Surviving cancer; what does it mean for you? An evaluation of a clinic based intervention for survivors of childhood cancer

Adolescent and young adult cancer survivors narrate their stories: Predictive model of their personal growth and their follow-up acceptance

PURPOSE

Few studies have captured the unique ways in which cancer affects the growth and development of adolescent and young adult cancer survivors. This paper illustrates the daily life of childhood cancer survivors who are now adolescents and young adults, their post-traumatic growth and follow-up perceptions, adopting a narrative approach.

METHODS

One thousand adolescent and young adult cancer survivors, mean age at diagnosis being 9.26 years old (SD = 4.29) and current mean age of 19.28 (SD = 2.96), were interviewed in depth using a new version of Ecocultural Family Interview-Cancer (EFI-C), which has proved to be a psychometrically reliable instrument.

RESULTS

Post-traumatic growth was predicted directly by age at diagnosis and, indirectly, by the mediation of the health medical staff-patient relationship during the illness, hospitalization memories, and patient's narrating skills. Positive feelings towards follow-up visits were predicted by the health staff-patient relationship during the illness (Chi-Square = 2.87; df = 3, p-value = 0.41; RMSEA = 0.0001).

CONCLUSION

Adolescent and young adult cancer survivors who were older and had established strong relationships with health professionals at the clinic were more able to narrate their experiences, display a positive comprehension of the events with a pragmatic acceptance of the follow-up procedures. Relationships with health professionals should therefore be monitored and improved, both during the cancer treatment and in the off-therapy period. The narrative technique allows adolescent and young adult cancer survivors to reorganize and give shape to their traumatic experience.

Supporting long-term follow-up of young adult survivors of childhood cancer: Correlates of healthcare self-efficacy

BACKGROUND

Healthcare self-efficacy (HCSE), the perceived confidence to manage one's health care, has been identified as a critical component in the transition process from pediatric to adult-oriented care for childhood cancer survivors (CCSs). HCSE is amenable to intervention and associated with long-term follow-up care among CCSs. However, factors associated with HCSE have not been fully explored among CCSs.

PROCEDURE

We identified correlates of HCSE among a sample of CCSs (n = 193). Descriptive statistics and linear regression methods were used in this cross-sectional analysis.

RESULTS

In univariate analyses, higher physical and psychosocial quality of life, posttraumatic growth, and religious/spiritual importance were associated with higher HCSE. Attendance at a survivorship clinic, having a regular source of care (both noncancer and oncologist), and any type of health insurance were also associated with HCSE. Hispanic ethnicity was negatively associated with HCSE relative to non-Hispanics. In a multivariable model, psychosocial quality of life, religious/spiritual importance, survivorship clinic attendance, having a regular oncologist, and Hispanic ethnicity remained significantly associated with HCSE.

CONCLUSIONS

CCSs who reported greater well-being, who rated religion and spirituality of high importance, and who accessed specialized cancer services expressed greater HCSE. Hispanic CCSs, however, reported less HCSE than non-Hispanics. Interventions that attend to the quality of life and spiritual needs of CCSs have potential to build HCSE to support the healthcare transition process. Because Hispanic CCSs may be at risk of lower perceived confidence to navigate their health care, culturally competent, efficacy-enhancing interventions are needed for this population.

Adventure Therapy: A Mental Health Promotion Strategy in Pediatric Oncology

In adventure therapy (AT), health professionals and adolescents with cancer come together to explore the wilderness of nature. One goal of this therapy is to encourage the adolescents to enhance their self-concept as part of an overall physical, cognitive, emotional or spiritual, social and psychological, or developmental rehabilitation that promotes health. The adolescents with cancer who participate in AT also learn about themselves through self-evaluation, self-exploration, self-reevaluation, self-acceptance, and self-realization. Mental health promotion (MHP) is considered a perspective and a strategy to promote health. An AT experience could be an example of an MHP initiative in which nurses can take a leadership role in participating, and further investigating, the health effects of AT on adolescents with cancer.

Cancer-related information needs and cancer's impact on control over life influence health-related quality of life among adolescents and young adults with cancer

OBJECTIVE

Adolescents and young adults (AYAs) diagnosed with cancer between 15 and 39 years of age often report need for greater amounts of cancer-related information and perceive that cancer has had a negative impact on control over their life. We examined whether unmet information need and perceived control over life are associated with health-related quality of life (HRQOL).

METHODS

We examined data from 484 AYA cancer survivors recruited from population-based cancer registries in 2007-2008. Participants completed surveys a median of 11 months after diagnosis. Multivariable linear regression analyses estimated associations of unmet cancer-related information needs and impact of cancer on control over life on HRQOL (SF-12).

RESULTS

Two-thirds of AYAs reported an intermediate or high level of unmet information need, and half (47%) reported a negative impact of cancer on control. Greater unmet information need was associated with lower overall mental and physical HRQOL and lower levels of all HRQOL subscales except vitality. A negative impact on control over life was associated with lower overall mental HRQOL as well as lower HRQOL across all subscales except general health perceptions (all p <0.05). In multivariable analyses, perceived control and unmet information need were independently associated with HRQOL (p-values for interaction >0.1).

CONCLUSIONS

Adolescent and young adult patients with cancer have high levels of unmet cancer-related information needs and perceived negative impact of cancer on control over life; both were independently associated with lower HRQOL. Addressing unmet information needs among AYA cancer survivors and finding ways to increase their sense of control may help improve HRQOL in this understudied population.

Peer and romantic relationships among adolescent and young adult survivors of childhood hematological cancer: a review of challenges and positive outcomes

This review focuses on peer and romantic relationship experiences of adolescent and young adult (AYA) survivors of childhood cancer, highlighting those surviving leukemia or lymphoma. While most AYA survivors adjust well to life following a hematological cancer diagnosis and treatment, many unique experiences, both positive and challenging, have been documented with respect to successfully navigating developmentally normative social goals. Therefore, the social implications of surviving childhood leukemia or lymphoma are explored. Specifically, the development of peer and romantic relationships, perceptions of social acceptance, parental influences and attachment, perceived vulnerabilities and body image, and risks to fertility are discussed.

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.

Views of childhood cancer survivors and their families on the provision and format of a treatment summary

INTRODUCTION

Summaries of diagnosis, treatments, and their potential late adverse health effects (treatment summaries) are increasingly being provided routinely to survivors of childhood cancer. There is relatively little research into opinions of service users on the provision and format of treatment summaries.

METHODS

Semistructured interviews were conducted with 24 survivors of childhood cancer, and 25 parents of 20 of these survivors (n=49) were asked to explore these issues. Survivors were aged 4 to 22 years, with a range of previous oncological diagnoses. The mean (range) interval since treatment completion was 4.5 (0.5 to 13) years.

RESULTS

Twelve survivors (50%) and 16 parents (64%) fully supported the use of treatment summaries as: a memory aid, a reference tool for planned and emergency medical situations, life and financial planning, and to promote ownership of health. Four survivors felt they did not want, or did not need, a reminder of their medical past. Most participants (63% of survivors) desired a verbal explanation plus a written A4 paper treatment summary. However, other formats (wallet sized, audio guides) were suggested to address practical and individual needs raised by participants.

CONCLUSIONS

Most service users would benefit from treatment summaries, although notably not all. The format and timing of the provision need to be carefully considered.

Factors that contribute to post-treatment follow-up care for survivors of childhood cancer

INTRODUCTION

As children complete cancer treatment and enter survivorship, follow-up care is critical to monitor for and treat relapses, secondary malignancies, and late effects of treatment. Relative contributions of cancer and treatment variables and sociodemographic factors in engagement with follow-up care are not fully understood. This study aimed to identify risk factors for inadequate follow-up care.

METHODS

The sample included a cohort of 173 children (birth-18 years) diagnosed with cancer in 2004 and treated at a children's hospital. Sociodemographics (gender, patient current age, ethnic minority status, distance from hospital, type of insurance), cancer and treatment variables (patient age at diagnosis, type of cancer, treatment modality, time off treatment, relapse, on clinical trial protocol), and follow-up care through 2009 were gathered via the hospital tumor registry and medical charts.

RESULTS

In simultaneous linear regression analysis (full model: F(12, 160) = 3.49, R2 = 0.21, p = 0.001), having a liquid tumor (p < 0.05), presence of relapse (p = 0.009), and shorter distance from hospital (p = 0.006) predicted total number of follow-up visits between completion of treatment and 5 years post-diagnosis. In simultaneous logistic regression analysis (full model: χ2 (12, N = 173) = 53.27, p < 0.001), being male (p = 0.077), having a brain tumor (p = 0.055), longer time off treatment (p = 0.004), and greater distance from hospital (p = 0.003) decreased the likelihood of completing a follow-up or survivorship visit between completion of treatment and 5 years post-diagnosis. In simultaneous linear regression analysis (full model: F(12, 160) = 4.52, R2 = 0.25, p = 0.001), non-White race (p = 0.001) and having public insurance (p = 0.002) predicted total number of no shows between completion of treatment and 5 years post-diagnosis.

DISCUSSION/CONCLUSIONS

These results extend knowledge of health disparities in pediatric cancer follow-up care suggesting that cancer and treatment-related variables (type of cancer, relapse, number of treatment modalities) and sociodemographic factors (distance from treatment center, non-White race, public insurance) are important predictors of engagement in follow-up care.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors at risk for poor engagement may benefit from targeted interventions designed to increase likelihood of follow-up care.

Psychosocial outcomes and service use among young adults with cancer

At the crossroads between pediatric and older adult groups, young adults with cancer may be underserved or inadequately or inappropriately served by existing support services. Empirical evidence has not established well the extent to which utilization of psychosocial support services delivered throughout a continuum of care results in desired outcomes. If self-efficacy is demonstrated to play a significant role in promoting quality of life and psychological well-being in young adult cancer patients, then a cancer-specific self-efficacy model can serve as an evidence-based framework for developing, implementing, and testing new interventions. A focus on self-efficacy has the potential to promote young adults' abilities to remain active and independent, seek and understand medical information, manage stress, cope with treatment-related side effects, maintain a "positive attitude," regulate emotions, and seek social support. Future research should aim to identify which patients represent at-risk targets for intervention, as well as the most appropriate time points along the continuum of care at which patients/survivors are most likely to benefit from delivery/utilization of psychosocial support services.

Design and recruitment of the Chicago Healthy Living Study: a study of health behaviors in a diverse cohort of adult childhood cancer survivors

BACKGROUND

Adult childhood cancer survivors are at higher risk for developing late medical effects related to their cancer treatments. Health-promoting behaviors may reduce the risk of some late effects and the severity of others. This article describes the design and recruitment of the Chicago Healthy Living Study (CHLS), an on-going study designed to examine the health behaviors and body mass index of minority adult childhood cancer survivors compared with nonminority survivors and noncancer controls.

METHODS

Survivors are identified by the hospital cancer registries at 5 treating institutions in the Chicago area; then, a multilevel recruitment plan will be implemented with the objective of enrolling 450 adult survivors of childhood cancer (150 in each racial/ethnic group). Simultaneously, 375 adult African-American, Hispanic, and non-Hispanic white noncancer controls (125 in each racial/ethnic group) living in the Chicago area will be recruited by using listed, targeted digit dialing. All participants will complete a 2-hour interview of questionnaires related to diet, physical activity, smoking, and associated mediators. Height and weight also will be measured.

CONCLUSIONS

The CHLS will provide important information on the health behaviors of adult minority childhood cancer survivors that can be used to inform the development of interventions to improve modifiable risks.

Posttraumatic stress in long-term young adult survivors of childhood cancer: A questionnaire survey

BACKGROUND

Posttraumatic stress is one of many psychological late effects in young adult survivors of childhood cancer and needs to be explored thoroughly.

OBJECTIVE

The purpose of this study was to examine the characteristics and correlates of posttraumatic stress symptoms in a sample of young adult survivors of childhood cancer.

DESIGN

Cross-sectional and correlational descriptive design was used. Data was collected by a mailed survey. The University of California at Los Angeles Post Traumatic Stress Disorder Index (PTSDI) was the measure selected for the evaluation of posttraumatic stress.

SETTING

The study took place in a medical center in the Eastern part of the United States.

PARTICIPANTS

The inclusion criteria for participants were: (a) diagnosis of childhood cancer between birth and 19 years of age; (b) 3 or more years post successful completion of cancer treatment; (c) free of active cancer; (d) at least 19 years of age; and (e) able to read and write English. A total of 51.1% (N=46) of the potentially eligible survivors responded to the survey. The analysis was based on the data from 45 respondents who had a mean age of 27.4 years.

RESULTS

The mean PTSDI score was 15.7 (SD=11.0, range=0-43). Thirteen percent (n=6) of participants had PTSDI scores that exceeded the cutoff point of 32, which is considered indicative of clinically significant posttraumatic stress disorder (PTSD). Participants who lived alone (t=-2.17, p=.035), had no health insurance (t=2.08, p=.044) and did not have a history of bone marrow transplantation (t=4.52, p=.000) reported significantly higher scores on PTSDI than others. The clinically significant PTSD group had a significantly higher rate of living alone than the non-PTSD group (p=.038).

CONCLUSION

Cancer-related posttraumatic stress emerges in childhood cancer survivors in young adulthood. Health care providers should screen childhood cancer survivors for posttraumatic stress so that referrals can be made to provide survivors with further assistance.

Transitioning to survivorship: a pilot study

There are no clear transition guidelines for adolescent and young adult cancer patients, their parents, and their primary care providers (PCPs) when completing active therapy and within the first few years after therapy. The purpose of this pilot study was to identify needs and concerns of recently treated adolescent cancer patients and their parents, young adult cancer survivors, and the community PCPs of adolescent patients. Four focus group interviews were conducted with survivors and parents, and 3 in-depth interviews were conducted with PCPs. All interviews were audiotaped and transcribed for content analysis. A range of needs were identified, including lack of adequate written and verbal information about their prior treatment, its potential side effects, and appropriate follow-up care. The best sources for education were identified as the primary oncologist, nurse practitioner, or nurse. At completion of treatment, parents and adult survivors felt a lack of psychosocial support. Suggestions from participants included use of informational videos for survivors, weekend education and support programs, ongoing support groups, use of the Internet, and educational newsletters. The PCPs reported a lack of general pediatric oncology knowledge and specific patient information, time constraints in their patient schedules, and having few survivors in their practices as barriers to optimal survivorship care. Further research is needed to look at the unmet educational and psychological needs of childhood cancer survivors and their parents during the critical time when they transition off treatment.

Models of care for survivors of childhood cancer

With improvements in therapy for childhood cancer, the expectation that most childhood cancer patients will survive and enter adulthood is a reality. There is clear evidence that survivors are at risk for adverse health-related long-term sequelae associated with their cancer and its treatment, requiring appropriate health care resources. What is less clear is how this health care should optimally be delivered. We review the functional and operational needs for long-term follow-up for childhood cancer survivors and present alternatives for models of care. Programs for childhood cancer survivors should provide mechanisms for monitoring and management of late effects, as well as support and advocacy for addressing psychosocial issues, health education, and assistance with financial concerns. Access to research is an important component as clinical care and research are integrally related. A multidisciplinary model that provides continuity of care throughout the disease course is optimal, providing transitions from acute anti-neoplastic therapy to follow-up and primary care, as well as from pediatric care to adult-oriented care. There is no single best model of care for all childhood cancer survivors. In evaluating different models, considerations include available resources as well as the particular cancer population being served. Not all survivors require the same level of services and the service level requirement for individual patients may change with time. As outcome research progresses for childhood cancer survivors, methodological issues of optimal health care delivery for this population deserve to be the subject of such research.

Barriers to follow-up care of survivors in the United States and the United Kingdom

Survivors of pediatric cancer face an increased risk of morbidity, mortality, and diminished quality of life associated with their previous cancer therapy. Because these risks are often modifiable, periodic lifetime medical follow-up is recommended for all survivors. This article assesses the current status of follow-up care in the United States and the United Kingdom. Potential barriers in both cultures and health care environments are described. A better understanding of these barriers has led to the development and testing of interventions intended to optimize the health care of survivors.

Care and support needs of children and young people with cancer and their parents

The importance of psychosocial support services for children with cancer and their families is recognised but evaluation of such services is less well developed with little information available about different patterns of provision. This paper provides an overview of psychosocial support children and their families in the UK receive during and after treatment. It reports the results of a postal survey of 303 families, within which parents and children identified their satisfaction with support services and also areas of unmet need. Satisfaction was identified in a range of areas, including medical information and support from nurses and social workers. However, areas of unmet need were also highlighted, especially age appropriate facilities, emotional support and information in different formats. Although British government policy currently seeks to develop standards and guidelines of care throughout the National Health Service, this paper demonstrates that there is still a need to develop psychosocial support services and work towards recently established guidelines in order to ensure that families receive flexible but equitable packages of care and support, wherever treatment is received.

Survey of psychosocial support provided by UK paediatric oncology centres

AIM

To obtain a comprehensive overview of current patterns of psychosocial support provided by National Health Service (NHS) paediatric oncology treatment centres across the UK.

METHODS

A postal questionnaire was sent to co-ordinators in the UK Children's Cancer Study Group (a professional body that is responsible for the organisation of treatment and management of childhood cancer in the UK) in 21 treatment centres and three separate Teenage Cancer Trus units. A range of psychosocial topics were explored, including ratio of staff providing support to patients; facilities provided for children and families; psychosocial support services such as support groups; information provision; and transition support.

RESULTS

There were many good areas of support provided by centres, but there was also a lack of standard practices and procedures. All centres employed social workers, play specialists, and paediatric oncology outreach nurses, but patient to staff ratios varied across centres. The poorest staff provision was among psychologists, where patient to staff ratios ranged from 132:1 to 1100:1. Written information was standard practice, while provision of other types of information (audiovisual, online) varied; none of the centres provided audio information specifically for children/young people.

CONCLUSION

This variability in practices among centres frequently occurred, as centres rarely had procedures formally agreed or recorded in writing. British government policy currently seeks to develop standards and guidelines of care throughout the National Health Service. This study further demonstrates the importance of standards and the need to agree guidelines for the provision of psychosocial support for children/young people and their families throughout the course of the illness.

The psycho-social impact of infertility on young male cancer survivors: a qualitative investigation

Intensive treatment regimes that are known to have a potential risk of infertility sometimes have to be given to boys who have aggressive malignant disease. Long-term care must therefore include further discussion of these patients' impaired fertility. This study describes the results of a series of semi-structured interviews with 15 young male cancer survivors regarding their experience of receiving feedback on their probable fertility status. All the interviews were conducted by a psychologist formerly uninvolved with their treatment. The interviews were analysed qualitatively using a grounded theory approach. The findings of the study are organised under four headings: (a) Emotional reaction to news of probable infertility. (b) Coping style adopted. (c) Response to the offer of semen analysis. (d) Implications for clinical practice.The results of this thematic analysis are compared to the wider research literature in oncology and health psychology.