Development of health-related quality of life and symptoms of anxiety and depression among persons diagnosed with cancer during adolescence: a 10-year follow-up study

Factors Affecting Psychosocial Distress in Adolescents and Young Adults with Cancer: BRIGHTLIGHT Cross-Sectional and Longitudinal Cohort Study Results

BACKGROUND/OBJECTIVES

AYAs face unique psychosocial challenges compared to younger children and older adults. Little published data exists about symptoms of psychological distress in AYAs, particularly in large cohorts over time. This study aimed to (1) explore relationships between distress and variables known to impact mental health, (2) examine distress over time, and (3) consult with a patient and public involvement group (Young Advisory Panel, YAP) to contextualize the results.

METHODS

Secondary data analyses were conducted from a multicentre longitudinal cohort study, which recruited 830 participants aged 13-24 years newly diagnosed with different cancers. The mean age was 20.1 (SD 3.3) and 45% were female. Bespoke surveys, including a validated measure of psychosocial distress, were administered five times over 3 years following diagnosis. Participatory workshops were conducted with the YAP to gather their impressions of the study results and inform conclusions.

RESULTS

At the first time point, higher social support was associated with higher distress scores (β = 0.202, p < 0.001) and AYAs with higher depressive symptoms were more likely to see a mental health professional (p < 0.01). Over time, anxiety symptoms remained stable (p = 0.090); however, depressive symptoms improved (p < 0.001). The YAP highlighted the mixed effects of social support and the under-recognition and undertreatment of distress.

CONCLUSIONS

This information identifies key targets, such as social support, that can inform the design of personalized screening and intervention tools. It also highlights specific timepoints at which these efforts can be directed to mitigate distress and improve quality of life. Future research should include longer-term follow-up, qualitative explorations of distress along the disease trajectory, and ongoing co-production efforts.

Examining the emotional healing process through bibliotherapy in adolescents with cancer: A qualitative descriptive study

PURPOSE

This study aimed to investigate how interactive bibliotherapy impacted the emotional healing process of adolescents with cancer, drawing upon the three-stage emotional healing process theory-identification, catharsis, and insight.

METHOD

A qualitative descriptive study was conducted on data from 14 adolescents, aged 10-19 years, diagnosed with or relapsing from leukemia or osteosarcoma within the past two years. Participants received two interactive bibliotherapy sessions using The Rabbit Listened and You Are Special. Data were collected through semistructured interviews and content analyzed.

RESULTS

Analysis identified six themes in The Rabbit Listened and eight in You Are Special. Adolescents primarily engaged in identification, empathizing with protagonists and recalling personal experiences. They underwent catharsis, releasing negative emotions and fostering positivity. Insights emerged on companionship, listening, and others' criticism.

CONCLUSIONS

Our study validates the use of the three-stage emotional healing process in interdisciplinary bibliotherapy for understanding emotional changes in adolescents with cancer. It sheds light on their concerns and coping strategies. Healthcare practitioners can utilize interactive bibliotherapy based on this framework to initiate therapeutic communication with adolescent cancer patients and improve interventions and care.

Longitudinal changes of psychological distress among childhood cancer survivors: The Swiss Childhood Cancer Survivor Study

BACKGROUND

Childhood cancer survivors may experience psychological distress due to the disease, cancer treatments, and potential late effects. Limited knowledge exists regarding longitudinal changes in psychological distress after childhood cancer. We aimed to determine changes in psychological distress over time and explore determinants of changes.

METHODS

The Swiss Childhood Cancer Survivor Study collected data at baseline (2007-2009) and follow-up (2010-2012). Psychological distress was measured using the Brief Symptom Inventory 18 (BSI-18), including three symptom scales (somatization, depression, anxiety) and an overall distress index (Global Severity Index, GSI). Sum-scores were T-standardized (mean = 50; standard deviation [SD] = 10). Survivors with a score ≥57 on the GSI or two symptom scales were classified as cases with distress. We used linear mixed effects regression to identify potential sociodemographic and clinical determinants of change in psychological distress.

RESULTS

We analyzed 696 survivors at baseline (mean age = 24 years [SD = 4], 49% females, mean time since diagnosis = 16 years [SD = 4]). On follow-up (2.4 years, SD = 1), 317 survivors were analyzed, including 302 participants with repeated measures. We found that 13% (39/302) were cases at baseline, and 25% (76/302) were cases on follow-up. Those older at study and longer since diagnosis, females, diagnosed with central nervous system (CNS) tumors, and those reporting late effects were more likely to experience higher levels of distress. Females and unemployed are at higher risk for developing or persisting psychological distress than males and those who are employed or in training.

CONCLUSION

We observed an increase in psychological distress score over time, with higher proportion of psychological distress on follow-up. Anticipatory guidance and screening should be implemented in regular follow-up care.

Prevalence and risk of psychological distress, anxiety and depression in adolescent and young adult (AYA) cancer survivors: A systematic review and meta-analysis

BACKGROUND

Adolescent and young adult (AYA) cancer survivors (CS) face unique psychosocial challenges, which may affect their mental health. However, there are inconsistencies in AYA definitions and varying prevalence data on psychological distress, anxiety, and depression. We aimed to synthesize published literature on prevalence, risk, longitudinal changes, and predictors for these outcomes and estimate pooled prevalences.

METHODS

We searched for observational studies published in English before June 1 2022, in PubMed, PsycINFO, Scopus, and Web of Science. Two researchers extracted independently information on study characteristics, prevalence, and risk. The pooled prevalence (PP) of psychological distress, anxiety, and depression was estimated using random-effects models. Geographical region, treatment status, and assessment instruments were considered in stratified meta-analyses.

RESULTS

Sixty-eight studies were included in the systematic review and 57 in the meta-analyses. We estimated an overall prevalence of 32% (n = 30; 4226/15,213 AYAs; 95% CI, 23%-42%; I2  = 99%) for psychological distress, 29% for anxiety (n = 24; 2828/8751 AYAs; 95% CI, 23%-36%; I2  = 98%), and 24% (n = 35; 3428/16,638 AYAs; 95% CI, 18%-31%; I2  = 98%) for depression. The range of PP of psychological distress varied across geographical regions, treatment status, and assessment instruments. The PP of anxiety varied significantly across continents, while no variations were seen for depression. Studies found higher risks for psychological distress, anxiety, and depression in AYAs compared to older cancer survivors or cancer-free peers.

CONCLUSIONS

Our research found that one in three AYA-CS experience psychological distress or anxiety and one in four are affected by depression, highlighting the need for specialized psychological services for AYA-CS in oncology settings and AYA-focused interventions.

Food Insecurity and Nutritional Challenges in Adolescent and Young Adult Cancer Survivors in the U.S.A.: A Narrative Review and Call to Action

Advancements in cancer treatments over the past several decades have led to improved cancer survival in adolescents and young adults (AYAs, ages 15–39 years). However, AYA cancer survivors are at an increased risk for “late effects”, including cardiovascular, pulmonary and bone diseases as well as fatigue, infertility and secondary cancers. The treatments for cancer may also alter taste, lead to nutritional deficiencies and increase financial burdens that, when taken together, may increase the risk of food and nutrition security in AYA cancer survivors. Furthermore, although AYAs are often merged together in cancer survivorship studies, adolescents and young adults have distinct developmental, psychosocial and pathophysiological differences that may modify their risk of nutritional challenges. In this narrative review and “Call to Action”, rationale is provided for why there is a need to better understand nutritional challenges and food insecurity in AYA cancer survivors as a special population. Then, recommendations for next steps to advance knowledge and policy in this field are provided. In particular, integrating screening for food and nutrition insecurity and enhancing awareness of existing resources (e.g., the Supplemental Nutrition Assistance Program, SNAP) might help AYA cancer survivors combat nutritional deficiencies and reduce late effects while improving their overall survival and quality of life.

Prevalence and associated factors of psychological distress among young adult cancer patients in Japan

OBJECTIVES

Adolescent and young adult (AYA) cancer patients may be at high risk of experiencing psychological distress because their diagnosis came during a key time of consolidation of identity and social growth. This study aimed (1) to examine the prevalence of psychological distress among AYA cancer patients within a year of diagnosis to long-term survivors and (2) to describe socio-demographic and cancer-related characteristics associated with psychological distress.

METHODS

In a cross-sectional web-based survey, patients who scored 5 or more on the Kessler Psychological Distress Scale were assessed for significant psychological distress. Logistic regression examined whether demographics, clinical variables, and social support were associated with psychological distress.

RESULTS

A total of 206 young adult cancer patients participated. The median age at the survey was 34.5 years (range: 22-39 years), and 87.4% were female. The prevalence of psychological distress was 55.3%. Psychological distress among patients diagnosed within a year and long-term survivors (≥10 years since diagnosis) was significantly higher than patients 1-4 years since diagnosis. Pain, decrease in income after a cancer diagnosis, experience of negative change in work/school after a cancer diagnosis and poor social support were significantly associated with psychological distress.

SIGNIFICANCE OF RESULTS

Over half of young adult patients had significant psychological distress in Japan. Our findings potentially contribute to the intervention components for distress management among AYA cancer survivors.

What Proportion of Patients With Musculoskeletal Sarcomas Demostrate Symptoms of Depression or Anxiety?

BACKGROUND

It is estimated that the 12-month prevalence of depression in the United States is 8.6%, and for anxiety it is 2.9%. Although prior studies have evaluated depression and anxiety in patients with carcinoma, few have specifically evaluated patients with sarcoma, who often have unique treatment considerations such as mobility changes after surgery.

QUESTIONS/PURPOSES

We evaluated patients with sarcoma seen in our orthopaedic oncology clinic to determine (1) the proportion of patients with depression symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the nine-item Patient Health Questionnaire (PHQ-9), and if their symptoms varied by disease state; (2) the proportion of patients with anxiety symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the seven-item Generalized Anxiety Disorder Scale (GAD-7), and if they symptoms varied by disease state; (3) whether other factors were associated with the proportion and severity of symptoms of anxiety or depression, such as tumor location in the body (axial skeleton, upper extremity, or lower extremity), general type of tumor (bone or soft tissue), specific diagnosis, use of chemotherapy, length of follow-up (less than 1 year or greater than 1 year), and gender; and (4) what proportion of patients accepted referrals to mental health professionals, when offered.

METHODS

This study was a cross-sectional survey study performed at a single urban National Cancer Institute-designated Comprehensive Cancer Center from April 2021 until July 2021. All patients seen in the orthopaedic clinic 18 years of age and older with a diagnosis/presumed diagnosis of sarcoma were provided the PHQ-9 as well as the GAD-7 in our clinic. We did not track those who elected not to complete the surveys. Surveys were scored per survey protocol (each question was scored from 0 to 3 and summed). Specifically, PHQ-9 scores the symptoms of depression as 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). The GAD-7 scores symptoms of anxiety as 5 to 9 (mild), 10 to 14 (moderate), and 15 to 21 (severe). Patients with PHQ-9 or GAD-7 scores of 10 to 14 were referred to social work and those with scores 15 or higher were referred to psychiatry. Patients with thoughts of self-harm were referred regardless of score. Patients were divided based on disease state: patients during their initial management; patients with active, locally recurrent disease; patients with active metastatic disease; patients with prior recurrence or metastatic lesions who were subsequently treated and now have no evidence of disease (considered to be patients with discontinuous no evidence of disease); patients with no evidence of disease; and patients with an active, noncancerous complication but otherwise no evidence of disease. We additionally looked at the association of gender, chemotherapy administration, and tumor location on survey responses. Data are summarized using descriptive statistics. Differences across categories of disease state were tested for statistical significance using Kruskal-Wallis tests for continuous variables and Fisher exact tests for categorical variables as well as pairwise Wilcoxon rank sum tests.

RESULTS

Overall, symptoms of depression were seen in 35% (67 of 190) of patients, at varying levels of severity: 19% (37 of 190) had mild symptoms, 9% (17 of 190) had moderate symptoms, 6% (12 of 190) had moderately severe symptoms, and 1% (1 of 190) had severe symptoms. Depresssion symptoms severe enough to trigger a referral were seen in 17% (32 of 190) of patients overall. Patients scored higher on the PHQ-9 during their initial treatment or when they had recurrent or metastatic disease, and they were more likely to trigger a referral during those timepoints as well. The mean PHQ-9 was 5.7 ± 5.8 during initial treatment, 6.1 ± 4.9 with metastatic disease, and 7.4 ± 5.2 with recurrent disease as compared with 3.2 ± 4.2 if there was no evidence of disease (p = 0.001). Anxiety symptoms were seen in 33% (61 of 185) of patients: 17% (32 of 185) had mild symptoms, 8% (14 of 185) had moderate symptoms, and 8% (15 of 185) had severe symptoms. Anxiety symptoms severe enough to trigger a referral were seen in 16% (29 of 185) of patients overall. Patients scored higher on the GAD-7 during initial treatment and when they had recurrent disease or an active noncancerous complication. The mean GAD-7 was 6.3 ± 3.2 in patients with active noncancerous complications, 6.8 ± 5.8 in patients during initial treatment, and 8.4 ± 8.3 in patients with recurrent disease as compared with 3.1 ± 4.2 in patients with no evidence of disease (p = 0.002). Patients were more likely to trigger a referral during initial treatment (32% [9 of 28]) and with recurrent disease (43% [6 of 14]) compared with those with no evidence of disease (9% [9 of 97]) and those with discontinuous no evidence of disease (6% [1 of 16]; p = 0.004). There was an increase in both PHQ-9 and GAD-7 scores among patients who had chemotherapy. Other factors that were associated with higher PHQ-9 scores were location of tumor (upper extremity versus lower extremity or axial skeleton) and gender. Another factor that was associated with higher GAD-7 scores included general category of diagnosis (bone versus soft tissue sarcoma). Specific diagnosis and length of follow-up had no association with symptoms of depression or anxiety. Overall, 22% (41 of 190) of patients were offered referrals to mental health professionals; 73% (30 of 41) accepted the referral.

CONCLUSION

When treating patients with sarcoma, consideration should be given to potential concomitant psychiatric symptoms. Screening, especially at the highest-risk timepoints such as at the initial diagnosis and the time of recurrence, should be considered. Further work should be done to determine the effect of early psychiatric referral on patient-related outcomes and healthcare costs.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Comparison of Psychological Quality of Life Between Long-term Survivors of Childhood Cancer and Their Families

Purpose: Although treatment outcomes for childhood cancer have improved in recent years, some patients continue to experience physical symptoms and psychological stress several years after the end of treatment. This study aimed to examine the correlation between the quality-of-life (QOL) scores of childhood cancer survivors (CCSs) aged 18-39 and (1) their families and (2) the time since the end of treatment. Methods: Measuring the QOL of CCSs attending the long-term follow-up (LTFU) and those of their families. The Short-Form Health Survey (SF-36) was used for CCSs and the Caregiver Quality of Life Index-Cancer (CQOLC) for their families. Spearman's rank correlation analyses were used to examine the relationship between the CCSs' and their families' QOL and the time since the end of treatment. Results: Twenty-nine CCSs (mean age, 24.2 years; mean the time since the end of treatment, 13.9 years), each paired with one family member, were included. Time since the end of treatment was positively correlated with the CCSs' QOL on the physical component score (ρ = 0.42, p = 0.03) and negatively correlated with mental health (MH) (ρ = -0.50, p = 0.01), a subscale of the mental component score (MCS). Furthermore, the CCSs' QOL on the MCS was positively correlated with their families' QOL scores (ρ = 0.58, p < 0.01). Conclusion: Psychological stress may persist in CCSs long after treatment, even when physical symptoms improve. Therefore, it is necessary to establish a comprehensive support system for the LTFU of CCSs, including MH care and QOL monitoring for patients and their families.

Identification of Evidence for Key Positive Psychological Constructs in Pediatric and Adolescent/Young Adult Patients with Cancer: A Scoping Review

Introduction: Children and adolescents/young adults (AYAs) with cancer are a vulnerable population susceptible to numerous late effects, such as fatigue and depression, which may diminish their long-term psychological, physical, spiritual, and emotional health. A well-rounded understanding of how positive psychological constructs affect the quality of care and treatment outcomes is therefore warranted. Methods: We conducted a scoping review of 15 positive psychological constructs in children and AYAs with cancer. The primary research questions were (1) what is known about positive psychological constructs in children and AYAs with cancer; (2) what value is ascribed to these constructs by patients? Results: Two hundred seventy-six articles were included after database search and screening. These studies were mostly observational or qualitative and conducted in North America. Constructs were often poorly defined, and measurement tools used to gather data were wide ranging. Numerous factors were correlated with increased or decreased expression of certain constructs, but overall themes were difficult to identify. Similarly, patients often spoke of what increased or decreased expression of a construct, with less emphasis on what they implicitly value. Discussion: This scoping review found ample evidence for what increases or decreases expression of positive psychological constructs, but this evidence was observational and often conflicting. In the future, we recommend the development of a core set of psychological outcomes, with definitions and corresponding measurement tools. We further recommend an emphasis on randomized trials to more rigorously study how expression of constructs can be improved and what effect this has on the quality of life.

Help-seeking behaviour and attitudes towards internet-administered psychological support among adolescent and young adults previously treated for cancer during childhood: protocol for a survey and embedded qualitative interview study in Sweden

INTRODUCTION

A subgroup of adolescent and young adult childhood cancer survivors (AYACCS) are at increased risk of psychological distress. Despite this, AYACCS experience difficulties accessing psychological support. E-mental health (e-MH) may offer a solution to reduce this treatment gap. However, research examining e-MH for AYACCS has experienced difficulties with recruitment, retention and adherence. Such difficulties may relate to: (1) help-seeking behaviour and/or (2) e-MH acceptability. The overall study aims are to: (1) examine potential associations between health service use factors, informed by Andersen's behavioural model of health services use, and help-seeking behaviour; (2) examine attitudes towards e-MH interventions; and (3) explore perceived need for mental health support; past experience of receiving mental health support; preferences for support; and barriers and facilitators to help-seeking.

METHODS AND ANALYSIS

An online and paper-based cross-sectional self-report survey (98 items) and embedded qualitative interview study across Sweden, with a target sample size of n=365. Participants are aged 16-39 years, diagnosed with cancer when 0-18 years and have completed successful cancer treatment. The survey examines sociodemographic and clinical characteristics, actual help-seeking behaviour, attitudes towards e-MH, stigma of mental illness, mental health literacy, social support and current symptoms of depression, anxiety, and stress. Survey respondents with past and/or current experience of mental health difficulties are invited into the qualitative interview study to explore: (1) perceived need for mental health support; (2) past experience of receiving mental health support; (3) preferences for support; and (4) barriers and facilitators to help-seeking. Potential associations between health service use factors and help-seeking behaviour are examined using univariable and multivariable logistic regressions. Qualitative interviews are analysed using content analysis.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Swedish Ethical Review Authority (Dnr: 2020-06271). Results will be disseminated in scientific publications and academic conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN70570236.

Moderating effect of sense of coherence on the relationship between symptom distress and health-related quality of life in patients receiving cancer chemotherapy

PURPOSE

This study is aimed at examining the buffering effect of sense of coherence (SOC) on symptom distress during cancer drug therapy, which thereby affects health-related quality of life (QoL), and obtaining suggestions for promoting supportive care.

METHODS

We investigated health-related QoL (SF-8), symptom distress (using the Symptom Distress Scale (SDS)), and SOC (the SOC 13-item Scale) in 66 patients receiving adjuvant chemotherapy for non-small cell lung cancer. We employed descriptive statistics to seek the correlation of each variable; then, a hierarchical multiple regression analysis was conducted with SF-8 score as the dependent variable.

RESULTS

Results showed that significant changes in bodily pain showed a buffering effect on the SDS and sense of comprehensibility (β = - 0.658, p < 0.01, β = - 0.319, p < 0.05), sense of manageability (β = - 0.658, p < 0.01, β = 0.398, p < 0.01), and meaningfulness (β = - 0.658, p < 0.01, β = - 0.257, p < 0.05). Significant changes in general health perception showed a buffering effect on the SDS and sense of manageability (β = - 0.406, p < 0.01, β = 0.329, p < 0.05). As a result of the simple inclination test, SOC proved to be effective under high levels of symptom distress; the buffering effect of sense of manageability was reversed regarding bodily pain; and when meaningfulness was lower, it had a positive effect on QoL.

CONCLUSION

This study revealed that SOC exerts a buffering effect in situations where symptoms are highly painful. It also revealed that the effect of SOC was reversed for bodily pain and that a high SOC had a negative effect on QoL.

A review of psychological symptoms and post-traumatic growth among adolescent and young adult survivors of childhood cancer

The majority of childhood cancer patients survive well into adulthood, but remain at risk for psychological late effects that can impact overall health and quality of life. The current narrative review summarizes the literature on psychological late effects, including anxiety, depression, psychological distress, post-traumatic stress disorder, suicidality, psychoactive medication use, and post-traumatic growth in survivors of childhood cancers. While results were mixed, many studies demonstrated that psychological symptoms occurred at levels higher than would be expected in the general population. Treatment, environmental, and behavioral risk factors, as well as symptom onset and trajectory merit further investigation.

ESGO-SIOPE guidelines for the management of adolescents and young adults with non-epithelial ovarian cancers

The European Society of Gynaecological Oncology and the European Society for Paediatric Oncology jointly developed clinically relevant and evidence-based guidelines for the management of adolescents and young adults aged 15 to 25 years with non-epithelial ovarian cancers, including malignant ovarian germ cell tumours, sex cord-stromal tumours, and small cell carcinoma of the ovary of hypercalcaemic type. The developmental process of these guidelines is based on a systematic literature review and critical appraisal process involving an international multidisciplinary developmental group consisting of experts from relevant disciplines (paediatric oncology, paediatric surgery, medical oncology, pathology, psycho-oncology, gynaecological oncology, and reproductive endocrinology). Given the specific and often complex issues involved in treating this group of patients, fertility sparing surgery and decrease of acute and long-term toxicities from treatment were important criteria for guidelines definition. Prior to publication, the guidelines were reviewed by 54 independent international practitioners in cancer care delivery.

Heeding the psychological concerns of young cancer survivors: a single-arm feasibility trial of CBT and a cognitive behavioral conceptualization of distress

Background

A subgroup of adolescent and young adult (AYA) survivors of cancer during adolescence report high levels of psychological distress. To date, evidence-based psychological interventions tailored to the cancer-related concerns experienced by this population are lacking. The present study aimed to (1) examine the feasibility and preliminary efficacy of an individualized cognitive behavioral therapy (CBT) intervention for AYA survivors of cancer during adolescence; and (2) identify and conceptualize cancer-related concerns as well as maintaining factors using cognitive-behavioral theory.

Methods

A single-arm trial, whereby AYA survivors of cancer during adolescence (aged 17–25 years) were provided individualized face-to-face CBT at a maximum of 15 sessions. Clinical outcomes were assessed at baseline, post-intervention, and three-month follow-up. Intervention uptake, retention, intervention delivery, and reliable change index scores were examined. An embedded qualitative study consisted of two unstructured interviews with each participant pre-intervention. Along with individual behavioral case formulations developed to guide the intervention, interview data was analyzed to identify and conceptualize cancer-related concerns and potential maintaining factors.

Results

Ten out of 213 potential participants invited into the study were included, resulting in an overall participation rate of 4.7%. Nine participants completed the intervention, with respectively seven and eight participants completing the post-intervention and three month follow-up assessment. The majority of reported cancer-related concerns and maintaining factors were conceptualized into four themes: social avoidance, fear of emotions and bodily symptoms, imbalance in activity, and worry and rumination.

Conclusions

Given significant recruitment difficulties, further research is required to examine barriers to help-seeking in the AYA cancer survivor population. However, the conceptualization of cancer-related concerns and maintaining factors experienced by the population may represent an important first step in the development of psychological support tailored toward AYA cancer survivors’ unique needs.

Severe fatigue after treatment for childhood cancer

BACKGROUND

Treatment strategies for childhood cancer are improving, resulting in higher survival rates. However, the consequences of childhood cancer do not end with the successful completion of cancer treatment. Most patients will develop late effects after cessation of treatment. Severe fatigue is seen as a common and debilitating late effect in cancer survivors. Although most research on fatigue has been performed in patients after adult-onset cancer, our review focuses on fatigue after childhood cancer.

OBJECTIVES

To estimate the prevalence of severe fatigue after treatment for childhood cancer. Secondary objectives are to describe the course of severe fatigue following cancer treatment and to examine risk factors for fatigue, or factors associated with it.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019; issue 8 March 2019), MEDLINE/PubMed (from 1945 to 8 March 2019), Embase/Ovid (from 1947 to 8 March 2019), reference lists of included articles and several conference proceedings from 2011 to 2018.

SELECTION CRITERIA

Observational studies, randomised controlled trials and controlled clinical trials reporting on fatigue in participants after treatment for childhood cancer. Case series and case reports were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risks of bias. If the publication did not present the prevalence of severe fatigue, we contacted study authors for additional information.

MAIN RESULTS

We included 30 studies (18,682 participants in total). Eighteen studies contributed to the main objective and 22 studies contributed to the secondary objectives. We found substantial differences between studies in cancer diagnosis, cancer treatment, age of participants, questionnaires used to assess fatigue, and sample size. All included studies scored at least one 'Risk of bias' item as unclear or high risk. We identified both clinical and statistical heterogeneity and therefore could not pool results, so we present them descriptively. Eighteen studies (describing 14,573 survivors) reported the prevalence of severe fatigue, which ranged from 0% to 61.7%. In a subgroup of three studies including children aged up to 18 years at fatigue assessment (268 survivors), prevalence rates ranged from 6.7% to 12.5%. In comparison, in a subgroup of 12 studies including participants aged 16 and over (13,952 survivors), prevalence rates ranged from 4.4% to 61.7%. The prevalence of severe fatigue in a subgroup of survivors of haematological cancer was presented in seven studies and ranged from 1.8% to 35.9% (1907 survivors). Prevalence of severe fatigue in brain cancer survivors was presented in two studies (252 survivors) and was 14.6% and 21.1% respectively. One study presented a prevalence for bone cancer survivors of 0.0% (17 survivors). Four studies provided prevalence rates of severe fatigue in control groups of siblings or population-based controls, which ranged from 3.1% to 10.3%. In these four studies, survivors were more often fatigued than controls, but this difference was statistically significant in only two studies. Studies assessing risk and associated factors for fatigue were heterogeneous, and definitions of the factors under study were often inconsistent, with results therefore presented descriptively. They found that depression might be associated with fatigue. In contrast, age at diagnosis and education level did not seem to be associated with fatigue. We were unable to calculate any overall risk estimate for any of the reported risks and associated factors, because we could not conduct meta-analysis. One study provided information about the course of fatigue over time, and found that over the course of 2.7 years, 32 of the 102 participants (31.4%) reported persistent severe fatigue.

AUTHORS' CONCLUSIONS

It is unclear how many childhood cancer survivors suffer from severe fatigue. This review encountered several difficulties. We found statistical and clinical heterogeneity and great variation in the reporting of possible risk and associated factors. The evidence in this review is therefore weak, and the exact prevalence of severe fatigue after treatment for childhood cancer remains to be determined. This is also the case for the course of severe fatigue following treatment and the strength of the relationship between fatigue and associated and risk factors. Despite these limitations, our review does provide a comprehensive overview of the existing literature about severe fatigue after treatment for childhood cancer.

The Relationship between Anxiety and Immunity in Pediatric Oncology Patients

Background: Pediatric onco-hematology is not a frequently encountered medical specialty, and it influences everyday life, basic activities, and the immune system, mostly through psychosocial changes, which may affect every individual and their families differently. Anxiety is the most frequently encountered mental health disorder occurring during childhood and adolescence. The effect of stress and anxiety on the immune system is suggested by the fact that stress hormones elevate proinflammatory cytokines and subsequently lower the anti-inflammatory response.

Objective: Our main objective was to analyze the relationship between anxiety disturbance and cytokine levels in oncologic pediatric patients from Târgu Mureș in order to answer the following question: does anxiety influence immunity?

Material and methods: After testing pediatric oncology patients from the Pediatrics Clinic no. 2 of Târgu Mureș, Romania with the SCARED child test, we took blood samples from each participant. IL-6, IL-10, IL-1β, IL-12p40 and TNF-α levels were evaluated with a Human Cytokine Magnetic Panel using the xMAP technique on Flexmap 3D platform (Luminex Corporation, Austin, USA). C-reactive protein levels were determined with the BN Pro Spec nephelometer with CardioPhase hsCRP (Siemens Healthcare Diagnostics, GmbH, Marburg, Germany) reagent.

Results: The 46 pediatric oncology patients had 6 main diagnostic groups, the most frequent pathology was acute leukemia (58.7%) followed by malignant solid tumors (21.74%) and lymphomas (6.52%). In the anxious group (45.65%) we observed 4 of the 5 studied anxiety types: panic disorder, separation, social, and generalized anxiety. We measured the cytokine levels of all the participants from the two main groups: anxious/non-anxious. Statistical analysis (linear regression) showed statistically significant positive correlations in the anxious group related to the IL-1β and IL-6, a moderate/weak correlation related to IL-12p40, as well as a negative moderate correlation between IL-10 values in the anxious group and a positive trend in the non-anxious group.

Conclusions: Psycho-oncology is a relatively young specialty with few studies in the last two decades. IL-1β, IL-6, and TNF-α present high levels in anxious patients, while IL-10 and IL-12p40 have low serum levels in mental disorders. C-reactive protein levels are not influenced by anxiety.

Health-Related Quality of Life Among Survivors of Cancer in Adolescence: An Integrative Literature Review

PROBLEM

Adolescence is a critical developmental period, but little research is available on the quality of life for individuals ages 10-19, especially those who have faced a life-threatening illness. This integrative review examines factors related to quality of life among survivors of a childhood cancer that occurred during adolescence.

ELIGIBILITY CRITERIA

The Garrard Matrix Method guided this review of studies that were conducted from 1990 to 2017. Studies were eligible if participants were diagnosed with cancer during adolescence, the studies followed survivorship from cancer diagnosis to treatment completion, and health-related quality of life measures were taken.

SAMPLE

Fifteen articles met the inclusion criteria.

RESULTS

Most survivors of a childhood cancer that occurred during adolescence reported physical and psychological health-related quality of life scores similar to, or higher than, healthy controls. Risk factors for poorer quality of life were type of cancer, type of treatment, late effects, and time since diagnosis. Factors for better quality of life were older age, positive feelings such as happiness and optimism, social support, and coping strategies. Most studies used the Short Form-36 and the PedsQL Generic Core Scales to measure quality of life.

CONCLUSIONS

Protective factors such as social support and subjective feelings positively affected quality of life.

IMPLICATIONS

In order to promote the best patient outcomes, relevant protective factors that improve quality of life should be incorporated in long-term care plans for survivors of a childhood cancer that occurred during adolescence.

Purchases of antidepressants after cancer at a young age in Finland

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

Exploration of psychological distress experienced by survivors of adolescent cancer reporting a need for psychological support

Objective

In this qualitative study, we aimed to provide an in-depth exploration of cancer-related psychological distress experienced by young survivors of cancer during adolescence reporting a need for psychological support.

Methods

Two individual interviews were held with ten young survivors of cancer diagnosed in adolescence. The interviews were audio-recorded and transcribed verbatim. Analysis followed the guidelines for inductive qualitative manifest content analysis.

Results

The survivors described distress experienced during and after the end of treatment. Five categories comprising 14 subcategories were generated. The categories included: A tough treatment, Marked and hindered, Not feeling good enough, Struggling with the fragility of life, and finally, An ongoing battle with emotions.

Conclusion

Young survivors of adolescent cancer reporting a need for psychological support described feeling physically, socially, and mentally marked by the cancer experience. They struggled with powerlessness, insecurity, social disconnection, loneliness, and feelings of being unimportant and a failure, and had difficulties understanding and managing their experiences. These concerns should be addressed in psychological treatments for the population irrespective of which approach or model is used to understand survivors’ difficulties. A trans-diagnostic approach targeting processes that underpin different manifestations of distress may be effective.

Guided internet-administered self-help to reduce symptoms of anxiety and depression among adolescents and young adults diagnosed with cancer during adolescence (U-CARE: YoungCan): a study protocol for a feasibility trial

INTRODUCTION

A subgroup of adolescents and young adults diagnosed with cancer during adolescence reports elevated levels of anxiety and depressive symptoms and unmet needs for psychological support. Evidence-based psychological treatments tailored for this population are lacking. This protocol describes a feasibility study of a guided-internet-administered self-help programme (YoungCan) primarily targeting symptoms of anxiety and depression among young persons diagnosed with cancer during adolescence and of the planned study procedures for a future controlled trial.

METHODS/ANALYSIS

The study is an uncontrolled feasibility trial with a pre-post and 3-month follow-up design. Potential participants aged 15-25 years, diagnosed with cancer during adolescence, will be identified via the Swedish Childhood Cancer Registry. 30 participants will be included. Participants will receive YoungCan, a 12-week therapist-guided, internet-administered self-help programme consisting primarily of cognitive-behavioural therapy organised into individually assigned modules targeting depressive symptoms, worry and anxiety, body dissatisfaction and post-traumatic stress. Interactive peer support and psychoeducative functions are also available. Feasibility outcomes include: recruitment and eligibility criteria; data collection; attrition; resources needed to complete the study and programme; safety procedures; participants' and therapists' adherence to the programme; and participants' acceptability of the programme and study methodology. Additionally, mechanisms of impact will be explored and data regarding symptoms of anxiety, depression, post-traumatic stress, body dissatisfaction, reactions to social interactions, quality of life, axis I diagnoses according to the Mini International Neuropsychiatric Interview and healthcare service use will be collected. Exploratory analyses of changes in targeted outcomes will be conducted.

ETHICS/DISSEMINATION

This feasibility protocol was approved by the Regional Ethical Review Board in Uppsala, Sweden (ref: 2016/210). Findings will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals and presentations at scientific and clinical conferences.

TRIAL REGISTRATION NUMBER

ISRCTN97835363.

Development of health-related quality of life and symptoms of anxiety and depression among persons diagnosed with cancer during adolescence: a 10-year follow-up study

OBJECTIVE

The main aim was to investigate the development of health-related quality of life (HRQOL) and symptoms of anxiety and depression in a cohort diagnosed with cancer during adolescence from shortly after up to 10 years after diagnosis.

METHODS

Participants (n = 61) completed the SF-36 and the HADS shortly; six, 12, and 18 months; and two, three, four, and 10 years (n = 28) after diagnosis. Polynomial change trajectories were used to model development.

RESULTS

Polynomial change trajectories showed an initial increase which abated over time into a decrease which abated over time for the SF-36 subscales Mental Health and Vitality; an initial decline which abated over time into an increase for HADS anxiety; and an initial decline which abated over time into an increase which abated over time for HADS depression. The SF-36 mental component summary showed no change from two to 10 years after diagnosis whereas the SF-36 physical component summary showed an increase from two years after diagnosis which declined over time. Ten years after diagnosis 29% reported possible anxiety.

CONCLUSIONS

Development of HRQOL and symptoms of anxiety and depression appears to be non-linear among persons diagnosed with cancer during adolescence. Well into permanent survivorship an increase in symptoms of anxiety is shown and approximately a third of the participants report possible anxiety. The findings indicate the need for: studies designed to pinpoint the times of highest psychological risk, clinical follow-up focusing on psychological problems, and development of effective psychological interventions for survivors of adolescent cancer. © 2015 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.