Predicting and modifying substance use in childhood cancer survivors: application of a conceptual model

Modifiable Lifestyle Risk Factors in Adult Survivors of Childhood Cancer: A Nationally Representative Study

OBJECTIVES

Given the vulnerable health condition of adult childhood cancer survivors, it is essential that they develop positive health behaviors to minimize controllable health risks. Therefore, we evaluated if adult survivors of non-childhood cancer and childhood cancer differ in the odds of each modifiable risk factor compared with each other and compared with the general population.

METHODS

This nationally representative study leveraged the National Health Interview Survey (NHIS) sample from 2000 to 2018 and the Behavioral Risk Factor Surveillance System (BRFSS) sample from 2016 to 2021. Our study population included adults diagnosed with cancer when they were ≤14 years of age. Outcomes included physical activity, body mass index (BMI), current smoking, ever-smoking, alcohol use, and binge drinking.

RESULTS

Insufficient physical activity was not statistically significant in the BRFSS, but in the NHIS, childhood cancer survivors had significantly more insufficient physical activity compared with non-childhood cancer survivors (aOR 1.29, P =0.038) and the general population (aOR 1.40, P =0.006). Childhood cancer survivors also had a higher likelihood of being significantly underweight (aOR 1.84, P =0.018) and having ever-smoked (aOR 1.42, P =0.001) compared with the general population in the NHIS. There was a significantly higher likelihood of smoking among childhood cancer survivors in the BRFSS (aOR 2.02, P =0.004).

CONCLUSIONS

The likelihoods of many risky behaviors between adult childhood cancer survivors and general population controls were comparable, although rates of physical activity may be decreased, and rates of smoking may be increased among childhood cancer survivors. Targeted interventions are needed to promote healthy behaviors in this vulnerable population.

Cancer-Related Worry as a Predictor of 5-yr Physical Activity Level in Childhood Cancer Survivors

PURPOSE

Cancer-related worry (CRW; concerns related to cancer and its late effects) is prevalent among childhood cancer survivors. Elevated CRW has been associated with self-reported suboptimal physical activity. The aim of this investigation was to describe associations between CRW and objectively assessed physical activity in childhood cancer survivors.

METHODS

CRW was assessed at a baseline evaluation using six survey items. Weekly minutes of moderate and vigorous physical activity were captured by actigraphy 5.25 (3.8-8.0) yr later. Factor analysis was used to identify types of worry; multiple regression determined independent associations between CRW and moderate and vigorous physical activity adjusting for sex, race, diagnosis, age at baseline, anxiety level at baseline, self-reported physical activity at baseline, and pain interference at baseline.

RESULTS

Participants ( n = 1223) were an average of 30.9 (SD, 6.9) yr at baseline and 36.1 (SD, 7.1) yr at follow-up. Thirty-seven percent were survivors of leukemia, 26% of non-CNS solid tumors, 19% of lymphoma, 11% of CNS tumors, and 6% of other malignancies. Two types of CRW were identified: "body-focused" and "general fear." Body-focused CRW ( β = -19.6, P = 0.012), endorsing pain interference ( β = -27.7, P = 0.002) at baseline, and having a diagnosis of CNS tumor ( β = -41.3, P = 0.0003) or non-CNS solid tumor ( β = -19.4, P = 0.02) were negatively associated with physical activity at follow-up.

CONCLUSIONS

CRW related to bodily function and appearance is associated with decreased physical activity. Clinicians should consider the potential negative impact of CRW on physical activity levels and provide behavioral counseling.

Health behaviors in adolescent survivors of cancer: An integrative review

PROBLEM

Adolescent survivors of cancer face an increased risk of chronic health conditions that can be improved by healthy behaviors. The purpose of this review is to synthesize the extent/prevalence of health behaviors (physical activity [PA], diet, human papillomavirus [HPV] vaccination, alcohol use, smoking, marijuana use, and unprotected sex) compared to age-matched peers and factors associated with those behaviors.

ELIGIBILITY CRITERIA

Four databases (PubMed, EMBASE, PsycINFO, and CINAHL) were searched for peer-reviewed primary studies published since 2000 including adolescents aged 11-20 years-old, who had completed cancer treatments. Studies reporting at least one behavior were included.

SAMPLE

Of 1979 articles reviewed, 27 studies reporting any of the following health behaviors were included: PA, diet, HPV vaccination, alcohol use, smoking, marijuana use, or unprotected sex.

RESULTS

Adolescent survivors of cancer engaged less in health risk behaviors (alcohol use, smoking, marijuana use, and unprotected sex) or health-promoting behaviors (PA, healthy diet, and HPV vaccination) compared to age-matched peers. Their health behaviors were associated with psychosocial factors including emotional discomfort (e.g., feeling depressed or nervous) and influence of others (family, friends, and healthcare providers).

CONCLUSIONS

Although health risk behaviors in adolescent survivors of cancer are not as prevalent as in their peers, the survivors' low engagement in health-promoting behaviors including PA, diet, and HPV vaccination is concerning.

IMPLICATIONS

More research is needed to develop and evaluate interventions to improve health-promoting behaviors in adolescent survivors of cancer by strengthening or facilitating psychosocial resources.

A cross-sectional examination of caregiver mental health and childhood cancer survivors' tobacco, alcohol, and marijuana use

PURPOSE

As childhood cancer survivors (CCS) age, they face numerous long-term consequences, or late effects, from their cancer treatments. Late effects may be mitigated by health-promoting behaviors, including the avoidance of substance use. CCS with greater depression symptomology have reported greater substance use, but whether their habits are associated with the mental health of their caregivers is unknown. The aim of this study was to examine caregiver psychosocial correlates of CCS substance use.

METHODS

This study utilizes data from the Project Forward pilot study, which collected data from 129 CCS-caregiver dyads (CCS mean age = 19.43, SD = 2.78; years since diagnosis = 7.62, SD = 2.06) from two large hospitals in Los Angeles County. CCS provided self-reported information on substance use, while caregivers self-reported on posttraumatic stress symptomatology (PTSS) associated with their child's cancer and current depressive symptoms.

RESULTS

Among CCS, prior 30-day tobacco, marijuana, binge drinking, and polysubstance use were 12.50%, 14.17%, 13.18%, and 12.40%. In multivariable logistic regression models, caregiver PTSS was independently positively associated with CCS tobacco use. No other significant relationships between caregiver mental health (PTSS or depressive symptoms) and CCS substance use were observed.

CONCLUSION

These findings suggest that caregiver PTSS is partially associated with CCS behavioral health. Survivorship care may improve tobacco use prevention efforts by incorporating family or caregiver mental health needs. Future research should examine the potential mediating effect of CCS mental health, including depressive symptoms, on this relationship.

Prevalence and predictors of cancer-related worry and associations with health behaviors in adult survivors of childhood cancer

BACKGROUND

Cancer-related worry (CRW) is common among cancer survivors; however, little is known about factors associated with CRW or its impact on health behaviors in adult survivors of childhood cancer.

METHODS

Survivors in the St. Jude Lifetime Cohort Study (n = 3211; 51% male; mean age, 31.2 years [SD, 8.4 years]; mean time after diagnosis, 22.8 years [SD, 8.3 years]) underwent medical evaluations and completed ratings of CRW, psychological symptoms, and health behaviors. Multivariable modified Poisson regression models examined associations between CRW and treatment exposures, chronic health conditions, psychological symptoms, and health behaviors.

RESULTS

Sixty-four percent of survivors (95% confidence interval [CI], 62.6-65.9) reported worry about subsequent malignancy, 45% (95% CI, 43.5-46.9) reported worry about physical problems related to cancer, and 33% (95% CI, 31.2-34.4) reported worry about relapse. Multiple psychological symptoms, treatment exposures, and chronic conditions significantly increased the risk of CRW. Survivors reporting CRW were at increased risk for substance use, inadequate physical activity, and increased health care utilization after adjustments for chronic conditions. For example, with adjustments for chronic conditions, those who endorsed CRW were more likely to have ≥5 cancer-related physician visits, ≥5 physician visits related to cancer, and ≥5 calls to a physician's office in the previous 2 years in comparison with survivors who were not worried. CRW was also associated with an increased risk of current tobacco use, past marijuana use, and current marijuana use.

CONCLUSIONS

A substantial proportion of adult survivors of childhood cancer reported CRW associated with increased health care utilization. CRW may serve as an intervention target to promote well-being and adaptive health behaviors.

Family and parent-child relationship correlates of pediatric cancer survivors' substance use

OBJECTIVE

The primary aims of this research were to examine substance use among adolescent and young adult survivors of pediatric cancer (AYA survivors) and AYA without a history of chronic or life threatening illness (AYA comparisons) and to explore links between demographic, medical, caregiver-AYA, and family system factors with AYA substance use patterns.

METHODS

Participants included 289 AYA (survivors, n = 171; comparisons = 118; 51% female; M_age = 17.15, SD_age = 2.86) and their caregivers (M_age = 46.54, SD_age = 6.81; 88% mothers). AYA and caregivers completed the family environment scale, and caregivers completed the parenting relationship questionnaire at the initial assessment. Two years later, AYA completed an assessment of substance use. Chi-square and frequency analyses were used to compare differences in substance use among AYA survivors and comparisons. Multivariate analysis of variance was used to examine links between AYA substance use patterns with family and caregiver-AYA system level factors.

RESULTS

Patterns of substance use did not differ between AYA survivors and comparisons. AYA survivors were more likely to report polysubstance use if caregivers endorsed problematic caregiver-AYA relationship patterns. Family functioning and caregiver relationship patterns did not predict AYA comparison substance use.

CONCLUSION

AYA survivors were just as likely as AYA comparisons to engage in substance use, increasing their vulnerability to problematic health outcomes. Findings indicate that the role caregiver-AYA relationship patterns may have on youth at risk for substance use and potential mechanisms for future intervention.

Health Behaviors of Chinese Childhood Cancer Survivors: A Comparison Study with Their Siblings

Purpose: This study aimed to compare health behaviors between the childhood cancer survivors (CCS) and their sibling controls and to examine the pattern of health behaviors of the Hong Kong Chinese CCS and its associations with their health-related quality of life and psychological distress. Methods: A cross-sectional telephone survey was conducted. A total of 614 CCS and 208 sibling controls participated in this study. Patterns of health behaviors including lifestyle behaviors, cancer screening practices, and insurance coverage were compared. Multivariate regression analyses were performed for examining factors associated with health behaviors in CCS. Results: CCS had less alcohol consumption when compared with their sibling controls (adjusted odds ratio (AOR) = 0.65, p = 0.035). The sibling controls were more likely to have cancer screening practices (AOR = 0.38, p = 0.005) and health (AOR = 0.27, p < 0.001) and life insurance coverage (AOR = 0.38, p < 0.001). Among the CCS, those who were male, having a job or higher education, shorter time since diagnosis, and type of cancer suffered were significantly associated with alcohol consumption. Those CCS who were drinkers indicated poorer mental health (p = 0.004) and more psychological distress. Female CCS undertaking cancer screening were more likely to be employed, married/cohabiting, and have received intensive cancer treatment. Conclusion: This study reveals that Chinese childhood cancer survivors are less likely to engage in unhealthy lifestyle behaviors, insurance coverage and cancer screening, when compared with their siblings. Implications for Cancer Survivors: It is crucial for healthcare professionals to identify strategies or target interventions for raising CCS's awareness of their cancer risks and healthy lifestyle throughout their life.

Associations Among Perceived Parent and Peer Support, Self-Esteem, and Cancer-Related Worry in Adolescent and Young Adult Cancer Survivors

Purpose: Cancer-related worry is common among adolescent and young adult (AYA) cancer survivors, and is associated with adverse psychosocial outcomes. Thus, it is crucial to identify possible modifiable covariates of cancer-related worry to aid in developing targeted interventions. This study aimed to explore the cross-sectional associations between cancer-related worry and potential covariates (i.e., perceived parental support, perceived peer support, self-esteem). Methods: One hundred fifty-two survivors between the ages of 15 and 25 who had been diagnosed with cancer between the ages of 14 and 21 completed the Inventory of Parent and Peer Attachment, the Rosenberg Self-Esteem Scale, the Self-Perception Profile for Adolescents, and a measure of cancer-related worry. Relationships among variables were assessed through structural equation modeling. Results: The model showed good fit [χ²(13) = 13.26, p = 0.43; comparative fit index = 0.997; root mean square error of approximation = 0.01 (90% confidence interval = 0.00-0.08); standardized root mean square residual = 0.04]; however, not all associations were in expected directions. Higher perceived parent and peer support were each significantly associated with lower self-esteem, which, in turn, was significantly associated with higher cancer-related worry. There was no direct association between support variables and cancer-related worry. Conclusion: These findings, which contradict existing theory about self-esteem development in healthy AYAs and prior research about the association between support and self-esteem in children and adolescents with cancer, suggest complex, and likely reciprocal, relationships among perceived support, cancer-related worry, and self-esteem in AYA cancer survivors. Support interventions involving peers with cancer and cognitive behavioral interventions targeting parent and peer relationships, self-esteem, and cancer-related worry may be beneficial in fostering AYA cancer survivors' psychosocial development.

Covariates of risky health behaviors in pediatric cancer survivors during adolescence

PURPOSE

Adolescent survivors of pediatric cancers may use alcohol and tobacco (73-90% and 10-29%, respectively) at similar rates as their healthy peers despite known adverse health effects of these substances. This is concerning given that these behaviors can increase the risk for adverse late effects among this population. This study explores the beliefs and behaviors associated with alcohol and tobacco use among adolescent survivors of pediatric cancer.

DESIGN

Cross-sectional study using assessment questionnaires by telephone.

PARTICIPANTS

Adolescent cancer survivors who had been seen at Memorial Sloan Kettering Cancer Center (n = 128).

METHODS

Questionnaires concerned participants' medical history, current health behaviors, attitudes about health behaviors, fear of cancer recurrence, cancer worry, knowledge of risk, and perceived risk of future health problems. Univariate and multiple logistic regression analyses determined the association between psychological covariates with having ever used alcohol and cigarettes.

RESULTS

In multiple logistic regression, higher positive attitude (OR = 3.65; p < 0.001) toward alcohol use and lower knowledge of the risk of binge drinking (OR = 0.38; p < 0.05) were significantly related to alcohol use. Older age (OR = 1.55; p < 0.01), lower knowledge of the risks of smoking (0.41; p < 0.05), and the subjective norm that smoking is desirable to others (OR = 1.90; p < 0.05) were significantly related to cigarette use.

CONCLUSION AND IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

Understanding the uptake of risky health behaviors and factors related to tobacco and alcohol use for adolescent survivors is imperative to promoting lifelong healthy behaviors and potentially reducing future adverse health effects. Despite broadly disseminated public service campaigns and anticipatory guidance of our cancer specialists to inform youth about the adverse effects of alcohol and tobacco use, there remains a gap in adolescent cancer survivors' knowledge of these risks. More effective interventions to increase knowledge of the risks of drinking and smoking are needed to bridge this gap.

Standardised patient encounters to improve quality of counselling for pre-exposure prophylaxis (PrEP) in adolescent girls and young women (AGYW) in Kenya: study protocol of a cluster randomised controlled trial

INTRODUCTION

Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP) demonstration projects observe that AGYW uptake and adherence to PrEP during risk periods is suboptimal. Judgemental interactions with healthcare workers (HCW) and inadequate counselling can be barriers to PrEP use among AGYW. Improving HCW competency and communication to support PrEP delivery to AGYW requires new strategies.

METHODS AND ANALYSIS

PrEP Implementation for Young Women and Adolescents Program-standardised patient (PrIYA-SP) is a cluster randomised trial of a standardised patient actor (SP) training intervention designed to improve HCW adherence to PrEP guidelines and communication skills. We purposively selected 24 clinics offering PrEP services under fully programmatic conditions in Kisumu County, Kenya. At baseline, unannounced SP 'mystery shoppers' present to clinics portraying AGYW in common PrEP scenarios for a cross-sectional assessment of PrEP delivery. Twelve facilities will be randomised to receive a 2-day training intervention, consisting of lectures, role-playing with SPs and group debriefing. Unannounced SPs will repeat the assessment in all 24 sites following the intervention. The primary outcome is quality of PrEP counselling, including adherence to national guidelines and communication skills, scored on a checklist by SPs blinded to intervention assignment. An intention-to-treat (ITT) analysis will evaluate whether the intervention resulted in higher scores within intervention compared with control facilities, adjusted for baseline SP scores and accounting for clustering by facility. We hypothesise that the intervention will improve quality of PrEP counselling compared with standard of care. Results from this study will inform guidelines for PrEP delivery to AGYW in low-resource settings and offer a potentially scalable strategy to improve service delivery for this high-risk group.

ETHICS AND DISSEMINATION

The protocol was approved by institutional review boards at Kenyatta National Hospital and University of Washington. An external advisory committee monitors social harms. Results will be disseminated through peer-reviewed journals and presentations.

TRIAL REGISTRATION NUMBER

NCT03875950.

Patient-reported outcomes in paediatric cancer survivorship: a qualitative study to elicit the content from cancer survivors and caregivers

OBJECTIVES

Content elucidation for patient-reported outcomes (PROs) in paediatric cancer survivorship is understudied. We aimed to compare differences in the contents of five PRO domains that are important to paediatric cancer survivorship through semistructured interviews with paediatric cancer survivors and caregivers, and identified new concepts that were not covered in the item banks of the Patient-Reported Outcomes Measurement Information System (PROMIS).

DESIGN

Semistructured interviews to collect qualitative PRO data from survivors and caregivers.

SETTING

A survivorship care clinic of a comprehensive cancer centre in the USA.

PARTICIPANTS

The study included 51 survivors (<18 years old) and 35 caregivers who completed interviews between August and December 2016. Content experts coded the transcribed interviews into 'meaningful concepts' per PROMIS item concepts and identified new concepts per a consensus. Frequencies of meaningful concepts used by survivors and caregivers were compared by Wilcoxon rank-sum test.

RESULTS

For pain and meaning and purpose, 'Hurt a lot' and 'Purpose in life' were top concepts for survivors and caregivers, respectively. For fatigue and psychological stress, 'Needed to sleep during the day'/'Trouble doing schoolwork' and 'Felt worried' were top concepts for survivors, and 'Felt tired' and 'Felt distress'/'Felt stressed' for caregivers. Survivors reported more physically relevant contents (eg, 'Hard to do sport/exercise'; 0.78 vs 0.23, p=0.007) for pain, fatigue and stress, whereas caregivers used more emotionally relevant concepts (eg, 'Too tired to enjoy things I like to do'; 0.31 vs 0.05, p=0.025). Both groups reported positive thoughts for meaning and purpose (eg, 'Have goals for myself'). One (psychological stress, meaning and purpose) to eleven (fatigue) new concepts were generated.

CONCLUSIONS

Important PRO contents in the form of meaningful concepts raised by survivors and caregivers were different and new concepts emerged. PRO measures are warranted to include survivorship-specific items by accounting for the child's and the caregiver's viewpoints.

The relationship between cancer-related worry and posttraumatic growth in adolescent and young adult cancer survivors

OBJECTIVES

To examine cancer-related worry in adolescent and young adult (AYA) cancer survivors and its relationship with posttraumatic growth over time, as the relationship between these constructs has not been assessed longitudinally in this population.

METHODS

A total of 153 AYA cancer survivors completed measures of cancer-related worry and posttraumatic growth 3 times across approximately 1 year. Descriptive statistics were calculated for cancer-related worry items, and mixed-effects modeling assessed the relationship between cancer-related worry and posttraumatic growth.

RESULTS

Most participants reported at least moderate cancer-related worry in at least 1 area at each assessment (88.2-93.9% across time points). Worry about future health was the most prevalent concern (65.4%-83.7% across time points). Cancer-related worry was positively related to posttraumatic growth in the mixed-effects model. However, post hoc analyses indicated that cancer-related worry and posttraumatic growth were modestly related; there was no evidence that either construct predicted the other over time.

CONCLUSIONS

Cancer-related worry appears to be a common psychosocial outcome in AYA cancer survivors. However, cancer-related worry appears to be only modestly related to the development of posttraumatic growth, implying that these may be independent constructs despite theoretical literature suggesting that posttraumatic growth may stem from posttraumatic distress. Thus, it is necessary to assess AYA survivors for cancer-related worry and posttraumatic growth, and develop interventions to target cancer-related worry and foster posttraumatic growth.

Posttraumatic stress-related psychological functioning in adult survivors of childhood cancer

PURPOSE

The majority of research examining posttraumatic stress symptoms/disorder (PTSS/PTSD) among adult survivors of childhood cancer has been oriented to cancer, assuming that cancer has been the most traumatic experience in their lives. Whether that assumption is valid, and how it might impact assessment of PTSS, is unknown.

METHODS

Survivors in the St. Jude Lifetime Cohort study completed an assessment of PTSS without cancer orientation, global psychological functioning, perceived stress, and cancer-related anxiety.

RESULTS

Participants (n = 2969; M_age = 32.5 ± 8.5 years, 24.1 years since diagnosis, 49.1% female) obtained a mean score on the PTSD Checklist of 27.7, which is comparable to a normative population. Using established cutoffs, 11.8% obtained scores in the at-risk range. Multivariable modeling indicated that psychological factors [global distress (p < 0.0001), perceived stress (p = 0.001), cancer-related anxiety (p < 0.0001)] and demographic variables [female gender (p < 0.0001), survivors with less than a college education (p = 0.002)] were risk factors for increased PTSS. Only 14.5% identified a cancer-related traumatic event, and there was no difference in PTSS scores between those who identified cancer vs. non-cancer events as most stressful (28.4 ± 12.6 vs. 28.5 ± 12.7, p = 0.93).

CONCLUSION

One in eight adult long-term survivors of childhood cancer had PTSS above the cutoff, though subgroups (e.g., females and those with lower education) report more distress symptoms. Most adult survivors do not identify cancer as their most stressful event.

IMPLICATIONS FOR CANCER SURVIVORS

Screening for distress in survivorship clinics should not assume that distress is directly related to the survivor's cancer experience.

Anxiety Among Adolescent Survivors of Pediatric Cancer

PURPOSE

The purpose of this review was to synthesize current knowledge about anxiety among adolescent survivors of pediatric cancer and highlights areas for future research.

METHODS

Systematic literature searches were conducted in five databases for articles published anytime before December 28, 2015. Manuscripts were reviewed by a team of six coders. Included manuscripts reported outcomes relevant to anxiety, worry, and post-traumatic stress in survivors of pediatric cancer (age at the time of study: 10-22 years) who were off treatment.

RESULTS

Twenty-four articles met inclusion criteria. Included results were categorized into the following domains: post-traumatic stress, anxiety, cancer-related worry, and interventions. With the exception of post-traumatic stress, there was little research about anxiety in this population; however, studies generally indicated that adolescent survivors of pediatric cancer are at elevated risk for anxiety, post-traumatic stress symptoms, and cancer-related worry.

CONCLUSIONS

This review provides preliminary evidence that anxiety is a relevant, but understudied, psychosocial outcome for adolescent survivors of pediatric cancer. More research is needed to better understand the presentation of anxiety in this population, its effect on survivors' quality of life, and possible areas for intervention.

The impact of childhood cancer: Perceptions of adult survivors

BACKGROUND

The objective of this study was to describe perceptions and associated risk factors of the impact of cancer on functional outcomes, including social relationships, exercise, finances, and religion, among adult survivors of childhood cancer.

METHODS

Evaluable participants included 3001 adult survivors (mean age, 32.5 years; range, 18.3-63.8 years; 24.1 years from diagnosis; 50.8% male; 84.9% Caucasian) who were enrolled in the St. Jude Lifetime Cohort study. Perceptions of the impact of cancer were assessed using the Brief Cancer Impact Assessment (BCIA). Regression models were used to evaluate risk factors for functional outcomes.

RESULTS

The median response on the BCIA was a perception that cancer had minimal impact on the domains assessed. Approximately 33.1% to 46.6% of survivors indicated this response across the 4 subscales, although responses ranged from very positive to very negative impact. Other than diagnosis (with survivors of brain tumors generally indicating a more negative impact of cancer, with subscale estimates of -1.25 for caregiving and finance and -1.01 for social and emotional and an odds ratio of 1.83 for exercise and diet), most variability was because of demographic factors, including sex, age, race, education, and employment.

CONCLUSIONS

The current findings highlight that many long-term adult survivors perceive minimal impact of childhood cancer on functional aspects of adulthood, including caregiving, finances, exercise, social-emotional relationships, and religion. This suggests that survivors may not be focusing on the influence of likely physical and psychological late effects of their disease in their day-to-day lives. For those who do perceive a negative impact, variability in responses suggests that there are of survivors who may benefit from interventions focused on the achievement of functional goals. Cancer 2017;123:1625-1634. © 2017 American Cancer Society.

Substance Use Risk Behaviors and Decision-Making Skills Among Cancer-Surviving Adolescents

The aims of this study were to compare decision making and substance use risk behaviors of a cohort of cancer-surviving adolescents to those of 2 earlier cohorts as well as adolescents in the US general population and to determine the relationship of decision making to substance use risk behaviors. This correlational study used a semistructured interview at the time of the annual clinic visit to obtain data. Teen cancer survivors (N = 76), ages 14-19 years, were recruited from 5 clinics within the United States. Adherence to quality decision-making skills reported by different cancer-surviving adolescent cohorts appears to remain the same over time. However, reported substance use risk behaviors by these teen survivor cohorts have decreased over time. The prevalence rates for lifetime use for the 2004 cohort of teen cancer survivors were 25%, 49%, and 16%, for cigarettes, alcohol, and marijuana use, respectively. These rates are somewhat lower than those in the US general population; yet, they are high given the health vulnerability of cancer-surviving adolescents. Poor-quality decision making was significantly associated with higher levels of substance use risk behaviors for these teen cancer survivors. In conjunction with the statistics related to higher health risks in this vulnerable group of teens, these findings support continued efforts in developing interventions for risk behavior counseling.

Engagement in High-Risk Behaviors Among Young Adult Survivors of Childhood Cancer Compared to Healthy Same-Age Peers Surveyed in the National Longitudinal Study of Adolescent Health

PURPOSE

This secondary data analysis compared smoking rates, alcohol consumption, and binge drinking, and examined risk factors for engaging in these behaviors among 90 young adult-aged childhood cancer survivors (CSS) with 15,490 young adults in the general population.

METHODS

The sample was drawn from the National Longitudinal Study of Adolescent Health. The sampling distribution of these healthy matched young adults was estimated through the use of bootstrapping, which involved randomly repeated for 10,000 samples of healthy controls.

RESULTS

The findings of repeated sampling analysis revealed that CCS were more likely to smoke daily (34.5% vs. 20.6 healthy matched controls; p = 0.03). The proportion of respondents who had any signs of alcohol abuse symptoms was 72.2% of CCS compared with 81.1% of matched controls (p = 0.16), while CCS with severe alcohol abuse was 51.1% compared with 59.1% of matched controls (p = 0.28). Whether they engaged in binge drinking in the past 12 months was 43.3% for CCS and 46.4% for healthy respondents. Logistic regression analyses were performed to examine predictors of smoking, alcohol use, and binge drinking among CCS. Smoking was very strongly associated with optimism. An optimism score of one unit higher was associated with a 39% reduction in odds of smoking (odd ratio [OR] = 0.61, p < 0.0001). Black CSS were less likely to smoke (OR = 0.15, p < 0.05). CCS in good health were more likely to binge drink (OR = 3.67, p < 0.05).

CONCLUSIONS

Data generated from this secondary data analyses add to the evidence base about the engagement in high risk behaviors among young adult-aged CCS. These findings further emphasize the need for widespread, available effective theory-based screening guidelines and interventions.

Exploratory Analyses of Substance Use in Adolescents With and Without Cancer

PURPOSE

This study explored self-reported substance use and factors associated with use among adolescents with and without cancer.

METHODS

Adolescents (aged 13-19) receiving cancer treatment at a Mid-Atlantic children's hospital (n=103) and healthy peers (n=98) answered questions about substance use (drinking or drug use in past 4 months) and psychosocial variables. Parents completed demographic and family functioning questionnaires.

RESULTS

Healthy adolescents reported more substance use (n=17) than adolescents with cancer (n=8). Associates of substance use in adolescents with cancer included more avoidant and substance use-related coping, less positive affect, worse parent-reported family functioning, and less nausea.

CONCLUSION

Substance use and its health implications in adolescent oncology need enhanced awareness, intervention and prevention efforts, and further research.

Survivor typologies predict medical surveillance participation: the childhood cancer survivor study

BACKGROUND

Adult survivors of childhood cancer adhere poorly to recommended medical surveillance. We sought to identify modifiable factors that contribute to non-adherence.

METHODS

Latent class analysis categorized survivors (ages 18-52 years) at risk of cardiac, breast, or bone late sequelae on the basis of their health-related concerns, fears, and motivation. These classifications were compared at two time points for self-reported adherence to recommended echocardiography, mammography, and bone densitometry screening.

RESULTS

Three classes (worried, collaborative, and self-controlling) characterized survivors in each of the three risk groups: cardiac (N=564; Bayesian information criterion [BIC] =10,824.66; Lo-Mendell-Rubin parametric likelihood ratio test [LRMLRT] P= .002), breast (N=584; BIC=11,779.97; LRMLRT P< .001), and bone (N=613; BIC=11,773.56; LMRLRT P= .028). Only 9% of at-risk survivors in the self-controlling class reported undergoing bone density screening in 2005, compared with 17.2% in the collaborative class (P= .034). Thirteen percent of the self-controlling, 24% of collaborative (P= .025), and 34% of worried (P= .010) classes reported undergoing bone densitometry in 2009. Whereas 73% of at-risk survivors in the worried class reported having had an echocardiogram in 2009, only 57% of the collaborative (P= .040) and 43% of self-controlling (P< .001) classes did. In 2005 and 2009, respectively, fewer survivors in the self-controlling class (37% and 53%) than in the collaborative (51%, P= .038 and 70%, P= .01) and worried (58%, P= .002 and 69%, P= .025) classes reported undergoing mammograms.

CONCLUSIONS

Modifiable intrapersonal characteristics associated with these three classes predict self-reported participation in medical surveillance. Continued observation and validation of these survivor profiles may inform tailored interventions to enhance survivors' screening participation. Copyright © 2012 John Wiley & Sons, Ltd.

Risky health behavior among adolescents in the childhood cancer survivor study cohort

OBJECTIVE

To report the prevalence and comparison of cancer-linked health behaviors and identify risk factors associated with unhealthy behavior among adolescent siblings and cancer survivors.

METHODS

The Child Health and Illness Profile--Adolescent Edition (CHIP--AE) was completed by 307 survivors and 97 sibling controls 14-20 years of age.

RESULTS

Risky behavior ranged from 0.7% to 35.8% for survivors and 1.0% to 41.2% for siblings. Comparisons of sexual behavior, tobacco, alcohol, or illicit drug use utilizing continuous data revealed no differences between groups. Categorically, survivors were less likely to report past smokeless tobacco use or current use of beer/wine or binge drinking (p-values range from .01 to .04). Survivors with better mental health were at lower risk for poor behavioral outcomes.

CONCLUSIONS

Adolescent survivors engage in risky health behaviors at rates generally equivalent to their siblings. Aggressive health education efforts should be directed toward this high-risk population.

Survivor profiles predict health behavior intent: the Childhood Cancer Survivor Study

OBJECTIVES

To determine whether unique groups of adult childhood cancer survivors could be defined on the basis of modifiable cognitive, affective, and motivation indicators. Secondary objectives were to examine to what extent group membership co-varied with more static variables (e.g. demographics, disease, and treatment) and predicted intent for subsequent medical follow-up.

METHODS

Using latent class analysis of data from 978 participants (ages, 18-52 years; mean, 31; and SD, 8) in the Childhood Cancer Survivor Study, we classified survivors according to their worries about health, perceived need for follow-up care, health motivation, and background variables. Intent to participate in medical follow-up, as a function of class membership, was tested using equality of proportions.

RESULTS

The best-fitting model (BIC = 18 540.67, BLMRT = <0.001) was characterized by three distinctive survivor classes (worried, 19%; self-controlling, 26%; and collaborative, 55%) and three significant class covariates (gender, perceptions of health, and severity of late effects). A smaller proportion of survivors in the self-controlling group (81%) than in the worried (90%) (P = 0.015) and collaborative (88%) (P = 0.015) groups intended to obtain a routine medical checkup. A smaller proportion of survivors in the self-controlling group (32%) than in the collaborative (65%) (P = <0.001) and worried (86%) (P = <0.001) groups planned a cancer-related check-up. A smaller proportion of survivors in the collaborative group (65%) than in the worried group (86%) (P = <0.001) were likely to obtain a cancer-related check-up.

CONCLUSIONS

Childhood cancer survivors can be classified according to the modifiable indicators. The classification is distinctive, predicts intent for future medical follow-up, and can inform tailored interventions.

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.

Determinants of Mammography Screening Participation in Adult Childhood Cancer Survivors: Results From the Childhood Cancer Survivor Study

Purpose/Objectives: To identify treatment, intrapersonal, and provider factors that influence childhood cancer survivors' adherence to recommended mammography screening.Design: Secondary analysis of data derived from three consecutive surveys within the Childhood Cancer Survivor Study.Sample: Female childhood cancer survivors: N = 335, X age = 30.92, X years after diagnosis = 21.79.Methods: T tests and structural equation modeling.Main Research Variables: Mammogram recency, health concerns, affect, motivation, and survivor-provider interaction.Findings: Forty-three percent of the variance was explained in mammogram recency. Survivors most likely to follow the recommended mammogram schedule were directly influenced by cancer treatment exposure to mantle radiation (p = 0.01), less intrinsic motivation (p = 0.01), positive affect (p = 0.05), recent visits to an oncology clinic (p = 0.01), discussion of subsequent cancer risks with a physician (p = 0.001), perceptions of more severe late effects (p = 0.05), age (40 years or older) (p Collapse

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Grants

• U24 CA055727 NCI NIH HHS
• R21 CA106972 NCI NIH HHS
• U24 CA055727-13 NCI NIH HHS
• R03 NR009203-02 NINR NIH HHS
• R03 NR009203 NINR NIH HHS

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Affiliation(s)

Cheryl L. Cox Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
Kevin Oeffinger Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
Michele Montgomery Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
Melissa M. Hudson Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
Wendy Leisenring Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
John Whitton
Leslie L. Robison Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee

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Medical screening participation in the childhood cancer survivor study

BACKGROUND

Despite their risk for serious late sequelae, survivors of childhood cancer do not adhere to recommended medical screening guidelines. We identified treatment, survivor, physician, and contextual factors that may influence survivor adherence to recommended echocardiography and bone densitometry screening.

METHODS

Structural equation modeling of data from the Childhood Cancer Survivor Study; 838 participants had received a diagnosis of and were treated for pediatric cancers between 1970 and 1986.

RESULTS

Survivors at risk of cardiac sequelae (n = 316; mean [SD] age, 31.01 [7.40] years; age at diagnosis, 9.88 [5.88] years; and time since diagnosis, 21.14 [4.37] years) who reported more cancer-related visits (P = .01), having discussed heart disease with a physician (P < or = .001), with a sedentary lifestyle (P = .05), and less frequent health fears (P = .05) were most likely to follow the recommended echocardiogram schedule (R(2) = 23%). Survivors at risk of osteoporosis (n = 324; age, 30.20 [7.09] years; age at diagnosis, 9 .01 [5.51]years; and time since diagnosis, 21.20 [4.27] years) who reported more cancer-related visits (P = .05), were followed up at an oncology clinic (P = .01), had discussed osteoporosis with a physician (P < or = .001), and had a lower body mass index (P = .05) were most likely to adhere to the recommended bone density screening guidelines (R(2) = 26%). Symptoms and motivation influenced screening frequency in both models.

CONCLUSIONS

Multiple factors influence survivor adherence to screening recommendations. It is likely that tailored interventions would be more successful in encouraging recommended screening in survivors of childhood cancer than would traditional health education approaches.

Promoting physical activity in childhood cancer survivors: results from the Childhood Cancer Survivor Study

BACKGROUND

Although physical activity may modify the late effects of childhood cancer treatment, from 20% to 52% of adult survivors are sedentary. The authors of this report sought to identify modifiable factors that influence survivors' participation in physical activity.

METHODS

Structural equation modeling of data were derived from the Childhood Cancer Survivors Study of adult survivors (current mean age, 30.98 years; mean years since diagnosis, 23.74; mean age at diagnosis, 9.25 years) who were diagnosed between 1970 and 1986.

RESULTS

Approximately 40% of the variance in male survivors' recent participation versus nonparticipation in physical activity was explained directly and/or indirectly by self-reported health fears (P = .01), perceived primary-care physician (PCP) expertise (P = .01), baseline exercise frequency (P < or = .001), education level (P = .01), self-reported stamina (P = .01), cancer-related pain (P < or = .001), fatigue (P < or = .001), age at diagnosis (P = .01), cancer-related anxiety (P < or = .001), motivation (P = .01), affect (P = .01), and discussion of subsequent cancer risk with the PCP (P < or = .001) (N = 256; chi-square test statistic = 53.38; degrees of freedom [df] = 51; P = .38, Comparative Fit Index [CFI] = 1.000; Tucker Lewis Index [TLI] = 1.000; root mean square of approximation [RMSEA] = 0.014; weighted root mean square residual [WRMR] = 0.76). Thirty-one percent of the variance in women' recent physical activity participation was explained directly and/or indirectly by self-reported stamina (P < or = .001), fatigue (P = .01), baseline exercise frequency (P = .01), cancer-related pain (P < or = .001), cancer-related anxiety (P = .01), recency of visits with PCP (<0.001), quality of interaction with the PCP (P = .01), and motivation (P < or = .001; N = 366; chi-square test statistic = 67.52; df = 55; P = .12; CFI = 0.98; TLI = 0.98; RMSEA = 0.025; WRMR = 0.76).

CONCLUSIONS

Gender-tailored intervention strategies in which providers specifically target motivation, fear, and affect may support physical activity in childhood cancer survivors.

Follow-up care for young adult survivors of cancer: lessons from pediatrics

INTRODUCTION

Recent advances in treatment of childhood cancer have resulted in overall survival rates approaching 75%, but approximately two-thirds experience late-effects related to the disease or treatment. Consequently, recommendations for comprehensive follow-up have been made. As the number of survivors of adult cancers increase, similar concerns about how to provide follow-up and achieve optimal quality of life are being raised. In this paper we propose that management of cancer survivors diagnosed in young adulthood (18-45 years) could benefit from experience gained treating survivors of childhood cancer.

MATERIALS AND METHODS

We reviewed research relating to differences in survival rates and late-effects; current arrangements for follow-up; effectiveness; and problems in organization of follow-up separately for survivors of child and adult cancers.

RESULTS

A number of models of follow-up were identified. Rationale for follow-up included early identification and treatment of second cancer and late-effects, health promotion and screening. Increasing numbers of survivors and range of late-effects were identified as problems in organizing services. A possible solution is risk-stratified follow-up, currently being developed in pediatrics.

CONCLUSIONS

New models of follow-up are needed that take account of financial costs for health services and survivors' concerns about their current and future health. Implications for continuing refinement of treatment protocols must be an integral part of the service.

IMPLICATIONS FOR CANCER SURVIVORS

International standards are needed to ensure all survivors have access to expert follow-up care and can benefit from new information that might lead to earlier treatment of late-effects.

Smoking and binge drinking among Canadian survivors of childhood and adolescent cancers: a comparative, population-based study

BACKGROUND

Objectives of this study were to describe the prevalence of smoking and binge drinking among survivors of childhood and adolescent cancer compared to controls who had never had cancer, and to identify factors associated with these behaviors.

PROCEDURE

Data came from a national, multi-centre, population-based study of survivors of childhood and adolescent cancer (n = 1,263) aged 16 to 37 years and an age and gender matched control group (n = 1,422). Logistic regression analyses were performed to determine the likelihood and predictors of current smoking and binge drinking.

RESULTS

Survivors were less likely to be current smokers (OR(adj) = 0.65, 95% CI = 0.54-0.77) and binge drinkers (OR(adj) = 0.66, 95% CI = 0.55-0.78) than the controls. Still, a substantial proportion of survivors reported smoking (23%) and binge drinking (25%). Survivors' smoking and binge drinking did not vary substantially by the clinical factors assessed. Survivors who received therapy associated with cardiac and/or pulmonary toxicity were as likely to smoke as non-exposed survivors. For both the survivors and controls current smoking and binge drinking were associated with lower education and higher reported stress. Binge drinking was also associated with being male and life dissatisfaction in both groups.

CONCLUSIONS

This study indicates a need to reduce smoking and binge drinking among survivors of childhood and adolescent cancer and to design interventions addressing the underlying reasons for adopting unhealthy behaviors despite their risk for late effects. We identified factors related to smoking and binge drinking among survivors: being male, lower educational attainment, life dissatisfaction and high stress, which should help inform intervention development.

Promoting healthy development among survivors of adolescent cancer

Cancer-surviving adolescents face significant health challenges including both physical and psychological late effects as they transition to young adulthood. A cancer diagnosis during adolescence, a time of social independence and increased personal decision making, can cause significant social and emotional struggles that may impair the ability of the adolescent to make health-promoting decisions and avoid risky behaviors such as substance use. This article reports on the little studied experiences of adolescents who have survived cancer with a focus on developing programs and policies that address their health-promotion needs in both community and survivorship clinics.

Correlates of physical activity in young adult survivors of childhood cancers

PURPOSE/OBJECTIVES

To examine correlates of participation in regular physical activities among young adult survivors of childhood cancers.

DESIGN

Descriptive, correlational.

SETTING

Web-based survey.

SAMPLE

117 well-educated, predominately Caucasian survivors of various types of childhood cancers (-X age = 24 years).

METHODS

Participants completed four rating scales, a stages of change measure, and background questions. Logistic regression and graphical methods were used to examine relationships among physical activity correlates and physical activity.

MAIN RESEARCH VARIABLES

Physical activity stages of change, autonomous motivation, physical activity pros and cons, self-efficacy, and self-reported worries.

FINDINGS

More than 80% of participants reported that they were physically active. Survivors who were autonomously motivated and who perceived fewer cons to being physically active were more likely to report being active than survivors with lower autonomous motivation scores and higher physical activity cons scores. Worries about the present and future moderated the effect of physical activity cons on physical activity. The estimated probabilities of reporting being active for women and men changed as the collective contribution of autonomous motivation, physical activity cons, and worries varied from low to high values.

CONCLUSIONS

Engaging in physical activity willingly and without a sense of pressure (autonomous motivation), perceiving fewer cons to physical activity participation (cognitive appraisal), and worrying about the present and future (affective response) were important correlates of self-reported physical activity beyond the influence of gender.

IMPLICATIONS FOR NURSING

Interventions that promote autonomous motivation, decrease physical activity cons, and address present and future worries may increase physical activity in young adult cancer survivors and may have a greater impact on women than men.

Health behaviours in childhood cancer survivors: a systematic review

AIM

To review (1) prevalence and predictors of risk behaviours especially smoking and (2) values of interventions to reduce risk behaviours in childhood cancer survivors.

METHOD

A systematic search of four databases (OVID Medline (1966 to May week 2, 2006), CINAHL, EMBASE, and Pubmed (US Library of Medicine and National Institute of Health)) for articles published between January 1990 and May 2006.

RESULTS

Twenty-three eligible articles. Incidence of risk behaviours are comparable with, or lower than the general population and controls. Socio-demographic (age, socio-economic status, diagnosis, ethnic group) and psychological variables (perceived vulnerability) predict risk behaviour. Improved knowledge and awareness of vulnerability have been found after interventions, but no changes in health behaviours.

CONCLUSION

This review illustrates an optimistic picture of low participation in substance use amongst survivors, although based mainly on smoking. However, smoking might not be the major problem for survivors and attention must also be directed to other health behaviours including exercise and healthy diet.