumor survive and, overall, more than 80% of all cancers that occur in children are cured [1]. This is usually due to the fact that doctors evaluate each cancer case on an individual basis in order to decide which treatment plan is the best course of action to take. In doing so, they have to consider the many variables that affect the nature and outcome of the disease, such as age, location, and severity, among many others. <span style="font-family: Arial,Helvetica,sans-serif;">There are three general categories of brain tumor treatment: radiation, chemotherapy, and surgery. [[|25]] Because brain tumors are located in high-impact areas in patients who are most vulnerable to those risks, the desired course is rarely to stand back and do nothing; regardless of whether the tumor is invasive or localized, brain tumors can disrupt brain function and invariably need to be removed. Surgery is the widely preferred treatment, but limitations due to tumor location require that other treatment options also be used.

<span style="font-family: Arial,Helvetica,sans-serif;">Surgery
<span style="font-family: Arial,Helvetica,sans-serif;">Surgical removal is often considered the first and best option for a tumor patient when conditions allow, since it can remove all tumor cells if done well. Also known as resection, it is used to excise the whole tumor or just some portion of it (known cytoreduction) to allow radiation to be more effective in particularly large or aggresssive tumor types]. Usually, it is most effective on benign tumors, as localized tumor cells are much easier to detect in their entirety than those that have invaded other parts of the brain. It is imperative that as much of the tumor is removed as possible; for this reason, surgery is often not sufficient for malignant brain tumors and may require the aforementioned combined approach of therapies. <span style="font-family: Arial,Helvetica,sans-serif;">Without a doubt, this the most physically invasive of all the brain tumor treatments, yet can be so at varying extents. Depending on the size and location of the tumor, a full craniotomy in which a large piece of the skull is removed may be necessary for aggressive forms of cancer; conversely, some doctors have been successful at removing tumors via smaller incisions (or through the nasal cavity), though it is not yet a common procedure to do so [21]. Additionally, surrounding, healthy tissue may also be removed either to access the tumor or to ensure that all tumor cells have been excised. One of the major points of concern for doctors is removing all the tumor tissue with minimal effects to the surrounding areas [2]. For this reason, s urgery is not always feasible, and some tumors are located too deep inside the brain or brain stem to safely remove. Radiation and chemotherapy alone must be used to tackle these cases. Surgery is less likely to contribute to unnecessary damage to healthy cells in the brain as radiation might, but there are risks that accompany brain surgery, beyond the obvious loss of function in the area of brain removed. Seizures, for example, are a common danger of surgery and epilepsy may become a long-term problem depending on the extent of damage.

<span style="font-family: Arial,Helvetica,sans-serif;">Chemotherapy
Chemotherapy works by killing the body's fastest growing cells; thus, this euphemistic poison is able to specifically target tumors cells. However, cancer cells are not the only in the body that rapidly divide, and hair folicles and stomach lining cells, for example, are affected, too; this causes the typical typical symtpoms like hair loss and nausea, among others. Because children have a greater number of fastly growing cells than adults, they similarly have a greater number of cells that are vulnerable and at risk for damage. [2] Chemotherapy is often used in children to avoid using radiation, yet its toxicity, high number of side-effects, and variable results make it less favorable than some treatment types. Since it improves survival for patients with primary malignant brain tumors only about 20% of the time, it is more often used in conjunction with other treatments if a tumor is malignant or there are multiple present [21]. It is best used as a follow-up treatment to kill tumor cells that were left after surgery. The common chemo drugs used for high-grade gliomas, which often carry the worst prognosis for cancer patients, include: Because of its high toxicity, there are number of variables that affect whether it is an acceptable form of treatment. For example, the age, general health, and immune system of the patient must be considered, since those with compromised health are unlikely to be able to tolerate the drugs. This can control dosage levels.
 * methotrexate
 * cyclophosphamide
 * vincristine
 * cisplatin
 * carboplatin
 * etoposide

<span style="font-family: Arial,Helvetica,sans-serif;">Radiation
<span style="font-family: Arial,Helvetica,sans-serif;">Like chemotherapy, radiation targets rapidly dividing cells, but with high-energy radiation. The hope is that it will kill cancer cells that divide at a rate faster than normal cells and that normal cells subject to its damage will be able to repair themselves faster. The benefit is that it can very specifically be directed at the tumor's location and carefully regulated amounts over a series of treatments. It is similarly used as a follow-up treatment to surgeries that could not remove all tumor cells, but also in cases where surgery could not occur. Despite its effectiveness at targeting rapidly dividing cancer cells, however, there are also many drawbacks to this treatment process. Numerous studies have illustrate the potential damages radiation therapy can cause to an individual, and there is overwhelming evidence that radiation, even at low-doses, greatly increases one's risk for cancer. <span style="font-family: Arial,Helvetica,sans-serif;">Results from a five year study done by the National Research Council demonstrate that even low doses of radiation, defined as 0 to 100 milliSieverts (units expressly describing amount of radiation), can potentially cause cellular injury. Since the effects of radiation seem to be cumulative, on a very generalized level, a greater amount of radiation correlates with a greater amoutn of DNA damage and, subsequently, an increase risk of cancer [8]. More interestingly, the study also shows that both age and gender are variables that contribute to the effects of radiation. Radiation exposure in the first year of life for males increase one's cancer risk three to four times that attributed to a similar dose given between ages twenty and fifty; a female child's risk is double that of a male's. While DNA damage is something to avoid at all ages, reducing the amount of radiation exposure for children is especially important. Not only are a child's cells dividing at a greater rate and, therefore, at greater risk of damage from radiation, but they are also getting a jumpstart on a life-long accumulation of DNA damage early, putting them at greater risk for cancer later in life [17]. Therefore, doctors especially avoid radiotherapy, particulary when directed toward the head, on children under three years since it contributes to markedly greater affects than in children just a few years older [2]. When it is absolutely necessary, they carefully monitor dosage level. Since radiation therapy is solely directed at the brain, the type of tumor that usually results later in life is typically a second type of brain tumor; the risk for it being malignant is much higher than in other patients. This risk was directly correlated with dosage and age; children treated with radiation under age 5 were the most likely to develop secondary tumors. While surgery is the best option for those with primary tumors, more radiation is usually used to treat these secondary tumors [14].
 * = //"There appears to be no threshold below which exposure can be viewed harmless." [8]// ||

<span style="font-family: Arial,Helvetica,sans-serif;">Long-term Health Risks
<span style="font-family: Arial,Helvetica,sans-serif;">As mentioned earlier, about 80% of children who have been diagnosed with cancer are cured. Sadly, 75% of those survivors face risks later in life as adults, with children surviving brain tumors having the greatest risk [1]. One study shows that only one in three people who survive childhood cancer remain healthy--that is to say, don't have other health problems, new tumor development, or a recurrence of the original cancer [3]. Many of these risks can be attributed to the actual treatment process for the original brain tumor(s). <span style="font-family: Arial,Helvetica,sans-serif;">There are a number of side effects that patients may experience in the weeks and months following treatment, most of which are just worsening of initial symptoms, including lethargy, overall exhaustion, lack of appetite, and more. These early delayed effects may be attributed to damage to the outside of the raidation and the process of remoign dead tumor cells. Considering that tehse symptoms are temporary, the more important issue is what effects a childhood cancer may experience later in life, sometimes more than ten or twenty years after treatment [[|28]]<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;"> [12].

<span style="font-family: Arial,Helvetica,sans-serif;">Brain Function
Recall that the brain is responsible for unceasing regulation of all the processes of the human body. It analyzes data supplied by the senses and tells the body how to respond appropriately [22]. It is not uncommon for a brain tumor to interfere with the processes occuring in this vital organ; damage and subsequent loss of brain function in particular areas can show distinctive changes in cognition or behavior. For example, seizures and motor incoordination, both of which survivors commonly experience, are related to the impact on brain function.

<span style="font-family: Arial,Helvetica,sans-serif;">The Cerebral Cortex
<span style="font-family: Arial,Helvetica,sans-serif;">Because this is the part of the brain responsible for learning, higher-order thinking, and memory, tumors in this area can pose particularly significant problems to children since they are at the stage in their lives when they are doing the most rapid learning. The physical presence of a tumor located in the neocortex can impose learning difficulties on a child; treatments can exacerbate these problems and, even after its absence, a child can continue to experience these same challenges. Losing function in the **frontal lobe** of one's brain can cause paralysis, inability to sequence of complex movements, and learning problems like difficulting problem solving, focusing, and flexible thinking. It can also change one's personality and social behavior. Damage done to the **parietal lobe** may cause lessened eye and hand coordination due to lack of self-awareness of of one's own body, an inability to name objects and locate words for writing, and difficulties with reading, drawing objects, math, and distinguishing between different directions. The **occiptal lobe** controls vision, so problems are often vision-based, including problems locating objects, recognizing words, identifying colors, or following movements. These problems can further complicate a child's ability to read and write. Finally, damage to the **temporal lobe** can result in both short and long-term memory loss and problems recognizing faces. Additionally, it can lead to difficulty identifying, categorizing, or verbalizing about objects. Furthermore, it may increase aggression in an individual's behavior. [11]

<span style="font-family: Arial,Helvetica,sans-serif;">The Brain Stem
<span style="font-family: Arial,Helvetica,sans-serif;">Problems with brain stem tend to create more physiological effects, like decreased breathing and swallowing capabilities, as well as some problems with balancing and movement, further causing vertigo. It also causes sleep problems. [11].

<span style="font-family: Arial,Helvetica,sans-serif;">The Cerebellum
<span style="font-family: Arial,Helvetica,sans-serif;">Like that seen in the brain stem, loss of normal function in cerebellum poses more physical hinderances than that seen in neocortex. This can include the difficulties walking and reaching for objects, slurring, and uncontrollable movement. [11]

<span style="font-family: Arial,Helvetica,sans-serif;">Learning Problems
<span style="font-family: Arial,Helvetica,sans-serif;">Studies have shown that the difficulties arising from altering the normal function of one's brain do actually become realities for many children who have had brain tumors. Some cognitive impairments caused by damage to specific portions of the brain put children at more risk for learning difficulties, specifically those related to: These manifest themselves in many different ways and are usually associated with overall learning; some specific problems, however, are seen in activities and skills like: Learning problems can also be influenced by changes to the neurosensory system. Problems with hearing and seeing--both of which can arise from brain damage--can make learning much more challenging for children, as well as influence language development [cancer.org]. The combination of cisplatin chemotherapy and radiation, for example, are known to cause hearing problems [6]. It is interesting that in studies of all types of childhood cancer, only those with brain tumors experienced any problems with educational attainment [4] ; this is a health risk that seems to be unique to brain tumor survivors. It is important to note that it is especially significant in populations who've had brain cancer as children, too. Adults may experience the same types of mental decline in they have had tumors, but they won't necessarily lose all the vital lessons, skills, and knowledge they absorbed as children; they've already fully developed and will not be missing out on the most important stages of learning in childhood. Conversely, children who have had brain tumors are at risk of missing those informative years entirely, which could affect them for life if they are unable to progress through those stages of learning. Because all three treatment types can leave a patient with brain damage, they are all similarly associated with subsequent learning problems Further damage to healthy cells by radiation, physical loss of brain tissue, and intravenous or intrathecal chemotherapy can all contribute to loss of brain function that results in lower educational attainment. Again, all effects are exacerbated by amount or dosage, as well as age. Learning problems can also be influenced by changes to the neurosensory system. Problems with hearing and seeing--both of which can arise from brain damage--can make learning much more challenging for children. Brain damage is a biological consequence of a brain tumor that can have profound effects on the learning process, yet there are social factors that must be considered as well. Survivors are far more likely to have post-traumatic stress disorder which can inhibit one's performance in school [31]. Higher stress levels can arise from not only having to deal with the treatment process itself, but also from the frustration of trying to work through resulting learning or mental disabilities, trying to catch up with peers after a long absence from school, working with teachers, and so on.
 * problems with concentration and attention
 * problems with memory
 * problems in areas of problem-solving like processing, planning, organization
 * poor hand-eye coordination
 * slowed development
 * behavior problems [2] [5]
 * handwriting
 * spelling
 * reading
 * vocabulary
 * math [5]
 * <span style="background-color: #ffffff; color: #0000ff; font-family: Arial,Helvetica,sans-serif;">//"Overall, survivors of childhood cancer experience a deficit in educational attainment compared with the general public. Specifically, only those who had central nervous system neoplasms, especially if they had received radiation to the head... performed worse than the general population. These differences were substantial and statistically significant." [4]// ||

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">Health Risks
<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">Studies show that individuals who faced CNS malignancies as children are thirteen times at risk of death than people without CNS tumors [18]. For example, one study finds that survivors of bone, nerve, and brain cancers, as well as Hodgkin's disease, are fifty-four times likely to need a joint replacment, fifteen times more likely to experience both congestive heart failure and the emergence of a second primary tumor, ten times more likely to have heart disease, and nine times more likely to suffer stroke or kidney failure [3]. Another study indicates that the risk of stroke may even be as high as 15 times more likely than that of a healthy sibling [19]. So even though a child may survive a brain tumor successfully, they are at more risk for health problems down the line than survivors of any other cancer.

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">Endocrine System
Some of the most significant health consequences of brain tumors occur in the Endocrine system due to damage to the hypothalamus, which regulates the hormones that affect growth, puberty, metabolism, and the body's stress repsonses to stimulus [12]. Damage to the pituitary gland of the hypothalamus due to radiation to the head, surgery, or the physical tumor itself creates hormonal imbalances which affect the normal functioning of the thyroid gland, resposible for further hormonal regulation. This most commonly contributes to symptoms like short stature, obesity, and early onset of maturity. Short stature can be a consequence of a growth hormone deficiency that causes slow bone growth; conversely, it also can be caused by an early release of growth hormones that cause rapid bone growth to occur before proper bone maturation, still leading to both short stature overall and unhealthy bones. Children treated for brain tumors as children are also likely to experience "precocious puberty," which means reaching puberty at an age earlier than normal; for girls, this is younger than age 8, while in boys it is age 9 [7]. Finally, a decrease in thyroid function has been correlated with weight gain, so those who experience radiation to the brain are at greater risk for obesity later in life. [2]

Other Physiological Problems
It should be noted survivors of CNS tumors are at the greatest risk for cardiac problems and strokes--ten and nine times more than the average person, respectively. Excluding new tumor development and relapse, heart disease is actually the biggest contributor to mortality. However, while being at a significant greater risk, these problems are found universally among cancer survivors and should be noted, but not emphasized here. Similarly, damage to the liver from certain chemotherapy agents (like cisplatin, for example) can appear later in life, but is not unique to childhood brain cancer survivors.

<span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">New Tumor Development
Similarly seen in Hodgkin's lymphoma, secondary tumor deveopment is seen far more often in childhood brain tumor survivors than in survivors of other types of cancer as is correlated to the same factors that control the damage of radiation exposure, such as age and dosage [14]. Because this radiation is concentrated in the brain, new tumors that arise tend to be other types of brain tumors, though often worse in prognosis than the first. Patients who are treated for these secondary tumors present the even more devastating long-term effects ﻿ if able to survive treatment again.

**Growth Hormone Therapy**
Because treatment of a brain tumor could lead to damage of the endocrine system which can ultimately lead to growth hormone deficiency it is common for children who are found to be deficient to undergo growth hormone therapy after their treatment from a brain tumor. Growth hormone therapy which simply is the supplementation of growth hormones is increasingly being used for the treatment of children and adults who are diagnosed with growth hormone deficiency. It is mitogenic, and because of this there are therefore concerns about its safety, especially when used to treat cancer patients who have become growth hormone deficient after treatment from a brain tumor. Studies done in the United Kingdom found that recurrence rates of brain tumor are not increased significantly after growth hormone therapy.[[|30]] Treatment with growth hormone can help to offset many negative long term effects such as short stature.

<span style="font-family: Arial,Helvetica,sans-serif;">Analysis and Personal Impressions
Before we began our research, we formulated a number of questions we hoped to answer or, at least, learn more about from examining the late-effects adults experience from having brain tumors as children. Most importantly, we wanted to focus on what factors were most important in influencing those outcomes, more specifcially: //Are neurological problems attributed more so to the impact of the physical tumors itself, or the treatment processes to remove it? Which are the most important factors?// <span style="font-family: Arial,Helvetica,sans-serif;">We had both assumed before research that things like age of severity of the tumor would have markedly differnet affects on the patient for obvious reasons; if most development occurs in children, halting that process will have profound consequences, for example. Neither of us were certain to the extent the factors would play a role, though. We initially chose to explore: We also asked: <span style="font-family: Arial,Helvetica,sans-serif;">We soon found in our research, however, that this was far too ambitious a set of research objectives to be feasible for in-depth analysis.
 * <span style="font-family: Arial,Helvetica,sans-serif;">age of diagnosis
 * <span style="font-family: Arial,Helvetica,sans-serif;">location in the brain
 * <span style="font-family: Arial,Helvetica,sans-serif;">type of cell affected/tumor type
 * rate of spread
 * type/length of treatment
 * malignant versus benign growth
 * <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">What is the likelihood of developing a new type of cancer from the therapies used to combat the first?
 * <span style="font-family: Arial,Helvetica,sans-serif;">Does adult surviving a brain tumor experience the same long-term effects as a child with a similar type of tumor?
 * <span style="font-family: Arial,Helvetica,sans-serif;">How is surgery compared to other types of brain surgeries? Are there similar long-term effects?
 * <span style="font-family: Arial,Helvetica,sans-serif;">What effects can a benign tumor cause if left untreated? Is it more beneficial over the long-term to leave a benign tumor intact or remove it? Does this still depend on location?
 * <span style="font-family: Arial,Helvetica,sans-serif;">Should knowledge of the effects of the different types of treatment affect a parent's judgment in deciding how to best treat their child? Is such consideration up to the doctor alone?

Are neurological problems attributed more so to the impact of the physical tumors itself, or the treatment processes to remove it? Which are the most important factors?
We focused most on this since, while cancer is unique and can be influenced in a variety of ways, we expected some factors play a more pivotal role than others. However, it appears that this is not entirely the case, as most factors are linked to one another and play equally important roles. Consistently, we found evidence that suggested that radiation as a method of treatment and age are significant contributors to neurocognitive impairments [6]. In terms of treatment, chemotherapy, surgery, and radiation all have their downsides, but it seems that there is a lot more negative attention devoted to the affects of radiation because they can extend the damage beyond that for which the tumor is responsible. Amount of radiation and age of the patient are some of the strongest causative links to secondary tumor development later in life; chemotherapy is not correlated with new tumor development. However, if you want to examine the loss of specific brain function, however, then chemotherapy, as well as location of the tumor, may also be influential factors to consider. Gender also plays a role in prognosis and is a variable we did not expect. We are not entirely sure of the detailed biological explanation for why this occurs, though we can infer that it might have something to do with the fact that girls develop at a younger age than boys, potentially allowing a tumor to impact an earlier, more essential stage of growth in the brain. The fact that radiation given in the first year of their life increases their cancer risk for a girl almost double that for a boy is significant in its consequences for the healthcare choices parents make for their children [low exposure article]. This also speaks to the significance of radiation therapy since its affects are compounded over time. If exposure occurs earlier in life, not only is the affect of that exposure more detrimental, but it speeds up the process by which those exposure events accumulate.

<span style="font-family: Arial,Helvetica,sans-serif;">**Hard Decisions**
<span style="font-family: Arial,Helvetica,sans-serif;">There are many diseases and conditions with clear-cut treatment options that are widely considered to be the single best option or the most effective. From our research, it became clear that cancer is excluded from this category. Certainly there are some treatment options that are better suited for types of cancer (put in example from earlier here), but the distinctive character of every tumor generally makes treatment difficult. We talked about the future of personalized medicine in class briefly, but, for now, this puts many hard decisions in the hands of doctors and patients' parents. As we just described above, there is no one variable that stands above the rest, so all must be considered when trying to decide what teh best course of treatment is. <span style="font-family: Arial,Helvetica,sans-serif;">There is also no easy way to tell a parent that, while therapy has a high likelihood of completely eliminating his or her child's tumor, it will almost certainly cause long-term effects. Since the connotation of the term "cure" often implies that all traces of a disease are gone, it is difficult to remind parents that their child may live with certain health and mental consequences for life, even if no physical tumor is left within the body.

<span style="font-family: Arial,Helvetica,sans-serif;">Social Implications
This was touched upon earlier, but should be highlighted again to emphasized the wholistic nature of cancer. Dealing with the biology of the disease is essential, but social consequences further complicate the nature of the disease and must be addressed. What does it mean for a child who cannot play with his friends and grow up living normally? How will they suffer in school if they are absent for months are return with certain impairments? Because cancer is such an unique disease with varying effects, naturally, every child will individually deal with it differently. Therefore it is not only the physical effects, but how a child manages stress and works through those impairments which can shape the course of the disease. Also, if you apply the understanding of what decreased educational attainment means to a broader perspective, you can see many social ramifications. It's not hard to follow that a child who does not do well in high school may not do well or even attend college, who, furthermore, may not be able to get as good of a job. Studies show that these children are the least adapated to adulthood, so are unlikely to do as well [32]. That may put them at a disadvantage at gaining access to the health resources they need as a cancer survivor, increasing their risk of more health problems. While this may not be the norm, one can see the cycle in which the unluckiest survivor may be trapped.

For the Future
After gaining a better understanding of the many long-term effect brain tumor survivors suffer many years after being cured, the need for life-time follow-up care was never more obvious. Both close health evaluation and tracking of educational progress is essential for the wellbeing of the patient. Regular check-ups are particularly important for monitoring the progression of secondary tumor growth, hopefully catching at the early stages of development [risk of second primary tumors]. Research indicates that many survivors do not have adequate access to the services they desire with a lack of psychosoical services and illness information being the most common complaints. Consistent with what we know about factors influencing brain tumor consequences, women, patients who were younger at diagnosis, and those with general malaise reported the greatest insufficiency in resources [33]. For the future, we should dedicate more time and effort to follow-up care, including it as part of the treatment process itself.

**Extra**
Graphs that pertains to Childhood Brain Cancer. Source from SEER website. [[|27]]

Table of some known Causes of Childhood Brain cancer. Taken from Seer website. [[|27]]

<span style="font-family: Arial,Helvetica,sans-serif;">References
<span style="font-family: Arial,Helvetica,sans-serif;">[1 ] Haddy, Richard I and Theresa B Haddy. "Lifetime Follow-Up Care after Childhood Cancer." __Journal of the American Board of Family Medicine__. 23.5. 2010. 647-654. Medscape News. 6 May 2011. []. [2] "Childhood Cancer: Late Effects of Cancer Treatment." __American Cancer Society__. 20 Dec 2010. 3 Jun 2011. [] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[3] <span style="font-family: Arial,Helvetica,sans-serif;">"Child cancer survivors face bad health as adults." __MSNBC__. Reuters. 14 Nov 2006. 16 May 2011. []. [4] "Childhood survivors of CNS cancers and leukemia have lowered educational attainment." __ScienceDaily__. 27 Jan 2010. Journal of the National Cancer Institute. 8 May 2011. []. [5] "Educational Issues Following Treatment for Childhood Cancer."__CureSearch: Children's Oncology Group__. vs. 3.0. Oct 2008. 3 Jun 2011. []. [6] "Educational Late Effects." __Children's Brain Tumor Foundation__. Children's Brain Tumor Foundation. 12 Nov 2009. 3 Jun 2011. []. [7] "Endocrine Problems after Childhood Cancer: Precocious Puberty."__CureSearch: Children's Oncology Group__. vs. 3.0. Oct 2008. 3 Jun 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[8] "Even Low Exposure To X-rays, Gamma Rays Increases Cancer Risk, Study Finds." __ScienceDaily__. 27 Oct 2005. Stanford University. 27 Apr 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[9] "Late Effects of Treatment for Childhood Cancer." __Masonic Cancer Center__. 13 Aug 2009. University of Minnesota. 6 May 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[10] "Late Effects of Treatment for Childhood Cancer." __National Cancer Institute__. 25 March 2011. National Institutes of Health. 6 May 2011. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[]. [11] Lehr, Robert P. "Brain Functions and Map." __CNS: Centre for Neuro Skills__. 2011. 3 Jun 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[12] <span style="font-family: Arial,Helvetica,sans-serif;">"Medical Late Effects." __Children's Brain Tumor Foundation__. Children's Brain Tumor Foundation. 10 Nov 2009. 16 May 2011. <span style="font-family: 'Times New Roman','serif'; font-size: 10pt; line-height: 115%;">[] ﻿. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[13] "My Child Has... Brain Tumors." __Children's Hospital Boston__. 2010. Children's Hospital Boston Department of Neurosurgery. 5 May 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">﻿[14] Neglia, JP, DL Friedman, Y Yasui, AC Mertens, S Hammond, M Stovall, SS Donalson, AT Meadows, and LL Robinson. "Second malignant neoplasms in fiver-year survivors of childhood cancer: childhood cancer survivor study." __Journal of the National Cancer Institute__. 93.8. 18 Apr 2001. 616-29. National Center for Biotechnology Information, U.S. National Library of Medicine. 5 May 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[14] "Radiation Increases Risk Of Second Primary Tumors For Childhood Survivors." __Journal of the National Cancer Institute__. 1 Nov 2006. ScienceDaily.6 May 2011. []. [15] "Recovery for children with brain tumors." __CancerHelp UK__. Cancer Research UK. 3 Jun 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[16] Ron, Elaine. "Childhood Cancer--Treatment at a Cost." __Journal of the National Cancer Institute__. 98.21. 1 Nov 2006. National Institutes of Health. 5 May 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[17] Sanders, Robert. "Radiation expert warns of danger form overuse of medical X-rays, claiming they're responsible for many cancer and heart disease deaths." __Public Affairs.__ (510) 642-3734. 16 Nov 1999. UC Berkeley. 27 Apr 2011. []. <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[18] "Survivors Of Childhood Central Nervous System Cancer Face Persistent Risks As Adults." __Science Daily__. 22 Jun 2009. Journal of the National Cancer Institute. 8 May 2011. []. [19] "Survivors Of Childhood Leukemia, Brain Tumors More At Risk For Strokes Later In Life." __ScienceDaily__. 21 Nov 2006. UT Southwestern Medical Center. 3 Jun. 2011. []. [20] "U.S. News Best Children's Hospitals: Cancer." __U.S. News & World Report__. 2011. 10 May 2011. []. [21] Wikipedia contributors. "Brain Tumor." __Wikipedia, The Free Encyclopedia__. Wikipedia, The Free Encyclopedia. 3 Jun 2011. 3 Jun 2011. []. [22] Wikipedia contributors. "Human brain." __Wikipedia, The Free Encyclopedia__. Wikipedia, The Free Encyclopedia. 16 May 2011. 10 May 2011. [].

[23]"Brain Tumor - Children Diagnosis - Brain Tumor - Children Health Information - NY Times Health." //Health News - The New York Times//. Web. 03 June 2011. <[]>. [24]"Brain Tumor Facts & Statistics - Facts & Statistics - Revolution Health." //Revolution Health - Start Your Revolution - Revolution Health//. Web. 03 June 2011. <[]>. [25]"Brain Tumor Treatment | Seattle Children's Hospital." //Seattle Children's Hospital - World Class Child Health Care | Seattle Children's Hospital//. Web. 03 June 2011. <[]>. [26]"Recovery for children with brain tumor" : Cancer Research UK : CancerHelp UK." //CancerHelp UK Homepage : Cancer Research UK : CancerHelp UK//. Web. 03 June 2011. <[]>. //[27]SEER Web Site//. Web. 03 June 2011. <[]> [28]"Symptoms of Brain Tumors - Symptoms of Brain Tumors in Children." //About Cancer//. Web. 03 June 2011. <[]>. [29]"Types of Brain Tumors." //St. Jude Children's Research Hospital//. Web. 03 June 2011. <[]>. [30]"Growth Hormone Treatment of Children with Brain Tumors and Risks of Tumor Recurrence-[] <span style="color: #000000; font-family: Arial,Helvetica,sans-serif;">[31] <span style="font-family: Arial,Helvetica,sans-serif;">"Survivors of Childhood Cancers Four Times More likely to Develop Post-traumatic Stress Disorder." __Children's Brain Tumor Foundation__. Children's Brain Tumor Foundation. 5 May 2010. 16 May 2011. []. [32] Ellenberg, Leah. "Neurocognitive Status in Long-Term Survivors of Childhood CNS Malignancies: A Report From the Childhood Cancer Survivor Study." __Neurospsychology__. 23.6. 2009. American Psychological Association. 705-717. 3 Jun 2011. []. [33] "Unmet care needs in adult life following childhood brain tumor, Swedish study finds." __ScienceDaily.__7 Apr 2011. Karolinska Institutet. 3 Jun 2011. [].

List of original research questions here. Class blog [|here].