Multi-component behavioral intervention to promote health protective behaviors in childhood cancer survivors: the protect study

Efficacy of the Survivor Health and Resilience Education (SHARE) program to improve bone health behaviors among adolescent survivors of childhood cancer

PURPOSE

The purpose of this study is to test the efficacy of the Survivor Health and Resilience Education Program intervention--a manualized, behavioral intervention focusing on bone health behaviors among adolescent survivors of childhood cancer.

METHODS

Participants were 75 teens aged 11-21 years, one or more years post-treatment, and currently cancer-free. Teens were randomized to a group-based intervention focusing on bone health or a wait-list control. Bone health behaviors were assessed at baseline and 1-month post-intervention.

RESULTS

Controlling for baseline outcome measures and theoretical predictors, milk consumption frequency (p=0.03), past month calcium supplementation (p<0.001), days in the past month with calcium supplementation (p<0.001), and dietary calcium intake (p=0.04) were significantly greater at 1-month follow-up among intervention participants compared with control participants.

CONCLUSIONS

The intervention had a significant short-term impact on self-reported bone health behaviors among adolescent survivors of childhood cancer. Research examining long-term intervention effectiveness is warranted.

Adolescents, young adults, and cancer--the international challenge

Cancer in adolescents and young adults is an important public health issue, because there are approximately 1 million new cases annually. The distribution of diseases in this age group varies geographically, contributing to differences in survival rates. Although an overall survival rate exceeding 80 % has been reported in optimal circumstances, emerging knowledge about distinctions in tumor biology and enhanced clinical accrual to clinical trials should lead to further gains. The challenges of cancer survivorship demand further attention with a particular focus on the quality of life of survivors and amelioration of the long-term complications of treatment. Programs in cancer screening and prevention provide potential for considerable benefits in this age group. A renewed perspective on the adolescent and young adult cohort is required; and, in all of these opportunities for change, there are important roles to be played by advocacy groups internationally.

Increasing rates of breast cancer and cardiac surveillance among high-risk survivors of childhood Hodgkin lymphoma following a mailed, one-page survivorship care plan

BACKGROUND

Hodgkin lymphoma (HL) survivors face substantially elevated risks of breast cancer and cardiovascular disease. They and their physicians are often unaware of these risks and surveillance recommendations.

PROCEDURE

A prospective one-arm study was conducted among a random sample of 72 HL survivors, ages 27-55 years, participating in the Childhood Cancer Survivor Study (CCSS) who were at increased risk for breast cancer and/or cardiomyopathy and had not had a screening mammogram or echocardiogram, respectively, within the prior 2 years. A one-page survivorship care plan with recommendations for surveillance was mailed to participants. In addition, survivors' primary physicians were contacted and provided patient-specific information and a web-based Virtual Information Center was made available for both survivors and physicians. Outcomes were assessed by telephone 6 months after the intervention.

RESULTS

The survivor participation (62/72; 86%) and 6-month retention (56/61; 92%) rates were high. Tension and anxiety, measured by the Profile of Mood States, did not increase following risk notification; 91% of survivors described their reactions to receiving the information in positive terms. At 6 months, 41% of survivors reported having completed the recommended mammogram; 20% reported having an echocardiogram (females 30%, males 10%). Only 29% of survivors visited the website. Nine physicians enrolled, and none used the study resources.

CONCLUSION

A mailed, personalized survivorship care plan was effective in communicating risk and increasing compliance with recommended medical surveillance. Internet- and telephone-based strategies to communicate risk were not utilized by survivors or physicians.

Improving short-term sun safety practices among adolescent survivors of childhood cancer: a randomized controlled efficacy trial

INTRODUCTION

Skin cancer is one of the most common secondary neoplasms among childhood cancer survivors. However, little evidence exists for effective interventions to promote sun safety behaviors within this population.

METHODS

This small-scale randomized controlled trial examined the efficacy of the Survivor Health and Resilience Education (SHARE) Program intervention, a multiple health behavior change intervention designed to increase sun safety practices among adolescent survivors of childhood cancer. Adolescent survivors of childhood cancer (11-21 years) were randomly allocated to a group-based behavioral intervention (n  =  38) or wait-list control (n  =  37). Self-reported sun safety behaviors were assessed using a valid, 8-item scale at baseline and 1-month post-intervention.

RESULTS

Controlling for baseline sun safety, gender, and seasonal influences, intervention participants reported significantly more sun safety practices (e.g., using sunscreen, reapplying sunscreen regularly) at 1-month post-intervention than control participants (B  =  2.64, 95% CI  =  1.02, 4.27, p  =  0.002).

CONCLUSIONS

The results suggest that SHARE was efficacious in producing improvements in short-term self-reported sun safety practices among adolescent survivors of childhood cancer. Future research is needed to build upon this work by incorporating objective measures of sun safety behaviors and examining intervention durability.

IMPLICATIONS FOR CANCER SURVIVORS

Behavioral interventions addressing lifestyle factors, including sun safety behaviors, among adolescent survivors of childhood cancer should be integrated into long-term care to reduce the risk for secondary malignancies and diseases.

Evaluation of a survivorship educational program for adolescent and young adult survivors of childhood cancer

Educational programs to address specific needs of adolescent and young adult (AYA) childhood cancer survivors are scarce. A quarterly speaker series and 1-day conference involved presentations by oncology experts to increase knowledge of AYA cancer survivorship issues and awareness of community programs and resources. Pre- and post-evaluations were administered to determine the program's efficacy. Most rated program satisfaction as "moderately high" to "high" and having met expectations. Self-report ratings indicated a significant increase in perceived knowledge of survivorship topics and resource awareness for AYA childhood cancer survivors and caregivers. Nearly one third attended more than one presentation, indicating that the educational program was beneficial to them. This program was effective in increasing self-reported survivorship education for AYA survivors of childhood cancer, families, and health care providers.

Diet and physical activity in childhood cancer survivors: a review of the literature

Treatment advances have led to a growing population of childhood cancer survivors. Many are at risk for developing treatment-related late effects. Diet and physical activity may affect levels of health risk. A number of papers have examined these behaviors in childhood cancer survivors. The purpose of this study was to provide a review and summary of the published studies in the areas of diet, physical activity, and related interventions among childhood cancer survivors. A systematic search was conducted for studies published prior to October 2009. Descriptive and intervention studies that included survivors of childhood cancers and a measurement of diet and/or physical activity were reviewed. Twenty-six manuscripts met criteria: ten addressed diet; 20 addressed physical activity, and six included intervention studies. Results suggest that childhood cancer survivors engage in health-promoting activities at rates comparable to the general population. Behavioral interventions have mostly targeted physical activity. Results, overall, are not encouraging, due primarily to difficulties recruiting and retaining participants. Although more rigorous studies are needed, recommendations for health-promoting behaviors should be a regular topic of discussion between health care providers and their childhood cancer survivor patients.

Design and recruitment of the Chicago Healthy Living Study: a study of health behaviors in a diverse cohort of adult childhood cancer survivors

BACKGROUND

Adult childhood cancer survivors are at higher risk for developing late medical effects related to their cancer treatments. Health-promoting behaviors may reduce the risk of some late effects and the severity of others. This article describes the design and recruitment of the Chicago Healthy Living Study (CHLS), an on-going study designed to examine the health behaviors and body mass index of minority adult childhood cancer survivors compared with nonminority survivors and noncancer controls.

METHODS

Survivors are identified by the hospital cancer registries at 5 treating institutions in the Chicago area; then, a multilevel recruitment plan will be implemented with the objective of enrolling 450 adult survivors of childhood cancer (150 in each racial/ethnic group). Simultaneously, 375 adult African-American, Hispanic, and non-Hispanic white noncancer controls (125 in each racial/ethnic group) living in the Chicago area will be recruited by using listed, targeted digit dialing. All participants will complete a 2-hour interview of questionnaires related to diet, physical activity, smoking, and associated mediators. Height and weight also will be measured.

CONCLUSIONS

The CHLS will provide important information on the health behaviors of adult minority childhood cancer survivors that can be used to inform the development of interventions to improve modifiable risks.

Bilateral breast cancer in a survivor of acute lymphoblastic leukemia: a case report

Although breast cancer is the most common disease for women, bilateral breast cancer is a rare situation. Development of a second malignancy which is the most frightening side effect, may be related with genetic predisposition or cancer treatment. Because our case is a survivor of acute lymphoblastic leukemia, development of bilateral breast cancer which occurs rarely in early ages, is discussed with the help of literature.

Smoking cessation interventions in cancer care: opportunities for oncology nurses and nurse scientists

Smoking cessation is essential after the diagnosis of cancer to improve clinical outcomes. The purpose of this chapter is to provide a systematic review of research on smoking cessation in the context of cancer care with an emphasis on nursing contributions to the field. Data sources included research reports of smoking cessation interventions conducted in people with cancer. Nineteen primary studies were reviewed. High intensity interventions, targeting multiple behaviors, and/or using a multicomponent intervention that included pharmacotherapy, behavioral counseling, and social support were characteristics of the most successful treatments for tobacco dependence. The majority of interventions were conducted in adults with smoking-related malignancies during acute phases of illness. The most striking finding was that more than one half of the studies tested the efficacy of nurse-delivered interventions. Conceptual and methodological issues that can be improved in future studies include: using theoretical frameworks to specify how the intervention will affect outcomes, ensuring adequate sample sizes, using biochemical verification to monitor smoking outcomes, and using standardized outcome measures of abstinence. Although effective interventions are available for healthy populations, further research is needed to determine if tailored cessation interventions are needed for patients with cancer. To provide optimal quality care it is imperative that delivery of evidence-based smoking cessation interventions be integrated into the cancer treatment trajectory. Multiple barriers, including patient and nurse attitudes toward smoking and lack of knowledge related to tobacco treatment, prevent translating evidence-based tobacco dependence treatment into clinical practice. Further nursing research is needed to address these barriers.

Prevalence of multiple health-related behaviors in adolescents with cancer

OBJECTIVE

This preliminary study investigated prevalence rates of multiple health-related behaviors (ie, tobacco, alcohol, and other drug use; sexual risk-taking; nutrition/physical activity; overweight and dietary behaviors; sun safety) among 42 adolescents on active treatment for cancer, as compared with healthy adolescent norms.

METHODS

Health-related behaviors were assessed using the 2005 National Youth Risk Behavior Survey, for which healthy adolescent norms were publicly available.

RESULTS

Adolescents with cancer reported significantly lower current and lifetime rates of tobacco, alcohol, and other drug use; fruit/vegetable consumption; physical activity; and dietary behavior, in addition to lower rates of lifetime sexual intercourse, early-onset sexual intercourse, and alcohol/drug use before last sexual intercourse, compared with healthy peers. Among those who have previously engaged in sexual intercourse, there appeared to be a trend toward increased partners, current sexual activity, and lack of protection at last episode of sexual intercourse. Adolescents with cancer also reported significantly higher rates of television watching compared with healthy peers.

CONCLUSIONS

Adolescents on active treatment for cancer are engaging in multiple health-risk behaviors, including sedentary behavior, poor nutrition, lack of sun safety, and sexual risk-taking (eg, multiple partners, lack of protection at last sexual intercourse). Health promotion interventions are needed during active treatment to facilitate the acquisition of good health practices as adolescents transition into survivorship.

Cancer screening practices of adult survivors of retinoblastoma at risk of second cancers

BACKGROUND

The aim of the current study was to investigate the pattern of cancer screening behavior in adult retinoblastoma survivors, who are at high risk of developing second cancers.

METHODS

Self-reported cancer screening practices were investigated in a cohort of retinoblastoma survivors to evaluate whether they were receiving adequate screening for specific cancers and compare these rates with those of other adult survivors of childhood cancer and the general population. The prevalence of breast self-examination, clinical breast examination, mammography, Papanicolaou (Pap) test, testicular self-examination, and magnetic resonance imaging (MRI) or computed tomography (CT) scanning was determined from computer-aided telephone interviews with 836 retinoblastoma survivors aged >18 years.

RESULTS

Among female survivors, 87% had a Pap test within the past 2 years, and 76% of females age >40 years reported having a mammogram within the past 2 years; 17.4% of male survivors had performed monthly testicular self-examinations. A significantly higher proportion of hereditary compared with nonhereditary survivors reported having undergone an MRI or CT scan in the past 5 years. Higher education, greater contact with the medical care system, and having a second cancer were found to be associated positively with most screening practices. Cancer screening practices reported by retinoblastoma survivors were similar to national screening rates for breast, cervical, and testicular cancer.

CONCLUSIONS

To the authors' knowledge, the current study provides the first report of cancer screening practices of retinoblastoma survivors. Survivors of hereditary retinoblastoma should be encouraged to maintain, if not increase, their current screening practices to ensure early detection of second cancers in this high-risk population.

Education and health promotion in adolescent and young adult cancer survivors

The increasing numbers of long-term adolescent and young adult cancer survivors and their well-established risk of cancer-related morbidity strongly support the need for effective health promotion programs that motivate and sustain positive lifestyle changes. To date, the priority of these initiatives has been relatively low as only a handful of studies have been organized that prospectively evaluate lifestyle interventions and health education curricula with these aims. To effectively integrate lifestyle interventions into pediatric oncology care, prioritization and funding of health promotion research efforts must be comparable to that of disease control in frontline cancer trials.

Promoting healthy development among survivors of adolescent cancer

Cancer-surviving adolescents face significant health challenges including both physical and psychological late effects as they transition to young adulthood. A cancer diagnosis during adolescence, a time of social independence and increased personal decision making, can cause significant social and emotional struggles that may impair the ability of the adolescent to make health-promoting decisions and avoid risky behaviors such as substance use. This article reports on the little studied experiences of adolescents who have survived cancer with a focus on developing programs and policies that address their health-promotion needs in both community and survivorship clinics.

Health-risk behaviors and health promotion in adolescent and young adult cancer survivors

A diagnosis of cancer during adolescence, a period characterized by experimentation and risk-taking behaviors, has the potential to derail critical developmental tasks required for successful transition into adulthood. Health professionals caring for adolescents and young adults have an opportunity to influence behavioral practices by correcting knowledge deficits, addressing factors that enhance the survivor's sense of vulnerability to health problems, and providing personalized health counseling that encourages the practice of health promoting behaviors. The approach to health counseling in childhood cancer survivors should consider their unique educational needs related to their cancer experience. Previous investigations of adolescent and young adult survivor health behavior indicate that survivors perceive themselves as more vulnerable to health problems than their peers without cancer and recognize a need to protect their health. However, these perceptions of health vulnerability do not always correlate with health promoting behavioral practices, suggesting that factors other than health perceptions should be investigated to motivate behavioral change. Very few studies have been undertaken to prospectively evaluate the effectiveness of health promotion programs in adolescent and young adult survivors of cancer. The scarcity of knowledge in the issue of health promotion after childhood cancer underscores the need for more research to define 1) the optimal timing of health counseling; 2) the influence of developmental status and neurocognitive function; 3) the most effective methods and venues for health education; 4) the feasibility and cost-effectiveness of health promotion strategies; and 5) psychosocial and economic impediments to practice of healthy behaviors.

Health behaviours in childhood cancer survivors: a systematic review

AIM

To review (1) prevalence and predictors of risk behaviours especially smoking and (2) values of interventions to reduce risk behaviours in childhood cancer survivors.

METHOD

A systematic search of four databases (OVID Medline (1966 to May week 2, 2006), CINAHL, EMBASE, and Pubmed (US Library of Medicine and National Institute of Health)) for articles published between January 1990 and May 2006.

RESULTS

Twenty-three eligible articles. Incidence of risk behaviours are comparable with, or lower than the general population and controls. Socio-demographic (age, socio-economic status, diagnosis, ethnic group) and psychological variables (perceived vulnerability) predict risk behaviour. Improved knowledge and awareness of vulnerability have been found after interventions, but no changes in health behaviours.

CONCLUSION

This review illustrates an optimistic picture of low participation in substance use amongst survivors, although based mainly on smoking. However, smoking might not be the major problem for survivors and attention must also be directed to other health behaviours including exercise and healthy diet.

Multiple behavioral risk factors among adolescent survivors of childhood cancer in the Survivor Health and Resilience Education (SHARE) program

BACKGROUND

Health-compromising behaviors among survivors of childhood cancer may increase their risks of cancer recurrence and the onset of chronic disease in adulthood. Regardless of whether such behaviors occur singly or in combination with one another, multiple behavioral risk factors must be identified and addressed early to promote better health outcomes within this special population. Adolescent survivors may be especially vulnerable, as reported rates of smoking and other risky behaviors are at or near levels of their healthy peers. The psychological literature suggests stress may play a role in risk behavior initiation and maintenance, including multiple behavioral risks, and that adolescent survivors are stress-prone. This report focuses on the prevalence and co-occurrence of three behavioral risk factors (cigarette use, insufficient physical activity, and non-adherence to sun protection recommendations) and describes stress-health behavior relationships in this special population.

PROCEDURE

All patients in this study (n = 75) were adolescent survivors of childhood cancer and completed a baseline assessment of their health behaviors and stress as part of a randomized controlled trial of health promotion.

RESULTS

Twenty-eight percent of the patients reported one of three risk factors, 12% reported two of three risk factors, and 7% reported all three risk factors. Non-adherence to sun protection was the single most common risk factor; physical inactivity and non-adherent sun protection were the most common co-occurring risk factors. Greater age and stress were significantly associated with the presence of more behavioral risk factors.

CONCLUSIONS

The evidence suggests interventions to reduce multiple health-compromising behaviors in these patients are warranted, and that efforts to address these patients' personal and family stress levels are important as well.

Medical follow-up visits in adults 5-25 years after treatment for childhood acute leukaemia, lymphoma or Wilms' tumour

AIM

One aspect of organizing medical follow-up for adult survivors of childhood cancer is to determine to what extent the former patient experiences a need for health services. In the present paper, we studied how the healthcare needs, both subjectively and objectively, were fulfilled for our former patients.

METHODS

335 survivors over 18 y of age, with a follow-up time of more than 5 y after completion of therapy, were sent a questionnaire probing their present use of health services.

RESULTS

The response rate was 73%. A majority (60%) of the survivors had no regular follow-up visits, and 42% of these reported that they missed not having one. More than one third were thus far dissatisfied with the follow-up programme. Only 3% of those who had regular follow-ups found them "unnecessary". Complaints subjectively related to their diseases or treatments were reported by 47%. Out of all responders, 34% did not miss having regular follow-up visits. Neither perceived disease-related complaints nor radiation therapy was a predictor for having a scheduled follow-up visit.

CONCLUSION

In the absence of a long-term follow-up programme, many survivors were not receiving proper medical healthcare, whether from their perspective or from a professional one.

Smoking rates and the state of smoking interventions for children and adolescents with chronic illness

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

A process evaluation of a telephone-based peer-delivered smoking cessation intervention for adult survivors of childhood cancer: the partnership for health study

OBJECTIVE

We report on the process evaluation of an efficacious national smoking cessation intervention for adult survivors of childhood cancer. We examine associations between intervention implementation characteristics and study outcomes, as well as participant characteristics related to level of involvement in the intervention.

METHODS

The study was conducted at the Dana-Farber Cancer Institute in Boston, Massachusetts, from 1999-2001. Participants (n = 398) were randomly assigned to receive a proactive telephone-based peer counseling intervention. They received up to 6 counseling calls, individually tailored and survivor-targeted materials, and nicotine replacement therapy (NRT) patches if they were prepared to quit smoking.

RESULTS

Forty-two percent of survivors participated in the maximum number of calls (5-6), and 29% of participants requested and received NRT. Total counseling time was an average of 51 min. Quit status at follow-up was related to intervention dose, and participants who received NRT were significantly more likely to make a 24-h quit attempt. Demographic variables (females, White), higher daily smoking rate, poorer perceived health and moderate perceived risk of smoking were significantly related to greater intervention involvement.

CONCLUSIONS

A brief peer-delivered, telephone counseling intervention is an effective way to intervene with adult survivors of childhood cancer who are smoking. Findings from the process evaluation data (call length and number, frequency, and spacing) will inform future telephone counseling cessation programs.

Health status and health-related quality of life in adolescent survivors of cancer in childhood

PURPOSE

Adolescent survivors of cancer in childhood face particular challenges due to their maturational trajectory, including psychosocial adjustments, self-help skills, intellectual functioning and socialization. To better understand these, we assessed the health status and health-related quality of life (HRQL) in a 20-year cohort of such survivors in a single institution.

METHODS

Health status and HRQL were measured with a self-complete questionnaire from the Health Utilities Index (HUI) family of multi-attribute, preference-based instruments that provide utility scores for single attributes and overall HRQL.

RESULTS

Eighty-four (42 males, 42 females) of 129 eligible subjects (65%) participated. More than 80% of the respondents reported some form of morbidity. Overall HRQL utility scores were lower for both the males and females than for corresponding members of the Canadian general population. Female survivors self-reported a significantly greater burden of morbidity (mean overall HUI2/HUI3 scores: .83/.73 vs. .90/.84 for males, p < .02), which was most evident in the attributes of emotion and cognition.

CONCLUSIONS

The majority of adolescent survivors of cancer in childhood carry a morbidity burden into their teen and young adult years. These findings may guide the support required by this population.

Barriers to follow-up care of survivors in the United States and the United Kingdom

Survivors of pediatric cancer face an increased risk of morbidity, mortality, and diminished quality of life associated with their previous cancer therapy. Because these risks are often modifiable, periodic lifetime medical follow-up is recommended for all survivors. This article assesses the current status of follow-up care in the United States and the United Kingdom. Potential barriers in both cultures and health care environments are described. A better understanding of these barriers has led to the development and testing of interventions intended to optimize the health care of survivors.

Monitoring child and parent refusals to enrol in clinical research protocols

AIMS

The aim of this paper is to report the rates and reasons for refusal given by 817 eligible participants from 10 completed and ongoing nursing and behavioural medicine studies in paediatric oncology from 1994 to 2004.

BACKGROUND

Eligible participants have the right to accept or decline participation in research studies. Information about rates of refusal and reasons for refusal could be useful in determining participant-perceived burden related to study participation, in accurately estimating the time needed to accrue an adequate number of participants to achieve the study aims, and in interpreting study findings from certain groups of participants.

METHODS

A 13-item survey form about study characteristics was completed prospectively for each study included in this report; categories of reasons for refusal were inductively identified and defined using a semantic content analytic technique.

RESULTS

The overall rate of refusal was 23.6% (range: 6.7-46.7%). The studies that involved blood sampling or end-of-life decision-making had the highest refusal rates and an instrumentation study had the lowest. Eligible male participants had consistently higher rates of refusal than did females across the 10 studies. Nine categories of refusal were inductively identified, with the most commonly reported reason being the burden of the research methods.

CONCLUSION

A careful informed consent process will still result in some refusals. The refusal rates reported here can be used to help future researchers more accurately estimate accrual periods for studies involving blood sampling or investigating sensitive topics in paediatric oncology.

Long-term follow-up of pediatric cancer survivors: education, surveillance, and screening

Cancer and its treatment predispose childhood cancer survivors to chronic or late occurring health problems that may not become clinically significant until many years after therapy. Frequently, long-term survivors of childhood cancer report late cancer-related effects that diminish quality of life and increase the risk of early mortality. Risk-based health care that involves a personalized plan for surveillance, screening, and prevention is recommended to reduce cancer-related morbidity in childhood cancer survivors. To implement optimal risk-based care, the survivor and health care provider must have accurate information about cancer diagnosis, treatment modalities, and potential cancer-related health risks to guide screening and risk-reducing interventions. However, previous studies evaluating health knowledge of childhood cancer survivors demonstrate noteworthy deficits and misperceptions about their cancer diagnosis, treatment, and cancer-related health risks. In addition, because of the relative rarity of childhood cancer, many health care providers lack familiarity with cancer-related health risks and risk-reduction methods relevant for this population. To correct these deficits, the Scottish Intercollegiate Guidelines Network (SIGN) and the Children's Oncology Group (COG) developed clinical practice guidelines to foster appropriate risk-based survivor care. Herein, we discuss the development, benefits, and limitations of the SIGN and COG guidelines and the foundation they provide for standardizing long-term follow-up care of the ever-growing vulnerable population of childhood cancer survivors.

Predicting and modifying substance use in childhood cancer survivors: application of a conceptual model

PURPOSE/OBJECTIVES

To identify factors that predict or modify substance use in childhood cancer survivors and to describe how a risk-counseling intervention reduced young survivors' substance use.

DESIGN

Secondary analysis of clinical trial data and primary analysis of medical record data.

SETTING

Outpatient clinic.

SAMPLE

149 females and 118 males 12-18 years of age whose cancer had been in remission for at least two years were randomly assigned to intervention (n = 132) and standard care (n = 135) groups.

METHODS

Self-report questionnaires, abstracted medical record data, confirmatory factor analysis, and structural equation modeling.

MAIN RESEARCH VARIABLES

Smoking, alcohol consumption, knowledge, risk perceptions, motivation, and worry about cancer and treatment effects.

FINDINGS

Three factors directly predicted substance use at baseline: being in a higher grade in school (independent of age), feelings of being more susceptible to late effects of cancer therapy, and worrying more about cancer and its treatment. At follow-up a year later, grade in school and worry predicted increased substance use. In addition, a desire to change health behavior, influenced by the intervention and gender, predicted decreased substance use. The mechanism of influence of the intervention was evident: The intervention led to a need to change, which precipitated a desire to change and ultimately resulted in decreased substance use.

CONCLUSIONS

Young survivors' worries and concerns about their cancer and treatment-related late effects are a new intervention target. Motivation is sensitive to behavioral change interventions and positively affects risk reduction.

IMPLICATIONS FOR NURSING

Two new intervention strategies to address the impact of survivors' concerns about their cancer and its treatment are implied: (a) Replace substance use with new coping methods to reduce fear and anxiety, and (b) tailor motivation-based interventions to age and gender to communicate graphically and realistically to survivors the personal importance of behavioral change in modifying the risks of late effects.

Creating the basis for a breast health program for female survivors of Hodgkin disease using a participatory research approach

PURPOSE/OBJECTIVES

To learn from female survivors of Hodgkin disease about their perceptions of their current health status and future health risks, self-care practices to prevent or diminish health risks, and what kind of breast health program could benefit them, including the most effective methods and optimal times for learning about breast health.

DESIGN

Participatory research using focus groups.

SETTING

Urban pediatric cancer center.

SAMPLE

1 African American and 19 Caucasian female survivors of Hodgkin disease aged 16-26 years, diagnosed at least two years before the start of the study, and treated with mantle radiation therapy. Participants were recruited during visits to an outpatient clinic.

METHODS

Six open-ended questions were asked during three separate focus group sessions. Transcribed data were evaluated by content analysis techniques and analyzed to identify common themes.

MAIN RESEARCH VARIABLES

Current health status and perceived health risks, current health practices, and effective methods and timing for breast health teaching.

FINDINGS

Survivors reported feeling damaged by their cancer and its treatment and perceived that they were at risk for breast cancer. Self-care and risky behaviors also were reported. Internal influences (e.g., fear) and external influences (e.g., family) motivated survivors to participate in health promotion activities. Effective methods identified for learning about breast health included having access to other survivors, being respected as an adult, and having one-on-one staff teaching and peer support. The preferred timing of teaching varied, but survivors generally supported a gradual provision of information.

CONCLUSIONS

A positive listening environment is important for developing a breast health program for survivors. An essential first step is to create an opportunity for survivors to tell about their experiences with cancer, including its impact on their lives. Information regarding breast health must be provided in multiple formats during and after treatment if good practices are to be undertaken.

IMPLICATIONS FOR NURSING

The provision of adequate information during and after therapy as well as peer counseling in a positive listening environment are important in helping survivors participate in health promotion activities.

Adolescent survivors: a secondary analysis of a clinical trial targeting behavior change

BACKGROUND

The late effects of radiation and chemotherapy increase childhood cancer survivors' risk of chronic health problems. Survivors' behavior is important in modifying this risk, yet adolescent and young adult survivors fail to engage in important health-promoting behaviors and frequently practice high-risk behaviors. This secondary analysis re-evaluated a multi-component behavior-change intervention that had previously demonstrated no impact in adolescent survivors of childhood cancer.

PROCEDURE

The parent trial compared 132 adolescent survivors in the intervention arm with 135 in the standard-care arm at baseline and at 1 year for disease and treatment knowledge, perception of late effects risk, and the frequency of health-risk and health-protective behaviors (combined as a single summative measure). In contrast, the secondary analysis examined each of the 14 behaviors separately. Additionally, an analysis of covariance (ANCOVA) was conducted to examine the change in health behaviors while statistically controlling for age, gender, and the wide variation in baseline behaviors.

RESULTS

Knowledge (P = 0.038), breast self-examination (BSE) (P < or = 0.0001) and testicular self-examination (P = 0.004) increased, as did perceptions about the need to change behavior (P = 0.004) and the effort needed to stay healthy (P < or = 0.0001). In the treatment group, junk food consumption decreased (P = 0.052) and smoking abstinence was maintained (P = 0.088). Significant interactions between gender and treatment group were demonstrated.

CONCLUSIONS

Health-risk and health-protective behaviors cannot be effectively combined in a one-dimensional measure. Gender and age influence the impact of interventions targeting health behavior in survivors. Future trials should include observation of the patient-clinician encounter, more complex sampling methods, and pre-trial knowledge of the distribution of the study behaviors.

Shifting perspectives: adolescent-focused oncology nursing research

PURPOSE/OBJECTIVES

To describe contextual features of the experience of adolescents with cancer in the United States; to relate these features to a different theoretical perspective, the Shifting Perspectives Model of Chronic Illness; and to derive implications from that model for conducting research with adolescents who have cancer.

DATA SOURCES

64 qualitative and quantitative studies and clinical anecdotes.

DATA SYNTHESIS

Unique features of adolescents with cancer related to person, disease, and treatment indicate that existing theories on adolescence do not adequately guide research efforts with this patient population, nor do they adequately assist in explaining study findings.

CONCLUSIONS

The Shifting Perspectives Model of Chronic Illness is useful in generating potentially important hypotheses about adolescents and their experiences with cancer and has the promise of guiding research design and method selection for studies involving adolescents with cancer. The model also highlights a moral responsibility for researchers who conduct studies with this patient population.

IMPLICATIONS FOR NURSING

Nurse researchers who use this model to guide their research will create a purposeful balance in methods that allows adolescents with cancer to choose the amount of time and detail they will give to illness-related or to wellness-related responses in studies, particularly those that rely on self-report methods.

Health promotion for survivors of childhood cancer: a minimal intervention

We report the evaluation of an information booklet aimed to explain the purpose of follow-up to survivors of childhood cancer. Evaluations drew on theoretical concepts in the elaboration likelihood and stages of change models. We predicted that survivors who adopt central rather than peripheral processing would show greater understanding and increased readiness to change health behaviour. Forty-eight survivors were shown an example page of the booklet in the clinic and then completed questionnaires about attitude to clinic, readiness to change behaviour, and the importance and scariness of the information. They were then given the whole booklet and asked to complete a second questionnaire at home. After reading the booklet, survivors reported a more positive attitude to clinic. Survivors using central processing rated information as more important and were more ready to change health behaviour than peripheral processors. We recommend that methods to encourage central processing should be routinely included when providing children with health information.

Improving health care for adult survivors of childhood cancer: recommendations from a delphi panel of health policy experts

OBJECTIVES

To identify barriers to, models of care for, and initiatives to improve health care of adult survivors of childhood cancer.

METHODS

Seventeen health care policy experts were asked to respond to the three objectives through a three-iterative Delphi process.

RESULTS

Key barriers identified were that primary care physicians are unfamiliar with the health problems of survivors and survivors are often unaware of their risks. The recommended model of care would incorporate the chronic disease management model. Highest priority initiatives recommended were targeted education of primary care physicians and survivors, development and evaluation of standards of survivorship care, and a national web-based information center.

CONCLUSIONS

The insights and recommendations of the panel provide a foundation intended to improve health care of cancer survivors.

A model of care for childhood cancer survivors that facilitates research

The majority of children and adolescents diagnosed with cancer will achieve long-term survival after contemporary therapy. Consequent to this success are challenges inherent in coordinating lifelong health care for a group predisposed to a variety of cancer-related complications. With increasing numbers of aging adult survivors of childhood cancer, clinicians now face the additional challenge of studying delayed effects of childhood cancer in the context of organ senescence. Clinicians must also address the transition of survivor health care from the pediatric oncology setting to the adult community. Salient issues influencing health care of long-term childhood cancer survivors are summarized, and a model for monitoring late treatment effects used at a pediatric cancer facility is presented. This model is remarkable for its ability to enhance optimal delivery of long-term survivor care, facilitate the transition of survivor care from the pediatric treatment center to community, providers, and support investigations of late cancer-related morbidity and mortality.

The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND

The current study characterized the self-reported cancer screening practices of adult survivors of childhood cancer.

METHODS

A cohort of 9434 long-term survivors of childhood cancer and a comparison group of 2667 siblings completed a 289-item survey that included items regarding cancer-screening practices.

RESULTS

Overall, 27.3% of female respondents reported performing breast self-examination (BSE) regularly, 78.2% reported undergoing a Papanicolaou smear within the previous 3 years, 62.4% underwent a clinical breast examination (CBE) within the last year, and 20.9% had gotten a mammogram at least once in their lifetime. Approximately 17.4% of male respondents reported performing regular testicular self-examination (TSE). Women age > or =30 years who had been exposed to chest or mantle radiation therapy were more likely to report undergoing CBE (odds ratio [OR], 1.59; 95% confidence interval [95% CI], 1.32-1.92) and mammography (OR, 1.92; 95% CI, 1.47-2.56). Compared with the sibling comparison group, survivors demonstrated an increased likelihood of performing TSE (OR, 1.52; 95% CI, 1.22-1.85) or BSE (OR, 1.30; 95% CI, 1.10-1.52), of having undergone a CBE within the last year (OR, 1.18; 95% CI, 1.02-1.35), and of ever having undergone a mammogram (OR, 1.82; 95% CI, 1.52-2.17).

CONCLUSIONS

The results of the current study demonstrate that the cancer screening practices among survivors of childhood cancer are below optimal levels. Primary care physicians who include childhood cancer survivors among their patients could benefit these individuals by informing them about future cancer risks and recommending appropriate evidence-based screening.

Fertility issues for young adult survivors of childhood cancer

BACKGROUND

The effects of cancer and its treatment on reproduction and fertility are well-documented, yet knowledge of the psychosocial and behavioral ramifications of these outcomes for young adult survivors of childhood cancer is limited. As a qualitative exploratory study, this work identifies concerns, attitudes, and behaviors that may be associated with childhood cancer survivors' reproductive capacity.

PROCEDURE

As part of a semi-structured interview assessing the impact of cancer on long-term survivors' quality of life, a convenience sample of 32 childhood cancer survivors between the ages of 19-37 and at least five years beyond diagnosis were asked if they had physical limitations as a result of their cancer or treatment, and if having cancer has affected their ability to have children.

RESULTS

These data are organized around two major themes: (1) survivors' reproductive capacity and (2) their attitudes, experiences and concerns about children and parenting. Fifty-nine percent of survivors reported that they are uncertain about their fertility status, and half recall a parent or health care provider ever mentioning potential reproductive problems associated with their past cancer treatment.

CONCLUSIONS

While some survivors profess to know nothing about their risks for infertility, others possess and recall information that influences their personal relationships, their beliefs about having children, and possibly subsequent decisions and behaviors with regard to having children.

Childhood cancer survivors--living beyond cure

Advances in diagnosis and treatment along with improved supportive care have contributed to the current survival rates for pediatric malignancies. Recent concept of a truly "cured child" in pediatric oncology envisages not only a biological cure of the disease but a child on par with peers in growth and development physically and in achievements and aspirations, both mentally and emotionally. Because of the young age of these survivors and their potential for longevity, the delayed consequences of therapy may have a serious impact on their lives and family at large than do the acute complications of the cytotoxic therapies that they had experienced. Though figures from India are not available, it has been estimated that, in USA, the prevalence of childhood cancer survivors is expected to increase from 1 in 900 persons among young adults to 1:250 persons by 2010. Although this constitutes a remarkable medical achievement, the late morbidity in this growing survivor population has become an area for concern. It is estimated that 50% of the survivors are likely to develop disabilities that alter the quality of life.

Online exclusive: a model of health behavior to guide studies of childhood cancer survivors

PURPOSE/OBJECTIVES

To describe the Interaction Model of Client Health Behavior (IMCHB) and its application to health promotion in childhood cancer survivors.

DATA SOURCES

Periodical literature about cancer survivors, health behavior models, and the IMCHB.

DATA SYNTHESIS

Childhood cancer survivors are at risk for various late complications of treatment. The primary goal of intervention is the modification of health-related behavior. Conceptual models that extend beyond health beliefs are needed to guide explanatory and intervention studies in this group.

CONCLUSIONS

The IMCHB identifies background, cognitive, affective, motivational, and contextual variables that explain health-related behaviors. The model defines the interactive and collective contributions of a survivor, family, and provider to adherence to protocols, reduction of risk behavior, and promotion of health-protective behavior.

IMPLICATIONS FOR NURSING

This model may identify new determinants of health-related behavior that can be targeted by specific inter- or intrapersonal interventions to protect the health of childhood cancer survivors and reduce their risk of late sequelae.

Uso de biofeedback de variabilidad de la frecuencia cardiaca durante la radioterapia como método de distracción cognitiva y autorregulación en un paciente pediátrico: Informe de caso

Objetivo: Evaluar la efectividad del uso de biofeedback de variabilidad de frecuencia cardiaca (VFC) durante la radioterapia como método de distracción cognitiva y autoregulación emocional en un paciente pediátrico. Método: La paciente es una niña de 11 años con diagnóstico de sarcoma de Ewing en la pierna izquierda. Recibió 28 sesiones de radioterapia. Antes de iniciar tratamiento, se evaluó psicológicamente a la paciente con la entrevista Mini Kid, identificando que no tenía psicopatología. Dos semanas previas a iniciar, se evaluó la frecuencia cardiaca (FC) y variabilidad (VFC) de la misma (indicadores que han sido utilizados previamente como correlatos fisiológicos de estrés y relajación) con un software especializado llamado EmWave, identificando que sí presentaba activación fisiológica asociada a estrés. Se hizo entrenamiento en respiración diafragmática apoyado con el equipo de retroalimentación dos semanas previas a la radioterapia. El día que inició tratamiento, se volvió a evaluar la frecuencia y variabilidad antes de comenzar. Durante la radioterapia se instrumentó a la paciente al software y se permitió que ella escogiera el juego (que registra las variables de FC y VFC e interactúa conforme ella logra autoregulación fisiológica) y éste era proyectado en el techo de la sala mientras recibía la radiación. Resultados: Se identificaron cambios en la variabilidad de la frecuencia cardiaca, logrando una autoregulación, mostrando así que la paciente aprendió a relajarse y que lo puso en práctica durante la radioterapia. Conclusión: El uso del biofeedback es innovador en el tratamiento con radioterapia; permite al paciente integrar los dos métodos más utilizados como preparación para la misma: distraer el foco atencional y lograr una autoregulación. Se sugiere ampliar la muestra para conocer los efectos y generalizar los resultados.