Providing Personalized Prognostic Information for Adult Leukemia Survivors

Prediction of subsequent leukemia-free survival (LFS) and chronic graft-versus-host disease (GVHD) in adults with acute leukemia who survived at least 1 year after allogeneic hematopoietic cell transplantation is difficult. We analyzed 3339 patients with acute myeloid leukemia and 1434 patients with acute lymphoblastic leukemia who received myeloablative conditioning and related or unrelated stem cells from 1990 to 2005. Most clinical factors predictive of LFS in 1-year survivors were no longer significant after 2 or more years. For acute myeloid leukemia, only disease status (beyond first complete remission) remained a significant adverse risk factor for LFS 2 or more years after transplantation. For lymphoblastic leukemia, only extensive chronic GVHD remained a significant adverse predictor of LFS in the second and subsequent years. For patients surviving for 1 year without disease relapse or extensive chronic GVHD, the risk of developing extensive chronic GVHD in the next year was 4% if no risk factors were present and higher if noncyclosporine-based GVHD prophylaxis, an HLA-mismatched donor, or peripheral blood stem cells were used. Estimates for subsequent LFS and extensive chronic GVHD can be derived for individual patients or populations using an online calculator (http://www.cibmtr.org/LeukemiaCalculators). This prognostic information is more relevant for survivors than estimates provided before transplantation.     

Building Concern Free of Force in the Treatment of Adult Survivors of Childhood Incest

Incest brutally extinguishes the instinctive concern of a parent towards his/her child, transforming the relationship into one of force and destruction. This mode of communication tends to be re‐enacted in therapy. A main paradox embodied in the treatment of adult survivors of incest is, therefore, the paradox of force and concern. How can therapeutic relatedness sustain maternal concern when, at the same time, the therapeutic couple is unconsciously forced to re‐enact elements of an unforgiving past? By presenting clinical material, I demonstrate how this conflicting paradox blinded me while working with a female patient, leading us to an impasse, while overlooking and then re‐enacting an incestuous relationship. In the process of re‐enacting, maintaining genuine human concern was annihilated, as we both became figures in her previously written story. Concern free of force becomes possible when the therapeutic process is released from the burden of resolving the tension between concern and force, thereby gradually facilitating the evolution of a dialectical space that enables a more comprehensive mode of experience and communication. The force of abusive re‐enactment, then, does not negate the free choice of the patient and the therapist alike to react to force with concern.     

Visual and Verbal Short-Term Memory Deficits in Childhood Leukemia Survivors After Intrathecal Chemotheraphy

Assessed survivors of childhood lymphoblastic leukemia (ALL)treated with intrathecal chemotherapy, using the Wide RangeAssessment of Memory and Learning (WRAML), compared to controlswithout cancer, matched as closely as possible-in age, SES,and gender. Mild, but consistent, deficits were found in bothvisual-spatial and verbal single-trial memory tasks. In multitriallearning, only visual-spatial tasks resulted in deficient scores,while verbal learning was within the normal range. IQ resultsindicated scores 10–20 points lower in the ALL group.Memory results are related to deficits in strategic planningand attentional distractiveness. The WRAML may be a useful clinicaltool to evaluate differential memory deficits in children withALL.     

Prevalence of Cigarette Smoking among Adult Cancer Survivors in Korea

PurposeCigarette smoking is associated not only with increased risk of cancer incidence, but also influences prognosis, and the quality of life of the cancer survivors. Thus, smoking cessation after cancer diagnosis is necessary. However, smoking behavior among Korean cancer-survivors is yet unknown.ResultsOverall, 2.1% of Korean adults were cancer-survivors. The smoking rate of Korean cancer-survivors was lower than that of non-cancer controls (7.8±1.3% vs. 26.4±0.4%, p<0.001). However, 53.4% of the cancer-survivors continued to smoke after their cancer diagnosis. In multivariate analysis, male gender [odds ratio (OR), 6.34; 95% confidence interval (CI), 2.62-15.31], middle-aged group (OR, 2.74; 95% CI, 1.12-6.72), the lowest income (OR, 4.10; 95% CI, 1.19-14.15), living with smoking family member(s) (OR, 5.49; 95% CI, 2.42-12.48), and the poor self-perceived health status (OR, 2.78; 95% CI, 1.01-7.71) were independently associated with persistent smoking among Korean cancer-survivors.ConclusionThe smoking rate among Korean cancer survivors is low. However, the smoking cessation rate after the cancer diagnosis is also low. This mandates comprehensive and systematic intervention for smoking cessation among cancer-survivors.     

Behavioral Adkjustmnet and Social Functioning of Long-Term, Survivors of Childhood Leukemia: Parent and Teacher Reports

Obtained parent and teacher reports of behavior and social competencefor children who were survivors of acute lymphoblastic leukemia(ALL). At followup, children were 5–18 years of age, 48months postdiagnosis, in first continuous remission, and ofchemotherapy. Each child had been randomized to receive either1,800 cGY whole brain radiation therapy (WBRT) plus intrathecalmethotrexate (IT MTX), or IT MTX alone as central nervous systemprophylaxis, and one of four chemotherapy regimenss that variedin treatment intensity. Scores on standardized measures (CBCL-P/Tand PIC) were generally similar to instrument, norms. Parents,but not teachers, reported heightened child somatic concerns.There was no effect of WBRT or chemotherapy regimen on ratingsof behavioral adjustment. Results indicate minimal psychosocialmorbidity among long-term survivors of ALL and suggest thatthe stressful life envents associated with cancer and its treatmentdo not cause significant behavioral or emotional diffculties.     

Parenting Stress as a Mediator Between Childhood ADHD and Early Adult Female Outcomes

The purpose of this study is to examine the mediating role of parenting stress (both parental distress and stress due to dysfunctional interactions in the mother–daughter relationship [PSDI]) in the link between childhood attention-deficit/hyperactivity disorder (ADHD) status and several important young adult outcomes. The diverse sample comprised 140 girls with ADHD and 88 age- and ethnicity-matched comparisons, evaluated at ages 6–12 years and followed prospectively for five years (M age = 14.2) and 10 years (M age = 19.6). The PSDI experienced by a mother during her daughter's adolescence mediated the link between her daughter's childhood ADHD status and adult externalizing and internalizing symptoms. PSDI also mediated the link between ADHD status and young adult nonsuicidal self-injury and had an indirect effect in the relation between childhood ADHD and young adult depressive symptoms. The mediating role of PSDI with respect to internalizing symptoms and depressive symptoms remained in place even when covarying adolescent internalizing/depressive symptoms. Parenting stress, particularly related to maternal perceptions of dysfunctional interactions with adolescent daughters, serves as a key mediator in the association between childhood ADHD status and important domains of young adult functioning. Minimizing parenting stress and dysfunctional mother–daughter interactions during adolescence might reduce the risk of adverse adult outcomes for girls with ADHD.     

Neurocognitive Outcome in Survivors of Childhood Acute Lymphoblastic Leukemia: Experience at a Tertiary Care Hospital in Korea

This study was conducted to investigate long-term neurocognitive outcomes and to determine associated risk factors in a cohort of Korean survivors of childhood acute lymphoblastic leukemia (ALL). Forty-two survivors of ALL were compared with 42 healthy controls on measures of a neurocognitive test battery. We analysed potential risk factors (cranial irradiation, sex, age at diagnosis, elapsed time from diagnosis, and ALL risk group) on neurocognitive outcomes. ALL patients had lower, but non-significant full-scale intelligence quotient (FSIQ, 107.2±12.2 vs. 111.7±10.2), verbal intelligence quotient (VIQ, 107.7±13.6 vs. 112.2±11.4), and performance intelligence quotient (PIQ, 106.3±14.2 vs. 110.1±10.7) scores than healthy controls. However, patients treated with cranial irradiation performed significantly lower on FSIQ (102.2±8.1), VIQ (103.3±11.7), and PIQ (101.4±13.2) compared to non-irradiated patients and healthy controls. ALL patients also had poor attention, concentration, and executive functions. Among ALL survivors, cranial irradiation was a risk factor for poor FSIQ, being male was a risk factor for poor PIQ, and younger age was a risk factor for poor attention. Therefore, the delayed cognitive effects of ALL treatment and its impact on quality of life require continuing monitoring and management.

Graphical Abstract

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Body Image and Psychosocial Adjustment in Adolescent Cancer Survivors

Examined body image and social adjustment in 21 adolescentswho had completed cancer treatment and a healthy comparisongroup. Subjects completed questionnaires assessing body imageand social adjustment and were videotaped during an interview.Raters blind to health status independently rated subjects’attractiveness. Cancer survivors reported less than half asmany social activities as the healthy controls. No group differenceswere found on social anxiety, loneliness, or composite bodyimage scores. However, within the cancer group adolescents whohad been off treatment longer reported lower self–worth,more social anxiety, and more negative body image perceptions,but were not rated as less attractive by observers. Findingssugest body image concerns and social anxiety may not developuntil several years after treatment termination.     

Phobias of Attachment‐Related Inner States in the Psychotherapy of Adult Survivors of Childhood Complex Trauma

The clinical case described in this article illustrates the value of taking into account the dynamics of disorganized attachment in the assessment of attachment‐related phobias (phobia of attachment and phobia of attachment loss) during the psychotherapy of chronically traumatized patients. These seemingly opposite phobias typically coexist in the same patient, appear as phobias of both inner states (affect phobias) and relational experiences, and are linked to dissociated representations of self‐with‐other. Theory and research on attachment disorganization provide a clinician‐friendly conceptual framework for capturing both the intrapsychic (e.g., intrusive and nonintegrated mental states) and the relational (e.g., dramatic unsolvable dilemmas in interpersonal exchanges) aspects of the attachment‐related phobias. The therapeutic strategy and the key interventions that logically follow from a case formulation based on this conceptual framework are examined.     

A French Cohort of Childhood Leukemia Survivors: Impact of Hematopoietic Stem Cell Transplantation on Health Status and Quality of Life

The late effects and quality of life (QoL) in childhood acute leukemia survivors were compared between hematopoietic stem cell transplantation (HSCT) recipients and patients who underwent conventional therapy. The study included 943 patients, 256 of whom underwent HSCT (27.1%). Medical visits were conducted to detect the occurrence of physical late effects. Based on patient age, different questionnaires were used to assess QoL. To evaluate the association between HSCT and each type of late effect or QoL dimension, the appropriate multivariate regressions were performed. QoL mean scores were compared with those obtained for age- and sex-matched French control subjects. Of all the survivors, 674 (71.5%) had at least 1 late effect, with the risk being 5.0 CI95 (3.0-8.6) times higher for transplantation survivors. For child survivors, scoring of QoL showed no significant differences between the treatment groups. The adult HSCT survivors reported lower physical dimension QoL scores than chemotherapy survivors. Compared with French norms, the survivor group reported a significantly lower mental composite score; however, the physical composite score showed no significant difference. Thus, transplanted survivors have a high risk of developing late effects, resulting in a decreased physical well-being in adulthood. However, long after treatment completion, childhood leukemia survivors report that effects on psychological well-being are more important than they are in physical QoL dimensions.     

The Nature of Childhood Leukemia and Lymphoma

One hundred consecutive newly diagnosed cases of leukemia and lymphoma in children from 0 to 16 years of age presenting at the University of Minnesota from 1973 to 1977 were studied. Clinical features were correlated with phenotypic features of blast cells, including surface markers and cytomorphology. Four groups with distinct clinical and pathologic features emerged from the study: a) The acute leukemias of the “null” or “undifferentiated” group were those in which the malignant cells carried distinctive null leukemia surface antigen and lacked features of either T cells (E-rosette positivity) or B cells (surface immunoglobulin positivity). These cases occurred most frequently in the series (56% of total cases), peaked in incidence at 6 years, were associated with extensive bone marrow involvement, lacked distinguishing cytomorphologic features, and had the best response to therapy of all groups. b) The acute myelogenous leukemias, including those with myeloid, monocytoid, or erythroid features or a combination of the above, had extensive bone marrow involvement and the characteristic morphology. This group was seen with intermediate frequency and showed an intermediate response to therapy. c) Leukemia-lymphomas of the T-cell group were frequently associated with mediastinal masses and other masses, a cytomorphology which was different from the B-cell group but similar to the null group, and high white cell counts. These cases occurred with intermediate frequency (14%) and had a worse prognosis than the null group. d) Leukemia-lymphomas of the B-cell group had monoclonal surface immunoglobulin with μ-heavy and either κ or λ light chain. These patients were least frequent in the series, frequently presented with abdominal masses, and had a characteristic Burkitt cell morphology. Prognosis was the worst of all patients in our series. These data suggest that the major phenotypic groups of childhood leukemia and lymphoma have differing prognoses and should receive differing forms of therapy. Clinical and pathologic features of each group are sufficiently distinctive to suggest that they may have different causes.     

Electrophysiological Signs of Neurocognitive Deficits in Long-Term Leukemia Survivors

The long-term effects of disease and treatment on electrophysiologicalmeasures of neurocognitive function were studied in childrenwho had survived acute lymphoblastic leukemia (ALL) for at least4 years and were currently in remission. We report here changesin cognitive processing time as shown by the latency of theP3 wave of the auditory event-related EEG potential (ERP). P3latency was significantly prolonged in long-term ALL surivors,as well as in patients successfully trreated for solid tumors(ST)outside the CNS who received similar chemotherapy but did notreceive prophylactic treatment to the CNS. P3 latencies werestrongly correlated with measures of school performance andIQ in these individuals. The similarity in P3 latency betweenthe ALL and ST groups suggests that the treatments used on thesepateints produce changes in electrophysiological responses thatare associated with mild, but significant, cognitive deficits.     

Psychotherapy with Adult Survivors of Child Sexual Abuse

This paper explores issues raised in psychotherapeutic work with adult survivors of child sexual abuse. An analysis is made of the long-term psychological effects of the trauma and the psychic dilemma as experienced by the patient. Four themes relevant to the therapist are explored: the problems raised by the seduction theory, the dangers of interpreting the patient's experience as fantasy, the potential abuse of power and control, and the implications of the gender of the therapist.     

Postirradiation Treatment Outcomes for Children with Acute Lymphocytic Leukemia: Clarification of Risks

Developmental and educational consequences of treatment foracute lymphocytic leukemia (ALL) were examined in a group of26 elementary school children who were survivors of the disease.All of the survivors had received cranial irradiation as partof their treatment. Risks were assessed by comparing each ALLsurvivor to one normal sibling on a comprehensive battery oftests and on measures of behavior and school performance. Consistentwith previous findings, the ALL group performed less well thantheir siblings on tests of IQ, neuropsychological skills, andacademic achievement. Analysis of ratings by parents and teachersrevealed that the ALL group was less able to meet the academicdemands of school but did not differ from the sibling groupin behavioral adjustment. A greater number of children fromthe ALL group obtained borderline to low-average full-scaleIQ scores; and more received special educational assistanceat school. However, none of these children met criteria formental retardation. The present findings help to clarify therisks associated with treatment protocols that include prophylactic irradiation.     

Neuropsychological Effects of Central Nervous System Prophylactic Treatment in Childhood Leukemia: Methodological Considerations

Reviewed 53 studies on the effects of centred nervous systemprophylactic treatment (CNSPT) on cognition and neuropsychologicalfunctioning. CNSPT involves irradiation and/or chemotherapydirected to the brain, and is frequently administered to childrenwho have leukemia. The effects of CNSPT on neuropsychologicalfunctioning in long-term cancer survivors remains controversial.A number of studies failed to identify any neuropsychologicalimpact secondary to CNSPT, whereas others reported deficitsthat appear to be a function of CNSPT. Several methodologicalissues that make it difficult to draw meaningful conclusionsfrom this research literature are identified and discussed.Specific recommendations are made for improvements in researchon CNSPT in children.     

Childhood Precursors of Adult Interpartner Violence

Although childhood exposure to violence in one's family of origin is one of the most consistent correlates of later adult domestic violence, little is known about the developmental pathways or specific mechanisms of in-tergenerational transmission. This article (a) reviews the current knowledge regarding early exposure to domestic violence as precursor of later domestic violence, (b) identifies developmental considerations related to the impact of exposure, and (c) describes several conceptual models of the influence of early exposure. Research on both adults and children is reviewed. Implications for research focus on operational definitions, sex differences, life-span development, relational dynamics, typologies, and mediating processes. Implications for clinical practice focus on early socialization experience in adult treatment, and the development of early prevention programs.     

Adapted Delivery of Cognitive-Behavioral Treatment for Insomnia in Adolescent and Young Adult Cancer Survivors: A Pilot Study

Adolescent and young adult cancer survivors (AYACS) are at risk for the development of insomnia, though it remains vastly undertreated. Limited research has evaluated cognitive-behavioral treatment for insomnia (CBT-I) in AYACS. The present study piloted adapted CBT-I designed to improve treatment accessibility by delivering a three-session intervention in person and via videoconference. AYACS with insomnia (N = 12) enrolled in the study. Ten AYACS completed the intervention, with six in person and four via videoconference. Sleep variables improved immediately postintervention and were sustained at two-month follow-up. Within sample effect sizes of the adapted intervention for sleep, variables were large, and there were no noted differences on sleep outcomes between the in-person and videoconference participants. These pilot findings indicate that an adapted CBT-I intervention is feasible and promising in AYACS populations.     

Intervention Format and Delivery Preferences Among Young Adult Cancer Survivors

Background

Young adult cancer survivors face a number of increased medical and psychosocial risks, including an increased risk of cardiovascular disease and emotional distress. Although behavioral strategies, such as exercise, may diminish some of these risks, few behavioral interventions have been developed for this population.

Purpose

As a first step toward developing interventions specifically for young survivors, we conducted a qualitative study of their intervention-related preferences. A key objective was to identify the preferred format for delivering interventions (e.g., face-to-face, online).

Method

In-depth, semi-structured individual interviews were conducted with 20 young adult cancer survivors between the ages of 18 and 39. This research was conducted in Rhode Island, USA.

Results

Participants identified advantages and disadvantages to a variety of intervention formats including: telephone-based, print-based, computer-based, and several types of face-to-face interventions. The dominant theme that emerged was that interventions developed for young adult cancer survivors should take into account their multiple competing needs and obligations (e.g., work, family). Two closely related subthemes were: (1) the importance of developing interventions that are convenient and (2) the need for interventions that provide social support. Interventions for this population may be most successful if they take into account these themes.

Conclusion

Data indicate that young adult cancer survivors have some unique needs (e.g., multiple competing demands of young adulthood) and preferences (e.g., comfort with remotely delivered interventions) that differentiate them from older cancer survivors. Thus, young survivors would be best served by interventions designed to specifically target this population.