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Epidemiology
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Scholastic achievement of children with lymphoma or Wilms tumor at the end of comprehensive education—A nationwide, register-based study
Article first published online: 23 JUL 2008
DOI: 10.1002/ijc.23753
Copyright © 2008 Wiley-Liss, Inc.
Additional Information
How to Cite
Lähteenmäki, P. M., Sankila, R., Pukkala, E., Kyyrönen, P. and Harila-Saari, A. (2008), Scholastic achievement of children with lymphoma or Wilms tumor at the end of comprehensive education—A nationwide, register-based study. Int. J. Cancer, 123: 2401–2405. doi: 10.1002/ijc.23753
Publication History
- Issue published online: 12 SEP 2008
- Article first published online: 23 JUL 2008
- Manuscript Accepted: 21 MAY 2008
- Manuscript Received: 30 JAN 2008
Funded by
- Finnish Cancer Society
- Society for Turku University
- Nona ja Kullervo Väre Foundation
- The Finnish Medical Society Duodecim
- Abstract
- Article
- References
- Cited By
Keywords:
- child;
- kidney;
- late-effect;
- lymphoma;
- school grade
Abstract
Cancer treatment may affect school performance. School report grades after childhood lymphomas and Wilms tumor have not been previously reported. All Finnish patients with Wilms tumor (N = 74), Hodgkin lymphoma (HL) (N = 99) and non-Hodgkin lymphoma (NHL) (N = 94) who were born in 1974–1986 and had achieved the age of 16 years were identified from the Finnish cancer registry. Population controls (N = 1329) were matched for age, gender and residence. Their 9th grade school reports were obtained from Statistics Finland. The overall average and grades for mother tongue, first foreign language, mathematics and physical education were compared between the patients and their controls. Almost all the patients (>98%) had finished their comprehensive school. NHL patients had lower overall averages than their controls (difference −0.27 grade units; 95% CI −0.39, −0.15). Irradiation or age at diagnosis did not explain this difference in NHL patients. The grades of NHL patients were significantly lower than those of their controls in each academic school subject, especially in mathematics (−0.45; 95% CI −0.63, −0.27). In mother tongue, girls with irradiation had greatest difference (−0.66, 95% CI −0.99, −0.34) to their controls. Patients with HL and Wilms tumor performed similarly or even better than their controls in all academic subjects. Grades for physical education were impaired in Wilms tumor patients (−0.20; 95% CI −0.33, −0.06). Impairment of school report grades was observed in patients with NHL. The difference to controls was greatest in mathematics. The patients with HL and Wilms tumor, who had not received any central nervous system directed therapy, achieved equally good grades as their controls in all the academic subjects. © 2008 Wiley-Liss, Inc.
Along with the rapidly growing number of long term survivors of childhood cancer, the interest on the possible influences of the disease and treatment on cognitive functions and scholastic achievements has increased. At the greatest risk for learning difficulties are those childhood cancer patients who have received central nervous system (CNS)-directed treatment, e.g., patients with hematological malignancies or brain tumors.1–10 In the non-CNS tumor patients, some studies have found no impairment in academic achievements,3, 5 whereas others have reported significant educational deficits.2, 4, 11
Several factors may influence learning and school performance in cancer patients. CNS-directed therapy used in hematological malignancies typically includes glucocorticosteroids, and high-dose as well as intrathecal chemotherapy with or without CNS irradiation. This type of treatment may induce learning difficulties, especially memory impairment, concentration difficulties and slowness of processing.12, 13 Penetration of most anticancer drugs into brain is, however, very poor14 and thus, patients treated without CNS-directed therapy are believed to be at a low risk for cognitive impairment. Other factors such as the psychosocial burden caused by cancer diagnosis, school absenteeism, social isolation, poor nutrition and impairment of general condition may have adverse impact on learning and success at school.
Majority of patients with Wilms tumor are diagnosed young, usually before school-age, and treated with low-intensity chemotherapy protocols. Hodgkin lymphoma (HL) patients represent a group of patients diagnosed at school age and treated often with more intensive combination chemotherapy. Patients with nonHodgkin lymphoma (NHL) represent here the only group that has received CNS-directed therapy. Their treatment resembles that given to patients with acute lymphoblastic leukemia, but may differ from it in some NHL subgroups like in Burkitt lymphoma.
Previous studies have evaluated the level of education3, 5, 7 or utilization of special education services,4 but information of school grades has been given only concerning leukemia8, 10 and CNS tumor patients.6 Healthy volunteers have seldom been used as controls,3, 15 and register-based identification of study subjects has been reported only in 1 study.5
In the present register-based study, our aim was to assess performance in different school subjects after treatment of childhood lymphomas and Wilms tumor and compare that with the school report grades of population-based matched controls. The school report grades were obtained from the National statistics and the treatment data from the Finnish Cancer Registry (FCR). The results will help the recognition of those subgroups of patients who would need careful follow-up and supportive interventions. Our aim was also to find out whether other factors than CNS-directed therapy might have influence on school success after childhood malignancies.
Material and methods
Subjects
The population-based and nation-wide FCR has collected data on all cancer diagnoses in Finland since 1953.16 Patient series were identified from the FCR. Inclusion criteria were: all patients diagnosed with cancer before the age of 16 years, alive at their 16th birthday and born in 1974–1986. These years were chosen on the basis of available school report data. From FCR, it was possible to obtain patient's age at diagnosis and limited information about cancer treatment. Unfortunately, the FCR does not include information on the site or dose of irradiation, or the chemotherapy protocol used. The treatment protocols have not been uniform during this study period. During the last 2 decades most of the Burkitt lymphoma patients have been treated with the protocol introduced by Professor Patte,17 and the other NHL patients have mostly been treated with Nordic leukemia protocols.18, 19 Patients with HL have usually been treated with ABVD- or ABVD-hybrid treatment20 and most recently with the German protocols.21 Patients with Wilms tumor have most often been treated according to the American National Wilms Tumor Study protocols.22
Five matched controls were identified for each patient from the Population Register of Finland. Matching was made for age (same year and month of birth), gender and residence on the date of the diagnosis of cancer. The parents of the patients and their controls were identified from the population register of Finland in order to get the data on their education from the Examination Registry of Statistics Finland.
There were 99 HL, 94 NHL and 74 Wilms tumor patients fulfilling the inclusion criteria. The median age at diagnosis was 14.1 years (5.0–15.8) for HL, 9.8 years (range 0.7–15.7) for NHL and 3.9 years (0.0–15.7) for Wilms tumor patients. For these survivors, 1329 matched controls were identified. Information about parents' education was available for 62% of patients and 66% of controls.
School report data
In Finland, children enter school in the year of their 7th birthday. There are 9 grades of comprehensive education (6 primary and 3 secondary school grades). Usually children will complete the comprehensive school in the year of their 16th birthday. Comprehensive school system is coordinated by the National Board of Education, and only 0.8% of comprehensive schools are private.
Statistics Finland has collected the 9th grade school report data since 1990. The Finnish school report give grade units on a scale of 4 (failed) to 10 (best). Annual national tests are arranged in the main school subjects in 9th grade to ensure uniform grading. The overall average as well as grades for mathematics, mother tongue (Finnish in 94%, Swedish in 6%), the first foreign language (English in 93%) and physical education (sports) were taken into analyses. The parents' level of education was taken into the statistical model as a covariate, as it is known that a child's success at school is strongly associated with his parents' level of education.
Statistical analysis
The differences in overall average as well as in school grades for mother tongue, the first foreign language, mathematics and physical education were compared between the patients and their matched controls. The unknown education level of either of the parents (38% of patients and 34% of controls) was replaced by the arithmetic mean of the parents' education level of all children of the respective group. Models were also assessed with the data where replacement was not done. The parameter estimates from these models were in keeping with the models where replacement was done. The effect of parental education (6 levels) on patient's school grades was significant in both groups, as expected, and that is why parental education was taken into model as a covariate.
We used the ordinary linear regression to analyze the effects of irradiation, age at diagnosis and gender on the school performance. The difference in the grades between the case and his/her controls was set as the outcome of the study, the dependent variable in the linear regression analysis.
The analysis was carried out in strata defined by the irradiation status (yes or no) among the patients, separately for both genders (matching factor), and also in strata defined by the time of diagnosis (before school-age or at school-age). All the models included the constant term, representing the estimate for the difference in the grades between cases and controls, and parents' education as an independent variable. The significance of the differences was tested with the Wald test (SAS, 8th revision, 1999–2001).
The study was accepted by the Ethical Committee of the Hospital District of Southwest Finland. Appropriate permissions were obtained from the Ministry of Social Affairs and Health, Statistics Finland and the Population Register Center of Finland.
Results
Almost all the cancer patients and their controls had graduated from the primary school by the time of data collection. At least part of the 9th grade school report data was available for 99.0% HL (99.4% of their controls), for 98.9% NHL (99.4% of their controls) as well as for 98.6% Wilms tumor patients (99.2% of their controls). There were no significant differences between the groups.
As typical for the Finnish pupils, the mean average and the mean school grades also for the cases were higher in girls than boys. The decrease of the grades compared to controls was often greater in girls than boys in the overall average and in academic school subjects. Despite the greater lowering, the mean grades of patients in most cases remained still higher in girls than in boys (Table I).
| Cases (N) | Difference from controls (N) | 95% CI | p-value | |
|---|---|---|---|---|
| ||||
| Non-Hodgkin lymphoma | ||||
| Average, all subjects | 7.54 (87) | −0.27 (425) | −0.39,− 0.15 | <0.0001 |
| Males | 7.29 (52) | −0.25 (254) | −0.40, −0.11 | 0.0008 |
| Females | 7.91 (35) | −0.30 (171) | −0.50, −0.11 | 0.002 |
| Foreign language | 7.23(88) | −0.32 (432) | −0.49, −0.14 | 0.0005 |
| Males | 6.79 (53) | −0.39 (259) | −0.61, −0.17 | 0.0005 |
| Females | 7.89 (35) | −0.23 (170) | −0.51, 0.06 | 0.12 |
| Mother tongue | 7.34 (88) | −0.38 (432) | −0.52, −0.24 | <0.0001 |
| Males | 6.96 (53) | −0.35 (259) | −0.54, −0.15 | 0.0004 |
| Females | 7.91 (35) | −0.45 (173) | −0.66, −0.25 | <0.0001 |
| Mathematics | 7.00 (87) | −0.45 (429) | −0.63, −0.27 | <0.0001 |
| Males | 6.79 (53) | −0.50 (261) | −0.73, −0.27 | <0.0001 |
| Females | 7.32 (34) | −0.39 (168) | −0.70, −0.09 | 0.01 |
| Physical education | 7.81 (77) | −0.11 (323) | −0.24, 0.03 | 0.12 |
| Males | 7.85 (48) | −0.04 (200) | −0.21, 0.13 | 0.65 |
| Females | 7.72 (29) | −0.23 (123) | −0.45, −0.01 | 0.04 |
| Hodgkin lymphoma | ||||
| Average, all subjects | 7.85 (91) | 0.06 (444) | −0.05, 0.16 | 0.32 |
| Males | 7.58 (45) | 0.08 (217) | −0.08, 0.24 | 0.31 |
| Females | 8.11 (46) | 0.02 (227) | −0.13, 0.17 | 0.81 |
| Foreign language | 7.55 (95) | 0.13 (463)1 | −0.03, 0.28 | 0.12 |
| Males | 7.40 (48) | 0.32 (230) | 0.12, 0.52 | 0.002 |
| Females | 7.70 (47) | −0.08 (233) | −0.32, 0.16 | 0.51 |
| Mother tongue | 7.85 (95) | 0.15 (464) | 0.02, 0.20 | 0.03 |
| Males | 7.29 (48) | 0.09 (231) | −0.11, 0.29 | 0.36 |
| Females | 8.43 (47) | 0.17 (233) | −0.02, 0.35 | 0.08 |
| Mathematics | 7.36 (95) | 0.00 (464)1 | −0.18, 0.17 | 0.98 |
| Males | 7.40 (48) | 0.21 (231) | −0.04, 0.45 | 0.09 |
| Females | 7.32 (47) | −0.21 (233) | −0.46, 0.04 | 0.09 |
| Physical education | 7.84 (89) | −0.13 (391) | −0.27, 0.00 | 0.05 |
| Males | 7.85 (46) | −0.11 (194) | −0.30, 0.08 | 0.25 |
| Females | 7.84 (43) | −0.18 (197) | −0.37, 0.00 | 0.05 |
| Wilms tumor | ||||
| Average, all subjects | 7.71 (70) | −0.06 (342) | −0.18, 0.07 | 0.39 |
| Males | 7.42 (40) | −0.06 (195) | −0.24, 0.12 | 0.53 |
| Females | 8.10 (30) | −0.06 (147) | −0.24, 0.13 | 0.56 |
| Foreign language | 7.45 (69) | −0.01 (337) | −0.21, 0.19 | 0.94 |
| Males | 7.33 (39) | 0.15 (189) | −0.13, 0.43 | 0.53 |
| Females | 7.60 (30) | −0.26 (148) | −0.56, 0.05 | 0.10 |
| Mother tongue | 7.72 (71) | 0.04 (348)1 | −0.11, 0.19 | 0.61 |
| Males | 7.38 (40) | 0.19 (195) | −0.04, 0.42 | 0.10 |
| Females | 8.16 (31) | −0.15 (153) | −0.35, 0.04 | 0.12 |
| Mathematics | 7.30 (71) | −0.11 (348) | −0.31, 0.10 | 0.31 |
| Males | 7.08 (40) | −0.14 (195) | −0.43, 0.15 | 0.35 |
| Females | 7.58 (31) | −0.06 (153) | −0.36, 0.24 | 0.68 |
| Physical education | 7.76 (67) | −0.20 (301) | −0.33, −0.06 | 0.004 |
| Males | 7.57 (37) | −0.30 (168) | −0.49, −0.11 | 0.002 |
| Females | 8.00 (30) | −0.11 (133) | −0.31, 0.09 | 0.29 |
About the clinical significance of the differences, it can be addressed as follows: after comprehensive education, adolescents apply to gymnasium or to vocational education, and the possibility to get the place at second grade school depends on one's 9th grade school report results (the grade for overall average is usually the most important). A 0.1 grade unit difference may drop a student out as the lowest limit for entry to some schools might be 7.2 and to some others as high as 8.9 or even 9.1.
Non-Hodgkin lymphoma
Patients with NHL had significantly lower mean overall average and lower mean school grades in all the school subjects than their controls (Table I). No significant differences were detected between the irradiated and nonirradiated NHL patients (Table II). The only gender difference was seen in mother tongue: irradiated girls had significantly greater difference to their controls than the boys had (Table II). Age at diagnosis did not have significant effect on school performance (Table II).
| Cases (N) | Difference from controls (N) | 95% CI | Cases (N) | Difference from controls (N) | 95% CI | |
|---|---|---|---|---|---|---|
| ||||||
| Irradiated1 | Nonirradiated1 | |||||
| Average, all subjects | 7.71 (30) | −0.07 (146) | −0.24, 0.11 | 7.45 (57) | −0.38 (279) | −0.53, −0.232 |
| Males | 7.60 (21) | −0.04 (101) | −0.27, 0.18 | 7.08 (31) | −0.41 (153) | −0.60, −0.212 |
| Females | 7.96 (9) | −0.19 (45) | −0.48, 0.09 | 7.90 (26) | −0.33 (126) | −0.57, −0.092 |
| Foreign Language | 7.32 (31) | −0.14 (153) | −0.40, 0.12 | 7.18 (57) | −0.41 (279) | −0.64, −0.182 |
| Males | 6.95 (22) | −0.30 (108) | −0.62, 0.03 | 6.68 (31) | −0.47 (151) | −0.77, −0.172 |
| Females | 8.22 (9) | 0.05 (45) | −0.39, 0.48 | 7.77 (26) | −0.32 (128) | −0.68, 0.04 |
| Mother tongue | 7.45 (31) | −0.19 (152)3 | −0.41, 0.03 | 7.28 (57) | −0.49 (280) | −0.67, −0.302 |
| Males | 7.36 (22) | −0.06 (107) | −0.34, 0.22 | 6.68 (31) | −0.56 (152) | −0.82, −0.312 |
| Females | 7.67 (9) | −0.66 (45) | −0.99, −0.342 | 8.00 (26) | −0.38 (128) | −0.63, −0.132 |
| Mathematics | 7.06 (31) | −0.40 (153) | −0.67, −0.132 | 6.96 (56) | −0.48 (276) | −0.73, −0.242 |
| Males | 7.05 (22) | −0.40 (108) | −0.74, −0.062 | 6.61 (31) | −0.59 (153) | −0.90, −0.282 |
| Females | 7.11 (9) | −0.49 (45) | −0.97, −0.012 | 7.40 (25) | −0.33 (123) | −0.71, 0.05 |
| Physical Education | 6.90 (30) | −0.16 (148) | −0.74, 0.42 | 7.55 (53) | 0.62 (258) | 0.26, 0.982 |
| Males | 6.86 (21) | −0.19 (103) | −0.91, 0.54 | 7.65 (31) | 0.78 (151) | 0.31, 1.252 |
| Females | 7.00 (9) | −0.57 (45) | −1.56, 0.43 | 7.41 (22) | 0.42 (107) | −0.15, 1.00 |
| Age <7 years1 | Age 7 + years1 | |||||
| Average, all subjects | 7.63 (32) | −0.21 (158) | −0.40, −0.012 | 7.49 (55) | −0.30 (267) | −0.45, −0.152 |
| Males | 7.41 (20) | −0.14 (98) | −0.39, 0.10 | 7.22 (32) | −0.28 (156) | −0.47, −0.102 |
| Females | 7.99 (12) | −0.29 (60) | −0.61, 0.03 | 7.87 (23) | −0.34 (111) | −0.58, −0.102 |
| Foreign language | 7.16 (32) | −0.37 (159) | −0.64, −0.092 | 7.27 (56) | −0.29 (273) | −0.52, −0.072 |
| Males | 6.75 (20) | −0.47 (99) | −0.81, −0.132 | 6.82 (33) | −0.32 (160) | −0.61,− 0.032 |
| Females | 7.83 (12) | −0.20 (60) | −0.50, 0.10 | 7.91 (23) | −0.28 (113) | −0.64, 0.09 |
| Mother tongue | 7.38 (32) | −0.38 (159) | −0.61, −0.152 | 7.32 (56) | −0.38 (273) | −0.56, −0.202 |
| Males | 7.05 (20) | −0.32 (99) | −0.64, −0.012 | 6.91 (33) | −0.33 (160) | −0.57, −0.092 |
| Females | 7.92 (12) | −0.47 (60) | −0.79, −0.152 | 7.91 (26) | −0.48 (113) | −0.74, −0.222 |
| Mathematics | 7.06 (32) | −0.46 (160) | −0.77, −0.152 | 6.93 (55) | −0.44 (269) | −0.67, −0.212 |
| Males | 6.95 (20) | −0.40 (100) | −0.80, −0.042 | 6.70 (33) | −0.51 (161) | −0.80, −0.222 |
| Females | 7.42 (12) | −0.52 (60) | −1.04, 0.00 | 7.27 (22) | −0.35 (108) | −0.72, 0.02 |
| Physical education | 7.71 (28) | −0.23 (127) | −0.43, −0.022 | 7.86 (49) | −0.03 (196) | −0.21, 0.15 |
| Males | 7.71 (17) | −0.22 (79) | −0.49, 0.05 | 7.94 (31) | 0.09 (121) | −0.13, 0.30 |
| Females | 7.73 (11) | −0.25 (48) | −0.57, 0.07 | 7.72 (18) | −0.22 (75) | −0.51, 0.08 |
Hodgkin lymphoma
The overall average and the school grades for different school subjects were equally good in the patients with HL as in their controls. In fact, the patients treated for HL had slightly, but significantly better grades in mother tongue than their controls had (Table I). Irradiation status or age at diagnosis did not differentiate the patients (data not shown).
Wilms tumor
There was no difference in the overall average or any academic school subjects between the patients treated for Wilms tumor and their controls (Table I). The cases had significantly lower school grades for physical education than their controls (Table I). In the group of irradiated patients, the difference in school grades for physical education between boys (difference to controls −0.34, 95% CI −0.56, −0.12) and girls (difference to controls 0.04, 95% CI −0.19, 0.28) was significant (p = 0.03). The irradiation status did not, however, differentiate the whole patient groups as the difference to controls was −0.17 grade units (95% CI −0.34, −0.01) in irradiated patients and −0.24 grade units (95% CI −0.47, −0.01) in nonirradiated patients.
Discussion
In this population-based, controlled and registry-based study, the NHL patients, whose treatment requires CNS-directed therapy, had a general decline in their school grades. Instead, the patients with HL and Wilms tumor had equally good performance at school in academic subjects as their controls. Wilms tumor patients showed lower grades for physical education than their controls, and boys with irradiation were most affected.
NHL patients are a more heterogeneous group than leukemia patients and less well studied. One study showed that NHL patients were in a greater risk of not finishing high school than their siblings, and the risk was greater than in leukemia patients.4 In another study, patients with lymphoma repeated or failed a grade as often as patients with leukemia, but their academic or other school problems were less common than those of leukemia patients.15
The NHL patients here had a decline in school grades, but the decline was not related to irradiation or age at diagnosis. In our previous study on school success of leukemia patients, decline of school grades was most marked in patients that had received cranial irradiation.10 Only young girls diagnosed with leukemia before school age had a decline in their school grades if cranial irradiation was not used.10 Here a significant proportion of the NHL patients had been treated using Nordic leukemia protocols, often including even cranial irradiation, so 1 would expect a similar finding. In this study, however, irradiation was not related to a greater decline in school grades of NHL patients than chemotherapy alone. That may be due to the fact that NHL patients were older than the leukemia patients in our previous study: median age 9.8 years compared to 5.6 years in leukemia patients.10 Older patients have been shown to be less vulnerable for the harmful cognitive effects of radiation than the younger patients.23–25 Unfortunately, we could not obtain information on the site or dose of irradiation. Although we expect that CNS is the irradiated site in most cases, it is possible that mediastinum or e.g., bone lesions have been the irradiated sites in our patients.
In contrast to our previous finding in leukemia patients,10 chemotherapy alone was found to cause significant decline of school performance in NHL patients regardless of the age at diagnosis. One explanation may be that patients with Burkitt lymphoma, whose proportion among NHL may be even 53% in the Nordic countries,26 are included in this group. Many of them might have received treatment with very intensive CNS-directed chemotherapy according to Patte.17 Administration of methotrexate via a shorter infusion, like used in the Burkitt protocol by Patte, may cause more neuropsychological impairment than a longer 24-hr infusion.27 Intensity of the intrathecal therapy is also higher in the Burkitt lymphoma patients as combination of methotrexate, cytarabine and hydrocortisone is used instead of methotrexate alone. Unfortunately, it was not possible to analyze the patients with Burkitt lymphoma separately.
The 2 large groups of patients treated without CNS-directed treatment, patients with HL and Wilms tumor, succeeded as well as their controls at comprehensive school. Our findings with regard to cognitive functions in Wilms tumor patients are in keeping with a previous study, in which patients with kidney tumors did not differ significantly from controls when their educational outcomes were analyzed.15 The mobility of the Wilms tumor patients was more affected in our study than in the previous study of Barr et al.28 The lower grades in physical education in the Wilms tumor patients may be explained by vincristine-related neuropathy29, 30 or, e.g., scoliosis caused by abdominal radiation therapy.31 Two thirds of the irradiated Wilms tumor patients have been shown to have scoliosis or other musculosceletal late effects, such as muscular hypoplasia, limb length inequality, kyphosis or iliac wing hypoplasia.32 In fact, the effect of irradiation was seen to some extent here as the impairment in grades of physical education was most pronounced in the group of irradiated boys. Survivors of Wilms tumor have also shown to be more likely underweight than other survivors, which may indicate a decreased muscle mass.33
In the HL patients, the mean grades in some school subjects were even statistically higher than in their controls. This finding indicates that diagnosis of cancer by itself, school absenteeism or the psychosocial stress it brings had not significantly influenced the performance at school. Our results resemble those of Kelaghan et al., as their HL patients were more likely to complete high school than the controls.3 School grades, however, were not available in that previous study. One must keep in mind that many patients with HL experienced cancer treatment just during the last years of their comprehensive school and, thus, we cannot be sure that their academic capacity will remain on this level over the longer follow-up period. However, some researchers have reported that deficits in intellectual function might be progressive after treatment for leukemia, whereas for the solid tumor survivors they might improve.34
In the study of Mitby et al., the reason with greatest significance for using special education services in cancer patients compared to siblings was missed school.4 All Finnish childhood cancer centers have hospital schools which provide some bed-side teaching. Patient's own school is responsible for arranging home education when the patient is able to be at home but not able to return to school. School re-entry after cancer diagnosis is prepared by a rehabilitation nurse who visits the patient's own school. Education is highly valued in Finland, and the Finnish school system has been shown to be highly effective and uniform.35 According to our findings, it also provides good opportunities for school success for childhood cancer patients. In cases where CNS related treatment is not needed, personal teaching and great attention to school work in general education may lead to even better school performance than in controls at the end of 9 years at comprehensive school.
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