Family physician preferences and knowledge gaps regarding the care of adolescent and young adult survivors of childhood cancer

Pediatric Oncology and Obesity: An Introduction for General Pediatricians

For pediatric patients with cancer, a healthy lifestyle is important for treatment outcomes and beyond. General pediatricians play a major role in the care of these patients, particularly given the improved rates of survival. Pediatric obesity has many negative consequences, but it is an area where primary care providers can make an impact and provide support to childhood cancer survivors. To provide the best quality of care for this population, there must be collaboration between primary care and oncology providers. Additionally, general practioners should feel empowered to offer standard nutrition and physical activity recommendations to all childhood cancer survivors. For pediatric patients who carry a cancer diagnosis, cure is no longer the only goal. Pediatric providers across specialties need to work as a team to improve long-term quality of life for these patients, starting with modifiable healthy habits.

The integration of primary care and childhood cancer survivorship care: a scoping review

PURPOSE

This scoping review describes existing care models that integrate primary care and childhood cancer survivorship care, examines the effectiveness of these models, and characterizes barriers and facilitators to their integration.

METHODS

A systematic search (PubMed®, CINAHL®, Embase®) was conducted to identify citations which were evaluated against inclusion criteria using the PICOTTS framework. The PRISMA-ScR extension for scoping reviews was used to report review findings (protocol https://osf.io/92xbg ).

RESULTS

Twenty-three studies were included. Three care models integrating primary care and childhood cancer survivorship care were identified: consultative shared care in a primary care setting (N = 3); longitudinal shared care (N = 2); and PCP-led care employing a survivorship care plan (N = 5). While many described risk-adapted care, few used risk stratification approaches to inform care. Measures of model effectiveness varied, with discrepant findings regarding late effects detection in PCP-led approaches. The most frequently cited barriers and facilitators reflected provider- and system-level factors (PCP knowledge/experience identified as greatest barrier (N = 11); clinical information from oncologist identified as greatest facilitator (N = 9)).

CONCLUSIONS

Identified models depended on PCP knowledge and healthcare system coordination, and studies suggested the need for strong oncologic involvement in follow-up care. Improved training for PCPs and the coordinated transfer of clinical information could facilitate their involvement in such care. Overall, standardized measures of effectiveness are needed to deliver optimal childhood cancer survivorship care.

IMPLICATIONS FOR CANCER SURVIVORS

The literature revealed three care models defined by SCP use, provider involvement, and continuity of care, with several studies recommending oncologic involvement in follow-up care for high-risk survivors.

Knowledge and attitude on childhood cancer survivorship among healthcare trainees: a multicentre study from India

BACKGROUND

The proportion of childhood cancer survivors (CCS) in low/middle-income countries (LMICs) is rising. CCS often develop several physical and psycho-social long-term adverse effects, with unique healthcare needs. Primary healthcare providers (primary care physicians (PCPs)), especially in LMICs, are often not equipped to handle survivorship care. This study aimed to assess knowledge, and attitude among trainee healthcare providers concerning major issues of paediatric survivorship care.

METHODS

A multi-centre, cross-sectional, questionnaire-based study was conducted among nursing and medical undergraduate students, and postgraduate medical residents across three tertiary-care teaching hospitals in India-All India Institute of Medical Sciences, New Delhi; Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; and Maulana Azad Medical College, New Delhi. A questionnaire with total of 24 questions (14 knowledge-based and 10 attitude-based) was finalised after validation by expert review and piloting. The major domains covered in the questionnaire included knowledge and attitude regarding long-term adverse effects and psychosocial, employment-related issues faced by the survivors. It was administered to the study participants electronically. The knowledge-based questions had true/false responses (scored as 0 or 1 if incorrect or correct, respectively). Attitude-based questions were scored as 5-point Likert scale.

RESULTS

Total 898 responses were collected (median age: 21 years, 64% (576/898) female). Among the respondents, 44% were undergraduate medical students, 42% were nursing students and 14% were postgraduate medical residents. The mean (SD) of knowledge score was 8.72 (2.04) (out of 14). On multivariable analysis, only discipline of training predicted knowledge scores regarding survivorship care. Postgraduate medical residents (9.08) as well as undergraduate medical students (8.85), had significantly higher mean knowledge scores than nursing students (8.47) (p=0.004).Two questions were answered incorrectly by the majority; children and siblings of CCS need additional genetic screening (79% incorrectly answered true), and CCS face intimacy issues in relation to normal sexual functioning (59% incorrectly answered false).Nearly half (48%) of respondents believed that their knowledge of cancer survivorship issues was inadequate. Majority of respondents (84%) suggested that oncologists should handle long-term survivorship care rather than PCPs.

CONCLUSION

Trainee healthcare providers in India reported inadequate knowledge regarding survivorship care. Improving awareness by incorporating survivorship in teaching curriculum is imperative to equip future PCPs to provide survivorship care across the country.

Parent caregivers' preferences and satisfaction with currently provided childhood cancer survivorship care

PURPOSE

The aim of this study was to investigate the level of satisfaction of parent caregivers of childhood cancer survivors (CCSs) with currently provided survivorship care and their preferences for survivorship care provider.

METHODS

Study subjects were parent caregivers recruited at three hospitals in Korea. Study data were collected from self-administered questionnaires and medical records. We assessed parent caregivers' levels of satisfaction with specific survivorship care contents and preferred types of survivorship care provider among oncologists, primary care physicians (PCPs), and institutional general physicians (IGPs). Factors associated with parent caregivers' preferences for survivorship care provider were evaluated by multiple logistic regression analysis.

RESULTS

680 parent caregivers (mother 62.1% and father 37.9%) of 487 CCSs (mean age at diagnosis: 6.9 ± 5.1 years; mean time since treatment completion 5.4 ± 4.4 years) were included. Parent caregivers' dissatisfaction was the highest with screening for second primary cancer, followed by psychosocial problem management. Higher educational level of parent caregiver, parent caregiver's higher level of dissatisfaction with currently provided care, higher age of CCSs at cancer diagnosis, history of receiving hematopoietic stem cell transplant, and longer time lapse after cancer treatment were significantly associated with parent caregivers' higher preference for PCPs or IGPs than oncologists. Parent caregiver's multiple comorbidities and higher fear of cancer recurrence were associated with parent caregivers' higher preference for oncologists than PCPs or IGPs. Around 80% of parent caregivers recognized that a shared care system was helpful for promoting the health of CCSs.

CONCLUSION

Parent caregivers were substantially dissatisfied with currently provided care, especially regarding the health issues not directly associated with the primary cancer. Parent caregivers' preferences for survivorship care provider is influenced by multiple factors, including age and survival time of CCSs, characteristics of parent caregivers, satisfaction level with care, and specific survivorship care contents.

IMPLICATIONS FOR CANCER SURVIVORS

The findings of our study suggest that shared survivorship care for CCSs with consideration of specific care contents can complement the current oncologist-led survivorship care system.

Care Models and Barriers to Long-Term Follow-Up Care Among Childhood Cancer Survivors and Health Care Providers in Asia: A Literature Review

Most available data evaluating childhood cancer survivorship care focus on the experiences of high-income Western countries, whereas data from Asian countries are limited. To address this knowledge deficit, we aimed to characterize survivorship care models and barriers to participation in long-term follow-up (LTFU) care among childhood cancer survivors (CCSs) and health care providers in Asian countries. Twenty-four studies were identified. Most institutions in China and Turkey adopt the oncology specialist care model, whereas in Japan, India, Singapore, and South Korea, after completion of therapy LTFU programs are available in some institutions. In terms of survivor barriers, findings highlight the need for comprehensive age-appropriate education and support and personalized approaches in addressing individual preferences and challenges during survivorship. Health care professionals need education about potential late effects of cancer treatment, recommended guidance for health surveillance and follow-up care, and their role in facilitating the transition from pediatric to adult-focused care. To optimize the delivery of cancer survivorship care, efforts are needed to increase patient and family awareness about the purpose and potential benefits of LTFU care, improve provider education and training, and promote policy change to ensure that CCSs have access to essential services and resources to optimize quality of survival.

Protocol for the ONLOOP trial: pragmatic randomized trial evaluating a province-wide system of personalized reminders for evidence-based surveillance tests in adult survivors of childhood cancer in Ontario

BACKGROUND

Childhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time.

METHODS

This is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP's impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants' consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later. The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed.

DISCUSSION

The results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05832138.

Health Care Transitions Among Adolescents and Young Adults With Cancer

Survivors of adolescent and young adult (AYA) cancers, defined as individuals diagnosed with a primary malignancy between age 15 and 39 years, are a growing population with unique developmental, psychosocial, and health-related needs. These individuals are at excess risk of developing a wide range of chronic comorbidities compared with the general population and, therefore, require lifelong, risk-based, survivorship care to optimize long-term health outcomes. The health care needs of survivors of AYA cancers are particularly complicated given the often heterogeneous and sometimes fragmented care they receive throughout the cancer care continuum. For example, AYA survivors are often treated in disparate settings (pediatric v adult) on dissimilar protocols that include different recommendations for longitudinal follow-up. Specialized tools and techniques are needed to ensure that AYA survivors move seamlessly from acute cancer care to survivorship care and, in many cases, from pediatric to adult clinics while still remaining engaged in long-term follow-up. Systematic, age-appropriate transitional practices involving well-established clinical models of care, survivorship care plans, and survivorship guidelines are needed to facilitate effective transitions between providers. Future studies are necessary to enhance and optimize the clinical effectiveness of transition processes in AYA cancer survivors.

Coverage for evidence-based cancer survivorship care services

PURPOSE

The American Society of Clinical Oncology Cancer Survivorship Committee established a task force to determine which survivorship care services were being denied by public and private payers for coverage and reimbursement.

METHODS

A quantitative survey instrument was developed to determine the clinical practice-reported rates of coverage denials for evidence-based cancer survivorship care services. Additionally, qualitative interviews were conducted to understand whether coverage denials were based on payer policies, cost-sharing, or prior authorization.

RESULTS

Of 122 respondents from 50 states, respondents reported that coverage denials were common ("always," "most of the time," or "some of the time") for maintenance therapies, screening for new primary cancers or cancer recurrence. Respondents reported that denials in coverage for maintenance therapies were highest for immunotherapy (41.74%) and maintenance chemotherapy (40.17%). Coverage denials for new primary cancer screenings were highest for Hodgkin lymphoma survivors needing a PET/CT scan (49.04%) and breast cancer survivors at a high risk of recurrence who needed an MRI (63.46%), respectively. More than half of survey respondents reported denials for symptom management and supportive care services. Fertility services, dental services when indicated, and mental health services were denied "always" or "most of the time" 23.1%, 22.5%, and 12.8%, respectively. Respondents reported they often had a process in place to automatically appeal denials for evidence-based services. The denial process, however, resulted in greater stress for the patient and provider.

CONCLUSION

Our study demonstrates that additional advocacy with payers is needed to ensure that reimbursement policies are consistent with evidence-based survivorship care services.

Modifiable Cardiometabolic Risk Factors in Survivors of Childhood Cancer: JACC: CardioOncology State-of-the-Art Review

The growing community of childhood cancer survivors faces a heavy burden of late onset morbidities and mortality, with cardiovascular diseases being the leading noncancer cause. In addition to demographics and cancer treatment exposures, which cannot be altered, cardiometabolic risk factors (obesity, hypertension, diabetes, and dyslipidemia) and frailty potentiate the risk of morbidity and mortality associated with chronic health conditions. Important opportunities exist to target these risk factors and improve late health outcomes for survivors. Unfortunately, limited evidence exists on the optimal methods to prevent, screen, and treat cardiometabolic risk factors among survivors, resulting in significant underdiagnosis and undertreatment. In this review, we discuss the prevalence of, risk factors for, current survivor-specific recommendations, and gaps in knowledge to mitigate potentially modifiable cardiometabolic risk factors and frailty among survivors of childhood cancer.

Human Papillomavirus Vaccination in Pediatric, Adolescent, and Young Adult Cancer Survivors-Opportunity to Address Gaps in Cancer Prevention and Survivorship

The risks of secondary cancers associated with human papillomavirus (HPV) infection are as much as three times higher for survivors of pediatric, adolescent, and young adult cancer (PYAC) compared to the general population. Despite this, HPV vaccination rates among PYAC survivors remain low. Whereas pediatric oncology providers endorse HPV vaccination of PYAC survivors, many lack the resources or opportunities to intervene. The responsibility of HPV vaccination, therefore, falls to primary care providers and practices. This article provides an overview of the challenges with HPV vaccination that are distinct to PYAC survivors and discusses potential strategies to increase HPV vaccine coverage in this population.

Primary Care Utilization and Cardiovascular Screening in Adult Survivors of Childhood Cancer

Importance

Cardiovascular disease is the leading noncancer cause of premature death among survivors of childhood cancer. Adult survivors of childhood cancer are largely managed by primary care practitioners (PCPs), and health care utilization patterns related to cardiovascular screening are not well described.

Objective

To examine screening and health care utilization among survivors of childhood cancer at high risk for cardiovascular complications.

Design, Setting, and Participants

This multicenter cross-sectional study included participants enrolled in a randomized clinical trial from 2017 to 2021. Abstracted documentation of participants' cancer history, cardiotoxic treatment exposures, and survivorship care plans were obtained from participants' PCPs spanning 2 years preceding trial enrollment. Participants were members of the Childhood Cancer Survivor Study cohort at elevated risk for ischemic heart disease or heart failure, enrolled in a randomized trial focused on improving cardiovascular risk factor control. Data were analyzed from November 2022 to July 2023.

Main Outcomes and Measures

Outcomes of interest were numbers of PCP and specialist visits, cardiovascular risk factors (hypertension, dyslipidemia, and diabetes), risk factor screening, and cardiac testing. Multivariable logistic regression assessed characteristics associated with up-to-date cardiac testing at enrollment.

Results

Of 347 enrolled participants, 293 (84.4%) had evaluable medical records (median [range] age, 39.9 [21.5-65.0] years; 149 [50.9%] male) and were included in analyses. At baseline, 238 participants (81.2%) had a documented PCP encounter; 241 participants (82.3%) had undergone blood pressure screening, 179 participants (61.1%) had undergone lipid testing, and 193 participants (65.9%) had undergone diabetes screening. A total of 63 participants (21.5%) had echocardiography completed or planned. Only 198 participants (67.6%) had records referencing a cancer history. PCP documentation of prior cardiotoxic exposures was low compared with known exposures, including radiation therapy (103 participants [35.2%] vs 203 participants [69.3%]; P < .001) and anthracycline chemotherapy (27 participants [9.2%] vs 222 participants [75.8%]; P = .008). Few records referenced a need for cancer-related late effects surveillance (95 records [32.4%]). Independent factors associated with cardiac screening included documentation of increased cardiovascular disease risk (odds ratio [OR], 11.94; 95% CI, 3.37-42.31), a late-effects surveillance plan (OR, 3.92; 95% CI, 1.69-9.11), and existing cardiovascular risk factors (OR per each additional factor, 2.09; 95% CI, 1.32-3.31).

Conclusions and Relevance

This cross-sectional study of adult survivors of childhood cancer at increased risk of cardiovascular disease found low adherence to recommended cardiac testing and documentation of risk for these individuals. Improving accuracy of reporting of survivors' exposures and risks within the medical record may improve screening.

Improving quality and quantity of life for childhood cancer survivors globally in the twenty-first century

The contributions of cooperative groups to performing large-cohort clinical trials and long-term survivorship studies have facilitated advances in treatment, supportive care and, ultimately, survival for patients with paediatric cancers. As a result, the number of childhood cancer survivors in the USA alone is expected to reach almost 580,000 by 2040. Despite these substantial improvements, childhood cancer survivors continue to have an elevated burden of chronic disease and an excess risk of early death compared with the general population and therefore constitute a large, medically vulnerable population for which delivery of high-quality, personalized care is much needed. Data from large survivorship cohorts have enabled the identification of compelling associations between paediatric cancers, cancer therapy and long-term health conditions. Effectively translating these findings into clinical care that improves the quality and quantity of life for survivors remains an important focus of ongoing research. Continued development of well-designed clinical studies incorporating dissemination and implementation strategies with input from patient advocates and other key stakeholders is crucial to overcoming these gaps. This Review highlights the global progress made and future efforts that will be needed to further increase the quality and quantity of life-years gained for childhood cancer survivors.

Surveillance after childhood cancer: are survivors with an increased risk for cardiomyopathy regularly followed-up?

BACKGROUND

We aimed to study adherence to cardiac screening in long-term childhood cancer survivors (CCS) at high risk of cardiomyopathy.

METHODS

This study involved 976 5-year CCS at high risk for cardiomyopathy from the French Childhood Cancer Survivor Study. Determinants of adherence to recommended surveillance were studied using multivariable logistic regression models. Association of attendance to a long-term follow-up (LTFU) visit with completion of an echocardiogram was estimated using a Cox regression model.

RESULTS

Among participants, 32% had an echocardiogram within the 5 previous years. Males (adjusted RR [aRR] 0.71, 95% CI 0.58-0.86), survivors aged 36-49 (aRR 0.79, 95% CI 0.64-0.98), Neuroblastoma (aRR 0.53, 95% CI 0.30-0.91) and CNS tumour survivors (aRR 0.43, 95% CI 0.21-0.89) were less likely to adhere to recommended surveillance. Attendance to an LTFU visit was associated with completion of an echocardiogram in patients who were not previously adherent to recommendations (HR 8.20, 95% CI 5.64-11.93).

CONCLUSIONS

The majority of long-term survivors at high risk of cardiomyopathy did not adhere to the recommended surveillance. Attendance to an LTFU visit greatly enhanced the completion of echocardiograms, but further interventions need to be developed to reach more survivors.

Experiences of adult survivors of childhood cancer in a randomized cardiovascular health promotion trial: a qualitative report from the Childhood Cancer Survivor Study

PURPOSE

To better understand preferences and attitudes that adult-aged survivors of childhood cancer have toward survivorship care plans (SCP) and related SCP-based counseling.

METHODS

Semi-structured qualitative interviews were conducted with 20 survivors participating in the Childhood Cancer Survivor Study who were at increased risk for cardiovascular disease secondary to their original cancer treatment. All participants were part of a larger randomized clinical trial (NCT03104543) testing the efficacy of an SCP-based counseling intervention with goal-setting designed to improve control of cardiovascular risk factors (i.e., hypertension, dyslipidemia, diabetes). A primarily deductive thematic analysis methodology guided interpretation; coded interview segments were grouped into primary themes of facilitators, barriers, suggestions, and positive sentiments.

RESULTS

Participants described benefits of the intervention including facilitation of accountability, goal-setting, and increased knowledge of their health. Many participants also noted improved knowledge of their cancer treatment and subsequent risks, and they were interested in sharing this information with their primary care provider. However, several participants were disappointed when they did not achieve their goals or felt that they had low motivation. Participants generally wanted increased flexibility in the intervention, whether in the duration, frequency, or method of delivery.

CONCLUSIONS

The SCP-based intervention was generally well-received by those interviewed and appears promising for promoting goal-setting and accountability as part of an SCP-based intervention to improve control of cardiovascular risk factors.

IMPLICATIONS FOR CANCER SURVIVORS

Many survivors are at risk for cardiovascular disease or other potentially modifiable effects of their treatment. SCP-based interventions may facilitate improved control of these late effects.

Primary care physicians' knowledge and confidence in providing cancer survivorship care: a systematic review

PURPOSE

To systematically review existing literature on knowledge and confidence of primary care physicians (PCPs) in cancer survivorship care.

METHODS

PubMed, Ovid MEDLINE, CINAHL, Embase, and PsycINFO were searched from inception to July 2022 for quantitative and qualitative studies. Two reviewers independently assessed studies for eligibility and quality. Outcomes were characterized by domains of quality cancer survivorship care.

RESULTS

Thirty-three papers were included, representing 28 unique studies; 22 cross-sectional surveys, 8 qualitative, and 3 mixed-methods studies. Most studies were conducted in North America (n = 23) and Europe (n = 8). For surveys, sample sizes ranged between 29 and 1124 PCPs. Knowledge and confidence in management of physical (n = 19) and psychosocial effects (n = 12), and surveillance for recurrences (n = 14) were described most often. Generally, a greater proportion of PCPs reported confidence in managing psychosocial effects (24-47% of PCPs, n= 5 studies) than physical effects (10-37%, n = 8). PCPs generally thought they had the necessary knowledge to detect recurrences (62-78%, n = 5), but reported limited confidence to do so (6-40%, n = 5). There was a commonly perceived need for education on long-term and late physical effects (n = 6), and cancer surveillance guidelines (n = 9).

CONCLUSIONS

PCPs' knowledge and confidence in cancer survivorship care varies across care domains. Suboptimal outcomes were identified in managing physical effects and recurrences after cancer.

IMPLICATIONS FOR CANCER SURVIVORS

These results provide insights into the potential role of PCPs in cancer survivorship care, medical education, and development of targeted interventions.

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.

eHealth tools for childhood cancer survivorship care: A qualitative analysis of survivors', parents', and general practitioners' views

Objective

We assessed the acceptability of, and perceived benefits/barriers to, using Electronic health (eHealth) technology for childhood cancer survivorship care.

Methods

We interviewed survivors, their parents, and their nominated GP. We described a hypothetical eHealth tool to manage survivorship care and asked their likely use of, and perceived benefits/concerns for, the use of the tool.

Results

31 survivors (mean age = 27.0), 29 parents (survivors' mean age = 12.6), and 51 GPs (mean years practising = 28.2) participated. Most survivors/parents (85%) and GPs (75%) indicated that they would be willing to use an eHealth tool. Survivors/parents reported that an eHealth tool would increase their confidence in their ability, and their GP's ability, to manage their survivorship care. GPs agreed that an eHealth tool would provide easier access to survivors' medical information and increase their capacity to provide support during survivorship. Some GPs (7%) and survivors (43%) reported being hesitant to use eHealth tools due to privacy/security concerns.

Conclusion

Overall, eHealth tools appear acceptable and may help to improve the management of late effects for childhood cancer survivors and assist their GPs to coordinate their care.

Innovation

Concerns raised by key stakeholders should be addressed in the design of eHealth technologies to optimise their uptake and effectiveness.

Childhood cancer survivorship care: A qualitative study of healthcare providers’ professional preferences

Purpose

Childhood cancer survivorship care is a complex specialty, though it is increasingly being integrated into the general practitioner’s (GP) remit. Establishing the essential components of tertiary- and primary-led care, to maximize the benefits and overcome the challenges inherent to each, is essential to inform the development of survivor-centered, sustainable care models.

Methods

We used the qualitative principles of semi-structured interviewing, verbatim transcription, coding (supported by NVivo12) and thematic analysis, to collect and evaluate the views and preferences of pediatric oncologists, survivorship nurse coordinators, and GPs currently caring for childhood cancer survivors.

Results

Seventy healthcare providers (19 oncology staff and 51 GPs) from 11 tertiary hospitals and 51 primary practices across Australia and New Zealand participated. Participants reported specialist expertise and holistic family-centered care as the key benefits of tertiary and primary care respectively. Participants reported that tertiary-led survivorship care was significantly challenged by a lack of dedicated funding and costs/travel burden incurred by the survivor, whereas primary-led survivorship care was challenged by insufficient GP training and GPs’ reliance on oncologist-developed action plans to deliver guideline-based care. GPs also reported a need for ongoing access to survivorship expertise/consultants to support care decisions at critical times. The discharge of survivors into primary care limited late-effects data collection and the rapid implementation of novel research findings.

Conclusions

Healthcare professionals report that while a risk-stratified, collaborative model of survivor-centered care is optimal, to be implemented successfully, greater provisions for the ongoing engagement of GPs and further access to GP education/training are needed.

Impacts of the Early COVID-19 Pandemic Among a National Sample of Adolescent and Young Adult Cancer Survivors in the United States

Purpose: Adolescent and young adult cancer survivors (AYAs) experience early-onset chronic conditions and disrupted psychosocial development. We report prevalence of disruptions in care delivery and social support during the early wave of the pandemic in a national sample of AYAs in the United States. Materials and Methods: We used data from the population-based National Health Interview Survey (NHIS; July-December 2020), which allows for nationally representative estimates, and included questions related to COVID-19. We identified 61 AYAs diagnosed with cancer between ages 15 and 39 years and not currently receiving cancer treatment and 244 age- and sex-matched controls. We compared the proportion of AYAs and controls reporting delayed care due to the pandemic, not getting needed care due to the pandemic, and changes in social and emotional support. Results: AYAs were predominantly non-Hispanic White (61.3%) and female (58.8%), with a median age at diagnosis of 28 years (interquartile range [IQR] 21-31 years). Fewer AYAs were employed (52.1% vs. 71.5%), and more lived in poverty (32.0% vs. 12.4%) and felt depressed daily (9.9% vs. 3.0%, all p < 0.05). The proportion of AYAs reporting delayed care (39.8% vs. 15.3%) and not getting needed care (31.7% vs. 10.4%) due to the pandemic was more than double that of controls (both p < 0.01). One in five AYAs experienced less social and emotional support compared to the prior year, although not significantly different from controls (21.6% vs. 12.4%, p = 0.10). Conclusions: The pandemic disrupted AYAs' care and exacerbated their psychosocial challenges. Providers and health systems should prioritize reconnecting AYAs to affordable and comprehensive care.

Late-effect awareness and follow-up of cancer in general practice

OBJECTIVE

With increasing cancer incidence and survival rates, follow-up care becomes a major healthcare concern, placing increased demands on general practitioners (GPs). We explored GPs' awareness of late effects (LEs) after cancer treatment. Their degree of involvement and attitudes towards follow-up care was studied separately for solid cancers and Hodgkin's lymphoma (HL).

DESIGN AND SETTING

Mailed questionnaire study in Norwegian general practice.

SUBJECTS

185 responding GPs with responsibility for HL survivors, more than 10 years since diagnosis.

MAIN OUTCOME MEASURES AND RESULTS

All GPs reported some awareness of LEs. Increasing awareness of LEs was associated with female sex, being a specialist, having experience from hospital-based cancer care and familiarity with official guidelines on LEs after treatment. The majority of GPs were involved in follow-up care, which increased with patients' time since treatment and was associated with higher awareness of LEs. GPs with work experience in hospital-based cancer care were more likely to be engaged in HL follow-up. Most GPs were willing to provide follow-up care at some point after treatment. Older and more experienced GPs, and those satisfied with the collaboration with hospital specialists, were more likely to provide follow-up earlier.

CONCLUSION

GPs' awareness of LEs and their willingness to provide follow-up care were related to familiarity with guidelines and experience. GPs more involved in follow-up care also had higher knowledge of LEs. Distribution of guidelines on LEs and follow-up care, and improving collaboration with hospital specialists, might increase GPs' knowledge and willingness to become involved in follow-up care, especially early in their careers. GPs' involvement and attitude towards follow-up of survivors of common solid cancers and HL, a rare malignant disease, were similar.KEY POINTSNorwegian general practitioners (GPs) are involved in survivorship care after cancer treatment. We investigated their awareness of late effects (LEs), their involvement and their attitude towards follow-up care of solid cancers and Hodgkin's lymphoma. • GPs registered as specialists, aware of guidelines and with experience from hospital-based cancer care reported higher awareness of LEs.  • GPs with higher awareness of LEs were more frequently involved in follow-up care.  • GPs with longer experience in general practice were comfortable with follow-up care at an earlier stage after treatment.  • Results were similar for follow-up care of survivors of solid cancers and Hodgkin's lymphoma.

Underdiagnosis and Undertreatment of Modifiable Cardiovascular Risk Factors Among Survivors of Childhood Cancer

Background

Determine the prevalence and predictors associated with underdiagnosis and undertreatment of modifiable cardiovascular disease (CVD) risk factors (hypertension, dyslipidemia, glucose intolerance/diabetes) among adult survivors of childhood cancer at high risk of premature CVD.

Methods and Results

This was a cross‐sectional study of adult‐aged survivors of childhood cancer treated with anthracyclines or chest radiotherapy, recruited across 9 US metropolitan regions. Survivors completed questionnaires and in‐home clinical assessments. The comparator group was a matched sample from the National Health and Nutrition Examination Survey. Multivariable logistic regression estimated the risk (odds ratios) of CVD risk factor underdiagnosis and undertreatment among survivors compared with the National Health and Nutrition Examination Survey. Survivors (n=571; median age, 37.7 years and 28.5 years from cancer diagnosis) were more likely to have a preexisting CVD risk factor than the National Health and Nutrition Examination Survey (n=345; P<0.05 for all factors). While rates of CVD risk factor underdiagnosis were similar (27.1% survivors versus 26.1% National Health and Nutrition Examination Survey; P=0.73), survivors were more likely undertreated (21.0% versus 13.9%, P=0.007; odds ratio, 1.8, 95% CI, 1.2–2.7). Among survivors, the most underdiagnosed and undertreated risk factors were hypertension (18.9%) and dyslipidemia (16.3%), respectively. Men and survivors who were overweight/obese were more likely to be underdiagnosed and undertreated. Those with multiple adverse lifestyle factors were also more likely undertreated (odds ratio, 2.2, 95% CI, 1.1–4.5). Greater health‐related self‐efficacy was associated with reduced undertreatment (odds ratio, 0.5; 95% CI, 0.3–0.8).

Conclusions

Greater awareness of among primary care providers and cardiologists, combined with improving self‐efficacy among survivors, may mitigate the risk of underdiagnosed and undertreated CVD risk factors among adult‐aged survivors of childhood cancer.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03104543.

Implementing a mHealth intervention to increase colorectal cancer screening among high-risk cancer survivors treated with radiotherapy in the Childhood Cancer Survivor Study (CCSS)

Background

Cancer survivors treated with any dose of radiation to the abdomen, pelvis, spine, or total body irradiation (TBI) are at increased risk for developing colorectal cancer (CRC) compared to the general population. Since earlier detection of CRC is strongly associated with improved survival, the Children’s Oncology Group (COG) Long-Term Follow-Up Guidelines recommend that these high-risk cancer survivors begin CRC screening via a colonoscopy or a multitarget stool DNA test at the age of 30 years or 5 years following the radiation treatment (whichever occurs last). However, only 37% (95% CI 34.1–39.9%) of high-risk survivors adhere to CRC surveillance. The Activating cancer Survivors and their Primary care providers (PCP) to Increase colorectal cancer Screening (ASPIRES) study is designed to assess the efficacy of an intervention to increase the rate of CRC screening among high-risk cancer survivors through interactive, educational text-messages and resources provided to participants, and CRC screening resources provided to their PCPs.

Methods

ASPIRES is a three-arm, hybrid type II effectiveness and implementation study designed to simultaneously evaluate the efficacy of an intervention and assess the implementation process among participants in the Childhood Cancer Survivor Study (CCSS), a North American longitudinal cohort of childhood cancer survivors. The Control (C) arm participants receive electronic resources, participants in Treatment arm 1 receive electronic resources as well as interactive text messages, and participants in Treatment arm 2 receive electronic educational resources, interactive text messages, and their PCP’s receive faxed materials. We describe our plan to collect quantitative (questionnaires, medical records, study logs, CCSS data) and qualitative (semi-structured interviews) intervention outcome data as well as quantitative (questionnaires) and qualitative (interviews) data on the implementation process.

Discussion

There is a critical need to increase the rate of CRC screening among high-risk cancer survivors. This hybrid effectiveness-implementation study will evaluate the effectiveness and implementation of an mHealth intervention consisting of interactive text-messages, electronic tools, and primary care provider resources. Findings from this research will advance CRC prevention efforts by enhancing understanding of the effectiveness of an mHealth intervention and highlighting factors that determine the successful implementation of this intervention within the high-risk cancer survivor population.

Trial registration

This protocol was registered at clinicaltrials.gov (identifier NCT05084833) on October 20, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08082-3.

Integrating primary care and childhood cancer survivorship care: a scoping review protocol

INTRODUCTION

Improved treatment regimens have led to increased survival rates among childhood cancer survivors (CCS), and more than 84% of all children diagnosed with cancer will experience long-term survival or cure. Survivors are susceptible to late effects of cancer treatment often requiring lifelong follow-up care, as many of these conditions can be prevented or mitigated with surveillance. Integrating primary care (PC) and childhood cancer survivorship care can improve follow-up for survivors, however, little integrative research exists. This scoping review aims to: identify and describe existing models of care that integrate PC and childhood cancer survivorship care, examine the effectiveness of these models of care, and characterise the barriers and facilitators for the integration of PC for CCS.

METHODS AND ANALYSIS

A comprehensive empirical literature search of three electronic databases (PubMed, CINAHL, and Embase) was employed to identify potentially relevant citations on 1 October 2020. The population, independent variables/intervention, comparator, outcomes, timing, setting and study design/other limiters (PICOTSS) framework was used to inform protocol development. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and explanation will be used to report study findings. The search strategy will be completed again prior to publication to ensure recent empirical research is accounted for.

ETHICS AND DISSEMINATION

This research is exempt from Institutional Review Board (IRB) review. Approval from a research ethics board for this study was not required as it does not involve human participants or unpublished secondary data. The findings from this scoping review will be disseminated through peer-reviewed scientific manuscripts, clinical conference presentations, professional networks and digital communications using social media platforms such as Twitter. This study has been registered with Open Science Framework: https://osf.io/92xbg.

Late Effects Screening of Acute Lymphoblastic Leukemia Survivors in the Military Healthcare System

INTRODUCTION

Pediatric acute lymphoblastic leukemia (ALL) survivors are a growing portion of the population with unique health screening needs. These survivors receive care within late effects oncology clinics and primary care clinics. Prior attempts to quantify compliance with follow-up recommendations have shown variable rates ranging from 28% to 73%. This study set out to assess rates of adherence to recommended health screening among pediatric ALL survivors within the U.S. DoD, identify potential risk factors contributing to patient compliance, and better define the prevalence of chronic health conditions.

MATERIALS AND METHODS

This Institutional Review Board-approved, retrospective cohort study used data from the U.S. DoD MHS database and identified incident cases of pediatric ALL during 2007-2011 using a conservative case identification algorithm. Minimum duration of follow-up was instituted in order to ensure the entire study population had sufficient time for the assessment of each screening exam according to recommended guidelines. Rates of adherence to recommended screening measures were calculated across the full study follow-up period, and regression analyses assessed protective factors for compliance.

RESULTS

One hundred and forty-four incident ALL cases were identified. During the follow-up period, 31.3% developed a new mental health diagnosis. In terms of recommended screening, 94.4% had an annual complete blood count for the entire study period, 90.3% had a liver function screening, 81.9% had an echocardiogram, 34% had a bone density scan, and 54.2% had a mental health visit. Adolescents were less likely to have a bone density scan (odds ratio [OR] 0.32, 95% CI, 0.11-0.95) or a mental health visit (OR 0.28, 95% CI, 0.11-0.7).

CONCLUSION

The MHS provides universal access to healthcare for all beneficiaries. In this population with universal access to care, there is increased compliance with screening recommendations. Our results reflect actual screening testing as opposed to general screening visits that have been previously reported in the literature. We also highlight the significant number of mental health diagnoses among pediatric ALL survivors.

Obstetrical and Perinatal Outcomes in Female Survivors of Childhood and Adolescent Cancer: A Population-Based Cohort Study

BACKGROUND

The likelihood of pregnancy and risk of obstetrical or perinatal complications is inadequately documented in female survivors of pediatric cancer.

METHODS

We assembled a population-based cohort of female survivors of cancer diagnosed at age 21 years and younger in Ontario, Canada, between 1985 and 2012. Survivors were matched 1:5 to women without prior cancer. Multivariable Cox proportional hazards and modified Poisson models assessed the likelihood of a recognized pregnancy and perinatal and maternal complications.

RESULTS

A total of 4062 survivors were matched to 20 308 comparisons. Median (interquartile range) age was 11 (4-15) years at cancer diagnosis and 25 (19-31) years at follow-up. By age 30 years, the cumulative incidence of achieving a recognized pregnancy was 22.3% (95% confidence interval [CI] = 20.7% to 23.9%) among survivors vs 26.6% (95% CI = 25.6% to 27.3%) among comparisons (hazard ratio = 0.80, 95% CI = 0.75 to 0.86). A lower likelihood of pregnancy was associated with a brain tumor, alkylator chemotherapy, cranial radiation, and hematopoietic stem cell transplantation. Pregnant survivors were as likely as cancer-free women to carry a pregnancy >20 weeks (relative risk [RR] = 1.01, 95% CI = 0.98 to 1.04). Survivors had a higher relative risk of severe maternal morbidity (RR = 2.31, 95% CI = 1.59 to 3.37), cardiac morbidity (RR = 4.18, 95% CI = 1.89 to 9.24), and preterm birth (RR = 1.57, 95% CI = 1.29 to 1.92). Preterm birth was more likely in survivors treated with hematopoietic stem cell transplantation (allogenic: RR = 8.37, 95% CI = 4.83 to 14.48; autologous: RR = 3.72, 95% CI = 1.66 to 8.35).

CONCLUSIONS

Survivors of childhood or adolescent cancer are less likely to achieve a pregnancy and, once pregnant, are at higher risk for severe maternal morbidity and preterm birth.

Missed opportunities for concomitant HPV vaccination among childhood cancer survivors

Purpose

Childhood cancer survivors are at higher risk of human papillomavirus (HPV)‐related second cancers than adolescents without cancer, yet their HPV vaccination uptake is lower. Using a statewide sample, we evaluated whether survivors are at higher risk of missed opportunities for concomitant HPV vaccination.

Methods

From statewide healthcare data, we identified encounters where vaccines were received. Concomitant HPV vaccine missed opportunities were defined as a vaccine encounter where the HPV vaccine was not administered, although eligibility criteria were met. From these encounters, our sample included 327 survivors identified from the Utah Cancer Registry, diagnosed 2000–2016 at ages 0–9, and a birth year and sex‐matched sample without cancer from the general population (n = 1,911). Mixed‐effects Poisson regression estimated the rate of concomitant missed opportunities per vaccine encounter and 95% confidence intervals by vaccine encounter type (all vaccines, flu shot only, or adolescent/catch‐up) from 2013 to 2016.

Results

Survivors had more concomitant HPV vaccine missed opportunities than the population sample (70.0% vs. 59.0%). On average, survivors were 12% more likely to have missed opportunities at vaccine encounters and 4% more likely at flu shot only encounters. The predicted excess risk of concomitant missed opportunities for survivors ranged from 0.5 per10 vaccine encounters to 1.1 per10 vaccine encounters. Higher parental education, rurality, younger first vaccine age, and chemotherapy were associated with missed opportunities.

Conclusions

Childhood cancer survivors have more missed opportunities for concomitant HPV vaccination than a population sample. As flu shots should be administered annually, providers have a regular opportunity to recommend and deliver the HPV vaccine to survivors.

Childhood cancer survivors face a higher risk of HPV‐related cancers than adolescents without a cancer history; however, their vaccination rates tend to be lower. We assessed HPV vaccine missed opportunities among age‐eligible childhood cancer survivors and found significantly more missed opportunities for survivors than adolescents without a cancer history.

OUP accepted manuscript

Appropriate models of survivorship care for the growing number of adult survivors of childhood cancer are unclear. We conducted a realist review to describe how models of care that include primary care and relevant resources (eg, tools, training) could be effective for adult survivors of childhood cancer. We first developed an initial program theory based on qualitative literature (studies, commentaries, opinion pieces) and stakeholder consultations. We then reviewed quantitative evidence and consulted stakeholders to refine the program theory and develop and refine context-mechanism-outcome hypotheses regarding how models of care that include primary care could be effective for adult survivors of childhood cancer. Effectiveness for both resources and models is defined by survivors living longer and feeling better through high-value care. Intermediate measures of effectiveness evaluate the extent to which survivors and providers understand the survivor’s history, risks, symptoms and problems, health-care needs, and available resources. Thus, the models of care and resources are intended to provide information to survivors and/or primary care providers to enable them to obtain/deliver appropriate care. The variables from our program theory found most consistently in the literature include oncology vs primary care specialty, survivor and provider knowledge, provider comfort treating childhood cancer survivors, communication and coordination between and among providers and survivors, and delivery/receipt of prevention and surveillance of late effects. In turn, these variables were prominent in our context-mechanism-outcome hypotheses. The findings from this realist review can inform future research to improve childhood cancer survivorship care and outcomes.

Community based Primary Care for Adolescents and Young Adults Transitioning From Pediatric Specialty Care: Results from a Scoping Review

Background:

Ongoing primary care during adolescence is recommended by best practice guidelines for adolescents and young adults (AYAs; ages 12-25) with chronic conditions. A synthesis of the evidence on the roles of Primary Care Physicians (PCPs) and benefits of primary care is needed to support existing guidelines.

Methods:

We used Arksey and O’Malley’s scoping review framework, and searched databases (MEDLINE, EMBASE, PsychINFO, CINAHL) for studies that (i) were published in English between 2004 and 2019, (ii) focused on AYAs with a chronic condition(s) who had received specialist pediatric services, and (iii) included relevant findings about PCPs. An extraction tool was developed to organize data items across studies (eg, study design, participant demographics, outcomes).

Results:

Findings from 58 studies were synthesized; 29 (50%) studies focused exclusively on AYAs with chronic health conditions (eg, diabetes, cancer), while 19 (33%) focused exclusively on AYAs with mental health conditions. Roles of PCPs included managing medications, “non-complex” mental health conditions, referrals, and care coordination, etc. Frequency of PCP involvement varied by AYAs; however, female, non-Black, and older AYAs, and those with severe/complex conditions appeared more likely to visit a PCP. Positive outcomes were reported for shared-care models targeting various conditions (eg, cancer, concussion, mental health).

Conclusion:

Our findings drew attention to the importance of effective collaboration among multi-disciplinary specialists, PCPs, and AYAs for overcoming multiple barriers to optimal transitional care. Highlighting the need for further study of the implementation of shared care models to design strategies for care delivery during transitions to adult care.

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.

Impact of the model of long-term follow-up care on adherence to guideline-recommended surveillance among survivors of adolescent and young adult cancers

PURPOSE

Adolescent and young adult cancer survivors require lifelong healthcare to address the late effects of therapy. We examined the impact of different provider models of long-term follow-up (LTFU) care on adherence to recommended surveillance.

METHODS

We conducted a retrospective cohort study using administrative health databases in Ontario, Canada. Five-year survivors were identified from IMPACT, a database of patients aged 15-20.9 years at diagnosis of six cancers between 1992 and 2010. We defined three models of LTFU care hierarchically: specialized survivor clinics (SCCs), general cancer clinics (GCCs), and family physician (FP). We assessed adherence to the Children's Oncology Group surveillance guidelines for cardiomyopathy and breast cancer. Multistate models assessed adherence transitions and impacts of LTFU attendance.

RESULTS

A total of 1574 survivors were followed for a mean of 9.2 years (range 4.3-13.9 years) from index (5-year survival). The highest level of LTFU attended in the first 2-years post-index was a GCC (47%); only 16.7% attended a SCC. By the end of study, 72% no longer attended any of the models of care and only 2% still attended an SCC. Among 188 survivors requiring breast cancer surveillance, 6.9% were adherent to their first required surveillance testing. Attendance at a SCC in the previous year and higher cumulative FP or GCC visits increased the rate of subsequently becoming adherent. Among 857 survivors requiring cardiomyopathy surveillance, 11% were adherent at study entry. Each subsequent SCC visit led to an 11.3% (95% CI: 1.05-1.18) increase in the rate of becoming adherent.

CONCLUSION

LTFU attendance and surveillance adherence are sub-optimal. SCC follow-up is associated with greater adherence, but few survivors receive such care, and this proportion diminished over time. Interventions are needed to improve LTFU attendance and promote surveillance adherence.

Determinants of surveillance for late effects in childhood cancer survivors: a qualitative study using the Theoretical Domains Framework

PURPOSE

Most adult survivors of childhood cancer do not complete the recommended surveillance tests for late effects of their treatment. We used a theory-informed method to elucidate the barriers and enablers among childhood cancer survivors to accessing such tests.

METHODS

Semi-structured interviews were completed with adult survivors of childhood cancer. Participants were eligible for the surveillance tests of interest (echocardiogram, mammogram/breast MRI and/or colonoscopy) but had not attended a specialised aftercare clinic in over five years. The Theoretical Domains Framework (TDF), a tool specifically developed for implementation research to identify influences on desired behaviour(s), informed the interview guide and analysis; interview transcripts were coded line-by-line and mapped to domains in accordance with the framework.

RESULTS

Thirty childhood cancer survivors were interviewed (ages 25-60). The TDF domains described by survivors included: intention to complete the tests, which was facilitated by the fear of another cancer (emotion), confidence in the benefits of early detection (beliefs about consequences), and supportive reminders (memory, attention, and decision-making). In contrast, a lack of knowledge of late effects and relevant guidelines and the burden of arranging tests (social identity) were key barriers.

CONCLUSION

Interventions seeking to increase surveillance testing for late effects may be more effective if they feature components that explicitly address all the theory-informed determinants identified.

IMPLICATIONS FOR CANCER SURVIVORS

Awareness about the recommendations among survivors and their physicians is a necessary (but likely not sufficient) step towards implementation of guidelines regarding surveillance for late effects.

Childhood cancer survivors face markedly worse overall survival after diagnosis with breast cancer, melanoma, or colorectal cancer

BACKGROUND

Childhood cancer survivors (CCS) are at elevated risk of secondary malignancies (SM). Enhanced screening for SM is recommended, but compliance is poor. We hypothesized that CCS with adult-onset SM (colorectal cancer [CRC], melanoma, or breast cancer [BC]) would present with more advanced disease and have decreased overall survival (OS).

METHODS

The Surveillance, Epidemiology, and End Results Program was queried for patients diagnosed with cancer at age less than or equal to 18 also diagnosed with adult-onset CRC, melanoma, or BC. A cohort without a history of prior malignancy was likewise identified. Tumor features and clinical outcomes were compared.

RESULTS

CCS with a SM (n = 224) were compared with patients without a childhood cancer history (n = 1,392,670). CCS were diagnosed younger (BC = 37.6 vs. 61.3, p < 0.01, CRC = 35.0 vs. 67.1, p < 0.01, melanoma = 29.6 vs. 61.3 years old, p < 0.01). CCS with BC were more likely to have Stage III or IV disease (25.2% vs. 16.5%, p = 0.01). Hormone-receptor expression also differed; CCS were less likely to develop Luminal A-type tumors (48.6% vs. 66.9%, p = 0.01). After age-adjustment, CCS had worse OS (Hazard ratio: CRC = 2.449, p < 0.01, melanoma = 6.503, p < 0.01, BC = 3.383, p < 0.01).

CONCLUSION

CCS were younger when diagnosed with a SM. After age-adjustment, OS was diminished. Heightened surveillance may be necessary for CCS diagnosed with SM.

Application and Evaluation of Survivorship Care Guides for Hematopoietic Cell Transplantation Recipients

Hematopoietic cell transplantation (HCT) is a treatment for hematologic malignancies and disorders. Patients who receive HCT can face long-term physical and psychosocial effects. Survivorship care guides (care guides), which describe screening and preventive care practices were mailed to allogenic HCT recipients at clinically important timepoints (6, 12, and 24 months after HCT). The primary objective of this study was to evaluate how patients perceived and used the care guides. A cross-sectional, time-series survey was sent to all National Marrow Donor Program/Be The Match allogeneic HCT recipients from September 2012 to November 2016 after the care guides were sent; patients or caregivers could respond. Respondents who returned all 3 surveys were included (554 patients; 65 caregivers), for an overall response rate of 13% (maintenance rate of 45%). The majority of patients and caregivers strongly agreed or agreed that the care guides helped them understand that post-HCT care is important to staying healthy and that they were more familiar with recommended tests at check-up appointments. Most patients who did not share the care guides with their doctors at any of the timepoints believed their doctor knew which tests were needed. Results from this study can help inform and guide development of future tools and evaluations of educational resources for patients after HCT. Tools and educational resources, such as survivorship care guides, have the potential to help empower patients to be more knowledgeable and to understand and advocate for their survivorship care needs.

Subsequent Primary Neoplasms: Risks, Risk Factors, Surveillance, and Future Research

The authors' objective is to provide a brief update on recent advances in knowledge relating to subsequent primary neoplasms developing in survivors of childhood cancer. This includes a summary of established large-scale cohorts, risks reported, and contrasts with results from recently established large-scale cohorts of survivors of adolescent and young adult cancer. Recent evidence is summarized concerning the role of radiotherapy and chemotherapy for childhood cancer and survivor genomics in determining the risk of subsequent primary neoplasms. Progress with surveillance, screening, and clinical follow-up guidelines is addressed. Finally, priorities for future research are outlined.

Current overview and special considerations for second breast cancer in Hodgkin lymphoma survivors

Second breast cancer (SBC) is the most common solid cancer among Hodgkin Lymphoma (HL) female survivors. We reviewed the related modifying risk factors, radiation-induced carcinogenesis, tumors characteristics, management specificities, prevention and surveillance modalities based on current evidence. The risk of developing SBC may be influenced essentially by the age at HL treatment, follow-up latency, dose of irradiation received and the extent of irradiated field. SBCs generally develop at younger age, they are often bilateral, and exhibit more aggressive biological features and worse prognosis. No firm answer about the benefits of breast surveillance is provided by literature, but compelling evidence tends toward a clinical benefit in early detection. Increasing awareness among health providers' care and current survivors as well as the implementation of screening measures is crucial. Great efforts are ongoing in individualizing treatment strategies for future HL patients and response-adapted approaches are holding promise in prevention of these second malignancies.

Clinical Benefits, Harms, and Cost-Effectiveness of Breast Cancer Screening for Survivors of Childhood Cancer Treated With Chest Radiation : A Comparative Modeling Study

BACKGROUND

Surveillance with annual mammography and breast magnetic resonance imaging (MRI) is recommended for female survivors of childhood cancer treated with chest radiation, yet benefits, harms, and costs are uncertain.

OBJECTIVE

To compare the benefits, harms, and cost-effectiveness of breast cancer screening strategies in childhood cancer survivors.

DESIGN

Collaborative simulation modeling using 2 Cancer Intervention and Surveillance Modeling Network breast cancer models.

DATA SOURCES

Childhood Cancer Survivor Study and published data.

TARGET POPULATION

Women aged 20 years with a history of chest radiotherapy.

TIME HORIZON

Lifetime.

PERSPECTIVE

Payer.

INTERVENTION

Annual MRI with or without mammography, starting at age 25, 30, or 35 years.

OUTCOME MEASURES

Breast cancer deaths averted, false-positive screening results, benign biopsy results, and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

Lifetime breast cancer mortality risk without screening was 10% to 11% across models. Compared with no screening, starting at age 25 years, annual mammography with MRI averted the most deaths (56% to 71%) and annual MRI (without mammography) averted 56% to 62%. Both strategies had the most screening tests, false-positive screening results, and benign biopsy results. For an ICER threshold of less than $100 000 per quality-adjusted life-year gained, screening beginning at age 30 years was preferred.

RESULTS OF SENSITIVITY ANALYSIS

Assuming lower screening performance, the benefit of adding mammography to MRI increased in both models, although the conclusions about preferred starting age remained unchanged.

LIMITATION

Elevated breast cancer risk was based on survivors diagnosed with childhood cancer between 1970 and 1986.

CONCLUSION

Early initiation (at ages 25 to 30 years) of annual breast cancer screening with MRI, with or without mammography, might reduce breast cancer mortality by half or more in survivors of childhood cancer.

PRIMARY FUNDING SOURCE

American Cancer Society and National Institutes of Health.

Evaluation of the discussion of late effects and screening recommendations in survivors of adolescent and young adult (AYA) lymphoma

PURPOSE

The study objective was to assess the discussion of late effects (LEs) and screening recommendations (SRs) for adolescent and young adults (AYAs) treated for lymphoma.

METHODS

A retrospective study was conducted on AYA lymphoma survivors aged 15-24 years at diagnosis who received radiation therapy (RT) ± chemotherapy between 1984 and 2010 at any of the six British Columbia (BC) Cancer treatment centers across the province. Charts were reviewed to evaluate discussion of LEs and SRs. Susceptibility to specific LEs was determined by reviewing treatment details.

RESULTS

Of 305 patients, 212 (70%) had documented discussion of at least one specific LE, 39 (13%) had non-specific documentation only, and 54 (18%) had no documented discussion of LEs. Accounting only for patients susceptible to each LEs, the most frequently discussed LEs was radiation-induced (RI) neoplasm (42%), and the least frequently discussed LEs was carotid artery stenosis (0.4%). The most common SRs discussed in susceptible patients was for RI breast cancer (43%). Of patients discharged between 1985 and 1999 vs 2000 and 2014, LEs were discussed in 63 vs 93% (P < 0.0005), and SRs were discussed in 30 vs 65%, respectively (P < 0.0005). Older age at discharge, presence of a discharge note, and occurrence of a discharge appointment were associated with increased discussion of SRs.

CONCLUSIONS

Most survivors of AYA lymphoma received some discussion of LEs and SRs, but each relevant LEs and SRs was discussed in only a minority of susceptible patients.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors of AYA lymphoma and their primary care professionals may not be appropriately informed of health risks and how to screen for them.

Adherence to Surveillance for Second Malignant Neoplasms and Cardiac Dysfunction in Childhood Cancer Survivors: A Childhood Cancer Survivor Study

PURPOSE

To evaluate childhood cancer survivors' adherence to surveillance protocols for late effects of treatment and to determine the factors affecting adherence.

METHODS

Between 2014 and 2016, 11,337 survivors and 2,146 siblings in the Childhood Cancer Survivor Study completed a survey ascertaining adherence to Children's Oncology Group (COG) guidelines for survivors at high risk for second malignant neoplasms or cardiac dysfunction and to the American Cancer Society (ACS) cancer screening guidelines for average-risk populations. Adherence rates and factors affecting adherence were analyzed.

RESULTS

Median age at diagnosis was 7 years (range, 0-20.9 years), and median time from diagnosis was 29 years (range, 15-47 years). Among high-risk survivors, adherence to COG breast, colorectal, skin, and cardiac surveillance was 12.6% (95% CI, 10.0% to 15.3%), 37.0% (34.1% to 39.9%), 22.3% (21.2% to 23.4%), and 41.4% (40.1% to 42.7%), respectively. Among average-risk survivors, adherence to ACS breast, cervical, and colorectal screening was 57.1% (53.2% to 61.0%), 83.6% (82.7% to 84.5%), and 68.5% (64.7% to 72.2%), respectively. Twenty-seven percent of survivors and 20.0% of primary care providers (PCPs) had a survivorship care plan (SCP). For high-risk survivors, SCP possession was associated with increased adherence to COG breast (22.3% v. 8.1%; prevalence ratio [PR], 2.52; CI, 1.59 to 4.01), skin (34.8% v 23.0%; PR, 1.16; CI, 1.01 to 1.33), and cardiac (67.0% v 33.1%; PR, 1.73; CI, 1.55 to 1.92) surveillance. For high-risk survivors, PCP possession of a SCP was associated only with increased adherence to COG skin cancer surveillance (36.9% v 23.2%; PR, 1.24; CI, 1.08 to 1.43).

CONCLUSION

Guideline adherence is suboptimal. Although survivor SCP possession is associated with better adherence, few survivors and PCPs have one. New strategies to improve adherence are needed.

Paediatric cardio-oncology: epidemiology, screening, prevention, and treatment

With 5-year survival of children with cancer exceeding 80% in developed countries, premature cardiovascular disease is now a major cause of early morbidity and mortality. In addition to the acute and chronic cardiotoxic effects of anthracyclines, related chemotherapeutics, and radiation, a growing number of new molecular targeted agents may also have detrimental effects on the cardiovascular system. Survivors of childhood cancer also may have earlier development of conventional cardiovascular risk factors such as hypertension, dyslipidaemia, and diabetes, which further increase their risk of serious cardiovascular disease. This review will examine the epidemiology of acute and chronic cardiotoxicity relevant to paediatric cancer patients, including genetic risk factors. We will also provide an overview of current screening recommendations, including the evidence regarding both imaging (e.g. echocardiography and magnetic resonance imaging) and blood-based biomarkers. Various primary and secondary prevention strategies will also be discussed, primarily in relation to anthracycline-related cardiomyopathy. Finally, we review the available evidence related to the management of systolic and diastolic dysfunction in paediatric cancer patients and childhood cancer survivors.

Breast Cancer Screening Practices for High-Risk Women: A Cross-Sectional Survey of Primary Care Providers

Background: Little literature exists on primary care providers' knowledge and preferences toward breast cancer screening for high-risk women. Materials and Methods: A cross-sectional web-based survey of primary care providers in Minnesota was conducted in 2016. The primary aim was to determine the breast cancer screening practices of primary care providers for women at high risk for breast cancer. A multipart questionnaire focused on breast cancer screening practices for high-risk women and perceived risks/benefits of breast cancer screening was administered. Statistical analyses, included descriptive statistics and tests of differences in screening practices and knowledge across key professional characteristics, were conducted. Results: Eight hundred five primary care providers completed the survey (7.7% response). Participants were predominantly female (72.2%); 43.9% were physicians, 11.4% physician assistants, and 44.8% advanced practice registered nurses. One-quarter of providers recommended mammography and breast magnetic resonance imaging (MRI) for high-risk women ages 40-49 years. There were no differences in breast MRI recommendations based on years of experience or practice setting. In high-risk women with prior chest radiation and an increased risk of breast cancer, for whom guidelines recommend mammography and MRI, 75.0% of providers recommended mammography, but only 44.3% recommended breast MRI. Recent continuing education on breast cancer screening was associated with providers being more comfortable giving high-risk screening recommendations (p = 0.002). Conclusions: Most primary care providers believe mammography is helpful in women at high risk for breast cancer. Less than half of practitioners, however, recommend breast MRI to screen women at high risk for breast cancer, despite guidelines promoting the use of breast MRI. Increased provider education is warranted.

Prevalence and correlates of adherence to skin examination among adolescent and young adult survivors of melanoma from the Project Forward Study

BACKGROUND

Melanoma is a common cancer among adolescents and young adults (AYAs), yet adherence to recommended surveillance and factors related to adherence are not well understood in this population. This study assessed the prevalence and correlates of physician-conducted skin examination (PSE) and skin self-examination (SSE) among AYA-aged long-term survivors of melanoma.

PROCEDURES

Melanoma cases were identified from the Los Angeles County cancer registry and surveys were then completed by 128 respondents diagnosed between the ages 0 and 24, with stage 1 melanoma or higher, at least 5 years from diagnosis, and who were between the ages 18 and 39 at the time of survey.

RESULTS

Eighty-two percent of AYA melanoma survivors reported SSE within the past 6 months, while 65% reported annual PSE. Greater health care self-efficacy was positively associated with adherence to PSE, SSE, and both types of skin examinations (P < .01). Higher socioeconomic status and having a regular source of primary health care were positively associated with annual PSE and adherence to both surveillance practices (P < .05 and P < .01, respectively). Hispanic ethnicity was negatively associated with annual PSE compared to non-Hispanics (P < .01), and greater depressive symptoms were negatively associated with adherence to both skin examinations (P < .05).

CONCLUSIONS

High rates of SSE were observed, but PSE adherence was lower than optimal in this sample. Interventions to improve PSE are needed for at-risk AYA survivors of melanoma, and strategies that help melanoma survivors navigate the health care system and access primary care may facilitate greater adherence.

Communicating health information and improving coordination with primary care (CHIIP): Rationale and design of a randomized cardiovascular health promotion trial for adult survivors of childhood cancer

BACKGROUND

Long-term survival for children diagnosed with cancer exceeds 80%. Notably, premature cardiovascular disease has become the leading non-cancer cause of late mortality among these survivors.

METHODS/DESIGN

This randomized controlled trial (RCT; NCT03104543) focuses on adult participants in the Childhood Cancer Survivor Study identified as high risk for ischemic heart disease or heart failure due to their cancer treatment. Participants undergo a home-based evaluation of blood pressure and laboratory tests to determine the prevalence of undiagnosed and/or undertreated hypertension, dyslipidemia, and diabetes. Those with abnormal values are then enrolled in an RCT to test the efficacy of a 12-month personalized, remotely delivered survivorship care plan (SCP) intervention designed to reduce undertreatment of these three target conditions. The intervention approximates a clinical encounter and is based on chronic disease self-management strategies.

RESULTS

With a goal of 750, currently 342 out of 742 eligible participants approached have enrolled (46.1%). Initially, we randomized participants to different recruitment strategies, including shorter approach packets and a tiered consent, but did not find significant differences in participation rates (40.7% to 42.9%; p = .95). Subsequently, slightly greater participation was seen with larger upfront unconditional incentive checks ($50 vs. $25: 50.7% vs. 44.1%; p = .10). Overall, the financial impact of the $50 upfront incentive was cost neutral, and possibly cost-saving, vs. a $25 upfront incentive.

CONCLUSION

The overall study will determine if a National Academy of Medicine-recommended SCP intervention can improve cardiovascular outcomes among long-term survivors of childhood cancer. Modifications to the recruitment strategy may improve participation rates over time.

Current and coming challenges in the management of the survivorship population

With the widespread adoption of multimodality treatment, 5-year survival of children diagnosed with cancer has improved dramatically in the past several decades from approximately 60% in 1970 to greater than 85% currently. As a result, there are an estimated nearly half a million long-term survivors of childhood cancer living in the United States today. However, survivors have, on average, significantly greater serious medical and psychosocial late effects compared with the general population. In this review, we will discuss the current epidemiology of childhood cancer survivorship, including new methods to estimate the burden of late effects and genetic susceptibility toward late effects. We will also review the development of surveillance guidelines for childhood cancer survivors and early toxicity signals from novel agents now being tested and used increasingly to treat pediatric and adult cancers. We conclude with an overview of current models of survivorship care and areas for future research.

Burden of chronic diseases among sarcoma survivors treated with anthracycline chemotherapy: results from an observational study

Aim:

Cardiovascular disease is a leading cause of mortality among long-term cancer survivors treated with large total doses of doxorubicin. An increase in coronary artery disease (CAD) among childhood cancer survivors by age 45 has been observed and is driven by primarily anthracycline chemotherapy and to a lesser extent chest radiation that includes the heart in the radiation field. The risk factors and associated chronic diseases (hypertension, etc.) are well known for CAD and can be often prevented or treated, thus reducing the risk of CAD in these patients. We piloted a risk-based survivorship clinic in an academic medical center to characterize the distribution of risk factors for CAD and improve the quality of life in a population of sarcoma survivors treated with doxorubicin.

Methods:

We followed a prospective cohort of sixty-one survivors of bone and soft tissue sarcoma treated with doxorubicin chemotherapy (> 400 mg/m²) and at least 2 years post-therapy attending the sarcoma survivorship clinic. We collected clinical, demographic data, and patient reported outcomes via PROMIS questionnaires annually.

Results:

We demonstrated a high burden of chronic diseases in this population. Among six chronic conditions that are known risk factors for CAD (hypertension, diabetes, obesity, chronic inflammation, kidney disease and dyslipidemia), more than one-fourth (26%, 16/61) of patients had three or more of these risk factors at baseline visit, and 49% (30/61) had two or more.

Conclusion:

The results of this pilot study support the presence of modifiable CAD risk factors in this population of sarcoma survivors. Evidence-based guidelines for high-risk survivors of rare cancers are needed.

Providing health care for patients with childhood cancer and survivors: A survey of pediatric primary care providers

BACKGROUND

The current study was conducted to assess self-reported comfort levels of pediatric primary care providers (PCPs) in providing acute medical care to patients with childhood cancer who currently were receiving therapy (on-therapy patients) and health maintenance care to childhood cancer survivors, independently and in conjunction with pediatric oncologists, along with confidence levels regarding knowledge about immunizations for survivors. All levels were measured using 7-point Likert scales.

METHODS

A cross-sectional, 23-item survey mailed to practicing PCPs affiliated with a tertiary children's hospital was analyzed.

RESULTS

The response rate was 64.4% (259 of 402 eligible PCPs). The mean PCP comfort level was higher when collaborating with a pediatric oncologist to provide acute medical care for on-therapy patients and health maintenance care for childhood cancer survivors (mean ratings of 6.0 ± 1.5 and 6.4 ± 1.3, respectively) compared with independently providing such care (mean ratings of 4.6 ± 1.8 and 5.0 ± 1.7, respectively; P < .0001). Only approximately 30% of PCPs were confident in their knowledge regarding immunizations for survivors. Certain factors were found to be associated with PCP comfort in providing care in conjunction with a pediatric oncologist. For acute care, these factors were rural location compared with urban location (odds ratio [OR], 5.0; 95% CI, 1.9-13.1 [P = .03]) and having cared for ≥6 on-therapy patients within the past year versus none (OR, 3.8; 95% CI, 1.9-7.5 [P = .0001]). For survivor health maintenance care, practice location <50 miles from pediatric oncology specialty care versus ≥50 miles was the only factor found to be associated with PCP comfort (OR, 2.8; 95% CI, 1.3-6.1 [P = .009]).

CONCLUSIONS

The findings of the current study underscore the need for collaboration between pediatric oncologists and PCPs when caring for children with cancer across the spectrum of care.

Mortality patterns in long-term survivors of childhood or adolescent central nervous system tumour in Sweden

Purpose

A growing number of young patients with central nervous system (CNS) tumour survived for more than five years. However, these long-term survivors might be at risk of multiple late effects thus leading to a higher risk of late mortality. We aimed to explore the risk of late mortality and the pattern of mortality among long-term survivors of childhood or adolescent CNS tumour.

Methods

We identified 5-year survivors with childhood or adolescent CNS tumour before age 20 years through the Swedish Cancer Registry. Five controls were randomly matched for each patient to generate the reference group. We retrieved information about death via Cause of Death Register. We calculated the absolute excess risk (AER) of death and the hazard ratio (HR) of death using Cox proportional hazard model.

Results

Long-term survivors with CNS tumour suffered a significant higher risk of overall mortality (HR 6.56, 95% CI 5.71–7.53; AER 5.89, 95% CI 5.03–6.87). The mortality rate declined with the increasing survival time, but it was still higher even after 30 years of follow-up. Malignant neoplasms contributed mostly to late mortality with an AER of 3.75 (95% CI 2.95–4.75). Female survivors, survivors diagnosed at a younger age and survivors with medulloblastoma were particularly strongly associated with a higher risk of death.

Conclusions

Long-term survivors of childhood and adolescent CNS tumours are at a higher risk of late mortality, and the risk of death is affected by gender, age at diagnosis and types of CNS tumour.

Electronic supplementary material

The online version of this article (doi:10.1007/s11060-019-03321-w) contains supplementary material, which is available to authorized users.

Survivorship Care Plans in Cancer: A Meta-Analysis and Systematic Review of Care Plan Outcomes

BACKGROUND

The Institute of Medicine recommends that survivorship care plans (SCPs) be included in cancer survivorship care. Our meta-analysis compares patient-reported outcomes between SCP and no SCP (control) conditions for cancer survivors. Our systematic review examines the feasibility of implementing SCPs from survivors' and health care professionals' perspectives and the impact of SCPs on health care professionals' knowledge and survivorship care provision.

METHODS

We searched seven online databases (inception to April 22, 2018) for articles assessing SCP feasibility and health care professional outcomes. Randomized controlled trials comparing patient-reported outcomes for SCP recipients versus controls were eligible for the meta-analysis. We performed random-effects meta-analyses using pooled standardized mean differences for each patient-reported outcome.

RESULTS

Eight articles were eligible for the meta-analysis (n = 1,286 survivors) and 50 for the systematic review (n = 18,949 survivors; n = 3,739 health care professionals). There were no significant differences between SCP recipients and controls at 6 months postintervention on self-reported cancer and survivorship knowledge, physical functioning, satisfaction with information provision, or self-efficacy or at 12 months on anxiety, cancer-specific distress, depression, or satisfaction with follow-up care. SCPs appear to be acceptable and potentially improve survivors' adherence to medical recommendations and health care professionals' knowledge of survivorship care and late effects.

CONCLUSION

SCPs appear feasible but do not improve survivors' patient-reported outcomes. Research should ascertain whether this is due to SCP ineffectiveness, implementation issues, or inappropriate research design of comparative effectiveness studies.

IMPLICATIONS FOR PRACTICE

Several organizations recommend that cancer survivors receive a survivorship care plan (SCP) after their cancer treatment; however, the impact of SCPs on cancer survivors and health care professionals is unclear. This systematic review suggests that although SCPs appear to be feasible and may improve health care professionals' knowledge of late effects and survivorship care, there is no evidence that SCPs affect cancer survivors' patient-reported outcomes. In order to justify the ongoing implementation of SCPs, additional research should evaluate SCP implementation and the research design of comparative effectiveness studies. Discussion may also be needed regarding the possibility that SCPs are fundamentally ineffective.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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