Uncertainty, Posttraumatic Stress, and Health Behavior in Young Adult Childhood Cancer Survivors

Further validation of the Perceptions of Uncertainties in Genome Sequencing (PUGS) scale among patients with cancer undergoing tumor sequencing

It is important to understand how individuals perceive uncertainties and the consequent impact on their psychological well-being and health behavior. The Perceptions of Uncertainty in Genome Sequencing (PUGS) scale measures clinical, affective, and evaluative uncertainties about information from sequencing. The PUGS scale has been shown to be valid and reliable among individuals receiving results about their genomes. This study assessed whether its validity generalized to patients with cancer undergoing tumor sequencing. Exploratory factor analysis (EFA) was conducted on data from the Molecular Screening and Therapeutics Program (n=310) to identify a measurement model. Confirmatory factor analysis (CFA) was used to determine the adequacy of the resulting fit. EFA identified the same three-factor structure reported previously. CFA confirmed that the measurement model yielded a good fit (χ2/df=3.72, CFI=0.96, SRMR=0.05, RMSEA=0.09) and satisfied convergent and discriminant validity. These findings provide further evidence of the validity and reliability of the PUGS scale in measuring three types of uncertainty. Continued application will facilitate an evidence-based approach to intervention and enhance understanding of what it is like to receive results. In turn, this will improve clinical outcomes as undergoing sequencing becomes an increasingly common experience. This article is protected by copyright. All rights reserved.

The efficacy of interactive group psychoeducation for children with leukaemia: A randomised controlled trial

OBJECTIVE

To evaluate an interactive group psychoeducation programme for children treated for leukaemia.

METHODS

A longitudinal randomised controlled study across four UK hospitals with an immediate (N = 26) and delay control group (N = 32). The intervention covered the pathophysiology of leukaemia, its treatment, side effects and the importance of positive health behaviours. Primary outcomes were parent-reported child health related quality of life (HRQoL) and behavioural difficulties. Secondary outcomes were child-reported HRQoL, cancer-specific HRQoL, child confidence, caregiver burden, and treatment anxiety. Measures were completed pre- and immediately post-intervention, and at 13 and 26-weeks follow-up. Change over time was analysed using multilevel modelling. Acceptability questionnaires rated the intervention on benefits, recommendations, and barriers to participation.

RESULTS

The intervention significantly improved parent-reported child HRQoL but did not have a significant effect on other outcomes. Acceptability of the intervention was high.

CONCLUSIONS

This study provides initial evidence that interactive group psychoeducation is acceptable to families and improves HRQoL in children with leukaemia. Difficulties with recruitment removed power to detect effect sizes that are plausible for psychoeducational interventions.

PRACTISE IMPLICATIONS

Further studies to explore the potential of psychoeducation to improve outcomes for children with leukaemia and an examination of barriers to participation within this population are warranted.

Systematic review of illness uncertainty management interventions for cancer patients and their family caregivers

PURPOSE

Illness uncertainty pervades individuals' experiences of cancer across the illness trajectory and is associated with poor psychological adjustment. This review systematically examined the characteristics and outcomes of interventions promoting illness uncertainty management among cancer patients and/or their family caregivers.

METHODS

PubMed, Scopus, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and Cochrane Database of Systematic Reviews were systematically searched for relevant literature. We included randomized controlled trials (RCTs) and quasi-experimental studies focusing on interventions for uncertainty management in cancer patients and/or their family caregivers.

RESULTS

Our database searches yielded 26 studies. Twenty interventions were only offered to cancer patients, who were mostly elder, female, and White. All interventions included informational support. Other intervention components included emotional support, appraisal support, and instrumental support. Most interventions were delivered in person and via telephone (n = 8) or exclusively in person (n = 7). Overall, 18 studies identified positive intervention effects on illness uncertainty outcomes.

CONCLUSION

This systematic review foregrounds the promising potential of several interventions-and especially multi-component interventions-to promote uncertainty management among cancer patients and their family caregivers. To further improve these interventions' effectiveness and expand their potential impact, future uncertainty management interventions should be tested among more diverse populations using rigorous methodologies.

Fathers' psychological responses to pediatric cancer-induced financial distress

BACKGROUND

To describe how pediatric cancer-induced financial distress and perceptions of their social role affected fathers' psychological responses to this distress, and quality of life (QOL) for them and their families.

PROCEDURE

We analyzed father-only responses from a larger cross-sectional survey study about the impact of pediatric cancer-induced financial distress on parents. Our analytic sample was n = 87 fathers who participated in the larger study. We analyzed their data using descriptive statistics and directed content analysis.

RESULTS

Conflicting role responsibilities (be there for child; work to maintain income and insurance coverage) seemed to generate responses resembling characteristic posttraumatic stress symptoms in reaction to acute declines in family finances and/or the chronic stress of insufficient finances to meet financial demands, that is, financial trauma. Fathers' personal sense of not being able to adequately provide for their child with cancer and also meet their family's basic needs produced embarrassment and humiliation, which led to discomfort talking about finances; fear, persistent thoughts and anxiety about money; reduced joy; beliefs that they did not deserve to express their needs; and feeling vulnerable to repeated financial stressors.

CONCLUSIONS

Pediatric cancer-induced financial burden contributed to fathers' symptom severity and burden, and QOL declines. Clinicians should develop sensitivity to the multiple ways that pediatric cancer affects individuals and families. Future research should examine the effects of pediatric cancer-induced financial burden on mothers, and develop ways to sensitively and systematically assess financial burden, associated psychological responses and declines in QOL, and intervene as indicated.

Mindfulness-Based Interventions for Young People With Cancer: An Integrative Literature Review

BACKGROUND

Mindfulness-based interventions (MBIs) have demonstrated benefits for adults with chronic illness and are becoming increasingly popular among children and young people. Mindfulness-based interventions could have benefits for young people with cancer throughout the treatment journey, through to survivorship.

OBJECTIVE

The aim was to review intervention studies about MBI used with young people with cancer between the ages of 10 and 29 years.

METHODS

Six electronic databases were searched. The methodological quality of the included studies was assessed using the Joanna Briggs Institute critical appraisal tools.

RESULTS

Six contemporary studies met the inclusion criteria. Three studies adapted MBI to be age appropriate and some studies modified the intervention based on cancer-specific needs of young people. Formal and informal MBI activities were found to be acceptable by young people; however, recruitment of the participants was identified as a barrier. Variability in psychosocial outcomes was noted in the review by some demonstrating improvement in areas such as mindfulness, anxiety, and social isolation and others not eliciting significant benefits.

CONCLUSIONS

Mindfulness-based intervention shows promise as an acceptable intervention that may improve psychosocial well-being for young people with cancer. Future research studies with adequate sample sizes are warranted to determine the effectiveness of MBI among young people with cancer.

IMPLICATIONS FOR PRACTICE

Mindfulness-based intervention seems to be a promising approach to promote psychosocial well-being and reduce disease burden in young people with cancer. As validated MBI may be implemented without expert training, this could be promoted by healthcare providers, including nurses who care for young people with cancer.

Posttraumatic stress as a contributor to behavioral health outcomes and healthcare utilization in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

PURPOSE

To examine the association between posttraumatic stress symptoms (PTSS), neurocognitive and psychosocial late-effects, health behaviors, and healthcare utilization in long-term survivors of childhood cancer.

METHODS

Participants included individuals (N = 6844; 52.5% female; mean [SD] age at diagnosis = 7.6 [5.8], at follow-up = 34.9 [7.5]) in the Childhood Cancer Survivor Study (CCSS). Follow-up included the Posttraumatic Stress Scale, Brief Symptom Inventory-18, Short-form 36 Health-related quality of life (HRQOL) survey, CCSS Neurocognitive Questionnaire, and questions about sociodemographics, physical health, health behaviors, and healthcare utilization. Modified Poisson regression and multinomial logistic regression models examined associations between posttraumatic stress symptoms (PTSS) and neurocognitive, HRQOL, health behavior, and healthcare outcomes when adjusting for sociodemographics, disease, and treatment.

RESULTS

Long-term survivors with PTSS (N = 995, 14.5%) reported more impairment in mental (relative risk [RR] 3.42, 95% confidence interval [CI] 3.05-3.85), and physical (RR = 2.26, CI = 1.96-2.61) HRQOL. PTSS was also associated with increased impairment in task efficiency (RR = 3.09, CI = 2.72-3.51), working memory (RR = 2.55, CI = 2.30-2.83), organization (RR = 2.11, CI = 1.78-2.50), and emotional regulation (RR = 3.67, CI = 3.30-4.09). Survivors with PTSS were significantly more likely to attend cancer-specific health visits in the past 2 years (OR = 1.89, CI = 1.50-2.39), and showed greater likelihood of either high frequency (OR = 1.89, CI = 1.50-2.39) or complete lack of (OR = 1.63, CI = 1.32-2.01) primary care visits compared to survivors without PTSS.

CONCLUSIONS

Survivors with PTSS reported significantly more psychosocial and neurocognitive late effects, and were more likely to engage in variable use of healthcare.

IMPLICATIONS FOR CANCER SURVIVORS

PTSS is associated with additional challenges for a population vulnerable to adverse late effects. Inclusion of integrative services during follow-up visits may benefit functional outcomes.

Illness Uncertainty and Posttraumatic Stress in Young Adults With Congenital Heart Disease

BACKGROUND

Young adults with congenital heart disease (CHD) are at risk for chronic illness uncertainty in 4 domains: ambiguity about the state of their illness; lack of information about the disease, its treatment, and comorbidities; complexity of the healthcare system and relationship with healthcare providers; and unpredictability of the illness course and outcome. Chronic uncertainty has been associated with posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD).

OBJECTIVE

The aims of this study were to explore how young adults with CHD experience uncertainty and to describe the relationship between PTSS and the appraisal and management process.

METHODS

An exploratory, mixed methods design was used. Data were collected in person and via Skype from 25 participants (19-35 years old), who were diagnosed with CHD during childhood and able to read and write English. In-depth interviews and the University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index were used to collect data. Qualitative data were analyzed using the constant comparative method.

RESULTS

The 4 domains of uncertainty were evident in the narratives. The PTSD mean (SD) score was 31.3 (7.7). Six participants met criteria for PTSD. Narrative analysis revealed a relationship between severity of PTSS and the appraisal and management of uncertainty. Participants with PTSD used management strategies that included avoidance, reexperiencing, and hyperarousal.

CONCLUSIONS

Young adults with CHD may be at risk for the development of long-term psychological stress and PTSD in the setting of chronic uncertainty. Regular monitoring to identify PTSS/PTSD may be a means to promote treatment adherence and participation in healthcare.

A Mobile-Based Mindfulness and Social Support Program for Adolescents and Young Adults With Sarcoma: Development and Pilot Testing

BACKGROUND

Approximately 70,000 adolescents and young adults (AYA) are diagnosed with cancer each year in the United States. Sarcomas carry a particularly high symptom burden and are some of the most common cancers among AYA. Recent work has documented significant levels of unmet needs among AYA with cancer, particularly the need for psychosocial support. Mobile technology may be a cost-effective and efficient way to deliver a psychosocial intervention to AYA with cancer and cancer survivors.

OBJECTIVE

The two aims of this study were to (1) develop a pilot version of a mobile-based mindfulness and social support program and (2) evaluate program usage and acceptability. An exploratory aim was to examine change in psychosocial outcomes.

METHODS

Thirty-seven AYA with sarcoma or sarcoma survivors, parents, and health care providers participated in the study. Semistructured interviews were conducted with 10 AYA, parents of five of the adolescents, and six health care providers. Themes from the interviews helped to inform the development of a mobile-based mindfulness pilot program and a companion Facebook-based social support group. Twenty AYA consented to participate in a single-arm pre-post evaluation of the program; 17 downloaded the app and joined the Facebook group. Seven of these participants had participated in the semistructured interviews. Six additional health care providers consented to participate in the evaluation stage.

RESULTS

On average, participants completed 16.9 of the 28 unique sessions and used the mindfulness app for a mean 10.2 (SD 8.2) days during the 28-day evaluation period. The majority of participants (16/17) engaged in the social group and posted at least one reply to the moderator's prompts. The mean number of responses per person to the moderator of the social group was 15.2 of 31 (49%, range 0%-97%). Both AYA and health care providers responded positively to the Mindfulness for Resilience in Illness program and offered useful recommendations for improvements. Exploratory psychosocial analyses indicated there were no significant differences from pretest to posttest on measures of perceived social support, mindfulness, body image, or psychological functioning.

CONCLUSIONS

This study offers preliminary support for the feasibility and acceptability of a mobile-based mindfulness and Facebook-based social support program for AYA with sarcoma. The feedback from AYA and health care providers will assist in creating a fully developed intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03130751; https://clinicaltrials.gov/ct2/show/NCT03130751.

The Resilience in Illness Model Part 2: Confirmatory Evaluation in Adolescents and Young Adults With Cancer

BACKGROUND

Empirically derived and tested models are necessary to develop effective, holistic interventions to improve positive health outcomes in adolescents and young adults (AYA) with cancer, yet few exist. This article is the second of 2 articles reporting on evaluation of the Resilience in Illness Model (RIM) as a predictive model to guide positive health research and practice.

OBJECTIVE

The aim of this study was to report the confirmatory model evaluation of the RIM.

METHODS

A confirmatory evaluation of RIM was done using baseline data from a sample of 113 AYA aged 11 to 24 years who were undergoing hematopoietic stem cell transplant and enrolled in a randomized controlled trial of a behavioral intervention to enhance resilience. Data were analyzed using latent variable structural equation modeling.

RESULTS

Goodness-of-fit indices supported RIM as a confirmed model that accounted for large amounts of variance in the outcomes of self-transcendence (62%) and resilience (72%), and in 3 of 5 mediators, specifically social integration (74%), courageous coping (80%), and hope-derived meaning (87%), as well as small to moderate amounts of variance in the remaining mediators of defensive coping (1%) and family environment (35%).

CONCLUSIONS

Findings establish the RIM as a plausible predictive framework for explaining ways AYA with cancer transcend their illness and achieve resilience resolution and for guiding intervention studies in this population. Additional research is needed to explore RIM's transferability based on stage of illness, other chronic diseases, and cultural diversity.

IMPLICATIONS FOR PRACTICE

Results support the RIM as an appropriate guide for developing and evaluating interventions to foster positive adjustment in AYA with cancer.

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.

Health behaviors of minority childhood cancer survivors

BACKGROUND

Available data have suggested that childhood cancer survivors (CCSs) are comparable to the general population with regard to many lifestyle parameters. However, to the authors' knowledge, little is known regarding minority CCSs. This cross-sectional study describes and compares the body mass index and health behaviors of African American, Hispanic, and white survivors with each other and with noncancer controls.

METHODS

Participants included 452 adult CCSs (150 African American, 152 Hispanic, and 150 white individuals) recruited through 4 childhood cancer treating institutions and 375 ethnically matched noncancer controls (125 in each racial/ethnic group) recruited via targeted digit dial. All participants completed a 2-hour in-person interview.

RESULTS

Survivors and noncancer controls reported similar health behaviors. Within survivors, smoking and physical activity were found to be similar across racial/ethnic groups. African American and Hispanic survivors reported lower daily alcohol use compared with white individuals, but consumed unhealthy diets and were more likely to be obese.

CONCLUSIONS

This unique study highlights that many minority CCSs exhibit lifestyle profiles that contribute to an increased risk of chronic diseases and late effects. Recommendations for behavior changes must consider the social and cultural context in which minority survivors may live.

"Being Mindful": Does it Help Adolescents and Young Adults Who Have Completed Cancer Treatment?

PURPOSE

Feelings of excitement and relief upon finishing cancer treatment are often juxtaposed with a time that can be challenging, distressing, and uncertain for adolescents and young adults (AYAs). The purpose of this study was to examine whether a mindful dispositional trait was associated with better adaptive outcomes for these young people.

METHODS

AYAs who had finished cancer treatment (N = 76; mean age, 18.5; years, SD, 3.4 years) completed questionnaires measuring mindfulness, psychological distress, and uncertainty around their cancer experience. A median split was performed based on the total scores for the mindfulness measure to establish high and low mindfulness groups.

RESULTS

No significant differences were found between these 2 groups on demographic or cancer variables. There were significant differences between the groups on the distress and uncertainty scores such that the higher mindfulness group reported significantly less distress and uncertainty.

CONCLUSIONS

The current findings suggest the potential for a broader application of mindfulness to more fully assist young people throughout the whole pathway of cancer care.

Measuring health-promoting behaviors: cross-cultural validation of the Health-Promoting Lifestyle Profile-II

PURPOSE

Individual lifestyles have emerged as valuable health constructs. This study aims to psychometrically test the Portuguese (European) version of the Health-Promoting Lifestyle Profile-II.

METHODS

After an adequate linguistic and cultural adaptation of the Health-Promoting Lifestyle Profile-II scale, their psychometric properties were assessed (N = 889) by Cronbach's alpha and confirmatory factor analysis.

FINDINGS

Results showed an adequate fit to a 52-item, six-factor structure. A global alpha of .925 was obtained.

CONCLUSIONS

The Portuguese version demonstrated good validity and reliability in a wide adult sample, and can thus be applied to the Portuguese population.

IMPLICATIONS FOR NURSING PRACTICE

This instrument is useful as an evaluation tool for health-promoting lifestyles and as an instrument for testing the effectiveness of health-promoting programs.

Intervention format and delivery preferences among young adult cancer survivors

BACKGROUND

Young adult cancer survivors face a number of increased medical and psychosocial risks, including an increased risk of cardiovascular disease and emotional distress. Although behavioral strategies, such as exercise, may diminish some of these risks, few behavioral interventions have been developed for this population.

PURPOSE

As a first step toward developing interventions specifically for young survivors, we conducted a qualitative study of their intervention-related preferences. A key objective was to identify the preferred format for delivering interventions (e.g., face-to-face, online).

METHOD

In-depth, semi-structured individual interviews were conducted with 20 young adult cancer survivors between the ages of 18 and 39. This research was conducted in Rhode Island, USA.

RESULTS

Participants identified advantages and disadvantages to a variety of intervention formats including: telephone-based, print-based, computer-based, and several types of face-to-face interventions. The dominant theme that emerged was that interventions developed for young adult cancer survivors should take into account their multiple competing needs and obligations (e.g., work, family). Two closely related subthemes were: (1) the importance of developing interventions that are convenient and (2) the need for interventions that provide social support. Interventions for this population may be most successful if they take into account these themes.

CONCLUSION

Data indicate that young adult cancer survivors have some unique needs (e.g., multiple competing demands of young adulthood) and preferences (e.g., comfort with remotely delivered interventions) that differentiate them from older cancer survivors. Thus, young survivors would be best served by interventions designed to specifically target this population.

Feasibility and preliminary findings from a pilot study of allostatic load in adolescent-young adult childhood cancer survivors and their siblings

Adolescent-young adult (AYA) childhood cancer survivors experience at least 2 types of chronic stress that can increase their risk for cardiovascular disease: the physiological stress of cancer and its treatment and the psychosocial stress inherent in the cancer experience. Their siblings can also experience ongoing cancer-related psychosocial stress. The composite biomarker allostatic load (AL) describes the cumulative impact of responses to chronic stress on interrelated organ systems and risk for stress-related diseases including cardiovascular disease. AL could be useful as a surrogate response indicator in research and care that aims to improve cardiovascular outcomes of childhood cancer. However, the measurement of AL has requirements to which AYA might not agree or adhere. This study aimed to (a) evaluate the feasibility of studying AL in AYA cancer populations and (b) briefly describe preliminary findings concerning psychological distress, cancer-related stress symptoms, health behavior and AL in AYA survivors and their siblings within the context of a small pilot study. The results support the feasibility of studying AL in AYA survivors and their siblings, and also suggest that further study of AL and risk for cardiovascular disease in both groups is indicated.

Trajectories of Psychological Distress in Adolescent and Young Adult Patients With Cancer: A 1-Year Longitudinal Study

Purpose

To examine prevalence and changes in symptoms of psychological distress over 1 year after initial cancer diagnosis in adolescent and young adult (AYA) patients with cancer. Sociodemographic and clinical predictors of changes in distress were examined.

Patients and Methods

In this multisite, longitudinal, prospective study of an ethnically diverse sample, 215 patients age 14 to 39 years were assessed for psychological distress within the first 4 months of diagnosis and again 6 and 12 months later. Linear mixed models with random intercept and slope estimated changes in distress, as measured by the Brief Symptom Inventory-18 (BSI-18).

Results

Within the first 4 months of diagnosis, 60 respondents (28%) had BSI-18 scores suggesting caseness for distress. On average, distress symptoms exceeded population norms at the time of diagnosis, dipped at the 6-month follow-up, but increased to a level exceeding population norms at the 12-month follow-up. A statistically significant decline in distress over 1 year was observed; however, the gradient of change was not clinically significant. Multivariate analyses revealed that the reduction in distress over time was primarily a function of being off treatment and involved in school or work. Notably, cancer type or severity was not associated with distress.

Conclusion

Findings emphasize the importance of early psychosocial intervention for distress in AYAs as well as the need to manage treatment-related symptoms and facilitate AYAs' involvement in work or school to the extent possible. Continued research is needed to understand how distress relates to quality of life, functional outcomes, treatment, and symptom burden throughout the continuum of care.

Psychometric properties of the Spanish version of the Health-Promoting Lifestyle Profile II

The Health-Promoting Lifestyle Profile II (HPLPII) has been psychometrically validated across several linguistic and cultural groups; however the Spanish version has not been psychometrically tested for the Spanish population. The purpose of this research was to evaluate the reliability and factor structure of the Spanish version of the HPLPII for Spanish people. Principal component analysis (PCA) revealed that a six-component model for 44 items accounted for 40% of the variance, and the scale had an internal consistency of .87. Confirmatory factor analysis demonstrated that a better fit of the six-component structure emerged from the PCA than from the model proposed in the original version of the HPLPII, suggesting that the health-promoting lifestyle might be sensitive to context and culture.

Behavioral and psychosocial program needs of young adult cancer survivors

Behavioral interventions for cancer survivors have historically targeted older adults or young adult survivors of childhood cancer. In this study, 18- to 39-year-olds diagnosed with cancer during young adulthood were interviewed to identify the types of behavioral and psychosocial programs needed. These young adult cancer survivors were also asked to identify potential barriers to program utilization. Participants expressed interest in programs targeting physical activity, relaxation, emotional support, provision of cancer-related and other information, and nutrition/weight loss. Emergent themes included the importance of choice, flexibility, convenience, and similarity to other program participants. Barriers to participation included practical barriers (e.g., limited time), lack of awareness of programs, health issues (e.g., fatigue), and psychosocial barriers (e.g., low motivation). Results highlight a range of unmet psychosocial and behavioral needs among young adult cancer survivors. This information can be used to develop interventions for this population.

The symptom cluster experience profile framework

PURPOSE/OBJECTIVES

To present the novel Symptom Cluster Experience Profile (SCEP) framework for guiding symptom research in adult survivors of childhood cancers and other subgroups at risk for high symptom burden.

DATA SOURCES

Empirically derived model of symptom cluster experience profiles, existing theoretical frameworks, and data-based literature on symptoms and quality of life in adult survivors of childhood cancers.

DATA SYNTHESIS

In a previous study, the authors generated a preliminary model to characterize subgroups of adult survivors of childhood cancers with high-risk symptom cluster profiles. The authors developed the SCEP framework, which depicts symptom cluster experiences as subgroup-specific profiles that are driven by multiple sets of risk and protective factors. The risk and protective factors may directly and indirectly contribute to or alleviate symptoms through their effects on systemic stress. Systemic stress instigates and sustains the symptom experience that, in turn, is expressed through negative diffusion into other components of quality of life, such as functional status, general health perceptions, and overall quality of life.

CONCLUSIONS

The SCEP framework is an initial approach to unbundle the complex heterogeneity that underlies the clustering of symptoms. By measuring a wide range of risk and protective factors in future studies of adult survivors of childhood cancers and other subgroups at risk for high symptom burden, further development and validation of the SCEP framework will occur.

IMPLICATIONS FOR NURSING

The SCEP framework can be used to specify mechanisms underlying symptom cluster profiles and derive interventions targeted to high-risk symptom profiles. Findings from future studies can be translated to risk-based surveillance and symptom management clinical practice guidelines.

Test of a conceptual model of uncertainty in children and adolescents with cancer

Despite recognition as a significant stressor in childhood cancer, illness-related uncertainty from the perspective of children remains under-studied. We tested a conceptual model of uncertainty, derived from Mishel's uncertainty in illness theory, in 68 school-aged children and adolescents with cancer. As hypothesized, uncertainty was significantly related to psychological distress, but only one hypothesized antecedent (parental uncertainty) significantly predicted children's uncertainty. An alternative model incorporating antecedent developmental factors (age and illness-specific expertise) explained 21% of the variance in child uncertainty; controlling for stage of treatment, uncertainty was higher in children with shorter time since diagnosis, older age, lower cancer knowledge, and higher parental uncertainty. These findings provide the foundation for further studies to understand children's management of uncertainty and its contribution to psychological adjustment to illness.

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.

The Legacy of Pediatric Oncology Nursing in Advancing Survivorship Research and Clinical Care

Today, the growing population of cancer survivors, both pediatric and adult, along with the accumulated weight of data characterizing late and lingering effects of cancer and its treatment are attracting attention in the form of reports, conferences, publications and media coverage.The emphasis on survivorship research and outcomes-based clinical care began with pediatric oncology, and pediatric oncology nurses have been at the forefront of survivorship clinical care, research, and education for more than 30 years.This article highlights these contributions to the body of survivorship knowledge and quality of care, as well as areas of ongoing challenge and future directions suggested by thought leaders in our specialty. Key contributions are examined decade by decade and against the six recommendations for health care policy and practice delineated in the two recent IOM survivorship reports: evidence-based guidelines for follow-up care, standards and models of care, increasing awareness of late effects and needed follow-up care, improving professional education and training, improving access to care for survivors, and increasing research to prevent or manage late effects.

Feasibility and Preliminary Outcomes From a Pilot Study of Coping Skills Training for Adolescent—Young Adult Survivors of Childhood Cancer and Their Parents

Uncertainty is a central feature of long-term childhood cancer survivorship during which time it principally has to do with late effects. Therefore, the purposes of this article are (a) to assess feasibility of a randomized clinical trial of a telephone-delivered coping skills training (CST) intervention in terms of recruitment, retention, and timeline, as well as the performance of the study measures; and (b) to demonstrate trends in change on outcomes within the context of a small pilot study. The results of this pilot study suggest that HEROS PLUS CST has clinical relevance and that in-person long-term follow-up plus telephone-delivered psychosocial care is a practical way to deliver integrated care to adolescent—young adult childhood cancer survivors and their parents.

Symptom cluster experience profiles in adult survivors of childhood cancers

Although aggressive medical treatment protocols have led to 80% five-year survival rates for most childhood cancer patients, many long-term survivors experience multiple troubling symptoms. Using data from 100 adult survivors of childhood cancers (ACC-survivors), we used latent variable mixture modeling to generate unique subgroups of survivors based on their experiences with a cluster of eight symptoms: lack of energy, worry, pain, difficulty sleeping, feeling irritable, feeling nervous, difficulty concentrating, and feeling sad (as measured by the Memorial Symptom Assessment Scale). We also examined factors that were likely to predict subgroup membership (chronic health conditions [CHCs], health-promoting lifestyle, and demographic variables) and determined the extent to which satisfaction with quality of life (QoL) varied across the subgroups. The final mixture model included three subgroups of ACC-survivors: high symptoms (HS; n=21), moderate symptoms (MS; n=45), and low symptoms (LS; n=34). ACC-survivors who reported at least one CHC were six times as likely to be classified in the HS subgroup as compared with the LS subgroup. Mean health-promoting lifestyle scores were lowest in the HS subgroup and highest in the LS subgroup. Differences in QoL among the subgroups were statistically significant, thus validating that the subgroups were characterized uniquely for identifying those symptoms with highest life impact. To our knowledge, we are the first to identify distinct subgroups of ACC-survivors differentiated by symptom cluster experience profiles. The findings warrant additional research to confirm the subgroup-specific symptom cluster experience profiles in larger studies of ACC-survivors.

Disease knowledge and treatment adherence among patients with thalassemia major and their mothers in Taiwan

AIMS

The current study had three aims: (i) to examine disease knowledge in both thalassemia major patients and their mothers; (ii) to understand the relationships between disease knowledge and treatment adherence in thalassemia major patients; and (iii) to explore the importance of selected factors in predicting patients' knowledge about thalassemia major.

BACKGROUND

Patients with thalassemia major must be treated with life-long blood transfusions. Evidence suggests that patients with more knowledge/information about their illnesses adhere more readily to treatment schedules. However, there has been little evaluation of knowledge and treatment adherence in thalassemia major patients.

DESIGN AND METHODS

A cross-sectional correlational survey design and purposive sampling were used. Thirty-two thalassemia major patients (mean age 17.5 years) and 32 mothers (mean age 40.5 years) were recruited.

RESULTS

On a scale ranging from 0-20, the average of the patients' disease knowledge about thalassemia major was 15.19 and the average of their mothers' disease knowledge was 16.44. The scores for the patients' disease knowledge about thalassemia major were positively correlated with follow-up visit adherence (r = 0.690, p < 0.001) and with desferrioxamine infusion adherence (r = 0.791, p < 0.001). 95.6% of variance in patients' knowledge was explained by a model that included mothers' knowledge (beta = 0.901, p < 0.001), follow-up visit adherence (beta = 0.084, p = 0.140) and annual household income (beta = 0.042, p < 0.387).

CONCLUSIONS

The positive association between knowledge and treatment adherence and factors of patients' knowledge indicate the need for systematic education for patients and caregivers to improve adherence to treatment.

RELEVANCE TO CLINICAL PRACTICE

Improvement of the quality of patient care, reinforcement of medical education and enhanced efforts by clinical staff to provide practical knowledge to patients with thalassemia major should significantly improve patient adherence to treatment.

Coping with cancer: a Web-based educational program for early and middle adolescents

Educating patients is a primary responsibility of all nurses; however, because of time constraints and staff shortages, pediatric oncology nurses are often unable to adequately prepare patients for cancer treatment. Instead, patients frequently rely on the Internet as a source of information about cancer, some of which can be outdated and inaccurate. Adolescents regard the Internet as a valuable source of health information as it is easily accessible, less threatening, and confidential. Considering the need for accurate, readily available information for adolescents with cancer, the purpose of this study was to develop and validate an innovative, interactive Web-based educational program to prepare early and middle adolescents for cancer treatment. Titled "Coping With Cancer," this program was developed by the investigator after conducting in-depth interviews of adolescent cancer survivors and their parents. Based on the transactional model of coping, the program focuses on enhancing the adolescent's knowledge of cancer, cancer treatment, and healthy coping strategies. Coping With Cancer can be an effective resource for pediatric oncology nurses in providing ongoing education for adolescents with cancer.

Investigating the determinants of health-related quality of life among childhood cancer survivors

AIM

This paper is a report of a study to survey early childhood cancer survivors' perceived health-related quality of life and its determinants and to estimate the reliability of known psychometric scales used in the measurement of these determinants.

BACKGROUND

Young adult survivors of childhood cancer are considered to be a high-risk, vulnerable population for experiencing medical and psychosocial sequelae from their treatment that can adversely affect their health-related quality of life. Achieving an adequate level of health-related quality of life among childhood cancer survivors has been identified as a significant outcome in measuring the success of cancer treatment for these survivors throughout the world.

METHOD

An on-line survey approach was used, and data were collected from December 2005 to May 2006 in the United States of America. Specific determinants measured were physical health status, perceived sense of hopefulness, self-esteem, social support and affect. The internal consistency of the instruments to measure these constructs among early survivors of childhood cancer was evaluated.

FINDINGS

Early survivors of childhood cancer had a lower level of health-related quality of life, perceived self-esteem, physical health status and social support when compared with previously reported findings among samples of adolescents in active treatment for cancer, healthy same-age peers and other samples of childhood cancer survivors.

CONCLUSION

Investigations using web-based approaches to measure determinants of health-related quality of life among young adult survivors of childhood cancer have the potential to include international samples of childhood cancer survivors.

Posttraumatic stress in long-term young adult survivors of childhood cancer: A questionnaire survey

BACKGROUND

Posttraumatic stress is one of many psychological late effects in young adult survivors of childhood cancer and needs to be explored thoroughly.

OBJECTIVE

The purpose of this study was to examine the characteristics and correlates of posttraumatic stress symptoms in a sample of young adult survivors of childhood cancer.

DESIGN

Cross-sectional and correlational descriptive design was used. Data was collected by a mailed survey. The University of California at Los Angeles Post Traumatic Stress Disorder Index (PTSDI) was the measure selected for the evaluation of posttraumatic stress.

SETTING

The study took place in a medical center in the Eastern part of the United States.

PARTICIPANTS

The inclusion criteria for participants were: (a) diagnosis of childhood cancer between birth and 19 years of age; (b) 3 or more years post successful completion of cancer treatment; (c) free of active cancer; (d) at least 19 years of age; and (e) able to read and write English. A total of 51.1% (N=46) of the potentially eligible survivors responded to the survey. The analysis was based on the data from 45 respondents who had a mean age of 27.4 years.

RESULTS

The mean PTSDI score was 15.7 (SD=11.0, range=0-43). Thirteen percent (n=6) of participants had PTSDI scores that exceeded the cutoff point of 32, which is considered indicative of clinically significant posttraumatic stress disorder (PTSD). Participants who lived alone (t=-2.17, p=.035), had no health insurance (t=2.08, p=.044) and did not have a history of bone marrow transplantation (t=4.52, p=.000) reported significantly higher scores on PTSDI than others. The clinically significant PTSD group had a significantly higher rate of living alone than the non-PTSD group (p=.038).

CONCLUSION

Cancer-related posttraumatic stress emerges in childhood cancer survivors in young adulthood. Health care providers should screen childhood cancer survivors for posttraumatic stress so that referrals can be made to provide survivors with further assistance.

Uncertainty in Adolescents and Young Adults With Cancer

PURPOSE/OBJECTIVES

To describe uncertainty in three groups of adolescents and young adults with cancer at specific times in their cancer experience: newly diagnosed, diagnosed one to four years, and diagnosed five or more years.

DESIGN

Descriptive, cross-sectional, comparative.

SETTING

Six pediatric oncology centers in North America.

SAMPLE

193 adolescents and young adult cancer survivors aged 11-22 years, able to read English, with no central nervous system disease.

METHODS

A booklet of questionnaires was completed during a clinic visit or hospitalization. Uncertainty was measured using Mishel's Uncertainty in Illness Scale.

MAIN RESEARCH VARIABLES

Uncertainty and time since diagnosis.

FINDINGS

No significant differences were found in the overall level of uncertainty among the three time-since-diagnosis groups; however, analysis of variance on individual items detected significant group differences for 8 of the 33 items. Newly diagnosed survivors had significantly higher uncertainty for future pain, the unpredictable illness course, staff responsibilities, and concerns about when they would be able to care for themselves. Survivors five or more years from diagnosis had significantly higher uncertainty related to knowing what was wrong, and they had more unanswered questions and higher uncertainty compared to the two other groups about the probability of successful treatment. All of the survivors had high uncertainty about the multiple meanings of communication from doctors.

CONCLUSIONS

The overall level of uncertainty remained unchanged across the survivorship continuum, but differences existed in specific concerns.

IMPLICATIONS FOR NURSING

Uncertainty is important to consider far beyond the treatment period, particularly assessment of information needs and acknowledgment of inherent uncertainty throughout cancer survivorship.