Quality of life in childhood cancer survivors

Life satisfaction in adult survivors of cancer during adolescence: what contributes to the latter satisfaction with life?

PURPOSE

To compare the general and health-related life satisfaction (LS) in long-term survivors of adolescent cancer with a community sample and to identify medical and psychosocial factors associated with LS.

METHODS

LS of 820 survivors (age M = 30.4 ± 6.0 years; time since diagnosis M = 13.7 ± 6.0 years) was assessed with the Questions on Life Satisfaction (FLZ(M)) and compared to an age- and sex-matched community sample. The effects of medical, psychological, and socio-demographical factors on the survivors' general and health-related LS were investigated by means of multiple regression analyses.

RESULTS

Survivors were significantly less satisfied than the comparison group in terms of both their general (P < .001, d = -.35) and health-related (P < .001, d = -.47) life. Somatic late effects, symptoms of depression and anxiety, and less posttraumatic growth were associated with impaired general and health-related LS. Moreover, being married contributed significantly to higher general LS.

CONCLUSION

Adult survivors of cancer with onset during adolescence are experiencing less LS than the general population. Long-term routine follow-up visits are recommended to identify persisting effects of cancer survival on LS and to provide support for those with special needs. Physicians need to pay special attention to potential risk factors such as psychological distress, somatic late effects, persistent psychological distress, and a lack of posttraumatic growth, which are negatively correlated with LS.

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.

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

THE AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

PROCEDURE

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

RESULTS

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

CONCLUSIONS

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

High health-related quality of life among long-term survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Health-related quality of life (HRQoL) was assessed in a cohort of long-term childhood acute lymphoblastic leukemia (ALL) survivors.

PROCEDURE

Rand-36-Item health Survey (RAND-36) was used to assess subjective HRQoL in 74 survivors of ALL an average of 20 years after the diagnosis. Cranial irradiation had been administered to 46 of the survivors, while 28 survivors had solely been treated with chemotherapy. The control group consisted of 146 healthy young adults selected from local population registry. Survivors were examined by a physician and late effects were graded using the Common Terminology Criteria for Adverse Events (CTCAEv3).

RESULTS

ALL survivors achieved significantly higher scores than the controls on three of the eight HRQoL subscales; role limitations due to emotional problems (P = 0.030), mental health (P = 0.030) and vitality (P = 0.004). In comparison to controls, survivors with a follow-up of more than 20 years had significantly higher scores on vitality (P = 0.006) and mental health (P = 0.011). Survivors with severe (grade 3 and 4) late effects scored significantly better than controls on vitality (P = 0.043) and mental health (P = 0.040). Patients who had been treated for an ALL relapse and had received the most intensive chemo- and radiotherapy had significantly higher scores on mental health (P = 0.004) and vitality (P = 0.004) than the controls.

CONCLUSIONS

Long-term survivors of childhood ALL reported equal or better HRQoL in RAND-36. Higher HRQoL scores were associated with more severe late effects and intensive therapy. Our findings support the idea of response bias.

Psychometric evaluation of a new instrument to measure uncertainty in children and adolescents with cancer

BACKGROUND

Although uncertainty has been characterized as a major stressor for children and adolescents with cancer, it has not been studied systematically.

OBJECTIVES

The objective of this study was to describe the development and initial psychometric evaluation of a measure of uncertainty in school-aged children and adolescents with cancer.

METHODS

Interview data from the first author's qualitative study of uncertainty in children undergoing cancer treatment (Stewart, 2003) were used to generate 22 items for the Uncertainty Scale for Kids (USK), which were evaluated for content validity by expert panels of children with cancer and experienced clinicians (Stewart, Lynn, & Mishel, 2005). Reliability and validity were evaluated in a sample of 72 children aged 8 to 17 years undergoing cancer treatment.

RESULTS

The USK items underwent minor revision following input from content validity experts, and all 22 were retained for testing. The USK demonstrated strong reliability (Cronbach's alpha = .94, test-retest r = .64, p = .005), and preliminary evidence for validity was supported by significant associations between USK scores and cancer knowledge, complexity of treatment, and anxiety and depression. Exploratory factor analysis yielded two factors, not knowing how serious the illness is and not knowing what will happen when, which explained 50.4% of the variance.

DISCUSSION

The USK, developed from the perspective of children, performed well in the initial application, demonstrating strong reliability and preliminary evidence for construct and discriminant validity. It holds considerable promise for moving the research forward on uncertainty in childhood cancer.

Psychological outcomes and health beliefs in adolescent and young adult survivors of childhood cancer and controls

PURPOSE The purpose of this study was to compare adolescent and young adult (AYA) pediatric cancer survivors and peers without a history of serious illness on psychological distress, health-related quality of life (HRQOL), health beliefs; examine age at diagnosis and cancer treatment intensity on these outcomes; and examine relationships between number of health problems and the outcomes. PATIENTS AND METHODS AYA cancer survivors (n = 167) and controls (n = 170), recruited during visits to a cancer survivorship clinic and primary care, completed self-report questionnaires of distress, health problems, and health beliefs. For survivors, providers rated treatment intensity and health problems. Results There were no statistically significant differences between survivors and controls in psychological distress or HRQOL. Cancer survivors had less positive health beliefs. Survivors diagnosed as adolescents had significantly greater psychological distress and fewer positive health beliefs than those diagnosed earlier. Survivors with the highest level of treatment intensity had greater anxiety and fewer positive health beliefs than those with less intense treatments. Provider report of current health problems related to survivors' beliefs and mental HRQOL only, whereas patient report of health problems correlated significantly with most psychosocial outcomes and beliefs. CONCLUSION AYA cancer survivors did not differ from peers in psychological adjustment but did endorse less adaptive health beliefs. Survivors diagnosed during adolescence and who had more intensive cancer treatments evidenced poorer psychosocial outcomes. Beliefs about health may be identified and targeted for intervention to improve quality of life, particularly when patient perceptions of current health problems are considered.

Families of young pediatric cancer survivors: A cross-sectional survey examining physical activity behavior and health-related quality of life

The present study examined physical activity levels within young families of pediatric cancer survivors and the relationship between physical activity and health-related quality of life (HRQL). Nineteen families were recruited, including 33 parents, 17 pediatric cancer survivors, and 10 siblings. Families completed a self-report survey on background information, physical activity levels, and PedsQL generic core scale for child HRQL. Results of this cross-sectional study indicate that families were generally active, with mothers more frequently participating in overall physical activity (P < .001). Within families, parent-child physical activity levels were associated, but not survivor-sibling physical activity. Survivors and siblings did not differ in their self-reported physical activity levels or HRQL, and no association was observed between physical activity and HRQL. However, discrepancies between sibling self-report and parent proxy-reported HRQL were notable. Overall, results from this exploratory pilot work will assist in further research into physical activity behaviors and HRQL in families of pediatric cancer survivors.The nurse should consider the varied experiences of family members, particularly those of siblings, through long-term follow-up.

Perceived Social Competency in Children With Brain Tumors: Comparison Between Children on and off Therapy

Children with brain tumors are at risk for a number of cognitive, academic, and social difficulties as a consequence of their illness and its treatment. Of these, the least is known about social functioning, particularly over the course of the illness. Thirty children with brain tumors were evaluated using neurocognitive and psychological measures, including a measure of perceived competency. Results indicated that off-therapy brain tumor patients reported more concerns about their social competence than both a normative sample and children on treatment. Findings highlight the need for more research aimed at helping survivors cope with long-term stressors associated with their illness.

Rehabilitation for survivors of pediatric brain tumors: our work has just begun

CNS tumors are the second most common childhood cancer, and survival rates for children with these tumors have increased over the last few decades. Children are often treated with a combination of neurosurgery, chemotherapy and cranial radiation. Both the tumors and these therapies can lead to cognitive challenges, decreased social participation or coping, and physical dysfunction, which can impede a child’s ability to complete daily activities and participate in his or her environment. This review describes these late effects in the framework of the International Classification of Functioning, Disability and Health, and discusses the few studies that have attempted to improve children’s functioning in their environment beyond just survival.

Psychosocial outcomes and service use among young adults with cancer

At the crossroads between pediatric and older adult groups, young adults with cancer may be underserved or inadequately or inappropriately served by existing support services. Empirical evidence has not established well the extent to which utilization of psychosocial support services delivered throughout a continuum of care results in desired outcomes. If self-efficacy is demonstrated to play a significant role in promoting quality of life and psychological well-being in young adult cancer patients, then a cancer-specific self-efficacy model can serve as an evidence-based framework for developing, implementing, and testing new interventions. A focus on self-efficacy has the potential to promote young adults' abilities to remain active and independent, seek and understand medical information, manage stress, cope with treatment-related side effects, maintain a "positive attitude," regulate emotions, and seek social support. Future research should aim to identify which patients represent at-risk targets for intervention, as well as the most appropriate time points along the continuum of care at which patients/survivors are most likely to benefit from delivery/utilization of psychosocial support services.

Health-related quality of life in long-term survivors of childhood brain tumors

BACKGROUND

To identify predictors for health-related quality of life (HRQOL) in survivors of childhood brain tumors and its relationship to cognitive function.

PROCEDURE

One hundred twenty-six consecutive Danish childhood brain tumor patients treated 1970-1997 and being 7.9-40.4 years at follow-up were assessed for general intelligence (IQ) and administered the Minneapolis-Manchester Quality of Life (MMQL) questionnaire.

RESULTS

In multivariate linear regression treatment with RT was the most important risk factor for reduced HRQOL. Lower scores for physical functioning and energy, social functioning, cognitive functioning, body image, outlook of life, and intimate relations were significantly related to RT. Tumor location in the posterior fossa was associated with lower scores for physical functioning and energy, and tumor site in the third ventricle region was associated with lower scores for body image. Younger age at diagnosis was associated with lower scores for social functioning and intimate relations, and younger age at follow-up was associated with more physical symptoms. When IQ was included as a covariate, RT only remained significant for social functioning and intimate relations while tumor location in the third ventricle region remained significant for body image, younger age at diagnosis for social functioning and intimate relations, and younger age at follow-up for physical symptoms. In contrasts, neither gender nor presence of hydrocephalus requiring shunt inserted predicted significantly reduced HRQOL in the multivariate analyses.

CONCLUSION

RT is an important predictor of HRQOL primarily due to its effect on general intelligence, which suggests that IQ is a strong determinant of HRQOL.

Brain Tumor Survivors Speak Out

Although progress has been made in the treatment of childhood brain tumors,work remains to understand the complexities of disease, treatment, and contextual factors that underlie individual differences in outcome. A combination of both an idiographic approach (incorporating observations made by adult survivors of childhood brain tumors) and a nomothetic approach (reviewing the literature for brain tumor survivors as well as childhood cancer survivors) is presented. Six areas of concern are reviewed from both an idiographic and nomothetic perspective, including social/emotional adjustment, insurance, neurocognitive late effects, sexuality and relationships, employment, and where survivors accessed information about their disease and treatment and possible late effects. Guidelines to assist health care professionals working with childhood brain tumor survivors are offered with the goal of improving psychosocial and neurocognitive outcomes in this population.

Quality of life of adolescent and young adult survivors of childhood cancer

The purpose of this study was to assess the quality of life of Greek survivors of childhood cancer by addressing the physical, psychological, spiritual, and social dimensions of their functioning. The SF-36 Health Survey and the Quality of Life Questionnaire, which was designed for this study, were used. Survivors' scores on most subscales of SF-36 were similar to those of controls, despite some difficulties in their daily activities. They perceived self as more susceptible to health problems, but also more mature and grounded. Generally, they seem to adapt well and focus on the positive aspects of their cancer experience, which enhances the meaning and quality of their life.

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.

A predictive model of health-related quality of life in young adult survivors of childhood cancer

A predictive model of health-related quality of life in young adult survivors of childhood cancerThis study aimed to examine factors that affect survivors' health-related quality of life (HRQoL), using a theoretical model in which demographic and medical characteristics explain HRQoL mediated by course of life, coping and social support. In a cross-sectional design, 353 survivors aged 18-30 years completed questionnaires. Structural equation modelling was performed to investigate the relationships among the variables in the model and to test whether the model fitted the data. The model fitted the data closely: chi(2)(14) = 21.61, P = 0.087; root mean square error of approximation = 0.039, 90% confidence interval [0.00; 0.070]. The effect of medical and demographic characteristics on HRQoL was mediated by coping. Survivors having been treated with both chemotherapy and radiotherapy were most at risk for worse HRQoL because they suffer more from current health complaints and were less inclined to predictive and active coping. Screening survivors medically as well as psychosocially could help to identify patients with the greatest needs and direct interventions by which the follow-up care could be improved.

Children in remission from acute lymphoblastic leukaemia: mental health, psychosocial adjustment and parental functioning

Children in remission from acute lymphoblastic leukaemia: mental health, psychosocial adjustment and parental functioningThe objective of this study is to assess the mental health and psychosocial adjustment of children in remission from acute lymphoblastic leukaemia (ALL), and parental functioning compared to healthy controls. A cross-sectional study of 40 children treated for ALL (mean age 11.8 years, range 8.5-15.4) and healthy controls (n = 42) (mean age 11.8 years, range 8.11-15.0) were assessed by the Child Behaviour Checklist (CBCL), the Youth Self-Report (YSR) and the Strength and Difficulties Questionnaire (SDQ). The parent's own mental health was assessed by the General Health Questionnaire (GHQ-30). Children treated for ALL showed on average significantly more symptoms as measured by the CBCL Total Behaviour Score for mother's report (P = 0.005), and for father's report (P = 0.004) compared with healthy children. Fathers reported more anxiety (P = 0.03) and depression (P = 0.02) as measured by the GHQ-30 compared with healthy controls. Children in remission from ALL showed on average significantly more problems regarding mental health and psychosocial adjustment, as reported by their parents, compared with healthy controls. Adequate rehabilitation and follow-up programmes should be implemented for children in remission from ALL. The results indicate the need to pay attention to the mental health of fathers during the rehabilitation phase.

Late Effects of Childhood Cancer, Participation, and Quality of Life of Adolescents

This study investigated the late effects of childhood cancer on participation and quality of life. Ninety-two percent of survivors (9 to 18 years of age) reported living with late effects of lower extremity pain and numbness, memory and attention deficits, and fatigue, depression, or both. Semistructured interviews with 25 survivors using the Canadian Occupational Performance Measure and the Adolescent Activity Card Sort captured frequencies, interests, and barriers for a range of activities. Survivors reported diminished engagement in vigorous leisure activities, chores, and community activities. Lower engagement in social activities was correlated with lower quality of life scores, as measured by the Pediatric Cancer Quality of Life Inventory-32. Despite these findings of significant cognitive and physical problems, none of the 25 survivors had individualized education programs in school, nor were any receiving occupational therapy at the time the survey was completed. The findings emphasize the importance of advocacy for occupational therapy services for survivors of childhood cancer and examination of adolescent survivor participation in, and goals for, typical activities.

'A life on hold': adolescents' experiences of stem cell transplantation in a long-term perspective

Stem cell transplantation is one of the treatment methods for cancer in children and adolescents which has resulted in a positive outcome. Unfortunately this method of treatment brings with it a number of late effects such as short stature, cognitive effects and infertility. However, a majority of children and adolescents experience a good quality of life. By examining their medical records this study has gained a deeper understanding of the situation for the minority of young people who describe themselves as suffering severe mental distress which they relate to their illness and treatment. The population comprised seven adolescents who sought psychotherapeutic support several years after treatment. They describe how they are affected by the feeling of being different, the loss of contact with friends and their dependence on parents. The study points to the need for long-term psychosocial support for children and adolescents who have undergone stem cell transplantation.

Distress persists in long-term brain tumor survivors with glioblastoma multiforme

INTRODUCTION

Glioblastoma multiforme (GBM) is the most common and aggressive type of primary brain tumor. The prognosis for GBM patients is extremely poor with an estimated median survival of 12 months. Despite this statistic, a number of GBM patients are living longer than in the past as new detection and treatment approaches are used. However, little is known about the psychological correlates of this disease. To address this issue we investigated distress and its sources in long-term survivors (LTS) of this disease.

MATERIALS AND METHODS

Participants were asked to complete the National Comprehensive Cancer Network's (NCCN) Distress Thermometer, a single-item rapid screening tool for distress. Participants were also asked to designate sources of distress from a 34-item list developed by the NCCN. Distress scores and sources of distress for long-term GBM survivors (>18 months) were compared to patients diagnosed within the last 18 months (<18 months).

RESULTS

Eight-three brain tumor patients participated in this study. Fifty-nine percent of LTS met the > or = 4 cut-off score for distress (M = 4.61, SD 3.12) as compared to 49% of patients diagnosed less than 18 months (M = 3.93, SD = 2.21; x(2) = 0.406, NS), LTS reported fewer items of concern while more LTS reported being distressed.

CONCLUSIONS

This study indicates that LTS of GBM report experiencing distress at similar levels to other brain tumor patients. Level of distress for LTS is directly related to the total number of concerns in both emotional and physical domains.

IMPLICATIONS FOR CANCER SURVIVORS

Regardless of LTS status, distress continues to be a part of the disease trajectory for many GBM patients. As such, attention to distress in these survivors of a major life threatening disease is warranted in follow up surveillance visits.

Positive and negative consequences of childhood cancer influencing the lives of young adults

The aim of the study was to describe how young adults who have survived childhood cancer consider their present life to be influenced by the cancer experience. A cohort of 246 long-term survivors were approached a median of 16 years after diagnosis. Semi-structured telephone interviews were conducted based on the Swedish version of the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW). Interviews were analysed using content analyses. When asked if cancer negatively or positively currently affected their lives, 68% reported at least one negative consequence and 53% at least one positive consequence. The most frequently reported negative consequences include a variety of physical impairments and limitations in participating in activities; positive consequences describe a more positive view of life and of self. Women more often than men reported negative psychological impact, a changed body appearance and positive interaction with others. CNS tumours and combined treatment were somewhat associated to a higher extent of negative consequences. Overall, the results indicate that long-term survivors of childhood cancer are getting along quite well despite shortcomings.

The pediatric cancer hospitalization experience: reality co-constructed

Although pediatric cancer treatment has been reviewed by several authors, the lived experiences of children undergoing this process have seldom been discussed in the literature. The data for this article were obtained from a larger qualitative study that provided a collective view of the pediatric cancer experience at San Jorge Children's Hospital in Puerto Rico. In this article, findings that are directly related to the hospitalization process of these young patients are described, including the hospital as a safe haven, dealing with pain, taking control, and thriving in adversity. These findings provide a rationale for the development of a biopsychosocial model of health that emphasizes reciprocal interactions among the biological, psychological, social, cultural, and spiritual dimensions that influence health.

Repressive adaptive style and self-reported psychological functioning in adolescent cancer survivors

Low levels of posttraumatic stress disorder (PTSD), posttraumatic stress symptoms (PTSS), and psychosocial distress have been reported in pediatric cancer survivors. One explanation is the relatively high prevalence of the repressive adaptive style (low distress, high restraint) in this population. We investigated the relationship between this adaptive style and PTSD, PTSS, and psychosocial functioning in 29 adolescent cancer survivors (12 through 18 years). Adolescents categorized as repressors (n = 14) reported moderate/large effect size differences in PTSD, PTSS, and psychosocial distress (lower) as well as QOL (better) compared to non-repressors. Furthermore, repressors reported less PTSD and QOL variability. Thus, the repressive adaptive style, pronounced in this population, may obscure systematic and clinically meaningful adaptive style group differences across psychological measures.

A community-based physical activity program for adolescents with cancer (project TREK): program feasibility and preliminary findings

INTRODUCTION

As the number of pediatric survivors continues to grow, a greater emphasis is being placed on identifying long-term health risk/protecting behaviors. The primary purpose of this pilot study was to examine the feasibility of a theoretically-based physical activity (PA) intervention in adolescents with cancer.

METHODS

A group PA intervention was administered to participants over 16 weeks. Program attendance/adherence, total PA, physical fitness, and quality of life (QOL) were assessed at 5 different intervals over the 1-year study duration.

RESULTS

Over a period of 6 weeks, 11 adolescents responded to recruitment efforts. Ten ultimately enrolled and completed the 1-year study. Overall, the program was well received with attendance over the 16-week intervention averaging 81.5%. Although improvements in total PA, physical fitness, and QOL were noted across the intervention, follow-up data revealed that participants failed to maintain their postintervention PA levels at both the 3 and 12-month follow-up assessments.

CONCLUSIONS

Adolescents with a history of cancer are undoubtedly susceptible to the same maladaptive health habits as are their healthy peers. Innovative interventions aimed at improving their adherence to positive behavioral interventions, such as PA are warranted. Although not without limitations, this study provides preliminary data in support of a university-sponsored PA intervention.

Caring for adult survivors of childhood cancer

OPINION STATEMENT

Improved survival for pediatric oncology patients is a remarkable achievement of modern medicine. This success can be credited to the introduction of multimodality therapy and newer risk-based therapies developed and tested through national research protocols. With improved survival has come recognition of the many long-term effects of cancer and its treatment, such as vital organ dysfunction, subsequent malignancies, and psychosocial deficits. Childhood cancer survivors are vulnerable to adverse health outcomes which may not become apparent until years after therapy. These events may manifest well into adulthood when these individuals rarely return to their initial cancer center or seek preventive medical care. Risk-based follow-up can offer early detection and/or intervention and provides an opportunity to reduce cancer-related morbidity and mortality. An understanding of the late effects of cancer therapy is increasingly important for the medical community, both generalists and specialists-adult and pediatric, to better care for the growing population of adult survivors of childhood cancer.

Happiness and time perspective as potential mediators of quality of life and depression in adolescent cancer

BACKGROUND

Given the increase in 5- and 10-year survival rates of children and adolescents diagnosed with cancer, current psycho-oncology literature is focusing on finding correlates and predictors to their positive psychosocial adjustment. The purpose of this study was to evaluate two potential mediators to adolescent cancer survivors' quality of life (QOL) and depressive symptomology.

PROCEDURE

Adolescent cancer survivors (N = 50; 50% males; mean diagnosis age, 13.7; mean age at study, 20.2) were surveyed, testing the mediation effects of their happiness (Subjective Happiness Scale) and past-negative time perspective (Zimbardo Time Perspective Inventory) on QOL (PedsQL 4.0) and depressive symptomology (CES-D). Independent variables included gender and treatment intensity.

RESULTS

Happiness significantly mediated the relationship between treatment intensity in both depressive symptomology (beta = -0.65, P < 0.05, CI = -2.46, -6.41) and QOL (beta = 0.54, P < 0.05, CI = 3.66, 9.01). A past-negative time perspective significantly mediated the relationship between gender and depressive symptomology (beta = 0.60, P < 0.05, CI = 3.34, 9.78). Survivors' gender was not associated with happiness and treatment intensity was not associated with time perspective.

CONCLUSIONS

Happiness may be a more direct predictor of QOL and depression than the intensity of treatment for cancer. Also, thinking negatively about one's past may be a more direct predictor of depressive symptomology than being female. Therefore, interventions that cultivate happiness and reframe time perspective may be effective ways to improve survivors' QOL and decrease depressive symptoms-regardless of gender and intensity of treatment protocol.

Challenges after curative treatment for childhood cancer and long-term follow up of survivors

Childhood cancer survivors are at increased risk of serious morbidity, premature mortality, and diminished health status. Proactive and anticipatory risk-based health care of survivors and healthy lifestyles can reduce these risks. In this article, the authors first briefly discuss four common problems of survivors: neurocognitive dysfunction, cardiovascular disease, infertility and gonadal dysfunction, and psychosocial problems. Second, the authors discuss the concept of risk-based care, promote the use of recently developed evidence-based guidelines, describe current care in the United States, Canada, and the Netherlands, and articulate a model for shared survivor care that aims to optimize life long health of survivors and improve two-way communication between the cancer center and the primary care physician.

Long-term psychosocial support for families of children who have undergone allogeneic stem cell transplant

Stem cell transplant (SCT) in children has a continuing impact in the lives of the SCT recipients and their families. This realization has led to extended psychosocial support to these families. The aim of this study was to evaluate the extended psychosocial support. How many families accepted the proffered contact with the social worker and what kind of support did the families ask for? The data were collected from the patients' medical charts by the health care social worker. Content analysis was used as the research method. The study reveals a need for continued psychosocial support lasting many years after treatment. The need for support does not lessen with the passage of time, but the nature of the support changes.

Orthostatic intolerance in survivors of childhood cancer

PURPOSE

To compare the prevalence and severity of orthostatic intolerance in survivors of childhood cancer and in healthy controls, and to correlate results of self-reported measures of health status with orthostatic testing in survivors of childhood cancer.

PATIENT AND METHODS

Thirty-nine survivors of childhood cancer and 56 controls were recruited for this study. Each cancer survivor completed standardised self-report measures and all participants underwent a standing test (5 min supine, 10 min of motionless standing leaning against a wall, followed by another 2 min supine). The main outcomes of the standing test were orthostatic tachycardia (OT), defined as a heart rate increase of at least 30 beats per minute (bpm) during standing, and neurally mediated hypotension (NMH), defined as a drop in systolic blood pressure of at least 25 mmHg.

RESULTS

OT developed in 22/39 (56%) cancer survivors versus 17/56 (30%) controls (P=.01). Cancer survivors had a higher baseline and maximum standing heart rate (both P<.001) and a more rapid onset of significant OT (P=.005). No significant difference in scores on self-report measures was found between cancer survivors with or without OT.

CONCLUSION

This study provides preliminary evidence of a higher rate of orthostatic intolerance in childhood cancer survivors. Further study is warranted to better define whether this is a modifiable risk factor for fatigue in this population, and how orthostatic intolerance interacts with other known risk factors for lowered quality of life.

'Having cancer changed my life, and changed my life forever': survival, illness legacy and service provision following cancer in childhood

OBJECTIVES

To explore how having cancer in childhood influences social and personal wellbeing in young adulthood.

METHODS

Questionnaires (55) eliciting lengthy written responses and in-depth interviews (32) were used with male and female survivors of cancer in childhood (aged between 18 and 28 years). Analysis drew on a combination of grounded-theory techniques and narrative analysis.

RESULTS

Three key areas are outlined relating to the characterization of survivorship by participants. These include highlighting survival as not necessarily a simple end to a cancer story, issues relating to post-cancer bodily self-concept and its gendering, and, efforts at managing uncertainties through medical interactions and information gathering.

DISCUSSION

Participant stories in this study illustrate that even in long-term survival, cancer is present as a web of ongoing influences from the original disease and treatment, as well as the social and personal aftershocks that can occur well after malignant cells have been controlled. Findings highlight the necessity for complex redevelopment of healthcare services and social support provisions for this growing population.

Meeting the ongoing needs of survivors of rarer cancer

With more treatment options for people with cancer long-term survivorship is increasing. Physical and psycho-social needs have been identified in survivors of common cancers but very little has been written about the needs of patients with rarer cancers. Patients treated for rarer cancer are discharged to the primary health care team (PHCT), yet little is known about the assessment, management and support of these patients. Thirty-nine semi-structured interviews were conducted with (1) survivors of and (2) people living with rarer cancer (i.e. <5% of cancer burden). Participants were asked about physical and psycho-social needs and service provision. Data were analysed thematically using Atlas ti. Contrary to expectation, disease-free survivors of rarer cancer were indistinguishable from those living with disease in their ability to cope, and range of symptoms and needs. Participants with a clinical nurse specialist (CNS) reported that they were well supported on their return home and their needs were met. Participants without a CNS were referred to the PHCT who were unsure how to assess or support them. These participants felt abandoned. There is a need for the rehabilitation of patients with rarer cancer to strengthen individual coping mechanisms, and family and social support. Although there are resource and training implications, this is a potential role for the PHCT, district nursing in particular, and may lead to more focused and targeted provision of services.

Psychosocial dimensions of cancer in adolescents and young adults

Psychosocial research examining the impact of cancer on adolescents and young adults has focused mostly on domains relating to family, psychological/emotional impact and social effects. An overview of the evidence-based literature available in each of these domains is presented to highlight the trends and provide a basis for clinical application. A review of the research literature was conducted to summarize what is known regarding the psychosocial dimensions of cancer in adolescents and young adults. Key elements critical to the psychosocial adaptation of the adolescents and young adults with cancer, as well as later effects of the cancer experience, are discussed in terms of clinical implications. A case example is utilized to demonstrate the application of what has been investigated empirically in regard to psychosocial dimensions of cancer in young adults and adolescents. Studies have identified various psychosocial challenges that adolescents and young adults experience when faced with cancer. Further research, incorporating the effects of treatment stage and developmental level of the patient on specific psychosocial dimensions of the cancer experience, is needed. Evidence-based information regarding the influence and interaction of family, psychological and emotional state, and social status of adolescents and young adults with cancer can aid clinicians when developing psychosocial assessment and treatment approaches for these patients.

Factors associated with health-related quality of life in pediatric cancer survivors

BACKGROUND

Childhood cancer survivors are at risk for late effects of disease and treatment that may be attributed to multiple causes. This study describes health-related quality of life (HRQOL) in childhood cancer survivors and identifies factors related to poor quality of life outcomes.

PROCEDURE

Patients age 8-18 years, who attended the long-term information, follow-up, and evaluation (LIFE) clinic at Childrens Hospital Los Angeles during a 1-year time-period were eligible for the study. Eighty-six survivors (mean time off-treatment=7.8 years) completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scales, a LIFE Clinic Intake Questionnaire and rated their fatigue using a 10-point scale. Oncology nurses independently rated subjects' late effects using a 3-point severity scale. Linear regression procedures were used to evaluate the association between demographic and medical factors and HRQOL.

RESULTS

Fatigue and more severe late effects were associated with poorer physical functioning (fatigue, P<0.02; late effects, P<0.01). Fatigue, ethnic minority status, and a brain tumor diagnosis were associated with poorer psychosocial functioning (fatigue, P<0.0001; minority status, P<0.04; brain tumor, P<0.01). Fatigue was the only factor related to both poor physical and psychosocial HRQOL.

CONCLUSIONS

Long-term follow-up clinics for childhood cancer survivors are in a unique position to monitor HRQOL over time. Factors associated with poorer HRQOL include fatigue, ethnic minority status, a brain tumor diagnosis, and more severe late effects. Future studies need to clarify relationships between ethnicity, socioeconomic status (SES), and HRQOL in cancer survivors.

Hope and spiritual well-being in adolescents with cancer

This study examines the relationships of hope and spiritual well-being (SWB)--and its dimensions, religious well-being (RWB) and existential well-being (EWB)--to time since diagnosis among adolescents with cancer. A descriptive cross-sectional design was used. The sample of 78 adolescents diagnosed with cancer was recruited from two pediatric oncology clinics. Adolescents in the first two time periods reported significantly higher levels of SWB, RWB, and EWB than those in subsequent time periods. Hope did not significantly vary over time. Hence, time since diagnosis may influence adolescents' levels of SWB and its dimensions during the cancer experience. Adolescents' use of SWB, RWB, and EWB as coping resources should be examined in longitudinal studies from diagnosis through survivorship.

Health-related quality of life, anxiety and depression among adolescents and young adults with cancer: a prospective longitudinal study

The present study sets out to add to knowledge about the development over time of health-related quality of life (HRQL), anxiety and depression among survivors of adolescent cancer. The aim was to investigate if and how the HRQL, anxiety and depression of a group of adolescents with cancer differ from those of a reference group shortly after diagnosis, and subsequently at 6, 12 and 18 months after diagnosis. Adolescents diagnosed with cancer and a reference group randomised from the general population completed the Hospital Anxiety and Depression Scale (HADS) and the two subscales Mental Health and Vitality in the Short Form 36 (SF-36) in telephone interviews. The results indicate a steady increase in psychological well-being from the time of diagnosis, when the cancer patients' ratings were significantly worse than those of the general population, and onwards. The differences gradually disappeared and then were reversed, resulting in the cancer group reporting significantly better HRQL and lower levels of anxiety and depression than the reference group when 1.5 years had passed since diagnosis. The adolescents faced with cancer show signs of adaptation to trauma, which can be understood in relation to the theoretical framework of posttraumatic growth as well as response shift. Future research should continue to follow this development over time, to investigate if the positive effects of the cancer experience will wear off, or if it has facilitated a permanent positive outcome.

The effects of response bias on self-reported quality of life among childhood cancer survivors

BACKGROUND

Several studies of long-term adjustment in childhood cancer survivors (CCS) report very positive outcomes, while other studies find significant adjustment problems. These inconsistencies have prompted some investigators to suggest survivors may be biased responders, prone to underreporting on self-report measures. This study tested the hypothesis that CCS are elevated on self-deception response bias (SDRB), and that SDRB is associated with higher ratings of quality-of-life (QOL).

METHODS

One hundred and seven adult (mean age = 31.85) survivors of childhood cancers completed a demographic questionnaire, Short Form-12 (SF-12), Functional Assessment of Cancer Therapy-General (FACT-G), and Self-Deception Enhancement scale (SDE), an SDRB measure.

RESULTS

Survivors' QOL scores were similar to normative groups, but they evidenced much higher levels of response bias. SDE scores were significantly correlated with the FACT-G, and SF-12 Mental Health (but not Physical Health) scores even after accounting for demographic and treatment-related variables.

CONCLUSIONS

CCS show a biased response style, indicating a systematic tendency to deny difficulties on QOL measures. This may complicate QOL studies by inflating survivors' reports of their socio-emotional functioning. Understanding how response bias develops may help us learn more about cancer survivors' adaptation to illness, and the effects of the illness experience on their perceptions of QOL.

Stress and long-term survivors of brain cancer

INTRODUCTION

Adult brain tumor patients are joining the ranks of cancer survivors in increasing numbers in the United States. As a result, health care providers are faced with new challenges to address the need for psychosocial support in this population.

METHODS

Using the Perceived Stress Scale and the National Comprehensive Cancer Network's Distress Thermometer, levels of stress and cancer-related items of concern were assessed in adult long-term survivors of brain cancer.

RESULTS

Sixty-one percent of the sample population experienced elevated levels of stress. Scores were not significantly associated with age, gender, treatment status, or tumor grade. Long-term survivors were just as likely to report being stressed (chi(2) = 0.032, NS), while reporting fewer numbers of items of concern (5.02, SD = 3.509), compared to brain tumor patients diagnosed 18 months (M = 6.82, SD = 3.737, t = 2.467, p 0.05).

DISCUSSION/CONCLUSION

Despite their long-term survival status, long-term survivors of brain cancer continue to experience elevated levels of stress. Predictors of stress in this population are related to familial, emotional, and practical concerns. While the scientific community continues to examine the specific impact of stress on both the physical and mental outcomes of cancer patients, understanding the sources of stress within cancer populations is key in designing targeted interventions to help patients manage the stress associated with this disease. IMPLICATIONS FOR BRAIN TUMOR SURVIVORS: This study provides a better understanding of the unique needs of long-term survivors of brain cancer. An awareness of the sources and levels of stress experienced by this population could lead to the development of effective supportive care interventions to improve the quality of life of the survivor.

The Health Utilities Index 3 invalidated when completed by nurses for pediatric oncology patients

When health-related quality of life instruments developed for and validated in 1 respondent group are completed by a different respondent group, findings could be invalid. The purpose of this study was to summarize the instrument outcomes when a widely used health-related quality of life instrument (the Health Utilities Index 3 [HUI3]) created from a population-based strategy was completed by pediatric oncology nurses for their patients during cancer treatment. Fifty-four nurses completed the HUI3 a total of 261 times at 1 to 3 sequential data points (106, 94, and 61, respectively) for pediatric patients who were enrolled on a frontline therapeutic clinical trial for acute lymphoblastic leukemia. Data were collected at 2 children's hospitals. HUI3 scores could not be calculated for 52% to 61% of the nurse reports at each of the 3 data points because of nurses' use of the "do not know" response option. Missing data of this proportion indicate that the nurse serving as a proxy rater independent of directly soliciting responses from the patient will not be able to rate certain attributes of the HUI3 more than half of the time despite having ongoing familiarity with the patient. Because of this, use of the HUI3 by nurse proxies for patients with pediatric acute lymphoblastic leukemia is not recommended.