Stress-related mental disorders in childhood cancer survivors

Reintegration into school, kindergarten and work in families of childhood cancer survivors after a family-oriented rehabilitation program

Objective

To describe the situation of childhood cancer survivors and their parents before and one year after a family-oriented rehabilitation program (FOR) and to identify factors influencing reintegration.

Methods

We included parents of children diagnosed with leukemia or central nervous system tumor. We assessed parental functioning using the functioning subscale of the Ulm Quality of Life Inventory for Parents (ULQIE) and children's school/kindergarten related quality of life (parental assessment, subscale KINDL-R). Descriptive analyses, group comparisons and multiple regression analyses on data of 285 parents of 174 children diagnosed with leukemia or central nervous system tumor.

Results

Parents reported changes in their work situation (e.g., reduction of working hours) due to their child's diagnosis. Parental functioning increased significantly over time. Children's leukemia diagnosis and shorter time since the end of treatment were associated with higher functioning in parents one year after FOR. Parents reported difficulties in the child's work pace, concentration, stress resilience and empathy. The school/kindergarten-related quality of life (QoL) of the children was lower than in the general population. One year after FOR, most children reintegrated fully in school/kindergarten, partly with support (e.g., integration assistant). No significant predictors for children's reintegration were identified.

Discussion

Parents and children experience major changes in their work/school/kindergarten life. One year after FOR most parents reported a reintegration of their children, however the children's school/kindergarten-related QoL remained below average compared to norm values. Even after rehabilitation families of childhood cancer survivors might benefit from psychosocial and practical support offers to support families with the reintegration into work/school/kindergarten.

Examining associations between early adverse life events and health anxiety using the DanFund study

Childhood adverse life events, in particular illness-related events, have been proposed as a risk factor for development of health anxiety.

OBJECTIVE

To examine: 1) The association between accumulated early adverse life events and health anxiety in adulthood and 2) The influence of specific types of life events, i.e., illness, injury, loss, and the impact of their exposure time on health anxiety in adulthood.

METHOD

A population-based, cross-sectional study including 7454 participants from the Danish study of Functional Disorders (DanFunD). Health anxiety was assessed with Whiteley-6-R and early adverse life events with the Cumulative Lifetime Adversity Measure. Caseness was defined as a Whiteley-6-R score ≥ 90%ile. Generalised linear models were used to estimate the association with relative risk (RRa, adjusted for sociodemographics).

RESULTS

A cumulative effect was found for each additional adverse life event with 8.03% increased risk of health anxiety. Two categories were associated with a higher risk: violence (RRa = 1.65, 95% CI: 1.37-1.99, P < 0.001) and relationship stress (RRa = 1.34; 95% CI: 1.15-1.57, P < 0.001). Respondents with self-reported childhood illness were also more likely to report health anxiety (RRa = 1.52, 95% CI 1.11-2.09, P = 0.009). Timewise, health anxiety seemed associated with illness during school age and injury during adolescence.

CONCLUSIONS

Accumulated adverse life events, early exposure to specific categories and specific health-related life events were associated with self-reported health anxiety in adulthood. Our findings provide new knowledge on the potential role of early life events in health anxiety which could inform early intervention.

Program evaluation of a wilderness experience for adolescents facing cancer: A time in nature to heal, connect and find strength

OBJECTIVE

Despite advances in cancer treatment and increased survival, adolescents in treatment for cancer often suffer from psychosocial distress, negative mood, and chronic health problems. Wilderness therapy is considered a promising program to address psychosocial issues among adolescents with mental or behavioral health issues. There is little research on whether it may benefit adolescents in cancer treatment.

METHODS

This program evaluation in the form of a pilot study uses qualitative and quantitative measures to describe the feasibility, acceptability, safety, and to explore the impact of a nine-day wilderness program among adolescents aged 13-17 in treatment or who recently finished treatment for a cancer. Quantitative tracking documented recruitment, retention, safety, and participant satisfaction. PROMIS measures assessed mental and social health, positive affect, fatigue, pain interference and intensity over three time-points: pre, post, and three-months after the nine-day wilderness experience. Mean differences were compared over time. Qualitative data collection involved participant observation and open-ended interviews.

RESULTS

Study enrollment goals were met, enrolling eight adolescent participants with 100% participant retention. No serious adverse events were reported and participants described high satisfaction (9.25/10) with the wilderness experience on the final day and at three-months follow-up (9.5/10). Exploratory data analysis showed scores in a favorable direction indicating improved psychosocial outcomes in physical functioning, anxiety, depression, fatigue, and peer relations. From qualitative analysis it is suggested that program participation supported: increased self-confidence and peer connection. The program was evaluated as increasing personal accomplishment, supporting social interaction, having strong staff support, and capitalizing on the natural surroundings.

CONCLUSION

Use of a wilderness program is feasible, acceptable, and safe among this highly vulnerable adolescent cancer population. Participants described greater self-confidence and peer connection which developed as participants experienced physical competency, group leadership, and personal strength. Larger randomized controlled studies are needed to learn whether these programs can improve psychosocial outcomes.

A multisite randomized controlled trial of an early palliative care intervention in children with advanced cancer: The PediQUEST Response Study Protocol

Background

The Pediatric Quality of Life and Evaluation of Symptoms Technology Response to Pediatric Oncology Symptom Experience (PQ-Response) intervention aims to integrate specialized pediatric palliative care into the routine care of children, adolescents, and young adults (AYAs) with advanced cancer.

Aims

To evaluate whether PQ-Response, compared to usual care, improves patient’s health related quality of life (HRQoL) and symptom burden (aim 1), parent psychological distress and symptom-related stress (aim 2), and family and symptom treatment activation (aim 3).

Design

Multisite, randomized (1:1), controlled, un-blinded, effectiveness trial comparing PediQUEST Response (intervention) vs usual cancer care (control).

Setting

Five US large, tertiary level pediatric cancer centers.

Participants

Children (≥2 years old)/AYAs who receive care at any of the participating sites because of advanced cancer or any progressive/recurrent solid or brain tumor and are palliative care “naïve.” Target: 200 enrolled patient-parent dyads (minimum goal: 136 dyads randomized, N = 68/arm).

Interventions

PediQUEST Response: combines patient-mediated activation (weekly feedback of patient- and parent-reported symptoms and HRQoL to families and providers using the PediQUEST web system) with integration of the palliative care team. Usual Cancer Care: participants receive usual care, which can include palliative care consultation, and use PediQUEST web to answer surveys, with no feedback.

Methods

Following enrollment, patients (if ≥5 years) and one parent receive weekly PediQUEST-Surveys assessing HRQoL (Pediatric Quality of Life Inventory 4.0) and symptom burden (PediQUEST-Memorial Symptom Assessment Scale). After a 2-week run-in period, dyads who answer ≥2 PediQUEST surveys per participant (responders), are randomized (concealed allocation) and followed up for 16-weeks. Parents answer six additional surveys (parent outcomes).

Outcomes

Primary: mean patient HRQoL score over 16-weeks as reported by a) the parent; and b) the patient if ≥5 years-old. Secondary: patient’s symptom burden; parent’s anxiety, depressive symptoms, symptom-related stress; family activation; and symptom treatment activation.

Trial registration

ClinicalTrials.gov (NCT03408314) 1/24/18. https://clinicaltrials.gov/ct2/show/NCT03408314.

Recommendations for the surveillance of mental health problems in childhood, adolescent, and young adult cancer survivors: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Survivors of childhood, adolescent, and young adult (diagnosed when <25 years of age) cancer are at risk of mental health problems. The aim of this clinical practice guideline is to harmonise international recommendations for mental health surveillance in survivors of childhood, adolescent, and young adult cancer. This guideline was developed by a multidisciplinary panel of experts under the sponsorship of the International Guideline Harmonization Group. We evaluated concordance among existing survivorship clinical practice guidelines and conducted a systematic review following evidence-based methods. Of 7249 studies identified, 76 articles from 12 countries met the inclusion criteria. Recommendations were formulated on the basis of identified evidence in combination with clinical considerations. This international clinical practice guideline strongly recommends mental health surveillance for all survivors of childhood, adolescent, and young adult cancers at every follow-up visit and prompt referral to mental health specialists when problems are identified. Overall, the recommendations reflect the necessity of mental health surveillance as part of comprehensive survivor-focused health care.

Evaluation of Patient-Reported Outcome Measures of Positive Psychosocial Constructs in Children and Adolescent/Young Adults with Cancer: A Systematic Review of Measurement Properties

Introduction: Children, adolescents, and young adults with cancer are a vulnerable population in whom improvements in psycho-oncology care would be valuable. We previously published a scoping review exploring what is known about positive psychological constructs in this population. A key finding was that evidence-based patient-reported outcome measures (PROMs) were needed to standardize psycho-oncology research. Methods: We undertook a systematic review of measurement properties focused on PROMs in the pediatric and adolescent/young adults (AYAs) with cancer populations. We searched for PROMs that measured at least 1 of 15 previously identified, key positive constructs. This systematic review followed COSMIN guidelines, considered the gold standard manual for systematic reviews of measurement properties. Results: We identified 20 (22 if proxy reports are counted separately) unique PROMs that met inclusion criteria. Of those, only five were recommended for use given the current evidence. The remainder may be used if no alternative exists. Only eight PROMs had any evidence of content validity, considered the most important psychometric property by COSMIN. Many studies were at risk of bias owing to incomplete or suboptimal methods. Discussion: Five PROMs are considered reliable for the pediatric and AYA with cancer populations. A number of PROMs require additional research to ensure their items and instructions are comprehensive, relevant, and comprehensible to children and AYAs. Given the overall lack of research, this review may be considered a starting point for the future refinement of a core set of PROMs to measure positive psychological constructs.

A Reliability Generalization Meta-Analysis of 17 Patient-Reported Outcome Measures for Positive Psychosocial Constructs in Children, Adolescents, and Young Adults with Cancer

Introduction: Children, adolescents, and young adults (AYAs) with cancer are a special population who are subjected to a number of unique challenges, stressors, and barriers to high-quality psychological care. In a recent systematic review of measurement properties, we found that 5 of 18 identified patient-reported outcome measures (PROMs) had sufficient psychometric properties to justify their use. A next step is to analyze the reliability of these scale scores in a reliability-generalization meta-analysis. Methods: We conducted a systematic review of three databases for all studies reporting reliability data for previously identified PROMs. Included studies were further required to include patients with cancer, or survivors of cancer, ages 2-39. We next synthesized alpha and test-retest coefficients using best statistical practices, according to prespecified subgroups, where possible. We considered a threshold of 0.7 to represent sufficient evidence of reliability. Results: Seventy-one studies were included. Overall, reliability coefficients for scale and subscale scores exceeded 0.7. Subgroup analyses were limited by incomplete reporting and a lack of sufficient studies for each subgroup; however, where conducted, these subgroup analyses showed significant differences in the reliability of self-reports versus proxy reports and original versus adapted versions of PROMs. Discussion: We recommend better reporting of reliability data in future studies of children and AYAs with cancer. We discourage relying on historical reliability data in different samples and the reporting of only ranges of reliability coefficients for subscales. Our study suggests that significant differences in the reliability of PROMs may be associated with the PROM respondent and the version of the PROM, thus highlighting the need for further investigation.

[Childhood Cancer Patients in a Family-Oriented Rehabilitation Program: Goals and Change in Physical Functioning]

PURPOSE

Childhood cancer often leads to physical and psychosocial burdens that can persist beyond the end of treatment. Family-oriented rehabilitation programs (FOR) focus on long-term consequences and support families in returning to daily life. The objectives of this study were to describe rehabilitation goals and goal attainment, to analyze the relationship between physical functioning and physical well-being and to examine predictors of changes in physical functioning during the FOR.

METHODS

In a prospective observational study, statements of physicians regarding rehabilitation goals, goal achievement and physical functioning of 175 children (<18 years of age at the time of diagnosis of leukemia or central nervous system tumor) at the beginning and the end of a FOR were analyzed. The physical well-being of the patients was assessed from a parent and child perspective. Correlation coefficients were calculated to analyze the relation between physical functioning and physical well-being. Predictors of changes in physical functioning were examined with a multiple regression analysis.

RESULTS

The most frequently mentioned rehabilitation goals were the increase of physical functioning and the integration into the peer group. Overall, the goal achievement ranged from 82 to 100%. Physical functioning improved significantly during the FOR. A significant positive correlation between the physician's assessment of physical functioning and the parental assessment of physical well-being could be found at the beginning of the FOR. According to the regression model, female gender of the child and a longer time since diagnosis were associated with a lower change in physical functioning. Furthermore, a higher degree of physical consequential damages was associated with a larger change.

CONCLUSIONS

The 4-week multimodal rehabilitation program of the FOR addressed various physical and psychosocial burdens and was accompanied by a significant improvement of the physical functioning of childhood cancer patients. The change in physical functioning was associated with different sociodemographic and medical factors (eg, sex). The consideration of these factors could help with optimizing the program.

Neurocognitive impairment in Asian childhood cancer survivors: a systematic review

Childhood cancer survivors are at higher risk of developing neurocognitive deficits due to the intensive treatment they received at an early age. Most studies on childhood cancer survivorship have so far focused on the Western populations. Due to the ethnic, genetic, environmental, and cultural differences, clinical data of the Western populations may not be representative of Asian countries. This scoping review systematically summarized the existing clinical evidence of the neurocognitive impairment of Asian childhood cancer survivors. We searched the Embase and Medline databases for studies assessing the neurocognitive functions of survivors in Asia, who were diagnosed with cancer before the age of 19 and completed active treatment. The literature search identified 13 studies involving 2212 participants from five Asian countries: South Korea (n = 4, 30.8%), Taiwan (n = 3, 23.1%), Japan (n = 3, 23.1%), Hong Kong (n = 2, 15.4%), and Thailand (n = 1, 7.7%). The included studies focused on CNS tumors (n = 10, 76.9%), hematological malignancies (n = 7, 53.8%), or heterogeneous cancer diagnoses (n = 3, 23.1%). Collectively, mild-to-moderate impairment in intelligence was observed in 10.0 to 42.8% of survivors, which seemed higher than the reported rate in Western survivors. We speculate that the ethnic and genetic variations in drug responses and susceptibility to adverse chronic toxicities may have contributed to the differences in the prevalence and severity of neurocognitive impairment between these two populations. To better understand the effects of culturally relevant and region-specific environmental risk factors on the post-treatment neurocognitive development in cancer survivors, a holistic approach that addresses the complex interactions between biological, physical, and psychosocial factors is needed. This will aid the development of effective intervention strategies to improve the functional and psychosocial outcomes of cancer survivors in Asian societies.

Impact of multimorbidity subgroups on the health care use of early pediatric cancer survivors

BACKGROUND

Although pediatric cancer survivors in the United States are at an increased risk of developing chronic conditions, to the authors' knowledge there is limited information regarding the types and combinations of conditions they experience in the years immediately after the completion of cancer therapy.

METHODS

An observational cohort study of early pediatric cancer survivors (children who were ≥2 years from the end of therapy and aged ≤18 years) was conducted using the Truven Health MarketScan (r) Commercial Claims and Encounters database (2009-2014). Latent class analysis was used to identify comorbidity groups among the subset with ≥2 conditions. Group-level health care use was compared with survivors without chronic conditions using multivariate regression.

RESULTS

A total of 3687 early survivors were identified, of whom approximately 41.2% had no chronic conditions, 22.5% had 1 chronic condition, and 36.3% had ≥2 chronic conditions. Among those with ≥2 chronic conditions, 5 groups emerged: 1) general pediatric morbidity (35.4%); 2) central nervous system (CNS) (22.4%); 3) mental health conditions (22.2%); 4) endocrine (26.2%); and 5) CNS with endocrine (3.8%). The CNS group experienced the highest expenditures, at $17,964 more per year (95% CI, $1446-$34,482) compared with survivors without chronic conditions. The CNS group also had the highest odds of an emergency department visit (adjusted odds ratio, 1.71; 95% CI, 1.15-2.56). The endocrine group had the highest odds of hospitalization (odds ratio, 2.29; 95% CI, 1.24-4.22).

CONCLUSIONS

Multimorbidity is common among pediatric cancer survivors. The current study identified 5 distinct comorbidity subgroups, all of which experienced high, yet differential, rates of health care use. The results of the current study highlight the complex health care needs of early survivors and provide evidence for the design of targeted survivorship services and interventions.

Mapping the concept, content and outcome of wilderness therapy for childhood cancer survivors: protocol for a scoping review

INTRODUCTION

Long-term childhood cancer survivors are at risk for frailty and have significant health-related issues in adulthood. Various health promotion interventions have been proposed to enhance quality of life including wilderness therapy, which applies the impact of nature on health in a therapeutic context. Previous studies have described positive outcomes linked with various wilderness-related therapies for cancer survivors. However, there is no clarity on the role these therapies play in childhood cancer. The current scoping review aims to systematically map the concept, content and outcome of wilderness therapy for childhood cancer survivors.

METHODS AND ANALYSIS

This review will be guided by the Joanna Briggs Institute Reviewers' manual for scoping reviews. A systematic literature search using medical subject headings (MeSH) and text words related to wilderness therapy and childhood cancer survivors will be performed in EMBASE, ERIC, Medline, Psycinfo, CINAHL, Scopus, Web of Science, SPORTDiscus and Svemed+, Sociological Abstracts, supplemented by grey literature searches. Eligible quantitative and qualitative studies will be screened, included, assessed for quality and extracted for data by two reviewers independently. Results will be described in a narrative style, reported in extraction tables and diagrams, and where appropriate in themes and text.

ETHICS AND DISSEMINATION

This study describes a protocol for a scoping review that will undertake secondary analysis of data already published in literature and is therefore exempt from medical ethical review. The scoping review will inform understanding of the benefits and risks of wilderness therapy for childhood cancer survivors, their families, practitioners, clinicians and researchers, and will help elucidate the steps necessary for building its evidence base going forward. Results will be published in a peer-reviewed scientific journal.

Psychosocial interventions for rehabilitation and reintegration into daily life of pediatric cancer survivors and their families: A systematic review

Background

The survival rate of childhood cancer patients increased over the past decades. However, even after successful treatment the transition back to normalcy is often a major challenge for the whole family. Therefore, this study aims to provide an overview of psychosocial interventions for childhood cancer survivors and their families in the first years after the end of cancer treatment.

Methods

We conducted a systematic review following the PRISMA Checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO registration number: CRD42017059782). In November 2016 and September 2017, we searched the databases CINAHL, MEDLINE, PSYNDEX, and Web of Science. We included studies investigating psychosocial interventions for childhood cancer survivors diagnosed under the age of 21, their family members or the family as a whole. Further, we summarized the study characteristics and conducted a narrative synthesis of the results. Finally, we assessed the study quality with the Effective Public Health Practice Project Quality Assessment Tool.

Results

We identified a total of 8215 records based on our database searches and 17 additional records through hand searches. We included 33 articles in the qualitative synthesis. Most of the studies described interventions for the cancer survivor (n = 15). Nine studies investigated interventions for the whole family, and two studies interventions for siblings. The interventions mainly take place in an outpatient group setting (n = 15). Overall, most of the studies reported a significant psychosocial benefit of the interventions. However, the quality of the included studies was limited.

Conclusion

In summary, we identified a broad range of different interventions and thus could give a comprehensive overview of existing interventions for childhood cancer survivors and their families. However, there is a necessity for high quality studies. The results may help to optimize health care services that support families with the re-entry into daily life.

The role of rehabilitation measures in reintegration of children with brain tumours or leukaemia and their families after completion of cancer treatment: a study protocol

INTRODUCTION

For ill children as well as for their parents and siblings, childhood cancer poses a major challenge. Little is known about the reintegration into daily life of childhood cancer survivors and their families. The aim of this prospective observational study is to further the understanding of the role of rehabilitation measures in the reintegration process of childhood leukaemia or brain tumour survivors and their family members after the end of cancer treatment.

METHODS AND ANALYSIS

This prospective observational study consists of three study arms: a quantitative study in cooperation with three German paediatric oncological study registries (study arm 1), a quantitative study in cooperation with a rehabilitation clinic that offers a family-oriented paediatric oncological rehabilitation programme (study arm 2) and a qualitative study at 12-month follow-up including families from the study arms 1 and 2 (study arm 3). In study arm 1, children, parents and siblings are surveyed after treatment (baseline), 4-6 months after baseline measurement and at 12-month follow-up. In study arm 2, data are collected at the beginning and at the end of the rehabilitation measure and at 12-month follow-up. Families are assessed with standardised questionnaires on quality of life, emotional and behavioural symptoms, depression, anxiety, fear of progression, coping and family functioning. Furthermore, self-developed items on rehabilitation aims and reintegration into daily life are used. Where applicable, users and non-users of rehabilitation measures will be compared regarding the outcome parameters. Longitudinal data will be analysed by means of multivariate analysis strategies. Reference values will be used for comparisons if applicable. Qualitative data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

This study has been approved by the medical ethics committee of the Medical Chamber of Hamburg. Data will be published in peer-reviewed journals and presented at conferences.

Is developmental timing of trauma exposure associated with depressive and post-traumatic stress disorder symptoms in adulthood?

BACKGROUND

Trauma exposure is a known risk factor for psychopathology. However, the impact of the developmental timing of exposure remains unclear. This study examined the effect of age at first trauma exposure on levels of adult depressive and posttraumatic stress disorder (PTSD) symptoms.

METHODS

Lifetime trauma exposure (including age at first exposure and frequency), current psychiatric symptoms, and sociodemographic information were collected during interviews with adults participating in a study at a public urban hospital in Atlanta, GA. Multiple linear regression models assessed the association between timing of first trauma exposure, classified as early childhood (ages 0-5), middle childhood (ages 6-10), adolescence (ages 11-18), and adulthood (ages 19+), on adult psychopathology in 2892 individuals.

RESULTS

Participants exposed to trauma (i.e., child maltreatment, other interpersonal violence, non-interpersonal violence, and other events) at any age had higher depressive and PTSD symptoms compared to their unexposed peers. However, participants first exposed to child maltreatment during early childhood had depression and PTSD symptoms that were about twice as high as those exposed during later developmental stages. This association was detected even after controlling for sociodemographic characteristics, exposure to other trauma types, and frequency of exposure. Participants first exposed during middle childhood to other interpersonal violence also had depressive symptoms scores that were about twice as high as those first exposed during adulthood.

CONCLUSIONS

Trauma exposure at different ages may differentially impact depressive and PTSD symptoms in adulthood. More detailed examination of timing of trauma exposure is warranted to aid in identifying sensitive periods in development.

When Curing a Pediatric Tumor is not Enough: The Case of a Psychiatric Disorder in a Woman Surviving Osteosarcoma

Aims and background

We describe the case of a woman cured of osteosarcoma who took part in a mono-institutional study using different questionnaires to assess pediatric cancer survivors’ quality of life and behavioral features 12 years after completing her cancer treatment.

Results

The high levels of psychological distress and psychopathologic symptoms revealed by this patient prompted us to offer her specific and prolonged support at our institution, since she refused to seek the help of other psychiatric services. The woman revealed a dysfunctional social and family setting and a borderline personality disorder. She was hospitalized after attempting suicide. No psychological distress had previously come to light during her long follow-up for cancer.

Conclusions

Cancer survivors are at risk of psychological and behavioral problems, so they should be followed up over time. Questionnaires and standard scales are important, but not enough: the physician-patient relationship is crucial to bring out a patient's psychological issues and needs. This means that dedicated resources should be made available, whenever possible.

Quality of Life in Children With Advanced Cancer: A Report From the PediQUEST Study

CONTEXT

Modifiable factors of health-related quality of life (HRQOL) are poorly described among children with advanced cancer. Symptom distress may be an important factor for intervention.

OBJECTIVES

We aimed to describe patient-reported HRQOL and its relationship to symptom distress.

METHODS

Prospective, longitudinal data from the multicenter Pediatric Quality of Life and Symptoms Technology study included primarily patient-reported symptom distress and HRQOL, measured at most weekly with the Memorial Symptoms Assessment Scale and Pediatric Quality of Life inventory, respectively. Associations were evaluated using linear mixed-effects models adjusting for sex, age, cancer type, intervention arm, treatment intensity, and time since disease progression.

RESULTS

Of 104 enrolled patients, 49% were female, 89% were white, and median age was 12.6 years. Nine hundred and twenty surveys were completed over nine months of follow-up (84% by patients). The median total Pediatric Quality of Life score was 74 (interquartile range 63-87) and was "poor/fair" (e.g., <70) 38% of the time. "Poor/fair" categories were highest in physical (53%) and school (48%) compared to emotional (24%) and social (16%) subscores. Thirteen of 24 symptoms were independently associated with reductions in overall or domain-specific HRQOL. Patients commonly reported distress from two or more symptoms, corresponding to larger HRQOL score reductions. Neither cancer type, time since progression, treatment intensity, sex, nor age was associated with HRQOL scores in multivariable models. Among 25 children completing surveys during the last 12 weeks of life, 11 distressing symptoms were associated with reductions in HRQOL.

CONCLUSION

Symptom distress is strongly associated with HRQOL. Future research should determine whether alleviating distressing symptoms improves HRQOL in children with advanced cancer.

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.

Systematic Review: A Reevaluation and Update of the Integrative (Trajectory) Model of Pediatric Medical Traumatic Stress

OBJECTIVE

The objective of this systematic review is to reevaluate and update the Integrative Model of Pediatric Medical Traumatic Stress (PMTS; Kazak et al., 2006), which provides a conceptual framework for traumatic stress responses across pediatric illnesses and injuries.

METHODS

Using established systematic review guidelines, we searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and PubMed (producing 216 PMTS papers published since 2005), extracted findings for review, and organized and interpreted findings within the Integrative Model framework.

RESULTS

Recent PMTS research has included additional pediatric populations, used advanced longitudinal modeling techniques, clarified relations between parent and child PMTS, and considered effects of PMTS on health outcomes. Results support and extend the model's five assumptions, and suggest a sixth assumption related to health outcomes and PMTS.

CONCLUSIONS

Based on new evidence, the renamed Integrative Trajectory Model includes phases corresponding with medical events, adds family-centered trajectories, reaffirms a competency-based framework, and suggests updated assessment and intervention implications.

Assessing agreement between salivary alpha amylase levels collected by passive drool and eluted filter paper in adolescents with cancer

PURPOSE/OBJECTIVES

To assess the validity of filter paper (FP) against the gold standard of passive drool (PD) for collecting salivary alpha amylase as a surrogate biomarker of psychological stress in adolescents with cancer.

DESIGN

Part of a longitudinal, descriptive study of symptoms in adolescents with cancer during chemotherapy.

SETTING

A pediatric hematology/oncology treatment center.

SAMPLE

33 saliva sample pairs from nine adolescents with cancer, aged 13-18 years.

METHODS

Salivary alpha amylase was collected by PD and FP at four time points during a cycle of chemotherapy: days 1 (time 1) and 2 (time 2) of chemotherapy, day 7-10 (time 3), and day 1 of the next cycle (time 4). A random effects regression was used to assess the correlation between PD and FP values, and a Bland Altman analysis was conducted to assess agreement between the values.

MAIN RESEARCH VARIABLES

Salivary alpha amylase.

FINDINGS

The estimated correlation between PD and FP values was r = 0.91, p < 0.001. Regression results were also used to rescale FP values to the levels of the PD values because the FP values were on a different scale than the PD values. The Bland Altman analysis revealed that the agreement between the rescaled FP values and PD values was not satisfactory.

CONCLUSIONS

Eluted FP may not be a valid method for collecting salivary alpha amylase in adolescents with cancer.

IMPLICATIONS FOR NURSING

Psychological stress in adolescents with cancer may be linked to negative outcomes, such as greater symptom severity and post-traumatic stress disorder. Nurses need valid, efficient, biobehavioral measures to assess psychological stress in the clinical setting.

Prevalence and predictors of post-traumatic stress symptoms in adolescent and young adult cancer survivors: a 1-year follow-up study

OBJECTIVES

Post-traumatic stress symptoms (PTSS) have been identified as a meaningful indicator of distress in cancer survivors. Distinct from young adult survivors of childhood cancer, young people diagnosed with cancer as adolescents and young adults (AYAs) face unique psychosocial issues; however, there is little published research of PTSS in the AYA population. This study examines prevalence and predictors of PTSS among AYAs with cancer.

METHODS

As part of a longitudinal study of AYAs with cancer, 151 patients aged 15-39 years completed mailed surveys at 6 and 12 months post-diagnosis. Severity of PTSS was estimated at 6 and 12 months post-diagnosis. Multiple regression analyses were conducted to investigate the predictive effects of socio-demographic and clinical characteristics on changes in PTSS over time.

RESULTS

At 6 and 12 months, respectively, 39% and 44% of participants reported moderate to severe levels of PTSS; 29% had PTSS levels suggestive of post-traumatic stress disorder. No significant differences in severity of PTSS between 6 and 12 months were observed. Regression analyses suggested that a greater number of side effects were associated with higher levels of PTSS at 6 months. Currently receiving treatment, having surgical treatment, diagnosis of a cancer type with a 90-100% survival rate, remaining unemployed/not in school, and greater PTSS at 6 months were associated with higher levels of PTSS at 12 months.

CONCLUSIONS

Post-traumatic stress symptoms were observed as early as 6 months following diagnosis and remained stable at 12-month follow-up. The development of early interventions for reducing distress among AYA patients in treatment is recommended.

Need for psychological follow-up among young adult survivors of childhood cancer

Follow-up is recommended for survivors of childhood cancer. Decisions about care tend to be made in terms of physical health, but psychological late effects including post-traumatic stress disorder (PTSD) and symptoms (PTSS) are prevalent. We report prevalence of PTSD/PTSS in a UK cohort, self-care and implications for organisation of follow-up. Eligible survivors (n= 218) under regular follow-up were invited to complete measures of PTSD, late effects and self-efficacy. Information about late effects was also taken from medical notes. A total of 118 survivors responded (54.1%) and 108 (49.5%) completed questionnaires. Prevalence of clinical PTSD (13.9%) was comparable with US findings. Female subjects and those who reported more late effects reported more PTSD. In regression analyses, number of survivor-reported late effects (but not number-recorded in medical notes) and PTSS predicted self-efficacy. Significant numbers of survivors report PTSS but this is unrelated to diagnosis or treatment. Female subjects and those who reported more physical late effects also reported more PTSS. Decisions to discharge survivors from routine care must consider psychological well-being as well as physical late effects. We recommend routine psychological screening for all survivors of childhood cancer and suggest this can be acceptable to survivors and feasible in clinic.

Part 1: Hormone replacement for survivors of childhood cancer with ovarian failure--when is it worth the risk?

Survivors of childhood cancer represent a rapidly growing population of patients, some of whom experience temporary or permanent premature ovarian failure (POF) as a consequence of their disease or treatment. Although the risks and benefits of exogenous hormones have been extensively explored in menopausal women 50 years of age and older, there is scant data on the long-term safety of exogenous hormones in childhood cancer survivors. Although there are certainly benefits that can be achieved through hormone replacement for this unique population, many of these patients also have very long hormone exposure times and a markedly increased baseline risk for second malignancies, including breast cancer. Given the significant potential risks, hormone replacement should not be reflexively instituted in childhood cancer survivors with POF. It should only be considered following a thorough, balanced discussion of the risks and benefits of hormone replacement with each patient.

Prevalence and predictors of posttraumatic stress disorder in adult survivors of childhood cancer

OBJECTIVE

This study compared the prevalence of symptoms of posttraumatic stress disorder (PTSD), with functional impairment and/or clinical distress, among very long-term survivors of childhood cancer and a group of healthy siblings.

METHODS

A total of 6542 childhood cancer survivors >18 years of age who received diagnoses between 1970 and 1986 and 368 siblings of cancer survivors completed a comprehensive demographic and health survey.

RESULTS

A total of 589 survivors (9%) and 8 siblings (2%) reported functional impairment and/or clinical distress in addition to the set of symptoms consistent with a full diagnosis of PTSD. Survivors had more than fourfold greater risk of PTSD, compared with siblings (odds ratio [OR]: 4.14 [95% confidence interval [CI]: 2.08-8.25]). With controlling for demographic and treatment variables, increased risk of PTSD was associated with educational level of high school or less (OR: 1.51 [95% CI: 1.16-1.98]), being unmarried (OR: 1.99 [95% CI: 1.58-2.50]), having annual income below $20,000 (OR: 1.63 [95% CI: 1.21-2.20]), and being unemployed (OR: 2.01 [95% CI: 1.62-2.51]). Intensive treatment also was associated with increased risk of full PTSD (OR: 1.36 [95% CI: 1.06-1.74]).

CONCLUSIONS

PTSD was reported significantly more often by survivors of childhood cancer than by sibling control subjects. Although most survivors apparently are faring well, a subset reported significant impairment that may warrant targeted intervention.

Posttraumatic stress, depression and anxiety among adult long-term survivors of cancer in adolescence

BACKGROUND

To determine the prevalence of posttraumatic stress, depression and anxiety in adults who have survived cancer (5 years) diagnosed in adolescence, as compared to healthy controls.

PATIENTS AND METHODS

Survivors (n=820) of cancer during adolescence (age M=30.4+/-6.0 years; M=13.7+/-6.0 years since diagnosis) and 1027 matched controls without history of cancer (age M=31.5+/-6.9 years) completed standardised questionnaires measuring posttraumatic stress, depression and anxiety. Additionally, sub-groups of 202 survivors and 140 controls with elevated scores received structured interviews to ascertain DSM-IV-diagnoses.

RESULTS

A total of 22.4% of the survivors reported clinically relevant symptoms of posttraumatic stress, anxiety and/or depression compared to 14.0% of the controls (odds ratios [ORs] 1.77; 95% confidence interval [CI] 1.39-2.26). The odds of posttraumatic stress symptoms in male (OR 3.92, 95% CI 1.80-8.51) and female (OR 3.83, 95% CI 2.54-5.76) survivors were more than three times those in the controls. However, only female survivors reported symptoms of depression and anxiety significantly more often (respectively: OR 2.12, 95% CI 1.16-3.85; and OR 1.86, 95% CI 1.33-2.59) than the controls. A relevant subgroup of 24.3% of the survivors met DSM-IV criteria for at least one mental disorder compared to 15.3% of the controls.

CONCLUSION

Survivors of cancer during adolescence show an elevated risk of presenting symptoms of posttraumatic stress, anxiety and/or depression during adulthood which is also reflected in a greater number of DSM-IV diagnoses when compared to controls. Comprehensive follow-up assessments should include the examination of possible psychological late effects of a cancer diagnosis in adolescence in order to identify survivors needing psychosocial interventions even years after the completion of successful medical treatment.

Psychological Distress in Adult Survivors of Childhood Cancer: The Swiss Childhood Cancer Survivor Study

Purpose

To evaluate the degree of psychological distress in adult childhood cancer survivors in Switzerland and to characterize survivors with significant distress.

Methods

Childhood cancer survivors who were age younger than 16 years when diagnosed between 1976 and 2003, had survived more than 5 years, and were currently age 20 years or older received a postal questionnaire. Psychological distress was assessed using the Brief Symptom Inventory (BSI). Raw scores were transformed into T scores according to the German norm sample, and the proportion of participants being at increased risk for psychological distress was calculated (case rule: T ≥ 63). t tests and univariable and multivariable logistic regressions were used for statistical analyses.

Results

One thousand seventy-six survivors (63.% of eligible survivors, 71.9% of contacted survivors) returned the questionnaire, 987 with complete data on BSI. Comparison with the norm populations showed lower T scores (T < 50) in the Global Severity Index (GSI; T = 46.2), somatization (T = 47.6), obsessive-compulsive tendencies (T = 46.9), and anxiety (T = 48.4). However, more childhood cancer survivors (especially women) had increased distress for GSI (14.4%), interpersonal sensitivity (16.5%), depression (13.4%), aggression (16.9%), and psychotic tendencies (15.6%) than the expected 10% from the norm population. Caseness was associated with female sex, being a single child, older age at study, and self-reported late effects, especially psychological problems.

Conclusion

Results show that childhood cancer survivors, on average, have less psychological distress than a norm population but that the proportion of survivors at risk for high psychological distress is disproportionally large. Monitoring psychological distress in childhood cancer survivors may be desirable during routine follow-up, and psychological support should be offered as needed.

Comparison of self-reported late effects with medical records among survivors of childhood cancer

BACKGROUND

Survival rates following childhood cancer have increased, but survivors experience significant late effects. Long-term follow-up is recommended but imposes an increasing burden on health services. We report prevalence of morbidity in a cohort of survivors from South Yorkshire based on: (i) case-note analysis and (ii) self-reported late effects (parent-reported for under-16s).

METHODS

Treatment information was taken from case-notes. Comparisons were made between late effects described in notes and reported by 108 survivors aged >16 years, and 45 parents of survivors (12-15 years).

FINDINGS

Of 892 patients diagnosed with childhood cancer and some benign conditions registered on hospital databases from January 1990 to December 2005, 337 (37.8%) met eligibility criteria. Ninety-one survivors (16) (84.3%, confidence interval [CI]: 76.0-90.6) reported one or more late effects (mean=3.5; CI: 3.0-4.1), significantly higher than the number of late effects documented in medical notes (mean=0.7; CI: 0.5-0.9; t=-11.26, p<0.001). Thirty-five parents (77.8%, CI: 65.1-90.4) reported late effects for their children (mean=2.7; CI: 2.0-3.4), again higher than medical notes (mean=0.7; CI: 0.4-1.1; t=7.18, p<0.001). More than 30 specialties were involved in survivor care (mean=1.5; CI: 1.4-1.6; range 0-6). Those with more late effects saw more specialties (r=0.51, p<0.001).

INTERPRETATION

We confirm the wide range of late effects experienced by survivors of child cancer, significantly greater than those recorded in medical notes, and requiring care from a range of specialties. Decisions about follow-up need to take account of patient-reported morbidity and concerns.

A Report from the Singapore Childhood Cancer Survivor Study (SG-CCSS): A Multi-institutional Collaborative Study on Long-term Survivors of Childhood Cancer, Initial Analysis Reporting for the SG-CCSS

Introduction: Worldwide, the survival rates among childhood cancer patients are increasing. As such, assessing the risk of late effects and complications are increasingly becoming more important. The degree of risk of late effects may be influenced by various treatment-related factors. Materials and Methods: The Singapore Childhood Cancer Survivor Study (SG- CCSS) consists of all individuals who survived at least 2 or more years after treatment for cancer diagnosed during childhood or adolescence. Phase I of SG-CCSS is the identification of all eligible patients between 1981 and 2005. Results: There were a total of 1440 patients registered in the Singapore Childhood Cancer Registry. Among these, 704 (48.9%) patients were from the KK Women’s and Children’s Hospital (KKH) and 626 (43.5%) were from the National University Hospital (NUH). Of all the registered patients, the most common cancer in childhood was leukaemia [42.6% (n = 613)] and the second most common was brain tumour [14.9% (n = 215)]. A total of 1043 (72.4%) patients were surviving, of whom 839 (80.4%) were long-term survivors. Haematological malignancies were found in 492 (58.6%) survivors whilst 347 (41.4%) were diagnosed with various solid tumours. Among leukaemic patients (n = 613), 65.6% (n = 402) were long-term survivors. Acute lymphoblastic leukaemia (ALL) (n = 484) had the highest percentage of [80.9% (n = 392)] of surviving patients, of whom 73.4% were long term-survivors. For brain tumour (n = 215), there were 95 (44.2%) long-term survivors. Conclusion: Preliminary analysis revealed that 58.3% of patients were long-term survivors. Our hope is to tailor all future therapy for childhood cancers, optimising cure rates whilst minimising long-term side-effects. Key words: Late effects