Psychosocial consequences of cure

Understanding the school experiences of children and adolescents with serious chronic illness: a systematic meta-review

BACKGROUND

Serious chronic illness can have a detrimental effect on school attendance, participation and engagement, leaving affected students at risk of failing to meet their developmental potential. An improved understanding of factors that help to explain or mitigate this risk can help educators and health professionals deliver the most effective support. This meta-review critiqued the available evidence examining the link between six chronic illnesses (asthma, cancer, chronic kidney diseases, heart diseases, cystic fibrosis and gastrointestinal diseases) and children's and adolescents' school experiences and outcomes, as well as investigating the medical, school, psychosocial and sociodemographic factors that are linked to poorer or better school outcomes.

METHODS

We searched CINAHL, Cochrane Database, EMBASE, ERIC, MEDLINE, ProQuest Theses and Dissertations, and PsycINFO (2000-2015). Systematic and narrative reviews, and meta-analyses, of original studies examining students' subjective school experiences and objective school outcomes were eligible. We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria to critically appraise all systematic reviews. The Grading of Recommendations Assessment, Development, and Evaluation system guided our recommendations for practice and research.

RESULTS

Eighteen reviews of 172 studies including more than 40 000 students were eligible. Therefore, we chose to conduct a meta-review to provide an overview of the literature on the relationship between chronic illness and school experiences and outcomes. We also explored the associated medical, school, psychosocial and sociodemographic factors affecting the relationship between illness and school experiences and outcomes.

CONCLUSION

Students with chronic illness demonstrate mixed school experiences and outcomes that are often worse than students without chronic illness. Modifiable factors, such as students' engagement with school, may be novel yet appropriate targets of educational support to ensure that these students reach their full schooling potential.

Childhood leukaemia survivors' experiences of long-term follow-ups in an endocrine clinic - A focus-group study

The survival rate after childhood cancer has improved markedly and today more than 80% of patients will survive. Many childhood cancer survivors suffer from late complications due to radiotherapy and chemotherapy. Survivors of Acute Lymphoblastic Leukaemia (ALL), treated with cranial radiotherapy, are at a particularly high risk of having endocrine complications.

PURPOSE

To illuminate childhood ALL survivors' experiences of a long-term follow-up in an endocrine clinic.

METHOD

Data collection carried out using semi-structured focus-group interviews. Fifteen ALL survivors were included in the study, divided into 4 groups. Data was analysed with conventional qualitative content analysis.

RESULTS

The survivors' experiences were captured in the theme: "The need for understanding and support in order to manage daily life". An understanding of their situation, as well as support for managing daily life was fundamental. Lack of understanding and support from the community was connected with a fear for the future. The follow-up at the endocrine clinic was shown to be crucial for increasing the survivors' understanding of late complications. The past feeling of being out of control was replaced with an increased self-confidence.

CONCLUSION

Many leukaemia survivors experienced their daily lives as a struggle and as a complicated issue to cope with. The theme "understanding and support to manage daily life" mirrors how the survivors are in need of knowledge and support in order to handle and understand their complex situation after surviving leukaemia. Offering understanding and support with a holistic approach, may be a way in which to strengthen the survivors' health.

Psychosocial Support for Patients in Pediatric Oncology: The Influences of Parents, Schools, Peers, and Technology

The diagnosis and treatment of pediatric cancer can be associated with profound psychosocial changes in the life of young patients. Although nurses, physicians, and other health care professionals are important sources of support, psychosocial support is also available through parents, schools, and peers. This article presents a review of the literature on how parents, schools, and peers affect the coping and adjustment of young patients with cancer and critically reviews interventions directed at improving functioning in these areas. Special attention is paid to recent interventions that exploit technology such as video games, CD-ROMs, and the Internet to provide creative new forms of support for patients in pediatric oncology. Existing research on both technological and interpersonal forms of intervention and support shows promising results, and suggestions for further study are provided.

Pathways Linking Treatment Intensity and Psychosocial Outcomes among Adult Survivors of Childhood Leukemia

To determine the pathways between treatment intensity (age at diagnosis, dosage of chemotherapy [intrathecal methotrexate; IT-MTX] and cranial radiation [CRT]) and various psychosocial outcomes, review of medical records and structured interviews were carried out in 510 adult survivors of childhood leukemia. Structural equation modeling revealed that higher treatment intensity during childhood (indicated by treatment with high-dose CRT, low-dose IT-MTX, and adjusted by younger age at diagnosis) predicted more health- compromising behaviors as adults through lower educational achievement. Additionally, higher childhood treatment intensity predicted current negative mood both directly and via changes in perceived limitations. The present study's findings suggest that higher treatment intensity during childhood may serve as a risk factor for adult survivors' health-compromising behaviors through neuropsychological deficits that arise from cancer treatment.

Attendance at a survivorship clinic: impact on knowledge and psychosocial adjustment

PURPOSE

Due to their heightened risk of developing late-occurring adverse outcomes, pediatric cancer survivors are advised to receive follow-up care in specialized Survivor Clinics. However, little is known about the impact of attending such clinics on psychosocial adjustment, knowledge, and morbidity. This study assesses the differences between those who attended a Survivorship Clinic and those who did not on knowledge, perception of risk, and psychosocial adjustment.

METHODS

We assessed 102 survivors who attended our Long-Term Follow-Up (LTFU) Clinic and 71 survivors never seen in a specialized clinic (non-LTFU). Participants were diagnosed at least 5 years prior to the assessment, were at least 20 years old, and had no evidence of active disease. Groups were matched on gender, age at cancer diagnosis, diagnosis, and race.

RESULTS

On average, participants were currently 30 years of age and had been diagnosed with cancer around age 12. Most common reasons that non-LTFU survivors did not attend the clinic were "not aware" (71 %) or "not interested" (16 %). Survivors in each group were able to accurately report their cancer diagnosis, but few knew specific treatment information. There were no significant differences regarding survivors' perceptions of risk of future health problems with both groups similarly underestimating their risks. A significant minority in each group reported psychological or emotional problems (16-18 %), post-traumatic stress disorder (4.2-6.9 %), and/or psychological distress (7.8-19.7 %).

CONCLUSIONS

Survivors are in need of continued education about their specific cancer treatments, recommended follow-up practices, the importance of survivorship care, and their specific risks for late effects.

IMPLICATIONS FOR CANCER SURVIVORS

Among those childhood cancer survivors who do attend a Survivor clinic, a majority are in need of continued education about their specific cancer treatments, recommended follow-up practices, and risk of late effects. As many survivors of pediatric cancer appear to be unaware of the existence of Survivor clinics, improved methods of transitioning survivors after completion of treatment are needed.

Children's Oncology Group's 2013 blueprint for research: behavioral science

Behavioral science has long played a central role in pediatric oncology clinical service and research. Early work focused on symptom relief related to side effects of chemotherapy and pain management related to invasive medical procedures. As survival rates improved, the focused has shifted to examination of the psychosocial impact, during and after treatment, of pediatric cancer and its treatment on children and their families. The success of the clinical trials networks related to survivorship highlights an even more critical role in numerous domains of psychosocial research and care. Within the cooperative group setting, the field of behavioral science includes psychologists, social workers, physicians, nurses, and parent advisors. The research agenda of this group of experts needs to focus on utilization of psychometrically robust measures to evaluate the impact of treatment on children with cancer and their families during and after treatment ends. Over the next 5 years, the field of behavioral science will need to develop and implement initiatives to expand use of standardized neurocognitive and behavior batteries; increase assessment of neurocognition using technology; early identification of at-risk children/families; establish standards for evidence-based psychosocial care; and leverage linkages with the broader behavioral health pediatric oncology community to translate empirically supported research clinical trials care to practice.

Predictors of marriage and divorce in adult survivors of childhood cancers: a report from the Childhood Cancer Survivor Study

BACKGROUND/OBJECTIVE

Adult survivors of childhood cancer can have altered social functioning. We sought to identify factors that predict marriage and divorce outcomes in this growing population.

METHODS

This was a retrospective cohort study of 8,928 > or = 5-year adult survivors of childhood malignancy and 2,879 random sibling controls participating in the Childhood Cancer Survivor Study. Marital status, current health, psychological status, and neurocognitive functioning were determined from surveys and validated instruments.

RESULTS

Survivors were more likely to be never-married than siblings [relative risk (RR), 1.21; 95% confidence interval (95% CI), 1.15-1.26] and the U.S. population (RR, 1.25; 95% CI, 1.21-1.29), after adjusting for age, gender, and race. Patients with central nervous system tumors were at greatest risk of not marrying (RR, 1.50; 95% CI, 1.41-1.59). Married survivors divorced at frequencies similar to controls. In multivariable regression analysis, nonmarriage was most associated with cranial radiation (RR, 1.15; 95% CI, 1.02-1.31 for > 2,400 centigray). In analysis of neurobehavioral functioning, nonmarriage was associated with worse task efficiency (RR, 1.27; 95% CI, 1.20-1.35), but not with emotional distress, or problems with emotional regulation, memory, or organization. Physical conditions predictive of nonmarriage included short stature (RR, 1.27; 95% CI, 1.20-1.34) and poor physical function (RR, 1.08; 95% CI, 1.00-1.18). Structural equation modeling suggested that cranial radiation influenced marriage status through short stature, cognitive problems, and poor physical function.

CONCLUSIONS

Childhood cancer survivors married at lower frequencies compared with peers. Patients with central nervous system tumors, cranial radiation, impaired processing efficiency, and short stature were more likely to never marry. Divorce patterns in survivors were similar to peers.

Marriage, employment, and health insurance in adult survivors of childhood cancer

INTRODUCTION

Adult survivors of childhood cancer are at risk for disease- and therapy-related morbidity, which can adversely impact marriage and employment status, the ability to obtain health insurance, and access to health care. Our aim was to identify factors associated with survivors' attainment of these outcomes.

METHODS

We surveyed 1,437 childhood cancer survivors who were >18 years old and >10 years past diagnosis. We compared our cohort's data to normative data in the Medical Expenditure Panel Survey and the U.S. Census Bureau's Current Population Surveys. Respondents were stratified by hematologic malignancies, central nervous system tumors, or other solid tumors and by whether they had received radiation therapy.

RESULTS

Most respondents were survivors of hematologic malignancies (71%), white (91%), and working full-time (62%); 43% were married. Compared with age- and sex-adjusted national averages, only survivors of hematologic malignancies who received radiation were significantly less likely to be married (44 vs. 52%). Full-time employment among survivors was lower than national norms, except among survivors of hematologic malignancies who had not received radiation therapy. The rates of coverage of health insurance, especially public insurance, were higher in all diagnostic groups than in the general population. While difficulty obtaining health care was rarely reported, current unemployment and a lack of insurance were associated with difficulty in obtaining health care (P < 0.05 and P < 0.001, respectively). CONCLUSIONS/IMPLICATIONS FOR CANCER SURVIVORS: Subgroups of cancer survivors do experience long-term differences in functional outcomes that should be addressed early. Survivors who are unmarried, unemployed, and uninsured experience difficulty accessing health care needed to address long-term health concerns.

Alcohol consumption patterns and risk factors among childhood cancer survivors compared to siblings and general population peers

AIMS

This study describes alcohol consumption among adult survivors of pediatric cancer compared to sibling controls and a national sample of healthy peers. Risk factors for heavy drinking among survivors are described.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional data were utilized from the Childhood Cancer Survivor Study including adult survivors of pediatric cancer (n = 10 398) and a sibling cohort (n = 3034). Comparison data were drawn from the National Alcohol Survey (n = 4774).

MEASUREMENT

Alcohol consumption, demographic, cancer diagnosis, treatment and psychosocial factors were measured.

FINDINGS

Compared to peers, survivors were slightly less likely to be risky [adjusted odds ratio (ORadj) = 0.9; confidence interval (CI) 0.8-1.0] and heavy drinkers (ORadj = 0.8; CI 0.7-0.9) and more likely to be current drinkers. Compared to siblings, survivors were less likely to be current, risky and heavy drinkers. Risk factors for survivors' heavy drinking included being age 18-21 years (ORadj = 2.0; 95% CI 1.5-2.6), male (ORadj = 2.1; 95% CI 1.8-2.6), having high school education or less (ORadj = 3.4; 95% CI 2.7-4.4) and drinking initiation before age 14 (ORadj = 6.9; 95% CI 4.4-10.8). Among survivors, symptoms of depression, anxiety or somatization, fair or poor self-assessed health, activity limitations and anxiety about cancer were associated with heavy drinking. Cognitively compromising treatment, brain tumors and older age at diagnosis were protective.

CONCLUSIONS

Adult survivors of childhood cancer show only a modest reduction in alcohol consumption compared to peers despite their more vulnerable health status. Distress and poorer health are associated with survivor heavy drinking. Screening for alcohol consumption should be instituted in long-term follow-up care and interventions among survivors and siblings should be established to reduce risk for early drinking.

Long-term population-based marriage rates among adult survivors of childhood cancer in Britain

The objectives of this study were to assess the number of adult survivors of childhood cancer who ever married and the factors influencing marriage, compare observed marriages to those expected from the general population, and assess age at marriage and influencing factors. The data is based on the British Childhood Cancer Survivor Study (BCCSS), which is a population-based cohort of 18,119 individuals who were diagnosed with childhood cancer between 1940 and 91 and survived at least 5 years. Fourteen thousand five hundred thirty-nine were alive, aged at least 16 years and eligible to receive a postal questionnaire, which ascertained marriage status. Thirty-four percent of 9,954 survivors had married. Survivors with the following characteristics: males, CNS neoplasm, received radiotherapy, diagnosed with mental retardation, registered blind, low social functioning score (calculated from SF-36 health status measure), and achieved the highest level of educational attainment, were less likely to have married than the complementary survivor groups. The deficits in the proportion ever married compared to the general population were mostly between 9 and 18% among males and 7-10% among females. The largest ever married deficits were among male CNS neoplasm survivors aged 30 years or over (29-38%). Age at first marriage among survivors was related to: sex, childhood cancer type, age at diagnosis, chemotherapy, radiotherapy, mental retardation, and level of educational attainment. Regular follow-up for these survivors should address not just physical late-effects of the childhood cancer and treatment, but also psychosocial needs throughout the lifespan of the survivors to help them achieve life events as they occur in the general population.

Assessment of health-related quality of life of adolescent cancer patients using the Minneapolis-Manchester Quality of Life Adolescent Questionnaire

BACKGROUND

Improved survival after childhood cancer has shifted the focus to health-related quality of life (HRQL)-an understudied problem, especially among adolescents.

PROCEDURE

We assessed HRQL among adolescents utilizing a validated self-report tool, the Minneapolis-Manchester Quality of Life (MMQL) Adolescent Form, consisting of 46 items comprising seven domains: physical, cognitive, psychological and social functioning, body image, intimate relations, and outlook on life, and computed an overall QoL score. The MMQL Adolescent Form was administered to 226 adolescent survivors of childhood cancer a median of 7.8 years from diagnosis (off therapy-median age: 16.2 years), 136 adolescent cancer patients undergoing therapy (on therapy-median age: 16.4 years), and 134 healthy adolescents (controls-median age: 15.5 years). Primary diagnoses included leukemia (46%), lymphoma (26%), brain tumors (5%), and other solid tumors (23%).

RESULTS

Compared to healthy controls, on-therapy patients were at increased risk for reporting poor overall QoL [Odds Ratio (OR) = 3.3, P = 0.002)] and poor physical functioning (OR = 11.8, P < 0.001). Off-therapy survivors did not differ significantly from healthy controls for overall QoL (OR = 1.6, P = 0.5) or any HRQL domains. Female patients, both on- and off-therapy, were more likely to report poorer overall QoL, physical, psychological and cognitive functioning as well as poorer body image when compared with male patients.

CONCLUSIONS

While adolescent cancer patients undergoing active therapy report poor physical functioning, there is no evidence of long-term QoL sequelae.

Leaving home after cancer in childhood: a measure of social independence in early adulthood

BACKGROUND

Previous studies on psychosocial outcomes for childhood and adolescent cancer survivors have found diverse results concerning social independence. As a measure of social independence, we investigated whether cancer survivors displayed the same patterns of leaving home as population-based control group.

PROCEDURE

We identified 1,597 patients in the Danish Cancer Register, born in 1965-1980, in whom a primary cancer was diagnosed before they reached the age of 20 in the period 1965-1995. The patients were compared with a random sample of the general population (n = 43,905) frequency matched on sex and date of birth. By linking the two cohorts to registers in Statistics Denmark, we obtained socioeconomic data for the period 1980-1997. The relative risk for leaving home was estimated with discrete-time Cox regression models.

RESULTS

The risk for leaving home of survivors of hematological malignancies and solid tumors did not differ significantly from that of the control cohort. Adjustments for possible socioeconomic confounders did not change this pattern. In contrast, survivors of central nervous system (CNS) tumors had a significantly reduced risk for leaving home, which was most pronounced for men (relative risk, men: 0.66; 95% confidence interval, 0.55-0.80; women: 0.88, 95% confidence interval, 0.80-0.97).

CONCLUSION

Overall, the psychosocial effects of cancer in childhood or adolescence and its treatment on the survivor and family did not appear to impede social independence in early adulthood, except for survivors of CNS tumors.

Posttraumatic stress symptoms in adult survivors of childhood cancer

BACKGROUND

Previous research suggests that posttraumatic stress disorder (PTSD) is present in survivors of childhood cancer. The aim of the current study was to explore posttraumatic stress symptoms in a sample of young adult survivors of childhood cancer. In addition, the impact of demographic, medical and treatment factors on survivors' posttraumatic stress symptoms was studied.

PROCEDURE

Participants were 500 long-term survivors of childhood cancer. The median age at follow-up was 24 years (age range, 16- 49 years, 47% female). To assess symptoms of posttraumatic stress, all participants completed the Impact of Event Scale (IES), a self-report instrument consisting of two subscales, intrusion and avoidance.

RESULTS

Twelve percent of this sample of adult survivors of childhood cancer had scores in the severe range, indicating they are unable to cope with the impact of their disease and need professional help. Twenty percent of the female survivors had scores in the severe range as compared with 6% of the male survivors. Linear regression models revealed that being female, unemployed, a lower educational level, type of diagnosis and severe late effects/health problems were associated with posttraumatic stress symptoms.

CONCLUSIONS

The results indicate that, although the proportion of survivors reporting symptoms is well within the proportions found in the general population, a substantial subset of survivors report symptoms of posttraumatic stress. This finding supports the outcomes reported previously that diagnosis and treatment for childhood cancer may have significant long-term effects, which are manifested in symptoms of posttraumatic stress. The investigated factors could explain posttraumatic stress symptoms only to a limited extent. Further research exploring symptoms of posttraumatic stress in childhood cancer survivors in more detail is clearly warranted. From a clinical perspective, health care providers must pay attention to these symptoms during evaluations in the follow-up clinic. Early identification and treatment of PTSD symptoms can enhance the quality of life for survivors of childhood cancer.

Self-concept in adult survivors of childhood acute lymphoblastic leukemia: a cooperative Children's Cancer Group and National Institutes of Health study

BACKGROUND

Self-concept was compared between adult survivors of childhood acute lymphoblastic leukemia (ALL) and sibling controls. Adult survivor subgroups at greatest risk for negative self-concept were identified.

PROCEDURE

Survivors (n = 578) aged > or =18 years, treated before age 20 years on Children's Cancer Group (CCG) ALL protocols, and 396 sibling controls completed a telephone interview and the Harter Adult Self-Perception Profile (ASPP).

RESULTS

Survivors global self-worth scores were significantly lower than sibling controls (mean 3.09 vs. 3.18; P = 0.022). Unemployed survivors reported lower global self-worth scores than employed (mean 2.77 vs. 3.12; P = 0.0001), whereas employment status was not associated with self-worth in controls. Among survivors, predictors of negative self-concept included unemployment (odds ratio (OR) = 2.87; 95% CI: 1.50-5.50), and believing that cancer treatment limited employability (OR = 3.17; 95% CI: 1.79-5.62). Unemployment increased the odds for negative self-concept among survivors who received combinations of central nervous system (CNS) irradiation (CRT) and intrathecal methotrexate (IT-MTX), except high CRT with no or low dose IT-MTX. Employed survivors who perceived that treatment limited their employability showed increased odds of negative self-concept for all treatment groups compared to those who did not. Minority ethnic group membership was a borderline significant predictor of negative self-concept (OR = 1.79; 95% CI: 0.94-3.33).

CONCLUSIONS

Global self-worth was significantly lower in ALL survivors than sibling controls, however, 81% of survivors had positive self-concept. Survivor subgroups most vulnerable to negative self-concept were the unemployed survivors, believing that cancer treatment affected employability, and ethnic minority group members. Targeted intervention may have greater clinical relevance for these subgroups.

A jeep trip with young adult cancer survivors: lessons to be learned

The paper describes major areas of concern and preferred coping mechanisms among 17 young survivors of childhood cancer who participated in an 8-day adventure jeep trip in Greece. The paper also deals with various aspects of "adventure therapeutic activity." The participants were videotaped and interviewed during and after the trip. The data gathered were studied through a process of content analysis. Survivors' main areas of concern included: coping with uncertainty, dependency versus autonomy, social exclusion, separation processes, body image, intimacy, sexuality and fertility, and occupation. Preferred coping styles included use of humor, religious beliefs, cognitive reframing, and use of imagination. The trip provided the young adults with an opportunity for physical challenges, and they reported improvements in self-confidence, independence, and social contacts. The trip served as a catalyst for further group activities and group support. An adventure trip seems to be a suitable therapeutic milieu for young adult cancer survivors, where they can profit from a nurturing setting in which rehabilitation-promoting resources are available. It still remains to be seen which components of such an activity are more health promoting, what contraindications there could be, if any, for participation in such a trip, and what role health professionals should play in this kind of activity.

Psychosocial correlates of paediatric cancer in the United Arab Emirates

To study the psychosocial factors and illness variables associated with children's and parents' perceptions of and ways of coping with cancer, in 38 childhood cancer patients aged 5-15 years, coping was studied in relation to sociodemographic variables and self-perception in terms of competence, behaviour and self-worth. Less optimal coping was found to be associated with poor family communications and lack of sharing/expression of emotions ( P=0.005), presence of behavioural and emotional problems in the child ( P=0.008) and parental lack of hope ( P=0.001). No association was found with gender, parental education or occupation, socioeconomic status, or child's self-perception including global estimation of self-worth. Furthermore, none of the illness variables was found to be associated with coping. Awareness about health-related issues was found to be strongly associated with parental education ( P=0.000). Our findings suggest that parental hope and both social and family communication are integral to helping patients and families cope with the illness experience.

Parent and adolescent adjustment to pediatric cancer: associations with coping, social support, and family function

This article presents preliminary results investigating the relationship between parental and adolescent adjustment and coping and their relationship to social support and family functioning in a sample of adolescents (ages 11-18) with cancer and one of their parents. Parents and adolescents from two pediatric oncology clinics completed measures of distress, coping, social support, and family cohesion/adaptability. Low levels of distress were reported by both children and their parents with positive correlations noted between parent and child adjustment. Adolescents reported that their parents and a close friend were the greatest sources of social support and described their families as having a high degree of cohesion and adaptability. Both adolescents and parents used more adaptive than maladaptive coping strategies, although distress was associated with reduced use of adaptive coping. Adolescents are able to adapt to cancer in the context of strong family and social supports. In addition, there is a relationship between parental and adolescents adjustment, and between greater use of adaptive coping styles and lower distress.

Depression in children with cancer

In this study, children with cancer and healthy students between the ages of 9 and 13 were investigated in terms of depression status. A demographic data form and the Children's Depression Inventory were given to both groups. The research group consisted of 50 children with cancer who were followed up in pediatric hematology and oncology outpatient clinics at Ankara University. The control group was comprised of 50 healthy students who attended Türközü Timur Primary School. It was found that there were significant differences between depression scores of children with cancer and children that are healthy. Children with cancer have higher depression scores than healthy students.

Physical sequelae and self-perceived attachment in adult survivors of childhood cancer

The association between the physical sequelae of childhood cancer and self-reported attachment behavior was investigated in 97 adult survivors. Attachment was assessed using standardized self-report questionnaires. Functional disability and cosmetic sequelae of the cancer and its treatment were evaluated by the attending oncologist using a standardized rating scale. Results suggest that attachment is not significantly associated with physician-rated physical sequelae, but may be related to the time of onset of the functional deficits, independent of the current age or age at diagnosis. Further, survivors with functional sequelae in adulthood describe themselves as more insecure in their relationships in general and more ambivalent in their relationship with their parents. These findings, if replicated, suggest that the duration of the functional deficits as well as the developmental stage of the individual when they began may be important variables which affect the survivor's capacity to develop and maintain intimate relationships that are secure and satisfying.

Characteristics of adolescent cancer survivors who pursue postsecondary education

This study aimed to identify differences between adolescent cancer survivors who participate in postsecondary education and those who do not, as well as factors that helped these survivors to cope. American College Testing records for 129,824 adolescents were meshed with Iowa's Cancer Registry to identify Iowans who had received a diagnosis of cancer between the ages of 12 and 17 years. The potential subject pool contained 85 persons. A questionnaire was sent to the 28 persons who agreed to participate in the study, and 75% responded. Most of the respondents were girls with normal levels of physical function. Measures of adjustment and mood state indicated low distress levels. Fatigue was their area of highest distress. All the respondents were enrolled in education programs or had graduated. Help from family, friends, and teachers was seen as supportive, but lack of knowledge about their disease was cited most frequently by this same group as interfering with their coping. The respondents demonstrated more discipline, stamina, and commitment than was expected. However, the accrual protocol and respondents' comments revealed a stigmatization of patients with cancer by professional health workers, indicating a need to confront the value that health professionals place on this stigmatized population and health professionals' contribution to this societal posture.

A clinical profile to predict decision making, risk behaviors, clinical status, and health-related quality of life for cancer-surviving adolescents. Part 1

The purpose of this two-part series is to describe a multifactorial model of clinical factors predicting decision-making quality, risk behaviors, clinical status, and health-related quality of life for cancer-surviving adolescents. This model was developed as a clinical profile to help health professionals in better identifying cancer-surviving adolescents at highest risk for substance use. Findings in the literature and results from the program of research by the author are presented to support the conceptualization of the model. In part 1, support for the antecedent predictors, both primary and secondary factors, is presented. Part 2 addresses decision making as a mediator, risk motivation as a moderator, and the expected outcomes related to risk behaviors, clinical status, and quality of life. In addition to describing the first part of the clinical profile in part 1, the background, theoretical basis of the model, and definitions of the model constructs also are provided.

Managed care: the new context for social work in health care--implications for survivors of childhood cancer and their families

The changing organization of health care requires social workers to deal with a variety of new demands, and in some cases alter their traditional professional practice. Using the specific case of childhood cancer as a framework (or set of case examples), this paper identifies key issues faced by oncology social workers in hospital settings under managed care and ways they have responded to them. The general content involves pressures on oncology social workers to adapt to the new corporate culture and ideals fundamental to managed care at the same time that the expressed psychosocial needs and desires of survivors of childhood cancer necessitate increased attention and expansion of service provision. Caught in conflicts that challenge them to reconcile simultaneous commitments to client service/empowerment and institutional conformity, social workers must establish a more powerful position to negotiate institutional and public policies that uphold the primacy of a core Social Work ethic: A commitment to client-centered service.

Young adult survivors of childhood cancer: attending to emerging medical and psychosocial needs

As survival rates for childhood cancer have increased during the past three decades, a significant population of young adult survivors has emerged. Medical late effects of particular concern to this population, including reproductive issues, osteoporosis, cardiotoxicity, hepatitis C, and second malignancies are discussed. Educational, occupational, insurance, and other significant psychosocial sequelae are addressed. Models for medical and psychosocial follow-up with this population are described, and a psycho-educational intervention model, implemented by members of the Long-Term Information, Follow-up, and Evaluation (LIFE) team at Children's Hospital Los Angeles, is presented for consideration. Future research and clinical challenges are discussed.

'In an important way, I did die': uncertainty and revival in persons living with HIV or AIDS

This study reports the revival experiences of persons who once were reconciled to their death from HIV/AIDS but who, as a result of dramatic treatment responses, now believe they may survive (popularly known as the Lazarus Syndrome). A purposive sample of men and women living with HIV infection or AIDS were interviewed in six focus groups. As part of a larger study of uncertainty in HIV illness, participants described their uncertainty accompanying renewed health and a return to the joys and problems of continued life. While new discoveries about the disease and exciting antiretroviral therapies hold the promise of improved survival, ambiguity about the durability of treatment response and ultimate survival contribute to the level of uncertainty with which a patient must cope. The experience of uncertainty in the narratives about revival involved renegotiation. Participants described physical renewal as an unexpected new stressor forcing them to renegotiate: (a) feelings of hope and future orientation, (b) social roles and identities, (c) interpersonal relations, and (d) the quality of their lives. Implications for prevention, practice, research and theory are presented and suggestions for education and assistance are offered.

Military service of male survivors of childhood malignancies

BACKGROUND

The objective of this study was to assess the eligibility for and the course of compulsory military service of childhood cancer survivors.

METHODS

The medical, military recruitment, conscription, and military service data of male Finnish childhood cancer survivors were collected from manually filed records. Inclusion criteria were: survivors born 1977 or earlier, treated for a malignancy between birth and age 15 years, and followed by a pediatrician until at least age 18 years. The documents of 207 survivors from the Pediatric Clinics of Finnish University Hospitals were examined, and 130 of these survivors were considered eligible for military service. Demographic factors, the predictors of fitness for military service, factors associated with service interruption, the attained level of military training, and the health status of conscripts during service were evaluated. Comparisons were made with the Finnish male population of the same age and with conscripts serving at the corresponding time.

RESULTS

Approximately 60% of studied survivors were enlisted. Positive predictors of fitness for service were year of birth of 1973 or later (odds ratio [OR], 3.2), height at call-up age of 170-174.9 cm (OR, 3.6), and the man's own positive opinion of his fitness for service (OR, 62.3). Negative predictors were age at diagnosis > or = 11 years (OR, 0.5), central nervous system radiotherapy (OR, 0.3), limb defects (OR, 0.02), and the group of sequelae concerning neurologic, cardiopulmonary, and gastrointestinal systems, or secondary malignancies (OR, 0.3). Survivors interrupted their service more often (20%) (P < 0.001). Leukemia survivors were less likely to interrupt their service (7%) compared with other survivors (P = 0.04). Factors associated with service interruption were: diagnosis (P = 0.04), the man's own opinion of his fitness for service (P = 0.013), surgery (P = 0.003), and height (P = 0.049), weight (P = 0.019), and body mass index (P = 0.035) at the beginning of military service. The attained level of military training was equal to that of controls. The survivors visited the garrison physician less frequently in total (mean, 5.9 times) (P < 0.001), visited because of infections as much as controls, and were off duty more (mean, 11.9 days) (P = 0.012) than controls.

CONCLUSIONS

The current study found that childhood cancer survivors were less likely to meet the requirements set for military service in Finland. The causes of rejection usually were obvious, but approximately 30% were rejected merely on the basis of a former cancer diagnosis. However, enlisted survivors coped well with military service if their treatment sequelae were taken into consideration carefully at the time of enlistment. Vocational opportunities within the armed forces might be an appropriate career option even for survivors of childhood malignancies.

Quality of life in adult survivors of childhood cancer

Sixty-four adult survivors of childhood cancer, recruited via Israel's largest pediatric cancer treatment center, participated in a multi-dimensional assessment of long-term adjustment and quality of life in the domains of educational achievement, employment status, military service, family status, health, and psychological well-being. Subjects had been diagnosed with cancer prior to age 18, were three years or more off therapy with no evidence of disease, and over 18 years old at the time of the study. Data from structured interviews were compared to responses on similar items from a control group with no history of serious illness during childhood, matched for age, sex, and parental education levels. Results indicated an overall pattern of integration into the social mainstream, with similar objective levels of achievement for survivors and controls for most measures of education, employment, significant relationships, and psychological well-being. Results also indicated certain areas of disadvantage, such as military recruitment difficulties, lower income levels, and higher rates of workplace rejection. Significantly, almost half of the survivor sample reported subjective feelings that their illness experience had impaired their achievement in several domains. Quality of life is considered an important outcome parameter in terms of clinical decision making as well as in guiding preventive and supportive intervention efforts.

The health status of adult survivors of cancer in childhood

The success of treatment for children with cancer has resulted in a growing population of adult survivors, yet these individuals may be at risk of serious long-term health problems as a result of the treatment they have received. This study explores the pattern of morbidity within a population of 290 adult survivors of cancer in childhood assessed at a median of over 15 years from diagnosis. Acute lymphoblastic leukaemia (33%) and Hodgkin's disease (15%) were the most common primary diagnoses represented. 85% of the whole group had received treatment with chemotherapy, 81% with radiotherapy, 48% with significant surgery and 28% with all three modalities. Overall, 58% of the survivors had at least one 'chronic medical problem' and 32%, two or more. Infertility (14%), nephrectomy (11%), thyroid hormone deficiency (9%), visual handicap (9%), sex hormone (7%) and growth hormone (7%) replacement therapy were the most common problems. Compliance with long term follow-up was good and an audit of an unselected sub group of all the survivors in the study showed that 84% had attended for surveillance over a period of 1 year, accounting for 222 visits of follow up clinics: 15% were also attending other specialist follow-up including psychiatry, orthopaedic, endocrine, dental and cardiac clinics. In conclusion, survivors of cancer in childhood experience actual or potential threats to future health. More than half have at least one chronic medical problem and demonstrate a significant use of medical resources. These data support the need for the continuing follow-up of survivors of cancer in childhood into adult life and the provision of the resources to do so. Optimal patterns of care and future approaches to the reduction of sequelae in future generations of survivors are discussed.

Smoking in adult survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Health-related behaviors are of particular concern in survivors of childhood cancer as they are at increased risk for second cancers and long-term organ dysfunction. The purpose of this study was to compare the smoking behavior and associated factors in young-adult survivors of childhood acute lymphoblastic leukemia (ALL) with those in sibling controls.

METHODS

A telephone interview that surveyed smoking behavior was conducted with 592 young-adult survivors, treated before age 20 years on Children's Cancer Group ALL protocols, and 409 sibling controls. Using stratified chi-squared analyses and Cox proportional hazards models, we compared the rates of smoking initiation and smoking cessation between survivors and control subjects. Demographic characteristics (age, sex, race, and education) and psychological factors (mood and self-concept) were examined as predictors interacting with survivorship in logistic regression analyses to try to distinguish a subgroup of survivors who may be at greater risk for smoking.

RESULTS

Survivors were significantly less likely to have ever smoked (23.0% versus 35.7%; P<.0001) and thus were less likely to ever be regular, daily smokers than sibling controls (19.1% versus 31.3%; P<.0001). Survivors were less likely to quit smoking than sibling controls (26.6% versus 35.2%), although this result was not statistically significant. There were no interactions between survivor status and either demographic or psychological features on smoking behavior.

CONCLUSIONS

Young-adult survivors of childhood ALL are less likely to experiment with smoking but, once having started, are at similar risk for becoming habitual, persistent smokers as sibling controls.

Evaluation of a cancer-based coping and caring course used in three different settings

Cancer in the family may affect the psycho-social adjustment of the children involved. Children who have survived childhood cancer or with a parent or sibling with cancer, may find protection from the risk of emotional and behavioural difficulties from effective external support systems. A training course was developed by the Cancer Research Campaign to help professionals who make up potential external support systems, cope with children experiencing cancer-related life crises. The course was offered to, and evaluated with, practising teachers, student teachers and Cancer Aid and Listening Line workers. Results from interviews and pre and post course questionnaires indicated that after the course all three groups felt more confident in dealing with children under stress. Participants felt that specific skills such as 'attentive listening' had increased as a result of the course. Of the three groups the practising teachers have found the course the most useful in their work and have been able to disseminate their newly acquired skills throughout their schools. Teachers are expected to cope with students' various life crises as they arise in schools. Basic counselling skills training for teachers could help them cope with these in a more confident manner, thereby reducing the risk of emotional and behavioural difficulties and contributing towards a Health Promoting School ethos.

Sexuality of young women surviving leukaemia

This study was designed to assess the sexuality of young women surviving acute leukaemia in childhood or early adolescence. Thirty of 31 survivors were compared with 50 healthy age matched controls. Three methods were used: a self report questionnaire, a face to face interview conducted by a psychiatrist, and a projective psychological test. The age at initiation of dating and sexual activity, the frequency of sexual intercourse, and opinions on sexual behaviour were similar in the two groups. With regard to inner sexuality, however, the survivors differed significantly from the healthy controls. Their images of sexuality were more restrictive, and their attitudes, especially those concerning sexual pleasure, were more negative than those of the controls. Sexual identity among the survivors was less often feminine and more often infantile as compared with the controls. The findings obtained with the three methods of assessment were concordant.

Decision making and risk behaviors of cancer-surviving adolescents and their peers

The specific aims of this descriptive, comparative study were (1) to compare the decision-making quality and prevalence of risk behaviors (smoking, alcohol consumption, and illicit drug use) between 52 cancer-surviving adolescents and their peers; (2) to compare the relationship of decision-making quality and risk behavior prevalence in a subset of survivors who had a history of therapy with cognitive threat due to late effects of treatment to those without cognitive threat; and (3) to test the hypothesis that the higher the number of quality decision criteria adhered to, the fewer the risk behaviors exhibited by cancer-surviving adolescents. Findings indicated that the majority of teen survivors reported practicing poor-quality decision making for five of the seven criteria (peers, four of seven). There were no significant differences in decision making between teen survivors and their peers nor between survivors with cognitive threat and those without. Peers were significantly more likely to engage in one or more risk behaviors than teen survivors, but comparisons with two normative samples (state and national) revealed that cigarette smoking and alcohol use of the teen survivors were comparable with the general population. There was no significant difference in risk behaviors between survivors with a history of therapy with cognitive threat and those without. Survivors who reported higher adherence to quality decision criteria were less likely to report exhibiting risk behaviors than those with poorer decision making. Using the context of late effects due to cancer treatment, oncology nurses need to provide guidance in quality decision making as well as in risk behavior education.

Family relationships in survivors of childhood cancer: resource or restraint?

Family relationships may be an important mediator between childhood cancer and psychosocial adjustment in adult life. This paper focuses on the developmental task of the transition from adolescence to adulthood, with regard to the cancer survivor's family relationships. Theories, concepts and findings relevant to this specific focus are considered in relation to whether these relationships may prove a resource or a restraint in this process. Potential aspects of family relationships that may be of interest to research are discussed, and clinical implications drawn.

Children with malignant disorders: the health and life situation of their parents examined over a 7-year interval

The parents of 31 children with malignant disorders were clinically examined and interviewed to characterize their life situation and somatic health during treatment of their child. The follow-up was for 7 years. Comparison groups were from the mean Finnish population matched for age, sex and occupation. The parents were generally healthy. Hypertension, headache and abdominal pain were the main symptoms. Sick leave and contact with a physician were less common than in the control population. The frequency of paramedical drug use was high but tranquilizers were used rarely. At the beginning the mothers had many symptoms indicating stress. Their attitude about their own state of health improved during the follow-up in spite of ageing. The spare-time physical activities of the parents increased during follow-up. Few marital conflicts and problems with the siblings were reported. The increment in economic burden caused by the child's disease was not regarded as essentially changing the family life.

The relationship of illness longevity and relapse with self-perception, cancer stressors, anxiety, and coping strategies in children with cancer

A descriptive, correlational design was used to investigate the relationship of the longevity of the cancer experience and the presence of a relapse to the child's self-perception, cancer stressors, anxiety, and use of coping strategies. The 44 children included in this study were 6 1/2 to 13 1/2 years of age. Fifteen of the children had experienced a relapse of the disease either on or off therapy. The longevity of the cancer treatment and the presence of a relapse were negatively associated with the child's self-perception. Trait anxiety was positively associated with duration of the cancer experience and with the presence of a relapse. Longevity of the cancer experience and the presence of a relapse may be factors that signal the need for interventions designed to enhance the child's self-perception throughout treatment. Because children in this study who reported lower self-perception and higher trait anxiety levels also reported experiencing more cancer stressors, nursing efforts to develop innovative strategies designed to enhance patients' feelings of self-worth and decrease their anxiety may prove to be important contributions to the care of children receiving treatment for cancer.

Developing a measure of health outcomes in survivors of childhood cancer: a review of the issues

The success of treatment for childhood cancer has prompted greater attention to issues of quality of life for the survivors. Work on health-related quality of life has proceeded faster for adults than for children. This paper reviews the results of such work for adults and points to the potential for applications in children. Specific problems in adapting measures and in interpreting the results in the context of a child's development are discussed. An approach to the assessment of the health-related quality of life for survivors of childhood cancer is proposed.

Cancer stressors and protective factors: predictors of stress experienced during treatment for childhood cancer

Perceptions of cancer stressors and protective factors are predictors of stress experienced during treatment for childhood cancer were assessed in this study. Cancer stressors were the type of treatment received during two clinic visits and the child's perception of the cancer experience. Protective factors were self-perception, coping strategies, perceived social support, and family environment. The child's responses to stressors were assessed by epinephrine, norepinephrine, and cortisol levels of urine, and measures of state anxiety. Forty-four children between 6 1/2 and 13 1/2 years of age receiving treatment for cancer were evaluated during two clinic visits. Epinephrine was elevated for children during both clinic visits, while norepinephrine and cortisol remained normal. Stepwise multiple regression analyses revealed that the family environment and global self-worth were the best predictors of epinephrine levels, while social support from friends predicted norepinephrine levels. The family environment and social support from teachers predicted state anxiety.

The psychological status of children with cancer

The psychological and social functioning of a sample of 16 children with cancer was assessed 3-5 years after diagnosis using Achenbach's Child Behavior Checklist. Analysis indicated that 81% of the children were involved in age-appropriate social interactions and the same percentage showed normal behavioral patterns. No significant differences were found due to gender, type of tumor, or behavior over time. The children in this sample appeared to be functioning normally, both psychologically and socially, three to five years after a diagnosis of cancer.

The quality of life of long-term survivors of Hodgkin's disease

BACKGROUND

The large majority of studies of the quality of life of cancer survivors has been carried out in the United States, and has employed a follow-up period of less than 10 years. As one cannot assume that the results of these studies can be generalized to the European setting, a study was undertaken of the quality of life of long-term survivors of Hodgkin's disease in The Netherlands.

PATIENTS AND METHODS

The patient sample was composed of 81 former Hodgkin's disease patients who had been treated in The Netherlands Cancer Institute in the period between 1972 and 1979, and who had remained disease-free since the time of initial treatment. One hundred sixteen hospital visitors, matched for age and statistically adjusted for gender, formed a control group. A Dutch translation of the MOS 36-Item Short-Form Health Survey (SF-36) was used to assess a range of health status and quality-of-life domains. Also included were two multi-item scales assessing intimacy and sexuality, and a range of single items assessing finances, insurance and work status.

RESULTS

In comparison with the healthy controls, cases reported significantly: (1) more restrictions in physical functioning (primarily in strenuous levels of activity) and in role functioning (work and daily activities); (2) lower perceived overall health; (3) less satisfaction with their sexual lives; (4) greater difficulty in obtaining financial loans and life insurance; and (5) more health-related employment limitations. No significant differences were noted between cases and controls in social functioning, bodily pain, mental health, vitality, satisfaction with the (non-sexual side of the) partner relationship, or in obtaining health insurance.

CONCLUSIONS

The self-reported health status and quality of life of recurrence-free survivors of Hodgkin's disease is still affected 10 to 18 years after treatment. In particular, physical and role functioning, sexuality, and overall health perceptions appear to be compromised. While some evidence of discrimination against former cancer patients was found, the magnitude of such problems appears to be lower in the Netherlands than in the United States.