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Winning AM, Howard Sharp K, Ferrante AC, Ralph J, Desjardins L, Friedman DL, Young-Saleme TK, Vannatta K, Compas BE, Gerhardt CA. CNS-Directed Cancer Treatment and Child Adjustment: Moderating Effects of Maternal Parenting. J Pediatr Psychol 2022; 47:916-928. [PMID: 35303090 PMCID: PMC9372750 DOI: 10.1093/jpepsy/jsac021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The aim of this study was to examine whether maternal parenting behaviors (i.e., warmth, behavioral/psychological control) moderate the association between central nervous system (CNS)-directed treatment and adjustment among pediatric cancer survivors at 3 years post-diagnosis or relapse. METHODS Three years after their child's cancer diagnosis or relapse, mothers (N = 84) reported on their child's academic and social competence, as well as their internalizing and externalizing problems. Children (N = 84; Mage = 13.21 years, 52.4% male) reported on maternal parenting behaviors. Using medical chart data, children were separated into CNS (i.e., received cranial radiation, intrathecal chemotherapy, and/or neurosurgery; N = 45) or non-CNS-directed treatment (N = 39) groups. Twelve moderation models were tested when examining two-way interactions between CNS treatment group and maternal parenting behaviors. RESULTS Children in the CNS-directed treatment group demonstrated significantly worse academic and social competence. Moderation analyses revealed four significant two-way interactions between CNS treatment group and maternal parenting behaviors when predicting children's adjustment. High levels of maternal behavioral control buffered the negative impact of CNS-directed treatment on children's social competence. In addition, maternal warmth had a contrasting effect, as CNS-directed treatment was associated with worse academic competence at high levels of warmth. Analyses with psychological control revealed that low levels of this parenting style were not protective against internalizing or externalizing problems among those with CNS-directed treatment. CONCLUSIONS Children who receive CNS-directed treatment may benefit from a different pattern of parenting during early cancer survivorship. Findings highlight the importance of considering the broader family context when conceptualizing the impact of illness-related factors on adjustment among pediatric cancer survivors.
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Affiliation(s)
- Adrien M Winning
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, USA
| | - Katianne Howard Sharp
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, USA.,The Ohio State University, USA
| | - Amanda C Ferrante
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, USA
| | - Jessica Ralph
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, USA
| | | | | | | | - Kathryn Vannatta
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, USA.,The Ohio State University, USA
| | | | - Cynthia A Gerhardt
- The Abigail Wexner Research Institute at Nationwide Children's Hospital, USA.,The Ohio State University, USA
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2
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Murphy LK, Heathcote LC, Prussien KV, Rodriguez EM, Hewitt JA, Schwartz LE, Ferrante AC, Gerhardt CA, Vannatta K, Compas BE. Mother-child communication about possible cancer recurrence during childhood cancer survivorship. Psychooncology 2020; 30:536-545. [PMID: 33227159 DOI: 10.1002/pon.5600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/29/2020] [Accepted: 11/18/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Providing opportunities to communicate about possible cancer recurrence may be adaptive for youth in remission, yet parents may experience difficulty guiding discussions related to fears of cancer recurrence (FCR). This study aimed to characterize mother-child discussions about potential cancer recurrence during post-treatment survivorship and to determine predictors of maternal communication. METHODS Families (N = 67) were recruited after the child's initial cancer diagnosis (age 5-17 years) and mothers self-reported their distress (post-traumatic stress symptoms; PTSS). During survivorship 3-5 years later, mothers were video-recorded discussing cancer with their children. Presence and length of discussion about potential cancer recurrence, triggers for FCR, expressed affect, and conversational reciprocity were examined. Hierarchical regressions were used to assess maternal PTSS near the time of cancer diagnosis and child age as predictors of maternal communication. RESULTS Three-quarters of dyads spontaneously discussed risk for or fears about cancer recurrence; mothers initiated the topic more frequently than their children. Dyads discussed internal (bodily symptoms) and external (medical, social) triggers of FCR. Higher maternal PTSS at diagnosis predicted significantly lower levels of maternal positive affect (β = -0.36, p = 0.02) and higher levels of maternal negative affect (β = 0.30, p = 0.04) during discussion of recurrence 3-5 years later. Older child age significantly predicted higher levels of maternal negative affect (β = 0.35, p = 0.02). Higher maternal PTSS at diagnosis predicted shorter discussions about recurrence for younger children (β = 0.27, p = 0.02). CONCLUSIONS Understanding predictors and characteristics of mother-child discussions about recurrence can guide family-based FCR interventions, particularly those promoting communication as a supportive tool. Both maternal PTSS and child age are important to consider when developing these interventions.
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Affiliation(s)
- Lexa K Murphy
- Department of Psychology & Human Development, Vanderbilt University, Nashville, Tennessee, USA
| | - Lauren C Heathcote
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kemar V Prussien
- Department of Psychology & Human Development, Vanderbilt University, Nashville, Tennessee, USA
| | - Erin M Rodriguez
- Department of Psychology, University of Texas at Austin, Austin, Texas, USA
| | - Jackson A Hewitt
- Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura E Schwartz
- Department of Psychology, University of Memphis, Memphis, Tennessee, USA
| | - Amanda C Ferrante
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Cynthia A Gerhardt
- The Research Institute at Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Kathryn Vannatta
- The Research Institute at Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Bruce E Compas
- Department of Psychology & Human Development, Vanderbilt University, Nashville, Tennessee, USA
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Nahata L, Morgan TL, Ferrante AC, Caltabellotta NM, Yeager ND, Rausch JR, O'Brien SH, Quinn GP, Gerhardt CA. Congruence of Reproductive Goals and Fertility-Related Attitudes of Adolescent and Young Adult Males and Their Parents After Cancer Treatment. J Adolesc Young Adult Oncol 2019; 8:335-341. [DOI: 10.1089/jayao.2018.0134] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Leena Nahata
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Division of Endocrinology, Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Taylor L. Morgan
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Amanda C. Ferrante
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Nicole M. Caltabellotta
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Nicholas D. Yeager
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R. Rausch
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sarah H. O'Brien
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
- Division of Hematology/Oncology, Nationwide Children's Hospital, Columbus, Ohio
- Center for Innovation and Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Gwendolyn P. Quinn
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York
| | - Cynthia A. Gerhardt
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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Lehmann V, Ferrante AC, Winning AM, Gerhardt CA. The perceived impact of infertility on romantic relationships and singlehood among adult survivors of childhood cancer. Psychooncology 2019; 28:622-628. [DOI: 10.1002/pon.4999] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 12/04/2018] [Accepted: 01/11/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Vicky Lehmann
- Center for Biobehavioral Health; The Research Institute at Nationwide Children's Hospital; Columbus Ohio USA
- Department of Psychology; St. Jude Children's Research Hospital; Memphis Tennessee USA
| | - Amanda C. Ferrante
- Center for Biobehavioral Health; The Research Institute at Nationwide Children's Hospital; Columbus Ohio USA
| | - Adrien M. Winning
- Psychology Department; Loyola University Chicago; Chicago Illinois USA
| | - Cynthia A. Gerhardt
- Center for Biobehavioral Health; The Research Institute at Nationwide Children's Hospital; Columbus Ohio USA
- Department of Pediatrics; The Ohio State University; Columbus Ohio USA
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5
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Prussien KV, Murphy LK, Gerhardt CA, Vannatta K, Bemis H, Desjardins L, Ferrante AC, Shultz EL, Keim MC, Cole DA, Compas BE. Longitudinal associations among maternal depressive symptoms, child emotional caretaking, and anxious/depressed symptoms in pediatric cancer. J Fam Psychol 2018; 32:1087-1096. [PMID: 30211572 PMCID: PMC6289594 DOI: 10.1037/fam0000463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Research has shown that children experience increased emotional distress when engaging in emotional caretaking of a parent. The current study is the first to examine this process in families in which the source of the stress is the child's illness. Prospective associations were tested among mothers' depressive symptoms near the time of their child's cancer diagnosis, mothers' expressed distress and their child's emotional caretaking during an interaction task, and child anxious/depressed symptoms at 1 year postdiagnosis. Families (N = 78) were recruited from two pediatric hospitals soon after their child's (Ages 5-18) new diagnosis or relapse of cancer. Mothers reported on their own depressive symptoms and their child's anxious/depressed symptoms near the time of diagnosis or recurrence (Time 1) and 1 year later (Time 3). At Time 2 (4 months after Time 1), mother-child dyads completed a video-recorded discussion of their experience with cancer that was coded for observed maternal expressed distress (anxiety, sadness) and observed child emotional caretaking. Maternal expressed distress during the interaction was significantly related to more emotional caretaking behaviors by both boys and girls. Results of a moderated mediation model showed that child emotional caretaking at Time 2 significantly mediated the relation between maternal depressive symptoms at Time 1 and child anxious/depressed symptoms at Time 3 for girls but not for boys. The findings suggest that children's emotional caretaking behaviors contribute to subsequent anxious/depressed symptoms for girls, but not for boys, with cancer. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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Fisher RS, Rausch JR, Ferrante AC, Prussien KV, Olshefski RS, Vannatta KA, Compas BE, Gerhardt CA. Trajectories of health behaviors across early childhood cancer survivorship. Psychooncology 2018; 28:68-75. [PMID: 30402997 DOI: 10.1002/pon.4911] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/27/2018] [Accepted: 10/02/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The majority of childhood cancer survivors develop at least one late effect subsequent to treatment (eg, cardiovascular disease and obesity). Consistent engagement in recommended health behaviors may mitigate some of these conditions. Researchers have identified early survivorship as a teachable moment, yet few studies have examined positive health behaviors during this period. METHODS Families of children with cancer (ages 5-17) were initially recruited following a diagnosis or relapse of cancer. Three years post diagnosis, survivors (n = 82, Mage = 13.3, SD = 3.7) and their mothers (n = 103, Mage = 41.1, SD = 7.6) completed a questionnaire assessing exercise, dietary, and sleep patterns among survivors. A follow-up assessment was conducted 2 years later. Mixed models tested change in health behavior over time. RESULTS At 3- and 5-year post diagnosis, mother and self-report indicated that few survivors engaged in appropriate levels of low-intensity exercise, fruit/vegetable intake, and dairy consumption. However, most survivors engaged in recommended levels of high intensity exercise, fast food restriction, and sleep. Health behaviors remained stable over time, except for mother report of sleep duration, which decreased (b = -0.6, P < 0.001). Brain tumor diagnosis predicted a larger decrease in self-report of sleep duration compared with other diagnoses (P = 0.04). Income predicted fast food intake such that higher income was associated with decreased intake over time, whereas lower income was associated with increased intake (P = 0.04). CONCLUSIONS During early survivorship, several health behaviors fell short of expectations for exercise and diet and did not improve upon reaching 5-year post diagnosis. Providers should evaluate survivors' health behaviors, including sleep, early and often, intervening when necessary.
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Affiliation(s)
- Rachel S Fisher
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R Rausch
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Amanda C Ferrante
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Kemar V Prussien
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee
| | - Randal S Olshefski
- Department of Pediatrics, The Ohio State University, Columbus, Ohio.,Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Kathryn A Vannatta
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio.,Department of Psychology, The Ohio State University, Columbus, Ohio
| | - Bruce E Compas
- Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee
| | - Cynthia A Gerhardt
- Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio.,Department of Psychology, The Ohio State University, Columbus, Ohio
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Ferrante AC, Gerhardt CA, Yeager ND, Rausch JR, Lehmann V, O'Brien S, Quinn GP, Nahata L. Interest in Learning About Fertility Status Among Male Adolescent and Young Adult Survivors of Childhood Cancer. J Adolesc Young Adult Oncol 2018; 8:61-66. [PMID: 30260730 DOI: 10.1089/jayao.2018.0094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE As many as two-thirds of male childhood cancer survivors are at risk for fertility impairment as a consequence of treatment. Despite this, survivorship guidelines lack concrete recommendations as to when fertility status conversations should happen between patients and providers and what should be discussed. Thus, conversations may be inconsistent, or do not occur at all in survivorship. To inform recommendations for fertility-related conversations in survivorship, this pilot study aimed to better understand background (e.g., age, diagnosis and treatment intensity) and psychosocial factors (i.e., perceived barriers and perceived susceptibility) associated with survivor interest in learning about fertility status. METHODS Male survivors (N = 45) 15-25 years of age were recruited within 1-8 years of completing treatment. Survivors completed questionnaires based on the Health Belief Model (HBM) to assess perception of infertility risk and attitudes toward testing. RESULTS Most survivors (n = 31; 69%) reported they were informed of their risk for infertility by a healthcare provider before treatment, but only 31% (n = 14) of the sample banked sperm. Nearly two-thirds of survivors (n = 29; 64%) were interested in learning more about their fertility post-treatment. This interest was significantly correlated with greater perceived susceptibility to infertility by survivors, but it was not associated with other psychosocial or background factors. CONCLUSION Informing survivors of their personal infertility risk may increase interest in pursuing testing. Offering opportunities for fertility testing and family planning alternatives may mitigate potential psychological distress and unplanned pregnancy. While additional research is needed, future survivorship guidelines should encourage regular communication about fertility status and offer fertility testing for male survivors.
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Affiliation(s)
- Amanda C Ferrante
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Cynthia A Gerhardt
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,2 Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Nicholas D Yeager
- 2 Department of Pediatrics, The Ohio State University, Columbus, Ohio.,3 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph R Rausch
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,2 Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Vicky Lehmann
- 4 Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sarah O'Brien
- 2 Department of Pediatrics, The Ohio State University, Columbus, Ohio.,3 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio.,5 Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Gwendolyn P Quinn
- 6 Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York
| | - Leena Nahata
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,2 Department of Pediatrics, The Ohio State University, Columbus, Ohio.,7 Division of Endocrinology, Nationwide Children's Hospital, Columbus, Ohio
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Lehmann V, Keim MC, Ferrante AC, Olshefski RS, Gerhardt CA. Psychosexual development and satisfaction with timing of developmental milestones among adult survivors of childhood cancer. Psychooncology 2018; 27:1944-1949. [DOI: 10.1002/pon.4746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Vicky Lehmann
- Center for Biobehavioral Health; The Research Institute at Nationwide Children's Hospital; Columbus OH USA
- Department of Psychology; St. Jude Children's Research Hospital; Memphis TN USA
| | | | - Amanda C. Ferrante
- Center for Biobehavioral Health; The Research Institute at Nationwide Children's Hospital; Columbus OH USA
| | - Randal S. Olshefski
- Division of Pediatric Hematology/Oncology; Nationwide Children's Hospital; Columbus OH USA
| | - Cynthia A. Gerhardt
- Center for Biobehavioral Health; The Research Institute at Nationwide Children's Hospital; Columbus OH USA
- Department of Pediatrics; The Ohio State University; Columbus OH USA
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Lehmann V, Nahata L, Ferrante AC, Hansen-Moore JA, Yeager ND, Klosky JL, Gerhardt CA. Fertility-Related Perceptions and Impact on Romantic Relationships Among Adult Survivors of Childhood Cancer. J Adolesc Young Adult Oncol 2018; 7:409-414. [PMID: 29466084 DOI: 10.1089/jayao.2017.0121] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To present an overview of fertility-related perceptions and describe the perceived negative/positive impact of (potential) infertility on romantic relationships among childhood cancer survivors. METHODS Male and female long-term childhood cancer survivors (N = 92) aged 22-43 and 7-37 years postdiagnosis, completed an online survey about fertility-related perceptions (i.e., knowledge, beliefs, uncertainty, concern, and attitudes toward testing) and romantic relationships. Potential differences based on sociodemographic/cancer-specific factors were tested. RESULTS Most survivors (82.4%, n = 75) knew about infertility risk due to childhood cancer treatment. Seventy percent (n = 65) reported being told they were personally at risk, but less than one-third believed it (29.2%, n = 19/65). Half of survivors (48.9%, n = 45) never underwent fertility testing and were unaware of their fertility status. Fertility-related uncertainty and concerns were more common among survivors without children and those who desired (additional) children (d's > 0.5). Among survivors without biological children (n = 52), partnered survivors felt more uncertain about their fertility than singles (d = 0.8). Ten survivors (10.9%) reported a negative impact of infertility on romantic relationships, 6 (6.5%) reported a positive impact, and 7 (7.6%) reported both (e.g., pressure on relationship, fights, break-ups, being closer, and open partner communication). CONCLUSIONS Fertility-related perceptions varied among survivors, but the majority never underwent fertility testing. Uncertainty or concerns differed by current circumstances (e.g., wanting children and relationship status). Providers should routinely discuss potential infertility and offer testing throughout survivorship. A negative impact on romantic relationships may seem small, but should be considered for survivors who desire children and may discover they are infertile in the future.
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Affiliation(s)
- Vicky Lehmann
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital , Columbus, Ohio.,2 Department of Psychology, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Leena Nahata
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital , Columbus, Ohio.,3 Department of Pediatrics, The Ohio State University , Columbus, Ohio
| | - Amanda C Ferrante
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital , Columbus, Ohio
| | - Jennifer A Hansen-Moore
- 3 Department of Pediatrics, The Ohio State University , Columbus, Ohio.,4 Division of Pediatric Psychology and Neuropsychology, Nationwide Children's Hospital , Columbus, Ohio
| | - Nicholas D Yeager
- 3 Department of Pediatrics, The Ohio State University , Columbus, Ohio.,5 Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital , Columbus, Ohio
| | - James L Klosky
- 2 Department of Psychology, St. Jude Children's Research Hospital , Memphis, Tennessee
| | - Cynthia A Gerhardt
- 1 Center for Biobehavioral Health, The Research Institute at Nationwide Children's Hospital , Columbus, Ohio.,3 Department of Pediatrics, The Ohio State University , Columbus, Ohio
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