Cancer-related follow-up care among Hispanic and non-Hispanic childhood cancer survivors: The Project Forward study

Factors Associated With Agreement Between Parent and Childhood Cancer Survivor Reports on Child's Health Related Quality of Life

Pediatric Health Related Quality of Life (HRQoL) among childhood cancer survivors (CCS) measures the impact of illness and treatment from the patient's perspective. However, parents often serve as proxies when the child cannot provide information directly. Studies of agreement between parents' proxy assessment and child's self-report have shown discrepancies. Understanding the reasons for discrepancies is under studied. Thus, this study examined the agreement of 160 parent-CCS dyads on the child's domains of HRQoL by mean difference, intra-class correlation coefficients, and Bland-Altman plots. Differences in agreement were assessed by patients' age, ethnicity, and whether or not they lived with their parents. Overall, the Physical Function Score showed good agreement between parents and CCS (ICC = 0.62), while the Social Function Score had fair agreement (ICC = 0.39). CCS were more likely to rate their Social Function Score higher than their parent. The lowest agreement for the Social Function Score was found for 18-20 years old's (ICC = .254) versus younger or older CCS, and among non-Hispanic whites (ICC = 0.301) versus Hispanics. Differences in agreement varied by patient age and ethnicity, suggesting that other factors, including emotional, familial, and cultural factors, may influence parental awareness of CCS HRQoL.

Excess risk of chronic health conditions in Hispanic survivors of adolescent and young adult cancers

PURPOSE

There is a growing population of survivors of adolescent and young adult (AYA) cancers (age 15-39 years at diagnosis). Studies in AYA cancer survivors have identified racial and ethnic disparities in long-term outcomes. To understand the extent to which a cancer diagnosis exacerbates pre-existent health disparities within a minoritized population, comparisons should be made to those of the same race or ethnicity without a cancer history.

METHODS

Self-reported data from the National Health Interview Survey (2009-2018) were used to identify Hispanic AYA cancer survivors and Hispanic age- and sex-matched controls. SES factors (marital status, income, education, insurance) and prevalence of chronic health conditions were compared between groups using chi-square tests. The log-odds of chronic conditions were modeled by survey-weighted logistic regression with relation to age at survey, sex, marital status, education, family income, and cancer group (control versus cancer), together with interactions between each variable and cancer group (survivors vs. controls).

RESULTS

Five hundred thirty-nine survivors and 5390 controls were included. Compared with controls, survivors were less likely to be married and have family income > 45 K/year, and more likely to be insured and have completed some college. Survivors had higher odds than controls of chronic health conditions (odds ratio (OR): 7.39, p < 0.001 for at least 1 and OR: 4.78, p < 0.001 for 3 or more) including cardiovascular disease, diabetes, and hypertension. Female sex, higher educational attainment, and public insurance were each associated with increased odds of chronic conditions in Hispanic AYA survivors.

CONCLUSIONS

An AYA cancer diagnosis is associated with poor SES outcomes and increased odds of comorbidities within the Hispanic population.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer history can exacerbate underlying health disparities. Screening for chronic conditions is especially important in minoritized populations.

Hispanic/Latinos and non-Hispanic whites' childhood cancer survivors and parents: a dyadic analysis of coping resources and mental health

PURPOSE

While limited, dyadic research demonstrates the interdependent relationship between the health and adjustment after treatment between cancer survivors and caregivers. We examined interrelationships between coping resources and mental health among childhood cancer survivors (CCS)-parent dyads.

METHODS

One hundred sixty CCS-parent dyads from the Project Forward pilot study completed validated questions assessing social support, religiosity, spirituality, depressive symptoms, and perceived stress. Bidirectional associations were identified with path analysis utilizing the actor-partner interdependence model (APIM). We used a multigroup approach to test for the moderating effects by Hispanic ethnicity on these relationships.

RESULTS

Mean age of CCS was 20 years old, 51% female, 30% diagnosed with leukemia, and mean of 7 years from diagnosis. The mean age of parents was 49 years old and 89% were mothers. For both CCS and parents, perceived social support was inversely associated with their depressive symptoms and perceived stress (e.g., actor effects). Parents' social support was not significantly associated with CCS's depressive symptoms and stress. However, higher perceived social support by the CCS was inversely associated with parents' depressive symptoms (β =  - 0.202, p < 0.01) and perceived stress (β =  - 0.164, p < 0.05) (e.g., partner effects). Additional actor effects were observed between spirituality, religiosity, and depressive systems when we explored the moderating effects of Hispanic ethnicity.

CONCLUSION

Partner effects of social support among CCS-parent dyads may influence psychological distress.

IMPLICATION FOR CANCER SURVIVORS

Our findings on parent-child associations between social support and psychosocial well-being imply that survivorship care can be enhanced when the social support needs of both survivors and their parents are addressed together.

Barriers to long-term follow-up in pediatric Hodgkin lymphoma survivors

BACKGROUND/PURPOSE

Pediatric Hodgkin lymphoma (HL) survivors have an increased risk of late effects following treatment. Barriers at the patient, provider, and payor level adversely affect adherence to long-term follow-up.

METHODS

We conducted a retrospective chart review of HL survivors diagnosed from 1999 to 2014 at Texas Children's Hospital. HL survivors were considered lost to follow-up if there were no documented visits to Texas Children's Cancer Center Long-Term Survivor (LTS) clinic for 2 or more years after their last LTS clinic visit. Univariate and multivariable logistic regression analyses were conducted to explore factors contributing to loss to follow-up. Reasons for not attending subsequent LTS visits were assessed by phone interviews in a subset of lost to follow-up patients.

RESULTS

There were 120 HL survivors who had at least one LTS clinic visit in this timeframe; 64 (53%) were classified as lost to follow-up, and of these, 23 (36%) were interviewed. Eleven (47%) indicated that the reason for failure to follow-up was lack of or inadequate insurance, and seven (30%) stated they were unaware of the importance of continued follow-up. Loss to follow-up was associated with lack of insurance, earlier diagnosis, and lack of comorbidities in univariate analyses. Only earlier year of diagnosis (odds ratio [OR] 0.84, 95% confidence interval [CI]: 0.7-0.9, p = .01) and lack of insurance (OR 22.2, 95% CI: 4-123, p < .001) were associated with loss to follow-up in multivariable analyses.

CONCLUSIONS

Insurance status and awareness of the need for long-term follow-up care are key factors associated with loss to follow-up in survivors of HL. Targeted education and low-cost options for survivorship care are potential strategies for improving adherence to long-term follow-up care in HL survivors.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Social support experiences of hispanic/latino parents of childhood cancer survivors in a safety-net hospital: a qualitative study

PURPOSE

To describe the social support experiences of Hispanic/Latino parents while caregiving for childhood cancer survivors.

RESEARCH APPROACH

Semi-structured one-on-one interviews were conducted among 15 caregivers from a safety-net hospital in Los Angeles. A thematic analysis approach was used to analyze data.

FINDINGS

The positive influence of social support throughout their caregiving experience included (1) sharing information-enhanced knowledge, (2) receiving comfort and encouragement, (3) receiving tangible assistance reducing the caregiving burden, and (4) enhancing caregiving empowerment/self-efficacy. Sub-themes regarding the lack of social support included (1) being a single parent and (2) family and friends withdrawing after the child's cancer diagnosis.

CONCLUSION

We found Hispanic/Latino parents strongly value social support as it enables them to have essential resources that support caregiving for their child and themselves. Efforts should ensure that caregivers are routinely screened to identify their supportive needs so that support services for caregivers can be optimized and tailored, as those with a lack of social support may experience excessive caregiver burden.

Beyond depression: correlates of well-being in young adult survivors of childhood cancers

PURPOSE

This study investigated the correlates of well-being with psychosocial and clinical factors in young adult childhood cancer survivors (YACCS) above and beyond depressive symptoms.

METHODS

Participants were from the Project Forward Cohort, a population-based study of young adult survivors of childhood cancers. Participants (n = 1166, Mage = 25.1 years) were recruited through the Los Angeles Cancer Surveillance Program (Cancer Registry covering Los Angeles County). A majority received a diagnosis of leukemia (36.1%) or lymphoma (21.7%). Participants completed self-reported questionnaires at one timepoint. Multiple regression analyses were performed with well-being as the outcome variable and psychosocial and clinical variables (social support, sense of adulthood, posttraumatic growth, treatment intensity, and self-rated health) as the independent variables. Covariates included demographics (age, gender, relationship status, race/ethnicity) and depressive symptoms.

RESULTS

In the multivariable model, posttraumatic growth, social support, sense of adulthood, and self-rated health were significantly associated with well-being (all ps < .05), when controlling for depressive symptoms. Treatment intensity and years since diagnosis were not significantly associated with well-being, when controlling for depressive symptoms.

CONCLUSIONS

There are unique correlates of well-being above and beyond depressive symptoms among YACCS. This finding illuminates individual differences that may be associated with well-being and provides targets for intervention.

IMPLICATIONS FOR CANCER SURVIVORS

Psychosocial interventions and survivorship care for YACCS should consider the broad aspects of well-being, independent of depressive symptoms.

Disparities in pediatric cancer survivorship care: A systematic review

BACKGROUND

Childhood cancer survivors (CCS) experience many long-term health problems that can be mitigated with recommended survivorship care. However, many CCS do not have access to survivorship care nor receive recommended survivorship care. We reviewed the empirical evidence of disparities in survivorship care for CCS.

METHODS

This systematic review searched PubMed, CINAHL, and PsycINFO for studies on survivorship care for CCS (PROSPERO: CRD42021227965) and abstracted the reported presence or absence of disparities in care. We screened 7945 citations, and of those, we reviewed 2760 publications at full text.

RESULTS

A total of 22 studies reported in 61 publications met inclusion criteria. Potential disparities by cancer treatment (N = 14), diagnosis (N = 13), sex (N = 13), and current age (N = 13) were frequently studied. There was high quality of evidence (QOE) of survivorship care disparities associated with non-White race, Hispanic ethnicity, and being uninsured. Moderate QOE demonstrated disparities among CCS who were unemployed and older. Lower QOE was found for disparities based on cancer diagnosis, cancer treatment, age at diagnosis, time since diagnosis, sex, insurance type, income, educational attainment, and geographic area.

CONCLUSIONS

We found strong empirical evidence of disparities in survivorship care for CCS associated with race, ethnicity, and insurance status. Multiple other disparate groups, such as those by employment, income, insurance type, education, cancer diagnosis, age at diagnosis, time since diagnosis, cancer treatment, geographic area, sex, and self-identified gender warrant further investigation. Prospective, multilevel research is needed to examine the role of other patient characteristics as potential disparities hindering adequate survivorship care in CCS.

HPV Vaccination Initiation and Completion Among Pediatric, Adolescent, and Young Adult Cancer Survivors and a Comparison Population Sample Receiving Primary Care

Human papillomavirus (HPV) vaccinations can reduce pediatric, adolescent, and young adult (PAYA) cancer survivors' susceptibility to HPV-related subsequent cancers. We examined differences in HPV vaccination initiation and completion among a Utah-based cohort of PAYA cancer survivors and a cancer-free population sample. Participants received primary care at 1 of 2 health care systems during study follow-up: 2006-2016. Vaccination records were identified from these health care systems, statewide vaccination records, and an all-payer claims database. HPV vaccination initiation (1 dose) and completion (3 doses) were compared between cancer survivors (N=1579) and age-matched and sex-matched cancer-free population sample (N=4513). Individuals were 9 to 21 years old at cohort entry. Mixed-effects Poisson regression estimated incidence rate ratios (IRRs) and 95% confidence intervals (CIs). Relative to the population sample, cancer survivors were less likely to initiate vaccination (IRR=0.8, 95% CI: 0.73-0.98). The most severe disparity compared with the population sample for vaccine initiation (IRR=0.5, 95% CI: 0.31-0.74) or completion (IRR=0.5, 95% CI: 0.28-0.89) was observed for Hispanic survivors. PAYA cancer survivors are less likely to initiate HPV vaccination series than noncancer counterparts. Targeted interventions should be directed at PAYA survivors to raise HPV vaccination with emphasis on high-risk groups such as Hispanic survivors.

Sociodemographic factors associated with Wilms tumor treatment and survival: a population-based study

INTRODUCTION

Though Wilms tumor (WT) is one of the most common malignancies in children, there is a paucity of epidemiologic studies exploring sociodemographic disparities in treatment and survival. Here, we leveraged a national cancer registry to examine sociodemographic factors associated with receipt of adjuvant therapy, either chemotherapy or radiation, as well as overall survival among pediatric patients with WT.

MATERIALS AND METHODS

Within the Surveillance Epidemiology and End Results database (2000-2016), we identified 2043 patients (≤ 20 years of age) with unilateral WT. Multivariable logistic regression and Cox proportional hazard models were constructed to examine the association of sociodemographic factors with, respectively, adjuvant chemotherapy/radiotherapy and overall survival (OS).

RESULTS

Patients in the lowest SES quintile (OR 0.56, 95% CI 0.33-0.93, p = 0.03) were less likely to receive chemotherapy as compared to those in the highest SES quintile, though this association did not persist in sensitivity analyses including only patients at least 2 years of age and patients with regional/distant disease. In addition, female patients were more likely to receive chemotherapy (OR 1.46, 95% CI 1.08-1.97, p = 0.02) than male patients. Age, race, year of diagnosis, insurance status, and tumor laterality were not associated with receipt of chemotherapy. No sociodemographic variables were associated with receipt of radiotherapy. Lastly, as compared to Non-Hispanic-White patients, Hispanic patients had worse OS (HR 1.59, 95% CI 1.08-2.35, p = 0.02); no other sociodemographic variables were associated with OS.

CONCLUSIONS

This study suggests multilevel sociodemographic disparities involving ethnicity and SES in WT treatment and survival.

The Impact of Hispanic Ethnicity and Language on Communication Among Young Adult Childhood Cancer Survivors, Parents, and Medical Providers and Cancer-Related Follow-Up Care

PURPOSE

The triad of communication between young adult childhood cancer survivors (YACCSs), their parents, and their medical providers is an important process in managing health care engagement. This study sought to identify communication patterns among this triad, factors associated with communication, and engagement of survivorship care.

METHODS

We analyzed data from Project Forward, a population-based study that surveyed YACCSs and their parents. YACCSs were on average age 20 years, 7 years from diagnosis, 50% female, and 57% identified as Hispanic/Latino (N = 160 dyads). Latent class analysis of nine communication indicators from parent and YACCS surveys identified distinct classes of communication between YACCSs, parents, and medical providers. Associations between resulting classes and YACCS/parent characteristics were examined using multinomial logistic regression. Logistic regression was used to examine the association between communication classes and cancer-related follow-up care.

RESULTS

Latent class analysis identified three classes of triad communication: (1) high health care-focused communication (37.5%), (2) high comprehensive communication (15.6%), and (3) overall low communication (46.9%). After adjusting for covariates, greater time since diagnosis was associated with reduced odds of membership in class 2 while dyads with Spanish-speaking Hispanic parents were more likely to be in class 2 (v class 3). Additionally, YACCSs who were in either of the high communication groups were more likely to have received recent follow-up care.

CONCLUSION

Examining language preference provides an important contextual understanding as we found Spanish-speaking Hispanic parents engaged in high communication, which was associated with cancer-related follow-up care. Yet, our results also support the need to enhance communication between this triad to improve outcomes.

Fertility Preservation Discussions Between Young Adult Rectal Cancer Survivors and Their Providers: Sex-Specific Prevalence and Correlates

BACKGROUND

Young adults (YA) diagnosed with rectal cancer are disproportionately impacted by the gonadotoxic effects of treatment and potential subsequent infertility.

OBJECTIVE

The purpose of this study was to characterize the prevalence of fertility preservation measures used, reasons why such measures were not used, and correlates of discussion between providers and YA rectal cancer survivors.

DESIGN

An online, cross-sectional survey was administered on the Facebook page of a national colorectal cancer (CRC) advocacy organization. Eligible participants were rectal cancer survivors diagnosed before age 50, between 6 and 36 months from diagnosis or relapse, and based in the US.

RESULTS

Participants were 148 rectal cancer survivors. Over half of the survivors reported that their doctor did not talk to them about potential therapy-related fertility complications. Only one-fifth of survivors banked sperm (males) or eggs/embryos (females) prior to their cancer therapy. Older age at diagnosis and greater quality of life were significantly associated with a higher likelihood of fertility discussions among males. Greater quality of life was significantly associated with a higher likelihood of fertility discussion among females.

CONCLUSIONS

These findings indicate that the majority of YA rectal cancer survivors do not receive, or cannot recall, comprehensive cancer care, and help to identify patients with rectal cancer who may be at risk for inadequate fertility counseling. Clinicians should provide proper counseling to mitigate this late effect and to ensure optimal quality of life for YA rectal cancer survivors.

Insurance coverage change and survivorship care among young adult survivors of childhood cancer

OBJECTIVE

To (1) characterize change in type of insurance coverage among childhood cancer survivors from diagnosis to survivorship and (2) examine whether insurance change is associated with cancer-related follow-up care utilization.

DATA SOURCES

Participants in this study were derived from the Project Forward study, a population-based, observational study of childhood cancer survivors in Los Angeles County that used California Cancer Registry data to identify participants.

STUDY DESIGN

Multivariable logistic regression models incorporating survey nonresponse weights estimated the change in the marginal predicted probabilities of insurance change and survivorship care, adjusting for demographic, socioeconomic, and clinical covariates and clustering by treating hospital.

DATA COLLECTION/EXTRACTION METHODS

Study participants were diagnosed with cancer who were younger than age 20 years while living in Los Angeles County from 1996 to 2010 and were older than the age 18 years at the time of survey participation, from 2015 to 2017 (N = 1106).

PRINCIPAL FINDINGS

Most participants were 18-26 years of age, male, diagnosed before 2004, Hispanic/Latino race/ethnicity, single, without children, highly educated, not employed full time, and lived with their parents at survey. Almost half (N = 529) of participants experienced insurance change from diagnosis to survivorship. Insurance change was associated with insurance coverage at diagnosis, as those who were uninsured were most likely to experience change and gain coverage during survivorship (by 51 percentage points [ppt], standard error [SE] of 0.05). Survivors who experienced any change had decreased probability of reporting a recent cancer-related follow-up care visit, a disparity that was magnified for those who lost insurance coverage (-5 ppt, SE 0.02 for those who gained coverage; -15 ppt, SE 0.04 for those who lost coverage).

CONCLUSIONS

Insurance coverage change was associated with lower cancer-related follow-up care utilization. Indeed, survivors who experienced any insurance coverage change had decreased probability of having a cancer-related follow-up care visit, and this was magnified for those who lost their insurance coverage.

Acculturation discrepancy and mental health associations among Hispanic childhood cancer survivors and their parents

OBJECTIVE

Acculturation discrepancy occurs when the rate of host culture acquisition and/or heritage culture retention between non-native parents and their children diverges. The resulting conflict may exacerbate mental health conditions in already vulnerable populations. The present study examined discrepancies between Hispanic and Anglo-American acculturation, as two separate constructs, and mental health symptomology in Hispanic childhood cancer survivors (HCCS) and their parents.

METHODS

Participants were 68 matched parent-child dyads (HCCS (M_age  = 19.4 (2.77) years., 50.0% female); and parent (M_age  = 46.3 (6.07) years., 89.7% female)). Study variables were HCCS posttraumatic-growth (PTG) and quality-of-life (PedsQL); parent posttraumatic stress (PTSD); and parent/HCCS depressive symptoms (CESD) and acculturation orientations. Discrepancy was calculated as the dyadic difference between like acculturation measures.

RESULTS

After controlling for covariates, Hispanic acculturation discrepancy and HCCS psychosocial health (a subset of PedsQL) was negatively correlated (r = -0.26, p < 0.5); while Anglo-American acculturation discrepancy was positively associated with HCCS PTG (r = 0.34, p < 0.01) and overall PedsQL (r = 0.24, p < 0.05), and moderated the relationship between parent CESD and HCCS PedsQL.

CONCLUSION

The findings suggest that the two acculturation discrepancy constructs have opposite effects. HCCS losing their heritage culture while their parents simultaneously retain it appears to be a deleterious process; whereas, HCCS learning the US culture more rapidly than parents may have protective benefits. This study has important implications for mental health interventions among HCCS. Findings should be used to inform the survivorship clinical community of the value of acculturation timing and parent/child discrepancy.

Racial and Ethnic Disparities in Health Outcomes Among Long-Term Survivors of Childhood Cancer: A Scoping Review

The five-year survival rate of childhood cancer has increased substantially over the past 50 yr; however, racial/ethnic disparities in health outcomes of survival have not been systematically reviewed. This scoping review summarized health disparities between racial/ethnic minorities (specifically non-Hispanic Black and Hispanic) and non-Hispanic White childhood cancer survivors, and elucidated factors that may explain disparities in health outcomes. We used the terms “race”, “ethnicity”, “childhood cancer”, “pediatric cancer”, and “survivor” to search the title and abstract for the articles published in PubMed and Scopus from inception to February 2021. After removing duplicates, 189 articles were screened, and 23 empirical articles were included in this review study. All study populations were from North America, and the mean distribution of race/ethnicity was 6.9% for non-Hispanic Black and 4.5% for Hispanic. Health outcomes were categorized as healthcare utilization, patient-reported outcomes, chronic health conditions, and survival status. We found robust evidence of racial/ethnic disparities over four domains of health outcomes. However, health disparities were explained by clinical factors (e.g., diagnosis, treatment), demographic (e.g., age, sex), individual-level socioeconomic status (SES; e.g., educational attainment, personal income, health insurance coverage), family-level SES (e.g., family income, parent educational attainment), neighborhood-level SES (e.g., geographic location), and lifestyle health risk (e.g., cardiovascular risk) in some but not all articles. We discuss the importance of collecting comprehensive social determinants of racial/ethnic disparities inclusive of individual-level, family-level, and neighborhood-level SES. We suggest integrating these variables into healthcare systems (e.g., electronic health records), and utilizing information technology and analytics to better understand the disparity gap for racial/ethnic minorities of childhood cancer survivors. Furthermore, we suggest national and local efforts to close the gap through improving health insurance access, education and transportation aid, racial-culture-specific social learning interventions, and diversity informed training.

Project Forward: A Population-Based Cohort Among Young Adult Survivors of Childhood Cancers

Background

Childhood cancer survivors (CCS) face increased risk of morbidity and are recommended to receive lifelong cancer-related follow-up care. Identifying factors associated with follow-up care can inform efforts to support the long-term health of CCS.

Methods

Eligible CCS (diagnosed between 1996 and 2010) identified through the Los Angeles County Cancer Surveillance Program responded to a self-report survey that assessed demographic, clinical, health-care engagement, and psychosocial risk and protective factors of recent (prior 2 years) cancer-related follow-up care. Weighted multivariable logistic regression was conducted to identify correlates of care. All statistical tests were 2-sided.

Results

The overall response rate was 44.9%, with an analytical sample of n = 1106 (54.2% Hispanic; mean [SD] ages at survey, diagnosis, and years since diagnosis were 26.2 [4.9], 11.6 [5.4], and 14.5 [4.4] years, respectively). Fifty-seven percent reported a recent cancer-related visit, with lower rates reported among older survivors. Having insurance, more late effects, receipt of a written treatment summary, discussing long-term care needs with treating physician, knowledge of the need for long-term care, having a regular source of care, and higher health-care self-efficacy were statistically significantly associated with greater odds of recent follow-up care, whereas older age, Hispanic or Other ethnicity (vs non-Hispanic White), and years since diagnosis were associated with lower odds of recent care (all Ps < .05).

Conclusions

Age and ethnic disparities are observed in receipt of follow-up care among young adult CCS. Potential intervention targets include comprehensive, ongoing patient education; provision of written treatment summaries; and culturally tailored support to ensure equitable access to and the utilization of care.

Persistent Symptoms, Quality of Life, and Correlates with Health Self-Efficacy in Adolescent and Young Adult Survivors of Childhood Cancer

Purpose: The numbers of adolescent and young adult (AYA) survivors of childhood cancer are exponentially growing. To ensure suitable services are available to meet the needs of this growing population, understanding the experience of late effects, quality of life, and potentially modifiable factors, such as self-efficacy, is required. Methods: AYA survivors of childhood cancer recruited through an After Cancer Therapy Service at a Children's Hospital rated their symptoms experience, quality of life, and self-efficacy using the Patient Reported Outcome Common Terminology Criteria for Adverse Events, Functional Assessment of Cancer Therapy-General (FACT-G), and Patient-Reported Outcomes Measurement Information System (PROMIS^®), respectively. Descriptive statistics were used to characterize the sample. Quality-of-life scores were compared with population norms. Regression analyses were used to explore the relationships between symptom experience, quality of life, and self-efficacy. Results: Thirty participants (mean age 22 ± 4.4 years) reported an average of nine symptoms as persistently experienced at moderate or higher rated intensity among participants (standard deviation ±8.7; range: 0-32; interquartile range: 2-16); over half (n = 17, 56.7%) had finished treatment 10 or more years ago. Participants scored lower on the FACT-G Physical Well-being and Emotional Well-being, and higher on Social Well-being subscales than the general population. Around two-thirds of participants were confident in their ability to self-manage their health based on their health self-efficacy score. Bivariate linear regression identified a statistically significant increase in the overall quality of life with increased self-efficacy, adjusted for age and sex (0.60, 95% confidence interval [CI] 0.30-0.90, p < 0.01). Higher symptom burden was associated with a lower overall quality of life after adjusting for age and sex (-0.95, 95% CI: -1.35 to -0.54, p < 0.001). Conclusion: Young cancer survivors experience a substantial number of persistent symptoms related to their cancer treatment that may negatively impact aspects of their quality of life. Health self-efficacy is a potential target for future interventions.

Acculturation, Mental Health, and Wellbeing Among Hispanic/Latinx Young Adult Survivors of Childhood Cancer

Purpose: Ethnic disparities in childhood cancer survivor (CCS) mental health have been identified, although prior survivorship research has focused predominantly on non-Hispanic/Latinx (H/L) white survivors. Methods: This study examined the association of acculturation with depressive symptoms and wellbeing among 582 young adult H/L CCS recruited to a population-based study of CCS in Southern California. Results: In multivariable regression models adjusted for covariates, greater identification with both the Hispanic and Anglo cultures was positively associated with wellbeing (p = 0.007 and p < 0.0001, respectively), and Hispanic cultural identification was associated with fewer depressive symptoms (p = 0.04). Conclusions: Greater understanding of unique protective factors among minority CCS may inform tailored interventions promoting mental health.

Parental Cancer-related Information Seeking, Health Communication and Satisfaction with Medical Providers of Childhood Cancer Survivors: Differences by Race/Ethnicity and Language Preference

For childhood cancer survivors (CCS), parents play an important role in communicating with providers and conveying patient's needs. This exploratory study examined the prevalence of cancer-related information-seeking among parents of CCS and investigated the association between parents' race/ethnicity and language preference with health communication and satisfaction with child's medical providers. One hundred and sixty CCS and their parents from two hospitals in Los Angeles County were recruited from the SEER registry. Multivariable logistic regression analyses assessed associations between parents' race/ethnicity and language preference and their health communication with their child and with their child's medical care providers. Among the parents, 29% were Spanish-speaking Hispanics, 27% English-speaking Hispanics, and 43% English-speaking non-Hispanics. Regardless of language preference, Hispanic parents were more likely than non-Hispanic parents to receive health information about their CCS's cancer from hospital sources versus the internet. There was no difference by ethnicity/language in parent satisfaction with their CCS's medical provider. Spanish-speaking Hispanic parents were more likely to report talking to their CCS about the need for cancer-related follow-up care compared to non-Hispanic English-speaking parents. These findings point to the potential importance of parents' ethnicity and language for sources of health information and frequency of communication with their CCS about their cancer care.

Relationships between parent and adolescent/young adult mental health among Hispanic and non-Hispanic childhood cancer survivors

PURPOSE

To examine associations between parents and adolescent and young adult (AYA) childhood cancer survivors' (CCS) mental health, and differences by Hispanic ethnicity.

SAMPLE

Participants were 129 CCS (Mage = 19.5 yrs.; 49.9% female) and their parents (Mage = 49.0 yrs.; 87.6% female); 52.7% identified as Hispanic.

METHODS

CCS completed assessments of Depressive Symptoms (CES-D), Posttraumatic Growth (PTG) and Pediatric Quality of Life (PedsQL), while parents completed CES-D, Perceived Stress (PSS) and Posttraumatic Stress Disorder (PTSD) measures.

RESULTS

After controlling for covariates, all three negative parental mental health measures (Parent CES-D, PSS, and PTSD), were positively associated with CCS CES-D indicating that higher depressive symptoms and stress in parents was associated with higher depressive symptoms in CCS. Parent CES-D was negatively associated with CCS PedsQL and parent PSS was negatively associated with CCS PTG. Moderation analysis revealed parent PSS to be negatively associated with PedsQL and positively related to CES-D among Hispanic families only.

CONCLUSION

Higher parental negative mental health measures may adversely affect CCS levels of depression, while lower values for parental negative health measures were associated with positive CCS mental health outcomes in AYA. Hispanic parents experience more associations with stress than non-Hispanics.

IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Long-term survivorship follow-up care guidelines should address the mental health needs of both parents and CCS, paying particular attention to perceived stress in Hispanic families.

Estimating cancer treatment intensity from SEER cancer registry data: methods and implications for population-based registry studies of pediatric cancers

OBJECTIVE

The Intensity of Treatment Rating (ITR) Scale condenses treatment and clinical characteristics into a single measure to study treatment effects on downstream health outcomes across cancer types. This rating was originally developed for clinicians to determine from medical charts. However, large studies are often unable to access medical charts for all study participants. We developed and tested a method of estimating treatment intensity (TI) using cancer registry and patient self-reported data.

METHODS

We estimated two versions of TI for a cohort of pediatric cancer survivors-one utilized information solely available from cancer registry variables (TIR) and the other included registry and self-reported information (TIS) from survey participants. In a subset of cases (n = 135) for whom the gold standard TI (TIC) was known, both TIR and TIS were compared to TIC by calculating percent agreement and weighted Cohen's kappa, overall and within cancer subtypes.

RESULTS

In comparison to TIC, 71% of TI scores from both methods were in agreement (k = 0.61 TIR/0.54 TIS). Among subgroups, agreement ranged from lowest (46% TIR/39% TIS) for non-defined tumors (e.g., "Tumor-other"), to highest (94% TIR/94% TIS) for acute lymphoblastic leukemia (ALL).

CONCLUSIONS

We developed a methodology to estimate TI for pediatric cancer research when medical chart review is not possible. High reliability was observed for ALL, the most common pediatric cancer. Additional validation is needed among a larger sample of other cancer subgroups. The ability to estimate TI from cancer registry data would assist with monitoring effects of treatment during survivorship in registry-based epidemiological studies.

Cancer‑related fatigue during combined treatment of androgen deprivation therapy and radiotherapy is associated with mitochondrial dysfunction

Combined androgen deprivation therapy (ADT) and radiation therapy (RT) is the standard of care treatment for non-metastatic prostate cancer (NMPC). Despite the efficacy, treatment-related symptoms including fatigue greatly reduce the quality of life of cancer patients. The goal of the study is to examine the influence of combined ADT/RT on fatigue and understand its underlying mechanisms. A total of 64 participants with NMPC were enrolled. Fatigue was assessed using the Functional Assessment of Cancer Therapy-Fatigue. Mitochondrial function parameters were measured as oxygen consumption from peripheral blood mononuclear cells (PBMCs) extracted from participants' whole blood. An ADT/RT-induced fatigue mouse model was developed, with fatigue measured as a reduction in voluntary wheel-running activity (VWRA) in 54 mice. Mitochondrial function was assessed in the ADT/RT mouse brains using western blot analysis of glucose transporter 4 (GLUT4) and transcription factor A, mitochondrial (TFAM). The results demonstrated that fatigue in the ADT group was exacerbated during RT compared with the non-ADT group. This effect was specific to fatigue, as depressive symptoms were unaffected. PBMCs of fatigued subjects exhibited decreased ATP coupling efficiency compared to non-fatigued subjects, indicative of mitochondrial dysfunction. The ADT/RT mice demonstrated the synergistic effect of ADT and RT in decreasing VWRA. Brain tissues of ADT/RT mice exhibited decreased levels of GLUT4 and TFAM suggesting that impaired neuronal metabolic homeostasis may contribute to fatigue pathogenesis. In conclusion, these findings suggest that fatigue induced by ADT/RT may be attributable to mitochondrial dysfunction both peripherally and in the central nervous system (CNS). The synergistic effect of ADT/RT is behaviorally reproducible in a mouse model and its mechanism may be related to bioenergetics in the CNS.

A comparison of two models of follow-up care for adult survivors of childhood cancer

PURPOSE

Few studies have compared follow-up-care models for adult survivors of childhood cancer (ASCCs), though choice of model could impact medical test adherence, and health-related quality of life (QOL). This study compared two follow-up-care models, cancer-center-based versus community-based, for ASCCs in Alberta, Canada, to determine which model would demonstrate greater ASCC adherence to guideline-recommended medical screening tests for late effects, QOL, physical symptoms, and adherence to yearly follow-up.

METHODS

ASCC discharged to a community model (over 15 years) and those with comparable birth years (1973-1993) currently followed in a cancer center model were recruited via direct contact or multimedia campaign. Chart review identified chemotherapeutic and radiation exposures, and required medical late effect screening tests. ASCCs also completed questionnaires assessing QOL, physical symptoms, and follow-up behavior.

RESULTS

One hundred fifty-six survivors participated (community (n = 86); cancer center (n = 70)). Primary analysis indicated that cancer center ASCCs guideline-recommended total test adherence percentage (Mdn = 85.4%) was significantly higher than the community model (Mdn = 29.2%, U = 3996.50, p < 0.0001). There was no significant difference in QOL for cancer center ASCCs (M = 83.85, SD = 20.55 versus M = 77.50, SD = 23.94; t (154) = 1.77, p = 0.078) compared to community-based ASCCs. Cancer center-based ASCCs endorsed from 0.4-7.1% fewer physical symptom clusters, and higher adherence to follow-up behavior in comparisons using effect sizes without p values.

CONCLUSION

This study highlights the cancer center model's superiority for adherence to exposure-based medical late effect screening guidelines, cancer-specific follow-up behaviors, and the reporting of fewer physical complaints in ASCCs.

IMPLICATIONS FOR CANCER SURVIVORS

ASCCs followed in a cancer center model likely benefit from earlier late-effects detection and opportunities for early intervention.

Population-Based Survey Methods for Reaching Adolescent and Young Adult Survivors of Pediatric Cancer and Their Parents

PURPOSE

Contacting childhood cancer survivors (CCS) to assess reasons for declining receipt of follow-up care after treatment is difficult and participation in surveys may be low, resulting in biased results. We sought to demonstrate effective recruitment and population-based sampling methods to improve response and minimize bias.

METHODS

Four hundred and seventy CCS diagnosed between 2000 and 2007 at two hospitals in Los Angeles County were selected from the California Cancer Registry and were 15-25 years of age at the time of interview. Surveys of survivors and their parents were completed by multiple methods including mail, online, and telephone. Effectiveness of "plain" versus "designer" formatting of study materials was tested. Variables associated with response were analyzed using univariate and multivariable methods. Effort required for recruitment was quantified.

RESULTS

Fifty percent of survivors (n = 235) and 36.5% of parents (n = 171) responded, and there were 160 parent-child dyads among them. Among located survivors, 61% participated. Response was higher for women, parents of younger survivors, and those from higher socioeconomic status areas. Among Hispanics, no variables were related to response. More effort was required to reach men and older survivors, but efforts beyond 15 calls and 7 remailings were unproductive. Formatting (i.e., plain vs. designer) did not affect response.

CONCLUSION

Efforts to reach survivors must include multiple methods to be successful. Use of an intensive recruitment strategy and population-based sample resulted in a largely representative sample of CCS, especially for Hispanics. Expensive design efforts had little effect on recruitment, suggesting that plainer materials are sufficient. This example may inform similar studies.

Co-Occurring Symptoms Contribute to Persistent Fatigue in Prostate Cancer

PURPOSE

Cancer-related fatigue is one of the most debilitating side effects of cancer and cancer therapy. We aimed to investigate co-occurring symptoms associated with persistent fatigue in men receiving external beam radiation therapy (EBRT) for nonmetastatic prostate cancer.

METHODS

A sample of 47 men with prostate cancer scheduled to receive radiotherapy (RT) were followed at baseline and 1 year after RT. Clinical and demographic data were obtained from chart review. Symptom measurements included urinary dysfunction (American Urological Association symptoms score), fatigue (Functional Assessment of Cancer Therapy - Fatigue questionnaire), sleep disturbance (Patient-Reported Outcomes Measurement Information System - Sleep Disturbance form), pain (physical well-being domain pain item of the Functional Assessment of Cancer Therapy - General), and depressive symptoms (Hamilton Depression Rating Scale). Paired t tests, correlations, general linear models, and logistic regressions were used to determine associations between fatigue and other symptom scores.

RESULTS

At 1 year after RT, 34% of subjects continued to experience fatigue. Urinary dysfunction was the best clinical predictor of persistent fatigue. Pain and depressive symptoms further improved the predictive power of the model. A multivariate linear regression model containing all these three clinical variables (urinary dysfunction, pain, and depressive symptoms) explained 74% of total variance associated with persistent fatigue after RT.

CONCLUSIONS

Persistent fatigue at 1 year after EBRT in prostate cancer survivors is likely related to a cluster of symptoms elicited by chronic inflammation. Therapies that target each of these symptoms will likely reduce fatigue in this patient population.

Insurance Coverage, and Having a Regular Provider, and Utilization of Cancer Follow-up and Noncancer Health Care Among Childhood Cancer Survivors

The objective of this study was to assess the role of health insurance coverage on patterns of health care utilization and access to cancer-related follow-up and non-cancer care among childhood cancer survivors (CCS). Cross-sectional survey design was used. Childhood cancer survivors were from 2 large hospitals in Los Angeles County. In all, 235 were identified through the Los Angeles Cancer Surveillance Program, diagnosed between the ages of 5 and 18 in 2000-2007 with any cancer type except Hodgkin lymphoma. At data collection in 2009-2010, participants were between 15 and 25 years old. Study exposure was health insurance coverage (private, public, and uninsured). Main outcomes and measures were respondents' regular source of care for cancer follow-up, noncancer care, and both; and having a cancer follow-up visit, primary care visit, and hospital emergency department visit in the past 2 years. Compared with those with private insurance, the uninsured were less likely to have a regular source for cancer follow-up (odds ratio [OR] = 4.3, 95% confidence interval [CI] = 1.9-9.4), less likely to have a source for noncancer care (OR = 3.3, 95% CI 1.6-6.9), and less likely to have a source of care for both (OR = 5.3, 95% CI = 2.1-13.5). Furthermore, uninsured CCS were less likely to have made visits to cancer specialists (OR = 4.5, 95% CI = 2.1-9.50) and were less likely to have seen a primary care physician in the past 2 years (OR = 3.9, 95% CI = 1.8-8.2). In addition, those with public (vs private) insurance were less likely to have a regular provider for primary care (OR = 2.5, 95% CI = 1.1-5.4) and less likely to have made a primary care visit in the past year (OR = 2.8, 95% CI = 2.1-13.5). Uninsured CCS are at risk of not obtaining cancer follow-up care, and those with public (vs. private) insurance have less access to primary care. Policies that ensure continuity of coverage for survivors as they age into adulthood may result in fewer barriers to needed care, which may lead to fewer health problems for CCS in the future.

Hispanic Orientation and Cancer-Related Knowledge in Childhood Cancer Survivors

Cancer-related knowledge among childhood cancer survivors (CCSs) has been underexplored. In particular, little is known about factors impacting knowledge of the need for lifelong follow-up care in CCSs. This secondary analysis of data examined acculturation, cancer-related knowledge, demographics, and clinical factors in 193 ethnically and culturally diverse CCSs (age at study 19.9 ± 2.8 years). Cancer-related knowledge gaps were found across all participants. Univariate and multivariable logistic regression analyses indicated that Hispanic CCSs with greater Hispanic orientation were significantly more likely to be aware of a need for lifelong follow-up care. A greater focus on targeted risk communication with CCSs is warranted.

Validation of the Spanish Version of the Psychosocial Assessment Tool (PAT) in Pediatric Cancer

Objective

Family psychosocial risk screening is an important initial step in delivering evidence-based care and in addressing health disparities. There is currently no validated measure of family psychosocial risk in Spanish. The Psychosocial Assessment Tool (PAT) is a brief parent report screener based on the trilevel Pediatric Preventative Psychosocial Risk Model (PPPHM; Universal, Targeted, and Clinical). The current article validates a Spanish version of the PAT (Version 3.0) in pediatric oncology.

Method

Spanish-speaking Hispanic primary caregivers of 79 children newly diagnosed with cancer participated in this 4-institution multisite investigation, completing Spanish versions of the PAT and validation measures using REDCap.

Results

Over 60% of the sample had a high school or lower level of education and they primarily identified as Hispanic in terms of acculturation. Internal consistency for the total score (KR20 = 0.76) and the Social Support, Child Problems, Sibling Problems, and Family Problems subscales was strong (KR20 = 0.69-0.79). Stress Reactions, Family Structure, and Family Beliefs subscales were lower (KR20 = 0.43-0.55). Moderate to strong correlations with the criteria measures provided validation for the total and subscale scores. Nearly two-thirds of the sample scored in the Targeted or Clinical range of the PPPHM. The PAT was successful in identifying clinical cases.

Conclusions

The Spanish version of the PAT can be used with families of children newly diagnosed with cancer. Elevated psychosocial risks were found and warrant particular attention in providing psychosocial care attentive to the needs of Spanish-speaking families.

Childhood Cancer Survivorship and Substance Use Behaviors: A Matched Case-Control Study Among Hispanic Adolescents and Young Adults

PURPOSE

This case-control study compared substance use behaviors between Hispanic adolescent and young adult survivors of childhood cancers (cases) and a community sample of participants without cancer (controls).

METHODS

A total of 100 cases were matched to controls (200 participants) one to one by ethnicity, age, and sex (mean age at survey 19.27, standard deviation = 1.92). Differences in self-reported previous 30-day use of tobacco, alcohol, binge drinking of alcohol, and marijuana were examined using conditional multivariable logistic regression.

RESULTS

The odds of tobacco, alcohol, binge drinking, and marijuana use were significantly lower for cases than for controls (all p's <.05). When stratified by age, cases (vs. controls) under 21 years of age reported lower levels of substance use (all p's <.05), whereas differences over the age of 21 were nonsignificant.

CONCLUSIONS

Lower levels of substance use among Hispanic adolescent and young adult survivors of childhood cancers (vs. controls) are most apparent at younger ages. Future work needs to examine a potential delay in initiation of use among survivors.

Acculturation, Mental Health, and Quality of Life among Hispanic Childhood Cancer Survivors: A Latent Class Analysis

Objective

Acculturation appears to be an important aspect of the association between ethnicity and disease, but it has not been explored in depth among childhood cancer survivors (CCS). The purpose of our study was to identify distinct acculturative profiles among Hispanic CCS and to assess differences in quality of life and depressive symptoms.

Design

Latent class analysis was used to identify distinct acculturative profiles using 9 indicator items reflecting Hispanic and Anglo cultural orientation. Multinomial logistic regression was performed to explore differences in depressive symptoms and quality of life between acculturation classes.

Setting and Participants

Participants were diagnosed in Los Angeles County, California, USA between 2000-2007 and were recruited for the study in 2009.

Main Outcome Measures

Center for Epidemiologic Studies depression scale and the PedsQL 4.0 quality of life scale.

Results

Three distinct acculturation classes emerged. All classes displayed a high probability of endorsing all Anglo orientation items. One class additionally demonstrated a high probability of endorsing all Hispanic orientation items and was labeled bicultural 40%); another demonstrated low probability of endorsing the Hispanic items so was labeled assimilated (32%); and the last demonstrated a high probability of endorsing only the Hispanic items related to language use and was labeled linguistically Hispanic/culturally Anglo (LH) (28%).

Conclusions

The assimilated group had significantly more depressive symptoms and lower quality of life than the other two groups. This may indicate that loss of the Hispanic culture may be associated with poorer psychosocial health among CCS.

Prevalence and correlates of health information-seeking among Hispanic and non-Hispanic childhood cancer survivors

PURPOSE

Childhood cancer survivors (CCS) report high unmet information needs. This study examined the prevalence of cancer-related information-seeking among CCS and investigated associations between information-seeking behavior and positive health outcomes such as follow-up care.

METHODS

Participants (n = 193) were young adult CCS diagnosed with cancer in Los Angeles County, 54% of Hispanic ethnicity, with a mean age of 19.87, in remission, and at least 2 years from completion of treatment. CCS were asked where they accessed health information related to their cancer with response options categorized into four information domains: hospital resources, social media, other survivors, and family members. Multivariable logistic regression was used to assess variables associated with each information domain, including sociodemographics, post-traumatic growth (i.e., reporting positive changes since cancer diagnosis), health care engagement, level of education, and health insurance status.

RESULTS

Hospital resources were the most commonly accessed information domain (65.3%), and CCS of Hispanic ethnicity (vs. non-Hispanic) were more likely to access this source. Seeking information from other cancer survivors was positively associated with follow-up care and post-traumatic growth. Hispanic CCS were marginally less likely to seek information from other survivors and family than non-Hispanics.

CONCLUSIONS

While CCS obtain information from a variety of sources, hospital resources are an important site for access, particularly for individuals of Hispanic ethnicity. Information sharing between survivors may promote positive health care engagement; however, Hispanic CCS may be less likely to utilize this resource and may face barriers in information sharing with other cancer survivors.

Posttraumatic growth among childhood cancer survivors: Associations with ethnicity, acculturation, and religious service attendance

This study assessed the association between ethnicity, religious service attendance (RSA), and acculturation with posttraumatic growth (PTG) in a diverse sample of 235 childhood cancer survivors (CCS). PTG scores were estimated for each ethnicity, and by level of RSA and acculturation. There was a significant curvilinear relationship (inverted U) between RSA and PTG, such that moderate levels of RSA were associated with the highest PTG scores. Hispanics reported the highest PTG, and both Hispanic and Anglo cultural orientation were significantly positively associated with PTG. CCS with high or low frequency of RSA as well as Hispanic CCS who lack a strong sense of cultural identity may benefit from targeted efforts to promote psychosocial adaptation in the aftermath of cancer.

The role of TRAIL in fatigue induced by repeated stress from radiotherapy

Fatigue is one of the most common and debilitating side effects of cancer and cancer treatment, and yet its etiology remains elusive. The goal of this study is to understand the role of chronic inflammation in fatigue following repeated stress from radiotherapy. Fatigue and non-fatigue categories were assessed using ≥ 3-point change in Functional Assessment of Cancer Therapy-Fatigue questionnaire (FACT-F) administered to participants at baseline/before radiotherapy and one year post-radiotherapy. Whole genome microarray and cytokine multiplex panel were used to examine fatigue-related transcriptome and serum cytokine changes, respectively. The study included 86 subjects (discovery phase n = 40, validation phase n = 46). The sample in the discovery phase included men with prostate cancer scheduled to receive external-beam radiotherapy. A panel of 48 cytokines were measured and the significantly changed cytokine found in the discovery phase was validated using sera from a separate cohort of men two years after completing radiotherapy for prostate cancer at a different institution. Effects of the significantly changed cytokine on cell viability was quantified using the MTT assay. During the discovery phase, tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and TRAIL decoy receptor, TNFRSF10C (TRAIL-R3), were significantly upregulated in fatigued (≥3-point decrease from baseline to 1yr-post radiotherapy) subjects (n = 15). In the validation phase, TRAIL correlated with fatigue scores 2yrs post-radiotherapy. TRAIL caused selective cytotoxicity in neuronal cells, but not in microglial and muscle cells, in vitro. Late-onset inflammation directed by TRAIL may play a role in fatigue pathogenesis post-repeated stress from irradiation.

Predictors of Suboptimal Follow-up in Pediatric Cancer Survivors

Attendance to follow-up care after completion of cancer treatment is an understudied area. We examined demographic, clinical, and socioeconomic predictors of follow-up by pediatric cancer patients at a large center in 442 newly diagnosed patients using multivariable logistic regression analyses. Patients who did not return to clinic for at least 1000 days were considered lost to follow-up. Two hundred forty-two (54.8%) patients were lost. In multivariable analyses, the following variables were independent predictors of being lost to follow-up: treatment with surgery alone (odds ratio [OR]=6.7; 95% confidence interval [CI], 3.1-14.9), older age at diagnosis (reference, 0 to 4; ages, 5 to 9: OR=1.8, 95% CI, 1.1-3; ages, 10 to 14: OR=3.3; CI, 1.8-6.1; and ages, 15 and above: OR=4.8; CI, 2.1-11.7), lack of history of stem cell transplantation (OR=2, 95% CI, 1.04-3.7) and lack of insurance (OR=3.4; CI, 1.2-9.2). Hispanic patients had the best follow-up rates (53.7%) compared to whites and blacks (P=0.03). Attendance to long-term follow-up care is suboptimal in childhood cancer survivors. Predictors that were associated with nonattendance can be used to design targeted interventions to improve follow-up care for survivors of pediatric cancer.

Supporting long-term follow-up of young adult survivors of childhood cancer: Correlates of healthcare self-efficacy

BACKGROUND

Healthcare self-efficacy (HCSE), the perceived confidence to manage one's health care, has been identified as a critical component in the transition process from pediatric to adult-oriented care for childhood cancer survivors (CCSs). HCSE is amenable to intervention and associated with long-term follow-up care among CCSs. However, factors associated with HCSE have not been fully explored among CCSs.

PROCEDURE

We identified correlates of HCSE among a sample of CCSs (n = 193). Descriptive statistics and linear regression methods were used in this cross-sectional analysis.

RESULTS

In univariate analyses, higher physical and psychosocial quality of life, posttraumatic growth, and religious/spiritual importance were associated with higher HCSE. Attendance at a survivorship clinic, having a regular source of care (both noncancer and oncologist), and any type of health insurance were also associated with HCSE. Hispanic ethnicity was negatively associated with HCSE relative to non-Hispanics. In a multivariable model, psychosocial quality of life, religious/spiritual importance, survivorship clinic attendance, having a regular oncologist, and Hispanic ethnicity remained significantly associated with HCSE.

CONCLUSIONS

CCSs who reported greater well-being, who rated religion and spirituality of high importance, and who accessed specialized cancer services expressed greater HCSE. Hispanic CCSs, however, reported less HCSE than non-Hispanics. Interventions that attend to the quality of life and spiritual needs of CCSs have potential to build HCSE to support the healthcare transition process. Because Hispanic CCSs may be at risk of lower perceived confidence to navigate their health care, culturally competent, efficacy-enhancing interventions are needed for this population.

Clinical Predictors of Fatigue in Men With Non-Metastatic Prostate Cancer Receiving External Beam Radiation Therapy

BACKGROUND

Fatigue is one of the most distressing symptoms experienced by people with cancer receiving radiation therapy.

OBJECTIVES

The goal of this study is to evaluate clinical predictors of worsening fatigue during external beam radiation therapy (EBRT) in men with non-metastatic prostate cancer.

METHODS

Thirty-five men with non-metastatic prostate cancer scheduled for EBRT were followed at baseline, midpoint, and completion of EBRT. The Functional Assessment of Cancer Therapy-Fatigue scale was administered. Demographic and clinical data were obtained by chart review. Paired t-tests, correlations, general linear models, and logistic regressions were used to determine associations between fatigue scores and clinical data.

FINDINGS

Red blood cells, hemoglobin, and hematocrit levels were highly intercorrelated and, therefore, were grouped as one composite variable termed heme. Heme levels at baseline and androgen-deprivation therapy (ADT) were significantly correlated with worsening of fatigue symptoms from baseline to midpoint and endpoint. ADT alone did not have a significant correlation with fatigue, but it indirectly affected fatigue levels by influencing heme markers as treatment progressed. These findings provide evidence that hematologic markers and the use of ADT assist in predicting radiation therapy-related fatigue and guide symptom management.

Substance use among adolescent and young adult cancer survivors

OBJECTIVE

Health-promoting behaviors are recommended to childhood cancer survivors (CCS) to reduce late effects resulting from cancer treatment. Understanding factors associated with substance use is needed, especially among Hispanic CCS who are underrepresented in previous studies. The objective of this study is to examine substance use behaviors of recently treated Hispanic and non-Hispanic CCS.

METHODS

One hundred ninety-three Los Angeles County CCS who were diagnosed between 2000 and 2007 (54% Hispanic; mean age 19.9 years, SD = 2.8; mean age at diagnosis = 12.1, SD = 3.0; mean years since diagnosis = 7.8, SD = 2.0) provided self-reported information on substance use, demographics, clinical factors, religiosity, and depressive symptoms. Risk and protective factors for substance use were examined using multivariable logistic regression.

RESULTS

Prevalence of 30-day substance use was 11%, 25%, and 14% for tobacco, alcohol, and marijuana, respectively. In controlled regression models, age was positively associated with tobacco use, binge drinking, and polysubstance use (use of at least two of the three substances). Male gender, higher depressive symptoms, and higher socioeconomic status were associated with greater marijuana use. In addition, religiosity was negatively associated with the use of all substances.

CONCLUSIONS

The prevalence rates for substance use in this ethnically diverse representative sample of CCS are lower than those observed in the general population. Older CCS were at higher risk of substance use, and depression was associated with greater marijuana use. No differences by ethnicity were observed. Interventions for substance use prevention/cessation among CCS may be most effective if implemented before the age of 21 years and address mental health as part of survivorship care. Copyright © 2015 John Wiley & Sons, Ltd.

Childhood cancer survivorship research in minority populations: A position paper from the Childhood Cancer Survivor Study

By the middle of this century, racial/ethnic minority populations will collectively constitute 50% of the US population. This temporal shift in the racial/ethnic composition of the US population demands a close look at the race/ethnicity-specific burden of morbidity and premature mortality among survivors of childhood cancer. To optimize targeted long-term follow-up care, it is essential to understand whether the burden of morbidity borne by survivors of childhood cancer differs by race/ethnicity. This is challenging because the number of minority participants is often limited in current childhood cancer survivorship research, resulting in a paucity of race/ethnicity-specific recommendations and/or interventions. Although the overall childhood cancer incidence increased between 1973 and 2003, the mortality rate declined; however, these changes did not differ appreciably by race/ethnicity. The authors speculated that any racial/ethnic differences in outcome are likely to be multifactorial, and drew on data from the Childhood Cancer Survivor Study to illustrate the various contributors (socioeconomic characteristics, health behaviors, and comorbidities) that could explain any observed differences in key treatment-related complications. Finally, the authors outlined challenges in conducting race/ethnicity-specific childhood cancer survivorship research, demonstrating that there are limited absolute numbers of children who are diagnosed and survive cancer in any one racial/ethnic minority population, thereby precluding a rigorous evaluation of adverse events among specific primary cancer diagnoses and treatment exposure groups. Cancer 2016;122:2426-2439. © 2016 American Cancer Society.

Psychosocial Follow-Up in Survivorship as a Standard of Care in Pediatric Oncology

Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory.