Health-Related Quality of Life Among Child and Adolescent Survivors of Childhood Cancer

Health related quality of life (HRQOL) in long-term survivors of pediatric low grade gliomas (LGGs)

The purpose of this study was to assess the health-related quality of life (HRQOL) and the impact of treatment on HRQOL in long-term survivors of pediatric low-grade gliomas (LGGs) using an adult instrument. QOL of 121 patients with a diagnosis of LGG from the Mayo Clinic were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30 for cancer in general) and (EORTC QLQ-BN20 specific for brain tumors). Median follow-up was 21.9 years for the participants. Median age at diagnosis was 11.8 years and at assessment was 33 years. Mean (standard deviation) global QOL score for the study was 78 (18) and 76.4 (22.8) in a reference population of healthy adults. Using QLQ-C30, radiation treated patients compared to non-radiation patients reported lower physical functioning (p = 0.002), role functioning (p = 0.004), and more constipation problems (p < 0.001). Patients with tumor recurrence reported lower role functioning (p = 0.016), social functioning (p = 0.040), and more financial problems (p = 0.029) compared to their counterparts. Using QLQ-BN20, patients with deep tumors compared to cortical tumors reported more bladder control problems (p = 0.016). Radiation treated patients also reported more bladder control problems (p < 0.001) compared to their counterparts. In the multivariable analysis, radiation therapy remained an independent predictor of physical and role functioning as well as symptoms related to brain tumors like visual disorders and motor dysfunction. Global QOL of long-term survivors of pediatric LGGs is similar to that of a reference population of healthy adults. The following tumor and treatment related factors were most consistently associated with poorer QOL: CNS tumor location, post-operative radiation, and tumor recurrence. Future studies are necessary to identify strategies to improve QOL in this subgroup of patients.

Symptom burden and medication use in adult sarcoma patients

PURPOSE

Limited data are available on how symptom burden affects health-related quality of life (HRQoL) in patients with sarcoma. This study aims to describe the symptom burden, HRQoL, and medication use in adult sarcoma patients.

METHODS

A single-center, cross-sectional study was conducted, and 79 patients were evaluated using three tools: the Rotterdam Symptom Checklist (RSCL), the Beck Anxiety Inventory (BAI), and the Functional Assessment of Cancer Therapy scale-General (FACT-G). Patients' demographic and clinical information, medication history, and use of concomitant medications were recorded. The proportion of patients with clinically significant RSCL score for a particular symptom was compared with the percentage of patients receiving medication for that symptom.

RESULTS

The mean age was 57.3 ± 15.2 years, with majority of the patients diagnosed with stromal tumor (46.8 %), leiomyosarcoma (15.2 %), and liposarcoma (10.1 %). The most prevalent physical symptoms experienced were tiredness (2.38 ± 1.00), lack of energy (2.04 ± 1.02), and difficulty sleeping (2.00 ± 1.15). The most common psychological symptoms experienced were irritability (1.92 ± 1.01), worrying (1.86 ± 0.90), and anxiety (1.68 ± 0.74). Few (6.3 %) patients received hypnotics while 33.0 % of patients reported difficulty sleeping. A proportion of patients (27.9 %) reported experiencing lack of appetite with only 1.3 % received appetite stimulants.

CONCLUSION

Adult sarcoma patients experience significant physiological and psychological symptom burden, which has a strong negative impact on HRQoL, with a number of physiological symptoms undertreated with pharmacotherapy.

Health-related quality of life of adolescent and young adult survivors of childhood brain tumors

OBJECTIVE

Our aim was to expand research on predictors of health-related quality of life (HRQOL) for adolescent and young adult survivors of childhood brain tumors who are not living independently by evaluating the mediating role of family functioning in the association of disease severity/treatment late effects with survivor self-report and caregiver-proxy report of physical and emotional HRQOL.

METHODS

Mothers (N = 186) and their survivors living at home (N = 126) completed self-report and caregiver-proxy report of physical and emotional HRQOL. Mothers completed family functioning measures of general family functioning, caregiving demands, and caregiver distress. Medical file review and caregiver report were used to evaluate disease severity/treatment late effects.

RESULTS

Using structural equation models, family functioning was adjusted for sociodemographic factors. Disease severity/treatment late effects had significant direct effects on self-report and caregiver-proxy report of physical and emotional HRQOL. Family functioning had a significant direct effect on caregiver-proxy report of physical and emotional HRQOL, but these findings were not confirmed for self-report HRQOL. Model-fit indices suggested good fit of the models, but the mediation effect of family functioning was not supported.

CONCLUSIONS

Disease severity/treatment late effects explained self-report and caregiver-proxy report of physical and emotional HRQOL for these adolescent and young adult survivors of childhood brain tumors. Family functioning was implicated as an important factor for caregiver-proxy report only. To enhance physical and emotional HRQOL, findings underscore the importance of coordinated, multidisciplinary follow-up care for the survivors who are not living independently and their families to address treatment late effects and support family management.

Cohort Profile: the French childhood cancer survivor study for leukaemia (LEA Cohort)

The main aim of the Leucémies de l'Enfant et l'Adolescent (LEA) project (Childhood and Adolescent Leukaemia) is to study the determinants (medical, socioeconomic, behavioural and environmental) of medium- and long-term outcomes of patients treated for childhood acute leukaemia (AL). The LEA study began in 2004 and is based on a French multicentric prospective cohort. Included are children treated for AL since January 1980 (incident and prevalent cases), surviving at month 24 for myeloblastic AL and lymphoblastic AL grafted in first complete remission or at month 48 for lymphoblastic AL not grafted in first complete remission. Information is collected during specific medical visits and notably includes the following data: socioeconomic data, AL history, physical late effects (such as fertility, cardiac function and metabolic syndrome) and quality of life. Data are collected every 2 years until the patient is 20 years old and has had a 10-year follow-up duration from diagnosis or last relapse. Thereafter, assessments are planned every 4 years. In active centres in 2013, eligible patients number more than 3000. The cohort has already included 2385 survivors, with rate of exhaustiveness of almost 80%. Data access can be requested from principal coordinators and must be approved by the steering committee.

Trajectories of social isolation in adult survivors of childhood cancer

PURPOSE

Long-term childhood cancer survivors may be at increased risk for poor social outcomes as a result of their cancer treatment, as well as physical and psychological health problems. Yet, important challenges, namely social isolation, are not well understood. Moreover, survivors' perspectives of social isolation as well as the ways in which this might evolve through young adulthood have yet to be investigated. The purpose of this research was to describe the trajectories of social isolation experienced by adult survivors of a childhood cancer.

METHODS

Data from 30 in-depth interviews with survivors (9 to 38 years after diagnosis, currently 22 to 43 years of age, 60 % women) were analyzed using qualitative, constant comparative methods.

RESULTS

Experiences of social isolation evolved over time as survivors grew through childhood, adolescence and young adulthood. Eleven survivors never experienced social isolation after their cancer treatment, nor to the present day. Social isolation among 19 survivors followed one of three trajectories; (1) diminishing social isolation: it got somewhat better, (2) persistent social isolation: it never got better or (3) delayed social isolation: it hit me later on.

CONCLUSIONS

Knowledge of when social isolation begins and how it evolves over time for different survivors is an important consideration for the development of interventions that prevent or mitigate this challenge.

IMPLICATIONS FOR CANCER SURVIVORS

Assessing and addressing social outcomes, including isolation, might promote comprehensive long-term follow-up care for childhood cancer survivors.

Implications of parent and child quality of life assessments for decisions about growth hormone treatment in eligible children

OBJECTIVE

To determine differences between parents and children in ratings of child health-related quality of life (HRQL) prior to growth hormone treatment.

METHOD

HRQL measures were collected from 144 children and their caregivers. Inclusion criteria were aged between 10 and 16 years, diagnosed with Turner's syndrome, acquired or idiopathic growth hormone deficiency (AGHD or IGHD) and eligible to begin human GH treatment (GHT), or non-growth hormone deficient (GHD) short stature.

RESULTS

Parents rated children to have poorer physical and psychosocial HRQL than children rated themselves. Differences depended on the measure used. Parents rated children with IGHD and non-GHD short stature better than children rated themselves, but they rated children with AGHD or Turner's much worse than children rated themselves in terms of physical but not psychosocial functioning.

CONCLUSIONS

Decisions to prescribe GHT should include children's perspectives of HRQL whenever possible. Differences between parents and children are most likely in conditions that involve more complex medical needs (AGHD and Turner's). Generic and disease-specific HRQL measures may vary in sensitivity to HRQL differences between groups. More work is required to evaluate HRQL among younger children.

Determination of School-Related Problems in Children Treated for Cancer

This descriptive and case–control study was carried out in a pediatric oncology outpatient clinic to determine the school-related physical, social, and psychological problems and problems experienced in academic achievement of children treated for cancer. The sample of the study consisted of 56 Turkish patients with cancer, aged 7–18 years, who were in remission and attending school as well as their parents, a control group of patients who did not have cancer, and their teachers. A Child Information Form, a Child Health Questionnaire Parent’s Form of 50 questions, a Behavior Evaluation Scale for Children, and Young People and a Teacher’s Report Form were used as data collection tools in the study. Of the children, 30.3% experienced various physical difficulties stemming from cancer therapy that affected their school life. The number of late enrollments, the number of children repeating a grade, and the rates of school absenteeism were also found to be higher in the survivors than in the controls.

Childhood chronic physical condition, self-reported health, and life satisfaction in adolescence

The present study investigates the prevalence and type of chronic conditions at 7 years of age-with special reference to atopic conditions-and their longitudinal associations with self-reported health and life satisfaction in adolescence. The data were obtained from Northern Finland Birth Cohort 1986 (NFBC 1986), which is a longitudinal 1-year birth cohort from an unselected, regionally defined population (n = 9,432). The present study investigated a sample of 8,036 children with data of chronic conditions at 7 years of age and a sample of 6,680 children with data of chronic conditions at 16 years of age. According to parents' report the prevalence of CC at 7 years of age was 14.8 % among boys and 13.2 % among girls, these figures being at 16 years of age 20.7 and 19.4 %, respectively. Atopic conditions were the most common chronic conditions at 7 years of age (12.7 % vs. other chronic conditions 4.7 %). Childhood chronic condition was associated with subsequent self-reported health in adolescence, but not with subsequent self-reported life satisfaction. Chronic condition at 7 years of age increased the risk of reporting health as "poor" even if the chronic condition was no longer prevalent at 16 years of age. Atopic conditions seemed to be linked with self-reported poor/moderate health more often than other chronic conditions among girls. Conclusion Childhood chronic conditions seem to affect adolescent's subjective health, but fortunately, they do not affect adolescents' subjective well-being to such an extent that it could lower their life satisfaction.

Considering quality of life for children with cancer: a systematic review of patient-reported outcome measures and the development of a conceptual model

OBJECTIVES

An appraisal of pediatric cancer-specific quality-of-life (QOL) instruments revealed a lack of clarity about what constitutes QOL in this population. This study addresses this concern by identifying the concepts that underpin the construct of QOL as determined by a content analysis of all patient-reported outcome (PRO) instruments used in childhood cancer research.

METHODS

A systematic review was performed of key databases (i.e., MEDLINE, CINAHL, PsychINFO) to identify studies of QOL in children with cancer. A content analysis process was used to code and categorize all items from generic and cancer-specified PRO instruments. Our objective was to provide clarification regarding the conceptual underpinnings of these instruments, as well as to help inform the development of theory and contribute to building a conceptual framework of QOL for children with cancer.

RESULTS

A total of 6,013 English language articles were screened, identifying 148 studies. Ten generic and ten cancer-specific PRO instruments provided 957 items. Content analysis led to the identification of four major domains of QOL (physical, psychological, social, and general health), with 11 subdomains covering 98 different concepts. While all instruments reflected items relating to the broader domains of QOL, there was substantial heterogeneity in terms of the content and variability in the distribution of items.

CONCLUSIONS

This systematic review and the proposed model represent a useful starting point in the critical appraisal of the conceptual underpinnings of PRO instruments used in pediatric oncology and contribute to the need to place such tools under a critical, yet reflective and analytical lens.

Self-reported psychosocial wellbeing of adolescent childhood cancer survivors

PURPOSE

To describe self-reported psychosocial wellbeing of adolescent childhood cancer survivors (CCS) compared with a control group of their peers.

METHODS

In this case-control study, 170 CCS aged 12-18 years completed an internet survey. The survey was a modified version of the Youth'07 Health and Wellbeing Survey of Secondary School Students in New Zealand. The control group (historical comparison) were the 9107 Youth'07 survey participants. Psychosocial wellbeing was assessed by measures of a) wellbeing (WHO-5), b) anxiety (MASC-10), c) depression (RADS2-SF) and d) emotional and behavioural difficulties (SDQ).

RESULTS

The majority of CCS scored within the normal range across all four measures: wellbeing (89%), anxiety (93%), depression (94%) and emotional and behavioural difficulties (82%), leaving a small but important minority of CCS reporting significant clinical issues. Compared to their peers, adolescent CCS were no more likely to have an abnormal score for any of the psychosocial measures, and less likely to report abnormal psychosocial wellbeing (OR = 0.44, p = 0.0003) and prosocial behaviour problems (OR = 0.53, p = 0.009). Survivors of central nervous system tumours, older age, older age at diagnosis, and lower socioeconomic status were associated with some psychosocial difficulty.

CONCLUSIONS

Following a diagnosis of childhood cancer, intensive therapy, and the subsequent risk of adverse health outcomes, one might expect CCS to be doing less well than their peers in terms of psychosocial wellbeing. The findings of this study, however, show that CCS are doing as well, and in some respects better, than their peers.

Health-related quality of life and cognitive functioning at on- and off-treatment periods in children aged between 6-13 years old with brain tumors: a prospective longitudinal study

PURPOSE

Our study aimed to examine the relationship between intelligence and health-related quality of life (HRQOL) in children (6-13 years old) diagnosed as having a brain tumor.

MATERIALS AND METHODS

We administered a Korean version of the Wechsler Intelligence Scale for Children-III, the Pediatric Quality of Life Inventory, version 4.0 (PedsQL), the Korean version of the Parenting Stress Index-Short Form, and the Korean Version of the Parenting Sense of Competence (K-PSOC) scale before or after initial radiotherapy (T1) and after treatment termination (T2). In total, 13 patients completed both the T1 and T2 interviews.

RESULTS

Scores significantly declined between T1 and T2 on the full-scale intelligence quotients (FIQ), verbal intelligence quotients (VIQ), performance intelligence quotients (PIQ), similarity and coding tests, as well as the K-PSOC, which measures parental anxiety. FIQ scores at T1 were correlated with the self-reported PedsQL total scores (r=0.739) and the parent proxy-report PedsQL scores for school functioning (r=0.706) at T2. Also, the FIQ scores at T2 were correlated with the self-reported PedsQL total scores (r=0.748) and scores for physical health (r=0.728) at T2.

CONCLUSION

The cognitive ability and intelligence level of the patients significantly declined between on and off treatment periods, and higher intelligence functioning at both on and off treatment was correlated with long-term higher HRQOL. Further investigations that monitor intelligence, HRQOL and parenting stress over a longer period, using a greater number of participants, are needed.

Bone mineral density deficits in childhood cancer survivors: Pathophysiology, prevalence, screening, and management

As chemotherapy and other sophisticated treatment strategies evolve and the number of survivors of long-term childhood cancer grows, the long-term complications of treatment and the cancer itself are becoming ever more important. One of the most important but often neglected complications is osteoporosis and increased risk of fracture during and after cancer treatment. Acquisition of optimal peak bone mass and strength during childhood and adolescence is critical to preventing osteoporosis later in life. However, most childhood cancer patients have multiple risk factors for bone mineral loss. Cancer itself, malnutrition, decreased physical activity during treatment, chemotherapeutic agents such as steroids, and radiotherapy cause bone mineral deficit. Furthermore, complications such as growth hormone deficiency and musculoskeletal deformity have negative effects on bone metabolism. Low bone mineral density is associated with fractures, skeletal deformity, pain, and substantial financial burden not only for childhood cancer survivors but also for public health care systems. Thus, it is important to monitor bone health in these patients and minimize their risk of developing osteoporosis and fragility fractures later in life.

Recruitment and retention of older adolescent and young adult female survivors of childhood cancer in longitudinal research

PURPOSE/OBJECTIVES

To describe the challenges encountered in the recruitment and retention of a sample of older adolescent and young adult female survivors of childhood cancer for a longitudinal study testing a targeted psychosocial intervention aimed at enhancing hope.

DATA SOURCES

Published literature on constructing longitudinal intervention studies and strategies in the recruitment and retention of childhood cancer survivors in research was used to develop the protocol of this study.

DATA SYNTHESIS

Using empirical literature to construct the study's design resulted in achieving certain goals for the design, but not in the recruitment and retention of study participants. Using online technology to deliver the intervention and collect data was efficient and effective. Traditional approaches to recruitment and retention of those survivors, however, were not effective. Use of more novel approaches to enroll study participants demonstrated only modest success.

CONCLUSIONS

Additional research is needed on strategies to successfully recruit and retain older adolescents and young adult female survivors of childhood cancer in longitudinal intervention studies.

IMPLICATIONS FOR NURSING

The improvement in the psychological well-being of female survivors of childhood cancer remains an important outcome in ongoing care. The need to continue to identify creative and effective ways to recruit and retain those survivors is warranted.

[Survivors of pediatric cancer. Developmental paths and outcomes between trauma and resilience]

In Europe and North America, about 80% of all patients with cancer in childhood and adolescence survive their leukemia, lymphomas or tumors. Therefore, neuropsychological impairments, psychopathological comorbidity and health-related quality of life become relevant parameters for treatment evaluation and conceptualization of future therapy protocols. During the last decade, a number of patient registries, multicenter studies and meta-analyses have analyzed the interaction of disease- and treatment-associated risk factors with pre-existing socio-demographic and psychosocial vulnerability factors. Brain tumors and treatment strategies including CNS surgery, cranial radiotherapy and intrathecal chemotherapy carry an increased risk for neurological and neuropsychological long-term outcomes, which in turn also threatens the patients' psychosocial and vocational participation. In the area of psychosocial adaptation, a wide range of developmental paths results, ranging from increased psychological comorbidity, to subclinical impairments in quality of life, to normal courses to resilient outcomes, even with a developmental benefit. A hypothetical model is presented to explain this enormous variance in outcomes. Protective cognitive-emotional schemata already established at the premorbid stage predispose patients to be able to cope successfully with cancer-related challenges and thus further enhance the patients' future adaptability. In contrast, dysfunctional schemata at the premorbid level increase risks of coping failure and thus intensify the long-term risk for psychopathological comorbidity in terms of post-traumatic stress disorder, anxiety disorder or depression.

Health related quality of life in Middle Eastern children with beta-thalassemia

Background

Thalassemia is a common disorder worldwide with a predominant incidence in Mediterranean countries, North Africa, the Middle East, India, Central Asia, and Southeast Asia. Whilst substantial progress has been made towards the improvement of Health related quality of life (HRQoL) in western countries, scarce evidence-based data exists on HRQol of thalassemia children and adolescents living in developing countries.

Methods

We studied 60 thalassemia children from Middle Eastern countries with a median age of 10 years (range 5 to 17 years). HRQoL was assessed with the Pediatric Quality of Life Inventory (PedsQL) 4.0. The Questionnaire was completed at baseline by all patients and their parents. The agreement between child-self and parent-proxy HRQoL reports and the relationship between HRQoL profiles and socio-demographic and clinical factors were investigated.

Results

The scores of parents were generally lower than those of their children for Emotional Functioning (mean 75 vs 85; p = 0.002), Psychosocial Health Summary (mean 70.3 vs 79.1; p = 0.015) and the Total Summary Score (mean 74.3 vs 77.7 p = 0.047). HRQoL was not associated with ferritin levels, hepatomegaly or frequency of transfusions or iron chelation therapy. Multivariate analysis showed that a delayed start of iron chelation had a negative impact on total PedsQL scores of both children (p = 0.046) and their parents (p = 0.007).

Conclusions

The PedsQL 4.0 is a useful tool for the measurement of HRQoL in pediatric thalassemia patients. This study shows that delayed start of iron chelation has a negative impact on children’s HRQoL.

Health-related quality of life in pediatric cancer survivors: a multifactorial assessment including parental factors

AIM

We aimed to evaluate the health-related quality of life (HRQOL) and the effect of associated factors such as cancer type, treatment strategies, sex, age, and parental factors like education and psychopathology in pediatric cancer survivors and make a comparison with healthy children.

PATIENTS AND METHODS

"Pediatric Quality of Life Inventory (PedsQL) 4.0 TM, Generic Core Scale" for children and parents, and "Brief Symptom Inventory" for parents were used. Three hundred and two survivors without major mental or motor deficit and 272 healthy controls of 8 to 18 years of age were enrolled to study.

RESULTS

Comparison of scores according to child self-report between survivor and control groups revealed lower points in physical and school subscale of survivor group (P<0.01 and P<0.001, respectively). Female survivors had reported significantly worse HRQOL in physical and emotional subscales of PedsQL than male survivors (P<0.001). Female survivors of ≥16 years of age had reported worse scores in school subscale than females of younger age groups and male survivors of same age group. Parents of control group reported better results in school subscales (P<0.001) and social functioning subscales (P<0.05) than parents of survivor group. Brief Symptom Inventory score had significant effect on child self-report and parent proxy-report of physical functioning (P<0.001), emotional functioning (P<0.001), social functioning (P<0.001), and school subscales (P<0.001) of PedsQL. Significantly better scores of physical functioning subscale in the survivors whose parents are university graduate than the survivors whose parents are primary school graduate were detected (P<0.001). The survivors with central nervous system tumors had reported lower scores in the social, emotional, physical, and school functioning subscales of PedsQL than patients with non-Hodgkin and Hodgkin lymphoma (P<0.001). Child self-report school subscale scores were lower in survivors treated with radiotherapy in combination or as sole therapy than survivors in whom radiotherapy was not given (P<0.001).

CONCLUSIONS

Our study has provided evidence about less-studied determinants of HRQOL like parental factors such as psychopathology or educational level in childhood cancer survivors. Future research can build on this evidence to obtain additional factors other than well-known medical and treatment-related factors.

Quality of life of methylphenidate treatment-responsive adolescents with attention-deficit/hyperactivity disorder

Quality of life (QOL) in methylphenidate treatment-responsive adolescents with attention deficit/hyperactivity disorder (ADHD) was assessed. Patients were 12- to 18-year-old adolescents with ADHD (total n = 45) who had been on methylphenidate treatment for at least 3 months and were clinically judged to be improved. The self-completed Taiwanese Quality of Life Questionnaire for Adolescents (TQOLQA) was used, and the resulting measures were compared between adolescents with ADHD and: (1) community adolescents (n = 2316); (2) treatment-responsive adolescents with a chronic medical condition (i.e., adolescents with leukemia in its first and complete continuous remission for at least 3 years after chemotherapy) (n = 39). Patients' cognitive profile and their daily executive functioning were also obtained for analysis. The QOL of the treated adolescents with ADHD was reported to be worse than that of both the community healthy adolescents and the adolescent leukemia survivors in the self-reported TQOLQA domain of "psychological well-being". Treated adolescents with ADHD still had impaired executive skills in natural, everyday environments, and the scores for daily executive abilities could predict the QOL measures. Factors besides pharmacotherapy should be explored to further improve the QOL of medication-treated adolescents with ADHD.

Health related quality of life in adolescent and young adult survivors of lower extremity bone tumors

BACKGROUND

Dramatic increases in survival rates have led to increased interest regarding the health related quality of life (HRQOL) of adolescent and young adult survivors of bone tumors. This study investigated HRQOL and physical disability in adolescent and young adult survivors of lower extremity bone tumors as a function of type of surgical intervention, gender, and age at assessment.

PROCEDURE

Twenty-eight participants (age range 18-32 years) completed three generic and one disease-specific measures of HRQOL and a measure of physical disability. For analysis, surgical intervention was grouped into limb sparing surgeries (LS; allograft fusion and endoprosthesis) and ablative surgeries (AMP; amputation or Van Nes rotationplasty). Age at study was grouped into ≤ 25 years of age and ≥ 26 years of age. The MOS-SF-36, HUI2, HUI3, and EORTC-QLQ-C30 were used to measure HRQOL and the TESS was used to assess physical disability.

RESULTS

Survivors reported HRQOL equivalent to the general population, with the exception of physical functioning. LS reported poorer HRQOL than AMP participants for emotional functioning and fatigue. Males reported better HRQOL compared with females for overall HRQOL, general health, physical functioning, and social functioning. Finally, younger participants generally reported better HRQOL than older participants for overall HRQOL and physical functioning.

CONCLUSIONS

This study identifies LS surgical intervention, female gender and older age as risk factors for reduced HRQOL in adolescent and young adult survivors of lower extremity bone tumors. This study also provides information about what instrument may be most useful in identifying these specific difficulties and subgroups.

Health-related quality of life, activities of daily living and parenting stress in children with brain tumors

OBJECTIVE

To compare health-related quality of life (HRQOL), activities of daily living (ADL), and parenting stress between children with brain tumors and those of normal control (NC).

METHODS

Participants were 31 brain tumor patients who had received chemotherapy, radiotherapy, or peripheral blood stem cell transplantation after surgical resection and 125 NC subjects. We administered the Pediatric Quality of Life Inventory, version 4.0 (PedsQL), to assess HRQOL; the Korean version of the Parenting Stress Index-Short Form (K-PSI-SF), to assess parenting stress; and examined ADL.

RESULTS

The mean self-report PedsQL scores for physical health, emotional functioning, social functioning, school functioning, and total scores in the patients were significantly lower than those of the NC group. The mean parent proxy-report PedsQL scores for all scales except emotional functioning in the patient group were significantly lower than those of the NC group. The ADL impairment for the patients was significantly more than that of the NC group. The K-PSI-SF mean scores for stress related to having a difficult child and for stress related to parent-child interaction in the patient group tended to be higher than those of the NC group (p=0.09).

CONCLUSION

The children with brain tumors had lower HRQOL and difficulties in performing ADL. The parents of children with brain tumors tended to experience stress related to having a difficult child and to parent-child interaction. We suggest that long-term monitors for the child's HRQOL and ADL, and parenting stress in children with brain tumors are needed.

The impact of educating parents of leukemic children on the patients' quality of life

BACKGROUND

The quality of life of children with leukemia is reduced by fear and anxiety of parents after diagnosis, lack of information about the disease, treatments, and care of the child. This study aims to evaluate the effect of educating parents of leukemic children on the patients' quality of life.

METHODS

In this interventional study, sixty parents of ALL children who met inclusion criteria were selected using simple random sampling method, and assigned to the experimental and control groups. The study tool included a valid and reliable questionnaire (TNO-AZL), that was filled in through interview by parents before and two months after the intervention for both groups. The first part of the questionnaire included demographic items and the second part (7 dimensions, each with 8 sections) contained questions related to the quality of life. The scores could range between 56 and 280 and a higher score represented a better quality of life. The intervention included three one-hour classes composed of lecture and question-answer sessions which were held for groups of 4-6 participants, accompanied by a booklet.

RESULTS

Before the intervention, the quality of life score in the experimental and control groups was 180.83±14.43 and 174.28±20.72, respectively; after the intervention, these figures changed to 226.9±11.76 and 174.41±20.42 respectively. Paired samples T-test proved a significant increase in the quality of life in the experimental group.

CONCLUSION

Parent education successfully increased the quality of life of leukemic children; therefore, parental consultation sessions and educational programs are recommended.

Health-related quality of life in children and adolescents with sickle cell disease

OBJECTIVE

To assess health-related quality of life (HRQOL) in children and adolescents with sickle cell disease (SCD).

DESIGN, SETTING, AND PARTICIPANTS

The PedsQL 4.0 Generic Scales, a multidimensional self-report instrument that has been shown to be valid and reliable for use in children and adolescents with chronic illness, consists of 23 items that assess physical, emotional, social, and school functioning. Questionnaires were administered to 124 children and adolescents (ages 8 to 18 years, child self-report) with SCD (100 sickle cell anemia, 24 sickle β zero thalassemia) and their parents (parent-proxy report). Summary scores for children's and parents' ratings of overall HRQOL and psychosocial health and subscale scores for physical, emotional, social, and school functioning were compared with published data for healthy children. Both summary and subscale scores for children with SCD also were compared with those of their parents.

RESULTS

Children with SCD and their parents rated overall HRQOL and all subdomains of HRQOL lower than did healthy children and their parents (P < .001). Children with SCD rated their own HRQOL significantly better than their parents did for overall HRQOL and all subdomains (P < .001) except emotional functioning (P = .06).

CONCLUSIONS

Children with SCD and their parents perceived overall HRQOL and all HRQOL subdomains to be lower than scores reported in healthy children. Therefore, successful therapeutic efforts to improve HRQOL could represent important advances in the health of children with SCD.

Identifying determinants of quality of life of children with cancer and childhood cancer survivors: a systematic review

PURPOSE

This paper describes a systematic review conducted to identify factors that have been investigated as explanations of variability in the quality of life of children with cancer and childhood cancer survivors. Our purpose was to build an evidence base that could be used to guide and direct future research.

METHODS

MEDLINE, CINAHL, EMBASE, PsycINFO, Cancerlit, and Sociological Abstracts were searched from the inception of each database to June 15, 2009 using the following search terms: "quality of life," "health-related quality of life," "quality adjusted life years," "health status," "functional status," "well-being," or "patient-reported outcome." Sample characteristics and information about the relationship between a quality of life domain or total scale score and at least one factor (e.g., child gender or age, coping skills, family income) were extracted from eligible studies.

RESULTS

Nine cancer-specific and nine generic QOL questionnaires were used in 58 publications described 239 factors (50 unique factors). The large number of cancer, treatment, child, and family variables considered indicates that extensive research activity has occurred. However, most of the variables identified were examined in only a few studies and most represent medical and treatment variables with less research attention paid to child and family variables.

CONCLUSIONS

Our study has compiled evidence about determinants of QOL for children with cancer and childhood cancer survivors from the existing literature. Future research can build on this evidence base to expand the range of factors studied as most research to date has focused on medical and treatment factors.

Residential pesticides and childhood leukemia: a systematic review and meta-analysis

It is a systematic review and meta-analysis of previous observational epidemiologic studies examining the relationship between residential pesticide exposures during critical exposure time windows (preconception, pregnancy, and childhood) and childhood leukemia. Searches of Medline and other electronic databases were performed (1950-2009). Study selection, data abstraction, and quality assessment were performed by two independent reviewers. Random effects models were used to obtain summary odds ratios (ORs) and 95% confidence intervals (Cis). Of the 17 identified studies, 15 were included in the meta-analysis. Exposures during pregnancy to unspecified residential pesticides insecticides, and herbicides were positively associated with childhood leukemia. Exposures during childhood to unspecified residential pesticides and insecticides were also positively associated with childhood leukemia, but there was no association with herbicides. Positive associations were observed between childhood leukemia and residential pesticide exposures. Further work is needed to confirm previous findings based on self-report, to examine potential exposure-response relationships, and to assess specific pesticides and toxicologically related subgroups of pesticides in more detail.

Child-related determinants of health-related quality of life in children with brain tumours 1 year after diagnosis

OBJECTIVES

Infratentorial tumour site and health-related quality of life (HRQL) 1 month after diagnosis have been shown to predict HRQL 1 year after diagnosis in children with brain tumours. This study aimed to identify additional early child-related determinants of parent- and child-report HRQL.

METHODS

Longitudinal prospective study. Semi-structured interviews took place approximately 1 and 12 months after diagnosis. HRQL was measured using the self- and parent-report Pediatric Quality of Life Scales (PedsQL 4.0) Total Scale Score and Health Utilities Index Mark 3 (HUI3) multi-attribute utility function. Child variables included performance and verbal IQ, general memory, selective attention executive function, behaviour problems, adaptive behaviour, symptoms of depression and anxiety and event related anxiety. Univariate analyses were used to identify potential early predictors of HRQL. Regression analysis was then used to identify the most important determinants of HRQL at 1 year.

RESULTS

Thirty-five patients completed the 12-month interviews. Multivariate analysis showed infratentorial tumour site remained an important determinant of HRQL 1 year after diagnosis. Infratentorial tumour site and selective attention at 1 month generally best predicted poor self- and parent-report HRQL at 12 months. Adaptive behaviour and performance IQ may be important.

CONCLUSION

Selective attention and infratentorial tumour site are most important in predicting both parent- and self-report HRQL at 1 year after diagnosis. Larger prospective studies are needed to confirm these findings. Cognitive remediation or/and pharmacological intervention, particularly aimed at children with infratentorial tumours may improve attention and subsequently HRQL and both merit further investigation.

A Narrative Review Summarizing the State of the Evidence on the Health-Related Quality of Life Among Childhood Cancer Survivors

This narrative review summarizes the state of the evidence about the phenomenon of health-related quality of life (HRQOL) among survivors of childhood cancer. A major strength of the state of the evidence on the HRQOL among survivors of childhood cancer is the availability and quality of the data generated from the Childhood Cancer Survivor Study (CCSS). Findings from most studies find comparable levels of HRQOL among survivors and constructed cohort samples; however, a poorer level of HRQOL exists among female survivors. Factors that predict a lower or poorer level of HRQOL among survivors include age at diagnosis, age attained, time since diagnosis, socioeconomic status (education level, household income, and employment status), physical role functioning, and health insurance. Those survivors who received cranial radiation, especially survivors of central nervous system tumors, are at an increased risk for poorer HRQOL and long-term negative effects.

Quality of life of adolescents with cancer: family risks and resources

Purpose

The goal of this study was to evaluate the relative contribution of treatment intensity, family sociodemographic risk, and family resources to health-related quality of life (QOL) of 102 adolescents in treatment for cancer.

Methods

Adolescents and parents completed self-report measures of teen QOL, family functioning, and parent-child bonding. Based on parent report of family sociodemographic variables, an additive risk index was computed. A pediatric oncologist rated treatment intensity.

Results

Simultaneous regression analyses demonstrated the significant contribution of roles in family functioning and quality of parent-child relationship to prediction of psychosocial QOL (parent and teen-reported) as well as parent-reported teen physical QOL over and above the contribution of treatment intensity. Family sociodemographic risk did not contribute to QOL in these regression analyses. In additional analyses, specific diagnosis, types of treatment and individual sociodemographic risk variables were not associated with QOL. Parent and teen ratings of family functioning and quality of life were concordant.

Conclusions

Family functioning, including quality of parent-child relationship, are central and potentially modifiable resistance factors in teen QOL while under treatment for cancer. Even more important than relying on diagnosis or treatment, screening for roles and relationships early in treatment may be an important aspect of determining risk for poor QOL outcomes.

Health status of the oldest adult survivors of cancer during childhood

BACKGROUND

Young adult survivors of childhood cancer have an increased risk for treatment-related morbidity and mortality. In this study, the authors assessed how treatment for childhood cancer affects older-adult health and health practices.

METHODS

One hundred seven adults treated for childhood cancer between 1947 and 1968, known to have survived past age 50 years, were identified from a single-institution cohort established in 1975. Updated vital status on eligible cases was obtained from public records. Survivors and a control group of their age-matched siblings and cousins completed a mailed survey to assess physical and social function, healthcare practices, and the prevalence of common adult illnesses.

RESULTS

Of the 107 survivors known to be alive at age 50 years, 16 were deceased at follow-up; 7 deaths could be associated with prior treatment (second malignancy in radiation field [3], small bowel obstruction after abdominal radiation [2], and cardiac disease after chest irradiation [2]). The 55 survivors (median age, 56 years; range, 51-71 years), and 32 family controls (median age, 58 years; range, 48-70 years), reported similar health practices, health-related quality of life, and social function. However, survivors reported more frequent visits to healthcare providers (P < .05), more physical impairments (P < .05), fatigue (P = .02), hypertension (P = .001), and coronary artery disease (P = .01). An increased risk of hypertension was associated with nephrectomy during childhood (odds ratio, 18.9; 95% confidence interval, 3.0-118.8).

CONCLUSIONS

The oldest adult survivors of childhood cancer continue to be at risk for treatment-related complications that potentially decrease their life expectancy and compromise their quality of life.

Residential pesticides and childhood leukemia: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis of previous observational epidemiologic studies examining the relationship between residential pesticide exposures during critical exposure time windows (preconception, pregnancy, and childhood) and childhood leukemia.

DATA SOURCES

Searches of MEDLINE and other electronic databases were performed (1950-2009). Reports were included if they were original epidemiologic studies of childhood leukemia, followed a case-control or cohort design, and assessed at least one index of residential/household pesticide exposure/use. No language criteria were applied.

DATA EXTRACTION

Study selection, data abstraction, and quality assessment were performed by two independent reviewers. Random effects models were used to obtain summary odds ratios (ORs) and 95% confidence intervals (CIs).

DATA SYNTHESIS

Of the 17 identified studies, 15 were included in the meta-analysis. Exposures during pregnancy to unspecified residential pesticides (summary OR = 1.54; 95% CI, 1.13-2.11; I2 = 66%), insecticides (OR = 2.05; 95% CI, 1.80-2.32; I2 = 0%), and herbicides (OR = 1.61; 95% CI, 1.20-2.16; I2 = 0%) were positively associated with childhood leukemia. Exposures during childhood to unspecified residential pesticides (OR = 1.38; 95% CI, 1.12-1.70; I2 = 4%) and insecticides (OR = 1.61; 95% CI, 1.33-1.95; I2 = 0%) were also positively associated with childhood leukemia, but there was no association with herbicides.

CONCLUSIONS

Positive associations were observed between childhood leukemia and residential pesticide exposures. Further work is needed to confirm previous findings based on self-report, to examine potential exposure-response relationships, and to assess specific pesticides and toxicologically related subgroups of pesticides in more detail.

Family, demographic and illness-related determinants of HRQL in children with brain tumours in the first year after diagnosis

AIMS

To evaluate the relationship between parent- and child-report Health-Related Quality of Life (HRQL) and demographic, tumour and family variables in children with a brain tumour in the first year after diagnosis and to identify determinants of HRQL at 12 months.

PROCEDURE

Longitudinal prospective study: Semi-structured interviews took place approximately 1, 6 and 12 months after diagnosis. HRQL was measured using the self- and parent-report PedsQL 4.0 Total Scale Score. Tumour and treatment variables considered included tumour site and grade, hydrocephalus at diagnosis, chemotherapy and radiotherapy. Family variables included measures of family function, family support and family stress, the primary carer's coping strategies and symptoms of depression and anxiety. Univariate analyses were used at all three time points, and to identify potential early predictors of HRQL at 1 year. Regression analysis was then used to identify the most important determinants of HRQL at 1 year.

RESULTS

Thirty-five patients completed the 12-month interviews. There were consistent significant negative correlations between concurrent family impact of illness and parent and self-report HRQL, and positive correlations between concurrent family support and parent-report HRQL. Treatment with radio- or chemotherapy correlated with child-report HRQL only at some time points. Multivariate analysis showed infratentorial tumour site, and poor HRQL at 1 month best predicted poor self- and parent-report HRQL at 12 months.

CONCLUSION

Children with infratentorial tumours and poor HRQL early after diagnosis tend to have poor HRQL at 1 year. While family factors are important modulators of concurrent HRQL, they do not appear important in predicting HRQL.

Long-term outcomes among adult survivors of childhood central nervous system malignancies in the Childhood Cancer Survivor Study

BACKGROUND

Adult survivors of childhood central nervous system (CNS) malignancies are at high risk for long-term morbidity and late mortality. However, patterns of late mortality, the long-term risks of subsequent neoplasms and debilitating medical conditions, and sociodemographic outcomes have not been comprehensively characterized for individual diagnostic and treatment groups.

METHODS

We collected information on treatment, mortality, chronic medical conditions, and neurocognitive functioning of adult 5-year survivors of CNS malignancies diagnosed between 1970 and 1986 within the Childhood Cancer Survivor Study. Using competing risk framework, we calculated cumulative mortality according to cause of death and cumulative incidence of subsequent neoplasms according to exposure and dose of cranial radiation therapy (RT). Neurocognitive impairment and socioeconomic outcomes were assessed with respect to dose of CNS radiotherapy to specific brain regions. Cumulative incidence of chronic medical conditions was compared between survivors and siblings using Cox regression models. All tests of statistical significance were two-sided.

RESULTS

Among all eligible 5-year survivors (n = 2821), cumulative late mortality at 30 years was 25.8% (95% confidence interval [CI] = 23.4% to 28.3%), due primarily to recurrence and/or progression of primary disease. Patients who received cranial RT of 50 Gy or more (n = 813) had a cumulative incidence of a subsequent neoplasm within the CNS of 7.1% (95% CI = 4.5% to 9.6%) at 25 years from diagnosis compared with 1.0% (95% CI = 0% to 2.3%) for patients who had no RT. Survivors had higher risk than siblings of developing new endocrine, neurological, or sensory complications 5 or more years after diagnosis. Neurocognitive impairment was high and proportional to radiation dose for specific tumor types. There was a dose-dependent association between RT to the frontal and/or temporal lobes and lower rates of employment, and marriage.

CONCLUSIONS

Survivors of childhood CNS malignancies are at high risk for late mortality and for developing subsequent neoplasms and chronic medical conditions. Care providers should be informed of these risks so they can provide risk-directed care and develop screening guidelines.

Quality of life in survivors of childhood cancer: a systematic review of the literature (2001-2008)

PURPOSE

The purpose of this paper was to provide a comprehensive, contemporary systematic review of studies that have examined the quality of life (QOL) of survivors of childhood cancer in order to extend upon the findings of earlier reviews.

MATERIALS AND METHODS

A review was conducted that used the databases MEDLINE, PubMed, PsycINFO, and CINAHL. Articles were included that were published in English between 2001 and 2008 and used quantitative measures and statistical tests to compare health-related quality of life (HRQL) or QOL of childhood cancer survivors with population norms or matched comparison groups.

RESULTS

Thirteen studies were identified. Findings were contradictory across studies, yet by and large, reflected those of past reviews. In general, survivors' scores on subscales representing physical, psychological, and social domains of HRQL/QOL were similar to comparisons, with the greatest differences being in physical well-being. Key personal and environmental factors were negatively correlated with the three domains across studies for survivors including: older age at diagnosis, longer time since diagnosis, certain cancer and treatment types, female gender, and a number of socioeconomic factors.

CONCLUSIONS

Lack of comparability across studies remains a problem due to wide variation in study focus and designs. Conceptual and methodological issues include: use of numerous HRQOL and QOL measures, lack of distinction between conceptualization and measurement of HRQL and QOL, lack of initial qualitative input from survivors about QOL, little examination of the influence of environmental factors on QOL, little attention to survivors' satisfaction with life quality, use of small heterogeneous samples, and need for population-based longitudinal studies.

Longitudinal health-related quality of life outcomes and related factors after pediatric SCT

Our purpose was to investigate longitudinally health-related quality of life (HRQOL) outcomes and related factors up to 2 years post-pediatric SCT. A total of 99 mothers of patients, aged 1.5-17 years, completed two standardized HRQOL questionnaires, generic and disease specific (DS), about the child, and reported on their own symptoms of depression and family function pre-SCT, 12 and 24 months post-SCT. Clinical (diagnosis, radiation), child (age) and family (maternal depression) information was also obtained. Significant improvement in physical and psychosocial HRQOL from pre-SCT to 1 or 2 years post-SCT was reported. Survivors of ALL were reported to have poorer physical and psychosocial HRQOL than survivors of solid tumors on the DS measure. Maternal depression was negatively associated with physical and psychosocial HRQOL. Maternal education (higher) at pre-SCT predicted improvements in physical domains 2 years post-SCT; mother's age (older) and child's age (younger) also predicted improvements of physical and emotional HRQOL. We conclude that survivors of pediatric SCT improved physical and psychosocial HRQOL by 1 and 2 years post-SCT. Older survivors whose mothers are younger and distressed, with lower education at SCT have compromised HRQOL compared to other survivors. This study has important implications for the care of SCT survivors and their families.

Effect of dexamethasone on quality of life in children with acute lymphoblastic leukaemia: a prospective observational study

Background

Glucocorticoids are important in the treatment of childhood acute lymphoblastic leukaemia (ALL). However, cyclic administration of high dose glucocorticoids may cause rapid and substantial changes in quality of life (QoL). The maintenance phase of the Dutch ALL-9 protocol consisted of alternating two weeks on and five weeks off dexamethasone (6 mg/m²/day). The present study was performed to assess the effect of dexamethasone on QoL during treatment for ALL according to this protocol.

Methods

In a multicentre prospective cohort study, QoL was assessed halfway (T1) and at the end of the two-year treatment (T2). A generic (Child Health Questionnaire) and disease specific (PedsQL™ cancer version) QoL questionnaire were used to assess QoL in two periods: on and off dexamethasone, respectively.

Results

41 children (56% males) were evaluated, mean age at diagnosis was 5.6 years. The CHQ physical and psychosocial summary scores were significantly lower than population norms. At T1 and T2, overall QoL showed no significant change. However, regarding specific domains (pain, cognitive functioning, emotion/behaviour and physical functioning) QoL decreased over time. QoL was significantly more impaired during periods on dexamethasone.

Conclusion

Dexamethasone was associated with decreased QoL. At the end of treatment, reported QoL during dexamethasone deteriorated even more on certain scales (pain, cognitive functioning, emotion/behaviour and physical functioning). Knowledge of the specific aspects of QoL is essential to improve counselling and coping in paediatric oncology. Adverse effects of specific drugs on QoL should be taken into account when designing treatment protocols.

Twenty-five-year follow-up among survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for late effects of cancer therapy. Five-year ALL survivors (< 21 years at diagnosis; n = 5760 eligible, 4151 participants), diagnosed from 1970 to 1986 were compared with the general population and a sibling cohort (n = 3899). Cumulative mortality of 5760 5-year survivors was 13% at 25 years from diagnosis. Recurrent ALL (n = 483) and second neoplasms (SNs; n = 89) were the major causes of death. Among 185 survivors, 199 SNs occurred, 53% in the CNS. Survivors reported more multiple chronic medical conditions (CMCs; odds ratio [OR], 2.8; 95% CI, 2.4-3.2) and severe or life-threatening CMCs (OR, 3.6; 95% CI, 3.0-4.5) than siblings. Cumulative incidence of severe CMCs, including death, 25 years from diagnosis was 21.3% (95% CI, 18.2-24.4; 23.3% [95% CI, 19.4-27.2] and 13.4% [95% CI, 8.4-18.4] for irradiated and nonirradiated survivors, respectively). Survivors reported more adverse general and mental health, functional impairment, and activity limitations compared with siblings (P < .001). Rates of marriage, college graduation, employment, and health insurance were all lower compared with sibling controls (P < .001). Long-term survivors of childhood ALL exhibit excess mortality and morbidity. Survivors who received radiation therapy as part of their treatment or had a leukemia relapse are at greatest risk for adverse outcomes.

Health-related quality of life in children with thoracic insufficiency syndrome

BACKGROUND

The traditional techniques to treat thoracic insufficiency syndrome (TIS) are not able to stabilize or improve chest wall size or pulmonary function while allowing spine growth. To this end, vertical expandable prosthetic titanium rib (VEPTR) was specifically designed to treat TIS by allowing growth of the thoracic cavity and control/correction of spine deformity. The purpose of this study was to determine quality of life (QOL) of children with TIS and its impact on their parents before and after implantation of the VEPTR and also compare these results to those of healthy children.

METHODS

As part of the original multicenter evaluation of the VEPTR, a Child Health Questionnaire (CHQ) was collected preoperatively on 45 patients who were subsequently treated with expansion thoracoplasty using the VEPTR. The average age was 8.2 +/- 2.6 years, and the parent form of the CHQ was filled out by the primary caretaker. Patients were divided into 3 diagnostic categories: rib fusion (n = 15), hypoplastic thorax syndromes (n = 17), and progressive spinal deformity (n = 13).

RESULTS

There were significant differences between the study patients and healthy children in physical domains. Compared with parents of healthy children, parents of children with TIS experienced more limitations on their time and emotional lives due to their children's health problems. There were no significant differences in CHQ before and after the surgery except for a significant decrease in the self-esteem among a subgroup of patients with hypoplastic thorax syndromes. There were no significant differences in postoperative QOL between patients who had VEPTR-related complications and patients who did not have the complications.

CONCLUSIONS

The children with TIS had lower physical scores and higher caregiver burden scores than healthy children. However, the scores in psychosocial domains were similar to those in healthy children. Our study demonstrated that QOL of children and burden of care in their parents remained the same after VEPTR instrumentation. Children's QOL seemed to be not affected by whether they had VEPTR-related complications or not.