Late outcomes of adult survivors of childhood non-Hodgkin lymphoma: A report from the St. Jude Lifetime Cohort Study

BACKGROUND

Survivors of childhood non-Hodgkin lymphoma (NHL) are at increased risk for chronic health conditions. The objective of this study was to characterize health conditions, neurocognitive function, and physical performance among a clinically evaluated cohort of 200 childhood NHL survivors.

METHOD

Chronic health and neurocognitive conditions were graded as per a modified version of the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) and impaired physical function defined as performance < 10th percentile of normative data. Multivariable regression was used to investigate associations between sociodemographic characteristics, therapeutic exposures, and outcomes.

RESULTS

Survivors were a median age of 10 years (range 1-19) at diagnosis and 34 years (range 20-58) at evaluation. Eighty-eight (44%) received radiation, 46 (23%) cranial radiation, and 69 (35%) high-dose methotrexate. Most prevalent CTCAE Grades 3-4 (severe life-threatening) conditions were obesity (35%), hypertension (9%), and impairment of executive function (13%), attention (9%), and memory (4%). Many had impaired strength (48%), flexibility (39%), muscular endurance (36%), and mobility (36%). Demographic and treatment-related factors were associated with the development of individual chronic diseases and functional deficits.

CONCLUSIONS

Clinical evaluation identified a high prevalence of chronic health conditions, neurocognitive deficits, and performance limitations in childhood NHL survivors.

The role of body image dissatisfaction in the association between treatment-related scarring or disfigurement and psychological distress in adult survivors of childhood cancer

OBJECTIVE

To examine the potential mediating role of body image dissatisfaction on the association between treatment-related scarring/disfigurement and psychological distress in adult survivors of childhood cancer.

METHODS

Participants included 1714 adult survivors of childhood cancer (mean [SD] age at evaluation = 32.4 [8.0] years, time since diagnosis = 24.1 [8.1] years) enrolled in the St. Jude Lifetime Cohort Study. Survivors completed measures of body image, emotional distress, and posttraumatic stress symptoms (PTSS). Body image dissatisfaction (BID) was categorized into 2 groups (cancer-related and general) based on factor analysis. Using causal mediation analysis, we estimated the proportion of psychological distress associated with treatment-related scarring/disfigurement that could be eliminated by resolving BID through a hypothetical intervention.

RESULTS

Among survivors with scarring/disfigurement of the head, a sizable proportion of the relative excess of psychological distress could be eliminated if BID was successfully treated (males: [cancer-related BID: depression: 63%; anxiety: 100%; PTSS: 52%]; [general BID: depression: 70%; anxiety: 100%; PTSS: 42%]; females: [cancer-related BID: depression: 20%; anxiety; 36%; PTSS: 23%]; [general BID: depression: 32%; anxiety: 87%; PTSS: 38%]). The mediating effect of BID was less pronounced for the association between scarring/disfigurement of the body and psychological distress for both males and females.

CONCLUSIONS

Body image dissatisfaction mediates the association treatment-related scarring/disfigurement and psychological distress among adult survivors of childhood cancer, particularly among survivors with scarring/disfigurement of the head and male survivors. Successful treatment of body image dissatisfaction has the potential to eliminate a substantial proportion of psychological distress related to scarring/disfigurement among adult survivors of childhood cancer.

Relationship between the cumulative burden (CB) of chronic health conditions (CHC) and health-related quality of life (HRQoL) among childhood cancer survivors (CCS): The St. Jude Lifetime (SJLIFE) cohort

10560

Background: Adult CCS experience an excess burden of CHC. The association between disease burden (estimated using CB) and HRQoL has not been extensively assessed. Methods: 2878 CCS (mean [range] age 32.1 [18.3-66.2] years; time from diagnosis 25.0 [10.2-51.0] years) were enrolled in SJLIFE (eligibility: survived >10 years and >18 years of age) and clinically evaluated for 168 graded CHC using the St. Jude modified Common Terminology Criteria for Adverse Events. HRQoL was assessed using the Short Form 36 survey and categorized into Low (< -0.5 SDs), Average (-0.5 to 0.5 SDs), and High (> 0.5 SDs) subgroups from the Physical and Mental Component Summary (PCS, MCS) and Vitality Scale using cohort age- and sex-specific values. CB (average number of grade 3-4 [severe/life-threatening] CHC/survivor) for each CHC was calculated and summed for each HRQoL subgroup. Results: Survivors with low PCS had, on average, more CHC CB compared to those with High and Average PCS. Higher CHC CB was also associated with poorer Vitality and MCS, but the differences in effect size were smaller than PCS. When CB for each of the 3 HRQoL scores were compared by subgroups across 12 organ systems and subsequent neoplasms, CB at age 50 differed significantly (p<0.05) across PCS, MCS, and Vitality in 9, 3 and 7 of the 13 systems, respectively. Conclusions: Survivors with lower HRQoL scores have more CHC, but the patterns of this association vary in PCS, MCS and Vitality by CHC organ systems, suggesting adult CCS adjust better to certain types of CHC than others. Future research will focus on CHC with greatest impact on functioning. [Table: see text]

Psychological and educational outcomes among adolescent survivors of wilms tumor: A report from the Childhood Cancer Survivor study

10049

Background: Little is known about psychological and educational problems experienced by adolescent survivors of Wilms tumor (WT), including the impact of treatment exposures and chronic health conditions. Methods: Parent-reports from the Childhood Cancer Survivor Study were analyzed for 666 adolescent survivors of WT (Mean[SD] age at survey = 15.3[1.65] years; age at diagnosis = 2.8[1.77] years) and 698 siblings (15.4[1.66] years). Adjusting for race and household income, survivors were compared to siblings on the Behavior Problem Inventory and educational services. Among survivors, therapeutic exposures and chronic medical conditions (CTCAE 4.03 coding) were examined via multivariable log binomial regression adjusting for sex, race, income and age at diagnosis to calculate adjusted Relative Risk (aRR) and 95% confidence intervals (CI). Results: Compared to siblings, survivors were more likely to use psychoactive medication (9.4 vs. 5.1%, p = .0002) or be in special education for learning problems, inattention, and/or low test scores (19.1 vs. 11.1%, p = .003) but had similar rates of depression/anxiety, headstrong behavior, inattention, social withdrawal, and antisocial behavior (p’s > .05). Survivors who received radiation therapy (RT) to the abdomen (aRR 1.64, CI 1.03-2.61) or abdomen and chest (aRR 1.95, CI 1.16-3.26) were more likely to be in special education for any reason than those without RT. Those with grade 2-4 cardiovascular conditions were more likely to have anxiety/depression (aRR 2.04, CI 1.26-3.30), headstrong behavior (aRR 1.95, CI 1.30-2.93), or inattention (aRR 1.58, CI 1.04-2.42) compared to survivors with grade 0/1 conditions. Survivors were more likely to be in special education if they had problems with antisocial behavior, anxiety/depression, headstrong behavior, inattention or social withdrawal (p’s < .05). Conclusions: Psychological intervention may be needed for adolescent survivors of WT treated with RT to the abdomen or abdomen and chest or with higher grade cardiovascular conditions. These survivors are more likely to experience behavioral and emotional problems, which in turn increases risk for placement in special education.

Association between health status and social integration/loneliness in survivors of adolescent and young adult (AYA) cancers

e21563

Background: AYA cancer survivors are at risk of various adverse health outcomes, but the relation between health status, social integration (i.e., social network and support) and loneliness is understudied. Methods: 102 AYA survivors (mean age = 25 years; diagnoses = leukemia 27%; lymphoma 24%; brain tumors 9%; solid tumors 41%) and 102 age-sex-matched controls were recruited from a community-based online panel. Participants reported social network information (e.g., contact frequency, resources for health counseling) for up to 25 of closest friends/relatives, which was used to create a functional social network index. UCLA Loneliness Scale, Duke-UNC Functional Social Support Questionnaire and PROMIS Health Profile were used to measure loneliness, social support and health-related outcomes (physical functioning, depression, anxiety, fatigue and pain), respectively. Multiple linear regression was used to compare functional social network, social support and loneliness between survivors and controls, and to assess the relation between health outcomes and perceived loneliness. Results: Compared to controls, survivors of lymphoma (b = 1.98; p = 0.005), leukemia (b = 1.67; p = 0.012) and solid tumors (b = 1.22; p = 0.030) had a higher functional social network index. However, social support did not differ between survivors and controls (p’s > 0.05). Brain tumor survivors (b = 15.65; p = 0.006) and solid tumor survivors (b = 10.83; p < 0.001) had more loneliness than controls. Compared to low loneliness controls, high loneliness survivors had significantly lower physical functioning (b = -7.72; p < 0.001) and higher anxiety (b = 8.35; p < 0.001), depression (b = 10.57; p < 0.001), fatigue (b = 5.52; p = 0.011) and pain (b = 6.37; p < 0.001) after adjusting for age, sex, education, social integration, and number of self-reported chronic health conditions. Conclusions: Loneliness is significantly associated with poor health-related outcomes in AYA survivors, which is independent of the influence of social integration. Future research is warranted to understand the relation between health status and social interactions among AYA survivors to inform intervention-based strategies.

Biomarkers of brain injury and neurologic outcomes in children treated with chemotherapy for acute lymphoblastic leukemia (ALL)

10521

Background: Little is known about neurotoxic mechanisms associated with chemotherapy in children with ALL. Cerebrospinal fluid (CSF) biomarkers of brain injury may provide insight into this process. Methods: 235 patients (51% male; mean [SD] age diagnosed 6.8 [4.7] years) treated on a chemotherapy only protocol provided CSF samples following diagnosis and through consolidation. CSF was assayed for biomarkers of myelin degradation (myelin basic protein [MBP]), neuronal damage (nerve growth factor [NGF], total-Tau [T-Tau]) and astrogliosis (glial fibrillary acidic protein [GFAP]). Leukoencephalopathy was evaluated by brain MRI’s during therapy. At ≥5 years post-diagnosis, 138 (70%) of the 198 still eligible survivors (without relapse and unrelated neurologic injury) completed neurocognitive testing and brain diffusion tensor imaging of white matter integrity at age 13.6 [4.6] years. Log-binomial and general linear models were used to examine whether biomarker changes from baseline through consolidation were related to serum methotrexate exposure, acute leukoencephalopathy, and long-term brain outcomes. Results: NGF and T-Tau increased from baseline to consolidation ( P's < 0.001), while MBP and GFAP were elevated at baseline and remained so through consolidation. The number of intrathecal injections (methotrexate, hydrocortisone, cytarabine) was positively correlated with NGF increase at consolidation ( P= 0.005). Increases in GFAP (RR 1.2; 95% CI [1.0 – 1.4]), MBP (RR 1.1 [1.0 – 1.1]) and T-Tau (RR 1.8 [1.1 – 2.8]) were related to higher risk for acute leukoencephalopathy, and higher diffusivity in frontal lobe white matter at ≥5 years post-diagnosis ( P’s < 0.05). Increase in T-Tau at consolidation was associated with worse long-term sustained attention ( P= 0.03), and visual- ( P= 0.04) and visual-motor ( P= 0.02) processing speed. Conclusions: Glial injury, which is evident at diagnosis, may be related to leukemia and methotrexate exposure. Neuronal injury is associated with intrathecal chemotherapy and long-term neurocognitive and brain imaging outcomes. Monitoring CSF biomarkers may be useful in identifying individuals at risk for poor neurological outcomes.

Subcortical brain volumes and neurocognitive function in survivors of childhood acute lymphoblastic leukemia (ALL) treated with chemotherapy-only

10517

Background: Brain deep grey nuclei and glucocorticoid receptor rich hippocampal subregions may be sensitive to neurotoxic effects of chemotherapy-only protocols for childhood ALL and associated with neurocognitive problems in long-term survivors. Methods: Brain MRIs and neurocognitive tests were obtained on 176 survivors (49% male, mean [range] age at diagnosis 6.8 [1-18] years, 14.5 [8-27] years at evaluation). MRI’s were also obtained on 82 healthy community controls (57% male, 13.8 [8-26] years at evaluation). General linear models were used to compare subcortical brain volumes between survivors and controls. Among survivors, gender stratified multivariable linear models were used to test associations between subcortical volumes, and serum concentration of dexamethasone (DEX) and high-dose methotrexate (HDMTX), adjusting for age at diagnosis, and intracranial volume (ICV). Volumes were also compared to neurocognitive tests. Results: Survivors had smaller volumes in bilateral thalami (p’s < 0.05) and hippocampal subregions (p’s < 0.001) compared to controls. After controlling for ICV, HDMTX exposure and younger age at diagnosis were associated with smaller bilateral thalami in male survivors (p’s < 0.05). DEX was associated with a smaller right thalamus in males (p = 0.04). Smaller hippocampi in both males and females were associated with younger age at diagnosis (p’s < 0.01). Smaller left thalamus was associated with worse verbal fluency scores in all survivors (p’s < 0.05). Smaller bilateral thalami and hippocampal subregions in girls were associated with worse processing speed, inhibition and cognitive flexibility; poor memory span correlated with smaller left CA1 and right thalamus volumes (all p’s < 0.05). Smaller bilateral thalami and right hippocampal subregions, in girls, correlated with slower processing speed (p’s < 0.05). In males, smaller left fimbria volume was correlated with poor attention (p = 0.03). Conclusions: ALL survivors have significantly smaller thalamic and hippocampal volumes compared to healthy community controls. In survivors, smaller volumes correlate with worse cognitive performance.

Temporal trends in late-onset morbidity and mortality after medulloblastoma diagnosed across three decades: A report from the Childhood Cancer Survivor Study (CCSS)

10516

Background: Therapy for medulloblastoma and primitive neuroectodermal tumor has evolved from surgery and adjuvant radiotherapy to risk-adapted multimodal regimens. The impact of these changes in treatment on long-term outcomes remains unknown. Methods: Cumulative incidence of late mortality ( > 5 years from diagnosis), subsequent malignant neoplasms (SMN), chronic health conditions and psychosocial functioning were evaluated among 5-year survivors in CCSS diagnosed between 1970 and 1999. Survivors were stratified according to treatment decade (1970s, 1980s, 1990s) and treatment exposure (surgery + craniospinal irradiation [CSI] ≥30 Gy, no chemotherapy; surgery + CSI ≥30 Gy + chemotherapy [high-risk therapy], surgery + CSI ˂30 Gy + chemotherapy [standard-risk therapy]). Rate ratios (RRs), odds ratios (ORs) and 95% confidence intervals (CIs) were estimated for long-term outcomes among treatment eras and exposure groups using multivariable piecewise-exponential models. Results: Among 1,380 eligible survivors (median [range] age 29 [6-20] years; 21.4 [5-44] years from diagnosis), the 15-year cumulative incidence of all-cause (21.9% 1970s vs. 12.8% 1990s; p = 0.003) and recurrence-related (16.2% vs 9.6%, p = 0.03) late mortality decreased with no reduction in mortality attributable to late effects of therapy including SMN. Among 959 participants, the incidence of SMN did not decrease by era or by treatment group. However, survivors treated in the 1990s had an increased cumulative incidence of severe, life-threatening and fatal health conditions (16.9% 1970s vs 25.4% 1990s; p = 0.03), and were more likely to develop multiple severe or life-threatening health conditions, RR = 2.98 (95% CI, 1.10-8.07). Survivors of standard-risk therapy were less likely to use special education services than high-risk therapy patients, OR = 0.51 (95% CI, 0.33-0.78). Conclusions: Historical changes in therapy have improved 5-year survival, reduced risk of late mortality due to disease recurrence, and reduced special education utilization, at the cost of increased risk for multiple, severe and life-threatening chronic health conditions.

Impact of sleep, fatigue, and systemic inflammation on neurocognitive and behavioral outcomes in long-term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Long-term survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for neurocognitive impairment, which may be associated with fatigue, sleep problems, systemic inflammation, and oxidative stress. We examined these associations among survivors of childhood ALL treated with chemotherapy only.

METHODS

Survivors of childhood ALL (male, n = 35 and female, n = 35; mean age, 14.3 years [standard deviation, 4.7 years] and mean years from diagnosis, 7.4 years [standard deviation, 1.9 years]) completed neurocognitive testing, behavioral ratings, and reported sleep quality and fatigue symptoms 5 years after diagnosis. Serum was collected concurrently and assayed for interleukin (IL)-1β and IL-6, tumor necrosis factor α (TNF-α), high-sensitivity C-reactive protein (hsCRP), malondialdehyde, myeloperoxidase, and oxidized low-density lipoprotein. General linear modeling was used to assess associations among biomarkers and functional outcomes, adjusting for age and stratified by sex.

RESULTS

Survivors performed worse than population norms on executive function and processing speed and reported more behavioral problems (P < .05 adjusted for multiple comparison). In female survivors, fatigue was associated with poor executive function (r = 0.41; P = .02), processing speed (r = 0.56; P < .001), and attention (r = 0.36-0.55; P < .05). Female survivors with frequent nighttime awakening displayed more inattention (P = .01), hyperactivity (P = .03), and aggression (P = .01). Worse executive function, processing speed, and behavioral symptoms were observed in female survivors with higher levels of IL-6, IL-1β, and hsCRP (P < .05). Male survivors with high levels of TNF-α demonstrated worse organization (P = .03), but no significant associations between neurocognitive outcomes and sleep/fatigue measures were observed.

CONCLUSION

Neurocognitive function in female survivors of childhood ALL appears more susceptible to the effects of sleep disturbance and fatigue. Systemic inflammation may play a role in neurocognitive impairment and behavioral symptoms. Cancer 2017;123:3410-9. © 2017 American Cancer Society.

Association between dehydroepiandrosterone-sulfate and attention in long-term survivors of childhood acute lymphoblastic leukemia treated with only chemotherapy

Long-term survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for neurocognitive impairment, as well as compromised hypothalamic-pituitary-adrenal (HPA) function. Dehydroepiandrosterone-sulfate (DHEAS) is an adrenal androgen commonly used as a marker of HPA function. In the general population, a low level of DHEAS has been associated with poorer cognition. At ≥2years post-treatment, we examined the association of DHEAS with attention outcomes in 35 male and 34 female long-term survivors of childhood ALL (mean[standard deviation] age at evaluation 14.5[4.7] years; 7.5[1.9] years post-diagnosis) who were treated with only chemotherapy and without prophylactic cranial irradiation. Male survivors with low-normal levels of DHEAS had worse performance than male survivors with high levels of DHEAS on multiple measures of attention (all P's<0.05). However, association between DHEAS and attention measures were not found in female survivors. Our results suggest that survivors of ALL who suffer from partial but persistent adrenal insufficiency may be at risk for neurocognitive deficits. This finding should be validated in a larger prospective study, with attention to sex differences in the potential impact of adrenal insufficiency on neurocognitive outcomes.

Long-term functional outcomes and quality of life in adult survivors of childhood extremity sarcomas: a report from the St. Jude Lifetime Cohort Study

PURPOSE

This study compared measured physical performance, health-related quality of life (HRQOL), and social role attainment between extremity sarcoma survivors and controls, and evaluated associations between disease and treatment exposures, health conditions, and performance measures.

METHODS

Survivors of extremity sarcoma from the St. Jude Lifetime cohort and controls frequency matched by age-, sex-, and race completed physical performance testing and questionnaires. Survivors with Z-scores on outcome measures ≤ -2.0 SD (compared to controls) were categorized with severe impairment/limitation.

RESULTS

Among 206 survivors (52.4 % male median age 36 years (range 19-65)), 37 % had low relative lean mass, 9.7 % had an ejection fraction <50 %, 51.5 % had diffusion capacity for carbon monoxide <75 %, 27.7 % had sensory and 25.2 % motor neuropathy, and 78.2 % had musculoskeletal complications. Severe impairments/limitations were present among ≥25 % of survivors on fitness, balance, and physical HRQOL measures, and among ≥15 % on strength and activity of daily living measures. Lower extremity tumor location (OR 8.23, 95 % CI 2.54-26.67, P value 0.0004) and amputation (OR 8.07, 95 % CI 3.06-21.27, P value <0.0001) were associated with poor fitness. Poor fitness was associated with increased odds of scoring <40 on the SF-36 physical component summary (OR 4.83, 95 % CI 1.95-11.99, P value 0.001) and role-physical subscale (OR 3.34, 95 % CI 1.33-8.43, P value 0.01). Survivors and controls had similar rates of marriage, independent living, employment, and college attendance.

CONCLUSIONS

Extremity sarcoma survivors experience high rates of physical impairment and report lower than expected physical HRQOL. However, they are as likely as peers to be married, live independently, be employed, and attend college.

IMPLICATIONS FOR CANCER SURVIVORS

Follow-up for extremity sarcoma survivors should include assessment of need for further orthopedic care and rehabilitation to address cardiopulmonary and musculoskeletal health.

Effect of Temporal Changes in Therapeutic Exposure on Self-reported Health Status in Childhood Cancer Survivors

BACKGROUND

The effect of temporal changes in cancer therapy on health status among childhood cancer survivors has not been evaluated.

OBJECTIVE

To compare proportions of self-reported adverse health status outcomes among childhood cancer survivors across 3 decades.

DESIGN

Cross-sectional. (ClinicalTrials.gov: NCT01120353).

SETTING

27 North American institutions.

PARTICIPANTS

14 566 adults, who survived for 5 or more years after initial diagnosis (median age, 27 years; range, 18 to 48 years), treated from 1970 to 1999.

MEASUREMENTS

Patient report of poor general or mental health, functional impairment, activity limitation, or cancer-related anxiety or pain was evaluated as a function of treatment decade, cancer treatment exposure, chronic health conditions, demographic characteristics, and health habits.

RESULTS

Despite reductions in late mortality and the proportions of survivors with severe, disabling, or life-threatening chronic health conditions (33.4% among those treated from 1970 to 1979 and 21.0% among those treated from 1990 to 1999), those reporting adverse health status did not decrease by treatment decade. Compared with survivors diagnosed in 1970 to 1979, those diagnosed in 1990 to 1999 were more likely to report poor general health (11.2% vs. 13.7%; P < 0.001) and cancer-related anxiety (13.3% vs. 15.0%; P < 0.001). From 1970 to 1979 and 1990 to 1999, the proportions of survivors reporting adverse outcomes were higher (P < 0.001) among those with leukemia (poor general health, 9.5% and 13.9%) and osteosarcoma (pain, 23.9% and 36.6%). Temporal changes in treatment exposures were not associated with changes in the proportions of survivors reporting adverse health status. Smoking, not meeting physical activity guidelines, and being either underweight or obese were associated with poor health status.

LIMITATION

Considerable improvement in survival among children diagnosed with cancer in the 1990s compared with those diagnosed in the 1970s makes it difficult to definitively determine the effect of risk factors on later self-reported health status without considering their effect on mortality.

CONCLUSION

Because survival rates after a diagnosis of childhood cancer have improved substantially over the past 30 years, the population of survivors now includes those who would have died in earlier decades. Self-reported health status among survivors has not improved despite evolution of treatment designed to reduce toxicities.

PRIMARY FUNDING SOURCE

The National Cancer Institute.

Emotional distress impacts quality of life evaluation: a report from the Childhood Cancer Survivor Study

PURPOSE

We compared health-related quality of life (HRQOL) between adult survivors of childhood cancer and siblings by investigating the mediating role of emotional distress on HRQOL assessment, and examining the extent to which emotional distress affected the item responses of HRQOL measures given the same underlying HRQOL (i.e., measurement non-invariance).

METHODS

Cancer survivors (7103) and siblings (390) enrolled in Childhood Cancer Survivor Study who completed the SF-36 measuring HRQOL and the Brief Symptom Inventory-18 measuring anxiety, depression, and somatization were analyzed. Multiple Indicators & Multiple Causes modeling was performed to identify measurement non-invariance related to emotional distress on the responses to HRQOL items. Mediation analysis was performed to test the effects of cancer experience on HRQOL accounting for the mediating role of emotional distress.

RESULTS

Twenty-nine percent, 40%, and 34% of the SF-36 items were identified with measurement non-invariance related to anxiety, depression, and somatization, respectively. Survivors reported poorer HRQOL than siblings in all domains (ps < 0.05), except for pain. Other than physical functioning and general health perceptions, poorer HRQOL was explained by the mediating role of emotional distress (ps < 0.05).

CONCLUSIONS

Differences in HRQOL between survivors and siblings appear due, in part, to the mediating effect of emotional distress through which cancer experience influences the responses to HRQOL measures.

IMPLICATIONS OF CANCER SURVIVORS

Interventions to treat emotional distress may improve cancer survivors' HRQOL.

Approach for Classification and Severity Grading of Long-term and Late-Onset Health Events among Childhood Cancer Survivors in the St. Jude Lifetime Cohort

Characterization of toxicity associated with cancer and its treatment is essential to quantify risk, inform optimization of therapeutic approaches for newly diagnosed patients, and guide health surveillance recommendations for long-term survivors. The NCI Common Terminology Criteria for Adverse Events (CTCAE) provides a common rubric for grading severity of adverse outcomes in cancer patients that is widely used in clinical trials. The CTCAE has also been used to assess late cancer treatment-related morbidity but is not fully representative of the spectrum of events experienced by pediatric and aging adult survivors of childhood cancer. Also, CTCAE characterization does not routinely integrate detailed patient-reported and medical outcomes data available from clinically assessed cohorts. To address these deficiencies, we standardized the severity grading of long-term and late-onset health events applicable to childhood cancer survivors across their lifespan by modifying the existing CTCAE v4.03 criteria and aligning grading rubrics from other sources for chronic conditions not included or optimally addressed in the CTCAE v4.03. This article describes the methods of late toxicity assessment used in the St. Jude Lifetime Cohort Study, a clinically assessed cohort in which data from multiple diagnostic modalities and patient-reported outcomes are ascertained. Cancer Epidemiol Biomarkers Prev; 26(5); 666-74. ©2016 AACR.

Adult Survivors of Childhood Cancer Have Poor Adherence to Dietary Guidelines

BACKGROUND

Poor nutritional intake can exacerbate the chronic disease burden in childhood cancer survivors, whereas a healthful diet serves a protective function. Few studies have provided detailed evaluations of the diet of childhood cancer survivors.

OBJECTIVES

This study aimed to evaluate diet quality and dietary intakes of key food groups and nutrients in a large cohort of childhood cancer survivors and whether cancer and treatment characteristics have an impact on survivors' long-term intake.

METHODS

Diet was assessed in 2570 adult survivors of childhood cancer enrolled in the St. Jude Lifetime cohort (mean age = 32.3 y) by using the Block food-frequency questionnaire. The Healthy Eating Index-2010 (HEI-2010) was calculated to quantify diet quality. Cancer diagnosis and treatment exposure were abstracted from medical records. Differences in HEI-2010 by patient characteristics and treatment exposure were examined by using ANCOVA.

RESULTS

The mean ± SD HEI-2010 in childhood cancer survivors was 57.9 ± 12.4 of a maximum score of 100. Referenced to Dietary Reference Intakes, survivors consumed inadequate amounts of vitamin D, vitamin E, potassium, fiber, magnesium, and calcium (27%, 54%, 58%, 59%, 84%, and 90% of the recommended intakes) but excessive amounts of sodium and saturated fat (155% and 115% of the recommended intakes) from foods. Survivors diagnosed when <5 y of age had a lower diet quality than did those diagnosed when ≥5 y of age (mean HEI-2010 score: 56.9 compared with 58.2; P = 0.046). Survivors who received higher radiation doses to the abdomen had a lower diet quality than those who received lower doses (mean HEI-2010 scores = 58.9, 57.2, 56.7, and 56.1 for doses of 0, 1-19.9, 20-29.9, and ≥30 Gy, respectively; P = 0.02).

CONCLUSIONS

Long-term childhood cancer survivors have poor adherence to the 2010 Dietary Guidelines for Americans. Findings reinforce the need to incorporate nutrition into cancer care to improve diet quality and to reduce morbidities.

Predictors of fatigue and poor sleep in adult survivors of childhood Hodgkin's lymphoma: a report from the Childhood Cancer Survivor Study

PURPOSE

Survivors of pediatric Hodgkin's lymphoma (HL) are at risk for a number of debilitating late effects. Excessive fatigue and poor sleep quality are primary complaints of HL survivors. Understanding the emotional and physical factors that influence fatigue and sleep quality may provide opportunities for intervention to improve health-related quality of life for HL survivors.

METHODS

Data from 751 adult survivors of childhood HL who participated in the Childhood Cancer Survivor Study (CCSS) from 2000-2002 were analyzed. Multivariable logistic regression analyses investigated the demographic, psychological, and physical variables that predicted clinically significant levels of poor sleep quality, fatigue, and excessive daytime sleepiness.

RESULTS

Survivors' self-reported level of emotional distress, pain, and physical functioning limitations did not differ from population norms. Clinically elevated levels of emotional distress (OR 8.38, 95% CI 4.28-16.42) and pain (OR 3.73, 95% CI 2.09-6.67) increased the risk for endorsing elevated levels of fatigue. Survivors with elevated levels of emotional distress (OR 6.83, 95% CI 2.71-15.90) and pain (OR 5.27, 95% CI 1.78-15.61) were more likely to report poor sleep quality. Pain (OR 2.11, 95% CI 1.39-3.34) was related to excessive daytime sleepiness.

CONCLUSIONS

Emotional and physical factors are associated with elevated levels of fatigue, excessive daytime sleepiness, and poor sleep quality in survivors of pediatric HL. This is consistent with findings from research conducted with non-cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

These results suggest that interventions designed to target sleep and fatigue difficulties in the general population may be well suited for pediatric HL survivors as well.

Impact of chronic disease on emotional distress in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

The current study was performed to examine associations between childhood cancer therapies, chronic health conditions, and symptoms of emotional distress in adult survivors of childhood cancer.

METHODS

Participants included 5021 adult survivors of childhood cancer (mean age, 32.0 years [standard deviation, 7.6 years] with a time since diagnosis of 23.2 years [standard deviation, 4.5 years]) who completed measures assessing symptoms of anxiety, depression, and posttraumatic stress. Cardiac, pulmonary, and endocrine conditions were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.03; grades 1-4). Structural equation modeling was used to examine hypothesized pathways between cancer treatment exposures, chronic health conditions, and symptoms of emotional distress. Multivariable models were used to estimate relative risks (RRs) for associations between chronic health conditions and distress.

RESULTS

Survivors with cardiovascular, endocrine, or pulmonary conditions were found to have a significantly higher prevalence of emotional distress symptoms. In path analyses and multivariable models, significant effects were observed between endocrine (β = .12 [P = .002] and RR, 1.3 [95% confidence interval (95% CI), 1.1-1.6]) and pulmonary (β = .13 [P<.001] and RR, 1.4 [95% CI, 1.1-1.7]) conditions and depression, and between cardiac (β = .13 [P = .001] and RR, 1.5 [95% CI, 1.2-1.8]) and pulmonary (β = .15 [P<.001] and RR, 1.6 [95% CI, 1.3-2.0]) conditions and anxiety. All treatment-related chronic health conditions were found to be associated with posttraumatic stress symptoms (cardiac: β = .09 [P = .004] and RR, 1.3 [95% CI, 1.2-1.5]; endocrine: β = .12 [P<.001] and RR, 1.3 [95% CI, 1.2-1.5]; and pulmonary: β = .13 [P<.001] and RR, 1.4 [95% CI, 1.2-1.6]).

CONCLUSIONS

Chronic health conditions resulting from childhood cancer therapies contribute to emotional distress in adult survivors. Targeted mental health screening efforts in this at-risk population appear warranted. Therapeutic approaches should consider the complex interplay between chronic health conditions and symptoms of emotional distress. Cancer 2017;123:521-528. © 2016 American Cancer Society.

Cognitive, behaviour, and academic functioning in adolescent and young adult survivors of childhood acute lymphoblastic leukaemia: a report from the Childhood Cancer Survivor Study

BACKGROUND

Survivors of childhood acute lymphoblastic leukaemia (ALL) are at risk for neurocognitive deficits that affect development in adolescence and young adulthood, and influence educational attainment and future independence. We examined a large and diverse cohort of survivors to identify risk predictors and modifiers of these outcomes.

METHODS

In this cohort study, cognitive and behaviour symptoms were assessed via a standardised parent questionnaire for 1560 adolescent survivors of ALL diagnosed between 1970 and 1999. Clinically significant symptoms (≥90th percentile) and learning problems were compared between survivors and a sibling cohort. Multivariable regression models were used to examine associations with demographic and treatment characteristics. Models were adjusted for inverse probability of sampling weights to reflect undersampling of ALL survivors in the expansion cohort. In a subset of survivors with longitudinal data (n=925), we examined associations between adolescent symptoms or problems and adult educational attainment.

FINDINGS

Compared with siblings, survivors treated with chemotherapy only were more likely to demonstrate headstrong behaviour (155 [19%] of 752 survivors vs 88 [14%] of 610 siblings, p=0·010), inattention-hyperactivity (15 [19%] vs 86 [14%], p<0·0001), social withdrawal (142 [18%] vs 75 [12%], p=0·002), and had higher rates of learning problems (191 [28%] vs 76 [14%], p<0·0001). In multivariable models among survivors, increased cumulative dose of intravenous methotrexate (ie, >4·3 g/m²) conferred increased risk of inattention-hyperactivity (relative risk [RR] 1·53, 95% CI 1·13-2·08). Adolescent survivors with cognitive or behaviour problems and those with learning problems were less likely to graduate from college as young adults than adolescent survivors without cognitive or behaviour problems.

INTERPRETATION

Although modern therapy for childhood ALL has eliminated the use of cranial radiation therapy, adolescent survivors treated with chemotherapy only remain at increased risk for cognitive, behaviour, and academic problems that adversely affect adult education outcomes.

FUNDING

National Cancer Institute, American Lebanese-Syrian Associated Charities.

Uric Acid and Neurocognitive Function in Survivors of Childhood Acute Lymphoblastic Leukemia Treated with Chemotherapy Only

BACKGROUND

Hyperuricemia is implicated in cardiovascular and cerebrovascular diseases. This study evaluated associations between uric acid (UA), cardiovascular health, and neurocognitive function in adolescent and adult survivors of childhood acute lymphoblastic leukemia treated with chemotherapy only.

METHODS

126 adolescent [mean (SD) age 14.6 (5.0); 7.8 (1.7) years postdiagnosis] and 226 adult survivors [age 25.4 (4.2) years; 18.1 (4.4) years postdiagnosis] completed comprehensive neurocognitive testing. Concurrent UA measurements were conducted for both groups. For adult survivors, cardiovascular risk factors were assessed, and UA measurements during adolescence [12.3 (4.0) years before neurocognitive testing] were also collected. UA levels were categorized into quartiles for age- and gender-based ranking, and associations with neurocognitive outcomes were examined.

RESULTS

Survivors demonstrated worse attention, processing speed, and executive functions than population norms (P values < 0.05). Adolescent survivors with elevated UA had poorer attention (P = 0.04), visual-processing speed (P = 0.03), and cognitive flexibility (P = 0.02). UA was not associated with neurocognitive outcomes in adult survivors. Adult survivors developed dyslipidemia (46%), hypertension (32%), and abdominal obesity (26%), and high UA during adolescence was associated with these cardiovascular risk factors as adults (all P values < 0.01). Fine-motor processing speed was slower in adult survivors with dyslipidemia (P = 0.04) and abdominal obesity (P = 0.04). Poorer attention was marginally associated with hypertension (P = 0.06).

CONCLUSIONS

Elevated UA is associated with neurocognitive performance in adolescent survivors. In adult survivors, relative elevation of UA during adolescence was predictive of cardiovascular health, which was associated with poorer neurocognitive outcomes.

IMPACT

Future studies should evaluate the mediating role of chronic cardiovascular health conditions between elevated UA and subsequent neurocognitive impairment in survivors. Cancer Epidemiol Biomarkers Prev; 25(8); 1259-67. ©2016 AACR.

Childhood cancer survivorship research in minority populations: A position paper from the Childhood Cancer Survivor Study

By the middle of this century, racial/ethnic minority populations will collectively constitute 50% of the US population. This temporal shift in the racial/ethnic composition of the US population demands a close look at the race/ethnicity-specific burden of morbidity and premature mortality among survivors of childhood cancer. To optimize targeted long-term follow-up care, it is essential to understand whether the burden of morbidity borne by survivors of childhood cancer differs by race/ethnicity. This is challenging because the number of minority participants is often limited in current childhood cancer survivorship research, resulting in a paucity of race/ethnicity-specific recommendations and/or interventions. Although the overall childhood cancer incidence increased between 1973 and 2003, the mortality rate declined; however, these changes did not differ appreciably by race/ethnicity. The authors speculated that any racial/ethnic differences in outcome are likely to be multifactorial, and drew on data from the Childhood Cancer Survivor Study to illustrate the various contributors (socioeconomic characteristics, health behaviors, and comorbidities) that could explain any observed differences in key treatment-related complications. Finally, the authors outlined challenges in conducting race/ethnicity-specific childhood cancer survivorship research, demonstrating that there are limited absolute numbers of children who are diagnosed and survive cancer in any one racial/ethnic minority population, thereby precluding a rigorous evaluation of adverse events among specific primary cancer diagnoses and treatment exposure groups. Cancer 2016;122:2426-2439. © 2016 American Cancer Society.

Behavioral, Social, and Emotional Symptom Comorbidities and Profiles in Adolescent Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

PURPOSE

In the general population, psychological symptoms frequently co-occur; however, profiles of symptom comorbidities have not been examined among adolescent survivors of childhood cancer.

PATIENTS AND METHODS

Parents of 3,893 5-year survivors of childhood cancer who were treated between 1970 and 1999 and who were assessed in adolescence (age 12 to 17 years) completed the Behavior Problems Index. Age- and sex-standardized z scores were calculated for symptom domains by using the Childhood Cancer Survivor Study sibling cohort. Latent profile analysis identified profiles of comorbid symptoms, and multivariable multinomial logistic regression modeling examined associations between cancer treatment exposures and physical late effects and identified symptom profiles. Odds ratios (ORs) and 95% CIs for latent class membership were estimated and analyses were stratified by cranial radiation therapy (CRT; CRT or no CRT).

RESULTS

Four symptoms profiles were identified: no significant symptoms (CRT, 63%; no CRT, 70%); elevated anxiety and/or depression, social withdrawal, and attention problems (internalizing; CRT, 31%; no CRT, 16%); elevated headstrong behavior and attention problems (externalizing; CRT, no observed; no CRT, 9%); and elevated internalizing and externalizing symptoms (global symptoms; CRT, 6%; no CRT, 5%). Treatment with ≥ 30 Gy CRT conferred greater risk of internalizing (OR, 1.7; 95% CI, 1.0 to 2.8) and global symptoms (OR, 3.2; 95% CI, 1.2 to 8.4). Among the no CRT group, corticosteroid treatment was associated with externalizing symptoms (OR, 1.9; 95% CI, 1.2 to 2.8) and ≥ 4.3 g/m(2) intravenous methotrexate exposure was associated with global symptoms (OR, 1.5; 95% CI, 0.9 to 2.4). Treatment late effects, including obesity, cancer-related pain, and sensory impairments, were significantly associated with increased risk of comorbid symptoms.

CONCLUSION

Behavioral, emotional, and social symptoms frequently co-occur in adolescent survivors of childhood cancer and are associated with treatment exposures and physical late effects. Assessment and consideration of symptom profiles are essential for directing appropriate mental health treatment for adolescent survivors.

Comorbid symptoms of emotional distress in adult survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at risk for emotional distress symptoms, but symptom comorbidity has not been previously examined. This study examined distress profiles for adult survivors of childhood cancer diagnosed between 1970 and 1999.

METHODS

Self-reported depression, anxiety, and somatization symptoms from Brief Symptom Inventory 18 were examined in survivors (n = 16,079) and siblings (n = 3085) from the Childhood Cancer Survivor Study. A latent profile analysis identified clusters of survivors with individual and comorbid symptoms. Disease, treatment, and demographic predictors of distress comorbidity patterns were examined with multinomial logistic regressions.

RESULTS

Four clinically relevant profiles were identified: low distress on all subscales (asymptomatic, 62%), high distress on all subscales (comorbid distress, 11%), elevated somatization (somatic symptoms, 13%), and elevated depression and anxiety (affective distress, 14%). Compared with siblings, fewer survivors were asymptomatic (62% vs 74%, P < .0001), and more had comorbid distress (11% vs 5%, P < .0001). Survivors of leukemia (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.12-1.61), central nervous system tumors (OR, 1.30; 95% CI, 1.05-1.61), and sarcoma (OR, 1.26; 95% CI, 1.01-1.57) had a greater risk of comorbid distress than survivors of solid tumors. Psychoactive medications were associated with comorbid distress (P < .0001), and this suggested that this group was refractory to traditional medical management. Comorbid distress was associated with poor perceived health (OR, 31.7; 95% CI, 23.1-43.3), headaches (OR, 3.2; 95% CI, 2.8-3.7), and bodily pain (OR, 4.0; 95% CI, 3.2-5.0).

CONCLUSIONS

A significant proportion of survivors are at risk for comorbid distress, which may require extensive treatment approaches beyond those used for individual symptoms. Cancer 2016;122:3215-24. © 2016 American Cancer Society.

Neurocognitive and Patient-Reported Outcomes in Adult Survivors of Childhood Osteosarcoma

IMPORTANCE

This study provides the first objective data documenting neurocognitive impairment in long-term survivors of childhood osteosarcoma.

OBJECTIVE

To examine neurocognitive, neurobehavioral, emotional, and quality-of-life outcomes in long-term survivors of childhood osteosarcoma.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional cohort study at an academic research hospital, with prospective treatment and chronic health predictors. Outcome data were collected from June 2008 to August 2014. Data analysis was completed in April 2015. Survivors of osteosarcoma recruited from the St Jude Lifetime Cohort Study were compared with community controls.

MAIN OUTCOMES AND MEASURES

Neurocognitive function, neurobehavioral symptoms, emotional distress, and quality of life. Outcomes were examined in relation to pharmacokinetic indices of methotrexate exposure and current chronic health conditions, which were assessed through medical examination and coded according to Common Terminology Criteria for Adverse Events, Version 4.03.

RESULTS

Eighty survivors of osteosarcoma (mean [SD] age, 38.9 [7.6] years; time since diagnosis, 24.7 [6.6] years; 42% female) were compared with 39 community controls (age, 39.0 [11.7] years; 56% female). Survivors demonstrated lower mean scores in reading skills (-0.21 [95% CI, -0.32 to -0.10] vs 0.05 [95% CI, -0.13 to 0.23]; P = .01), attention (-0.78 [95% CI, -1.32 to -0.24] vs 0.24 [95% CI, -0.07 to 0.55]; P = .002), memory (-0.24 [95% CI, -0.48 to 0] vs 0.27 [95% CI, -0.08 to 0.62]; P = .01), and processing speed (-0.15 [95% CI, -0.35 to 0.05] vs 0.74 [95% CI, 0.44 to 1.03]; P < .001). Results of pharmacokinetic analysis showed that high-dose methotrexate maximum plasma concentration (estimate = 0; P = .48), median clearance (estimate = -0.11; P = .76), and median/cumulative exposure (estimate = 0; P = .45) were not associated with neurocognitive outcomes. Any grade 3 or 4 Common Terminology Criteria for Adverse Events cardiac, pulmonary, or endocrine condition was associated with poorer memory (t = 2.93; P = .006) and slower processing speed (t = 3.03; P = .002). Survivor-reported poor general health was associated with decreased sustained attention (estimate = 0.24; P = .05) and processing speed (estimate = 0.34; P = .005).

CONCLUSIONS AND RELEVANCE

Long-term survivors of osteosarcoma are at risk for neurocognitive impairment, which is related to current chronic health conditions and not to original treatment with high-dose methotrexate. Prospective longitudinal studies are needed to identify onset and progression of impairment to inform optimal interventions.

Oxidative Stress, Motor Abilities, and Behavioral Adjustment in Children Treated for Acute Lymphoblastic Leukemia

PURPOSE/OBJECTIVES

To examine associations among oxidative stress, fine and visual-motor abilities, and behavioral adjustment in children receiving chemotherapy for acute lymphoblastic leukemia (ALL)
.

DESIGN

A prospective, repeated-measures design
.

SETTING

Two pediatric oncology settings in the southwestern United States.

SAMPLE

89 children with ALL were followed from diagnosis to the end of chemotherapy.

METHODS

Serial cerebrospinal fluid samples were collected during scheduled lumbar punctures and analyzed for oxidative stress biomarkers. Children completed fine motor dexterity, visual processing speed, and visual-motor integration measures at three time points. Parents completed child behavior ratings at the same times.

MAIN RESEARCH VARIABLES

Oxidative stress, fine motor dexterity, visual processing, visual-motor integration, and behavioral adjustment
.

FINDINGS

Children with ALL had below-average fine motor dexterity, visual processing speed, and visual-motor integration following the induction phase of ALL therapy. By end of therapy, visual processing speed normalized, and fine motor dexterity and visual-motor integration remained below average. Oxidative stress measures correlated with fine motor dexterity and visual-motor integration. Decreased motor functioning was associated with increased hyperactivity and anxiety
.

CONCLUSIONS

Oxidative stress occurs following chemo-therapy for childhood ALL and is related to impaired fine motor skills and visual symptoms
.

IMPLICATIONS FOR NURSING

Early intervention should be considered to prevent fine motor and visual-spatial deficits, as well as behavioral problems.