Surviving a childhood cancer: impact on education and employment

Burden of Childhood Cancer and the Social and Economic Challenges in Adulthood: A Systematic Review and Meta-Analysis

Importance

Significant advancements in pediatric oncology have led to a continuously growing population of survivors. Although extensive research is being conducted on the short-, medium-, and long-term somatic effects, reports on psychosocial reintegration are often conflicting; therefore, there is an urgent need to synthesize the evidence to obtain the clearest understanding and the most comprehensive answer.

Objective

To provide a comprehensive review and analysis of the socioeconomic attainment of childhood cancer survivors (CCSs) compared with their unaffected peers.

Data Sources

A systematic review and meta-analysis was conducted using data obtained from a comprehensive search of MEDLINE (via PubMed), Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) databases on October 23, 2021; the search was updated until July 31, 2023.

Study Selection

Eligible articles reported on educational attainment, employment, family formation, quality of life (QoL), or health-risk behavior-related outcomes of CCSs, and compared them with their unaffected peers. Study selection was performed in duplicate by 4 blinded independent coauthors.

Data Extraction and Synthesis

Data extraction was performed in duplicate by 4 independent authors following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome measures were odds ratios (ORs) and mean differences with 95% CIs; data were pooled using a random-effects model.

Results

The search identified 43 913 articles, 280 of which were eligible for analysis, reporting data on a total of 389 502 survivors. CCSs were less likely to complete higher levels of education (OR, 0.69; 95% CI, 0.40-1.18), had higher odds of health-related unemployment (OR, 2.94; 95% CI, 1.90-4.57), and showed lower rates of marriage (OR, 0.72; 95% CI, 0.63-0.84) and parenthood (OR, 0.60; 95% CI, 0.49-0.74) compared with population-based controls.

Conclusion and Relevance

Study findings suggest that CCSs face several socioeconomic difficulties; as a result, the next goal of pediatric oncology should be to minimize adverse effects, as well as to provide lifelong survivorship support aimed at maximizing social reintegration.

Employment among Childhood Cancer Survivors: A Systematic Review and Meta-Analysis

To date, there are heterogeneous studies related to childhood cancer survivors’ (CCS) employment rates. Given the importance of this topic, we aimed to perform a systematic review and meta-analysis to investigate the prevalence of employment among CCS and to examine its association with socio-demographic and clinical factors. We followed the PRISMA guidelines to search for pertinent articles in relevant electronic databases. Eighty-nine articles comprising 93 cohorts were included. The overall prevalence of employment was 66% (CI: 95% 0.63–0.69). Subgroup meta-analyses showed that lower rates were found for central nervous system tumor survivors (51%, CI: 95% 0.43–0.59), and for CCS treated with cranial-radiotherapy (53%, CI: 95% 0.42–0.64) or haematopoietic stem-cell transplantation (56%, CI: 95% 0.46–0.65). The studies conducted in Asia highlighted employment rates of 47% (CI: 95%, 0.34–0.60). Univariate meta-regressions identified the following socio-demographic factors associated with higher rates of employment: a female gender (p = 0.046), a higher mean age at the time of investigation (p = 0.00), a longer time since diagnosis (p = 0.00), a higher educational level (p = 0.03), and a married status (p = 0.00). In conclusion, this systematic review and meta-analysis provides evidence that two-thirds of CCS are employed worldwide. Identifying vulnerable groups of CCS may allow for the design of multidisciplinary support strategies and interventions to promote employment in this population.

Addressing Schooling in Children With Cancer-It's Everybody's Job, So It's Nobody's Job: An Explanatory Mixed-Methods Evaluation

Background: Neurocognitive deficits from childhood cancer treatment are common, long-standing, and negatively impact multiple domains of life leading to challenges with schooling and education. The purpose of this study is to describe caregiver-reported experiences of neurocognitive effects from therapy and to understand the roles clinicians play in this domain in the United States. Methods: An explanatory mixed-methods study of 174 caregivers of children with cancer provided insight into how clinicians provided information on neurocognitive effects of treatment and their experiences with school-related resources. Clinicians provided descriptions of how they provide this information and assist families with accessing services or transition back to school after therapy. Results: Caregivers identified that physicians, nurses, and social workers primarily provide information regarding neurocognitive effects of treatment. Over half (55.9%) of families seek additional information elsewhere and 49.4% report doing so because the information they received from their team was inadequate. Nearly 40% of caregivers report accessing school supports feels like a constant fight and over 40% were not offered homebound educational services by their school. Qualitative interviews with providers found that clinicians focus on therapy-related physical symptoms of treatment and only discuss neurocognitive effects when prompted by families or when children are returning to school. Discussion: Clinicians' focus on physical symptoms and just-in-time thinking when it comes to providing education or school-related services may explain why families endorse infrequent education on the topic and challenges with school reintegration. Improved education for clinicians on this topic, integration of interdisciplinary teams, and new clinical practice models may improve the family experience.

Recommendations for the surveillance of education and employment outcomes in survivors of childhood, adolescent, and young adult cancer: A report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Educational achievement and employment outcomes are critical indicators of quality of life in survivors of childhood, adolescent, and young adult (CAYA) cancer. This review is aimed at providing an evidence-based clinical practice guideline (CPG) with internationally harmonized recommendations for the surveillance of education and employment outcomes in survivors of CAYA cancer diagnosed before the age of 30 years. The CPG was developed by a multidisciplinary panel under the umbrella of the International Late Effects of Childhood Cancer Guideline Harmonization Group. After evaluating concordances and discordances of 4 existing CPGs, the authors performed a systematic literature search through February 2021. They screened articles for eligibility, assessed quality, and extracted and summarized the data from included articles. The authors formulated recommendations based on the evidence and clinical judgment. There were 3930 articles identified, and 83 of them, originating from 17 countries, were included. On a group level, survivors were more likely to have lower educational achievement and more likely to be unemployed than comparisons. Key risk factors for poor outcomes included receiving a primary diagnosis of a central nervous system tumor and experiencing late effects. The authors recommend that health care providers be aware of the risk of educational and employment problems, implement regular surveillance, and refer survivors to specialists if problems are identified. In conclusion, this review presents a harmonized CPG that aims to facilitate evidence-based care, positively influence education and employment outcomes, and ultimately minimize the burden of disease and treatment-related late adverse effects for survivors of CAYA cancers. LAY SUMMARY: A multidisciplinary panel has developed guidelines for the surveillance of education and employment outcomes among survivors of childhood, adolescent, and young adult cancer. On the basis of evidence showing that survivors are at risk for lower educational achievement and unemployment, it is recommended that all survivors receive regular screening for educational and employment outcomes.

Sickness absence and disability pension trajectories in childhood cancer survivors and references- a Swedish prospective cohort study

Background

Childhood cancer survivors are at high risk of chronic health conditions. We aimed to explore future long-term sickness absence and disability pension in young adult childhood cancer survivors and matched references.

Methods

We performed a prospective cohort study using microdata from five Swedish nationwide registers. Among all individuals born 1976–1998 and living in Sweden, we included 3632 childhood cancer survivors and 17,468 matched references that could be followed-up for 15, 10, or 5 years, respectively. A group-based trajectory model was applied to identify trajectories of mean annual sickness absence and/or disability pension days (SADP) in each sub-cohort, with 95% confidence intervals (CI). Potential risk factors for trajectory belonging were explored using χ² test and multinomial logistic regression.

Results

Most young adult childhood cancer survivors (90.2–96.5%) and references (97.4–98.8%) followed a No SADP trajectory. A larger proportion of childhood cancer survivors than references followed a Moderate (33–102 days/year) or High (115–260 days/year) SADP trajectory (15-year follow-up cohorts: Moderate 4.6% versus 1.2%; High 5.1% versus 1.5%). Childhood cancer survivors of central nervous system (CNS) tumors were at higher risk of the High SADP trajectory than childhood cancer survivors of hematological or non-CNS solid tumors (hematological versus CNS: odds ratio = 2.30, 95% CI 1.23–4.30; hematological versus non-CNS: odds ratio = 0.32, 95% CI 0.13–0.79).

Conclusions

Although most young adult childhood cancer survivors had no SADP during follow-up, 9.7% experienced moderate or high numbers of SADP days/year throughout the 15-year follow-up; compared to 2.7% among references. CNS tumor survivors were at particular risk of SADP long-term and need extra attention in their future work prospect.

Educational Attainment and Employment Outcome of Survivors of Pediatric CNS Tumors in Switzerland-A Report from the Swiss Childhood Cancer Survivor Study

Background: Childhood cancer survivors diagnosed with a central nervous system (CNS) tumor are at risk for educational and vocational challenges. This study compared educational attainment and employment outcome in survivors of CNS tumors to survivors of other malignancies. Methods: The questionnaire-based Swiss Childhood Cancer Survivor Study (SCCSS) included cancer patients diagnosed between 1976 and 2010, aged ≤20 years, who survived ≥5 years after diagnosis. We classified participants aged ≥16 years into three groups: CNS tumor and non-CNS malignancy with and without CNS-directed treatment. We analyzed educational attainment, employment outcome and special schooling. Subgroup analyses included survivors aged ≥25 years. Results: We analyzed 2154 survivors, including 329 (15%) CNS tumor survivors, 850 (40%) non-CNS tumor survivors with and 975 (45%) without CNS-directed treatment. Fewer CNS tumor survivors aged ≥25 years reached tertiary education (44%) compared to those without CNS-directed treatment (51%) but performed similar to survivors with CNS-directed treatment (42%). Among CNS tumor survivors, 36 (14%) received special schooling. Higher parental education was associated with higher levels in survivors. Employment outcome did not significantly differ between the three diagnostic groups. A higher proportion of CNS tumor survivors received disability pension or were unemployed. Conclusions: Our findings suggest that CNS tumor survivors need more time to achieve their highest educational level. This should influence clinical care of these survivors by offering vocational counseling.

Age-stratified distress thermometers with Worry and Learning problem domains for the paediatric oncology population: Development and validation

BACKGROUND

The long-term psychological/neuro-psychological sequalae for a minority of survivors of childhood cancer are considerable. This project aims to develop and validate a psychosocial and memory/learning distress thermometer (DT) for paediatric/young adult cancer patients.

METHODS

Pilot/Development Age-appropriate versions of the DT were developed. A pilot study tested acceptability, usability, and design.

VALIDATION

Seven collaborating paediatric-oncology centres with 549 participants validated the DT against Strengths and difficulties questionnaire (SDQ) and Hospital Anxiety and depression scale (HADS) for psychological issues, Utilities Index Mark 2 (HUI2) for memory/learning issues, PedsQL and SF-8 measured quality of life.

RESULTS

Using a cut-off of four, sensitivity against SDQ for under 18 was 75.8%, 18plus against HADS was 94.1%. The specificity was 53.3% against the SDQ for the 18plus specificity against the HADS was 47.1%. The sensitivity against the HUI2 for all age groups was 89.0% specificity was 70.3%.

CONCLUSION

The DT is a valid and reliable measure screening instrument. It can be used to identify early on those experiencing psychological distress and memory problems.

[Consequences of childhood cancer in the quest for first job in the Grand Ouest inter-region: A mixed-method study designed from the Grand Ouest Cancer de l'Enfant (GOCE) organization in childhood cancer survivors and professionals]

INTRODUCTION

The professional situation of patients treated for childhood cancer differs from country to country. The aim of the study is to study, with the French sociocultural specificities, the first professional integration of these young people.

METHODS

A sequential quantitative-qualitative mixed approach associates 16 individual interviews and responses to a self-questionnaire of 254 young cancer survivors (sex-ratio=1, median age 23.5 years diagnosed between 2000 and 2010; 68% leukemia) to 30 individual and collective interviews of professionals. Results They seem to have had fewer difficulties than the general population to find their first job (33% vs. 44%). Young women had more difficulties, young people thought they had stopped studying too early and those who mentioned their sequelae (mainly psychological and neurocognitive). The qualitative phase shows that, in this context, the information provided during the job interview plays an important role in access to the first job.

DISCUSSION

The study showed a need for information, communication and training for all actors whose main axes could be: i) for young people: learn to introduce themselves and adapt speeches and postures, be aware of their non-obligation to reveal a situation relating to health and to the handicap; ii) for the medical profession: to promote communication and to find spaces for exchanges between specialists, generalists, occupational physicians; iii) for employers: better know the disease and the laws to adapt their eyes and practices.

Maintaining Schooling for Children With Cancer During and Post Treatment: Parents' Perspectives of a Theory-Based Program

This study explored parents' perceptions of a hospital-based schooling intervention for children with cancer. A qualitative design using semi-structured interviews was employed. Participants were nine parents whose children had participated in the program. Parents participated in semi-structured interviews, which were transcribed verbatim and analysed thematically. Five major themes were identified: experiences with program components, the bigger picture of the program, communication, a burden of responsibility for parents, and perceived impacts of cancer on schooling. Results showed that the parents valued the focus upon schooling and viewed several aspects as being beneficial. Challenges for parents included a lack of communication and individualized planning, and a burden of responsibility. Findings suggest that schooling is important to families and should be a fundamental psychosocial consideration of service providers. The schooling-related needs of parents should also be addressed.

A systematic review of the educational experiences and needs of children with cancer returning to school

AIMS

To critically review and synthesize empirical studies on childhood cancer survivors' experiences and needs on returning to school after treatment.

DESIGN

A mixed-method systematic review.

DATA SOURCES

A search of CINAHL, PsycINFO, EMBASE, MEDLINE, ERIC and Web of Science was conducted for studies published in English, Spanish and Portuguese languages between January 2010 and May 2020.

REVIEW METHODS

Twenty-one studies were eligible for inclusion (13 qualitative studies, 6 quantitative and 2 mixed-method studies). The quality of the studies was assessed using the Critical Appraisal Skills Programme and the Mixed Methods Appraisal Tool. Findings were synthesized using data-based convergent synthesis design.

RESULTS

Findings were synthesized under four themes: academic continuity and school re-entry; physical and psychological well-being; school life and participation and stakeholders' responses to childhood cancer. Findings indicated that prolonged/recurring absences, physical and mental changes, personal/health factors impacted children's social participation, peer relationships and school re-integration. Factors which contributed to a more positive experience included maintaining contact with peers and teachers throughout treatment, peer relationships, understanding and support from school community. Sharing information about cancer was an ongoing challenging issue for children, that needed to be handled sensitively.

CONCLUSION

It is evident that re-entry to school was very challenging for most children due to treatment side effects, prolonged absences, disrupted peer relationships, lack of preparation and lack of communication between schools, families and healthcare professionals.

IMPACT

Despite the growing number of childhood cancer survivors worldwide, there is a deficit of studies about children's re-entry experiences and educational needs. This review illustrates the considerable challenges that children face on school re-entry and the critical importance of better care, support and collaboration from healthcare professionals, parents and school personnel. Nurses could help by raising awareness and leading on preparation for school re-entry.

Summer sun-exposure in Australian childhood cancer survivors and community reference groups

PURPOSE

Sun-exposure can cause health problems, including melanoma and nonmelanoma skin cancer, especially in Australia where the incidence of skin cancer is particularly high. Childhood cancer survivors (CCSs) have an augmented risk due to previous cancer history and treatment. Despite recommendations advising sun protection, CCSs may be placing themselves at risk. We considered daily summer sun-exposure in an Australian cohort of CCSs and in community reference groups, and identified factors associated with sun-exposure in these populations.

METHODS

Summer sun-exposure data were collected on 471 CCSs (119 parents of survivors aged <16, and 352 survivors aged ≥16) and a reference group of 470 participants from the community (155 parents of children aged <16, and 355 adults aged ≥16). Survivors completed paper questionnaires and the reference groups completed an online survey. Medical records confirmed survivors' clinical information. Ordinal logistic regressions identified factors associated with daily summer sun-exposure.

RESULTS

More daily summer sun-exposure was reported by both parents reporting for the young survivors (U = 5,522.5, P < .001; U = 31,412, P < .001) and by older survivors (U = 5,039.5, P < .001; U = 29,913, P < .001). Among younger participants greater sun-exposure was associated with being a CCS, while in older participants, greater sun-exposure was associated with being a CCS, a male, smoker/ex-smoker and was also increased in those with more sensitive skin reaction to sunlight. Focusing only on the CCSs, when treatments were considered, none statistically predicted sun-exposure in young CCSs while older CCSs who received radiotherapy were less likely to spend excess time in the sun.

CONCLUSION

CCSs have sun-exposure at times of day when sun-related skin damage is highest, despite advice to avoid highest risk times. This data can inform sun-protection programs and lifestyle advice aimed at ameliorating the potential increased risk of skin cancer in CCSs.

Understanding survivors' needs and outcomes: the role of routinely collected data

PURPOSE OF REVIEW

The number of cancer survivors is growing due to population ageing, earlier detection and more effective therapies. Routinely collected data (RCD), generally cancer registry data, has been used to investigate survivors' needs and outcomes. We reviewed uses of RCD since 2017, identifying novel findings and research directions.

RECENT FINDINGS

Survival is improving internationally but continues to vary between subgroups. Longitudinal survivor surveys suggest malignancy-specific temporal patterns in unmet needs and health-related quality-of-life (HRQoL). Unmet needs are a risk factor for future depression and depression predicts poorer HRQoL in all domains. Emerging evidence suggests links between posttraumatic stress and poor HRQoL and posttraumatic growth and improved HRQoL. Evidence for a link between cancer-related financial hardship and poor HRQoL is accumulating. Surveys and linkage studies continue to show poorer work outcomes in survivors. Among survivors of childhood and young adult cancers, large linkage studies demonstrate significant risk of late effects, including hospitalization, pregnancy and labour complications, and cardiac death.

SUMMARY

RCD plays a significant role in understanding survivors' needs and outcomes. New approaches which overlay different types of data - including detailed clinical and treatment data, biomarker data and nonhealth administrative data - have the potential to generate considerable new knowledge.

Social Inequalities Along the Childhood Cancer Continuum: An Overview of Evidence and a Conceptual Framework to Identify Underlying Mechanisms and Pathways

Inequalities in health according to social conditions are regarded as unnecessary and unjust. There is a large body of evidence on inequalities in adult cancer, observable throughout the societies on a national level as well as on a global scale. Socioeconomic influences on health matter at all ages including childhood, for which childhood cancer is the leading cause of disease related death in high-income countries (HICs). Substantial differences in the reported incidence of childhood cancers have been observed globally by socioeconomic development of a population. This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, and for cancer in infants (below 1 year), compared to low- and middle-income countries (LMICs). Considerable inequalities between populations and degree of socioeconomic development are also noted for survival from childhood cancer, with substantially lower survival rates seen in most LMICs compared to HICs. With respect to inequalities by socioeconomic position (SEP) within countries, findings of an association between SEP and childhood cancer risk are diverse and limited to studies from HICs. On the contrary, observations on social inequalities in survival within countries are accumulating and indicate that survival inequalities do not only concern resource-poor countries but also high-income populations including European countries. In turn, a childhood cancer diagnosis in itself may have implications on the parents' socioeconomic situation as well as on the later socioeconomic life after having survived the disease. The underlying mechanisms and causal pathways of these empirically demonstrated social inequalities are poorly understood, although it is of significant public health relevance for any actions or strategies to reduce childhood cancer-related inequity. We propose a conceptual framework on potential underlying mechanism and pathways specifically addressing social inequalities in childhood cancer and after childhood cancer to (i) illustrate potential pathways by which social determinants may create health inequities at different points of the childhood cancer continuum; (ii) illustrate potential pathways by which a childhood cancer diagnosis may impact the socioeconomic situation of the concerned family or the later life of a childhood survivor; and (iii) point out how major determinants may relate to each other.

Surviving childhood cancer: a systematic review of studies on risk and determinants of adverse socioeconomic outcomes

Substantial improvements in childhood cancer survival have resulted in a steadily increasing population of childhood cancer survivors. Whereas somatic late effects have been assessed in many studies, less is known about the impact of childhood cancer on socioeconomic outcomes in survivors. The aim of this article was to evaluate and summarise the evidence on the socioeconomic conditions of childhood cancer survivors and to identify survivors at particular risk of adverse socioeconomic outcomes. An extensive literature search of three electronic databases was conducted. Of 419 articles identified, 52 met the inclusion criteria. All the selected articles were appraised for quality, and findings were summarised in a narrative synthesis. Childhood cancer survivors were at higher risk of adverse socioeconomic outcomes with regard to educational achievement, income and social security benefits than the general population or a sibling comparison group. The risks for unemployment and a lower occupational position were significantly increased only for survivors of a central nervous system tumour. Notably, survivors of central nervous system tumours, survivors treated with cranial radiotherapy and those diagnosed at younger age independent of cancer type were determinants of particular adverse socioeconomic outcomes. Given the increasing population of childhood cancer survivors, targeted follow-up interventions and support strategies addressing not only the somatic and psychiatric late effects but also the socioeconomic difficulties that some childhood cancer survivors face is of high importance to reduce social inequity, and ensure a high quality of life after childhood cancer.

Unemployment Following Childhood Cancer

BACKGROUND

Childhood cancer survivors are at risk of physical and mental long-term sequelae that may interfere with their employment situation in adulthood. We updated a systematic review from 2006 and assessed unemployment in adult childhood cancer survivors compared to the general population, and its predictors.

METHODS

Systematic literature searches for articles published between February 2006 and August 2016 were performed in CINAHL, EMBASE, PubMed, PsycINFO, and SocINDEX. We extracted unemployment rates in studies with and without population controls (controlled /uncontrolled studies). Unemployment in controlled studies was evaluated using a meta-analytic approach.

RESULTS

We included 56 studies, of which 27 were controlled studies. Approximately one in six survivors was unemployed. The overall meta-analysis of controlled studies showed that survivors were more likely to be unemployed than controls (Odds Ratio [OR] = 1.48, 95% confidence interval [CI]: [1.14; 1.93]). Elevated odds were found in survivors in the US and Canada (OR = 1.86, 95% CI: [1.26; 2.75]), as well as in Europe (OR = 1.39, 95% CI: [0.97; 1.97]). Survivors of brain tumors in particular were more likely to be unemployed (OR = 4.62, 95% CI: [2.56; 8.31]). Narrative synthesis across all included studies revealed younger age at study and diagnosis, female sex, radiotherapy, and physical late effects as further predictors of unemployment.

CONCLUSION

Childhood cancer survivors are at considerable risk of unemployment in adulthood. They may benefit from psycho-social care services along the cancer trajectory to support labor market integration.