Treatment, behavioral, and psychosocial components of cardiovascular disease risk among survivors of childhood and young adult cancer

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.

Obesity Predisposes Anthracycline-Treated Survivors of Childhood and Adolescent Cancers to Subclinical Cardiac Dysfunction

Anthracyclines are effective chemotherapeutics used in approximately 60% of pediatric cancer cases but have a well-documented risk of cardiotoxicity. Existing cardiotoxicity risk calculators do not include cardiovascular risk factors present at the time of diagnosis. The goal of this study is to leverage the advanced sensitivity of strain echocardiography to identify pre-existing risk factors for early subclinical cardiac dysfunction among anthracycline-exposed pediatric patients. We identified 115 pediatric patients with cancer who were treated with an anthracycline between 2013 and 2019. Peak longitudinal left ventricular strain was retroactively calculated on 495 surveillance echocardiograms via the TOMTEC AutoSTRAIN software. Cox proportional hazards models were employed to identify risk factors for abnormal longitudinal strain (> - 16%) following anthracycline treatment. High anthracycline dose (≥ 250 mg/m2 doxorubicin equivalents) and obesity at the time of diagnosis (BMI > 95th percentile-for-age) were both significant predictors of abnormal strain with hazard ratios of 2.79, 95% CI (1.07-7.25), and 3.85, 95% CI (1.42-10.48), respectively. Among pediatric cancer survivors, patients who are obese at the time of diagnosis are at an increased risk of sub-clinical cardiac dysfunction following anthracycline exposure. Future studies should explore the incidence of symptomatic cardiomyopathy 10-15 years post-treatment among patients with early subclinical cardiac dysfunction.

Health-related quality of life, fatigue and health behaviours in Australian adolescent and young adult cancer survivors

INTRODUCTION

Current knowledge of the long-term health behaviours and well-being of adolescent and yong adult (AYA) cancer survivors is limited. The aim of this study was to evaluate the health behaviours of AYA cancer survivors compared to Australian normative data and describe their health-related quality of life (HR-QoL) and levels of fatigue.

METHOD

A cross-sectional online survey of participants aged 15-25 years at diagnosis and 2-7 years post treatment completion was conducted at a comprehensive cancer centre. Validated questionnaires assessed health behaviours and functioning including current physical activity (PA) levels, diet quality, fatigue (FACIT-F) and HR-QoL (AQoL-6D, Short Form 36v2 [SF-36v2]) were compared to Australian normative data.

RESULTS

Ninety individuals completed the survey (26% response rate) with a mean age of 25.4 years and median time post treatment of 61 months (24-85 months). Compared to normative data, a higher proportion of AYA cancer survivors was consuming the recommended daily serves of fruit and vegetables (16.7% vs. 3.9%, p < .0001), had a lower presence of overweight or obesity (46.7% vs. 57.7%, p = .04) and lower percentage of current smokers (2.2% vs. 16.7%, p < .0001). However, AYA cancer survivors reported increased fatigue (t[df = 596] = -4.1, p < .0001) and reduced HR-QoL compared to normative data (t[df = 533] = 9.2, p < .0001) along with a higher proportion suffering from one or more chronic health conditions (65% vs. 40%, p < .0001).

CONCLUSION

AYA cancer survivors from a single Australian institution, who were on average 5 years post treatment, exhibited better health behaviours compared to Australian normative data, but still below recommended guidelines. However, they continue to experience issues with fatigue and reduced HR-QoL, especially in those not meeting the PA guidelines.

Long-term cardiovascular disease mortality among 160 834 5-year survivors of adolescent and young adult cancer: an American population-based cohort study

AIMS

Our aim was to assess the risk of cardiovascular disease (CVD) mortality in US 5-year survivors of adolescent and young adult (AYA) cancer compared with those of the general population and contemporaneous 5-year survivors of childhood cancer.

METHODS AND RESULTS

A total of 160 834 5-year AYA cancer survivors (aged 15-39 years at diagnosis) were included, representing 2 239 390 person-years of follow-up. Overall, 2910 CVD deaths occurred, which was 1.4-fold [95% confidence interval (CI) 1.3-1.4] that expected in the general population, corresponding to 3.6 (95% CI 3.2-3.9) excess CVD deaths per 10 000 person-years. The highest risk of cardiac mortality was experienced after Hodgkin's lymphoma (HL), and the highest risk of cerebrovascular mortality was observed with central nervous system (CNS) tumours. Even survivors in their 6th and 7th decades of life, the risk of CVD mortality remained markedly higher than that of the matched general population. Competing risk analysis showed that the cumulative mortality of CVD was elevated among AYA cancer survivors compared with childhood cancer survivors during the whole study period.

CONCLUSION

Long-term AYA cancer survivors have a greater risk of CVD mortality than the US general population and childhood cancer survivors. Vulnerable subgroups, especially survivors of HL and CNS tumours, require continued close follow-up care for cardiovascular conditions throughout survivorship.

Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement From the American Heart Association

Cardiovascular disease is a competing cause of death in patients with cancer with early-stage disease. This elevated cardiovascular disease risk is thought to derive from both the direct effects of cancer therapies and the accumulation of risk factors such as hypertension, weight gain, cigarette smoking, and loss of cardiorespiratory fitness. Effective and viable strategies are needed to mitigate cardiovascular disease risk in this population; a multimodal model such as cardiac rehabilitation may be a potential solution. This statement from the American Heart Association provides an overview of the existing knowledge and rationale for the use of cardiac rehabilitation to provide structured exercise and ancillary services to cancer patients and survivors. This document introduces the concept of cardio-oncology rehabilitation, which includes identification of patients with cancer at high risk for cardiac dysfunction and a description of the cardiac rehabilitation infrastructure needed to address the unique exposures and complications related to cancer care. In this statement, we also discuss the need for future research to fully implement a multimodal model of cardiac rehabilitation for patients with cancer and to determine whether reimbursement of these services is clinically warranted.

Does Daily Physical Activity Level Determine the Physical Efficiency of Children After Treatment of Leukemia?

The aim of the study was to assess daily physical activity level and its influence on the physical efficiency of children after the treatment of leukemia. The study was comprised of 34 children (23 boys and 11 girls) after the treatment of acute lymphoblastic leukemia or myeloid leukemia (mean age of 11.29 ± 2.81 years, mean body height of 146.88 ± 16.11 cm, and mean body weight of 43.68 ± 13.93 kg). The mean time since treatment completion was 3.09 ± 1.80 years. The level of physical activity was assessed with the Health Behavior in School-Aged Children questionnaire (HBSC). Physical efficiency was assessed based on the palant ball throw (assessment of strength, coordination, and upper limb speed), the long jump (assessment of jumping ability, speed and coordination) and the 60 m run (assessment of speed). Measurements of motor skills were normalized, classified according to age and sex, and converted into grades. The mean values obtained in the run and the ball throw showed low pass grades in the study group. In the case of the long jump, satisfactory grades were obtained. A correlation of r = 0.512 was found between vigorous physical activity (HBSC 3) and the grade in the run. A correlation of r = −0.437 was observed between the duration of computer use in leisure time (HBSC 6) and the grade in the long jump, whereas correlations of r = −0.482 and −0.485 were noted between the number hours per week spent on games (HBSC 5) and the duration of computer use in leisure time (HBSC 6) and the grade obtained in the ball throw, respectively. In addition, different levels of physical activity and physical efficiency were demonstrated depending on the time elapsed since treatment completion. Supervised programs promoting daily physical activity should include children after the treatment of leukemia. These programs should also be aimed at improving their physical efficiency.

Physical Fitness of School-Age Children after Cancer Treatment

The aim of the study was to assess physical fitness of school-age children after cancer treatment. The study was comprised of one hundred and fifty six children-children after cancer treatment (n = 71, mean age 11.22 ± 3.11 years) vs. healthy children previously untreated for cancer (n = 85, mean age 10.71 ± 1.22 years). Physical fitness was assessed indirectly based on a ball throw (assessment of strength, coordination, and upper limb speed), long jump (assessment of jumping ability, speed, and coordination), and a 60 m run (assessment of speed). The analysis was performed based on the Student's t-test for independent samples and the analysis of variance and the post-hoc least significant difference test (LSD test). Children from the study group threw the ball closer and had shorter long jump performance compared to the control group, i.e., 12.93 [m] vs. 19.79 [m], respectively (p < 0.001) and 2.46 [m] vs. 2.70 [m], respectively (p = 0.02). However, their mean running time was longer, i.e., 13.33 [s] vs. 11.73 [s], respectively (p = 0.01). Division according to sex showed additionally significantly shorter ball throw distance in the study group in both girls (p = 0.001) and boys (p < 0.001), significantly shorter jump length in the group of girls (p = 0.01), and significantly longer running time in the group of boys (p = 0.04). Children treated for cancer are characterized by decreased physical fitness, and motor ability is sex-dependent. Both groups showed decreased strength, coordination, and upper limb speed. Additionally, worse jumping ability was found in girls whereas decreased speed was observed in boys.

Depressive Symptoms and Quality of Life Among Adolescent and Young Adult Cancer Survivors: Impact of Gender and Latino Culture

Ethnic and sex variations in depressive symptoms and quality of life (QOL) among adolescent and young adult (AYA) childhood cancer survivors were explored among a sample of Latino and non-Latino childhood cancer survivors (CCSs) (n = 194) treated at hospitals in Los Angeles County. Latinos scored higher in depressive symptoms and lower in QOL when compared with non-Latinos. Males had higher depressive symptoms. Among Latinos, higher levels of acculturation were associated with depression and a poorer QOL, and we found that more acculturated Latino males were more likely to have meaningful levels of depression than less acculturated males or females. Interventions addressing depressive symptoms may be most needed for Hispanic male CCSs.

Cardiovascular disease incidence in adolescent and young adult cancer survivors: a retrospective cohort study

PURPOSE

Few population-based studies have focused on cardiovascular disease (CVD) risk in adolescent and young adult (AYA; 15-39 years) cancer survivors and none have considered whether CVD risk differs by sociodemographic factors.

METHODS

Analyses focused on 79,176 AYA patients diagnosed with 14 first primary cancers in 1996-2012 and surviving > 2 years after diagnosis with follow-up through 2014. Data were obtained from the California Cancer Registry and State hospital discharge data. CVD included coronary artery disease, heart failure, and stroke. The cumulative incidence of developing CVD accounted for the competing risk of death. Multivariable Cox proportional hazards regression evaluated factors associated with CVD and the impact of CVD on mortality.

RESULTS

Overall, 2249 (2.8%) patients developed CVD. Survivors of central nervous system cancer (7.3%), acute lymphoid leukemia (6.9%), acute myeloid leukemia (6.8%), and non-Hodgkin lymphoma (4.1%) had the highest 10-year CVD incidence. In multivariable models, African-Americans (hazard ratio (HR) = 1.55, 95% confidence interval (CI) = 1.33-1.81; versus non-Hispanic Whites), those with public/no health insurance (HR = 1.78, 95% CI = 1.61-1.96; versus private) and those who resided in lower socioeconomic status neighborhoods had a higher CVD risk. These sociodemographic differences in CVD incidence were apparent across most cancer sites. The risk of death was increased by eightfold or higher among AYAs who developed CVD.

CONCLUSION

While cancer therapies are known to increase the risk of CVD, this study additionally shows that CVD risk varies by sociodemographic factors.

IMPLICATIONS FOR CANCER SURVIVORS

The identification and mitigation of CVD risk factors in these subgroups may improve long-term patient outcomes.

Racial Differences in 20-Year Cardiovascular Mortality Risk Among Childhood and Young Adult Cancer Survivors

PURPOSE

Whether cardiovascular disease (CVD) risk differs according to race and cancer type among survivors of childhood or young adulthood cancers is unknown.

METHODS

Data from the years 1973-2011 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) registries. Cases were categorized by ICD-0-3/WHO 2008 Adolescent and Young Adult classification. CVD death was determined by ICD-10 codes for diseases of the heart, atherosclerosis, cerebrovascular diseases, or other diseases of the arteries. Cox proportional hazards models were fitted to evaluate the hazard ratio (HR) and 95% confidence intervals (CIs) for the effects of race on time-to-event outcomes.

RESULTS

A total of 164,316 cases of childhood and young adult primary cancers were identified. There were 43,335 total and 1466 CVD deaths among Black and White survivors. Black survivors had higher risks of all-cause mortality (HR: 1.75, 95% CI: 1.70-1.7) and CVD mortality (HR: 2.13, 95% CI: 1.85-2.46) compared to White survivors. The increased risk of CVD for Black survivors compared to White survivors persisted at 5-years (HR: 2.38, 95% CI: 1.83-3.10), 10-years (HR: 2.59, 95% CI: 2.09-3.21), and 20-years (HR: 2.31, 95% CI: 1.95-2.74) postdiagnosis, and varied by cancer type, with the highest HRs for melanoma (HR: 8.16, 95% CI: 1.99-33.45) and thyroid cancer (HR: 3.43, 95% CI: 1.75-6.73).

CONCLUSIONS

Black survivors of childhood or young adulthood cancers have a higher risk of CVD mortality compared to Whites that varies by cancer type. Knowledge of at-risk populations is important to guide surveillance recommendations and behavioral interventions. Further study is needed to understand the etiology of racial differences in CVD mortality in this population.

Juvenile competitive triathlete after cardiotoxic anthracycline therapy for Acute Myeloid Leukemia

OBJECTIVE

The treatment of Acute Myeloid Leukemia (AML) leads to several functional limitations. Especially cardiac burden following cardiotoxic chemotherapy, which limits exercise and competitive sport in the long-term survivors.

SUBJECT AND METHODS

We report on a young female amateur triathlete born in 1997, who was diagnosed with AML at the age of fifteen. She had chemotherapy with a cumulative dose of about 1000 mg/m² anthracyclines and allogeneic stem cell transplantation which was successful, but she suffered from cardiotoxic systolic heart failure with a left ventricular ejection fraction (LVEF) <55 % and an impaired peak oxygen uptake of 23.2 ml/min/kg and 53 % of predicted, respectively. After medical examination and counselling with a sport scientist she started a tailored training of aerobic exercise. She was evaluated at regular intervals which resulted in increasing the training load and volume. Eventually her training hours was stepwise increased to 12 h training per week, which includes high intensity intervals.

RESULTS

Within almost 3 years, her exercise performance improved tremendously. Workload doubled from 2.1 W/kg to 4.2 W/kg, peak oxygen uptake increased from 23.2 ml/min/kg to 49.1 ml/min/kg and from 53 to 135 %, respectively. Moreover, she participated in several competitions. However, LVEF remains almost unchanged.

CONCLUSION

With the right training and under medical surveillance competitive exercise with an anthracycline-damaged heart is still achievable. Moreover, competitive training and exercise seems to be safe and feasible.

Care Transitions in Childhood Cancer Survivorship: Providers' Perspectives

PURPOSE

Most adolescent and young adult (AYA)-aged childhood cancer survivors develop physical and/or psychosocial sequelae; however, many do not receive long-term follow-up (LTF) critical for screening, prevention, and treatment of late effects. To develop a health services research agenda to optimize care models, we conducted qualitative research with LTF providers examining existing models, and successes and challenges in maintaining survivors' connections to care across their transition to adulthood.

METHODS

We interviewed 20 LTF experts (MDs, RNs, social workers, education specialists, psychologists) from 10 Children's Oncology Group-affiliated institutions, and analyzed data using grounded theory and content analysis techniques.

RESULTS

Participants described the complexity of survivors' healthcare transitions. Survivors had pressing educational needs in multiple domains, and imparting the need for prevention was challenging. Multidisciplinary LTF teams focused on prevention and self-management. Care and decisions about transfer were individualized based on survivors' health risks, developmental issues, and family contexts. An interplay of provider and institutional factors, some of which were potentially modifiable, also influenced how transitions were managed. Interviewees rarely collaborated with community primary care providers to comanage patients. Communication systems and collective norms about sharing care limited comanagement capacity. Interviewees described staffing practices, policies, and informal initiatives they found reduced attrition.

CONCLUSIONS

Results suggest that survivors will benefit from care models that better connect patients, survivorship experts, and community providers for uninterrupted LTF across transitions. We propose research priorities, framing attrition from LTF as a public health concern, transition as the central challenge in LTF, and transition readiness as a multilevel concept.