Measuring perceived benefit and disease-related burden in young cancer survivors: validation of the Benefit and Burden Scale for Children (BBSC) in The Netherlands

PURPOSE

Perceiving favourable changes from one's illness may go hand in hand with experiencing harmful psychosocial effects. Each of these constructs should be considered when examining children's levels of psychological adjustment following stressful life events. A paediatric instrument that accounts for both positive and negative impact of stressful events has not been investigated in The Netherlands before. The aim of the study was to investigate psychometric properties of the Dutch version of the Benefit and Burden Scale for Children (BBSC), a 20-item questionnaire that intends to measure potential benefit and burden of illness in children.

METHODS

Dutch paediatric survivors of childhood cancer aged 8-18 (N = 77) completed the BBSC and other psychological questionnaires: Pediatric Quality of Life Inventory (health-related quality of life), State-Trait Anxiety Inventory for Children (anxiety), Children's Revised Impact of Event Scale (posttraumatic stress) and Strengths and Difficulties Questionnaire (behavioural functioning). Reliability and validity were evaluated.

RESULTS

Internal consistency (Cronbach's alpha, benefit 0.84, burden 0.72), test-retest reliability (benefit r = 0.74, burden r = 0.78) and homogeneity (mean inter-item correlation, benefit r = 0.34, burden r = 0.22) were satisfactory. Burden was associated with HRQoL (-), anxiety (+), posttraumatic stress symptoms (+) and behavioural problems. Benefit did not correlate with the psychological outcomes.

CONCLUSIONS

The Dutch version of the BBSC shows promising psychometric properties. Perceived benefit and disease-related burden are distinct constructs; both should be considered when examining children's psychological adjustment to potentially traumatic experiences. The BBSC may be useful as monitoring and screening instrument.

Complementary therapies for children undergoing stem cell transplantation: report of a multisite trial

BACKGROUND

Children undergoing stem cell transplant (SCT) experience high levels of somatic distress and mood disturbance. This trial evaluated the efficacy of complementary therapies (massage, humor therapy, relaxation/imagery) for reducing distress associated with pediatric SCT.

METHODS

Across 4 sites, 178 pediatric patients scheduled to undergo SCT were randomized to a child-targeted intervention involving massage and humor therapy, the identical child intervention plus a parent intervention involving massage and relaxation/imagery, or standard care. Randomization was stratified by site, age, and type of transplant. The interventions began at admission and continued through SCT Week +3. Primary outcomes included patient and parent reports of somatic distress and mood disturbance obtained weekly from admission through Week +6 using the Behavioral, Affective, and Somatic Experiences Scales. Secondary outcomes included length of hospitalization, time to engraftment, and usage of narcotic analgesic and antiemetic medications.

RESULTS

A mixed model approach was used to assess longitudinal trends of patient and parent report outcomes and to test differences between groups on these measures. Significant changes across time were observed on all patient and parent report outcomes. However, no significant differences between treatment arms were found on the primary outcomes. Similarly, no significant between-group differences were noted on any of the medical variables as secondary outcomes.

CONCLUSIONS

Results of this multisite trial failed to document significant benefits of complementary interventions in the pediatric SCT setting.

The N-terminus of COX-1 and its effect on cyclooxygenase-1 catalytic activity

Cyclooxygenases are encoded by COX-1 and COX-2. They share over sixty percent sequence identity in human and are similar to each other in their crystallographic structures. One major difference in the primary structure of these two isozymes is the presence of eight amino acids in the amino-terminal region of COX-1 that are not present in COX-2. The function of this amino acid sequence is unknown. In this study, a human COX-1 mutant (Delta7aa) with this sequence removed was studied in parallel with COX-1. Signal peptide cleavage, N-linked glycosylation, protein expression, distribution and dimerization were not affected by the mutation. The mutant was enzymatically active and showed the same sensitivity toward aspirin. The KM for the enzyme remained the same as COX-1. However, the V(max) of the COX-1 mutant decreased by 3.3-fold. We conclude that the COX-1 specific amino-terminal sequence has a subtle but detectable effect on COX-1 catalysis.

Brief report: Children's response to serious illness: perceptions of benefit and burden in a pediatric cancer population

OBJECTIVE

To examine a revised measure of benefit finding for children, in relation to perceptions of illness-related burden, and other measures of child psychological functioning.

METHODS

A sample of 78 children with cancer completed the newly revised Benefit/Burden Scale for Children (BBSC) and measures of optimism/pessimism, positive/negative affect, anxiety and defensiveness.

RESULTS

Factor analysis of the BBSC revealed a clear two-factor solution, with benefit finding and illness-related burden representing orthogonal factors. Both scales were internally consistent and demonstrated different patterns of correlation with the other measures assessed in the study.

CONCLUSION

The BBSC is internally reliable and preliminary data supports the validity of separate benefit and burden constructs. Children report positive and negative aspects of their illness simultaneously, and perceptions of benefit and burden function as independent constructs. The BBSC is a useful measure for pediatric cancer patients that could be applied to children experiencing other significant life events.

Optimism and pessimism in children with cancer and healthy children: confirmatory factor analysis of the youth life orientation test and relations with health-related quality of life

OBJECTIVE

To test the measurement equivalence of the Youth Life Orientation Test (YLOT) in children with cancer (N = 199) and healthy controls (N = 108), and to examine optimism and pessimism as predictors of children's health-related quality of life (HRQL).

METHODS

Confirmatory factor analysis (CFA) was conducted to establish the two factor structure of the YLOT and to test for metric invariance.

RESULTS

A two-factor structure for the YLOT was confirmed and found to be stable across our study groups. There were no differences in mean levels of optimism and pessimism between cancer patients and controls after controlling for race/ethnicity. Higher optimism was associated with lower self-reports of pain and better emotional/behavioral functioning, whereas pessimism was related to poorer mental health and general behavior, and greater impact on the family.

CONCLUSIONS

Optimism and pessimism appear to be differentially related to certain aspects of children's HRQL, and should be investigated separately in relation to these outcomes.

Allergic sensitization is enhanced in early life through toll-like receptor 7 activation

BACKGROUND

Prospective cohort studies suggest that children hospitalized in early life with severe infections are significantly more likely to develop recurrent wheezing and asthma.

OBJECTIVE

Using an inhalational mouse model of allergic airways inflammation, we sought to determine the effect of viral and bacterial-associated molecular patterns on the magnitude of the allergic inflammatory response and whether this effect was age dependent.

METHODS

BALB/c mice were sensitized by intranasal administration of endotoxin(low) ovalbumin (OVA) in the absence or presence of viral single-stranded (ss)RNA, lipoteichoic acid or flagellin as neonates (within the first 24 h of life) or as weanlings (4 weeks of age). Mice were challenged four times with OVA at 6 weeks of age and end-points (bronchoalveolar lavage cytology, histology, antigen-specific T and B cell responses) determined at 7 weeks of age.

RESULTS

Inhalational sensitization (<24 h or 4 weeks of age) and challenge with OVA induced a mild allergic inflammatory response in the airways as indicated by increased numbers of eosinophils and mucus cells, elevated serum OVA-specific IgG1, and production of T helper 2 (Th2) cytokines. Mice sensitized to endotoxin(low) OVA at birth in the presence of ssRNA or lipoteichoic acid, but not flagellin, showed an increase in the numbers of airway and tissue eosinophils, mucus producing cells and antigen-specific production of IL-13 as compared with mice exposed only to endotoxin(low) OVA. By contrast, all three TLR ligands failed to increase the magnitude of OVA-induced allergic inflammation in mice sensitized as weanlings.

CONCLUSIONS

Recognition of distinct microbial-associated patterns in early life may preferentially promote the de novo differentiation of bystander, antigen-specific CD4(+) T cells toward a Th2 phenotype, and promote an asthma-like phenotype upon cognate antigen exposure in later life.

Early production of thymic stromal lymphopoietin precedes infiltration of dendritic cells expressing its receptor in allergen-induced late phase cutaneous responses in atopic subjects

BACKGROUND

Thymic stromal lymphopoietin (TSLP) is an interleukin (IL)-7-like cytokine that triggers dendritic cell-mediated T helper (Th)2 inflammatory responses through a receptor consisting of a heterodimer of the IL-7 receptor alpha (IL-7Ralpha) chain and the TSLP receptor (TSLPR), which resembles the cytokine receptor common gamma chain. Dendritic cells activated by TSLP prime development of CD4(+) T cells into Th2 cells contributing to the pathogenesis of allergic inflammation. We hypothesized that allergen exposure induces expression of TSLP and results in recruitment of TSLPR bearing cells in the cutaneous allergen-induced late-phase reaction (LPR) in atopic subjects.

METHODS

Skin biopsies were obtained from atopic subjects (n = 9) at various times after cutaneous allergen challenge. In situ hybridization and immunohistochemistry were used to determine TSLP mRNA expression and to measure infiltration of TSLPR(+) DC in skin LPR. RT-PCR and flow cytometry were employed to analyse TSLPR expression on isolated blood DC.

RESULTS

Allergen-induced skin TSLP expression occurred as early as 1 h after allergen challenge, whereas TSLPR(+) and CD11c(+) cells infiltrated relatively late (24-48 h). The majority of TSLPR(+) cells were DC co-expressing blood DC antigen-1 (BDCA-1) or BDCA-2. Freshly isolated blood DC expressed both TSLPR and IL-7Ralpha chains. Maturation and stimulation with TSLP or polyriboinosinic-polyribocytidylic acid in vitro upregulated the expression of both TSLPR and IL-7Ralpha chains in DC but not in chemoattractant receptor-homologous molecule expressed on Th2 cells(+) CD4(+) T cells.

CONCLUSION

The data suggest that TSLP plays a role in augmenting, through DC recruitment and activation, the development of Th2-type T cells in allergic inflammation.

Interventions to improve neuropsychological functioning in childhood cancer survivors

A very brief historical review on the identification of neurocognitive deficits in patients treated for a pediatric malignancy that involved CNS disease, treatment, or a combination is provided. This review is particularly directed toward providing a foundation upon which the introduction of specific brain injury rehabilitation efforts and subsequent research were introduced into this population of patients. Three primary methods by which clinicians and researchers have attempted to improve neurocognitive functioning with survivors of pediatric cancer that have suffered a CNS insult are identified. From a pharmacological perspective, research is reviewed that documents the potential beneficial effects of stimulant medication. Results of two drug trials that used double-blind crossover methodology are reviewed, and it is highly likely that medications may be of significant benefit to pediatric cancer survivors who are experiencing attentional deficits, impairment in social functioning, and also declines in academic achievement. We next describe psychologically based brain injury rehabilitation efforts, including on-treatment schooling and reentry, within the survivor population. A phase III clinical trial of a comprehensive rehabilitation approach is discussed in detail. New directions in the area of brain injury rehabilitation for childhood cancer survivors are presented, and the need for professionals in this area to work toward a team approach is emphasized.

Stressful life events and posttraumatic stress symptoms in children with cancer

This study examined the contribution of stressful life events in posttraumatic stress symptoms (PTSS) stemming from childhood cancer among 121 patients. When controlling for demographic characteristics (age, gender, ethnicity, and socioeconomic status), cancer factors (treatment status, time since diagnosis, and cancer type), and intensity of parental PTSS, history of stressful life events in the child's life emerged as a salient correlate of PTSS across the different measures and reporting methods used in the study. Overall, children who had experienced more frequent and severe life stressors endorsed greater PTSS in relation to the cancer experience. Clinical work and future research on children with cancer should focus accordingly on the potential cumulative impact of stressful life events on PTSS.

Report from a multi-institutional randomized clinical trial examining computer-assisted problem-solving skills training for English- and Spanish-speaking mothers of children with newly diagnosed cancer

OBJECTIVES

To evaluate the feasibility and efficacy of a handheld personal digital assistant (PDA)-based supplement for maternal Problem-Solving Skills Training (PSST) and to explore Spanish-speaking mothers' experiences with it.

METHODS

Mothers (n = 197) of children with newly diagnosed cancer were randomized to traditional PSST or PSST + PDA 8-week programs. Participants completed the Social Problem-Solving Inventory-Revised, Beck Depression Inventory-II, Profile of Mood States, and Impact of Event Scale-Revised pre-, post-treatment, and 3 months after completion of the intervention. Mothers also rated optimism, logic, and confidence in the intervention and technology.

RESULTS

Both groups demonstrated significant positive change over time on all psychosocial measures. No between-group differences emerged. Despite technological "glitches," mothers expressed moderately high optimism, appreciation for logic, and confidence in both interventions and rated the PDA-based program favorably. Technology appealed to all Spanish-speaking mothers, with younger mothers showing greater proficiency.

CONCLUSIONS

Well-designed, supported technology holds promise for enhancing psychological interventions.

The Anger Expression Scale for Children: initial validation among healthy children and children with cancer

OBJECTIVE

To evaluate the proposed structure of the Anger Expression Scale for Children (AESC) in samples of healthy children and those with cancer, and to examine correlations between AESC subscales and other indicators of anger and hostility.

METHOD

A total of 803 children from two independent studies of healthy and ill children (mean age = 12.7, SD = 3.1) completed the AESC and other measures of anger expression and hostility, and a sub-sample of 298 of their parents completed measures of anger expression and hostility.

RESULTS

Results provided initial support for the proposed four-factor model of the AESC (Trait Anger, Anger Expression, Anger In, and Anger Control). Measurement invariance was established across groups using a series of nested tests. Correlations between AESC subscales and parent- and child-reported indices of anger, hostility, and aggression support the convergent validity of the scales.

CONCLUSIONS

Analyses supported the construct validity of the AESC and generalization of the factor structure across healthy and chronically ill children.

Cognitive and Academic Consequences of Stem-Cell Transplantation in Children

Purpose

To describe cognitive and academic outcomes in survivors after pediatric stem-cell transplantation (SCT) through 5-years post-SCT.

Patients and Methods

A battery of neurocognitive measures were administered before admission and at 1, 3, and 5 years post-SCT for 268 patients who underwent SCT; the study sample is comprised of 158 patients who survived and were evaluated at 1-year post-SCT. Random coefficient models were generated to depict change over time, and to test differences in slope and intercept for medical and demographic predictor variables.

Results

In the cohort as a whole, no significant changes were seen in global intelligence quotient and academic achievement. Despite the overall stability, some significant differences in slopes were found based on diagnosis, type of transplantation, use of total-body irradiation (TBI), and presence of graft-versus-host disease (GVHD). However, these differences were small, and of limited clinical significance. In comparison, differences as a function of socioeconomic status (SES) were much larger. SES was a significant determinant of all cognitive and academic outcomes, and the effect size generally dwarfed that of other significant predictor variables. Age, which had previously been identified as an important determinant of outcome, was not significantly predictive of outcome in this cohort.

Conclusion

The procedure of SCT entails minimal risk of late cognitive and academic sequelae. Subgroups of patients are at relatively higher risk: patients undergoing unrelated donor transplantation, receiving TBI, and those who experience GVHD. However, these differences are small relative to differences in premorbid functioning, particularly those associated with SES.

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

OBJECTIVE

To examine posttraumatic stress symptoms (PTSS) in parents of children with cancer as a function of time since diagnosis, treatment status, and relapse history, and as compared to parents of healthy children.

METHOD

Participants included parents of 199 children with cancer, comprising a cross-sectional sample of diagnoses and treatment phases, ranging from currently on therapy to long-term survivors, and 108 parents of healthy children obtained via acquaintance control methods. Parents completed a standardized self-report measure of PTSS.

RESULTS

Within the cancer group, parental report of PTSS differed as a function of treatment status and time since diagnosis. Parents of children on active treatment endorsed similar levels of PTSS as control parents, whereas parents of children off treatment reported significantly lower levels of PTSS than did controls. Similarly, parents of long-term survivors reported significantly lower levels of PTSS than did controls, while parents of recently diagnosed children did not differ from controls on PTSS. In contrast, parents of children who had suffered a relapse reported significantly higher levels of PTSS, and were much more likely to be identified as a posttraumatic stress disorder (PTSD) case.

CONCLUSIONS

As a group, parents of children with cancer did not demonstrate any evidence of increased PTSS relative to parents of healthy children. Time since diagnosis, child treatment status, and relapse history are significant determinants of parent PTSS. Only parents of children who experienced a relapse appear to be at increased risk of PTSD. The current results appear discrepant from the existing literature, and possible explanations for these discrepancies are examined.

Symptoms of posttraumatic stress in parents of children with cancer: are they elevated relative to parents of healthy children?

OBJECTIVE

To examine posttraumatic stress symptoms (PTSS) in parents of children with cancer as a function of time since diagnosis, treatment status, and relapse history, and as compared to parents of healthy children.

METHOD

Participants included parents of 199 children with cancer, comprising a cross-sectional sample of diagnoses and treatment phases, ranging from currently on therapy to long-term survivors, and 108 parents of healthy children obtained via acquaintance control methods. Parents completed a standardized self-report measure of PTSS.

RESULTS

Within the cancer group, parental report of PTSS differed as a function of treatment status and time since diagnosis. Parents of children on active treatment endorsed similar levels of PTSS as control parents, whereas parents of children off treatment reported significantly lower levels of PTSS than did controls. Similarly, parents of long-term survivors reported significantly lower levels of PTSS than did controls, while parents of recently diagnosed children did not differ from controls on PTSS. In contrast, parents of children who had suffered a relapse reported significantly higher levels of PTSS, and were much more likely to be identified as a posttraumatic stress disorder (PTSD) case.

CONCLUSIONS

As a group, parents of children with cancer did not demonstrate any evidence of increased PTSS relative to parents of healthy children. Time since diagnosis, child treatment status, and relapse history are significant determinants of parent PTSS. Only parents of children who experienced a relapse appear to be at increased risk of PTSD. The current results appear discrepant from the existing literature, and possible explanations for these discrepancies are examined.

Single parents of children with chronic illness: an understudied phenomenon

OBJECTIVE

To examine the chronic illness literature and evaluate the impact on single parenting and children and adolescents with chronic illness.

METHODS

We conducted literature reviews of relevant research pertaining to single-parent families on PubMed, Medline, and PsychINFO and also surveyed pertinent book chapters and all of the articles from the Journal of Pediatric Psychology since 1987 for articles, specifically examining the potential associations of single (lone) parenting versus two-parent households on children's psychosocial functioning and the impact of the child's illness on caregiver functioning.

RESULTS

While the literature has examined and discussed the stressors associated with parenting a child with an illness, including the impact of illness on finances, family roles, and caregiver burden, few studies have examined single parents of children and adolescents with chronic illnesses and related stressors stemming from being a lone caregiver.

CONCLUSIONS

There is a dearth of studies examining the association between lone parenting and psychosocial functioning among children and adolescents with chronic illnesses. Specific questions necessitating future investigation are summarized and recommendations are made for future research in this important area of inquiry.

Noninvasive Evaluation of Late Anthracycline Cardiac Toxicity in Childhood Cancer Survivors

Purpose

Childhood cancer survivors treated with anthracyclines and cardiac radiation are at risk for late-onset cardiotoxicity. The purpose of this study was to delineate the relationship between clinical factors and abnormalities of noninvasive cardiac testing (NICT).

Patients and Methods

Participants were recruited from a long-term follow-up clinic. Study measures comprised physical examination, laboratory evaluation, echocardiogram, and ECG. Mean fractional shortening (FS) and afterload were compared for survivors who did (at risk [AR]) and did not (no risk [NR]) receive potentially cardiotoxic modalities, and with values expected for comparable age- and sex-matched controls.

Results

The 278 study participants (mean age, 18.1 years; median age, 16.8 years; range, 7.5 to 39.7 years) included 223 survivors AR for cardiotoxicity after treatment with anthracyclines (median dose ± standard deviation [SD], 202 ± 109 mg/m2) and/or cardiac radiation. Mean FS (± SD) was lower for AR (0.33 ± 0.06) compared with NR survivors (0.36 ± 0.05; P = .004) and normative controls (0.36 ± 0.04; P < .001). Mean afterload (± SD) was higher for AR (58 ± 21 g/cm2) compared with NR survivors (46 ± 15 g/cm2; P < .001) and normative controls (48 ± 13 g/cm2; P < .001). The distribution of FS and afterload among NR survivors did not differ from that of controls. After adjustment for age group at diagnosis and time since completion of therapy, anthracycline dose predicted decline in distribution of FS (P < .001) and increase in distribution of afterload (P < .001). Treatment with anthracycline doses ≥ 100 mg/m2 increased the risk of abnormal NICT; survivors who received ≥ 270 mg/m2 had a 4.5-fold excess risk of abnormal NICT (95% CI, 2.1 to 9.6) compared with controls.

Conclusion

Childhood cancer survivors treated with anthracycline doses ≥ 270 mg/m2 are at greatest risk for abnormalities of FS and afterload.

Adaptive style in children with cancer: implications for a positive psychology approach

OBJECTIVE

To describe the adaptive style paradigm as a heuristic model for understanding the very positive psychosocial adjustment that has been observed in children with cancer, and to integrate findings regarding repressive adaptive style into a broader positive psychology framework.

METHOD

A selective review of the literature on adaptive style, and its' relevance to outcomes of depressive symptoms, posttraumatic stress symptoms, somatic distress, and health-related quality of life in children with cancer.

RESULTS

Studies have found children with cancer report low levels of psychological distress. Adaptive style is a much stronger predictor of psychosocial outcomes than is health history.

CONCLUSION

Children with cancer represent a flourishing population. A repressive adaptive style is one pathway to resilience in this population. Additional constructs from the domain of positive psychology are reviewed, and a positive psychology model is suggested as a framework for guiding future research in this area.

A prospective cohort study of late sequelae of pediatric allogeneic hematopoietic stem cell transplantation

As survivors of pediatric allogeneic hematopoietic stem cell transplantations (HSCTs) increase in number, it is increasingly important to evaluate their well-being. We conducted this prospective cohort study to evaluate the cumulative incidence and risk factors for late sequelae of HSCT. Comprehensive surveillance tests were performed annually on every participant, regardless of signs and symptoms, to obtain accurate information on the time-of-onset of each late event to allow hazard function analyses. All participants included in this report had been followed for at least 3 years after HSCT. With a median follow-up of 9 years and a current age of 18.5 years, only 20 of the 155 participants (13%) had no late sequelae; 18 survivors (12%) had 1 chronic health condition, 71 (46%) had 2-4 conditions, and 46 (30%) had 5-9 conditions. Risk factors for increasing number of chronic conditions included young age at the time of HSCT, female sex, high radiation dose, and history of chronic graft-versus-host disease. The cumulative incidence at 10 years for common late events was as follows (ordered by the median time-of-onset): osteonecrosis 13.8%, chronic renal insufficiency 26.8%, hypothyroidism 45.1%, growth hormone deficiency 31.2%, female hypogonadism 57.4%, osteopenia 47.7%, cataracts 43.4%, pulmonary dysfunction 63.2%, and male hypogonadism 20.3%. Coexistence of multiple late sequelae was common in HSCT survivors. Our findings provide a basis for more effective patient counseling, optimal surveillance, and early intervention.

Self-report of somatic symptoms in survivors of childhood cancer: effects of adaptive style

BACKGROUND

Screening for late effects in survivors of childhood cancer may be influenced by the patients' self-reporting of their somatic state. However, self report of somatic symptoms may be influenced by factors other than objectively documented physical functions. This study examined the self report of somatic symptoms in children with cancer and matched healthy control children as a function of child adaptive style.

PROCEDURE

Two groups of children age 7-18 were studied; children with cancer at least 6-month post completion of therapy (n = 120) and a group of healthy children (n = 120) matched on age, race, and gender. Children completed measures of somatic symptoms, body consciousness, and adaptive style.

RESULTS

Contrary to expectations, there were no differences between children with cancer and healthy controls in self-reported somatic symptoms, although cancer patients reported slightly lower symptomatology. In contrast, there were significant differences in self-reported somatic symptoms as a function of adaptive style. Children identified as repressors reported the lowest level of somatic symptoms and differed significantly from all other adaptive style groups.

CONCLUSION

These results do not support the prevailing hypothesis that a repressive style may be a risk factor for psychosomatic illness. However, the findings are consistent with a response bias interpretation, suggesting a general under-reporting of symptoms in repressors, including physical symptoms. These results have significant implications for health care providers and researchers following long-term survivors of childhood cancer.

Subclinical cardiac toxicity and health-related quality of life (hql) in childhood cancer survivors

9018

Background: Despite substantial information about late cardiotoxicity, little is known about its impact on the adolescent/young adult survivor's health-related quality of life (HQL). Using cross-sectional data, we assessed how HQL and New York Heart Association (NYHA) functional classification are related to survivors’ cardiac performance, cardiac risk factors, and treatment history. Methods: HQL indicators were examined in 164 long-term survivors of pediatric cancer (age 16–40 years), who had (n=132; 10 years (mean) after diagnosis of predominantly leukemia or lymphoma) or had not (n=32; 11 years (mean) after diagnosis of predominantly solid tumors) received anthracyclines and/or thoracic irradiation. Survivors underwent extensive noninvasive clinical and laboratory cardiac risk evaluation and completed a self-report questionnaire on selected subscales of the SF-36 (HQL). Results: Reported general health was lower in the cardiotoxic-therapy group (P = 0.05). Sex, current age, time since diagnosis, cardiac function, and cardiac risk factors were independent predictors of HQL subscales and NYHA class in multivariable analysis. Female sex and higher LDL cholesterol interacted to predict diminished reported vitality (P = 0.04) and physical health (P = 0.05) shown in table . Conclusions: Even in the absence of clinically evident cardiotoxicity, cardiac dysfunction and cardiac risk were strongly linked to decreased HQL and NYHA class, particularly among female survivors. Reduced HQL may be an indicator of unidentified sequelae that should be investigated and monitored.

No significant financial relationships to disclose.

[Table: see text]