Cardiovascular morbidity in long‐term survivors of early‐onset cancer: A population‐based study

Improvements in cancer therapy have resulted in an expanding population of early‐onset cancer survivors. In contrast to childhood and adolescent cancer survivors, there is still a lack of data concerning late morbidities among young adult (YA) cancer survivors. Thus, our aim was to investigate cardiac and vascular morbidity among early‐onset cancer survivors with a special interest in YA cancer survivors. In a population‐based setting, we explored the risk of cardiovascular disease in early‐onset cancer survivors compared to healthy siblings. Patients diagnosed with cancer below 35 years of age since 1975 were identified from the Finnish Cancer Registry, and 5‐year survivors were included in our study (N = 13,860). Information on cardiovascular morbidity was collected from the national hospital discharge registry. Compared to siblings, cancer survivors aged 0–19 and 20–34 at diagnosis had significantly elevated hazard ratios (HRs) for the studied outcomes: HR 13.5 (95% CI 8.9–20.4) and 3.6 (95% CI 2.8–4.6) for cardiomyopathy/cardiac insufficiency; HR 3.4 (95% CI 2.3–5.1) and 1.7 (95% CI 1.4–2.0) for atherosclerosis/brain vascular thrombosis; HR 3.3 (95% CI 1.7–6.5) and 1.8 (95% CI 1.5–2.1) for myocardial infarction/cardiac ischemia and HR 1.7 (95% CI 1.2–2.6) and 1.4 (95% CI 1.2–1.7) for cardiac arrhythmia. In both groups, depending on the outcome, the HR for adverse events was highest among lymphoma, brain tumor, leukemia and testicular malignancy survivors. Our results regarding late effects of childhood cancer survivors confirmed previous findings. Additionally, our study provides novel information concerning the YA cancer survivor population. Hence, our data may help in planning the risk‐based long‐term follow‐up of early‐onset cancer survivors.     

Preterm delivery among female survivors of childhood,adolescent and young adulthood cancer

We studied the deliveries of female cancer survivors and female siblings in a population‐based setting in Finland. Nationwide cancer and birth registries were merged to identify 1,309 first postdiagnosis deliveries of early‐onset (diagnosed under age 35) female patients with cancer and 5,916 first deliveries of female siblings occurring in 1987–2006. Multiple logistic regression models were used to estimate risk of preterm (<37 weeks), low birth weight (<2500 g) and small‐for‐gestational‐age deliveries. The risk of preterm delivery among cancer survivors compared with siblings was overall increased [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.14–1.85], the increase in risk being visible in all diagnostic age groups. Risk of low birth weight (LBW) was also significantly increased (OR 1.68; 95% CI 1.29–2.18) but not after adjustment for duration of pregnancy (OR 1.11; 95% CI 0.76–1.64). Neither was the risk of small‐for‐gestational‐age (SGA) increased. The risk of preterm delivery was most pronounced in survivors delivering 10 years or more after diagnosis. Site‐specific analyses indicated that survivors of germ cell tumors and central nervous system (CNS) tumors were at increased risk of preterm delivery, although numbers were small. In childhood survivors, kidney tumors formed the main cause of preterm delivery. Pediatric, adolescent and young adult cancer survivors are at risk for preterm delivery. Heightened surveillance is recommended especially for Wilms', germ cell and CNS tumor survivors. Such adverse pregnancy outcomes can occur a decade or more after cancer diagnosis, indicating a continued need for obstetric awareness, surveillance and counseling in former patients with cancer.     

Longitudinal patterns of psychological distress in adult survivors of childhood cancer

Background:

This study investigated longitudinal patterns of psychological distress in adult survivors of childhood cancer.

Methods:

Participants included 4569 adult survivors in the Childhood Cancer Survivor Study Cohort (CCSS) who completed the Brief Symptom Inventory-18 on three occasions between 1994 and 2010. Longitudinal latent class analysis was used to identify discrete classes of psychological distress. Predictors of class membership were examined through logistic regression modelling with odds ratios (ORs) and 95% confidence intervals (CIs) reported.

Results:

Survivors were a median of 39 years of age and 30 years from diagnosis at the most recent follow-up. Most survivors reported few or no symptoms of distress over time, although subsets of survivors reported persistently elevated (depression: 8.9% anxiety: 4.8% somatisation: 7.2%) or significant increases in distress symptoms over the follow-up period (depression: 10.2% anxiety: 11.8% somatisation: 13.0%). Increasing distress symptoms were predicted by survivor perception of worsening physical health over time (depression: OR=3.3; 95% CI=2.4–4.5; anxiety: OR=3.0; 95% CI=2.2–4.0; somatisation: OR=5.3; 95% CI=3.9–7.4). Persistent distress symptoms were also predicted by survivor perception of worsening physical health over time, as well as by worsening pain and ending analgesic use.

Conclusion:

Subgroups of adult survivors are at-risk for chronic distress or significant increases in distress decades following their original cancer diagnosis. Routine screening of psychological distress in adult survivors of childhood cancer is warranted, especially for survivors who experience physical health morbidities.     

Physical activity and obesity in Canadian cancer survivors: population-based estimates from the 2005 Canadian Community Health Survey

BACKGROUND.

Physical inactivity and obesity are associated with poorer disease outcomes in several cancer survivor groups. Few studies, however, have provided population‐based estimates of these risk factors in cancer survivors and compared them with individuals without a history of cancer. Here such estimates for the Canadian population are reported.

METHODS.

Data were obtained from the 2005 Canadian Community Health Survey consisting of computer‐assisted interviews of 114,355 adults representing an estimated 23,285,548 Canadians. Participants self‐reported their cancer history, height, and body weight to calculate body mass index and participation in various leisure‐time activities.

RESULTS.

Fewer than 22% of Canadian cancer survivors were physically active and over 18% were obese. Few differences were observed between cancer survivors and those without a history of cancer except that: 1) prostate cancer survivors were more likely to be active (adjusted odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.01–1.59) and less likely to be obese (adjusted OR = 0.71; 95% CI = 0.56–0.90); 2) skin cancer survivors (nonmelanoma and melanoma) were more likely to be active (adjusted OR = 1.33; 95% CI = 1.12–1.59); and 3) obese breast cancer survivors were less likely to be active compared with obese women without a history of cancer (adjusted OR = 0.51; 95% CI = 0.27–0.94).

CONCLUSIONS.

Canadian cancer survivors have low levels of physical activity and a high prevalence of obesity that, although comparable to the general population, may place them at higher risk for poorer disease outcomes. Population‐based interventions to increase physical activity and promote a healthy body weight in Canadian cancer survivors are warranted. Cancer 2008. © 2008 American Cancer Society.     

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.     

Late psychiatric morbidity in survivors of cancer at a young age: A nationwide registry‐based study

Childhood cancer survivors have been shown to be prone to psychosocial adverse outcomes. Data on young adults and their psychiatric late effects are still scarce. In a nationwide, registry‐based study, we explored the risk (HR) of new psychiatric diagnoses in 5‐year survivors of childhood and young adulthood (YA) cancer (n = 13,860) compared with a sibling cohort (n = 43,392). Hazard ratios (HRs) were calculated using Cox regression models. Patients and siblings were identified from the Finnish Cancer Registry and Central Population Registry, respectively. Outcome diagnoses were retrieved from the national hospital discharge register. The risk of organic memory/brain disorders was significantly increased in both childhood (HR 4.9; 95%CI 2.7–8.9) and YA (HR 2.1; 95%CI 1.4–3.1) cancer survivors compared with siblings. Mood disorders were also more common in childhood (HR 1.3; 95%CI 1.1–1.7) and YA survivors (1.3; 95%CI 1.1–1.5) than in siblings. Radiotherapy did not explain the differences. Female childhood cancer survivors had significantly increased HRs for mood disorders, psychotic disorders, neurotic/anxiety disorders, somatization/eating disorders and personality disorders. In survivors of YA cancers, females had significantly increased HR for neurotic/anxiety disorders, and the difference between female survivors and siblings was significantly (p < 0.05) higher than that between male survivors and male siblings. The effect of treatment era was also analyzed, and the risk of organic memory and brain disorders in childhood cancer survivors did not diminish over time. Despite the trend of decreased use of cranial irradiation in children, the risk of organic memory/brain disorders was elevated, even during the most recent era. Thus, additional research on chemotherapy‐only protocols and their impact on mental health, is warranted.     

Health insurance coverage in survivors of childhood cancer: the Childhood Cancer Survivor Study.

PURPOSE: To examine the prevalence and predictors of health insurance coverage and the difficulties obtaining coverage in a large cohort of childhood cancer survivors. PATIENTS AND METHODS: This study included 12,358 5-year survivors of childhood cancer and 3,553 sibling controls participating in the Childhood Cancer Survivor Study. Data were collected by surveys distributed in 1994 (baseline) and 2000 (follow-up). RESULTS: At baseline, 83.9% of adult survivors, compared with 88.3% of siblings, had health insurance coverage (P < .01); 6 years later, small but significant survivor-sibling differences remained (88% v 91%; P < .01). Twenty-nine percent of survivors reported having had difficulties obtaining coverage, compared with only 3% of siblings (P < .01). In multivariate analysis of survivors 18 years of age or older, factors associated with being uninsured included younger age at diagnosis (diagnosis age of 0 to 4 years; odds ratio [OR] = 1.7; 95% CI, 1.3 to 2.2), male sex (OR = 1.3; 95% CI, 1.2 to 1.5), age at baseline survey (age 22 to 24 years; OR = 1.6; 95% CI, 1.2 to 2.1), lower level of attained education (less than high school, OR = 2.6, 95% CI, 2.1 to 3.3; high school graduate, OR = 2.1, 95% CI, 1.8 to 2.5), income less than 20,000 dollars (OR = 5.6, 95% CI, 4.5 to 7.1), marital status (widowed/divorced/separated; OR = 1.3; 95% CI, 1.1 to 1.6), smoking status (current smoker, OR = 2.0, 95% CI, 1.7 to 2.3; former smoker, OR = 1.4, 95% CI, 1.2 to 1.8), and treatment that included cranial radiation (OR = 1.3, 95% CI, 1.0 to 1.6). CONCLUSION: Compared with siblings, adult survivors of childhood cancer had significantly lower rates of health insurance coverage and more difficulties obtaining coverage. Since lack of coverage likely has serious health and financial implications for this at-risk population, any disparity in availability and quality of coverage is of great concern.     

Romantic relationships of emerging adult survivors of childhood cancer

Objective: To assess whether childhood cancer survivors experience difficulties in their romantic relationships during emerging adulthood (18–25 years) and to identify who may be at risk for long‐term social sequelae. Methods: Emerging adult survivors of childhood cancer (n=60) and controls without a history of chronic illness (n=60) completed an online assessment of their romantic relationships, including perceived relationship satisfaction. Severity of initial treatment was rated by healthcare providers for participants with cancer. Results: Although survivors of childhood cancer do not differ from demographically similar controls in satisfaction with, conflict in, and duration of romantic relationships, they reported fewer romantic relationships and greater distress at relationship end. Within the survivor group, higher trait anxiety, older age at diagnosis, and more severe treatment intensity increased risk for relationship difficulties, including lower relationship satisfaction and more distress at break‐up. Conclusions: Findings appear to support the overall social resilience of survivors of childhood cancer. Certain subsets of survivors, however, may be at greater risk for difficulties in their close relationships as adults and therefore may be appropriate targets for intervention. Healthcare providers should routinely assess developmentally salient issues like love/romance that are important markers of identity development and ultimately impact long‐term quality of life for survivors. Copyright © 2008 John Wiley & Sons, Ltd.     

The cancer screening practices of adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND: The current study characterized the self-reported cancer screening practices of adult survivors of childhood cancer. METHODS: A cohort of 9434 long-term survivors of childhood cancer and a comparison group of 2667 siblings completed a 289-item survey that included items regarding cancer-screening practices. RESULTS: Overall, 27.3% of female respondents reported performing breast self-examination (BSE) regularly, 78.2% reported undergoing a Papanicolaou smear within the previous 3 years, 62.4% underwent a clinical breast examination (CBE) within the last year, and 20.9% had gotten a mammogram at least once in their lifetime. Approximately 17.4% of male respondents reported performing regular testicular self-examination (TSE). Women age > or =30 years who had been exposed to chest or mantle radiation therapy were more likely to report undergoing CBE (odds ratio [OR], 1.59; 95% confidence interval [95% CI], 1.32-1.92) and mammography (OR, 1.92; 95% CI, 1.47-2.56). Compared with the sibling comparison group, survivors demonstrated an increased likelihood of performing TSE (OR, 1.52; 95% CI, 1.22-1.85) or BSE (OR, 1.30; 95% CI, 1.10-1.52), of having undergone a CBE within the last year (OR, 1.18; 95% CI, 1.02-1.35), and of ever having undergone a mammogram (OR, 1.82; 95% CI, 1.52-2.17). CONCLUSIONS: The results of the current study demonstrate that the cancer screening practices among survivors of childhood cancer are below optimal levels. Primary care physicians who include childhood cancer survivors among their patients could benefit these individuals by informing them about future cancer risks and recommending appropriate evidence-based screening.     

Prevalence and predictors of prescription psychoactive medication use in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

Purpose

Childhood cancer survivors are at risk for late effects which may be managed pharmacologically. The purposes of this study were to estimate and compare the prevalence of psychoactive medication use of adult survivors of childhood cancer and sibling controls, identify predictors of medication use in survivors, and investigate associations between psychoactive medications and health-related quality of life (HRQOL).

Methods

Psychoactive medication use from 1994 to 2010 was evaluated in 10,378 adult survivors from the Childhood Cancer Survivor Study. A randomly selected subset of 3,206 siblings served as a comparison group. Multivariable logistic regression models were used to calculate odds ratios (OR) for baseline and new onset of self-reported psychoactive medication use and HRQOL.

Results

Survivors were significantly more likely to report baseline (22 vs. 15 %, p?<?0.001) and new onset (31 vs. 25 %, p?<?0.001) psychoactive medication use compared to siblings, as well as use of multiple medications (p?<?0.001). In multivariable models, controlling for pain and psychological distress, female survivors were significantly more likely to report baseline and new onset use of antidepressants (OR?=?2.66, 95 % CI?=?2.01–3.52; OR?=?2.02, 95 % CI?=?1.72–2.38, respectively) and multiple medications (OR?=?1.80, 95 % CI?=?1.48–2.19; OR?=?1.77, 95 % CI?=?1.48–2.13, respectively). Non-cranial radiation and amputation predicted incident use of analgesics >15 years following diagnosis. Antidepressants were associated with impairment across all domains of HRQOL, with the exception of physical function.

Conclusions

Prevalence of psychoactive medication use was higher among survivors for most medication classes, as was the use of multiple medications. Clinicians should be aware of the possible contribution of psychoactive medications to HRQOL.

Implications for Cancer Survivors

Survivors of childhood cancer are more likely to be prescribed psychoactive medication than their sibling counterparts, though use of such medication does not appear to normalize quality of life. Survivors are encouraged to consider additional interventions, including psychosocial support and physical exercise.     

Utilization of special education services and educational attainment among long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

BACKGROUND: The objective of the current report was to compare the self-reported rates of special education (SE) and educational attainment among specific groups of childhood cancer survivors and a random sample of sibling controls. METHODS: The Childhood Cancer Survivor Study is a retrospective cohort of individuals who were diagnosed with a cancer in childhood and survived at least 5 years postdiagnosis. This analysis includes 12,430 survivors and 3410 full siblings. Reported use of SE services and educational attainment were analyzed within subgroups defined by type of cancer, age at diagnosis, and type of treatment. RESULTS: The use of SE services was reported in 23% of survivors and 8% of siblings, with the greatest differences observed among survivors who were diagnosed before age 6 years, most notably survivors of central nervous system (CNS) tumors (odds ratio [OR], 18.8; 95% confidence interval [95%CI], 15.01-23.49), leukemia (OR, 4.4; 95%CI, 3.75-5.16), and Hodgkin disease (OR, 4.4; 95%CI, 2.64-7.24). It was found that intrathecal methotrexate (IT MTX) and cranial radiation (CRT), administered alone or in combination, significantly increased the likelihood that a survivor would use SE (IT MTX only: OR, 1.3; 95%CI, 1.09-1.78; CRT only: OR, 7.2; 95%CI, 6.14-8.39; IT MTX and CRT combined: OR, 2.6; 95%CI, 2.30-2.95). A positive dose response was identified between higher doses of CRT and use of SE. It was determined that survivors of leukemia (OR, 1.6; 95%CI, 1.23-2.16), CNS tumors (OR, 2.7; 95%CI, 1.92-3.81), non-Hodgkin lymphoma (OR, 1.8; 95%CI, 1.15-2.78), and neuroblastoma (OR, 1.7; 95%CI, 1.14-2.61) were significantly less likely to finish high school compared with siblings; however, when survivors received SE services, risk estimates approximated those of the sibling SE population. CONCLUSIONS: Children who are diagnosed with cancer should be followed closely during and after treatment to identify early signs of learning disabilities and to maximize intervention strategies for the successful completion of scholastic goals.     

Emotional distress among adult survivors of childhood cancer

Purpose

The purposes of this study were to estimate the prevalence of emotional distress in a large cohort of adult survivors of childhood cancer and to evaluate the interrelationship of risk factors including cancer-related late effects.

Methods

Adult survivors of childhood cancer (N?=?1,863), median age of 32 years at follow-up, completed comprehensive medical evaluations. Clinically relevant emotional distress was assessed using the Brief Symptom Inventory 18 and was defined as T-scores ≥63. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using multivariable logistic regression models to identify risk factors for distress. Path analysis was used to examine associations among identified risk factors.

Results

Elevated global distress was reported by 15.1 % of survivors. Cancer-related pain was associated with elevated distress (OR 8.72; 95 % CI, 5.32–14.31). Survivors who reported moderate learning or memory problems were more likely to have elevated distress than survivors who reported no learning or memory problems (OR 3.27; 95 % CI, 2.17–4.93). Path analysis implied that cancer-related pain has a direct effect on distress symptoms and an indirect effect through socioeconomic status and learning or memory problems. Similar results were observed for learning or memory problems.

Conclusions

Childhood cancer-related morbidities including pain and learning or memory problems appear to be directly and indirectly associated with elevated distress symptoms decades after treatment. Understanding these associations may help inform intervention targets for survivors of childhood cancer experiencing symptoms of distress.

Implications for Cancer Survivors

A subset of long-term childhood cancer survivors experience significant emotional distress. Physical and cognitive late effects may contribute to these symptoms.     

Cardiovascular medication after cancer at a young age in Finland: A nationwide registry linkage study

Despite improved survival rates, childhood and young adult (YA) cancer survivors face elevated risks for life‐threatening morbidities, especially cardiovascular complications. Our nationwide Finnish registry study investigated the purchases of cardiovascular medication from 1993 to 2011 in patients diagnosed with cancer aged below 35 years (N = 8,197) between 1993 and 2004 compared to siblings (N = 29,974) via linkage to the drug purchase registry. The cumulative incidence for purchasing cardiovascular medications was higher in childhood and YA cancer patients compared to siblings with a rising trend over time. After childhood cancer, the highest hazard ratio (HR) was found for purchasing anticoagulants (HR 19.8, 95% CI 8.5–45.9). The HRs for any cardiovascular medication (HR 7.2, 95% CI 5.1–10.1) and cardiac medication (HR 4.8, 95% CI 3.3–6.9) were markedly elevated after childhood cancer as well. Regarding YA cancer patients, the respective HRs were 2.5 (95% CI 2.0–3.2) for anticoagulants, HR 1.7 (95% CI 1.5–1.9) for any cardiovascular medication and HR 1.5 (95% CI 1.3–1.7) for cardiac medication. Among cancer patients, highest HRs for cardiovascular medication were observed after childhood acute lymphoblastic leukemia (ALL) and bone tumors (HR 10.2, 95% CI 6.8–15.5 and HR 7.4, 95% CI 4.0–13.7) and YA ALL and acute myeloid leukemia (HR 5.1, 95% CI 3.5–7.1 and HR 2.8, 95% CI 1.8–4.0). Our study demonstrated increased HRs for purchasing cardiovascular medication after early‐onset cancer compared to siblings reflecting elevated cardiovascular morbidity. Thus, the implementation of long‐term cardiovascular disease screening is imperative to prevent, detect and adequately treat cardiovascular late effects after cancer at a young age.     

Impact of radiation and chemotherapy on risk of dental abnormalities

BACKGROUND:

The current study was performed to describe frequencies and risk factors of altered oral health and odontogenesis in childhood cancer survivors.

METHODS:

In total, 9308 survivors who were diagnosed between 1970 and 1986 and 2951 siblings from the Childhood Cancer Survivor Study completed a survey that contained oral‐dental health information. The authors analyzed treatment impact, socioeconomic data, and patient demographics on dental outcomes using univariate and multivariate logistic regression models to estimate odds ratios (ORs).

RESULTS:

In multivariate analysis, survivors were more likely to report microdontia (OR, 3.0; 95% confidence interval [95% CI], 2.4‐3.8), hypodontia (OR, 1.7; 95% CI, 1.4‐2.0), root abnormalities (OR, 3.0; 95% CI, 2.2‐4.0), abnormal enamel (OR, 2.4; 95% CI, 2.0‐2.9), teeth loss ≥6 (OR, 2.6; 95% CI, 1.9‐3.6), severe gingivitis (OR, 1.2; 95% CI, 1.0‐1.5), and xerostomia (OR, 9.7; 95% CI, 4.8‐19.7). Controlling for chemotherapy and socioeconomic factors, radiation exposure of ≥20 Gray to dentition was associated significantly with an increased risk of ≥1 dental abnormality. Dose‐dependent alkylating agent therapy significantly increased the risk of ≥1 anatomic/developmental dental abnormalities in survivors who were diagnosed at age <5 years (OR, 1.7, 2.7, and 3.3 for alkylating agent scores of 1, 2, and 3, respectively).

CONCLUSIONS:

Radiation and chemotherapy were independent risk factors for adverse oral‐dental sequelae among childhood cancer survivors. The authors concluded that patients who received receiving alkylating agents at age <5 years should be closely monitored. Cancer 2009. © 2009 American Cancer Society.     

Purchases of antidepressants after cancer at a young age in Finland

According to previous studies, childhood cancer survivors have an elevated risk for late mental health effects. However, only few studies exist on young adulthood (YA) cancer survivors’ mental health outcomes. In our study, we examined first time antidepressant (AD) medication purchases of childhood and YA cancer patients compared to siblings. The first time AD medication purchases of 7,093 cancer patients aged 0–34 years at diagnosis and a sibling cohort (N = 26,882) were retrieved from the Social Insurance Institution of Finland (Kela) since 1.1.1993. Cancer patients diagnosed between 1.1.1994 and 31.12.2004 were identified from the Finnish Cancer Registry and sibling controls via the Population Registry Centre. Statistical analyses were performed via the Cox regression model, and the hazard ratios (HR) were adjusted for age and gender. Increased hazard ratios for AD purchases were found in the younger (0–19 years at cancer diagnosis) [HR 5.2, 95%CI (3.7–7.2)] and older (age 20–34 years at cancer diagnosis) [HR 4.5, 95%CI (3.9–5.2)] cancer patient groups compared to siblings. The gender effect was similar in patients and controls, showing that females have higher risk for AD purchases than males. Males in the younger patient group had highest HR (5.6) for AD purchases compared to siblings. Patients with sarcoma or CNS tumor in the younger age group and leukemia or CNS malignancy in the older age group had the highest risk for AD medication purchases. The frequency and risk for AD purchases has been increasing during recent decades in both cancer patient age groups compared to siblings. Thus, cancer patients’ psychological support should be properly assessed already after primary treatment. Certain diagnostic groups as well as female patients may require more psychological support than others.     

Twenty years of follow-up of survivors of childhood osteosarcoma: a report from the Childhood Cancer Survivor Study

BACKGROUND:

Osteosarcoma survivors have received significant chemotherapy and have undergone substantial surgeries. Their very long‐term outcomes (20 year) are reported here.

METHODS:

The authors assessed the long‐term outcomes of 733 5‐year survivors of childhood osteosarcoma diagnosed from 1970 to 1986 to provide a comprehensive evaluation of medical and psychosocial outcomes for survivors enrolled in the Childhood Cancer Survivor Study (CCSS). Outcomes evaluated included overall survival, second malignant neoplasms (SMNs), recurrent osteosarcoma, chronic health conditions, health status (general and mental health and functional limitations), and psychosocial factors. Outcomes of osteosarcoma survivors were compared with general‐population statistics, other CCSS survivors, and CCSS siblings.

RESULTS:

Survivors had a mean follow‐up of 21.6 years. The overall survival of children diagnosed with osteosarcoma who survived 5 years at 20 years from original diagnosis was 88.6% (95% confidence interval [CI], 86.6%‐90.5%). The cumulative incidence of SMNs at 25 years was 5.4%, with a standardized incidence ratio of 4.79 (95% CI, 3.54‐6.33; P<.01). Overall, 86.9% of osteosarcoma survivors experienced at least 1 chronic medical condition, and >50% experienced ≥2 conditions. Compared with survivors of other cancers, osteosarcoma survivors did not differ in their reported general health status (odds ratio [OR], 0.9; 95% CI, 0.7‐1.2), but were more likely to report an adverse health status in at least 1 domain (OR, 1.9; 95% CI, 1.6‐2.2), with activity limitations (29.1%) being the most common.

CONCLUSIONS:

Childhood osteosarcoma survivors in this cohort did relatively well, considering their extensive treatment, but are at risk of experiencing chronic medical conditions and adverse health status. Survivors warrant life‐long follow‐up. Cancer 2011. © 2010 American Cancer Society.     

Relationship between survivorship care plans and unmet information needs,quality of life,satisfaction with care,and propensity to engage with,and attend,follow-up care

Background

The impact of survivorship care plans (SCPs) on the proximal and distal outcomes of adult and childhood cancer survivors, and parent proxies, is unclear. This study aimed to determine the relationship between SCP receipt and these outcomes.

Methods

A cross-sectional survey of adult and childhood cancer survivors (and parent proxies for survivors aged younger than 16 years) across Australia and New Zealand was conducted. Multivariate regression models were fitted to measure the impact of SCP receipt on proximal (unmet information needs and propensity to engage with, and attend, cancer-related follow-up care) and distal outcomes (quality of life and satisfaction with cancer-related follow-up care) with control for cancer history and sociodemographic factors.

Results

Of 1123 respondents, 499 were adult cancer survivors and 624 were childhood cancer survivors (including 222 parent proxies). We found that SCP receipt was predictive of greater attendance at, and awareness of, cancer-related follow-up care (adult: odds ratio [OR], 2.46; 95% CI, 1.18–5.12; OR, 2.38; 95% CI, 1.07–5.29; child/parent: OR, 2.61; 95% CI, 1.63–4.17; OR, 1.63; 95% CI, 1.06–2.50; respectively). SCP receipt also predicted fewer unmet information needs related to “follow-up care required” and “possible late effects” (adult: OR, 0.44; 95% CI, 0.20–0.96; OR, 0.29; 95% CI, 0.13–0.64; child/parent: OR, 0.46; 95% CI, 0.30–0.72; OR, 0.57; 95% CI, 0.38–0.85; respectively). In terms of distal outcomes, SCP receipt predicted a better global quality of life for adult cancer survivors (β, 0.08; 95% CI, −0.01–7.93), proxy-reported health-related quality of life (β, 0.15; 95% CI, 0.44–7.12), and satisfaction with follow-up care for childhood cancer survivors (OR, 2.93; 95% CI, 1.64–5.23).

Conclusions

Previous studies have shown little impact of SCPs on distal end points. Results suggest that SCPs may be beneficial to cancer survivors’ proximal and distal outcomes.     

Siblings of childhood cancer survivors: How does this “forgotten” group of children adjust after cessation of successful cancer treatment?

Siblings of childhood cancer patients are labelled the “forgotten children” because they experience significant psychosocial distress and are isolated from support systems inside and outside the family. This study investigates the late consequences of the cancer experience for siblings. 60 siblings of cancer survivors were compared with control subjects on measures of psychosocial adjustment. No differences were found between siblings of cancer survivors and controls on emotional and behavioural problems and competence, suggesting that siblings adjust well to the period after cessation of treatment. The effect of demographic, family and disease-related characteristics on the siblings' psychosocial adjustment was limited. Whereas during treatment many psychosocial problems for siblings have been reported, this does not result in a heightened risk of psychological disturbance for siblings as a late effect. The implications for patient care are discussed.     

Obesity in adult survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study.

PURPOSE: To determine whether adult survivors (>or= 18 years of age) of childhood acute lymphoblastic leukemia (ALL) are at increased risk for obesity and to assess patient and treatment variables that influence risk. PATIENTS AND METHODS: A retrospective cohort of participants of the Childhood Cancer Survivor Study was used to compare 1,765 adult survivors of childhood ALL to 2,565 adult siblings of childhood cancer survivors. Body-mass index (BMI; kilograms per square meter), calculated from self-reported heights and weights, was used to determine the prevalence of being overweight (BMI, 25-29.9) or obese (BMI >or= 30.0). Polytomous logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for being overweight or obese among ALL survivors relative to the sibling control group. RESULTS: The age- and race-adjusted OR for being obese in survivors treated with cranial radiation doses >or= 20 Gy in comparison with siblings was 2.59 for females (95% CI, 1.88 to 3.55; P <.001) and 1.86 for males (95% CI, 1.33 to 2.57; P <.001). The OR for obesity was greatest among females diagnosed at 0 to 4 years of age and treated with radiation doses >or= 20 Gy (OR, 3.81; 95% CI, 2.34 to 5.99; P <.001). Obesity was not associated with treatment consisting of chemotherapy only or with cranial radiation doses of 10 to 19 Gy. CONCLUSION: Cranial radiotherapy >or= 20 Gy is associated with an increased prevalence of obesity, especially in females treated at a young age. It is imperative that healthcare professionals recognize this risk and develop strategies to enhance weight control and encourage longitudinal follow-up.     

Importance of updating family cancer history in childhood cancer survivors

Estimates of the number of childhood cancers with a genetic basis range from 5–8.5% found in germline samples to 29% based on clinical criteria. Family history-taking practice is a fundamental first step in detecting at risk individuals and families. This study focused on Li-Fraumeni Syndrome (LFS), a highly penetrant cancer syndrome. Reported family history in a cohort of 648 of cancer survivor cohort (CCS) was examined. Eligible CCS were: (i) aged up to 14 years at diagnosis; (ii) more than 5 years postdiagnosis; (iii) treated for a childhood cancer at the study hospitals in NSW, Australia; (iv) in remission for more than 3 years. CCS completed self-administered questionnaires. Medical records confirmed diagnosis and treatment-related information. Our findings reveal an increased cancer risk among sibling and relatives of CCS. 91% of siblings diagnosed with cancer were diagnosed under the age of 40 and about 30% diagnosed under the aged of 15 revealing a 5- (RR = 5.1; 95% CI, 3.3–7.9) and 44-fold (RR = 44.6; 95% CI, 18.4–108.3) increased risked of cancer compared with the Australian population, respectively. About 2% of CCS reported that they had been diagnosed with a genetic cancer syndrome. However, 11% of survivors described a family history pattern which met Chompret criteria for screening for TP53 mutations associated with LFS. Our data suggests that familial cancer predispositions may be initially overlooked. Aperiodic and accurate ascertainment of family cancer history of childhood cancer patients and survivors is therefore recommended.