Neurologic morbidity and quality of life in survivors of childhood acute lymphoblastic leukemia: a prospective cross-sectional study

Purpose

Childhood acute lymphoblastic leukemia (ALL) is treated with potentially neurotoxic drugs and neurologic complications in long-term survivors are inadequately studied. This study investigated neurologic morbidity and its effect on quality of life in long-term survivors of childhood ALL.

Methods

Prospective, single institution, cross-sectional, institutional review board-approved study of long-term ALL survivors. Participants were recruited from institutional clinics. Participants answered an investigator-administered questionnaire followed by evaluation by a neurologist. Quality of life (QOL) was also assessed.

Results

Of the 162 participants recruited over a 3-year period, 83.3 % reported at least one neurologic symptom of interest, 16.7 % had single symptom, 11.1 % had two symptoms, and 55.6 % had three or more symptoms. Symptoms were mild and disability was low in the majority of participants with neurologic symptoms. Median age at ALL diagnosis was 3.9 years (0.4–18.6), median age at study enrollment was 15.7 years (6.9–28.9), and median time from completion of ALL therapy was 7.4 years (1.9–20.3). On multivariable analyses, female sex correlated with presence of dizziness, urinary incontinence, constipation, and neuropathy; use of?≥10 doses of triple intrathecal chemotherapy correlated with urinary incontinence, back pain, and neuropathy; cranial radiation with ataxia; history of ALL relapse with fatigue; and CNS leukemia at diagnosis with seizures. Decline in mental QOL was associated with migraine and tension type headaches, while physical QOL was impaired by presence of dizziness and falls. Overall, good QOL and physical function was maintained by a majority of participants.

Conclusions

Neurologic symptoms were present in 83 % long-term ALL survivors. Symptoms related morbidity and QOL impairment is low in majority of survivors. Female sex, ≥10 doses of intrathecal chemotherapy, and history of ALL relapse predispose to impaired QOL.

Implications for Cancer Survivors

This study will educate survivors and their care providers regarding cancer or treatment-related neurologic symptoms and morbidity. This study will help them understand factors contributing to impaired QOL when present.     

Family physician preferences and knowledge gaps regarding the care of adolescent and young adult survivors of childhood cancer

Purpose

Childhood cancer survivors are at risk for long-term morbidity and early mortality. Since most adult and some adolescent survivors of childhood cancer will receive their long-term care from a primary care physician, we sought to determine family physicians’ comfort with caring for this population.

Methods

A survey was mailed to 2,520 United States (US) and Canadian family physicians to assess their attitudes and knowledge regarding the care of adolescent and young adult survivors of childhood cancer.

Results

One thousand one hundred twenty-four family physicians responded (704 US, 420 Canadian). Median age was 53 years; 63 % were men; 81 % had cared for ≤2 childhood cancer survivors in the past 5 years. Of those who had cared for a survivor, 48 % had never or almost never received a treatment summary from the referring cancer center; 85 % preferred to care for survivors in consultation with a cancer center-based physician or long-term follow-up program. Only 33, 27, and 23 % of respondents were very comfortable caring for survivors of childhood Hodgkin lymphoma, acute lymphoblastic leukemia or osteosarcoma, respectively. Only 16, 10, and 74 % of respondents correctly identified the guideline recommended surveillance for secondary breast cancer, cardiac dysfunction and hypothyroidism in response to a vignette describing a Hodgkin lymphoma survivor. Respondents rated access to clinical care guidelines and receipt of a patient-specific letter from specialists with surveillance recommendations as the modalities most likely to assist them in caring for survivors.

Conclusions

Most family physicians are willing to care for childhood cancer survivors in consultation with a cancer center, and with specific tools to facilitate this care.

Implications for Cancer Survivors

Adult and adolescent survivors of childhood cancer who receive their follow-up care from a family physician must be empowered to choose a physician who is comfortable with caring for survivors. Further, the survivor must ensure that their physician has access to a treatment summary as well as to patient-specific recommendations for surveillance for late effects of cancer therapy.     

Spättoxizität und Survivorship bei Keimzelltumoren

Context

Germ cell tumors and Hodgkin’s lymphoma are currently the malignant diseases with the highest cure rates. Even in advanced or metastasized disease stages these neoplasms can be cured by multimodal treatment approaches. Nevertheless, the curative treatment modalities applied, e.g. intensive systemic chemotherapy, radiotherapy and surgery, have side effects directly during the course of treatment and even delayed toxicity can occur, which may affect the health and quality of life of cancer survivors. This is why prevention and early detection as well as adequate treatment of toxic side effects affecting medical and psychosocial aspects are essential to maintain or improve patient quality of life.

Material and methods

Research of literature and analysis of clinical trials.

Results

Not only chronic dysfunction of many organ systems (e.g. cardiovascular risk) but also secondary cancer, infertility and the fear of relapse are common reasons for a variety of psychosocial problems which can prevent cancer survivors from living a normal daily life after curative treatment.

Conclusion

Survivorship programs offer these patients the opportunity of dynamic support adapted to their needs on the way to patients becoming long-term survivors.     

Incidental detection of late subsequent intracranial neoplasms with magnetic resonance imaging among adult survivors of childhood cancer

Purpose

Survivors of childhood cancer are at an increased risk of developing subsequent neoplasms. In long-term survivors of childhood malignancies treated with and without cranial radiation therapy (CRT), undergoing unenhanced magnetic resonance imaging (MRI) of the brain, we estimated detection of intracranial neoplasms.

Methods

To investigate neurocognitive outcomes, 219 survivors of childhood cancer underwent unenhanced screening MRI of the brain. Of the survivors, 164 had been treated for acute lymphoblastic leukemia (ALL) (125 received CRT) and 55 for Hodgkin lymphoma (HL) (none received CRT). MRI examinations were reviewed and systematically coded by a single neuroradiologist. Demographic and treatment characteristics were compared for survivors with and without subsequent neoplasms.

Results

Nineteen of the 219 survivors (8.7 %) had a total of 31 subsequent intracranial neoplasms identified by neuroimaging at a median time of 25 years (range 12–46 years) from diagnosis. All neoplasms occurred after CRT, except for a single vestibular schwannoma within the cervical radiation field in a HL survivor. The prevalence of subsequent neoplasms after CRT exposure was 14.4 % (18 of 125). By noncontrast MRI, intracranial neoplasms were most suggestive of meningiomas. Most patients presented with no specific, localizing neurological complaints. In addition to the schwannoma, six tumors were resected based on results of MRI screening, all of which were meningiomas on histologic review.

Conclusion

Unenhanced brain MRI of long-term survivors of childhood cancer detected a substantial number of intracranial neoplasms. Screening for early detection of intracranial neoplasms among aging survivors of childhood cancer who received CRT should be evaluated.

Implications for Cancer Survivors

The high prevalence of incidentally detected subsequent intracranial neoplasms after CRT in long-term survivors of childhood cancer and the minimal symptoms reported by those with intracranial tumors in our study indicate that brain MRI screening of long-term survivors who received CRT may be warranted. Prospective studies of such screening are needed.     

Factors related to decision making and substance use in adolescent survivors of childhood cancer: a presenting clinical profile

Background

Adolescent survivors of childhood cancer are more vulnerable to the consequences of health risk behaviors because of the late effects of their disease and its treatment. Decision making related to risk behaviors is important as they have reached an age during which initiation of substance use risk behavior is common.

Objective

Factors associated with decision making and substance use behaviors (smoking, alcohol use, and illicit drug use) were identified among adolescent survivors of childhood cancer, the role of cognitive function was examined, and their rates of substance use behaviors were compared to a sample from the general population.

Methods

A cohort of 243 adolescent survivors, ages 14–19 years, participated who were recruited from three cancer centers (St. Jude Children’s Research Hospital, Hackensack University, and Long Beach Medical Center). A cross-sectional survey was used to assess cognitive and psychosocial factors for a presenting clinical profile to predict quality decision making and substance use behaviors. Validated measures using online data entry were obtained at the time of their annual visit for evaluation of late effects of treatment. Cancer and treatment factors were abstracted from the medical record. Eight factors (nine for substance use risk behavior) were examined in two regression models, quality decision making and substance use.

Results

In the model to predict poor-quality decision making for this cohort, gender and risk motivation (a surrogate for resiliency to social influence) were each significant predictors, with male gender and less resiliency each associated with poor decision making. Significant predictors of lifetime substance use were older presenting age, lower resiliency to social influence, poorer abstract ability (representing executive function impairment), history of current school problems, and negative substance use risk behavior modeling by household members and closest friend; CNS-associated late effects were only marginally associated. For current substance use, three factors remained significant in this cohort: older presenting age, lower resiliency, and negative risk behavior modeling.

Implications for Cancer Survivors

Study results characterize a presenting clinical profile for adolescent survivors with poor-quality decision making regarding substance use risk behaviors that will be helpful to health professionals counseling teen survivors about the impact of risk behaviors on disease-and treatment-related late effects.     

Health-related behavior change after cancer: results of the American Cancer Society’s studies of cancer survivors (SCS)

Introduction

Cancer survivors are known to make positive health-related behavior changes after cancer, but less is known about negative behavior changes and correlates of behavior change. The present study was undertaken to examine positive and negative behavior changes after cancer and to identify medical, demographic, and psychosocial correlates of changes.

Methods

We analyzed data from a cross-sectional survey of 7,903 cancer survivors at 3, 6, and 11 years after diagnosis.

Results

Of 15 behaviors assessed, survivors reported 4 positive and 1 or 0 negative behavior changes. Positive change correlated with younger age, greater education, breast cancer, longer time since diagnosis, comorbidities, vitality, fear of recurrence, and spiritual well-being, while negative change correlated with younger age, being non-Hispanic African American, being widowed, divorced or separated, and lower physical and emotional health. Faith mediated the relationship between race/ethnicity and positive change.

Conclusions

Cancer survivors were more likely to make positive than negative behavior changes after cancer. Demographic, medical, and psychosocial variables were associated with both types of changes.

Implications for cancer survivors

Results provide direction for behavior interventions and illustrate the importance of looking beyond medical and demographic variables to understand the motivators and barriers to positive behavior change after cancer.     

Health behaviors,quality of life,and psychosocial health among survivors of adolescent and young adult cancers

Purpose

Survivors of adolescent and young adult (AYA) cancer may engage in unhealthy lifestyles (e.g., smoking), potentially heightening their risk for long-term health problems. We assessed health behaviors and constructs including quality of life (QOL) and psychosocial well-being among survivors of AYA cancer compared to the general population.

Methods

We used 2009 Behavioral Risk Factor Surveillance System data to evaluate health behaviors for survivors of AYA cancer compared to AYAs without cancer. Multivariable regressions assessed health behaviors (smoking, binge drinking, physical inactivity, and low fruit/vegetable intake) by sex and age between AYA survivors and controls, and among survivors to determine the effects of demographic, QOL, psychosocial, and cancer factors on behaviors.

Results

A greater proportion of female survivors of AYA cancer smoked than controls (currently aged 20–39: 27 vs. 14.3%, respectively; currently aged 40–64: 29.3 vs. 18.4%, respectively). Generally, survivors and controls were non-adherent to national health behavior guidelines. Uninsured survivors were at greater risk of smoking vs. insured (females, Relative Risk (RR)?=?1.64, 95 % confidence interval (CI) 1.43–1.90; males, RR?=?2.62, 95 % CI 1.71–4.02). Poor social/emotional support was associated with smoking (RR?=?1.26, 95 % CI 1.07–1.48) among female survivors and was associated with low fruit/vegetable intake among male (RR?=?1.12, 95 % CI 1.01–1.23) and female (RR?=?1.12, 95 % CI 1.05–1.19) survivors. Female survivors >10 years from diagnosis had higher risk of smoking (RR?=?1.26–1.91, all p?<?0.01) than survivors 5–10 years from diagnosis.

Conclusions

Unhealthy lifestyle behaviors are common in survivors of AYA cancer.

Implications for Cancer Survivors

AYA survivors require health behavior support.

     

Evaluation of traditional and novel measures of cardiac function to detect anthracycline-induced cardiotoxicity in survivors of childhood cancer

Purpose

Cardiovascular disease is the leading noncancer cause of death among survivors of childhood cancer. Ejection fraction (EF) and fractional shortening (FS) are common echocardiographic measures of cardiac function, but newer imaging modalities may provide additional information about preclinical disease. This study aimed to evaluate these modalities in detection of anthracycline-induced cardiac toxicity.

Methods

We compared mean radial displacement, EF, and FS among 17 adult survivors of childhood cancer exposed to ≥ 300 mg/m² of anthracyclines to 17 age- and sex-matched healthy controls. Survivors with a history of cardiac-directed radiation, diabetes, or heart disease were excluded.

Results

Survivors (35 % male), mostly with history of treatment for a solid tumor, had a median age at diagnosis of 15 years (1–20) and 27 years (18–50) at evaluation. Median anthracycline exposure was 440 (range 300–645) mg/m². FS (35.5 vs. 39.6 %, p?<?0.01) and radial displacement (5.6 vs. 6.7 mm, p?=?0.02) were significantly lower in survivors compared to controls, respectively. Although the mean EF was lower in survivors versus controls (55.4 vs. 59.7 %), it was not statistically significant (p?=?0.057). All echocardiographic measures were inversely associated with anthracycline dose, though radial displacement was no longer significantly correlated with anthracycline dose after controlling for survival time (p?=?0.07), while EF remained correlated (p?=?0.003).

Implications for Cancer Survivors

Radial displacement, EF, and FS are lower in childhood cancer survivors compared to controls. In this study, radial displacement added no new information beyond the traditional measures, but clinical utility remains undetermined and requires further longitudinal study.     

The EKZ/AMC childhood cancer survivor cohort: methodology, clinical characteristics, and data availability

Purpose

Childhood cancer survivors are at high risk of late adverse effects of cancer treatment, but there are still many gaps in evidence about these late effects. We described the methodology, clinical characteristics, data availability, and outcomes of our cohort study of childhood cancer survivors.

Methods

The Emma Children’s Hospital/Academic Medical Center (EKZ/AMC) childhood cancer survivor cohort is an ongoing single-center cohort study of ≥5-year childhood cancer survivors, which started in 1996 simultaneously with regular structured medical outcome assessments at our outpatient clinic.

Results

From 1966 to 2003, 3,183 eligible children received primary cancer treatment in the EKZ/AMC, of which 1,822 (57.2 %) survived ≥5 years since diagnosis. Follow-up time ranged from 5.0 to 42.5 years (median, 17.7). Baseline primary cancer treatment characteristics were complete for 1,781 (97.7 %) survivors, and 1,452 (79.7 %) survivors visited our outpatient clinic. Baseline characteristics of survivors who visited the clinic did not differ from those without follow-up. Within our cohort, 54 studies have been conducted studying a wide range of late treatment-related effects.

Conclusions

The EKZ/AMC childhood cancer survivor cohort provides a strong structure for ongoing research on the late effects of childhood cancer treatment and will continuously contribute in reducing evidence gaps concerning risks and risk groups within this vulnerable population.

Implications for Cancer Survivors

Our large cohort study of childhood cancer survivors with complete baseline characteristics and unique, long-term medical follow-up decreases gaps in evidence about specific risks of late effects and high-risk groups, with the ultimate goal of improving the quality of care for childhood cancer survivors.     

Trajectories of social isolation in adult survivors of childhood cancer

Purpose

Long-term childhood cancer survivors may be at increased risk for poor social outcomes as a result of their cancer treatment, as well as physical and psychological health problems. Yet, important challenges, namely social isolation, are not well understood. Moreover, survivors' perspectives of social isolation as well as the ways in which this might evolve through young adulthood have yet to be investigated. The purpose of this research was to describe the trajectories of social isolation experienced by adult survivors of a childhood cancer.

Methods

Data from 30 in-depth interviews with survivors (9 to 38 years after diagnosis, currently 22 to 43 years of age, 60 % women) were analyzed using qualitative, constant comparative methods.

Results

Experiences of social isolation evolved over time as survivors grew through childhood, adolescence and young adulthood. Eleven survivors never experienced social isolation after their cancer treatment, nor to the present day. Social isolation among 19 survivors followed one of three trajectories; (1) diminishing social isolation: it got somewhat better, (2) persistent social isolation: it never got better or (3) delayed social isolation: it hit me later on.

Conclusions

Knowledge of when social isolation begins and how it evolves over time for different survivors is an important consideration for the development of interventions that prevent or mitigate this challenge.

Implications for Cancer Survivors

Assessing and addressing social outcomes, including isolation, might promote comprehensive long-term follow-up care for childhood cancer survivors.     

Adolescent behavior and adult health status in childhood cancer survivors

Introduction

This study examined the longitudinal association between adolescent psychological problems following cancer treatment and obesity, limited exercise, smoking, and excess sun exposure during adulthood in the Childhood Cancer Survivor Study cohort.

Methods

Participants included 1,652 adolescent survivors of childhood cancer and 406 siblings of cancer survivors, initially evaluated at 12–17 years of age and ≥ 5 years post-diagnosis. A follow-up survey of these participants was conducted roughly 7 years later and included assessment of health status and health behaviors. Logistic regression models were used to assess the association between adolescent psychological problems and adult health behavior outcomes.

Results

During adolescence, survivors demonstrated higher rates of attention deficits, emotional problems, externalizing behavior and social withdrawal compared to sibling controls. Social withdrawal was associated with adult obesity (OR?=?1.5, 95% CI?=?1.1–2.1) and physical inactivity (OR?=?1.7, 1.1–2.5). Use of stimulant medication during adolescence was also associated with adult obesity (OR?=?1.9, 1.1–3.2), while antidepressant use was associated with physical inactivity (OR?=?3.2, 1.2–8.2).

Discussion/Conclusions

Adolescent survivors of childhood cancer display higher rates of psychological problems compared to siblings of cancer survivors. These psychological problems are associated with an increased risk for obesity and poor heath behavior in adulthood, which may increase future risk for chronic health conditions and secondary neoplasms.

Implications

In order to decrease risk of future health problems, adolescent survivors of childhood cancer should be routinely screened and treated for psychological problems following cancer therapy.     

Investigating efficacy of two brief mind–body intervention programs for managing sleep disturbance in cancer survivors: a pilot randomized controlled trial

Purpose

After completing treatment, cancer survivors may suffer from a multitude of physical and mental health impairments, resulting in compromised quality of life. This exploratory study investigated whether two mind–body interventions, i.e., Mind–Body Bridging (MBB) and Mindfulness Meditation (MM), could improve posttreatment cancer survivors’ self-reported sleep disturbance and comorbid symptoms, as compared to sleep hygiene education (SHE) as an active control.

Methods

This randomized controlled trial examined 57 cancer survivors with clinically significant self-reported sleep disturbance, randomly assigned to receive MBB, MM, or SHE. All interventions were conducted in three sessions, once per week. Patient-reported outcomes were assessed via the Medical Outcomes Study Sleep Scale and other indicators of psychosocial functioning relevant to quality of life, stress, depression, mindfulness, self-compassion, and well-being.

Results

Mixed effects model analysis revealed that mean sleep disturbance symptoms in the MBB (p?=?.0029) and MM (p?=?.0499) groups were lower than in the SHE group, indicating that both mind–body interventions improved sleep. In addition, compared with the SHE group, the MBB group showed reductions in self-reported depression symptoms (p?=?.040) and improvements in overall levels of mindfulness (p?=?.018), self-compassion (p?=?.028), and well-being (p?=?.019) at postintervention.

Conclusions

This study provides preliminary evidence that brief sleep-focused MBB and MM are promising interventions for sleep disturbance in cancer survivors. Integrating MBB or MM into posttreatment supportive plans should enhance care of cancer survivors with sleep disturbance. Because MBB produced additional secondary benefits, MBB may serve as a promising multipurpose intervention for posttreatment cancer survivors suffering from sleep disturbance and other comorbid symptoms.

Implications for Cancer Survivors

Two brief sleep-focused mind–body interventions investigated in the study were effective in reducing sleep disturbance and one of them further improved other psychosocial aspects of the cancer survivors’ life. Management of sleep problems in survivors is a high priority issue that demands more attention in cancer survivorship.     

Ovarian cancer survivors’ quality of life: a systematic review

Purpose

The assessment of quality of life (QOL) among ovarian cancer (OC) patients has mainly focused on the acute phase of treatment. This systematic review examines studies measuring QOL in patients who survived OC after treatment and synthesizes results in order to assess QOL and patient-reported outcome (PRO) data at long-term follow-up.

Methods

Articles published in English between 1990 to November 2014 were identified with the databases MEDLINE and PubMed, using the specific keywords “OC survivors” combined with the terms, “QOL,” “health-related QOL,” and “PROs.” Data were reviewed for design, time since end of treatment, measurement tools, and outcomes (categorized in three topics: global QOL compared to controls, treatment sequelae, and intervention strategies).

Results

The initial search strategy provided 148 articles of which 31 were considered eligible. Most studies focused on epithelial OC, and only a few studies investigated survivors of ovarian germ cell tumor. More than 60 instruments of QOL measures were used in the corpus. Despite the persistence of psychological and physical symptoms, treatment sequelae, sexual problems, and fear of recurrence in some survivors, most studies demonstrated that OC survivors generally have good QOL compared to healthy women. Studies proposing interventions are lacking.

Conclusions and Implications for Cancer Survivor

OC survivors experience a wide range of sequelae that may persist for a long time and negatively impact QOL. Further large-scale research is needed to fully understand problems that have significant effects on QOL, in order to develop interventions and treatments suitable for women at need.

     

Physical activity among adult survivors of childhood lower-extremity sarcoma

Introduction

Adult survivors of childhood lower-extremity sarcoma are largely physically inactive, a behavior which potentially compounds their health burden. Altering this behavior requires understanding those factors that contribute to their physical inactivity. Therefore, this investigation sought to identify factors associated with inactivity in this subpopulation of cancer survivors.

Methods

Demographic, personal, treatment, and physical activity information from adult survivors of childhood lower-extremity sarcomas was obtained from the Childhood Cancer Survivor Study (CCSS) cohort. Generalized linear models were used to identify variables that best identified those individuals who were physically inactive.

Results

Only 41% of survivors met Center for Disease Control (CDC) activity guidelines. Survivors were 1.20 (95% confidence intervals (CI) 1.11?C1.30) more likely compared to CCSS sibling cohort and 1.12 (95% CI 1.10?C1.15) times more likely than the general population to fail to meet CDC guidelines. Significant predictors of physical inactivity included female sex, hemipelvectomy surgery, and platinum and vinca alkaloid chemotherapy.

Conclusions

The primary findings of this study are that survivors of childhood onset lower-extremity sarcoma are (1) highly likely to be physically inactive and (2) less likely than their siblings or the general population to regularly exercise. This study has identified treatment-related risk factors associated with inactivity that will help health and wellness practitioners develop successful exercise interventions to help these survivors achieve recommended levels of physical activity for health.

Implications for cancer survivors

These results suggest that physical activity interventions for adult survivors of childhood lower-extremity sarcomas should be sex specific and responsive to unique physical late effects experienced by these survivors.     

Emotional well-being years post-treatment for breast cancer: prospective,multi-ethnic,and population-based analysis

Purpose

This study investigated factors associated with declines in emotional well-being (EWB) over time in breast cancer survivors.

Methods

Women with breast cancer (Stages I–III) residing in Los Angeles, CA, or Detroit, MI, and reported to the Surveillance, Epidemiology, and End Results registries between June 2005 and February 2007 completed surveys at 9 months and 4 years after diagnosis. EWB was measured by the Functional Assessment of Cancer Treatment-Breast. Using a stress coping framework, logistic regression models assessed associations between personal, social, and clinical correlates, appraisal (e.g., worry about recurrence) and coping factors (e.g., emotional support) to EWB declines.

Results

Among eligible women who completed primary breast cancer treatment, 772 completed both surveys, and 192 (24.9 %) experienced EWB declines over time. Women with past or current depression were more likely to report EWB decline (p?<?0.01). Survivors who perceived they did not receive enough information about risk of breast cancer recurrence during primary treatment were more likely to have EWB decline (OR 0.53, 95 % CI 0.32–0.87). Greater perceived likelihood of recurrence (OR 1.95, 95 % CI 1.01–5.29) and increased worry about recurrence (OR 1.38, 95 % CI 1.10–1.72) were associated with EWB decline. Higher spirituality beliefs and practices were associated with EWB decline.

Conclusions

A considerable number of breast cancer patients report emotional well-being declines over time. Early identification of women who are vulnerable, such as women with past depression, is crucial to improve quality of care. Women would benefit from education about cancer recurrence and tailored strategies to manage worry about recurrence over time.

Implication for cancer survivors

Understanding actual risk of recurrence and managing worry about recurrence is important for cancer survivors. Emotional concerns are common for individuals with cancer so survivors should feel free to reach out and discuss such concerns with providers well into the survivorship period.     

Melanoma survivorship: research opportunities

Introduction

The rising incidence and mortality rates of melanoma, the most fatal form of skin cancer, are among the greatest increases of all preventable cancers over the past decade. However, because of recent advances in early detection, secondary prevention efforts, and treatment, the number of melanoma survivors is increasing. Little research has been conducted on melanoma survivors and important opportunities exist for research in this understudied population. Here, we outline the important research opportunities related to the study of melanoma survivorship and summarize the paucity of literature currently available.

Materials and methods

A computerized literature search was performed of the MEDLINE® database of the National Library of Medicine from 1966–2005. The scope of the search was limited to those studies published in English. The search was conducted using the following MeSH headings: melanoma, neoplasms, skin neoplasms, survival, and survival rate. The reference lists of relevant book chapters and review articles were further reviewed, and printed materials from recent scientific meetings addressing this topic were obtained.

Results

Several factors that affect melanoma survivors warrant further study, including: physiologic long-term effects; psychosocial, behavioral, and cognitive factors; demographic characteristics; surveillance practices; recurrences, secondary primaries, and other cancers; family members of survivors; and economic issues, access to health care/life insurance.

Conclusions

Understanding recurrence and second primary cancer risk, psychosocial and cognitive characteristics, behaviors, surveillance patterns, economic sequelae, and family issues of melanoma survivors is important from a public health standpoint to promote the health and well-being of this cohort.

Implications for cancer survivors

Melanoma is an understudied cancer, and the incidence and mortality of this disease are increasing. Describing the long term burden of this cancer and identifying factors that contribute to them will facilitate efforts to develop responsive secondary prevention strategies.     

Risk of subsequent malignancies in survivors of childhood leukemia

Purpose

The diagnosis of childhood leukemia now carries a much improved overall survival. With this knowledge comes concern for late effects of therapy, especially the risk of secondary malignancy.

Methods

Patients diagnosed with AML or ALL between the ages of 0 and 18 years who survived at least 5 years after diagnosis were included in analysis. Cumulative incidence of subsequent malignancy at 30 years was calculated. To compare incidence of subsequent malignancies with rates of the US population, standardized incidence ratios (SIRs) were calculated.

Results

Four thousand eight hundred six patients were included in the analysis. Median follow-up was 14.5 years (range 5.0–35.9 years). A total of 82 patients developed a second malignancy. The most common second tumor was brain (24 %) followed by thyroid (22 %). Cumulative incidences of secondary malignancy at 30 years for ALL patients and AML patients were 3.9 and 4.3 %, respectively (p?=?0.10). Patients were at an increased risk of malignancy compared to the US population (SIR?=?3.9, 95 % CI?=?3.2–4.8). The SIR for all malignancies for patients diagnosed between 1973 and 1979, 1980 and 1989, and 1990 and 1999 were 2.1 (95 % CI?=?1.3–3.4), 4.3 (95 % CI?=?3.1–5.9), and 4.4 (95 % CI?=?2.7–6.6), respectively.

Conclusions

Although incidence of secondary malignancy at 30 years in survivors of childhood leukemia is low, the rate exceeds the expected rate of malignancy for a cohort of this age by nearly 4:1. The development of a subsequent malignancy has significant impact on overall-survival and continued research is needed to assess the long-term risk of subsequent malignancy with modern therapy.

Implications for Cancer Survivors

Although survivors of childhood leukemia experience an increased rate of malignancy compared to their peers, the development of a subsequent malignancy is still a rare event. However, continued long-term follow-up is warranted.     

The feasibility of psychosocial screening for adolescent and young adult brain tumor survivors: the value of self-report

Purpose

Psychosocial screening is increasingly applied to childhood cancer survivors generally, but less so with pediatric brain tumor survivors despite their psychosocial risks. This study examined the utility and acceptability of psychological screening in pediatric brain tumor survivors.

Methods

Eighty-four adolescents (age 12?C18) completed the Beck Youth Inventory-II and 79 young adults (age 19?C30) completed the Brief Symptom Inventory-18. Their scores were compared to clinician ratings on the global assessment of functioning following clinical interviews.

Results

Eighty-four percent of participants completed measures in <30?min, 90?% reported no associated distress, and 98?% found measures easy to understand. Using established cut-off scores, 14 adolescents (17?%) and 21 young adults (27?%) were identified as clinical cases by self-report. Agreement with clinician report was generally low (kappa?=?.19, p?=?.077, adolescents; kappa?=?.34, p?=?.003, young adults), with clinicians tending to rate a higher proportion of both groups as having significant distress (24?% in adolescents; 32?% in young adults). Low self-concept scores in adolescents and deficits in social and vocational functioning in young adults contributed significantly to the discrepancies between self-report and clinician ratings.

Conclusions

Pediatric brain tumor survivors are capable of completing self-report psychological measures without distress or burden. Self-report can be a valuable tool in the assessment of pediatric brain tumor survivors, particularly in adolescents, who may provide information not revealed in a clinical interview. However, self-report, should not be used as a ??stand-alone?? assessment because important areas of functioning may be minimized in survivors?? reports.

Implications for cancer survivors

Utilizing self-report for psychosocial screening of adolescent and young adult brain tumor survivors may enhance clinical care and allow for better identification of survivors in need of psychological services.     

Contribution of diet and physical activity to metabolic parameters among survivors of childhood leukemia

Purpose

Determine the relationship between diet and metabolic abnormalities among adult survivors of childhood acute lymphoblastic leukemia (ALL).

Methods

We surveyed 117 adult survivors of childhood ALL using the Harvard Food Frequency Questionnaire. Physical activity energy expenditure (PAEE) was measured with the SenseWear Pro2 Armband. Insulin resistance was estimated using the Homeostasis Model for Insulin Resistance (HOMA-IR). Visceral and subcutaneous adiposity were measured by abdominal CT. Adherence to a Mediterranean diet pattern was calculated using the index developed by Trichopoulou. Subjects were compared using multivariate analysis adjusted for age and gender.

Results

Greater adherence to a Mediterranean diet pattern was associated with lower visceral adiposity (p = 0.07), subcutaneous adiposity (p < 0.001), waist circumference (p = 0.005), and body mass index (p = 0.04). For each point higher on the Mediterranean Diet Score, the odds of having the metabolic syndrome fell by 31 % (OR 0.69; 95 % CI 0.50, 0.94; p = 0.019). Higher dairy intake was associated with higher HOMA-IR (p = 0.014), but other individual components of the Mediterranean diet, such as low intake of meat or high intake of fruits and vegetables, were not significant. PAEE was not independently associated with metabolic outcomes, although higher PAEE was associated with lower body mass index.

Conclusions

Adherence to a Mediterranean diet pattern was associated with better metabolic and anthropometric parameters in this cross-sectional study of ALL survivors.     

Anti-Müllerian hormone screening to assess ovarian reserve among female survivors of childhood cancer

Purpose

Anti-Müllerian hormone (AMH) is an indicator of oocyte reserve in healthy females. The role of AMH testing in oncology remains investigational, although its sensitivity and stability over the menstrual cycle make it an attractive screening test for fertility assessment among female cancer survivors. We measured AMH level in survivors of childhood cancer and evaluated its association with treatment and patient factors.

Methods

Participants were adult female survivors of childhood malignancy treated with chemotherapy. Serum AMH was measured at a random day of the menstrual cycle. Multivariate analysis was used to evaluate the association between AMH level, alkylating agent exposure using the cyclophosphamide equivalent dose (CED), and other covariates.

Results

Sixty-six females with a median attained age of 23.3 years were eligible for analysis. Median AMH was 25.5 pM (range 0.5–108.0), at a median time of 11.5 years (range 1.4–25.1) since cancer diagnosis. Twenty-three patients (34.8 %) had low AMH, including a significant proportion that reported normal menstrual cycles. Compared to ALL survivors, sarcoma survivors had significantly lower AMH levels. Among alkylating agents evaluated, procarbazine had the greatest adverse effect on AMH. In multivariate analysis, higher CED (p?=?0.001), older age at diagnosis (p?p?=?0.04) remained significantly associated with lower AMH.

Conclusions

Random AMH can reveal evidence of oocyte depletion among female survivors reporting normal cycles, although low AMH should be interpreted cautiously among those taking oral contraception. Age at exposure and CED can aid identification of those more likely to have low AMH, although CED may underestimate the effect of procarbazine on oocyte reserve.

Implications for cancer survivors

Measurement of AMH can reveal apparent depletion of ovarian reserve in female childhood cancer survivors reporting normal menstrual cycles. Sarcoma survivors and those exposed to procarbazine may benefit from targeted AMH evaluation in an outpatient setting, and thereby allow appropriate fertility counseling before the onset of premature ovarian failure. The cyclophosphamide equivalent dose may facilitate comparison of the potential effect of different regimens on fertility.