Educational attainment among survivors of childhood cancer: a population-based cohort study in Denmark

Educational achievement in Swiss childhood cancer survivors compared with the general population

BACKGROUND

The objective of this study was to describe educational achievements of childhood cancer survivors in Switzerland compared with the general population. In particular, the authors investigated educational problems during childhood, final educational achievement in adulthood, and its predictors.

METHODS

Childhood cancer survivors who were aged <16 years at diagnosis from 1976 to 2003 who had survived for ≥5 years and were currently ages 20 to 40 years received a postal questionnaire during 2007 to 2009. Controls were respondents of the Swiss Health Survey ages 20 to 40 years. Educational achievement included compulsory schooling, vocational training, upper secondary schooling, and university degree. The analysis was weighted to optimize comparability of the populations. The authors analyzed the association between demographic and clinical predictors and educational achievement using multivariable logistic regression. Subgroup analyses focused on survivors aged ≥27 years.

RESULTS

One-third of survivors encountered educational problems during schooling (30% repeated 1 year, and 35% received supportive tutoring). In the total sample, more survivors than controls achieved compulsory schooling only (8.7% vs 5.2%) and fewer acquired a university degree (7.3% vs 11%), but more survivors than controls achieved an upper secondary education (36.1 vs 24.1%). In those aged ≥27 years, differences in compulsory schooling and university education largely disappeared. In survivors and controls, sex, nationality, language region, and migration background were strong predictors of achievement. Survivors of central nervous system tumors or those who had a relapse had poorer outcomes (P < .05).

CONCLUSIONS

Childhood cancer survivors encountered problems during schooling and completed professional education with some delay. However, with the exception of patients who had central nervous system tumors and those who experienced a relapse, the final educational achievement in survivors of child cancer was comparable to that of the general population.

Educational achievement among long-term survivors of congenital heart defects: a Danish population-based follow-up study

BACKGROUND

Congenital heart defect patients may experience neurodevelopmental impairment. We investigated their educational attainments from basic schooling to higher education.

PATIENTS AND METHODS

Using administrative databases, we identified all Danish patients with a cardiac defect diagnosis born from 1 January, 1977 to 1 January, 1991 and alive at age 13 years. As a comparison cohort, we randomly sampled 10 persons per patient. We obtained information on educational attainment from Denmark's Database for Labour Market Research. The study population was followed until achievement of educational levels, death, emigration, or 1 January, 2006. We estimated the hazard ratio of attaining given educational levels, conditional on completing preceding levels, using discrete-time Cox regression and adjusting for socio-economic factors. Analyses were repeated for a sub-cohort of patients and controls born at term and without extracardiac defects or chromosomal anomalies.

RESULTS

We identified 2986 patients. Their probability of completing compulsory basic schooling was approximately 10% lower than that of control individuals (adjusted hazard ratio = 0.79, ranged from 0.75 to 0.82 0.79; 95% confidence interval: 0.75-0.82). Their subsequent probability of completing secondary school was lower than that of the controls, both for all patients (adjusted hazard ratio = 0.74; 95% confidence interval: 0.69-0.80) and for the sub-cohort (adjusted hazard ratio = 0.80; 95% confidence interval: 0.73-0.86). The probability of attaining a higher degree, conditional on completion of youth education, was affected both for all patients (adjusted hazard ratio = 0.88; 95% confidence interval: 0.76-1.01) and for the sub-cohort (adjusted hazard ratio = 0.92; 95% confidence interval: 0.79-1.07).

CONCLUSION

The probability of educational attainment was reduced among long-term congenital heart defect survivors.

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.

Psychosocial health in children and adolescents surviving cancer

AIM

To explore psychosocial health in children and adolescents surviving cancer three years after diagnosis compared with healthy controls, as assessed by adolescents themselves, their parents and teacher.

MATERIAL AND METHODS

Case-control study included 50 children and adolescents diagnosed with cancer between 1 January 1993 and 1 January 2003 and treated at the Paediatric Department St. Olav's University Hospital, Trondheim, Norway. Data were collected using the Strengths and Difficulties Questionnaire (self-report, parent report and teacher report), as well as the Achenbach System of Empirically Based Assessment questionnaire (teacher report).

RESULTS

Children surviving cancer had more emotional symptoms, higher total problem scores and poorer academic performance than their peers. Emotional problems were consistently reported by parents, teachers and adolescents themselves, in particular in children with brain tumours and among survivors with late effects.

CONCLUSION

Our study shows that children surviving cancer are at higher risk for emotional problems when compared with their friends, even after several years following diagnosis and treatment. We conclude that when planning long-term follow-up care, rehabilitation of children and adolescents with cancer, especially for survivors with brain tumours and late effects, should particularly take into account their psychological problems and psychosocial functioning.

Educational and vocational achievement among long-term survivors of adolescent cancer in Germany

BACKGROUND

Adolescence involves graduating from school and preparing one's professional career. The accomplishment of these tasks may be hampered by the experience of cancer. This study investigates the educational and professional achievements of German long-term survivors of adolescent cancer.

PROCEDURE

Adult survivors of cancer during adolescence (n = 820, age at onset between 15 and 18 years; M = 15.8, SD = 0.9 years; age at follow-up: M = 30.4, SD = 6.0 years) were recruited through the German Childhood Cancer Registry. They completed self-reports with standard items on their educational and vocational level and their current occupational situation. Outcomes were compared to an age-matched sample from the general population (German Socio-Economic Panel, n = 820, age: M = 30.4, SD = 6.7). Risk factors for educational and vocational underachievement were identified by subgroup analyses.

RESULTS

Compared to peers from the general population, survivors of cancer during adolescence achieved higher educational and vocational levels. A higher proportion of survivors was employed; however, survivors were significantly older when starting their first occupation. Subgroup analyses revealed that neuropsychological late effects were associated with reduced rates of graduation from university and of employment among the survivors. No such effect of neuro-cognitive late effects occurred for high school graduation.

CONCLUSIONS

Most German survivors of cancer during adolescence participate in school and vocational life without major difficulties. Problems particularly arise for survivors with neuropsychological sequelae. Further research should investigate whether these results can be attributed to the German support system for pediatric cancer patients or to sample effects.

School performance of childhood cancer survivors: mind the teenagers!

OBJECTIVE

To assess school performance in an unselected group of childhood cancer survivors and study risk factors for impairment.

STUDY DESIGN

Rates of repeating a grade were compared for patients with cancer, their siblings, and the general population. Phone questionnaires were administered to patients about the school career of their child in remission and their siblings. Responses about cancer survivors were compared with those concerning their siblings and various registries provided by the national board of education. The primary outcome was the rate of repeating a grade.

RESULTS

A total of 148 children in remission with a mean age of 15 ± 5.3 years and a mean follow-up period since diagnosis of 6.3 ± 1.3 years were included. More patients than siblings repeated a grade (33% versus 21%; P = .02), with a mean delay since diagnosis of 2 years. Risk factors were an older age at diagnosis, attending a secondary school, low education level of parents, bone marrow transplantation, cerebral surgery, and physical sequelae. In multivariate analysis, risk for repeating was associated with low educational level of the father, attending secondary school at diagnosis, and requiring school-organized educational support on return to school.

CONCLUSION

After cancer, repeating a grade is not an exceptional occurrence, especially for teenagers; follow-up and supportive interventions before returning to school would be beneficial.

Young age at diagnosis is a risk factor for negative late socio-economic effects after acute lymphoblastic leukemia in childhood

BACKGROUND

The increasing number of survivors after childhood cancer requires characterization of the late complications of these diseases and their treatment. We examined a large number of possible socio-economic late effects following treatment for acute lymphoblastic leukemia (ALL) in order to identify factors leading to a poor outcome.

PROCEDURE

All individuals who had been diagnosed with ALL and who were alive in January 2007 (n = 213; men = 107) were identified from a database of all patients with cancer before the age of 18 in Southern Sweden from 1970 to 1999. For each subject, 50 matched controls were identified from the Swedish Population Register. Information on marital status, children, education, employment, income, and support from the community was obtained from Statistics Sweden.

RESULTS

At the ages of 25 and 30, survivors of ALL had attained a lower level of education than controls. At the age of 30, they were less often employed (70% vs. 82%, P = 0.019), less often married (19% vs. 32%, P = 0.019), and had children to a lesser extent (31% vs. 47%, P = 0.011) than controls. We identified young age at diagnosis as a risk factor for adverse outcome in the majority of the socio-economic variables studied, apart from the known risk of cranial irradiation treatment. Furthermore, female survivors had a greater risk of achieving a lower level of education than both male survivors and controls.

CONCLUSIONS

Young age at diagnosis, as well as treatment with cranial irradiation, is a risk factor for socio-economic late effects after treatment for ALL in childhood.

Long-term outcomes of childhood cancer survivors in Sweden: a population-based study of education, employment, and income

BACKGROUND

Studies of different national populations were indispensable for estimating the impact of illness-related disability on social outcomes in adult childhood cancer survivors. The effects of childhood cancer on educational attainment, employment, and income in adulthood in a Swedish setting were studied.

METHODS

The study population was a national cohort of 1.46 million Swedish residents, including 1716 survivors of childhood cancer diagnosed before their 16th birthday, followed up in 2002 in registries at >25 years of age. Main outcomes were educational attainment, employment, and net income. Markers of persistent disability were considered, and outcomes were analyzed with multivariate linear and logistic regression models adjusted for age, sex, and socioeconomic indicators of the childhood households.

RESULTS

Non-central nervous system (CNS) cancer survivors had similar education, employment, and income as the general population in adjusted models, whereas survivors of CNS tumors more often had no more than basic (< or =9 years) education (relative risk [RR], 1.80 [95% confidence interval (95% CI), 1.45-2.23]), less often attained education beyond secondary school (RR, 0.69 [95% CI, 0.58-0.81]), and less often were employed (RR, 0.85 [95% CI, 0.77-0.94]). Predicted net income from work was lower in CNS tumor survivors (P <.001) than in the general population, even after the exclusion of individuals who received economic disability compensation.

CONCLUSIONS

CNS tumor survivors had poorer social outcomes compared with the general population, whereas outcomes for survivors of other childhood cancers were similar to the general population. Established late effects highlighted the importance of improved, safer pediatric CNS tumor treatment protocols and surveillance that identified individual needs for preventive and remedial measures.

Educational attainment among adult survivors of childhood cancer in Great Britain: a population-based cohort study

BACKGROUND

Previous studies of educational attainment among childhood cancer survivors were small, had contradictory findings, and were not population based. This study investigated educational attainment in a large population-based cohort of survivors of all types of childhood cancer in Great Britain.

METHODS

Four levels of educational attainment among 10,183 cancer survivors--degree, teaching qualification, advanced (A') levels, and ordinary (O') levels--were compared with expected levels in the general population. A questionnaire was used to obtain educational attainment data for survivors, and comparable information for the general population was available from the General Household Survey. Factors associated with level of educational attainment achieved by cancer survivors were identified using multivariable logistic regression together with likelihood ratio tests. Logistic regression adjusting for age and sex was used for comparisons with the general population. All statistical tests were two-sided.

RESULTS

Childhood cancer survivors had lower educational attainment than the general population (degree: odds ratio [OR] = 0.77, 99% confidence interval [CI] = 0.68 to 0.87; teaching qualification: OR = 0.85, 99% CI = 0.77 to 0.94; A'level: OR = 0.85, 99% CI = 0.78 to 0.93; O'level: OR = 0.81, 99% CI = 0.74 to 0.90; P < .001, all levels). Statistically significant deficits were restricted to central nervous system (CNS) neoplasm and leukemia survivors. For leukemia, only those treated with radiotherapy were considered. Odds ratios for achievement by irradiated CNS tumor survivors were 50%-74% of those for cranially irradiated leukemia or nonirradiated CNS tumor survivors. Survivors at greater risk of poorer educational outcomes included those treated with cranial irradiation, diagnosed with a CNS tumor, older at questionnaire completion, younger at diagnosis, diagnosed with epilepsy, and who were female.

CONCLUSIONS

Specific groups of childhood cancer survivors achieve lower-than-expected educational attainment. Detailed educational support and implementation of regular cognitive assessment may be indicated for some groups to maximize long-term function.

I'll Show Them: The Social Construction of (In)Competence in Survivors of Childhood Brain Tumors

Multimodal therapy for the treatment of childhood cancer has resulted in increased survival rates, yet as growing cohorts of children mature, late effects are becoming apparent. Specifically, brain tumor survivors tend to have poor social skills, peer relationship problems, academic difficulties, and delayed college entry. This article addresses findings specific to the unique experience of childhood cancer survivors as they transition from adolescence to adulthood. Qualitative methods involving focus groups and in-depth interviews with 14 childhood cancer survivors and 22 family members were used. The dialectic of incompetence/competence pervaded all narratives. Contradictory concepts of integration/ isolation, realistic/unrealistic goals, and the need for special help/no help were underscored by respondents. The struggle to deal with these contradictory factors led to the simultaneous resistance and acceptance of feelings of competence.

Disability in Adult Survivors of Childhood Cancer: A Swedish National Cohort Study

Purpose

We studied the effects of childhood or adolescent cancer and cancer treatment on disability as indicated by persistent aid needs in adult life.

Patients and Methods

A group of 2,503 survivors of childhood cancer diagnosed before their 16th birthday were studied with data from registers in a national cohort of 1.91 million Swedish residents. Disability indicators were created from information in national registers about income (sickness pension, handicap allowance), personal assistance, and family situation in 2002. Multivariate logistic regression on the log scale was used to estimate relative risk (RR) ratios.

Results

A total of 7.6% of survivors received handicap allowance indicating permanent disability, including brain tumors (14.0%), other solid tumors (6.3), and leukemias/lymphomas (2.9%), compared with 0.6% in the general population. Twenty-six percent of survivors of CNS tumor and 10% of survivors of solid tumors had at least one indication of a disability. Younger age at diagnosis suggested a higher risk for disability. CNS tumor survivors had an RR of 10.7 (95% CI, 9.3 to 12.8) for having at least one disability indication compared with the noncancer population, whereas leukemia and lymphoma survivors had an RR of 3.0, and survivors of other cancers had an RR of 3.8. Survivors of CNS tumor only had an increased RR for living in the parental household (RR = 1.6; 95% CI, 1.4 to 1.9).

Conclusion

Childhood cancer survivors more often have persistent needs of supportive measures provided by community and/or the parental household. The survivors of CNS tumors were at particular risk, indicating a need of safer treatment protocols, and tailored follow-up, prevention, and rehabilitation to address this persistent social disability.

Scholastic Achievements of Childhood Leukemia Patients: A Nationwide, Register-Based Study

Purpose

Studies concerning the scholastic achievement of survivors of childhood leukemia have yielded controversial results. We studied the school marks of childhood leukemia survivors in a register-based study.

Patients and Methods

Three hundred seventy-one patients with a diagnosis of leukemia before the age of 16 years who were born between 1974 and 1986 and alive on their 16th birthday were identified from the Finnish Cancer Registry. Five matched controls were sought for each patient from the Population Register Center of Finland. Information on the ninth-grade school report was obtained from Statistics Finland. The overall mark average and the marks (scale 4 to 10) for mother tongue, foreign language, mathematics, and physical education were compared between the patients and controls.

Results

The ninth-grade school report was obtained by 97.6% of the patients and 98.5% of the controls. The patients whose treatment included cranial irradiation had a lower overall mark average (mean difference, −0.24; 95% CI, −0.33 to −0.15) and lower marks for all assessed school subjects compared with their controls. Of the patients treated with chemotherapy alone, only the females with leukemia diagnosed before 7 years of age had lower school marks than their controls. The biggest difference was observed in the marks for foreign language among the irradiated females diagnosed at a young age (mean difference, −1.0; 95% CI, −1.25 to −0.74).

Conclusion

Leukemia treatment that includes cranial irradiation impairs scholastic achievement. It is noteworthy that treatment of leukemia with chemotherapy alone impairs school performance only in females diagnosed before school age.

Leaving home after cancer in childhood: a measure of social independence in early adulthood

BACKGROUND

Previous studies on psychosocial outcomes for childhood and adolescent cancer survivors have found diverse results concerning social independence. As a measure of social independence, we investigated whether cancer survivors displayed the same patterns of leaving home as population-based control group.

PROCEDURE

We identified 1,597 patients in the Danish Cancer Register, born in 1965-1980, in whom a primary cancer was diagnosed before they reached the age of 20 in the period 1965-1995. The patients were compared with a random sample of the general population (n = 43,905) frequency matched on sex and date of birth. By linking the two cohorts to registers in Statistics Denmark, we obtained socioeconomic data for the period 1980-1997. The relative risk for leaving home was estimated with discrete-time Cox regression models.

RESULTS

The risk for leaving home of survivors of hematological malignancies and solid tumors did not differ significantly from that of the control cohort. Adjustments for possible socioeconomic confounders did not change this pattern. In contrast, survivors of central nervous system (CNS) tumors had a significantly reduced risk for leaving home, which was most pronounced for men (relative risk, men: 0.66; 95% confidence interval, 0.55-0.80; women: 0.88, 95% confidence interval, 0.80-0.97).

CONCLUSION

Overall, the psychosocial effects of cancer in childhood or adolescence and its treatment on the survivor and family did not appear to impede social independence in early adulthood, except for survivors of CNS tumors.

Behavioral and educational limitations after chemotherapy for childhood acute lymphoblastic leukemia or Wilms tumor

BACKGROUND

The improved prognosis of childhood cancer makes monitoring of functional outcome important. The purpose of this study was to evaluate behavioral and educational functioning in survivors of childhood acute lymphoblastic leukemia (ALL) or a Wilms tumor. In this study, children with ALL received central nervous system directed chemotherapy without cranial irradiation.

METHODS

In a multicenter study, behavioral functioning and school performance was examined in 199 children age 4 to 18. Sixty-four children were at least 1 year from finishing treatment with chemotherapy for ALL (n = 28) or a Wilms tumor (n = 36). They were compared with siblings (n = 37) and with a control group of healthy schoolchildren (n = 98).

RESULTS

A moderately increased risk of behavioral and educational problems was found in children with ALL but not in children with Wilms tumor. School performance was poorer in children with ALL attending primary school compared with same-age peers; however, the rate of utilization of special education services was low. Teacher-rated behavior and mathematics performance was correlated with attention function in children with ALL. An excess of problem behavior and underperformance at school was found in the ALL high-risk group compared with the standard-risk group. No differences were found between siblings and controls.

CONCLUSION

Evidence is provided of subtle but significant behavioral and educational problems in survivors of childhood ALL, but no dysfunctions in survivors of a Wilms tumor. Careful follow-up of children with ALL treated with chemotherapy only is warranted.