Health-status of adult survivors of childhood cancer: a large-scale population-based study from the British Childhood Cancer Survivor Study

Physical performance limitations in adolescent and adult survivors of childhood cancer and their siblings

PURPOSE

This study investigates physical performance limitations for sports and daily activities in recently diagnosed childhood cancer survivors and siblings.

METHODS

The Swiss Childhood Cancer Survivor Study sent a questionnaire to all survivors (≥ 16 years) registered in the Swiss Childhood Cancer Registry, who survived >5 years and were diagnosed 1976-2003 aged <16 years. Siblings received similar questionnaires. We assessed two types of physical performance limitations: 1) limitations in sports; 2) limitations in daily activities (using SF-36 physical function score). We compared results between survivors diagnosed before and after 1990 and determined predictors for both types of limitations by multivariable logistic regression.

RESULTS

The sample included 1038 survivors and 534 siblings. Overall, 96 survivors (9.5%) and 7 siblings (1.1%) reported a limitation in sports (Odds ratio 5.5, 95%CI 2.9-10.4, p<0.001), mainly caused by musculoskeletal and neurological problems. Findings were even more pronounced for children diagnosed more recently (OR 4.8, CI 2.4-9.6 and 8.3, CI 3.7-18.8 for those diagnosed <1990 and ≥ 1990, respectively; p=0.025). Mean physical function score for limitations in daily activities was 49.6 (CI 48.9-50.4) in survivors and 53.1 (CI 52.5-53.7) in siblings (p<0.001). Again, differences tended to be larger in children diagnosed more recently. Survivors of bone tumors, CNS tumors and retinoblastoma and children treated with radiotherapy were most strongly affected.

CONCLUSION

Survivors of childhood cancer, even those diagnosed recently and treated with modern protocols, remain at high risk for physical performance limitations. Treatment and follow-up care should include tailored interventions to mitigate these late effects in high-risk patients.

Renal tumours: long-term outcome

Childhood cancer is rare, with an incidence of 100 new cases per million children and with renal tumours contributing 7% of cases. The introduction of multimodality treatment, surgery, radiotherapy and chemotherapy, has led to an exponential increase in the 5-year survival rate to >80%. However, this successful treatment has led to the development of late adverse effects. These treatment-related effects can cause premature deaths and increased morbidity compared with patients' peers. Radiation causes damage to tissue and organs within the radiation field, affecting growth and function, and is largely responsible for the leading cause of death, namely, second malignant neoplasms. Another important late effect is cardiac dysfunction due to anthracycline use with or without cardiac radiation. In addition, a few patients have genetic abnormalities predisposing to Wilms tumour development, which result in renal dysfunction in the long term and may be exacerbated by cancer treatment regimens. Awareness of late consequences of cancer treatment is important, as early recognition can improve outcome. When presented with a patient with a history of renal tumours, it is vital to enquire about previous treatment to understand whether it is relevant to the presenting problem.

Health-related quality of life in long-term survivors of relapsed childhood acute lymphoblastic leukemia

BACKGROUND

Relapses occur in about 20% of children with acute lymphoblastic leukemia (ALL). Approximately one-third of these children can be cured. Their risk for late effects is high because of intensified treatment, but their health-related quality of life (HRQOL) was largely unmeasured. Our aim was to compare HRQOL of ALL survivors with the general population, and of relapsed with non-relapsed ALL survivors.

METHODOLOGY/PRINCIPAL FINDINGS

As part of the Swiss Childhood Cancer Survivor Study (SCCSS) we sent a questionnaire to all ALL survivors in Switzerland who had been diagnosed between 1976-2003 at age <16 years, survived ≥5 years, and were currently aged ≥16 years. HRQOL was assessed with the Short Form-36 (SF-36), which measures four aspects of physical health and four aspects of mental health. A score of 50 corresponded to the mean of a healthy reference population. We analyzed data from 457 ALL survivors (response: 79%). Sixty-one survivors had suffered a relapse. Compared to the general population, ALL survivors reported similar or higher HRQOL scores on all scales. Survivors with a relapse scored lower in general health perceptions (51.6) compared to those without (55.8;p=0.005), but after adjusting for self-reported late effects, this difference disappeared.

CONCLUSION/SIGNIFICANCE

Compared to population norms, ALL survivors reported good HRQOL, even after a relapse. However, relapsed ALL survivors reported poorer general health than non-relapsed. Therefore, we encourage specialists to screen for poor general health in survivors after a relapse and, when appropriate, specifically seek and treat underlying late effects. This will help to improve patients' HRQOL.

Does the Brief Symptom Inventory-18 case rule apply in adult survivors of childhood cancer? Comparison with the Symptom Checklist-90

OBJECTIVE

Screening for psychological distress is an important tool for improving survivors' access to psychosocial care. The Brief Symptom Inventory-18 (BSI-18) has been widely used to identify psychological distress in cancer survivors, but few studies have reported on its validity. This study evaluated validity of the BSI-18 by comparing it to the Symptom Checklist-90 (SCL-90).

METHODS

Concordance of cases identified by the BSI-18 and SCL-90 was examined in a sample of 193 adult survivors of childhood cancer.

RESULTS

Receiver operating characteristics analysis showed strong diagnostic utility of the BSI-18 (area under curve = 0.922). However, the standard BSI-18 case-rule demonstrated low sensitivity (45.2%) against the SCL-90. An alternative case-rule showed better results; sensitivity (87.10%), specificity (83.33%).

CONCLUSIONS

The BSI-18 is a useful measure for evaluating distress in adult survivors of childhood cancers; however, the standard BSI-18 case-rule has not been validated for this population, and an alternative case rule should be considered.

Long-term health outcomes in a British cohort of breast, colorectal and prostate cancer survivors: a database study

Background:

The community-based incidence of cancer treatment-related long-term consequences is uncertain. We sought to establish the burden of health outcomes that have been associated with treatment among British long-term cancer survivors.

Methods:

We identified 26 213 adults from the General Practice Research Database who have survived 5 years or more following breast, colorectal or prostate cancer. Four age-, sex- and general practice-matched non-cancer controls were selected for each survivor. We considered the incidence of treatment-associated health outcomes using Cox proportional hazards models.

Results:

Breast cancer survivors had an elevated incidence of heart failure (hazards ratio (HR) 1.95, 95% confidence interval (CI) 1.27–3.01), coronary artery disease (HR 1.27, 95% CI 1.11–1.44), hypothyroidism (HR 1.26, 95% CI 1.02–1.56) and osteoporosis (HR 1.26, 95% CI 1.13–1.40). Among colorectal cancer survivors, there was increased incidence of dementia (HR 1.68, 95% CI 1.20–2.35), diabetes (HR 1.39, 95% CI 1.12–1.72) and osteoporosis (HR 1.41, 95% CI 1.15–1.73). Prostate cancer survivors had the highest risk of osteoporosis (HR 2.49, 95% CI 1.93–3.22).

Conclusions:

The study confirms the occurrence of increased incidence of chronic illnesses in long-term cancer survivors attributable to underlying lifestyle and/or cancer treatments. Although the absolute risk of the majority of late effects in the cancer survivors cohort is low, identifying prior risk of osteoporosis by bone mineral density scanning for prostate survivors should be considered. There is an urgent need to improve primary care recording of cancer treatment.

Late effects in childhood cancer survivors: a review with a framing effect bias?

Most publications report the adverse (negative) health issues in childhood cancer survivors. Presenting information to the newly diagnosed patient in a positive manner is advocated, while noting that recurrence is the most likely adverse event. Re-analysis of population-based studies on life-threatening toxicities from Nordic, Dutch, United Kingdom, French, Italian, and N. American publications shows that 5-year survivors have a near normal life expectancy, 75% have no severe or life-threatening treatment related toxicity and 87% remain free of a second malignancy. Children who received radiation or anthracycline >250-300 mg/m(2) are at greatest risk for treatment related life-threatening toxicities.

Social outcomes and quality of life of childhood cancer survivors in Japan: a cross-sectional study on marriage, education, employment and health-related QOL (SF-36)

Social outcomes and quality of life (QOL) of childhood cancer survivors (CCSs) remain unknown in Japan. We investigated these outcomes in young adult CCSs compared to those of their siblings in Japan, and analyzed the association between social outcome and SF-36 health survey subscale scores. Between 2007 and 2009, we performed a cross-sectional survey using self-rating questionnaires. We estimated social outcomes and health-related QOL by performing the SF-36 in each group: CCSs with or without stem cell transplantation (SCT)/radiotherapy (RT) and their siblings. Adjusted odds ratios for outcomes of interest were estimated using logistic regression analysis. Questionnaires from 185 CCSs and 72 CCS's siblings were analyzed. There were no differences in educational attainment or annual income. The SF-36 subscale scores of CCSs with SCT and RT were significantly lower than those of siblings in physical functioning (PF) (p < 0.001 and 0.003, respectively) and general health (GH) (both p = 0.001). Lower PF scores correlated with recurrence (p = 0.041) and late effects (p = 0.010), and poor GH scores with late effects (p = 0.006). The CCSs had made efforts to attain educational/vocational goals; however, a significant proportion of CCSs who had experienced late effects remain at increased risk of experiencing diminished QOL.

A systematic review of studies on psychosocial late effects of childhood cancer: structures of society and methodological pitfalls may challenge the conclusions

High survival rates after childhood cancer raise attention to possible psychosocial late effects. We focus on predictors of psychosocial outcomes based on diagnosis, treatment, demography, somatic disease, and methodological problems. Overall, survivors evaluate their health-related quality of life to be normal or even better than controls, although virtually all diagnostic subgroups report psychosocial impairment. Central nervous system tumor survivors have significant psychosocial problems. Negative outcomes were associated with cranial radiation therapy, female gender, and young age at diagnosis. Significant methodological problems hamper current knowledge. Systematic registration of psychosocial and somatic problems at diagnosis and prospectively through protocols is needed.

Unemployment among adult survivors of childhood cancer: a report from the childhood cancer survivor study

BACKGROUND

Adult childhood cancer survivors report high levels of unemployment, although it is unknown whether this is because of health or employability limitations.

OBJECTIVES

We examined 2 employment outcomes from 2003 in the Childhood Cancer Survivor Study (CCSS): (1) health-related unemployment and (2) unemployed but seeking work. We compared survivors with a nearest-age CCSS sibling cohort and examined demographic and treatment-related risk groups for each outcome.

METHODS

We studied 6339 survivors and 1967 siblings ≥25 years of age excluding those unemployed by choice. Multivariable generalized linear models evaluated whether survivors were more likely to be unemployed than siblings and whether certain survivors were at a higher risk for unemployment.

RESULTS

Survivors (10.4%) reported health-related unemployment more often than siblings (1.8%; Relative Risk [RR], 6.07; 95% Confidence Interval [CI], 4.32-8.53). Survivors (5.7%) were more likely to report being unemployed but seeking work than siblings (2.7%; RR, 1.90; 95% CI, 1.43-2.54). Health-related unemployment was more common in female survivors than males (Odds Ratio [OR], 1.73; 95% CI, 1.43-2.08). Cranial radiotherapy doses ≥25 Gy were associated with higher odds of unemployment (health-related: OR, 3.47; 95% CI, 2.54-4.74; seeking work: OR, 1.77; 95% CI, 1.15-2.71). Unemployed survivors reported higher levels of poor physical functioning than employed survivors, and had lower education and income and were more likely to be publicly insured than unemployed siblings.

CONCLUSIONS

Childhood cancer survivors have higher levels of unemployment because of health or being between jobs. High-risk survivors may need vocational assistance.

Burden of illness in adult survivors of childhood cancers: findings from a population-based national sample

BACKGROUND

The number of adult survivors of childhood cancer in the United States is increasing because of effective treatments and improved survival. The purpose of this study was to use a national, population-based sample to estimate the burden of illness in adult survivors of childhood cancer.

METHODS

A total of 410 adult survivors of childhood cancer and 294,641 individuals without cancer were identified from multiple years of the National Health Interview Survey. Multiple measures of burden, general health, and lost productivity were compared using multivariate regression analyses including: logistic, polytomous logit, proportional odds, and linear models.

RESULTS

Controlling for the effects of age, sex, race/ethnicity, and survey year, adult survivors of childhood cancer reported poorer outcomes across the majority of general health measures and productivity measures than individuals without cancer. Survivors were more likely to report their health status as fair or poor (24.3% vs 10.9%; P<.001); having any health limitation in any way (12.9% vs 3.4%; P<.001); being unable to work because of health problems (20.9% vs 6.3%; P<.001); and being limited in the amount/kind of work because of health problems (30.9% vs 10.6%; P<.001). When categorized by time since diagnosis, cancer survivors had poor health outcomes in every time interval, with the greatest limitations in the initial 4 years after diagnosis and 30 or more years after diagnosis.

CONCLUSIONS

Across multiple measures, adult survivors of childhood cancers have poorer health outcomes and more health limitations than similar individuals without cancer.

Cancer related factors do not explain the quality of life scores for childhood cancer survivors analysed with two different generic HRQL instruments

THE AIMS

The aims of this Finnish total cohort survey were to compare the health related quality of life (HRQL) of childhood cancer survivors with for age, gender and place of residence matched controls, to analyse whether the disease-related factors do explain the survivors scores, and to evaluate the similarity of HRQL scores gained with two different generic instruments.

METHODS

Questionnaires (SF-36 version 2 and the 15D) were mailed to 468 survivors and their controls.

RESULTS

A total of 271 survivors and 329 controls replied. The survivors rated with both instruments their HRQL in most areas as high or higher than their controls. Mobility score was, however, significantly lower for survivors than controls. Females rated their HRQL lower than respective males. Self-rated happiness had the highest effect in explaining the variation of 15D and mental component summary (MCS) scores. Survivors treated for osteosarcoma or with stem cell transplantation (SCT) rated their physical HRQL significantly lower than the others. SCT treatment indicated significantly lower MCS scores than the reference treatment. Correlation between the physical component summary (PCS) scores and 15D total scores was low (R=0.20-0.28). MCS and 15D total scores correlated (R=0.48-0.60) better with each other, but the gained correlation coefficients still differed significantly from each other (p=0.04) and showed better correlation in the controls.

CONCLUSIONS

Our findings suggest, that the diagnosis of osteosarcoma, and SCT treatment are substantial risks for adverse HRQL. However, disease related factors did not remarkably explain the variation of HRQL scores gained with generic HRQL instruments. Our findings suggest, that the diagnosis of osteosarcoma, and SCT treatment are substantial risks for adverse HRQL. More evaluation is needed in order to decide whether any of the available generic instruments are feasible for studying HRQL for this special population.

Long-term survivors of childhood cancer report quality of life and health status in parity with a comparison group

BACKGROUND

There is a need for more knowledge about how survivors of childhood cancer perceive their lives and what influence current health status has on their quality of life. The purpose was to describe this among a group of long-term survivors and among a comparison group.

PROCEDURE

Telephone interviews were performed with a cohort of 246 long-term survivors and 296 randomly selected from the general population using the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW). The participants nominated the areas they considered to be most important in life and rated the current status of each area on a seven-point category scale. An overall individual index score was calculated as a measure of quality of life. Self-reported health status was assessed using the Short Form Health Survey (SF-36).

RESULTS

Long-term survivors rated their overall quality of life and self-reported health status almost in parity with the comparison group. In both groups, family life, relations to other people, work and career, interests and leisure activities were the areas most frequently reported to influence quality of life. The survivors only differed from the comparison group on one of eight SF-36 scales reflecting problems with daily activities owing to physical health.

CONCLUSIONS

Health status was not shown to have a major impact on overall quality of life, indicating that health and quality of life should be evaluated distinctively as different constructs. This should be taken in consideration in clinical care of children with childhood cancer and long-term survivors.

Quality of life in young patients after bone tumor surgery around the knee joint and comparison with healthy controls

BACKGROUND

This study aimed to compare the health related quality of life (HRQoL) of children and adolescents after malignant bone tumor surgery of the leg with healthy controls.

PROCEDURE

Patients between 8 and 25 years old were cross-sectional recruited. Patients under 16 years of age received the TNO (Netherlands Organization for Applied Scientific Research) and AZL (Leiden University Medical Center) Children's Quality of Life Questionnaire (TACQOL), patients aged 16 years and older received the TNO-AZL Questionnaire for Adult's Quality of Life (TAAQOL) and the Short Form-36 (SF-36). Three age- and sex-matched normative random samples, drawn from large, nationwide studies, were used for the comparison with healthy controls. Patients were interviewed regarding their most important problems related to the disease and its treatment.

RESULTS

Eighty-one patients with a mean age of 16.9 years (SD 4.2) were included (41 female). Limb sparing surgery was executed in 38 patients, ablative surgery in 43 patients. In comparison with healthy controls, patients had significantly poorer HRQoL within the domains autonomy and motor function of the TACQOL, gross motor function, cognitive functioning, daily functioning and sexuality of the TAAQOL, and physical functioning, role physical, general health, and the physical and mental component summary scales of the SF-36. Patients reported limitations in physical activities, participation in sports, and cosmetic aspects as the most detrimental consequences of their disease and its treatment.

CONCLUSION

In children and adolescents who underwent surgery for a malignant tumor of the leg physical, functioning was significantly impaired as compared to healthy controls.

Posttraumatic stress, depression and anxiety among adult long-term survivors of cancer in adolescence

BACKGROUND

To determine the prevalence of posttraumatic stress, depression and anxiety in adults who have survived cancer (5 years) diagnosed in adolescence, as compared to healthy controls.

PATIENTS AND METHODS

Survivors (n=820) of cancer during adolescence (age M=30.4+/-6.0 years; M=13.7+/-6.0 years since diagnosis) and 1027 matched controls without history of cancer (age M=31.5+/-6.9 years) completed standardised questionnaires measuring posttraumatic stress, depression and anxiety. Additionally, sub-groups of 202 survivors and 140 controls with elevated scores received structured interviews to ascertain DSM-IV-diagnoses.

RESULTS

A total of 22.4% of the survivors reported clinically relevant symptoms of posttraumatic stress, anxiety and/or depression compared to 14.0% of the controls (odds ratios [ORs] 1.77; 95% confidence interval [CI] 1.39-2.26). The odds of posttraumatic stress symptoms in male (OR 3.92, 95% CI 1.80-8.51) and female (OR 3.83, 95% CI 2.54-5.76) survivors were more than three times those in the controls. However, only female survivors reported symptoms of depression and anxiety significantly more often (respectively: OR 2.12, 95% CI 1.16-3.85; and OR 1.86, 95% CI 1.33-2.59) than the controls. A relevant subgroup of 24.3% of the survivors met DSM-IV criteria for at least one mental disorder compared to 15.3% of the controls.

CONCLUSION

Survivors of cancer during adolescence show an elevated risk of presenting symptoms of posttraumatic stress, anxiety and/or depression during adulthood which is also reflected in a greater number of DSM-IV diagnoses when compared to controls. Comprehensive follow-up assessments should include the examination of possible psychological late effects of a cancer diagnosis in adolescence in order to identify survivors needing psychosocial interventions even years after the completion of successful medical treatment.

Transitioning Survivors of Central Nervous System Tumors: Challenges for Patients, Families, and Health Care Providers

Survivors of central nervous system tumors (SCNST) are a growing group of cancer survivors who require risk-based, long-term health care due to the chemotherapy, surgery, and radiation they have received.Although treatment strategies are being developed to reduce morbidity and mortality, ultimately this subgroup of pediatric cancer survivors often faces moderate to severe late effects of their treatment.As a result, they will need lifelong health care that includes risk-based health care due to cancer treatment exposures as well as primary adult health care, including primary and secondary preventative care. The best way to accomplish lifelong health care for SCNST as they enter adulthood is not clearly defined. In this article, the authors plan to (1) present an overview of the complexities of health care problems that make transition challenging for SCNST; (2) review the evolving transition literature; (3) explore the barriers to successful transition; (4) discuss methods to facilitate transition; (5) describe approaches, strategies, and models for survivorship care in SCNST; (6) present issues for consideration when transitioning SCNST; and (7) provide information on transition-related resources.

Comprehensive clinical follow-up of late effects in childhood cancer survivors shows the need for early and well-timed intervention

BACKGROUND

Due to recent advances in treatment, nearly 80% of childhood cancer patients become long-term survivors. Studies on the late effects of survivors are under way worldwide. However, data on Asian survivors remain limited.

METHODS

Data on 241 survivors at the Long-term Follow-up Clinic in Severance Hospital, South Korea, were collected and late effects were confirmed by oncologists.

RESULTS

The median follow-up from diagnosis was 7.8 years. Late effects were identified in 59.8% of survivors and 23.2% had two or more late effects. Grade 3 or higher late effects were present in 10.8%. The most common late effects involved endocrine system (29.0%). Late effects were present in 95.7% of brain tumor survivors and 36.0% of Wilms' tumor survivors. Chemotherapy, hematopoietic stem-cell transplantation and radiotherapy were significant factors associated with the number and severity of late effects (P < 0.05). Brain tumor survivors had more severe late effects (P < 0.001), whereas Wilms' tumor survivors had fewer and milder late effects (P < 0.05).

CONCLUSION

The observation that over 50% of cancer survivors suffered from late effects during the short follow-up period and that a high frequency of endocrine late effects was present indicates the need for early and well-timed intervention of the survivors.

Economic evaluation and health-related quality of life

Health-related quality of life (HRQL) is concerned with the opportunities that a person's health status affords, the constraints that it places upon the person and the value that a person places on his or her health status. The rationale for measuring HRQL falls into three categories: discrimination, evaluation, and prediction. Measures have to meet generally accepted psychometric criteria such as acceptability, reliability/reproducibility, responsiveness, validity, interpretability, and usefulness. HRQL instruments have been designed for self-administration or administration by interviews and some have been adapted to multiple cultural/linguistic needs. For adolescents and young adults with cancer several instruments are available. Overall HRQL is compromised, to varying degrees, in such survivors by comparison with peers in the general population; and the burden of morbidity is greatest after brain and bone tumors. As there is a burden of treatment-related morbidity and as the number of survivors within the health care system is growing, the economic dimension of care and cure has to be taken into consideration. Economic evaluation affords a comparison of the costs and consequences (effects) of relevant therapeutic alternatives. The future research activities with respect to HRQL have to consider these new dimensions of care.

The British Childhood Cancer Survivor Study: Objectives, methods, population structure, response rates and initial descriptive information

BACKGROUND

In Britain 75% of individuals diagnosed with childhood cancer survive at least 5 years. The British Childhood Cancer Survivor Study was established to determine the risks of adverse health and social outcomes among survivors. To be eligible individuals were diagnosed with childhood cancer in Britain between 1940 and 1991 and survived at least 5 years. The entire cohort of 17,981 form the basis of population-based studies of late mortality and the risks/causes of second malignant neoplasms using national registration systems.

METHODS

A postal questionnaire was sent to survivors who were alive and aged at least 16 years via their primary care physician.

RESULTS

Of the 14,836 survivors eligible to receive a questionnaire, 10,483 (71%) returned it completed. Of the 13,211 who were mailed a questionnaire by their primary care physician 10,483 (79%) returned it completed. Outline treatment information concerning initial radiotherapy, chemotherapy and surgery is available.

CONCLUSIONS

This is the largest available population-based cohort of childhood cancer survivors to have included investigation of a wide spectrum of adverse outcomes (the risk of which might be increased as a result of childhood cancer or its treatment). The study should provide useful information for counselling survivors, planning long-term clinical follow-up and evaluating the long-term risks likely to be associated with proposed treatment strategies.

Health status and quality of life in long-term survivors of childhood leukaemia: the impact of haematopoietic stem cell transplantation

We compared late side effects and quality of life (QoL) in 430 survivors of childhood acute leukaemia based on whether they had undergone haematopoietic cell transplantation (n=142) or not (n=288). Mean age was 18.2 years and mean follow-up duration was 11.9 years. Multivariate logistic regression analyses were performed to compare the risk of each type of late effect in the two groups. Based on age, VSP-A or SF36 questionnaires were used to assess QoL. For each QoL dimension, multiple linear regression was done to construct models of association with the treatment group. Transplanted patients experienced more side effects, including height growth failure, gonadal dysfunction, hypothyroidism and cataract. Children and adolescents in the two treatment groups reported similar QoL levels for almost all dimensions except a better perception of school work by young transplanted children and more difficulties in relating to the medical staff for transplanted adolescents. In adults, two differences in physical domain of QoL were detected but the calculated effect sizes were less than 0.2 in each case, suggesting an uncertain clinical significance. In spite of a higher risk of physical adverse events in the transplanted group, very few clinically significant differences in QoL are detectable.