Clinic audit for long-term survivors of childhood cancer

"It just never ends": Childhood cancer survivors' perceived psychosocial impacts of recurrence and second cancer

OBJECTIVES

Childhood cancer survivors are at risk of developing primary recurrences and new second cancers. Experiencing a recurrence and/or second cancer can be highly distressing for survivors and families. We aimed to understand the psychological impacts of experiencing a recurrence or second cancer and how this potentially influences survivors' engagement with survivorship care.

METHODS

We invited childhood cancer survivors or their parents if survivors were ≤16 years of age from 11 tertiary pediatric oncology hospitals across Australia and New Zealand to complete interviews. We conducted a thematic analysis facilitated by NVivo12.

RESULTS

We interviewed 21 participants of whom 16 had experienced a recurrence, 3 had a second cancer, and 2 had both a recurrence and second cancer. Participants reported that a recurrence/second cancer was a stressful sudden disruption to life, accompanied by strong feelings of uncertainty. Participants tended to be less aware of their second cancer risk than recurrence risk. Some participants reported feelings of anxiousness and despair, describing varying responses such as gratitude or avoidance. Participants shared that the fear of cancer recurrence either motivated them to adopt protective health behaviors or to avoid information and disengage from survivorship care.

SIGNIFICANCE OF RESULTS

Some survivors and their parents have a poor understanding and expressed reluctance to receive information about their risk of second cancer and other treatment-related late effects. Improving the delivery of information about late effects to families may improve their engagement with survivorship care and surveillance, although care must be taken to balance information provision and survivors' anxieties about their future health.

Caring for survivors of childhood cancer: it takes a village

PURPOSE OF REVIEW

Over 80% of children diagnosed with cancer are now cured. The burgeoning population of survivors of childhood cancer experiences high rates of morbidity and mortality due to 'late-effects' of treatment. These can be defined as any consequence of treatment that persists beyond or develops after the completion of cancer therapy. Awareness of late-effects is critically important for pediatricians and adult providers alike, as late-effects impact children in proximity to cancer treatment, as well as adults many decades removed. This review presents the importance of lifelong follow-up care for survivors, highlights existing screening guidelines, and reviews various models of survivor care.

RECENT FINDINGS

National and international guidelines have been developed to standardize screening for survivors, and multiple models of survivorship care exist. The optimal model likely depends on individual factors, including the survivor's needs and preferences, as well as local resources. Key strategies for the successful care of survivors include accurate risk-stratification for specific late-effects, individualized screening plans, education of survivors and professionals, clear communication between providers, and well coordinated transition of care across services.

SUMMARY

Early identification and management of late-effects are important for survivors of childhood cancer. Providers should be familiar with the risks for specific late-effects and have access to screening guidelines. The strengths and weaknesses of care models, along with individual circumstances, should be considered in designing the optimal approach to care for each survivor.

'Re-engage' pilot study protocol: a nurse-led eHealth intervention to re-engage, educate and empower childhood cancer survivors

INTRODUCTION

Many childhood cancer survivors are disengaged from cancer-related follow-up care despite being at high risk of treatment-related late effects. Innovative models of long-term follow-up (LTFU) care to manage ongoing treatment-related complications are needed. 'Re-engage' is a nurse-led eHealth intervention designed to improve survivors' health-related self-efficacy, targeted at survivors disengaged from follow-up. Re-engage aims to overcome survivor- and parent-reported barriers to care and ensure survivors receive the care most appropriate to their risk level.

METHODS AND ANALYSIS

This study will recruit 30 Australian childhood cancer survivors who are not receiving any cancer-related care. Participation involves two online/telephone consultations with a survivorship nurse for medical assessment, a case review, risk stratification and creation of a care plan by a multidisciplinary team of specialists. We will assess the feasibility of implementing 'Re-engage' and its acceptability to participants and health professionals involved. The primary outcome will be survivors' health-related self-efficacy, measured at baseline and 1 and 6 months postintervention. Secondary outcomes will include the effect of 'Re-engage' on survivors' health behaviours and beliefs, engagement in healthcare, information needs and emotional well-being. We will also document the cost per patient to deliver 'Re-engage'. If Re-engage is acceptable, feasible and demonstrates early efficacy, it may have the potential to empower survivors in coordinating their complex care, improving survivors' long-term engagement and satisfaction with care. Ideally, it will be implemented into clinical practice to recall survivors lost to follow-up and reduce the ongoing burden of treatment for childhood cancer.

ETHICS AND DISSEMINATION

The study protocol has been approved by the South Eastern Sydney Local Health District Human Research Ethics Committee (reference number: 16/366). The results will be disseminated in peer-reviewed journals and at scientific conferences. A lay summary will be published on the Behavioural Sciences Unit website.

TRIAL REGISTRATION NUMBER

ACTRN12618000194268.

Health promotion and information provision during long-term follow-up for childhood cancer survivors: A service evaluation

Health promotion is an important component of long-term follow-up (LTFU) care for childhood cancer survivors (CCS). However, little information exists about how survivors perceive their own health promotion needs. As part of a service evaluation, 51 CCS who had previously attended the LTFU clinic took part in a single semistructured interview to seek their views on information they had received regarding late adverse effects (LAEs) of treatment, the purpose of LTFU, and the provision of health promotion information. Although most (93%) CCS were satisfied with the information received about LAEs, 37% desired further details. Over half (59%) believed that the purpose of LTFU was to screen for LAEs, whereas 31% felt that it was to check for relapse. No survivor reported health promotion to be an aim of LTFU; only 14% of CCS expected to receive healthy lifestyle advice, and fewer than 10% wanted dietary and physical activity advice. Most (88%) CCS felt that their hospital-based health care professional was best placed to give healthy lifestyle advice, but there was no consensus about the optimum timing for health promotion. CCS varied in their knowledge, needs, and wishes regarding LTFU care. The results of this evaluation strongly indicate that the profile of health promotion needs to be raised within our service and identifies issues that may be pertinent to similar services. Further research is needed to understand the views of CCS regarding health promotion and lifestyle behaviors, with the aim of tailoring and improving the delivery of effective health education to CCS.

Preferences for long-term follow-up care in childhood cancer survivors

Follow-up care is important for childhood cancer survivors to facilitate early detection and treatment of late effects. We aimed to describe preferences for different organisational aspects and models of follow-up care among Swiss childhood cancer survivors, and characteristics associated with preferences for different models. We contacted 720 survivors aged 18+ years, diagnosed with cancer after 1990 (age 0-16 years), registered in the Swiss Childhood Cancer Registry (SCCR), and Swiss resident, who previously participated in a baseline survey. They received questionnaires to assess attendance and preferences for follow-up (rated on 4-point scales, 0-3). Clinical information was available from the SCCR. Survivors (n = 314: response rate 43.6%; 47.8% still attended follow-up) rated clinical reasons for follow-up higher than supportive reasons (p < .001). They rated checking for cancer recurrence (mean = 2.78, SD = 0.53) and knowing about risks for my children most important (mean = 2.22, SD = 0.83). They preferred to attend a children's hospital (mean = 1.94, SD = 1.11), adult hospital (mean = 1.86, SD = 0.98) or general practitioner (mean = 1.86, SD = 1.01) rather than a central specialised late effects clinic (mean = 1.25, SD = 1.06, p < .001), and be seen by paediatric (mean = 2.24, SD = 0.72) or medical oncologist (mean = 2.17, SD = 0.69). Survivors preferred decentralised clinic-based follow-up, rather than one central specialised late effects clinic. Survivors' preferences should be considered to ensure future attendance.

A systematic review of models of care for the follow-up of childhood cancer survivors

Follow-up care for survivors of childhood cancer is increasingly seen as a priority service as numbers of survivors increase. Despite this there are few published evaluations of the available options. We conducted a systematic review of published and unpublished literature. Seven uncontrolled studies, and one comparative study of a related intervention, were identified. Observational data suggest that follow-up care was useful even for patients who did not perceive this as a need. Suitably powered, well-conducted, controlled trials of adequate duration that directly compare follow-up models are required to provide robust evidence on the optimal care for these patients.

Adult survivors of childhood malignant lymphoma are not aware of their risk of late effects

PURPOSE

Survivors after malignant lymphoma are at high risk of late effects. In order to take full responsibility for their own health they need knowledge about their diagnosis, treatment and risk of late effects. We assessed such knowledge in adult survivors of childhood malignant lymphoma.

MATERIAL AND METHODS

In 2007-2009 128 five-year survivors after childhood malignant lymphoma participated in a national cross-sectional questionnaire-based survey combined with clinical examination. [Males: 69, females: 59, treatment period 1970-2000, median age (range) at diagnosis: 14 years (0-18), at survey: 32 years (19-55), Hodgkin lymphoma (HL): 84, Non-Hodgkin lymphoma (NHL): 44]. Prior to the clinical examination a semi-structured interview on the survivors' knowledge was conducted by a study nurse. The individual survivors' responses were compared with his/her medical record.

RESULTS

One hundred and twenty one reported their diagnosis correctly, seven reported that they had cancer, but could not specify malignant lymphoma. Thirty-three could not differentiate between HL and NHL. One hundred and twenty three reported their treatment modalities correctly (radiotherapy vs. chemotherapy vs. combined). Eighty-five (66%) were not aware of any risks for late effects. The remaining 43 listed at least one of the following late effects; infertility, heart-problems, impaired dental status, hypothyroidism, breast cancer, reduced muscle growth, fatigue and reduced memory or concentration. Thirty-seven survivors who provided additional comments reported that they had received some information about risk of late effects from their therapists. Age at diagnosis or educational level were not associated with knowledge about possible late effects while treatment period was.

CONCLUSIONS

Norwegian long-term survivors of childhood malignant lymphomas are showing improved level of knowledge of their diagnosis and treatment modalities during the last decade. Still, independent of age at diagnosis and level of education, they are insufficiently aware of their risk of late effects.

Long-term effects of radiation exposure among adult survivors of childhood cancer: results from the childhood cancer survivor study

In the last four decades, advances in therapies for primary cancers have improved overall survival for childhood cancer. Currently, almost 80% of children will survive beyond 5 years from diagnosis of their primary malignancy. These improved outcomes have resulted in a growing population of childhood cancer survivors. Radiation therapy, while an essential component of primary treatment for many childhood malignancies, has been associated with risk of long-term adverse outcomes. The Childhood Cancer Survivor Study (CCSS), a retrospective cohort of over 14,000 survivors of childhood cancer diagnosed between 1970 and 1986, has been an important resource to quantify associations between radiation therapy and risk of long-term adverse health and quality of life outcomes. Radiation therapy has been associated with increased risk for late mortality, development of second neoplasms, obesity, and pulmonary, cardiac and thyroid dysfunction as well as an increased overall risk for chronic health conditions. Importantly, the CCSS has provided more precise estimates for a number of dose-response relationships, including those for radiation therapy and development of subsequent malignant neoplasms of the central nervous system, thyroid and breast. Ongoing study of childhood cancer survivors is needed to establish long-term risks and to evaluate the impact of newer techniques such as conformal radiation therapy or proton-beam therapy.

Survey of childhood cancer survivors who stopped follow-up physician visits

BACKGROUND

Childhood cancer cure rates have increased remarkably; however, survivors face an increased risk of morbidity and mortality. Survivors may benefit from anticipatory guidance and periodic surveillance to minimize morbidity and mortality.

METHODS

Subjects included 114 5-year survivors of childhood cancer who were diagnosed and treated in three hospitals in Nagoya between 1975 and 2001 and who stopped follow-up physician visits during the preceding 2 years. We conducted a survey of their socioeconomic status, knowledge about their diagnosis and late effects of treatment received, and current hospital attendance patterns.

RESULTS

Eighty-eight of 114 subjects replied. Sixty-six survivors knew about their disease, but only 26 knew about possible late effects of cancer treatment. Although 78 respondents indicated they were healthy and had no trouble in their daily lives, 46 had at least one chronic condition. In response to the question regarding why they did not visit the hospital regularly, many subjects responded that the physician-in-charge told them they did not need to visit the hospital anymore; others thought it was unnecessary to consult a physician because they were in good health.

CONCLUSIONS

Some cancer survivors who stop follow-up physician visits may still be suffering from cancer-related illnesses. Both survivor-related and physician-related barriers contribute to cancer survivors stopping follow-up physician visits. To ensure that survivors undergo appropriate follow-up visits, it is necessary to educate survivors, their families, and medical staff about the late effects of cancer and its treatment and the importance of long-term follow up.

Differences in activities of daily living performance between long-term pediatric sarcoma survivors and a matched comparison group on standardized testing

BACKGROUND

In a cross-sectional study examining late effects of pediatric sarcoma therapy, long-term survivors were evaluated on their activities of daily living (ADL) performance.

PROCEDURE

Thirty-two persons with Ewing sarcoma family of tumors, rhabdomyosarcoma, and non-rhabdomysarcoma-soft tissue sarcoma enrolled an average of 17 years after treatment. Participants were evaluated using the Assessment of Motor and Process Skills (AMPS) 1, a standardized observational evaluation of ADL task performance. Means and 95% confidence intervals for ADL motor and ADL process ability measures were calculated for four groups: (1) sarcoma survivors, (2) "well" adults matched for age and gender, (3) "well" adults matched for gender that were 10 years older, and (4) "well" adults matched for gender that were 20 years older.

RESULTS

ADL motor ability was significantly lower for sarcoma survivors than for the age- and gender-matched comparison group (P < 0.05). There was no significant difference between ADL motor ability of sarcoma survivors and the comparison group 10 years older, but sarcoma survivors had significantly better ADL motor ability (P < 0.05) than the oldest comparison group (20 years older). Sarcoma survivors had significantly worse ADL process ability than the age-matched group (P < 0.05). There was no difference in ADL process ability between the sarcoma survivors and comparison groups that were 10 and 20 years older.

CONCLUSIONS

This first report of a clinical evaluation of ADL limitation in pediatric sarcoma survivors treated with intensive multimodal cancer therapy suggests that influences on performance of daily life activities are more common than previously reported.

Follow-up care for young adult survivors of cancer: lessons from pediatrics

INTRODUCTION

Recent advances in treatment of childhood cancer have resulted in overall survival rates approaching 75%, but approximately two-thirds experience late-effects related to the disease or treatment. Consequently, recommendations for comprehensive follow-up have been made. As the number of survivors of adult cancers increase, similar concerns about how to provide follow-up and achieve optimal quality of life are being raised. In this paper we propose that management of cancer survivors diagnosed in young adulthood (18-45 years) could benefit from experience gained treating survivors of childhood cancer.

MATERIALS AND METHODS

We reviewed research relating to differences in survival rates and late-effects; current arrangements for follow-up; effectiveness; and problems in organization of follow-up separately for survivors of child and adult cancers.

RESULTS

A number of models of follow-up were identified. Rationale for follow-up included early identification and treatment of second cancer and late-effects, health promotion and screening. Increasing numbers of survivors and range of late-effects were identified as problems in organizing services. A possible solution is risk-stratified follow-up, currently being developed in pediatrics.

CONCLUSIONS

New models of follow-up are needed that take account of financial costs for health services and survivors' concerns about their current and future health. Implications for continuing refinement of treatment protocols must be an integral part of the service.

IMPLICATIONS FOR CANCER SURVIVORS

International standards are needed to ensure all survivors have access to expert follow-up care and can benefit from new information that might lead to earlier treatment of late-effects.

A review of long-term follow-up for survivors of childhood cancer

Though cure from cancer is not guaranteed, children's chances of survival have increased significantly. As a result the paediatric oncology community is focused on providing appropriate follow-up care to an increasing number of young cancer survivors. How this care should be designed and delivered however remains the centre of ongoing discussion and was the focus of this review. The aims of the review were to (1) gain an understanding of current follow-up practices from studies involving health care professionals, (2) identify and evaluate studies presenting views of survivors, (3) examine commentaries on both the current and future design of long-term follow-up services and (4) evaluate existing follow-up guidelines. Empirical research, commentary papers and published guidelines were reviewed. Twenty-eight papers and five guidelines were analysed. Empirical papers were examined in relation to sample, design, findings and limitations. Commentary papers were assessed in relation to key issues about follow-up care. Guidelines were assessed on how far they were evidence-based, peer-reviewed and involved users in their development. Varying models of care were illustrated, and were dependent upon personnel and centre orientation. Variability in the level and degree to which long-term survivors were followed up was also reported. Inconsistencies in practice were noted. Nonetheless requirements for an effective service were highlighted in the majority of publications, these included communication and information. Although young people and professionals had a shared view on many aspects of follow-up care, these preferences were not consistently mirrored in service provision.

Follow-up after childhood cancer: evaluation of a three-level model

INTRODUCTION

Follow-up for cancer survivors is recommended to detect recurrence; monitor late-effects; record toxicity and provide care and education. We describe our experience with a three-level model developed to guide decisions about intensity and frequency of follow-up [Wallace WHB, Blacklay A, Eiser C, et al. Developing strategies for the long term follow-up of survivors of childhood cancer. BMJ 2001;323:271-274].

PROCEDURE

One hundred and ninety eight survivors (52% male) recruited over 12-months: (mean age=23.8 years, range=16-39 years; mean time since diagnosis=16.2 years, range 2.4-32.7 years) reported their number of symptoms and late-effects. Information was taken from the medical records to assign each survivor to the appropriate levels by six clinic staff independently.

RESULTS

The survivors were assigned to level 1 (n=8), level 2 (n=97) and level 3 (n=93). There were seven cases of disagreement. Level 3 survivors self-reported more symptoms and late-effects than level 2 survivors.

CONCLUSIONS

Coding was relatively simple for experienced clinic staff, although there were some disagreements for the survivors of ALL. The relationship between assigned level and self-reported symptoms and late-effects provides some evidence for validity of the model. We conclude that it is important to maintain flexibility to allow movement between levels for individual patients and that the default should always be to the higher level.

Long-term follow-up of people who have survived cancer during childhood

Substantial improvements in survival after treatment for malignant disease in childhood are leading to a rapidly increasing number of long-term survivors, many of whom are now adults. However, late chronic adverse effects of treatment are common, and have potentially severe effects on survivors' future physical, cognitive, or psychosocial health. The aim of long-term follow-up is to facilitate timely diagnosis and appropriate management of late adverse effects, thereby reducing the frequency of severe complications. Although the delivery of long-term follow-up care varies substantially--particularly in terms of who provides it, where, and how--recognition of the importance of appropriate multidisciplinary care and cross-speciality care is increasing, especially for adolescent and adult survivors of cancer during childhood. Several models of long-term follow-up care have been developed to address this need. This review discusses the present provision of long-term follow-up, and summarises information that might facilitate design and implementation of future models of long-term follow-up care.

Predictors of clinic satisfaction among adult survivors of childhood cancer

Childhood cancer survivors experience a wide range of late-effects. As survival rates improve, follow-up in paediatric clinics becomes less feasible, and alternative models of care have been proposed. In this study, satisfaction among those attending a traditional paediatric late-effects clinic was compared with a multi-disciplinary clinic in an adult setting. Survivors (adult clinic n=93, paediatric clinic n=105, age 16-39 years) completed measures of symptoms, understanding of vulnerability to late-effects, purpose of follow-up, satisfaction and number of topics discussed. Predictors of satisfaction were: number of topics discussed, greater understanding of the purpose of follow-up and sex. Females, and those reporting longer waiting time were less satisfied. Aspects of clinic organisation, including shorter waiting times and opportunities to discuss health concerns, are more important in determining patient satisfaction than clinic type. Survivors' understanding of the purpose of follow-up is also integral in determining satisfaction.

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

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

Caring for survivors of childhood cancers: the size of the problem

Many survivors of childhood cancer have significant health problems due to their illness or treatment. This population-based study examines the number of long-term survivors, their disabilities and consequent long-term care needs. Survival rates for children diagnosed with cancer between 1960 and 1999 in the West Midlands, United Kingdom (UK), were used to estimate future long-term survivor numbers. Treatment and late effects data on a cohort of patients surviving for more than 5 years were used to consider continuing care needs. Between the 1960s and 1990s, 5-year survival increased from 23% to 70%. There were 98 5-year survivors in 1970, and numbers may exceed 2,100 by the end of 2005. Most (at least 61%) survivors in the West Midlands Region have one or more chronic medical problems and may require multidisciplinary care. We conclude that, in order to determine how to provide cost-effective care for this increasing population, protocol delivered management with audit is needed.

Follow-up care for childhood cancer survivors: A focus group analysis

Follow-up of survivors of childhood cancer is recommended to improve detection of late-effects, and provide individuals with information and advice. This study aimed to follow-up survivors of childhood cancer and report on their attitudes to current follow-up methods. Twenty-six survivors (13-25 years) of childhood cancer and their parent(s) attended focus groups (n = 7) to discuss views about follow-up care. Transcripts were analysed using interpretative phenomenological analysis (IPA). Three themes were identified: strategies to achieve a normal life (through playing down possibility of late-effects or careful monitoring of health); expectations about follow-up (facts and information, advice about self-care, everyday living, and psychosocial consequences) and preferences for different models of care. Given that some families had reservations about the benefits of follow-up, it is important that services address survivors' interests and meet their expectations. Changes to service delivery must take account of individual needs and expectations. Possible limitations of focus group methods (recruitment, bias reduction, methods of analysis and influence of other participants' views) are discussed.

Health promotion for survivors of childhood cancer: a minimal intervention

We report the evaluation of an information booklet aimed to explain the purpose of follow-up to survivors of childhood cancer. Evaluations drew on theoretical concepts in the elaboration likelihood and stages of change models. We predicted that survivors who adopt central rather than peripheral processing would show greater understanding and increased readiness to change health behaviour. Forty-eight survivors were shown an example page of the booklet in the clinic and then completed questionnaires about attitude to clinic, readiness to change behaviour, and the importance and scariness of the information. They were then given the whole booklet and asked to complete a second questionnaire at home. After reading the booklet, survivors reported a more positive attitude to clinic. Survivors using central processing rated information as more important and were more ready to change health behaviour than peripheral processors. We recommend that methods to encourage central processing should be routinely included when providing children with health information.

Fertility issues for young adult survivors of childhood cancer

BACKGROUND

The effects of cancer and its treatment on reproduction and fertility are well-documented, yet knowledge of the psychosocial and behavioral ramifications of these outcomes for young adult survivors of childhood cancer is limited. As a qualitative exploratory study, this work identifies concerns, attitudes, and behaviors that may be associated with childhood cancer survivors' reproductive capacity.

PROCEDURE

As part of a semi-structured interview assessing the impact of cancer on long-term survivors' quality of life, a convenience sample of 32 childhood cancer survivors between the ages of 19-37 and at least five years beyond diagnosis were asked if they had physical limitations as a result of their cancer or treatment, and if having cancer has affected their ability to have children.

RESULTS

These data are organized around two major themes: (1) survivors' reproductive capacity and (2) their attitudes, experiences and concerns about children and parenting. Fifty-nine percent of survivors reported that they are uncertain about their fertility status, and half recall a parent or health care provider ever mentioning potential reproductive problems associated with their past cancer treatment.

CONCLUSIONS

While some survivors profess to know nothing about their risks for infertility, others possess and recall information that influences their personal relationships, their beliefs about having children, and possibly subsequent decisions and behaviors with regard to having children.

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

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

Having children after cancer. A pilot survey of survivors' attitudes and experiences

BACKGROUND

Although the prevalence of infertility after cancer treatment and the health of the offspring of survivors have been studied, little information has been available about survivors' attitudes, emotions, and choices with regard to having children.

METHODS

A questionnaire was received by 283 patients from the Cleveland Clinic Foundation tumor registry who were diagnosed before age 35 years, were age 18 years or older at the time of the survey, and were free of disease. The SF-36, a measure of health-related quality of life, was included, as well as questions about demographic and medical background, reproductive and fertility history, and a variety of concerns about having children after cancer.

RESULTS

The response rate to the survey was 47%, yielding a sample of 43 men and 89 women who had had cancer at various sites. Their mean age at diagnosis was 26 years and the mean time since diagnosis was 5 years. Before cancer, 35% had at least 1 child, compared with 46% currently. Of those currently childless, 76% want children in the future. Although about half of the entire sample view themselves as having impaired fertility, only 6% have undergone infertility treatment. Nineteen percent have significant anxiety that their cancer treatment could impact negatively on their children's future health. Of women, 18% fear that a pregnancy could trigger a cancer recurrence. Only 57% received information from their health care providers about infertility after cancer. Other reproductive concerns were discussed less often. Only 24% of childless men banked sperm before treatment. SF-36 scores were very similar to normative data for healthy Americans of similar age. About 80% of the sample viewed themselves positively as actual or potential parents. Feeling healthy enough to be a good parent after cancer was the strongest predictor (P < 0.001) of emotional well-being as measured by the Mental Component Score of the SF-36.

CONCLUSIONS

The great majority of younger cancer survivors see their cancer experience as potentially making them better parents. Those who are childless want to have children in the future. Many, however, are left with significant anxieties and insufficient information about reproductive issues.

Psychosocial aspects of infertility and decisions about reproduction in young cancer survivors: a review

BACKGROUND

Several types of cancer treatment interfere with male and female fertility or can complicate pregnancy. Rates of birth defects and cancer have also been studied in the offspring of cancer survivors. Little is known, however, about the impact of a history of cancer on survivors' attitudes, anxieties, and choices about having children of their own.

PROCEDURE

We review the relevant literature on cancer survivor's concerns about infertility and childbearing and propose areas for future research.

RESULTS

We generate several hypotheses, including that cancer survivors will be more distressed than infertility patients without a major medical disorder, that survivors diagnosed in adolescence will have the most anxieties about parenthood, that women will be more distressed over infertility and more concerned about their children's health than men, that survivors who rate their overall quality of life more negatively will be less concerned about infertility and more apt to decide to forego parenthood, that survivors of inheritable cancer syndromes will have more distress about childbearing issues than other survivors, and that survivors who do have children after treatment will perceive them more positively than do parents who have not confronted cancer.

CONCLUSIONS

Research on the emotional aspects of infertility after cancer and on the factors that influence survivors' decisions about having children assumes increasing importance with the growth in number of survivors of reproductive age.

Development and evaluation of an information booklet for adult survivors of cancer in childhood. The United Kingdom Children's Cancer Study Group Late Effects Group

AIMS

To determine the need for information among survivors of childhood cancer, to assess the acceptability of an information booklet, and to investigate the effectiveness of the booklet in increasing knowledge and influencing health related behaviours.

SUBJECTS

Fifty survivors of childhood cancer (age range 14-32 years) who were consecutive attendees at a long term follow up clinic.

METHODS

The booklet was developed for young people aged 14 years and above by the United Kingdom Children's Cancer Study Group Late Effects Group. Included is information about treatment of cancer, general advice about a healthy lifestyle, the rationale for long term follow up, and information about employment and life insurance problems. Survivors were interviewed at the follow up clinic, offered the booklet, and contacted approximately one week later for a telephone interview. The clinic interview assessed survivor's understanding of their illness and treatment and its impact on their lives, and their preferences for further information. The telephone interview determined survivors' general reaction to the booklet, whether it increased knowledge and influenced health related behaviours.

RESULTS

All those interviewed accepted the written information and agreed to a follow up interview. Survivors were enthusiastic about being given more information. Over three quarters learned new information from the booklet. There were no indications that the information was associated with anxiety for any demographic or clinical subgroups. After reading the booklet there was an increased awareness of the risk from sunbathing (p < 0.05), and greater appreciation of the importance of follow up (p < 0.05).

CONCLUSIONS

These results suggest that written information is likely to be an acceptable and effective supplement to discussions with medical professionals and may readily be incorporated into long term follow up clinics.

The Role of Monitoring in Determining Quality of Life Following Treatment for A Bone Tumor

Interviews were conducted with 34 young people who had previously been treated for a malignant bone tumor around the knee. These interviews focused on the impact of treatment on activities and perceptions of the risk of recurrence and need for future surgery A coding schema based on a "monitoring-blunting" framework was adopted (Miller, 1995). Quality of life was assessed using a generic and disease-specific measure. Based on interview data, respondents were categorized as negativistic monitors, adaptive monitors, and nonmonitors. There were no differences between groups in terms medical indicators (number of operations). Negativistic monitors reported poorer quality of life compared with the other two groups. There was no increase in nonmonitoring with time since diagnosis as reported in previous work. It is suggested that patients' self-ratings of quality of life are related to the way in which they monitor information and this may be independent of clinical function. Clinical implications, especially in terms of how potentially threatening information about late-effects of treatment are given to patients, are discussed.