The cancer is over, now what?: Understanding risk, changing outcomes

A qualitative study of young childhood cancer survivors and their parents' experiences with treatment-related late effects in everyday life post-treatment

AIMS

The purpose of this secondary analysis was to explore how young cancer survivors and their parents experience and manage treatment-related late effects in daily life post-treatment.

DESIGN

A phenomenological-hermeneutic explorative study.

METHODS

Using purposive sampling, we included 15 childhood cancer survivors (aged 11-18 years) and their parents who participated in semi-structured interviews from September 2019 through May 2020. We analysed the interviews paired using a thematic approach focused on meaning.

RESULTS

The central theme, 'Negotiation daily life', emerged as well as three interrelated sub-themes, that is 'A changed everyday life', 'Physical activity as a tool' and 'Friends as a tool'. The childhood cancer survivors and their parents experienced, understood and interpreted the late effects differently. The difference between the survivors' perceptions and those of their parents in managing treatment-related late effects in everyday life resulted in a continuous negotiation process between the parties. Parents highlighted the negative impact of late effects on their child's daily life in relation to physical activity, school and socialization while the survivors wished to leave the cancer experience behind and 'move on' with their friends. As a result, most of the survivors developed strategies to manage their social activities while their parents felt that the survivors neglected the late effects.

CONCLUSION

The ongoing negotiation process between the childhood cancer survivors and their parents show the complexity of the new family dynamics on returning to everyday life post-treatment. For clinical nurses, that means that there should be focus on family dynamics and how the childhood cancer survivors and parents, respectively, manage the childhood cancer survivors' late effects.

IMPACT

Healthcare providers should distinguish between the needs of the survivors and those of their parents as they transition from treatment to everyday life, and especially in the management of late effects caused by the treatment.

Risk-Stratified Pathways for Cancer Survivorship Care: Insights from a Deliberative Multi-Stakeholder Consultation

Risk-stratified pathways of survivorship care seek to optimize coordination between cancer specialists and primary care physicians based on the whole person needs of the individual. While the principle is supported by leading cancer institutions, translating knowledge to practice confronts a lack of clarity about the meaning of risk stratification, uncertainties around the expectations the model holds for different actors, and health system structures that impede communication and coordination across the care continuum. These barriers must be better understood and addressed to pave the way for future implementation. Recognizing that an innovation is more likely to be adopted when user experience is incorporated into the planning process, a deliberative consultation was held as a preliminary step to developing a pilot project of risk-stratified pathways for patients transitioning from specialized oncology teams to primary care providers. This article presents findings from the deliberative consultation that sought to understand the perspectives of cancer specialists, primary care physicians, oncology nurses, allied professionals, cancer survivors and researchers regarding the following questions: what does a risk stratified model of cancer survivorship care mean to care providers and users? What are the prerequisites for translating risk stratification into practice? What challenges are involved in establishing these prerequisites? The multi-stakeholder consultation provides empirical data to guide actions that support the development of risk-stratified pathways to coordinate survivorship care.

A Cardiac Rehabilitation Program for Breast Cancer Survivors: A Feasibility Study

Purpose

The purpose of this study was to determine the feasibility and preliminary efficacy of a cardiac rehabilitation (CR) intervention in the breast cancer population.

Methods

This single-arm feasibility study evaluated a 14-week CR intervention program in breast cancer survivors. Feasibility was defined as completion of at least 30/36 sessions of the program without serious adverse events (SAE) in 80% of patients. Secondary endpoints included the change in VO2 max, cardiovascular disease (CVD) risk factors, Duke Activity Secondary Index (DASI), Brief Fatigue Inventory (BFI), and QLQ-C30. All outcomes were reported as mean change and compared using paired t-tests.

Results

A total of 25 patients were enrolled in the study. 18 patients of the 25 enrolled (72%) completed the 14 weeks program without SAE. The overall adherence to the study protocol was 60%. Of the 18 participants who did not withdraw from the program, 15 (83%) adhered to the study protocol and completed 30 or more sessions. There was a nonsignificant improvement in VO2 max (mean Δ0.5, p=0.6). The scores for DASI, BFI, and QLQ-C30 improved from baseline to posttreatment.

Conclusion

A CR intervention in breast cancer survivors had high adherence in those who were able to complete the 14-week program. The program significantly improved patient reported physical activity, fatigue, and quality of life (QoL), without significant improvement in CVD risk factors. Implications for cancer patients are that early implementation of a CR program should be considered by practitioners as it improves QoL and exercise tolerance in breast cancer survivors.

Late effects in survivors treated for lymphoma as adolescents and young adults: a population-based analysis

PURPOSE

The study objective is to describe and quantify the incidence of treatment-induced late effects in AYA lymphoma patients.

METHODS

Consecutive patients diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) at 15-24 years of age were identified. All patients in British Columbia who received radiation therapy (RT) from 1974 to 2014 with ≥ 5-year survival post-RT were included. Late effects' analyses included only survivors who received RT to the relevant anatomical site(s) and/or relevant chemotherapy, and were reported as cumulative incidence (CI) ± standard error.

RESULTS

Three hundred and five patients were identified (74% HL). Median age of diagnosis was 21 years. Median follow-up was 19.1 years for secondary malignancy and 7.2 years for other endpoints. Hypothyroidism was the most prevalent late effect, with a CI of 22.4 ± 2.8% and 35.1 ± 4% at 5 and 10 years, respectively. CI of in-field secondary malignancy was 0.4 ± 0.4% at 10 years and 2.8 ± 1.2% at 20 years. CI of symptomatic pulmonary toxicity was 4.6 ± 1.5% and 6.8 ± 2.0% at 5 and 10 years, respectively, and was higher in patients receiving multiple RT courses (p = 0.009). Esophageal complications occurred at a CI of 1.4 ± 0.8% at 5 years and 2.2 ± 1.1% at 10 years. CI of xerostomia/dental decay was 2.6 ± 1.3% at 5 years and 4.9 ± 2.1% at 10 years. CI of cardiac disease was at 2.3 ± 0.9% at 5 years and 4.4 ± 1.5% at 10 years. CI of infertility was 6.5 ± 1.6% at 5 years and 9.4 ± 2.1% at 10 years.

CONCLUSION

Survivors of AYA lymphoma have a high incidence and diverse presentation of late effects.

IMPLICATIONS FOR CANCER SURVIVORS

AYA lymphoma survivors should be educated about their risks of late effects and offered screening and follow-up when appropriate.

Barriers and facilitators of risk-based health care for adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

Optimal risk-based survivor health care includes surveillance for late effects and education targeted at reducing or preventing risky health behaviors. Understanding the reasons for a lack of risk-based follow-up care is essential.

METHODS

Adult participants from the Childhood Cancer Survivor Study were surveyed about having a cancer-related visit in the past 2 years and the likelihood of having a cancer-related visit in the future. Additional factors thought to be related to the primary outcomes were also assessed.

RESULTS

Nine hundred seventy-five survivors completed the survey. Twenty-seven percent (95% confidence interval [CI], 24%-30%) had a cancer-related medical visit in the previous 2 years, and 41% (95% CI, 38%-44%) planned to have such a visit within the next 2 years. The likelihood of having had a cancer-related visit within the last 2 years was higher among survivors assigning greater importance to these visits (relative risk [RR], 1.2; 95% CI, 1.1-1.3), perceiving greater susceptibility to health problems (RR, 1.2; 95% CI, 1.1-1.3), having a moderate to life-threatening chronic health problem related to their cancer (RR, 2.1; 95% CI, 1.7-2.7), seeing a primary care provider for a cancer-related problem (RR, 1.3; 95% CI, 1.0-1.6), having a cancer treatment summary (RR, 1.3; 95% CI, 1.0-1.6), and endorsing greater confidence in physicians' abilities to address questions and concerns (RR, 1.2; 95% CI, 1.0-1.3).

CONCLUSIONS

Educational interventions improving awareness of treatment history and susceptibility to cancer-related late effects and corresponding risk-based care are likely to be beneficial for survivors of childhood cancers.

Understanding and Improving Knowledge of Cancer Survivorship Care Among College Providers

This study aimed to assess college providers' basic knowledge of the health risks of young adult cancer survivors (YAS) and related care guidelines and to determine whether an educational in-service is an effective platform for increasing college health providers' knowledge about survivorship care at a large university health center. During phase 1, staff from college health centers and office of disabilities in the Philadelphia area (n = 40 staff members from 24 colleges/universities) completed a needs assessment on their experiences with YAS and preferences for education and care coordination. During phase 2, a 1-h educational in-service, informed by results of the survey, was provided to 18 health center medical providers. While most providers indicated that YAS are at risk for chronic health conditions because of cancer treatment, nearly all were unfamiliar with the content of published long-term follow-up guidelines for cancer survivorship. Over half did not have knowledge of cancer survivorship services in their area. All respondents were interested in more education on cancer survivorship care. Attendees of the in-service increased their knowledge of survivorship follow-up guidelines, awareness of local survivorship resources, and comfort with caring for YAS at posttest relative to baseline. The in-service was highly acceptable to providers and feasible to implement. College providers had little baseline knowledge of cancer survivorship guidelines, but were motivated to obtain more information. Through an educational in-service, college health providers may be better equipped to provide acute and longitudinal survivorship care to a vulnerable population who are at risk for inadequate engagement in risk-based follow-up care.

An assessment of progress in cancer control

This article summarizes cancer mortality trends and disparities based on data from the National Center for Health Statistics. It is the first in a series of articles that will describe the American Cancer Society's vision for how cancer prevention, early detection, and treatment can be transformed to lower the cancer burden in the United States, and sets the stage for a national cancer control plan, or blueprint, for the American Cancer Society goals for reducing cancer mortality by the year 2035. Although steady progress in reducing cancer mortality has been made over the past few decades, it is clear that much more could, and should, be done to save lives through the comprehensive application of currently available evidence-based public health and clinical interventions to all segments of the population. CA Cancer J Clin 2018;000:000-000. © 2018 American Cancer Society.

Marijuana use and inpatient outcomes among hospitalized patients: analysis of the nationwide inpatient sample database

The purpose of this paper is to examine the relationship between marijuana use and health outcomes among hospitalized patients, including those hospitalized with a diagnosis of cancer. A total of 387,608 current marijuana users were identified based on ICD‐9 codes for marijuana use among hospitalized patients in the Nationwide Inpatient Sample database between 2007 and 2011. Logistic regression analysis was performed to determine the association between marijuana use and heart failure, cardiac disease, stroke, and in‐hospital mortality. All models were adjusted for age, gender, race, residential income, insurance, residential region, pain, and number of comorbidities. Among hospitalized patients, marijuana use was associated with a 60% increased odds of stroke (OR: 1.60, 95% CI: 1.44–1.77) compared with non‐users, but significantly reduced odds of heart failure (OR: 0.78, 95% CI: 0.75–0.82), cardiac disease (OR: 0.86, 95% CI: 0.82–0.91), or in‐hospital mortality (OR: 0.41, 95% CI: 0.38–0.44). Among cancer patients, odds of in‐hospital mortality was significantly reduced among marijuana users compared with non‐users (OR: 0.44, 95% CI: 0.35–0.55). Hospitalized marijuana users were more likely to experience a stroke compared with non‐users, but less likely to experience in‐hospital mortality. Prospective studies will be needed to better characterize the health effects of marijuana use, especially among older, sicker, and/or hospitalized patients. In the meantime, conversations regarding marijuana use/misuse may be warranted in the clinical setting in order for patients and healthcare providers to adequately weigh the anticipated benefits of marijuana use with potentially significant health risks.

Barriers to follow-up care among survivors of adolescent and young adult cancer

PURPOSE

Though the need for risk-based follow-up care for survivors of adolescent and young adult (AYA) cancer has been documented, survivors often report forgoing recommended care due to cost. We sought to understand whether additional barriers to follow-up care exist for AYA survivors.

METHODS

We recruited survivors who were diagnosed with cancer between the ages of 15 and 39 using the Utah Cancer Registry (UCR). Overall, 28 survivors participated in 6 focus groups held between March and May 2015 in Salt Lake City and St. George, UT. Focus group discussions focused on the reasons survivors may or may not attend recommended medical visits after completing therapy.

RESULTS

Survivors reported myriad barriers to follow-up medical visits, including lack of clear provider recommendation, fear of recurrent cancer diagnosis, wishing to move on with life, competing life responsibilities due to work and children, and not perceiving the need for a visit due to lack of symptoms.

CONCLUSIONS

Though cost likely plays a major part in follow-up care adherence for survivors of AYA cancer, in our focus groups, participants indicated there were many other psychosocial and logistic barriers to care. Such factors play an important role in the day-to-day lives of survivors and are critical in medical decision-making.

IMPLICATIONS FOR CANCER SURVIVORS

Several factors impede follow-up care adherence for survivors of AYA cancer that are amenable to interventions, including clearer provider recommendations, flexible appointment times, and childcare availability in clinics.

Care Transitions in Childhood Cancer Survivorship: Providers' Perspectives

PURPOSE

Most adolescent and young adult (AYA)-aged childhood cancer survivors develop physical and/or psychosocial sequelae; however, many do not receive long-term follow-up (LTF) critical for screening, prevention, and treatment of late effects. To develop a health services research agenda to optimize care models, we conducted qualitative research with LTF providers examining existing models, and successes and challenges in maintaining survivors' connections to care across their transition to adulthood.

METHODS

We interviewed 20 LTF experts (MDs, RNs, social workers, education specialists, psychologists) from 10 Children's Oncology Group-affiliated institutions, and analyzed data using grounded theory and content analysis techniques.

RESULTS

Participants described the complexity of survivors' healthcare transitions. Survivors had pressing educational needs in multiple domains, and imparting the need for prevention was challenging. Multidisciplinary LTF teams focused on prevention and self-management. Care and decisions about transfer were individualized based on survivors' health risks, developmental issues, and family contexts. An interplay of provider and institutional factors, some of which were potentially modifiable, also influenced how transitions were managed. Interviewees rarely collaborated with community primary care providers to comanage patients. Communication systems and collective norms about sharing care limited comanagement capacity. Interviewees described staffing practices, policies, and informal initiatives they found reduced attrition.

CONCLUSIONS

Results suggest that survivors will benefit from care models that better connect patients, survivorship experts, and community providers for uninterrupted LTF across transitions. We propose research priorities, framing attrition from LTF as a public health concern, transition as the central challenge in LTF, and transition readiness as a multilevel concept.

Cancer experiences and health-related quality of life among racial and ethnic minority survivors of young adult cancer: a mixed methods study

PURPOSE

Young adult (YA) racial and ethnic minority survivors of cancer (diagnosed ages 18-39) experience significant disparities in health outcomes and survivorship compared to non-minorities of the same age. However, little is known about the survivorship experiences of this population. The purpose of this study is to explore the cancer experiences and health-related quality of life (HRQOL) among YA racial/ethnic minorities in an urban US city.

METHODS

Racial and ethnic minority YA cancer survivors (0 to 5 years posttreatment) were recruited from a comprehensive cancer center using a purposive sampling approach. Participants (n = 31) completed semi-structured interviews, the FACT-G (physical, emotional, social well-being) and the FACIT-Sp (spiritual well-being). Mixed methods data were evaluated using thematic analysis and analysis of covariance (ANCOVA).

RESULTS

The majority of survivors were women (65 %), single (52 %), and Hispanic (42 %). Across interviews, the most common themes were the following: "changes in perspective," "emotional impacts," "received support," and "no psychosocial changes." Other themes varied by racial/ethnic subgroups, including "treatment effects" (Hispanics), "behavior changes" (Blacks), and "appreciation for life" (Asians). ANCOVAs (controlling for gender and ECOG performance status scores) revealed that race/ethnicity had a significant main effect on emotional (P = 0.05), but not physical, social, or spiritual HRQOL (P > 0.05).

CONCLUSIONS

Our findings suggest that minority YA cancer survivors report complex positive and negative experiences. In spite of poor health outcomes, survivors report experiencing growth and positive change due to cancer. Variations in experiences and HRQOL highlight the importance of assessing cultural background to tailor survivorship care among YA racial and ethnic minorities.

Primary Care Use before Cancer Diagnosis in Adolescents and Young Adults - A Nationwide Register Study

Introduction

Survival rates of cancer patients have generally improved in recent years. However, children and older adults seem to have experienced more significant clinical benefits than adolescents and young adults (AYAs). Previous studies suggest a prolonged diagnostic pathway in AYAs, but little is known about their pre-diagnostic healthcare use. This study investigates the use of primary care among AYAs during the two years preceding a cancer diagnosis.

Methods

The study is a retrospective population-based matched cohort study using Danish nationwide registry data. All persons diagnosed with cancer during 2002–2011 in the age group 15–39 years were included (N = 12,306); each participant was matched on gender, age and general practice with 10 randomly selected references (N = 123,060). The use of primary healthcare services (face-to-face contacts, blood tests and psychometric tests) was measured during the two years preceding the diagnosis (index date), and collected data were analysed in a negative binomial regression model.

Results

The cases generally increased their use of primary care already from 8 months before a cancer diagnosis, whereas a similar trend was not found for controls. The increase was observed for all cancer types, but it started at different times: 17 months before a diagnosis of CNS tumour, 12 months before a diagnosis of soft tissue sarcoma, 9 months before a diagnosis of lymphoma, 5–6 months before a diagnosis of leukaemia, bone tumour or GCT, and 3 months before a diagnosis of malignant melanoma.

Conclusion

The use of primary care among AYAs increase several months before a cancer diagnosis. The diagnostic intervals are generally short for malignant melanomas and long for brain tumours. A prolonged diagnostic pathway may indicate non-specific or vague symptomatology and low awareness of cancer among AYAs primary-care personnel. The findings suggest potential of faster cancer diagnosis in AYAs.

Planning for the future: the role of nurse practitioners and physician assistants in survivorship care

The number of cancer survivors in the United States now approaches 12 million individuals, with an estimated 7.2% of the general population aged 18 years or older reporting a previous cancer diagnosis. These figures highlight a number of questions about the care of survivors-how patients at risk for a known set of health problems should be followed, by whom, and for how long. At the same time that oncologists are developing strategies to provide services to this growing population, there are economic and systems challenges that have relevance to the previous questions, including a predicted national shortage of physicians to provide oncology services. Nurse practitioners (NPs) and physician assistants (PAs) have been identified as members of the health care team who can help reduce the oncology supply and demand gap in a number of ways. The ASCO Study of Collaborative Practice Arrangements (SCPA) in 2011 concluded that oncology patients were aware and satisfied when their care was provided by NPs and PAs; there was an increase in productivity in practices that utilized NPs and PAs; utilizing the full scope of practice of NPs and PAs was financially advantageous; and, physicians, NPs, and PAs are highly satisfied with their collaborative practices. Increasingly, the oncology and health policy literature contains evidence supporting innovative provider models. There is still much work to be done to move beyond pilot data to establish the true value of these models.

Age at Primary Malignancy Determines Survival in Adolescent and Young Adults That Develop a Secondary Thyroid Cancer

PURPOSE

Second malignancy status is a risk factor for death in adolescent and young adults (AYAs) (ages 15-39) with thyroid cancer (TC). This study investigates whether age at primary malignancy (PM) is an independent predictor of overall survival (OS) for AYA patients diagnosed with secondary TC who have survived ≥5 years from their PM.

METHODS

Surveillance, Epidemiology and End Results program (SEER) multiple-primary session (SEER-9 [1973-2010] and SEER-13 [1992-2010]) identified all secondary TCs in patients <40 years of age who were also 5-year survivors. Patients with a thyroid second malignant neoplasm (SMN) diagnosed as an AYA were categorized by age at PM (pediatric <15 years vs. AYA). Kaplan-Meier and Cox proportional analysis determined OS.

RESULTS

Four hundred twenty-eight cases of secondary AYA TCs in 5-year cancer survivors were identified; 71 had a pediatric PM and 357 an AYA PM. Median OS after a pediatric PM was 35.76 years and 33.22 years after an AYA-PM (p = 0.023); only one death was due to TC. Race, site and stage of PM, marital status, and three or more independent PMs also influenced OS (all p < 0.05). However, TC characteristics, stage, and treatment did not affect OS. Cox regression demonstrated that patients with an AYA PM had a 5.84 relative risk of death (95% confidence interval [95% CI]: 1.81-18.91) compared to patients with a pediatric PM. Among AYAs who develop a TC as a second PM, OS is not affected by the TC. The OS for these patients is associated with their demographics and the characteristics of their PM: patients who are black, male, have three or more primary cancers, and a higher stage of their first malignancy are more likely to die.

CONCLUSION

For AYA patients with thyroid SMNs, having a prior AYA PM (compared to a pediatric PM), Black race, and having three or more independent tumors predicted a decreased OS, independent of PM type or PM/SMN stage.

Reimagining care for adolescent and young adult cancer programs: Moving with the times

Literature regarding the development of adolescent and young adult (AYA) cancer programs has been dominantly informed by pediatric centers and practitioners. However, the majority of young adults are seen and treated at adult cancer centers, in which cancer volumes afford the development of innovative supportive care services. Although the supportive care services in adult cancer centers are helpful to AYAs, some of the most prominent and distinct issues faced by AYAs are not adequately addressed through these services alone. This article describes how the AYA Program at Princess Margaret Cancer Centre has collaborated with existing supportive care services in addition to supplying its own unique services to meet the comprehensive needs of AYAs in the domains of: symptom management (sexuality and fatigue), behavior modification (return to work and exercise), and health services (advanced cancer and survivorship). These collaborations are augmented by patient education interventions and timely referrals. The objective of this article was to assist other centers in expanding existing services to address the needs of AYA patients with cancer.

Preparing for the future: An examination of healthcare provider and patient communication regarding childhood cancer survivorship

BACKGROUND

This qualitative, exploratory study examines the content of communication between healthcare providers (HCP) and childhood cancer patients (CCP) during a medical appointment to evaluate the extent to which cancer survivorship issues (medical and psychosocial) are discussed.

METHODS

The content of the communication for 16 CCP ages 10-22 and their HCP were examined via audio recorded medical appointments occurring within 6 months of the end of active cancer treatment. The data were analysed using template analysis, a constructivist-interpretivist qualitative approach.

RESULTS

HCP addressed more medically focused than psychosocially focused issues related to survivorship.

CONCLUSIONS

Most discussions of survivorship are medically focused, potentially leaving patients with little information about future psychosocial functioning. Recommendations for future research on enhancing discussions about psychosocial issues are presented. This research has the potential to inform future interventions to enhance patient-provider communication on survivorship issues.

Models of Cancer Survivorship Care for Adolescents and Young Adults

OBJECTIVES

To review the literature on adolescent and young adult (AYA) oncology, discuss survivorship models of care, and focus on the unique needs of AYA patients with transition of care from treatment to survivorship.

DATA SOURCES

Peer-reviewed literature, workshop summaries, clinical practice guidelines.

CONCLUSION

Advancements have been made for AYAs with regard to identifying risk factors from cancer treatment and the need for ongoing follow-up care. Survivors face several unique care transitions. Several models of survivorship care are available for AYAs.

IMPLICATIONS FOR NURSING PRACTICE

The responsibilities of survivorship care for AYA patients fall on clinical providers, researchers, the government, advocacy groups as well as the survivors and families themselves. Nurses must remain cognizant and educated on AYA survivorship issues.

Identifying and addressing the needs of adolescents and young adults with cancer: summary of an Institute of Medicine workshop

Cancer is the leading disease-related cause of death in adolescents and young adults (AYAs). This population faces many short- and long-term health and psychosocial consequences of cancer diagnosis and treatment, but many programs for cancer treatment, survivorship care, and psychosocial support do not focus on the specific needs of AYA cancer patients. Recognizing this health care disparity, the National Cancer Policy Forum of the Institute of Medicine convened a public workshop to examine the needs of AYA patients with cancer. Workshop participants identified many gaps and challenges in the care of AYA cancer patients and discussed potential strategies to address these needs. Suggestions included ways to improve access to care for AYAs, to deliver cancer care that better meets the medical and psychosocial needs of AYAs, to develop educational programs for providers who care for AYA cancer survivors, and to enhance the evidence base for AYAs with cancer by facilitating participation in research.

Survivorship in adolescents and young adults

In the USA, approximately 26,000 adolescents and young adults (AYAs) aged 15-29 years are diagnosed with cancer every year. The cure rate among this population exceeds 80%, resulting in a growing number of AYA cancer survivors. AYA cancer survivors suffer from a wide range of long-term treatment-related toxicities that adversely affect quality of life and increase the risk of premature death. Therefore, it is important to recognize the unique medical needs of the AYA cancer survivors and develop a cost-effective and systemic approach to screen and prevent cancer treatment-related sequelae and the adverse health outcomes.

Medical care in adolescents and young adult cancer survivors: what are the biggest access-related barriers?

PURPOSE

Adolescent and young adult (AYA) cancer survivors experience barriers to utilizing healthcare, but the determinants of cancer-related medical care of AYAs has not been fully explored.

METHODS

We studied factors associated with medical care utilization among 465 AYA cancer survivors in the AYA Health Outcomes and Patient Experience Study, a cohort of 15 to 39 year olds recently diagnosed with germ cell cancer, lymphoma, sarcoma, or acute lymphocytic leukemia. Descriptive statistics and multivariate logistic regression methods were used.

RESULTS

Most AYA cancer survivors (95%), who were 15-35 months post diagnosis, received medical care in the past 12 months and 17% were undergoing cancer treatment. In multivariate analyses, compared with AYAs with no cancer-related medical visits in the previous year, AYAs receiving cancer-related care were more likely to currently have health insurance (odds ratio (OR) = 4.9; 95% confidence interval (CI) = 1.7-13.8) or have had health insurance in the past year (OR = 4.0; 95% CI = 0.99-16.3). Cancer recurrence, lacking employment, and negative changes in self-reported general health were associated with ongoing cancer treatment versus other cancer-related medical care. Eleven percent of all AYAs and 25% of AYAs who did not receive medical care in the past 12 months lost health insurance between the initial and follow-up surveys.

CONCLUSION

AYA cancer survivors with health insurance were much more likely to receive cancer-related medical care than those without insurance.

IMPLICATIONS FOR CANCER SURVIVORS

Despite the need for post-treatment medical care, lacking health insurance is a barrier to receiving any medical care among AYAs.

Comparison of secondary and primary thyroid cancer in adolescents and young adults

BACKGROUND

Thyroid cancer is one of the 5 most common malignancies in adolescent and young adult (AYA) patients (ages 15-39 years) and may develop de novo or in patients previously treated for cancer. This study compared the tumor characteristics, treatment, and overall survival (OS) of secondary malignant neoplasm (SMN) versus primary thyroid cancer in AYA patients.

METHODS

All cases of AYA thyroid cancer contained in the 1998 to 2010 American College of Surgeons National Cancer Database were divided into 2 cohorts according to primary or secondary occurrence. Comparisons using appropriate statistical methods were performed.

RESULTS

Of 41,062 cases, 1349 (3.3%) had experienced a prior malignancy. Compared with cases of primary thyroid cancer, SMNs were more likely multifocal (odds ratio [OR] = 1.173, 95% confidence interval [CI] = 1.049-1.313) microcarcinomas < 1 cm (OR = 1.496, 95% CI = 1.327-1.687) with tall/columnar cells (OR = 2.187, 95% CI = 0.534-0.692), of white race (OR = 2.643, 95% CI = 1.310-5.331) and age 35-39 years (OR = 1.239, 95% CI = 1.093-1.404) and less likely female (OR = 0.608, 95% CI = 0.534-0.692), Hispanic (OR = 0.779, 95% CI = 0.642-0.946) age 15-19 years (OR = 0.624, 95% CI = 0.510-0.763) or 25-29 years (OR = 0.711, 95% CI = 0.604-0.837), or less likely > 4 cm in size (OR = 0.610, 95% CI = 0.493-0.758). There was a 6.63-fold (95% CI = 4.97-8.86, P < .001) relative risk of death for secondary versus primary thyroid cancers after adjusting for demographic, tumor, and thyroid treatment factors. Only Hispanic origin, tall/columnar cell histology, and distant metastases decreased OS for SMNs.

CONCLUSIONS

AYAs who develop thyroid cancer as a SMN have a significantly decreased OS compared to AYAs with primary thyroid cancer. Multiple demographic and tumor differences exist between these 2 cohorts. Whether the outcome disparity results from previous cancer treatment or differences in biology, environment, or access to care are areas needing further investigation.

Evaluation of fitness levels of children with a diagnosis of acute leukemia and lymphoma after completion of chemotherapy and autologous hematopoietic stem cell transplantation

The aim of this study was to assess the fitness levels and possible deficits in physical performance in children with a diagnosis of childhood acute leukemia and lymphoma after 10 months of therapy ending through a specific test battery. A total of 58 subjects were enrolled in this study. The experimental group (EG) (7.55 ± 2.43 years; 41.8 ± 16.37 kg; 144.6 ± 10.21 cm) consisted of 18 children with diagnosed leukemia and lymphoma after completion of 10 months of therapy intervention and 40 healthy children who were enrolled in a control group (CG) (7.92 ± 1.78 years; 37.4 ± 12.37 kg; 140.6 ± 12.61 cm). A testing battery including the standing broad jump; the sit-up test; the 4 × 10 m shuttle run test, and the hand grip strength test were administered to both groups. An unpaired t-test was adopted to determine differences and the Pearson product moment was administered when appropriate. Results of the EG were generally lower when compared to the CG. Significant differences were identified for the standing broad jump (P < 0.05); 4 × 10 m shuttle run (P < 0.05); hand grip test DX (P < 0.05), and hand grip test SX (P < 0.05). No significant differences were found between the sit-up tests. Pearson product moment correlation revealed a good interaction for all EG participants. Findings suggest that the proposed testing battery could be an appropriate tool to evaluate residual fitness levels in children with previous hematological malignancies. However, our results have to be confirmed with a larger number of participants with the same diagnosis of our EG.

Are Current Care Models Meeting the Psychosocial Needs of Adolescent and Young Adult Cancer Survivors? A Literature Review

BACKGROUND

Adolescents and young adults diagnosed with cancer are expected to become long-term survivors. A cancer diagnosis during this critical life stage can have a profound impact on normal psychosocial development, increasing risk for adverse long-term and late effects and influencing quality of life.

PURPOSE

The purpose of this article was to review the impact of cancer on some key psychosocial aspects of adolescent and young adult cancer survivors, including the impact of a cancer diagnosis on psychosocial development, the effectiveness of current models of care in relation to addressing the psychosocial needs of this patient population, and the evaluation of current Canadian models of care and implications for clinical practice.

METHODS

A review of the English literature from 2002 to 2012 was performed using PubMed (National Center for Biotechnology Information), Ovid MEDLINE, and Google Scholar.

RESULTS AND CONCLUSIONS

Various survivorship care models have been implemented to assist adolescent and young adult cancer survivors in addressing the psychosocial issues associated with a cancer diagnosis, although the type of model used varies based on institutional resources and survivors' needs. Preliminary survivorship research identifies the need for long-term follow-up care including ongoing assessment for psychosocial issues. The literature also identifies the need to educate adolescents and young adults regarding their disease, which will empower these patients to act as their own health care advocates, resulting in improved health-related outcomes and overall quality of life. However, despite the increasing focus on the benefits of good survivorship care and the availability of government-funded survivorship programs in Canada, programs are often underused by this patient population. Survivorship care is a new focus for research that requires more evaluation regarding the feasibility and effectiveness of the different care models in meeting the psychosocial needs of adolescent and young adult cancer survivors.

Stakeholder validation of a model of readiness for transition to adult care

IMPORTANCE

That too few youth with special health care needs make the transition to adult-oriented health care successfully may be due, in part, to lack of readiness to transfer care. There is a lack of theoretical models to guide development and implementation of evidence-based guidelines, assessments, and interventions to improve transition readiness.

OBJECTIVE

To further validate the Social-ecological Model of Adolescent and Young Adult Readiness to Transition (SMART) via feedback from stakeholders (patients, parents, and providers) from a medically diverse population in need of life-long follow-up care, survivors of childhood cancer.

DESIGN

Mixed-methods participatory research design.

SETTING

A large Mid-Atlantic children's hospital.

PARTICIPANTS

Adolescent and young adult survivors of childhood cancer (n = 14), parents (n = 18), and pediatric providers (n = 10).

MAIN EXPOSURES

Patients and parents participated in focus groups; providers participated in individual semi-structured interviews.

MAIN OUTCOMES AND MEASURES

Validity of SMART was assessed 3 ways: (1) ratings on importance of SMART components for transition readiness using a 5-point scale (0-4; ratings >2 support validity), (2) nominations of 3 "most important" components, and (3) directed content analysis of focus group/interview transcripts.

RESULTS

Qualitative data supported the validity of SMART, with minor modifications to definitions of components. Quantitative ratings met criteria for validity; stakeholders endorsed all components of SMART as important for transition. No additional SMART variables were suggested by stakeholders and the "most important" components varied by stakeholders, thus supporting the comprehensiveness of SMART and need to involve multiple perspectives.

CONCLUSIONS AND RELEVANCE

SMART represents a comprehensive and empirically validated framework for transition research and program planning, supported by survivors of childhood cancer, parents, and pediatric providers. Future research should validate SMART among other populations with special health care needs.

Late morbidity leading to hospitalization among 5-year survivors of young adult cancer: a report of the childhood, adolescent and young adult cancer survivors research program

To estimate the risk of late morbidity leading to hospitalization among young adult cancer 5-year survivors compared to the general population and to examine the long-term effects of demographic and disease-related factors on late morbidity, a retrospective cohort of 902 five-year survivors of young adult cancer diagnosed between 1981 and 1999 was identified from British Columbia (BC) Cancer Registry. A matched comparison group (N = 9020) was randomly selected from the provincial health insurance plan. All hospitalizations until the end of 2006 were determined from the BC health insurance plan hospitalization records. The Poisson regression model was used to estimate the rate ratios for late morbidity leading to hospitalization except pregnancy after adjusting for sociodemographic and clinical risk factors. Overall, 455 (50.4%) survivors and 3,419 (37.9%) individuals in the comparison group had at least one type of late morbidity leading to hospitalization. The adjusted risk of this morbidity for survivors was 1.4 times higher than for the comparison group (95% CI = 1.22-1.54). The highest risks were found for hospitalization due to blood disease (RR = 4.2; 95% CI = 1.98-8.78) and neoplasm (RR = 4.3; 95% CI = 3.41-5.33). Survivors with three treatment modalities had three-fold higher risk of having any type of late morbidity (RR = 3.22; 95% CI = 2.09-4.94) than the comparators. These findings emphasize that young adult cancer survivors still have high risks of a wide range of late morbidities.

Attendance at a survivorship clinic: impact on knowledge and psychosocial adjustment

PURPOSE

Due to their heightened risk of developing late-occurring adverse outcomes, pediatric cancer survivors are advised to receive follow-up care in specialized Survivor Clinics. However, little is known about the impact of attending such clinics on psychosocial adjustment, knowledge, and morbidity. This study assesses the differences between those who attended a Survivorship Clinic and those who did not on knowledge, perception of risk, and psychosocial adjustment.

METHODS

We assessed 102 survivors who attended our Long-Term Follow-Up (LTFU) Clinic and 71 survivors never seen in a specialized clinic (non-LTFU). Participants were diagnosed at least 5 years prior to the assessment, were at least 20 years old, and had no evidence of active disease. Groups were matched on gender, age at cancer diagnosis, diagnosis, and race.

RESULTS

On average, participants were currently 30 years of age and had been diagnosed with cancer around age 12. Most common reasons that non-LTFU survivors did not attend the clinic were "not aware" (71 %) or "not interested" (16 %). Survivors in each group were able to accurately report their cancer diagnosis, but few knew specific treatment information. There were no significant differences regarding survivors' perceptions of risk of future health problems with both groups similarly underestimating their risks. A significant minority in each group reported psychological or emotional problems (16-18 %), post-traumatic stress disorder (4.2-6.9 %), and/or psychological distress (7.8-19.7 %).

CONCLUSIONS

Survivors are in need of continued education about their specific cancer treatments, recommended follow-up practices, the importance of survivorship care, and their specific risks for late effects.

IMPLICATIONS FOR CANCER SURVIVORS

Among those childhood cancer survivors who do attend a Survivor clinic, a majority are in need of continued education about their specific cancer treatments, recommended follow-up practices, and risk of late effects. As many survivors of pediatric cancer appear to be unaware of the existence of Survivor clinics, improved methods of transitioning survivors after completion of treatment are needed.

Clinical features and outcomes in patients with secondary Ewing sarcoma

BACKGROUND

Ewing sarcoma (EWS) is rarely diagnosed as a second malignancy. We sought to describe a cohort of patients with secondary EWS and investigate if patient characteristics and survival differ between patients with secondary and primary EWS.

PROCEDURE

Patients with EWS or peripheral primitive neuroectodermal tumor (PNET) reported to the Surveillance, Epidemiology, and End Results Program (SEER) database from 1973 to 2008 were evaluated based on primary or secondary tumor sequence. Overall survival was estimated by Kaplan-Meier methods and evaluated using the log-rank test. Competing risk analysis was used to describe risk of death due to malignancy rather than other causes.

RESULTS

Fifty-eight cases of secondary EWS were reported, accounting for 2.1% of all EWS cases. The median latency from primary malignancy to secondary EWS was 64 months (range 1-282 months). 12.1% of patients with secondary EWS received radiation to the site of secondary tumor during therapy for their primary malignancy. Patients with secondary EWS were more likely to have axial tumors (77.4% vs. 62.5%; P = 0.03) and smaller tumors (75.0% vs. 48.2% <8 cm; P = 0.001). Five-year overall survival from diagnosis was inferior for patients with secondary compared to primary EWS (34.3% vs. 52.2%; P = 0.002). However, patients with secondary tumors were less likely than those with primary EWS to die from their malignancy [hazard ratio 0.44; 95% confidence interval (CI) 0.23-0.85].

CONCLUSIONS

Secondary EWS accounts for a minority of cases of EWS. Tumor size and site and patient survival differ among patients with primary and secondary EWS.

Psychoneuroimmunology and cancer: a decade of discovery, paradigm shifts, and methodological innovations

This article introduces the supplement Advances in Cancer and Brain, Behavior, and Immunity and outlines important discoveries, paradigm shifts, and methodological innovations that have emerged in the past decade to advance mechanistic and translational understanding of biobehavioral influences on tumor biology, cancer treatment-related sequelae, and cancer outcomes. We offer a heuristic framework for research on biobehavioral pathways in cancer. The shifting survivorship landscape is highlighted, and we propose that the changing demographics suggest prudent adoption of a life course perspective of cancer and cancer survivorship. We note opportunities for psychoneuroimmunology (PNI) research to ameliorate the long-term, unintended consequences of aggressive curative intent and call attention to the critical role of reciprocal translational pathways between animal and human studies. Lastly, we briefly summarize the articles included in this compilation and offer our perspectives on future research directions.

Radiotherapy-induced hypopituitarism: a review

Hypopituitarism is a disorder caused by impaired hormonal secretions from the hypothalamic-pituitary axis. Radiotherapy is the most common cause of iatrogenic hypopituitarism. The hypothalamic-pituitary axis inadvertently gets irradiated in patients receiving prophylactic cranial radiotherapy for leukemia, total body irradiation and radiotherapy for intracranial, base skull, sinonasal and nasopharyngeal tumors. Radiation-induced hypopituitarism (RIH) is insidious, progressive and largely nonreversible. Mostly, RIH involves one hypothalamic-pituitary axis; however, multiple hormonal axes deficiency starts developing at higher doses. Although the clinical effects of the hypopituitarism are more profound in children and young adults, its implications in older adults are being increasingly recognized. The risk continues to persist or increase up to 10 years following radiation exposure. The clinical management of hypopituitarism is challenging both for the patients and healthcare providers. Here we have reviewed the scale of the problem, the risk factors and the management of RIH.

Primary care providers as partners in long-term follow-up of pediatric cancer survivors

PURPOSE

To develop a model of shared healthcare delivery that includes primary care providers (PCP) and ensures best practice in follow-up of pediatric cancer survivors.

METHOD

Structured interviews with healthcare professionals (HCPs) were used to ascertain familiarity and confidence in providing care to survivors. Partnerships were made with HCP societies, and survivor care lectures were given at HCP meetings. HCP's preferences for ongoing continuing education (CE) opportunities were ascertained. Cancer SurvivorLink(TM), a web-based tool, was developed to allow patients to securely store their healthcare documents and share them electronically with registered HCPs. Educational material developed for Cancer SurvivorLink(TM) includes CE modules and QuickFacts--concise summaries of late effects. Website utilization was monitored utilizing Google Analytics.

RESULTS

HCPs described moderate to very low familiarity with survivor care, but high interest in online CE learning. Thirty-one lectures were given to HCP groups to increase awareness. Preferred types of ongoing CE were: lectures, online text, and video modules. CE material was developed based on feedback from HCPs and website utilizations and includes 19 QuickFacts and 5 CE modules. During the first year, the website had 471 unique visitors and 1,129 total visits. QuickFacts received 345 views with Neurocognitive, Survivor Care 101, and Endocrine being most visited, and 49 CME modules have been completed.

CONCLUSIONS

PCPs are interested in partnering in models of shared care for pediatric cancer survivors. Effective educational initiatives include lectures within HCP's professional education constructs and web-based CE opportunities. PCP involvement in survivor care alleviates some barriers to care such as geographic distance to the the cancer center and ensures that more pediatric cancer survivors receive recommended coordinated surveillance for late effects of cancer therapy.

Analysis of outcomes in adolescents and young adults with chronic myelogenous leukemia treated with upfront tyrosine kinase inhibitor therapy

BACKGROUND

Outcomes in chronic myeloid leukemia have improved with tyrosine kinase inhibitor treatment. However, little is known about outcomes of chronic myeloid leukemia in adolescent and young adult patients.

DESIGN AND METHODS

We reviewed all 468 chronic myeloid leukemia patients treated at our institution with tyrosine kinase inhibitors as initial therapy: imatinib (n=281), nilotinib (n=98) or dasatinib (n=89).

RESULTS

Median age was 47 years, median follow up 71 months and median treatment time with initial tyrosine kinase inhibitors 48 months. Adolescent and young adult was defined as aged 15-29 years. Sixty-one adolescent and young adult patients were identified. The only significant differences between adolescent and young adult and older patients were incidence of splenomegaly and distribution in Sokal risk groups. Only 3 adolescent and young adult patients have died. Rates of complete cytogenetic, major molecular and complete molecular response were significantly higher in older patients compared to adolescent and young adult patients, with a favorable trend in event-free survival for older patients. Transformation-free and overall survival were similar for the two groups.

CONCLUSIONS

The unfavorable trend in outcome for adolescent and young adult patients with chronic myeloid leukemia is unexpected. Additional research in this population is required to better define outcomes, understand the cause of this difference, and to help make better treatment recommendations.