Multi-component behavioral intervention to promote health protective behaviors in childhood cancer survivors: the protect study

Care Models and Barriers to Long-Term Follow-Up Care Among Childhood Cancer Survivors and Health Care Providers in Asia: A Literature Review

Most available data evaluating childhood cancer survivorship care focus on the experiences of high-income Western countries, whereas data from Asian countries are limited. To address this knowledge deficit, we aimed to characterize survivorship care models and barriers to participation in long-term follow-up (LTFU) care among childhood cancer survivors (CCSs) and health care providers in Asian countries. Twenty-four studies were identified. Most institutions in China and Turkey adopt the oncology specialist care model, whereas in Japan, India, Singapore, and South Korea, after completion of therapy LTFU programs are available in some institutions. In terms of survivor barriers, findings highlight the need for comprehensive age-appropriate education and support and personalized approaches in addressing individual preferences and challenges during survivorship. Health care professionals need education about potential late effects of cancer treatment, recommended guidance for health surveillance and follow-up care, and their role in facilitating the transition from pediatric to adult-focused care. To optimize the delivery of cancer survivorship care, efforts are needed to increase patient and family awareness about the purpose and potential benefits of LTFU care, improve provider education and training, and promote policy change to ensure that CCSs have access to essential services and resources to optimize quality of survival.

Program evaluation of a wilderness experience for adolescents facing cancer: A time in nature to heal, connect and find strength

OBJECTIVE

Despite advances in cancer treatment and increased survival, adolescents in treatment for cancer often suffer from psychosocial distress, negative mood, and chronic health problems. Wilderness therapy is considered a promising program to address psychosocial issues among adolescents with mental or behavioral health issues. There is little research on whether it may benefit adolescents in cancer treatment.

METHODS

This program evaluation in the form of a pilot study uses qualitative and quantitative measures to describe the feasibility, acceptability, safety, and to explore the impact of a nine-day wilderness program among adolescents aged 13-17 in treatment or who recently finished treatment for a cancer. Quantitative tracking documented recruitment, retention, safety, and participant satisfaction. PROMIS measures assessed mental and social health, positive affect, fatigue, pain interference and intensity over three time-points: pre, post, and three-months after the nine-day wilderness experience. Mean differences were compared over time. Qualitative data collection involved participant observation and open-ended interviews.

RESULTS

Study enrollment goals were met, enrolling eight adolescent participants with 100% participant retention. No serious adverse events were reported and participants described high satisfaction (9.25/10) with the wilderness experience on the final day and at three-months follow-up (9.5/10). Exploratory data analysis showed scores in a favorable direction indicating improved psychosocial outcomes in physical functioning, anxiety, depression, fatigue, and peer relations. From qualitative analysis it is suggested that program participation supported: increased self-confidence and peer connection. The program was evaluated as increasing personal accomplishment, supporting social interaction, having strong staff support, and capitalizing on the natural surroundings.

CONCLUSION

Use of a wilderness program is feasible, acceptable, and safe among this highly vulnerable adolescent cancer population. Participants described greater self-confidence and peer connection which developed as participants experienced physical competency, group leadership, and personal strength. Larger randomized controlled studies are needed to learn whether these programs can improve psychosocial outcomes.

Disparities in pediatric cancer survivorship care: A systematic review

BACKGROUND

Childhood cancer survivors (CCS) experience many long-term health problems that can be mitigated with recommended survivorship care. However, many CCS do not have access to survivorship care nor receive recommended survivorship care. We reviewed the empirical evidence of disparities in survivorship care for CCS.

METHODS

This systematic review searched PubMed, CINAHL, and PsycINFO for studies on survivorship care for CCS (PROSPERO: CRD42021227965) and abstracted the reported presence or absence of disparities in care. We screened 7945 citations, and of those, we reviewed 2760 publications at full text.

RESULTS

A total of 22 studies reported in 61 publications met inclusion criteria. Potential disparities by cancer treatment (N = 14), diagnosis (N = 13), sex (N = 13), and current age (N = 13) were frequently studied. There was high quality of evidence (QOE) of survivorship care disparities associated with non-White race, Hispanic ethnicity, and being uninsured. Moderate QOE demonstrated disparities among CCS who were unemployed and older. Lower QOE was found for disparities based on cancer diagnosis, cancer treatment, age at diagnosis, time since diagnosis, sex, insurance type, income, educational attainment, and geographic area.

CONCLUSIONS

We found strong empirical evidence of disparities in survivorship care for CCS associated with race, ethnicity, and insurance status. Multiple other disparate groups, such as those by employment, income, insurance type, education, cancer diagnosis, age at diagnosis, time since diagnosis, cancer treatment, geographic area, sex, and self-identified gender warrant further investigation. Prospective, multilevel research is needed to examine the role of other patient characteristics as potential disparities hindering adequate survivorship care in CCS.

Healthy lifestyle interventions for childhood and adolescent cancer survivors: a systematic review and meta-analysis

PURPOSE

This study investigated the effects of healthy lifestyle interventions (HLSIs) on health-related quality of life (HR-QoL) in childhood and adolescent cancer survivors (CACS).

METHODS

Major databases were searched for English-language original articles published between January 1, 2000 and May 2, 2021. Randomized controlled trials (RCTs) and non-RCTs were included. Quality was assessed using the revised Cochrane risk-of-bias tool, and a meta-analysis was conducted using RevMan 5.3 software.

RESULTS

Nineteen studies were included. Significant effects on HR-QoL were found for interventions using a multi-modal approach (exercise and education) (d=-0.46; 95% confidence interval [CI]=-0.84 to -0.07, p=.02), lasting not less than 6 months (d=-0.72; 95% CI=-1.15 to -0.29, p=.0010), and using a group approach (d=-0.46; 95% CI=-0.85 to -0.06, p=.02). Self-efficacy showed significant effects when HLSIs provided health education only (d=-0.55; 95% CI=-0.92 to -0.18; p=.003), lasted for less than 6 months (d=-0.40; 95% CI=-0.69 to -0.11, p=.006), and were conducted individually (d=-0.55; 95% CI=-0.92 to -0.18, p=.003). The physical outcomes (physical activity, fatigue, exercise capacity-VO2, exercise capacity-upper body, body mass index) revealed no statistical significance.

CONCLUSION

Areas of HLSIs for CACS requiring further study were identified, and needs and directions of research for holistic health management were suggested.

Multimorbidity patterns and risk of hospitalisation in children: A population cohort study of 3.6 million children in England, with illustrative examples from childhood cancer survivors

Background

Population-level estimates of hospitalisation risk in children are currently limited. The study aims to characterise morbidity patterns in all children, focusing on childhood cancer survivors versus children without cancer.

Methods

Employing hospital records of children aged <19 years between 1997 to 2018 in England, we characterised morbidity patterns in childhood cancer survivors compared with children without cancer. The follow-up began on the 5^th anniversary of the index hospitalisation and the primary outcome was the incidence of comorbidities.

Findings

We identified 3,559,439 eligible participants having 12,740,666 hospital admissions, with a mean age at study entry of 11.2 years. We identified 32,221 patients who survived for at least 5 years since their initial cancer diagnosis. During the follow-up period and within the whole population of 3.6 million children, the leading conditions for admission were (i) metabolic, endocrine, digestive renal and genitourinary conditions (84,749, 2.5%), (ii) neurological (35,833, 1.0%) and (iii) musculoskeletal or skin conditions (23,574, 0.7%), fever, acute respiratory and sepsis (22,604, 0.7%). Stratified analyses revealed that females and children from socioeconomically deprived areas had a higher cumulative incidence for morbidities requiring hospitalisation (p < 0.001). At baseline (5 years after the initial cancer diagnosis or initial hospitalisation for survivors and population comparisons, respectively), cancer survivors experienced a higher prevalence of individual conditions and multimorbidity (≥ 2 morbidities) compared with children without cancer. Cox regression analyses showed that survivors had at least a 4-fold increase in the risk of hospitalisation for conditions such as chronic eye conditions (hazard ration (HR):4.0, 95% confidence interval (CI): 3.5-4.7), fever requiring hospitalisation (HR: 4.4, 95% CI: 3.8-5.0), subsequent neoplasms (HR: 5.7, 95% CI:5.0-6.5), immunological disorders (HR: 6.5, 95% CI:4.5-9.3) and metabolic conditions (HR: 7.1, 95% CI:5.9-8.5).

Interpretation

The overall morbidity burden among children was low in general; however, childhood cancer survivors experienced a higher prevalence and subsequent risk of hospitalisation for a range of morbidities. Targeted policies may be required to promote awareness on health vulnerabilities and gender disparity and to improve advocacy for healthcare in deprived communities.

Funding

Wellcome Trust, National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre and Academy of Medical Sciences. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Who Knows? Information Received, and Knowledge about, Cancer, Treatment and Late Effects in a National Cohort of Long-Term Childhood, Adolescent and Young Adult Cancer Survivors

Simple Summary

With the growing population of cancer survivors, survivorship management has become central for both medical professionals and patients. This entails, among other factors, empowering survivors with the necessary knowledge about their medical history and their risk for late effects, because informed patients make better lifestyle and health choices. Although a lack of information and low satisfaction with information received are fairly well-documented phenomena among childhood cancer survivors, less is known about survivors of young adult cancer and populations of long-term survivors no longer engaged in follow-up care. This paper aims to fill this gap by investigating information provision in childhood, adolescent and young adult cancer survivors.

Abstract

Background: Knowledge of medical history and late effects is central in modern survivorship management, especially for long-term childhood, adolescent and young adult cancer survivors’ (CAYACS) with long life expectancy rates and high risks of late effects. Identifying information and knowledge gaps is, therefore, important. As part of the population-based NOR-CAYACS study, we investigated the following: (1) written information received about their disease and treatment, and any information about late effects; (2) satisfaction with this information and associated factors; (3) knowledge about late effects and factors associated with low knowledge of specific late effects. Material and methods: A questionnaire-based survey (Nor-CAYACS) was mailed to 5361 CAYACS (childhood cancers, breast and colorectal cancer, acute lymphatic leukemia, non-Hodgkin lymphoma and malignant melanoma) identified by the Cancer Registry of Norway (CRN). Of these, 2018 answered questions about disease and late effects information and knowledge. Exposure variables were extracted from the questionnaire and CRN. Unfortunately, it was not possible to stratify by treatment in the analyses. We ran descriptive statistics for comparisons and logistic regressions to identify factors associated with outcomes of interest. Results: Overall, 50% to 60% of survivors reported not having received written information about their disease and treatment, or any information about late effects. There was a large variation in reported knowledge across 17 late effects. Lower levels of knowledge were associated with male sex, lower education and poorer health literacy in multivariable regression models. Conclusions: Knowledge of cancer history and risks of late effects is essential for effective self-management, yet significant information and knowledge gaps were reported in this population-based sample of long-term CAYACS. Systematic approaches to making (up-to-date) information available to long-term survivors are needed to ensure that information does not get lost in medical and life transitions.

OUP accepted manuscript

Appropriate models of survivorship care for the growing number of adult survivors of childhood cancer are unclear. We conducted a realist review to describe how models of care that include primary care and relevant resources (eg, tools, training) could be effective for adult survivors of childhood cancer. We first developed an initial program theory based on qualitative literature (studies, commentaries, opinion pieces) and stakeholder consultations. We then reviewed quantitative evidence and consulted stakeholders to refine the program theory and develop and refine context-mechanism-outcome hypotheses regarding how models of care that include primary care could be effective for adult survivors of childhood cancer. Effectiveness for both resources and models is defined by survivors living longer and feeling better through high-value care. Intermediate measures of effectiveness evaluate the extent to which survivors and providers understand the survivor’s history, risks, symptoms and problems, health-care needs, and available resources. Thus, the models of care and resources are intended to provide information to survivors and/or primary care providers to enable them to obtain/deliver appropriate care. The variables from our program theory found most consistently in the literature include oncology vs primary care specialty, survivor and provider knowledge, provider comfort treating childhood cancer survivors, communication and coordination between and among providers and survivors, and delivery/receipt of prevention and surveillance of late effects. In turn, these variables were prominent in our context-mechanism-outcome hypotheses. The findings from this realist review can inform future research to improve childhood cancer survivorship care and outcomes.

Complex behavioral interventions targeting physical activity and dietary behaviors in pediatric oncology: A scoping review

As cancer and its treatment negatively impacts the long-term health and quality of life of survivors, there is a need to explore new avenues to prevent or minimize the impact of adverse effects in children with cancer and cancer survivors. Therefore, this scoping review aimed to report on the state of the evidence on the use and effects of complex behavioral interventions (CBI) targeting physical activity and/or dietary behaviors in pediatric oncology. Fourteen quantitative studies were included, evaluating interventions that used a combination of two or three different treatment modalities. Overall, studies demonstrated that it is feasible to implement CBI and that they can potentially improve physical activity and dietary behaviors as well as patient outcomes such as physical and psychological health. Unfortunately, due to a paucity of studies and the heterogeneity of the studies included in this review, no conclusive evidence favoring specific interventions were identified.

Psychological Outcomes, Health-Related Quality of Life, and Neurocognitive Functioning in Survivors of Childhood Cancer and Their Parents

Childhood cancer disrupts the lives of patients and their families and affects acute and long-term psychological health. This article summarizes (1) psychological challenges, including depression, anxiety, worries, and posttraumatic stress, as well as positive outcomes such as benefit finding and posttraumatic growth in young survivors and parents; (2) health-related quality of life; (3) interventions to support survivors and parents with psychological difficulties; and (4) neurocognitive problems and interventions to help alleviate them. Although many survivors and parents fare well in the long term, many survivors may benefit from interventions. Interventions should be further evaluated and integrated into routine clinical care.

Association of Demographic and Cancer-Specific Factors on Health Behavior Recommendations Specific to Cancer Prevention and Control Among Adolescent and Young Adult Survivors of Childhood Cancer

Purpose: Adolescent and young adult survivors of childhood cancer (AYA) are at risk for long-term health problems that are exacerbated by not meeting health behavior recommendations (e.g., exercise). To identify AYA at risk for not meeting health behavior recommendations, we explored demographic (e.g., age) and cancer-specific (e.g., intensity of treatment) factors associated with not meeting specific health behavior recommendations that have implications for cancer prevention and control. Methods: Regression (linear/binary) was used to examine demographic and cancer-specific associates regarding fruit/vegetable intake, binge drinking, sleep duration, sunscreen use, tobacco use, and physical activity among 307 AYA (M^age = 20.33, range = 15-34) across three combined studies, treated at a pediatric cancer center. Health behavior measures were adapted from The Health Behaviors Survey and the Youth Risk Behavior Surveillance System questionnaire. Results: AYA in general did not meet health behavior recommendations. Compared with AYA with public insurance, AYA with private insurance (β = -0.19, p < 0.01) were more likely to meet multiple health behavior recommendations. AYA at greatest risk for not meeting specific health behaviors were more likely to be diagnosed in middle childhood (11.35^years) compared with early childhood (8.38^years), be closer to diagnosis (8.77^years vs. 11.76^years) and closer to treatment completion (6.97^years vs. 9.91^years), and have a solid tumor (32.7%) compared with a brain tumor (10.6%). Conclusion: Not meeting health behavior recommendations is common among AYA survivors of childhood cancer. Early education in the context of survivorship care is critical to provide teachable moments to AYA; such interventions might impact future long-term health and reduce risk for secondary cancers.

Mental Health and Its Predictors during the Early Months of the COVID-19 Pandemic Experience in the United States

To date, there has been relatively little published research on the mental health impacts of COVID-19 for the general public at the beginning of the U.S.' experience of the pandemic, or the factors associated with stress, anxiety, depression, and post-traumatic growth during this time. The current study provides a longitudinal examination of the predictors of self-reported stress, anxiety, depression, and post-traumatic growth for U.S. residents between April and May, 2020, including the influence of demographic, psychosocial, and behavioral factors on these outcomes. The findings indicate that, generally, the early months of the U.S. COVID-19 experience were characterized by a modest negative impact on mental health. Younger adults, people with pre-existing health conditions, and those experiencing greater perceived risk, higher levels of rumination, higher levels of co-rumination, greater social strain, or less social support reported worse mental health. Positive mental health was associated with the adoption of coping strategies, especially those that were forward-looking, and with greater adherence to national health-protection guidelines. The findings are discussed with regard to the current status of health-protective measures and mental health in the U.S., especially as these impact future management of the on-going pandemic.

Nutrition education and cooking workshops for families of children with cancer: a feasibility study

Background

Changes in food intake are common in children with cancer and are often caused by nausea and perturbations in sense of taste. The VIE (Valorization, Implication, Education) study proposes family-based nutrition and cooking education workshops during childhood cancer treatments. Process evaluation during implementation allows to assess if the intervention was delivered as planned and to determine its barriers and facilitators. The study objective was to describe the implementation process of a nutrition education and cooking workshop program for families of children actively treated for cancer in a non-randomized non-controlled feasibility study.

Methods

Six open-to-all in-hospital workshops were offered on a weekly basis during a one-year implementation phase. We collected qualitative and quantitative data using field notes and activity reports completed by the registered dietician facilitator; surveys and questionnaires fulfilled by the workshop participants and by the families enrolled in the VIE study. Field notes were used to collect only qualitative data. Survey respondents (n = 26) were mostly mothers (n = 19, 73%). Children’s mean age was 7.80 (± 4.99) years and the mean time since diagnosis was 7.98 (± 0.81) months. Qualitative data were codified using hybrid content analysis. The first deductive analysis was based on the Steckler & Linnan concepts. Subthemes were then identified inductively. Quantitative data were presented with descriptive statistics.

Results

Workshop attendance was low (17 participants over 1 year) and 71% of the planned workshops were cancelled due to lack of participants. The principal barriers to participation referred the child’s medical condition, parental presence required at the child’s bedside and challenges related to logistics and time management. The level of interest in the topics addressed was found high or very high for 92% of the participants. The themes that were perceived as the most useful by parents were related to the child’s specific medical condition.

Conclusions

Despite high interest, workshops delivered in a face-to-face format were poorly feasible in our sample population. This supports the need to develop educational programs in pediatric oncology using strategies and delivery formats that address the major barriers for participation encountered by families.

Predictors of Loss to Follow-Up Among Pediatric and Adult Hematopoietic Cell Transplantation Survivors: A Report from the Center for International Blood and Marrow Transplant Research

Follow-up is integral for hematopoietic cell transplantation (HCT) care to ensure surveillance and intervention for complications. We characterized the incidence of and predictors for being lost to follow-up. Two-year survivors of first allogeneic HCT (10,367 adults and 3865 children) or autologous HCT (7291 adults and 467 children) for malignant/nonmalignant disorders between 2002 and 2013 reported to the Center for International Blood and Marrow Transplant Research were selected. The cumulative incidence of being lost to follow-up (defined as having missed 2 consecutive follow-up reporting periods) was calculated. Marginal Cox models (adjusted for center effect) were fit to evaluate predictors. The 10-year cumulative incidence of being lost to follow-up was 13% (95% confidence interval [CI], 12% to 14%) in adult allogeneic HCT survivors, 15% (95% CI, 14% to 16%) in adult autologous HCT survivors, 25% (95% CI, 24% to 27%) in pediatric allogeneic HCT survivors, and 24% (95% CI, 20% to 29%) in pediatric autologous HCT survivors. Factors associated with being lost to follow-up include younger age, nonmalignant disease, public/no insurance (reference: private), residence farther from the tranplantation center, and being unmarried in adult allogeneic HCT survivors; older age and testicular/germ cell tumor (reference: non-Hodgkin lymphoma) in adult autologous HCT survivors; older age, public/no insurance (reference: private), and nonmalignant disease in pediatric allogeneic HCT survivors; and older age in pediatric autologous HCT survivors. Follow-up focusing on minimizing attrition in high-risk groups is needed to ensure surveillance for late effects.

A Phase I and Pharmacokinetic Study of Oral Dabrafenib in Children and Adolescent Patients with Recurrent or Refractory BRAF V600 Mutation-Positive Solid Tumors

PURPOSE

The 2-part, phase I/IIa, open-label study (NCT01677741) sought to determine the safety, tolerability, pharmacokinetics, and preliminary activity of dabrafenib in pediatric patients with advanced BRAF V600-mutated cancers.

PATIENTS AND METHODS

This phase I dose-finding part treated patients ages 1 to <18 years with BRAF V600 mutation-positive tumors with oral dabrafenib 3 to 5.25 mg/kg/day to determine the RP2D based on safety and drug exposure target.

RESULTS

Between May 2013 and November 2014, 27 patients [12 male; median age, 9 years (range, 1-17 years)] with BRAF V600-mutant solid tumors recurrent/refractory to treatment (low- or high-grade glioma, Langerhans cell histiocytosis, neuroblastoma, or thyroid cancer) were enrolled. The median treatment duration was 75.6 weeks (range, 5.6-148.7 weeks), with 63% treated for >52 weeks and 52% undergoing treatment at data cutoff date. The most common grade 3/4 adverse events suspected to be related to study drug were maculopapular rash and arthralgia (2 patients each). No dose-limiting toxicities were observed. Pharmacokinetic analyses showed a dose-dependent increase in AUC0-12 and achievement of adult exposure levels at the recommended phase II doses of 5.25 mg/kg/day (age <12 years) and 4.5 mg/kg/day (age ≥12 years) divided into 2 equal doses daily, not exceeding 300 mg daily.

CONCLUSIONS

In this first clinical trial in pediatric patients with pretreated BRAF V600-mutant tumors, dabrafenib was well tolerated while achieving target exposure levels; the average treatment duration was >1 year with many patients still on treatment. The phase II component is also closed and will be reported separately.

Challenges and opportunities in the care of survivors of adolescent and young adult cancers

Adolescents and young adults (AYA) with cancer are an understudied group. Much of what is known about long-term outcomes after AYA cancer has been derived from cohorts of childhood cancer survivors, which seldom include patients at the older end of the AYA age spectrum. In general, AYA cancer survivors have a lower risk for premature mortality, subsequent primary neoplasms and chronic health conditions than childhood cancer survivors. However, AYA cancer survivors are vulnerable to psychosocial challenges, concerns about fertility and relationships and financial toxicity. No single model is optimal for the care of these survivors, but it is generally agreed that all survivors require a survivor care plan that promotes their adherence to evidence-based surveillance guidelines. There is a need to create survivor cohorts that include the full range of AYA ages and diagnoses to be able to address the many pressing questions that remain unanswered in this vulnerable population.

Perceptions of future health and cancer risk in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study

BACKGROUND

Survivors of childhood cancer are at significant risk for serious chronic health conditions and subsequent cancers because of their prior treatment exposures. However, little is known about survivors' perceptions of their future health risks.

METHODS

This study examined self-reported levels of concern about future health and subsequent cancer in 15,620 adult survivors of childhood cancer (median age, 26 years; median time since diagnosis, 17 years) and 3991 siblings in the Childhood Cancer Survivor Study. The prevalence of concerns was compared between survivors and siblings, and the impact of participant characteristics and treatment exposures on concerns was examined with multivariable modified Poisson regression to estimate relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

A substantial proportion of survivors were not concerned about their future health (31%) or developing cancer (40%). The prevalence of concern in survivors was modestly higher (RR for future health, 1.12; 95% CI, 1.09-1.15) or similar (RR for subsequent cancer, 1.02; 95% CI, 0.99-1.05) in comparison with siblings. Survivors exposed to high doses of radiation (≥20 Gy) were more likely to report concern (RR for future health, 1.13; 95% CI, 1.09-1.16; RR for subsequent cancer, 1.14; 95% CI, 1.10-1.18), but 35% of these high-risk survivors were not concerned about developing cancer, and 24% were not concerned about their future health.

CONCLUSIONS

A substantial subgroup of survivors were unconcerned about their future health and subsequent cancer risks, even after exposure to treatments associated with increased risk. These survivors may be less likely to engage in beneficial screening and risk-reduction activities. Cancer 2018. © 2018 American Cancer Society.

Healthcare system barriers to long-term follow-up for adult survivors of childhood cancer in British Columbia, Canada: a qualitative study

PURPOSE

Risk-stratified life-long follow-up care is recommended for adult childhood cancer survivors (CCS) to ensure appropriate prevention, screening, and management of late effects. The identification of barriers to long-term follow-up (LTFU), particularly in varying healthcare service contexts, is essential to develop and refine services that are responsive to survivor needs. We aimed to explore CCS and healthcare professionals (HCP) perspectives of healthcare system factors that function as barriers to LTFU in British Columbia, Canada.

METHODS

We analyzed data from 43 in-depth interviews, 30 with CCS and 13 with HCP, using qualitative thematic analysis and constant comparative methods.

RESULTS

Barriers to accessible, comprehensive, quality LTFU were associated with the following: (1) the difficult and abrupt transition from pediatric to adult health services, (2) inconvenient and under-resourced health services, (3) shifting patient-HCP relationships, (4) family doctor inadequate experience with late effects management, and (5) overdue and insufficient late effects communication with CCS.

CONCLUSIONS

Structural, informational, and interpersonal/relational healthcare system factors often prevent CCS from initially accessing LTFU after discharge from pediatric oncology programs as well as adversely affecting engagement in ongoing screening, surveillance, and management of late effects.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding the issues faced by adult CCS will provide insight necessary to developing patient-centered healthcare solutions that are key to accessible, acceptable, appropriate, and effective healthcare.

Anxiety Among Adolescent Survivors of Pediatric Cancer

PURPOSE

The purpose of this review was to synthesize current knowledge about anxiety among adolescent survivors of pediatric cancer and highlights areas for future research.

METHODS

Systematic literature searches were conducted in five databases for articles published anytime before December 28, 2015. Manuscripts were reviewed by a team of six coders. Included manuscripts reported outcomes relevant to anxiety, worry, and post-traumatic stress in survivors of pediatric cancer (age at the time of study: 10-22 years) who were off treatment.

RESULTS

Twenty-four articles met inclusion criteria. Included results were categorized into the following domains: post-traumatic stress, anxiety, cancer-related worry, and interventions. With the exception of post-traumatic stress, there was little research about anxiety in this population; however, studies generally indicated that adolescent survivors of pediatric cancer are at elevated risk for anxiety, post-traumatic stress symptoms, and cancer-related worry.

CONCLUSIONS

This review provides preliminary evidence that anxiety is a relevant, but understudied, psychosocial outcome for adolescent survivors of pediatric cancer. More research is needed to better understand the presentation of anxiety in this population, its effect on survivors' quality of life, and possible areas for intervention.

Early Nutrition and Physical Activity Interventions in Childhood Cancer Survivors

PURPOSE OF REVIEW

Childhood cancer survivors experience excessive weight gain early in treatment. Lifestyle interventions need to be initiated early in cancer care to prevent the early onset of obesity and cardiovascular disease (CVD). We reviewed the existing literature on early lifestyle interventions in childhood cancer survivors and consider implications for clinical care.

RECENT FINDINGS

Few lifestyle interventions focus on improving nutrition in childhood cancer survivors. A consistent effect on reducing obesity and CVD risk factors is not evident from the limited number of studies with heterogeneous intervention characteristics, although interventions with a longer duration and follow-up show more promising trends. Future lifestyle interventions should be of a longer duration and include a nutrition component. Interventions with a longer duration and follow-up are needed to assess the timing and sustainability of the intervention effect. Lifestyle interventions introduced early in cancer care are both safe and feasible.

Development of a text messaging system to improve receipt of survivorship care in adolescent and young adult survivors of childhood cancer

PURPOSE

This study aimed to develop and examine the acceptability, feasibility, and usability of a text messaging, or Short Message Service (SMS), system for improving the receipt of survivorship care for adolescent and young adult (AYA) survivors of childhood cancer.

METHODS

Researchers developed and refined the text messaging system based on qualitative data from AYA survivors in an iterative three-stage process. In stage 1, a focus group (n = 4) addressed acceptability; in stage 2, key informant interviews (n = 10) following a 6-week trial addressed feasibility; and in stage 3, key informant interviews (n = 23) following a 6-week trial addressed usability. Qualitative data were analyzed using a constant comparative analytic approach exploring in-depth themes.

RESULTS

The final system includes programmed reminders to schedule and attend late effect screening appointments, tailored suggestions for community resources for cancer survivors, and messages prompting participant feedback regarding the appointments and resources. Participants found the text messaging system an acceptable form of communication, the screening reminders and feedback prompts feasible for improving the receipt of survivorship care, and the tailored suggestions for community resources usable for connecting survivors to relevant services. Participants suggested supplementing survivorship care visits and forming AYA survivor social networks as future implementations for the text messaging system.

CONCLUSIONS

The text messaging system may assist AYA survivors by coordinating late effect screening appointments, facilitating a partnership with the survivorship care team, and connecting survivors with relevant community resources.

IMPLICATIONS FOR CANCER SURVIVORS

The text messaging system has the potential to improve the receipt of survivorship care.

A home-based physical activity intervention using activity trackers in survivors of childhood cancer: A pilot study

BACKGROUND

Over 70% of childhood cancer survivors develop late complications from therapy, many of which can be mitigated by physical activity. Survivors engage in exercise at similar or lower rates than their sedentary healthy peers. We piloted a novel home-based exercise intervention with a motivational activity tracker. We evaluated (i) feasibility, (ii) impact on activity levels and physical fitness, and (iii) barriers, preferences, and beliefs regarding physical activity.

METHODS

Childhood cancer survivors currently 15 years or older and not meeting the Centers for Disease Control and Prevention physical activity guidelines were enrolled and instructed to wear the Fitbit One, a 4.8 cm × 1.8 cm motivational activity tracker, daily for 6 months. Baseline and follow-up evaluations included self-report surveys, an Actigraph accelerometer for 7 days, and a VO₂ maximum test by cardiac stress test.

RESULTS

Nineteen participants were enrolled (13.4% participation rate) with a mean age of 24.3 ± 5.8 years (range 15-35). Four participants withdrew with a 79% retention rate. Participants wore the Fitbit an average of 19.0 ± 4.7 days per month during months 1-3 and 15.0 ± 7.9 days per month during months 4-6. Total weekly moderate to vigorous physical activity increased from 265.6 ± 117.0 to 301.4 ± 135.4 min and VO₂ maximum increased from 25.7 ± 7.7 to 27.2 ± 7.4 ml/kg/min. These changes were not statistically significant (P = 0.47 and 0.30, respectively). Survey responses indicated no change in barriers, preferences, and beliefs regarding physical activity.

CONCLUSIONS

This pilot study of a motivational activity tracker demonstrated feasibility as measured by participant retention, receptivity, and belief of utility. Future studies with a large sample size are needed to demonstrate the efficacy and sustainability of this intervention.

Parental involvement in exercise and diet interventions for childhood cancer survivors: a systematic review

Childhood cancer survivors (CCS) are at risk of becoming overweight or obese due to treatment effects and/or post-treatment behaviors. Parents are key agents influencing child diet and physical activity (PA), which are modifiable risk factors for obesity. A systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was undertaken to evaluate current interventions that include diet and PA elements for CCS to determine if and to what extent parents were included, and whether parent involvement had a significant effect on behavioral outcomes or adiposity. A total of 2,386 potential articles were reviewed and 25 individual studies fulfilled inclusion criteria. Parental involvement was classified into three categories and varied across studies, although most had indirect or no parental involvement. The studies that included direct parental involvement showed positive outcomes on a variety of measures suggesting that increasing parental involvement in interventions for CCS may be one way to promote long-term lifestyle changes for pediatric cancer patients. However, additional research directly addressing parental involvement in obesity prevention and treatment among CCS is warranted.

Nutritional interventions for survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at a higher risk of developing health conditions such as osteoporosis, and cardiovascular disease than their peers. Health-promoting behaviour, such as consuming a healthy diet, could lessen the impact of these chronic issues, yet the prevalence rate of health-protecting behaviour amongst survivors of childhood cancer is similar to that of the general population. Targeted nutritional interventions may prevent or reduce the incidence of these chronic diseases.

OBJECTIVES

The primary aim of this review was to assess the efficacy of a range of nutritional interventions designed to improve the nutritional intake of childhood cancer survivors, as compared to a control group of childhood cancer survivors who did not receive the intervention. Secondary objectives were to assess metabolic and cardiovascular risk factors, measures of weight and body fat distribution, behavioural change, changes in knowledge regarding disease risk and nutritional intake, participants' views of the intervention, measures of health status and quality of life, measures of harm associated with the process or outcomes of the intervention, and cost-effectiveness of the intervention

SEARCH METHODS

We searched the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 3), MEDLINE/PubMed (from 1945 to April 2013), and Embase/Ovid (from 1980 to April 2013). We ran the search again in August 2015; we have not yet fully assessed these results, but we have identified one ongoing trial. We conducted additional searching of ongoing trial registers - the International Standard Randomised Controlled Trial Number register and the National Institutes of Health register (both screened in the first half of 2013) - reference lists of relevant articles and reviews, and conference proceedings of the International Society for Paediatric Oncology and the International Conference on Long-Term Complications of Treatment of Children and Adolescents for Cancer (both 2008 to 2012).

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) that compared the effects of a nutritional intervention with a control group which did not receive the intervention in this review. Participants were childhood cancer survivors of any age, diagnosed with any type of cancer when less than 18 years of age. Participating childhood cancer survivors had completed their treatment with curative intent prior to the intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and extracted data from each identified study, using a standardised form. We assessed the validity of each identified study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We used the GRADE criteria to assess the quality of each trial.

MAIN RESULTS

Three RCTs were eligible for review. A total of 616 participants were included in the analysis. One study included participants who had been treated for acute lymphoblastic leukaemia (ALL) (275 participants). Two studies included participants who had all forms of paediatric malignancies (266 and 75 participants). All participants were less than 21 years of age at study entry. The follow-up ranged from one month to 36 months from the initial assessment. All intended outcomes were not evaluated by each included study. All studies looked at different interventions, and so we were unable to pool results. We could not rule out the presence of bias in any of the studies.There was no clear evidence of a difference in calcium intake at one month between those who received the single, half-day, group-based education that focused on bone health, and those who received standard care (mean difference (MD) 111.60, 95% confidence interval (CI) -258.97 to 482.17; P = 0.56, low quality evidence). A regression analysis, adjusting for baseline calcium intake and changes in knowledge and self-efficacy, showed a significantly greater calcium intake for the intervention as compared with the control group at the one-month follow-up (beta coefficient 4.92, 95% CI 0.33 to 9.52; P = 0.04). There was statistically significant higher, self-reported milk consumption (MD 0.43, 95% CI 0.07 to 0.79; P = 0.02, low quality evidence), number of days on calcium supplementation (MD 11.42, 95% CI 7.11 to 15.73; P < 0.00001, low quality evidence), and use of any calcium supplementation (risk ratio (RR) 3.35, 95% CI 1.86 to 6.04; P < 0.0001, low quality evidence), with those who received this single, face-to-face, group-based, health behaviour session.There was no clear evidence of a difference in bone density Z-scores measured with a dual-energy X-ray absorptiometry (DEXA) scan at 36 months follow-up (MD -0.05, 95% CI -0.26 to 0.16; P = 0.64, moderate quality evidence) between those who received calcium and vitamin D supplementation combined with nutrition education and those who received nutrition education alone. There was also no clear evidence of a difference in bone mineral density between the intervention and the control group at the 12-month (median difference -0.17, P = 0.99) and 24-month follow-up (median difference -0.04, P = 0.54).A single multi-component health behaviour change intervention, focusing on general healthy eating principles, with two telephone follow-ups brought about a 0.17 lower score on the four-point Likert scale of self-reported junk food intake compared with the control group (MD -0.17, 95% CI -0.33 to -0.01; P = 0.04, low quality evidence); this result was statistically significant. There was no clear evidence of a difference between the groups in the self-reported use of nutrition as a health protective behaviour (MD -0.05, 95% CI -0.24 to 0.14; P = 0.60, low quality evidence).

AUTHORS' CONCLUSIONS

Due to a paucity of studies, and the heterogeneity of the studies included in this review, we are unable to draw conclusions regarding the effectiveness of nutritional interventions for use with childhood cancer survivors. Although there is low quality evidence for the improvement in health behaviours using health behaviour change interventions, there remains no evidence as to whether this translates into an improvement in dietary intake. There was also no evidence that the studies reduced the risk of cardiovascular and metabolic disorders in childhood cancer survivors, although no evidence of effect is not the same as evidence of no effect. This review highlights the need for further well designed trials to be implemented in this population.

The Effect of Clinic-Based Health Promotion Education on Perceived Health Status and Health Promotion Behaviors of Adolescent and Young Adult Cancer Survivors

More than 70% of children/adolescents diagnosed with cancer are long-term survivors. Little is known about the health perceptions and practices of this population, and limited previous studies have come exclusively from a risk reduction/health protection model rather than a health promotion model. This study was conducted to describe the perceived health status and health-promoting behaviors of adolescent/young adult cancer survivors. This study used Pender’s revised health promotion model; perceived health status and health-promoting behaviors were measured using the General Health Index (GHRI) and the Health Promoting Lifestyle Profile II (HPLP-II). The sample consisted of 60 cancer survivors 2 years after completion of cancer treatment and attending a survivorship clinic. Mean baseline scores for the GHRI (76.66; SD, 10.41) indicate perceived health status is positive and similar to normative (noncancer survivor) adolescent/young adult samples. Surprisingly, there was no correlation between scores on the GHRI and the HPLP-II in this sample (r = 0.03).

Skin Cancer Surveillance Behaviors Among Childhood Cancer Survivors

The risk of developing skin cancer is elevated among childhood cancer survivors (CCS), particularly among those treated with radiation. This survey study examined the skin cancer surveillance behaviors of 94 CCS. Approximately 48% of CCS had ever conducted skin self-examination (SSE) and 31% had ever received a physician skin examination. Rates of physician skin examination were 2.5 times higher among CCS treated with radiation compared to those without radiation. However, rates of SSEs did not differ based on treatment history. These findings highlight the need to promote skin cancer surveillance as an important aspect of CCS survivorship care.

Follow-up care of adolescent survivors of childhood cancer: The role of health beliefs

BACKGROUND

Little is known about follow-up care attendance of adolescent survivors of childhood cancer, and which factors foster or hinder attendance. Attending follow-up care is especially important for adolescent survivors to allow for a successful transition into adult care. We aimed to (i) describe the proportion of adolescent survivors attending follow-up care; (ii) describe adolescents' health beliefs; and (iii) identify the association of health beliefs, demographic, and medical factors with follow-up care attendance.

PROCEDURE

Of 696 contacted adolescent survivors diagnosed with cancer at ≤ 16 years of age, ≥ 5 years after diagnosis, and aged 16-21 years at study, 465 (66.8%) completed the Swiss Childhood Cancer Survivor Study questionnaire. We assessed follow-up care attendance and health beliefs, and extracted demographic and medical information from the Swiss Childhood Cancer Registry. Cross-sectional data were analyzed using descriptive statistics and logistic regression models.

RESULTS

Overall, 56% of survivors reported attending follow-up care. Most survivors (80%) rated their susceptibility for late effects as low and believed that follow-up care may detect and prevent late effects (92%). Few (13%) believed that follow-up care is not necessary. Two health beliefs were associated with follow-up care attendance (perceived benefits: odds ratio [OR]: 1.56; 95% confidence interval [CI]: 1.07-2.27; perceived barriers: OR: 0.70; 95%CI: 0.50-1.00).

CONCLUSIONS

We show that health beliefs are associated with actual follow-up care attendance of adolescent survivors of childhood cancer. A successful model of health promotion in adolescent survivors should, therefore, highlight the benefits and address the barriers to keep adolescent survivors in follow-up care.

Adult childhood cancer survivors' narratives of managing their health: the unexpected and the unresolved

Purpose

Currently, 80 % of children diagnosed with cancer will be cured. However, many of these survivors go on to develop long-term health problems or late effects related to their previous cancer and therapy and require varying degrees of lifelong follow-up care. The purpose of this study was to identify the different ways that adult survivors of childhood cancer manage their medical and psychological challenges.

Methods

Data from in-depth interviews with 30 adult survivors of a childhood cancer (9 to 38 years after diagnosis, currently 22 to 43 years of age, 60 % women) were analyzed using qualitative, thematic narrative analysis methods.

Results

The survivors had not expected the medical, psychological, and social challenges that arose over time and that often remained unresolved. Five narrative themes revealed distinct ways that survivors managed their health challenges: (1) trying to forget cancer, (2) trusting the system to manage my follow-up care, (3) being proactive about my health, (4) stumbling from one problem to the next, and (5) struggling to find my way.

Conclusions

Variation exists in the ways in which childhood cancer survivors frame their health, their perceived significance of health challenges, strategies used to manage health, interactions with healthcare professionals and the health system, and parental involvement.

Implications for Cancer Survivors

This research provides novel insights that can be used to inform the development of patient-centered health services that promote the assessment and tailoring of care to the diverse ways survivors enact their agency, as well as their psychoeducational coping styles, therapeutic relationship needs, and information needs.

Psychosocial Follow-Up in Survivorship as a Standard of Care in Pediatric Oncology

Childhood cancer survivors (CCS) have a high risk of medical late effects following cancer therapy. Psychosocial late effects are less often recognized. Many CCS do not receive long-term follow-up (LTFU) care, and those who do are rarely screened for psychosocial late effects. An interdisciplinary team conducted a systematic review of qualitative and quantitative studies to assess social, educational, vocational, psychological, and behavioral outcomes along with factors related to receipt of LTFU care. We propose that psychosocial screening be considered a standard of care in long-term follow-up care and that education be provided to promote the use LTFU care starting early in the treatment trajectory.

Needs and Lifestyle Challenges of Adolescents and Young Adults With Cancer: Summary of an Institute of Medicine and Livestrong Foundation Workshop

BACKGROUND

Among adolescents and young adults (AYAs) in the United States, cancer is the leading cause of disease-related death. AYA survivors face numerous short- and long-term health and psychosocial issues, as well as increased risk for behavioral and lifestyle challenges, including poor diet, low physical activity (PA), and substance abuse. Many of these behaviors are modifiable, but gaps in care serve as barriers for AYA survivors.

OBJECTIVES

The purpose of this article is to (a) raise awareness of AYAs' increased risk for poor diet, low PA, and substance abuse; (b) examine previous interventions addressing these issues; and (c) provide recommendations for future directions.

METHODS

This article summarizes a workshop coordinated by the Institute of Medicine and the Livestrong Foundation to address AYA survivors' needs and ways to enhance their quality of care.

FINDINGS

Oncology nurses can promote the inclusion of lifestyle behaviors in survivorship care plans of AYA patients and serve as a valuable resource in improving AYA care on a larger scale. In addition, oncology nurse researchers may offer greater understanding of AYA patients' and survivors' needs and best practices by conducting much-needed research with this understudied population.

Impact of Tailored Education on Awareness of Personal Risk for Therapy-Related Complications Among Childhood Cancer Survivors

Purpose

Survivors of childhood cancer carry a substantial burden of long-term morbidity; personal risk awareness is critical to ensure survivors' engagement in early detection/management of complications. The impact of education provided in survivorship clinics on survivors' understanding of their personal health risks is unclear.

Methods

Patients diagnosed with cancer at age 21 years or younger and at 2 or more years off therapy completed questionnaires about awareness of personal risk for therapy-related complications at T0 (first survivorship clinic visit) and at T1 to T5 (subsequent visits). After questionnaire completion at each clinic visit, survivors received education tailored to personal risk.

Results

A total of 369 survivors completed 1,248 visits (median, three visits; range, one to six visits). The median age at cancer diagnosis was 11 years (range, 0 to 21 years); the median age at T0 was 24 years (range, 5 to 57 years); 38% were white; 45% had leukemia; and 34% received hematopoietic cell transplantation. The cohort was at risk for a median of six (range, one to nine) complications. Awareness increased from 38.6% at T0 to 66.3% at T3. Generalized estimating equations (that adjusted for diagnosis, hematopoietic cell transplantation, race/ethnicity, and patient/parent education) showed significant gains in awareness from T0 to T1 (P < .001), T1 to T2 (P = .03), and T2 to T3 (P < .001) but no significant gain thereafter through T5 (P = .7). Predictors of low awareness included education less than a college degree (odds ratio [OR], 1.9; P = .02), longer time from diagnosis (OR, 1.03/year; P = .04), diagnosis of leukemia (OR, 2.1; P = .004), nonwhite race (OR, 2.8; P < .001), and risk for six or fewer complications (OR, 2.1; P = .002).

Conclusion

Risk-based education in a survivorship clinic significantly increases awareness of personal health risk through three sessions, with saturation thereafter. Vulnerable populations with minimal gain in awareness identified in this study could inform targeted interventions.

Understanding the Health Behaviors of Survivors of Childhood and Young-Adult Cancer: Preliminary Analysis and Model Development

The current study presents preliminary correlational data used to develop a model depicting the psychosocial pathways that lead to the health behaviors of survivors of childhood and young-adult cancer. Data collected from a sample of 18- to 30-year-old cancer survivors (n = 125) was used to examine the relations among interpersonal support and nonsupport, personal agency, avoidance, depressive symptoms and self-efficacy as they related to health behaviors. The outcome measures examined included tobacco and alcohol use, diet, exercise, sunscreen use, medication compliance and follow-up/screening practices. Correlational analyses revealed a number of significant associations among variables. Results are used to inform the development of a health behavior model. Implications for health promotion and survivorship programming are discussed, as well as directions for future research.

[Life style and occupational factors and prevention of second primary cancers after childhood and adolescent cancer: Current state of knowledge]

CONTEXT

Survival of children, adolescents and young adults treated for cancer increased with improved treatments. But there is still an increased risk of second primary cancer (SPC) in the long term compared to the population of the same age, especially related to treatments. A reflection on the follow-up of this population and the prevention of SPC is an important issue.

OBJECTIVES

To perform a synthesis of the available literature on SCP risk factors, related risk behaviors, occupational exposures and prevention strategies.

METHODS

Literature search on PubMed from the following equation: "cancer [Tiab] AND young adult [Tiab] or teen [Tiab] or childhood [Tiab] AND prevention [Tiab] AND survivors [Mesh term]".

RESULTS

Twenty-seven articles were included in this synthesis. Children, adolescents and young adults have similar risk behaviors than those of their peers regarding tobacco, diet and sun exposure; however, they have lower physical activity. There are few studies on prevention strategies focused on this population. Results of available studies remain inconclusive. No publication was found in relation to occupational exposure and risk of second cancer.

CONCLUSIONS

Children, adolescents and young adults treated for cancer are a population at risk and require long-term follow-up and the implementation of effective prevention strategies tailored to this population.

Health Behaviors of Childhood Cancer Survivors

There has been a dramatic increase in the number of childhood cancer survivors living to an old age due to improved cancer treatments. However, these survivors are at risk of numerous late effects as a result of their cancer therapy. Engaging in protective health behaviors and limiting health damaging behaviors are vitally important for these survivors given their increased risks. We reviewed the literature on childhood cancer survivors’ health behaviors by searching for published data and conference proceedings. We examine the prevalence of a variety of health behaviors among childhood cancer survivors, identify significant risk factors, and describe health behavior interventions for survivors.

Comparison of diabetes management status between cancer survivors and the general population: results from a Korean population-based survey

Purpose

This study aimed to determine and compare the prevalences of diabetes awareness, treatment, and adequate glycemic control among cancer survivors in a Korean population and two non-cancer control groups, comprising individuals without a history of cancer but with other chronic diseases (non-cancer, chronic disease controls) and individuals without a history of cancer or any other chronic disease (non-cancer, non-chronic disease controls).

Methods

We analyzed data from 2,660 subjects with prevalent diabetes (aged ≥30 years), who had participated in the 2007–2011 Korea National Health and Nutrition Examination Survey. Awareness was defined as a subject having been diagnosed with diabetes by a clinician. Treatment was defined as a subject who was taking anti-diabetic medicine. Adequate glycemic control was defined as a hemoglobin A1_c level of <7%. Multivariable logistic regression and predictive margins were used to evaluate whether awareness, treatment, or adequate glycemic control differed among cancer survivors and the two non-cancer control groups.

Results

Cancer survivors had greater awareness compared with the non-cancer, chronic disease and non-cancer, non-chronic disease control groups (85.1%, 80.4%, and 60.4%, respectively). Although the prevalences of treatment and adequate glycemic control were higher for survivors compared with the non-cancer, non-chronic disease controls, they were lower compared with the non-cancer, chronic disease controls. The prevalence of diabetes treatment was 67.5% for cancer survivors, 69.5% for non-cancer, chronic disease controls, and 46.7% for non-cancer, non-chronic disease controls; the prevalences of adequate glycemic control in these three groups were 31.7%, 34.6%, and 17.8%, respectively.

Conclusions

Cancer survivors were less likely than the non-cancer chronic disease subjects to receive diabetes management and to achieve adequate glycemic targets. Special attention and education are required to ensure that this population receives optimal diabetes care, and the systematic roles for primary care and specialist physicians need to be determined.

Decline in physical activity level in the Childhood Cancer Survivor Study cohort

BACKGROUND

We aimed to identify demographic and health-related predictors of declining physical activity levels over a four-year period among participants in the Childhood Cancer Survivor Study.

METHODS

Analyses included 7,287 ≥5-year childhood cancer survivors and 2,107 siblings who completed multiple follow-up questionnaires. Participants were classified as active if they met the Centers for Disease Control and Prevention guidelines for physical activity. Generalized linear models were used to compare participants whose physical activity levels declined from active to inactive over the study to those who remained active. In addition, selected chronic conditions (CTCAE v4.03 Grade 3 and 4) were evaluated as risk factors in an analysis limited to survivors only.

RESULTS

The median age at last follow-up among survivors and siblings was 36 (range, 21-58) and 38 (range, 21-62) years, respectively. The rate of decline did not accelerate over time among survivors when compared with siblings. Factors that predicted declining activity included body mass index ≥30 kg/m(2) [RR = 1.32; 95% confidence interval (CI), 1.19-1.46, P < 0.01], not completing high school (RR = 1.31; 95% CI, 1.08-1.60, P < 0.01), and female sex (RR = 1.33; 95% CI, 1.22-1.44, P < 0.01). Declining physical activity levels were associated with the presence of chronic musculoskeletal conditions (P = 0.034), but not with the presence of cardiac (P = 0.10), respiratory (P = 0.92), or neurologic conditions (P = 0.21).

CONCLUSIONS

Interventions designed to maximize physical activity should target female, obese, and less educated survivors. Survivors with chronic musculoskeletal conditions should be monitored, counseled, and/or referred for physical therapy.

IMPACT

Clinicians should be aware of low activity levels among subpopulations of childhood cancer survivors, which may heighten their risk for chronic illness.

Survivors of childhood and adolescent cancer: life-long risks and responsibilities

Survival rates for most paediatric cancers have improved at a remarkable pace over the past four decades. In developed countries, cure is now the probable outcome for most children and adolescents who are diagnosed with cancer: their 5-year survival rate approaches 80%. However, the vast majority of these cancer survivors will have at least one chronic health condition by 40 years of age. The burden of responsibility to understand the long-term morbidity and mortality that is associated with currently successful treatments must be borne by many, including the research and health care communities, survivor advocacy groups, and governmental and policy-making entities.

Innovative educational approaches to engage and empower the adolescent and young adult childhood cancer survivor

There is a long history of challenges when delivering care to adolescents and young adults (AYA) with chronic healthcare needs. For the AYA survivor of childhood cancer, these challenges may include complex medical care, a multitude of psychosocial issues and systemic barriers to care. Educating this population is critical as they assume age-appropriate responsibility for their health and become active partners in their survivorship care. We present our regional experience with educational programming directed to AYA survivors of childhood cancer featuring an innovative approach to engaging and empowering this population.

Recruitment strategies and rates of a multi-site behavioral intervention for adolescents and young adults with cancer

INTRODUCTION

To provide an overview of factors related to recruitment of adolescents and young adults (AYA) into research and recruitment rates and reasons for refusal from a multicenter study entitled "Stories and Music for Adolescent/Young Adult Resilience during Transplant" (SMART).

METHODS

A randomized clinical trial study design was used. The settings included 9 hospitals. The sample included AYAs (aged 11-24 years) who were undergoing a stem cell transplant. Several instruments were used to measure symptom distress, coping, resilience, and quality of life in AYA with cancer.

RESULTS

A total of 113 AYA were recruited (50%) for this study. Strategies were refined as the study continued to address challenges related to recruitment. We provide a description of recruitment strategies and an evaluation of our planning, implementing, and monitoring of recruitment rates for the SMART study.

DISCUSSION

When designing a study, careful consideration must be given to factors influencing recruitment as well as special considerations for unique populations. Dissemination of strategies specific to unique populations will be helpful to the design of future research studies.

Smoking Cessation Interventions and Cessation Rates in the Oncology Population

Objectives

To evaluate tobacco smoking cessation interventions and cessation rates in the oncology population through a systematic review and meta-analysis.

Data Sources

The literature was searched using PubMed, Google Scholar, Medline, EMBASE, and the Cochrane Library (inception to October 2012) by 3 independent review authors.

Review Methods

Studies were included if they were randomized controlled trials (RCTs) or prospective cohort (PCs) studies evaluating tobacco smoking cessation interventions with patients assigned to a usual care or an intervention group. The primary outcome measure was smoking cessation rates. Two authors extracted data independently for each study. When applicable, disagreements were resolved by consensus.

Results

The systematic review identified 10 RCTs and 3 PCs. Statistical analysis was conducted using StatsDirect software (Cheshire, UK). Pooled odds ratios (ORs) for smoking cessation interventions were calculated in 2 groups based on follow-up duration. The therapeutic interventions included counseling, nicotine replacement therapy, buproprion, and varenicline. Smoking cessation interventions had a pooled odds ratio of 1.54 (95% confidence interval [CI], 0.909-2.64) for patients in the shorter follow-up group and 1.31 (95% CI, 0.931-1.84) in the longer follow-up group. Smoking cessation interventions in the perioperative period had a pooled odds ratio of 2.31 (95% CI, 1.32-4.07).

Conclusion

Our systematic review and meta-analysis demonstrate that tobacco cessation interventions in the oncology population, in both the short-term and long-term follow-up groups, do not significantly affect cessation rates. The perioperative period, though, may represent an important teachable moment with regard to smoking cessation.

Do Childhood Cancer Survivors Meet the Diet and Physical Activity Guidelines? A Review of Guidelines and Literature

Despite advances in cancer treatment, childhood cancer survivors are at higher risk of developing chronic health conditions than peers who have not had cancer. Being overweight or obese adds to the already elevated risk of cardiovascular diseases and metabolic abnormalities. Diet and physical activity are modifiable behaviors that reduce obesity risk and have been shown to improve cancer survival in adult cancer survivors. Specific guidelines have been developed for cancer survivors that provide advice on nutrition, physical activity and weight management following cancer diagnosis and treatment. In this review, we report on existing nutrition and physical activity guidelines for cancer survivors, supplemented by available literature on diet and physical activity status of childhood cancer survivors and their associations with health-related outcomes. The 2012 American Cancer Society (ACS) and the 2008 Children’s Oncology Group (COG) guidelines provide similar advice on diet but the ACS guidelines also offer specific advice on physical activity and weight management. Thirty-one observational studies and 18 intervention trials published prior to June 2012 that met the inclusion criteria were reviewed. Results suggest that a high proportion of childhood cancer survivors had poor adherence to dietary and physical activity guidelines. Although findings from existing intervention trials are preliminary due to small sample size, available evidence suggests that exercise intervention is safe and feasible for patients and survivors of childhood cancer. Childhood cancer survivors should be encouraged to engage in physical activity, adopt a healthy diet, and maintain a healthy weight throughout cancer survivorship.

Childhood Cancer Survivor Study participants' perceptions and knowledge of health insurance coverage: implications for the Affordable Care Act

INTRODUCTION

Childhood cancer survivors face long-term health consequences, and comprehensive health insurance is critical. However, childhood cancer survivors may face barriers in accessing medical services due to being uninsured or underinsured. Little is known about the quality of survivors' health insurance coverage, and improving health insurance within the context of changes mandated by the 2010 Affordable Care Act requires understanding survivors' coverage. The current study explored adult childhood cancer survivors' quality of health insurance coverage.

METHODS

From 9/09 to 2/10, we conducted in-depth, semistructured qualitative interviews with 39 adult participants from the Childhood Cancer Survivor Study, a cohort of 5-year survivors of cancers diagnosed before age 21. Interviews were recorded and transcribed; content analyses were conducted by two coders (kappa = 0.88) using NVivo 8.

RESULTS

Most insured survivors reported satisfaction with the quality of their coverage; however, they expressed low expectations. Almost half reported annual out-of-pocket costs exceeding $2,000, yet most felt fortunate to simply have coverage. One third of insured survivors had difficulty obtaining coverage, and many had difficulties understanding how to utilize it. Most uninsured survivors minimized their need for care. Worry about future health care costs seemed inevitable among insured and uninsured survivors. Almost all participants lacked knowledge about existing health insurance-related laws.

CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS

Insured survivors had low coverage expectations, and uninsured survivors avoided care. Childhood cancer survivors will likely benefit from assistance in how to access and utilize the new health care reform provisions (e.g., Medicaid expansion, expansion of parents' insurance, and mandatory primary care coverage).

The impact of cancer on the physical, psychological and social well-being of childhood cancer survivors

PURPOSE

Notwithstanding the advances in medical treatment, childhood cancer survivors are at risk of adverse physical, psychological and social effects of the cancer treatment. The purpose of this study was to examine the impact of cancer and its treatments on the physical, psychological and social well-being of Hong Kong Chinese childhood cancer survivors.

METHOD

A total of 137 childhood cancer survivors (aged 9-16 years), who had their medical follow-up in an oncology out-patient clinic were invited to participate in the study. Participants were asked to respond to the standardized measures of depressive symptoms and self-esteem. Additionally, 15 participants from the group were selected for a semi-structured interview.

RESULTS

The results revealed that more than half of the participants presented depressive symptoms. Results also found that the mean depressive symptom scores for childhood cancer survivors were statistically significant higher than those of school children without cancer (p = 0.01), while the mean self-esteem scores for the survivors were statistically significant lower (p < 0.01). Additionally, qualitative interviews indicated that cancer and its treatments have great impact on the daily life of childhood cancer survivors.

CONCLUSION

The study reveals that cancer and its treatments have a great impact on the physical, psychological and social well-being of survivors. It is essential for healthcare professionals to develop appropriate interventions with the aim of promoting physical, psychological and social well-being for these children. Most importantly, it is crucial to help them develop a positive view of the impact that the cancer experience has upon their lives.

Psychosocial services in the first 30 days after diagnosis: results of a web-based survey of Children's Oncology Group (COG) member institutions

BACKGROUND

This study examines what proportion of families of recently diagnosed pediatric cancer patients are offered recommended psychosocial services, and if that proportion is linked to size of institution or number of psychosocial staff.

PROCEDURES

A web-based survey was offered to all institutions belonging to the Children's Oncology Group (COG).

RESULTS

Respondents from 127/212 (=59.9%) COG institutions provided information about percentage of families offered specific services within the first 30 days after diagnosis, and barriers to providing such services, as well as information about other factors that might affect their ability to provide psychosocial care. All sites reported that ≥50% of families are offered 21 of the 27 services investigated in this study. Over half of respondents (n=290) indicated that inadequate funding for staff (72%) and families' time constraints (63%) were barriers to providing psychosocial care. There was a positive relationship between the total number of psychosocial staff and the number of new patients seen annually (Pearson correlation=0.3409, P-value < 0.0004), but not between the total number of psychosocial staff and specific services offered. Most sites do not use validated assessment tools or evidence-based psychosocial interventions.

CONCLUSIONS

While some version of most recommended psychosocial services are offered across COG institutions, evidence-based psychosocial services are offered at only 11% of sites. Advances in psychosocial outcomes in pediatric oncology could be accelerated by multi-site collaboration, use of standardized assessment tools, and evidence-based interventions.

Health behaviors and weight status of childhood cancer survivors and their parents: similarities and opportunities for joint interventions

Childhood cancer survivors are at increased risk for chronic health conditions that may be influenced by their cancer treatment and unhealthy lifestyle behaviors. Despite the possibility that interventions targeting the survivor-parent dyad may hold promise for this population, a clearer understanding of the role of family factors and the lifestyle behaviors of both survivors and parents is needed. A mailed cross-sectional survey was conducted in 2009 to assess weight status (body mass index), lifestyle behaviors (eg, diet, physical activity), and the quality of the parent-child relationship among 170 childhood cancer survivors who were treated at MD Anderson Cancer Center and 114 of their parents (80% mothers). Survivors were more physically active and consumed more fruits and vegetables than their parents. However, fewer than half of survivors or parents met national guidelines for diet and physical activity, and their weight status and fat intakes were moderately correlated (r=.30-.57; P<0.001). Multilevel models showed that, compared with survivors with better than average relationships, those with poorer than average relationships with their parents were significantly more likely to consume high-fat diets (P<0.05). Survivors and their parents may thus benefit from interventions that address common lifestyle behaviors, as well as issues in the family environment that may contribute to an unhealthy lifestyle.