Unemployment Following Childhood Cancer

Insurance, legal, and financial hardships of childhood and adolescent cancer survivors-a systematic review

PURPOSE

Childhood and adolescent cancer survivors (CACS) experience medical and psychosocial adverse effects. Attention widens to include issues such as socio-bureaucratic hardships. This systematic review synthesized the available evidence on insurance, legal, and financial hardships to better understand the broader picture of socio-bureaucratic hardships as distinct but interrelated types of hardships.

METHODS

A systematic search of PubMed, Scopus, CINAHL, and PsycINFO was conducted for publications related to childhood and adolescent cancer; survivors; and insurance, legal, and financial hardships. Narrative data synthesis was performed on the extracted data.

RESULTS

This review included N = 58 publications, originating from 14 different countries, most from the last decade (n = 39). We found that a considerable proportion of CACS experience insurance and financial hardships, including foregoing medical care due to financial constraints, problems paying medical bills, and difficulties accessing loans or insurances. Legal hardships, such as workplace discrimination, were less frequently investigated and reported.

CONCLUSIONS

This systematic review highlights the many interrelated socio-bureaucratic hardships faced by CACS. It is important that these hardships are not underestimated or neglected. Our findings can serve as a basis for enhancing and expanding supportive care services and help inform collaborative efforts from research, policy, and practice.

IMPLICATIONS FOR CANCER SURVIVORS

This review emphasizes the importance of recognizing and addressing the socio-bureaucratic challenges that extend beyond medical care. Survivors should be informed about available options and be aware of their legal rights to identify instances of injustice and seek appropriate support.

Effects of Cognitive Flexibility, Prosocial and Problem Behaviours, Parenting Style and Social Support on Social Adaptation Among Children With Leukaemia: A Structural Equation Modelling Approach

BACKGROUND

Leukaemia children often encounter various social adaptation issues stemming from changes in their living environment. Identifying and optimising the factors associated with social adaptation is crucial in improving social adaptation in children with leukaemia.

OBJECTIVES

To investigate social adaptation in children with leukaemia and to clarify the impact pathway of cognitive flexibility, problem behaviour, prosocial behaviour, parenting style and social support on social adaptation.

METHODS

Using a convenience sampling method, 264 leukaemia children completed a cross-sectional survey. Data were collected using the Social Adaptation Assessment Scale for Children with Leukaemia, Strengths and Difficulties Questionnaire, Cognitive Flexibility Scale, Short-Egna Minnenav Barndoms Uppfostran and Multi-Dimensional Scale of Perceived Social Support. Structural equation modelling was used to test the influencing factors of social adaptation.

RESULTS

Social support directly influenced social adaptation (β = 0.19, p < 0.01) and indirectly influenced social adaptation through prosocial behaviour (β = 0.06, p < 0.01) and problem behaviour (β = 0.18, p < 0.01). Prosocial behaviour (β = 0.17, p < 0.01) and problem behaviour (β = -0.61, p < 0.01) directly influenced social adaptation. Negative parenting directly influenced social adaptation (β = 0.12, p < 0.01) and indirectly influenced social adaptation (β = -0.23, p < 0.01) through problem behaviour.

CONCLUSION

Our finding indicated that there are prominent social adjustment problems in the recovery process of children with leukaemia. These findings suggest that targeted education is needed to enhance social adaptation among children with leukaemia.

RELEVANCE TO CLINICAL PRACTICE

The final model should serve as a framework to guide intervention research targeting social support and negative parenting to improve the social adaptation of children with leukaemia. During the recovery process, nurses need to regularly follow up on the children's social adaptation and encourage them to participate in social activities to increase social support while providing family guidance based on improving parenting styles.

PATIENT OR PUBLIC CONTRIBUTION

The subjects of this study were children with leukaemia aged 8-18 years. All authors read and approved the final manuscript.

Public perceptions of families affected by pediatric cancer and educational work in pediatric oncology

BACKGROUND

This study aims to explore how Russian society perceives children with cancer and their families to determine its potential as a tool for solving the social struggles of cancer-affected youth.

METHODS

The study took place between 2019 and 2020 and involved 237 parents of cancer-affected children enrolled for inpatient treatment in 5 pediatric oncology clinics in the North Caucasus Federal District (Russia). The study exploits a specially designed questionnaire survey as its main research method.

RESULTS

About half of the parents did not observe changes in their attitude towards their child following a cancer diagnosis, with women more frequently noting these changes (40% vs. 18%). Public sentiment diverges between poles of sympathy and alienation: 53% acknowledge the expression of sympathy, while 39% perceive a sense of alienation. This study underscores the imperative for adequate support for these families, encompassing both financial and social dimensions.

CONCLUSION

The present findings can be used to design cancer awareness and anti-stigma programs aimed at educating the general population about the early symptoms of cancer, where to receive health consultation services, how to talk with and act around cancer-affected children, and how to support such children and their families.

IMPACT

Despite advances in modern medicine and multiple cases of pediatric cancer being successfully treated, stereotypes about the incurable nature of cancer still exist in many countries. The present findings can serve as a platform for the comparative study of cancer-related issues in other regions and countries. The results of this study can also be used to design cancer awareness and anti-stigma programs aimed at educating the general population about the early symptoms of cancer, where to receive health consultation services, how to talk with and act around cancer-affected children, and how to support such children and their families.

Late Adverse Effects after Treatment for Childhood Acute Leukemia

The aim of this review is to raise awareness and knowledge among healthcare professionals and policymakers about late adverse effects in survivors of childhood leukemia. With contemporary treatment, over 90% of children with acute lymphoblastic leukemia (ALL) and over 60% with acute myeloid leukemia (AML) are cured. Large cohort studies demonstrate that 20% of ALL and most AML survivors have at least one chronic health condition by 20-25 years after diagnosis. These are life-changing or threatening in some survivors and contribute to increased premature mortality. We describe the frequency, causes, clinical features, and natural history of the most frequent and severe late adverse effects in childhood leukemia survivors, including subsequent malignant neoplasms, metabolic toxicity, gonadotoxicity and impaired fertility, endocrinopathy and growth disturbances, bone toxicity, central and peripheral neurotoxicity, cardiotoxicity, psychosocial late effects, accelerated ageing and late mortality. The wide range of late effects in survivors of haemopoietic stem cell transplant is highlighted. Recent developments informing the approach to long-term survivorship care are discussed, including electronic personalized patient-specific treatment summaries and care plans such as the Survivor Passport (SurPass), surveillance guidelines and models of care. The importance of ongoing vigilance is stressed given the increasing use of novel targeted drugs with limited experience of long-term outcomes. CONCLUSION: It is vital to raise awareness of the existence and severity of late effects of childhood leukemia therapy among parents, patients, health professionals, and policymakers. Structured long-term surveillance recommendations are necessary to standardize follow-up care.

Excess healthcare expenditure in adults treated for solid cancer in childhood: a cohort study in France

BACKGROUND

Due to late effects, childhood cancer survivors (CCS) are more likely to have multiple chronic conditions than the general population. However, little is known about the economic burden of care of CCS in the long term.

OBJECTIVES

To estimate excess healthcare expenditure for long-term CCS in France compared to the general population and to investigate the associated factors.

METHODS

We included 5353 5-year solid CCS diagnosed before the age of 21 years before 2000 from the French CCS cohort and obtained a random reference sample from the general population for each CCS, matched on age, gender and region of residence. We used the French national health data system to estimate annual healthcare expenditure between 2011 and 2018 for CCS and the reference sample, and computed the excess as the net difference between CCS expenditure and the median expenditure of the reference sample. We used repeated-measures linear models to estimate associations between excess healthcare expenditure and CCS characteristics.

RESULTS

Annual mean (95% CI) excess healthcare expenditure was €3920 (3539; 4301), mainly for hospitalization (39.6%) and pharmacy expenses (17%). Higher excess was significantly associated with having been treated before the 1990s and having survived a central nervous system tumor, whereas lower excess was associated with CCS who had not received treatment with radiotherapy.

CONCLUSIONS

Of the variables that influence excess healthcare expenditure, a lever for action is the type of treatment administered. Future research should focus on addressing the long-term cost-effectiveness of new approaches, especially those related to radiotherapy.

Association between prevalence and severity of chronic kidney disease and employment status: a nationwide study in Korea

BACKGROUND

The prevalence of chronic kidney disease (CKD) is increasing globally, and understanding the association between CKD and employment status is crucial. This cross-sectional study aimed to investigate the association of CKD with employment and occupation type among patients with CKD.

METHODS

We analyzed data from 36,732 Korean adults aged ≥ 30 years, who participated in the Korean National Health and Nutrition Examination Survey between 2014 and 2021. CKD was detected based on the estimated glomerular filtration rate, and the employment status of the participants was classified into distinct categories: full-time permanent employment, unemployment, self-employment, and precarious employment. We analyzed the data using multiple logistic regression.

RESULTS

We observed a significant association between CKD and a higher likelihood of unemployment compared to that in individuals without CKD (odds ratio, 1.70; 95% confidence interval, 1.47-1.96). This association was more prominent in patients with severe CKD. In the multivariable logistic analysis, patients with CKD had a higher likelihood for precarious employment (odds ratio, 1.29; 95% confidence interval, 0.92-1.88), self-employment (odds ratio, 1.3; 95% confidence interval, 0.90-1.88), and unemployment (odds ratio, 2.10; 95% confidence interval, 1.51-2.92) compared to individuals without CKD.

CONCLUSIONS

Our study demonstrated that CKD is associated with a higher likelihood of unemployment and engagement in precarious employment. These findings highlight the challenges faced by patients with CKD in obtaining stable employment and emphasize the need for interventions to improve the employment outcomes of individuals with CKD.

Improving quality and quantity of life for childhood cancer survivors globally in the twenty-first century

The contributions of cooperative groups to performing large-cohort clinical trials and long-term survivorship studies have facilitated advances in treatment, supportive care and, ultimately, survival for patients with paediatric cancers. As a result, the number of childhood cancer survivors in the USA alone is expected to reach almost 580,000 by 2040. Despite these substantial improvements, childhood cancer survivors continue to have an elevated burden of chronic disease and an excess risk of early death compared with the general population and therefore constitute a large, medically vulnerable population for which delivery of high-quality, personalized care is much needed. Data from large survivorship cohorts have enabled the identification of compelling associations between paediatric cancers, cancer therapy and long-term health conditions. Effectively translating these findings into clinical care that improves the quality and quantity of life for survivors remains an important focus of ongoing research. Continued development of well-designed clinical studies incorporating dissemination and implementation strategies with input from patient advocates and other key stakeholders is crucial to overcoming these gaps. This Review highlights the global progress made and future efforts that will be needed to further increase the quality and quantity of life-years gained for childhood cancer survivors.

Importance of Social Support of Parents of Children with Cancer: A Multicomponent Model Using Partial Least Squares-Path Modelling

The purpose of the present study is to build a model combining some variables that have been previously studied separately to improve our understanding on how they relate in parents of children with cancer. A total of 112 parents with an average age of 41 completed the self-assessment questionnaires containing the factors studied: social support received, social support provided, stress, adjustment of parents and life satisfaction. Two models were developed: one for social support received and one for social support provided. Structural equation models based on the variance estimated through partial least squares were used to analyze factors involved in quality of life based on an exploratory model of second order. The estimated model was robust in terms of quality of measurement (reliability and validity). According to results from the structural model, in the model of social support received, the impact of social support received on stress was considerable (β = -0.26; p = 0.02) and it explained 16% of the variance. The impact of social support received by parents on their adjustment (β = -0.56; p < 0.001) was also considerable, explaining 32% of the variance. Finally, adjustment of parents also showed an effect on life satisfaction (β = -0.33; p < 0.001) and it explained 26% of the variance. However, the relation between social support received (β = 0.15; p = 0.11) and life satisfaction, the relation between stress (β = -0.15; p = 0.08) and life satisfaction, and the relation between adjustment of parents (β = 0.20; p = 0.07) and stress were not significant. In the model of social support provided by parents, social support provided (β = 0.35; p < 0.001), and adjustment of parents (β = -0.31; p < 0.01) impacted life satisfaction, explaining 36% of the variance. Social support provided (β = -0.34; p < 0.01) impacted adjustment of parents and it explained 12% of the variance. Adjustment of parents (β = 0.28; p < 0.05) also impacted parents' perception of stress, explaining 14% of the variance. However, the relation between social support provided (β = -0.17; p = 0.06) and stress, and the relation between stress (β = -0.13; p = 0.08) and life satisfaction, were not significant. Social support received showed a strong connection with stress and parents' adjustment. Additionally, social support received showed a decrease in stress and parents' adjustment. Social support provided by parents and the adjustments they experience are linked to their life satisfaction. Additionally, social support provided showed a decrease in adjustment and an increase in parents' life satisfaction. The models can be used to improve parents' situations and it has strong practical implications.

Perceived barriers and facilitators to physical activity in childhood cancer survivors and their parents: A large-scale interview study from the International PACCS Study

BACKGROUND

Physical activity (PA) may reduce risks of late effects in childhood cancer survivors, yet many have low activity levels. Using the WHO's International Classification of Functioning, Disability, and Health for Children and Youths (ICF-CY) as a conceptual framework, we aimed to identify perceived barriers and facilitators to PA in young survivors and their parents.

DESIGN/METHODS

We conducted individual, semi-structured interviews with 63 survivors, aged 9-18 years, ≥1-year off treatment, and 68 parents, recruited from three pediatric oncology departments in Norway and Denmark. Interviews were analyzed inductively using thematic analysis to identify barriers and facilitators to PA, which were mapped onto the ICF-CY model components; body function/structures, activities, participation, and environmental and personal factors.

RESULTS

Two-thirds of the survivors described how treatment-related impairments of bodily functions (e.g., fatigue, physical weakness, reduced lung capacity) caused physical limitations, reducing opportunities to participate in PA, especially team sports and school physical education. This resulted in a perceived ability gap between survivors and peers, reducing motivation for PA. These PA barriers were moderated by environmental factors that facilitated or further hindered PA participation (family, peer, and school support). Similarily, personal factors also facilitated (acceptance, motivation, goal setting) or hindered (anxiety, low motivation, and lack of trust) PA participation.

CONCLUSION

Treatment-related long-term or late effects represented significant barriers to PA as their functional consequences reduced survivors' capacities and capabilities to be active. Environmental and personal factors acting as facilitators or further barriers to PA were identified. Applying the ICF-CY framework in clinical practice could help to enable PA participation.

Socio-economic outcomes among long-term childhood acute lymphoblastic leukaemia survivors enrolled between 1971 and 1998 in EORTC CLG studies: Results of the 58LAE study

OBJECTIVE

The objective of this study is to evaluate the socio-economic outcomes of survivors of childhood acute lymphoblastic leukaemia (ALL).

METHODS

Childhood ALL adult survivors, enrolled in EORTC trials between 1971 and 1998 in France and Belgium, were invited to fill out a questionnaire with information about their socio-economic situation (living with a partner, having a university degree, having a job, working part time and history of having a paid job). The outcomes were compared with two matched control populations.

RESULTS

Among 1418 eligible patients, 507 (35.8%) participated, including 39 (8%) and 61 (12%) patients who received a haematopoietic stem cell transplantation (HSCT) and a cranial radiotherapy (CRT), respectively. The median time to follow-up was 20 years, and median age was 25 years. Survivors showed a socio-economic level at least as good as controls. HCST and CRT were associated with a higher probability of not obtaining a bachelor degree (respectively OR = 3.49, 95% CI: 1.46-8.35 and OR = 2.31, 95% CI: 1.04-5.15), HSCT was associated with unemployment (OR = 2.89, 95% CI: 1.09-7.65) and having a relapse was associated with a higher probability of not having a partner (OR = 1.88, 95% CI: 1.01-3.51) adjusting for confounders.

CONCLUSION

Childhood ALL survivors showed a high level of socio-economic participation. HCST and CRT were associated with poorer functioning.

Employment among Childhood Cancer Survivors: A Systematic Review and Meta-Analysis

To date, there are heterogeneous studies related to childhood cancer survivors’ (CCS) employment rates. Given the importance of this topic, we aimed to perform a systematic review and meta-analysis to investigate the prevalence of employment among CCS and to examine its association with socio-demographic and clinical factors. We followed the PRISMA guidelines to search for pertinent articles in relevant electronic databases. Eighty-nine articles comprising 93 cohorts were included. The overall prevalence of employment was 66% (CI: 95% 0.63–0.69). Subgroup meta-analyses showed that lower rates were found for central nervous system tumor survivors (51%, CI: 95% 0.43–0.59), and for CCS treated with cranial-radiotherapy (53%, CI: 95% 0.42–0.64) or haematopoietic stem-cell transplantation (56%, CI: 95% 0.46–0.65). The studies conducted in Asia highlighted employment rates of 47% (CI: 95%, 0.34–0.60). Univariate meta-regressions identified the following socio-demographic factors associated with higher rates of employment: a female gender (p = 0.046), a higher mean age at the time of investigation (p = 0.00), a longer time since diagnosis (p = 0.00), a higher educational level (p = 0.03), and a married status (p = 0.00). In conclusion, this systematic review and meta-analysis provides evidence that two-thirds of CCS are employed worldwide. Identifying vulnerable groups of CCS may allow for the design of multidisciplinary support strategies and interventions to promote employment in this population.

"I don't take for granted that I am doing well today": a mixed methods study on well-being, impact of cancer, and supportive needs in long-term childhood cancer survivors

PURPOSE

With increasing numbers of childhood cancer survivors (CCS), it is important to identify the impact of cancer and CCS' needs for support services that can mitigate the long-term impact on psychosocial wellbeing, including health-related quality of life (HRQOL). We aimed (1) to describe survivors' wellbeing, impact of cancer, and supportive care needs and (2) to determine how socio-demographic or clinical characteristics and impact of cancer relate to survivors' unmet needs.

METHOD

In this mixed methods study, a quantitative survey was used to assess HRQOL, psychological distress, impact of cancer, and supportive care needs. Qualitative interviews were conducted to explore the meaning of wellbeing, health, and impact of cancer.

RESULTS

Overall, 69 CCS participated in the survey of which 28 participated in qualitative interviews (aged ≥ 18 years, diagnosed with cancer ≤ 18 years). Few CCS (13%) reported poor physical HRQOL, but almost half reported poor mental HRQOL (49%) and psychological distress (42%). Health was considered to encompass both: physical and emotional aspects of wellbeing. Cancer positively impacted CCS' ability to care and attitude towards life, whereas relationships and insurance were negatively impacted. Risks for unmet needs increased in CCS with self-reported low health status, late effects, psychological distress, with older age at study or longer time since end of treatment.

CONCLUSION

In our study, many CCS experienced various psychosocial, psychological and informational unmet needs, indicating that survivors' needs are currently not duly addressed. Current efforts to provide supportive psychosocial care in Switzerland should be further operationalized to provide adequate support.

Educational Attainment and Employment Outcome of Survivors of Pediatric CNS Tumors in Switzerland-A Report from the Swiss Childhood Cancer Survivor Study

Background: Childhood cancer survivors diagnosed with a central nervous system (CNS) tumor are at risk for educational and vocational challenges. This study compared educational attainment and employment outcome in survivors of CNS tumors to survivors of other malignancies. Methods: The questionnaire-based Swiss Childhood Cancer Survivor Study (SCCSS) included cancer patients diagnosed between 1976 and 2010, aged ≤20 years, who survived ≥5 years after diagnosis. We classified participants aged ≥16 years into three groups: CNS tumor and non-CNS malignancy with and without CNS-directed treatment. We analyzed educational attainment, employment outcome and special schooling. Subgroup analyses included survivors aged ≥25 years. Results: We analyzed 2154 survivors, including 329 (15%) CNS tumor survivors, 850 (40%) non-CNS tumor survivors with and 975 (45%) without CNS-directed treatment. Fewer CNS tumor survivors aged ≥25 years reached tertiary education (44%) compared to those without CNS-directed treatment (51%) but performed similar to survivors with CNS-directed treatment (42%). Among CNS tumor survivors, 36 (14%) received special schooling. Higher parental education was associated with higher levels in survivors. Employment outcome did not significantly differ between the three diagnostic groups. A higher proportion of CNS tumor survivors received disability pension or were unemployed. Conclusions: Our findings suggest that CNS tumor survivors need more time to achieve their highest educational level. This should influence clinical care of these survivors by offering vocational counseling.

Employment status and occupational positions of childhood cancer survivors from Denmark, Finland and Sweden: A Nordic register-based cohort study from the SALiCCS research programme

BACKGROUND

A childhood cancer diagnosis and late effects of treatment may affect survivors' possibilities of employment or highly skilled occupations later in life. In this study, we compared the employment and occupational status of childhood cancer survivors with population comparisons and siblings.

METHODS

In a cohort study based on Nordic registers, we identified 10 461 survivors of childhood cancer diagnosed before age 20 years in Denmark, Finland and Sweden since 1971. Survivors were compared with 48 928 population comparisons matched to survivors by age, sex and geographical region and 12 605 siblings of survivors. Annual outcome information on employment, unemployment, health-related unemployment and occupational position was obtained from the statistical institutes between 1980-2017 and assessed in multivariate logistic regression analyses from age 30 onwards.

FINDINGS

By 30 years of age, 9.2% (95% CI, 8.6-9.9%) of survivors were unemployed for health reasons. Childhood cancer survivors had considerably higher odds of health-related unemployment at ages 30, 40 and 50 than population comparisons (OR_age30, 2.57; 95% CI, 2.35-2.81) and siblings (OR_age30, 2.50; 95% CI, 2.15-2.90). We observed no large difference in unemployment unrelated to health or in occupational position. Health-related unemployment was particularly pronounced among survivors of central nervous system tumours and survivors diagnosed below 15 years of age.

INTERPRETATION

Survivors at risk of health-related unemployment should be offered comprehensive survivorship care and interventions for obtaining and maintaining suitable employment.

FUNDING

NordForsk [76111], the Danish Childhood Cancer Foundation [2016-0293], Aarhus University [43239402], the Swedish Childhood Cancer Foundation [PR2020-0130] and [OB2019-0003], Tømrermester Jørgen Holm og Hustru Elisa F. Hansens Mindelegat [20088] and the Swiss National Science Foundation to LM [P2LUP3_175288].

Cohort Profile: The Socioeconomic Consequences in Adult Life After Childhood Cancer in Scandinavia (SALiCCS) Research Programme

INTRODUCTION

The growing number of survivors of childhood cancer, with many years of life ahead, demonstrates the increasing clinical and public health relevance of investigating the risks of social and socioeconomic impairment after a childhood cancer diagnosis and the life-saving treatment. To enrich understanding of the mental, social and socioeconomic difficulties that childhood cancer survivors may face during their life-course, identify particularly vulnerable survivors and overcome the limitations of previous research, we initiated the Socioeconomic Consequences in Adult Life after Childhood Cancer in Scandinavia (SALiCCS) research programme.

METHODS

This Nordic cross-border research programme is a collaboration between the Danish Cancer Society, the Finnish Cancer Registry and Karolinska Institutet to investigate a broad range of mental, social and socioeconomic conditions in long-term childhood cancer survivors in Denmark, Finland and Sweden. SALiCCS is based on a registry-based matched cohort design, comprising five-year survivors of cancer diagnosed at ages 0-19 years (1971-2008 in Denmark, 1971-2009 in Finland, 1971-2011 in Sweden), age-, sex- and country-matched population comparisons and sibling comparisons who were followed over time. Outcomes of interest included mental disorders, educational achievements, employment and profession, family life and the need of social security benefits. Individual-level data linkage among various national registries provided the data for the research programme.

RESULTS

The SALiCCS core population comprises 21,292 five-year survivors, 103,303 population comparisons and 29,644 siblings as a second comparison group. The most common diagnoses in survivors were central nervous system tumours, leukaemias and lymphomas.

DISCUSSION

SALiCCS is the largest, most comprehensive population-based research initiative in this field, based on high-quality registry data with minimal risk of bias. The findings will be informative for evidence-based survivorship care targeting not only somatic late effects but also psychosocial impairments.

"I have to do things differently now, but I make it work"-young childhood cancer survivors' experiences of self-management in everyday living

PURPOSE

Living with late effects can affect young childhood cancer survivors' (CCSs) self-management (SM) abilities. In this study, we explored different approaches to SM of everyday life by young CCS.

METHODS

This is a sub-study of a larger study on Physical Activity among Childhood Cancer Survivors (the PACCS study). We conducted individual interviews with 22 CCS aged 9 to 18 years who were at least 1 year off-treatment. An hybrid inductive-decductive thematic analysis was used.

RESULTS

Three main themes were identified: (1) managing everyday life with fatigue, (2) building self-management competence, and (3) cancer survivor as part of identity. Late effects, especially fatigue, contributed to a perceived ability gap compared to peers, limiting participation in everyday activities. CCS developed new SM skills to overcome such challenges and pushed themselves physically and mentally to master and balance activities and rest to regain energy. CCS changed activities, adapted their expectations, or legitimized their apparent lack of SM skills to regain a sense of self-efficacy. Managing the impact of cancer on relationships with family and friends also required use of SM strategies.

CONCLUSIONS

The findings expand our currently limited knowledge of young CCS and SM skills they develop to manage everyday life after treatment completion. These, combined with ongoing support from family and peers, "make it work".

IMPLICATIONS FOR CANCER SURVIVORS

The perspectives of young CCS illustrate their SM skills and support needs beyond transitioning off-treatment. Conceptualizing this within follow-up care may contribute to a feeling of mastery and increased satisfaction among CCS.

The long shadow of childhood cancer: a qualitative study on insurance hardship among survivors of childhood cancer

BACKGROUND

The long-term consequences of childhood cancer have received increasing attention due to the growing number of survivors over the past decades. However, insurance hardships of survivors are mostly unknown. This study explored qualitatively, in a sample of childhood cancer survivors (CCS), (i) the experiences and needs of CCS living in Switzerland with a special focus on hardships related to insurance; and (ii) the views of insurance and law experts with experience on childhood cancer.

METHODS

Semi-structured interviews were conducted with 28 childhood cancer survivors and 3 experts (one legal expert, two insurance experts). Data was analysed using qualitative content analysis.

RESULTS

Three key themes emerged from the interviews with the CCS: 1) experiences with insurance, 2) perception of discrimination, and 3) needs and barriers for support. The interviewed experts provided further detailed clarification of CCS' concerns. Our findings indicated that some CCS can move past their cancer history, while others continue to face hardships. CCS reported confusion about the opportunities and services within the social security system and most relied on their personal contacts for guidance. Finally, CCS expressed a strong need for socio-economic and legal support for social insurance questions, especially related to disability insurance.

CONCLUSIONS

With the growing population of CCS, it is essential to further assess the interplay between medical and psychosocial health and socio-economic hardship. Supportive psychosocial services should aim to ameliorate insurance hardships. Better understanding of the relationship between childhood cancer and insurance hardships during survivorship will inform efforts to improve long-term financial security and health outcomes for survivors. We call for the public, lawmakers, researchers, insurers, and patient organizations to come together and discuss future perspectives to avoid the risk of discrimination for cancer survivors.

Executive Function and Psychosocial Adjustment in Adolescent Survivors of Pediatric Brain Tumor

Adolescent survivors of pediatric brain tumor (PBT) are a sparsely studied subset of childhood cancer survivors. Sustaining a PBT may complicate the development of executive functions (EFs), which play a vital role in long-term psychosocial adjustment. In this study, 48 adolescent survivors and their parents completed questionnaires assessing EF, psychological symptoms, fatigue, and adaptive functioning, and 26 survivors underwent neuropsychological assessment. Survivors reported significantly more problems with adaptive functioning than a healthy control group, and this was most strongly associated to executive dysfunction, compared to psychological symptoms and fatigue. The findings have important implications for long-term follow-ups.

Social Support Received and Provided in the Adjustment of Parents of Children With Cancer

OBJECTIVE

The aim of the present study is to determine the relation between the satisfaction of parents of children with cancer with the social support received and provided from a multidimensional perspective (sources and types of support) and the disruptions that take place in different areas of their lives (partner, children, family, social relations, and economic and employment situation).

METHOD

One hundred twelve parents of children diagnosed with cancer who received treatment at the Mother and Child Hospital of Málaga (Spain) were recruited. Data were gathered through self-reporting measures. The instrument used includes a questionnaire about socio-demographic variables, a questionnaire about parents' adjustment to the situation and a questionnaire about social support received and provided based on the different sources and types of support.

RESULTS

There is a negative and significant relation between satisfaction with support received and provided and the magnitude of disruptions in parents' lives.

CONCLUSION

Satisfaction with emotional support received from the partner and family, and support provided to these sources, relate to lower disruption in different areas of parents' lives. These results can have significant practical implications for the psychosocial care provided to parents of children with cancer.

Post-traumatic stress in parents of long-term childhood cancer survivors compared to parents of the Swiss general population

BACKGROUND

We describe post-traumatic stress symptoms (PTSS) and post-traumatic stress disorder (PTSD) in parents of long-term childhood cancer survivors (CCS-parents) and compare them to parents of similar-aged children (comparison-parents) of the Swiss general population (SGP). We compare type of reported stressful event, prevalence of PTSS and PTSD, and psychosocial and cancer-related characteristics associated with PTSS. We further describe the respective normative data for the SGP.

METHODS

We conducted a nationwide cross-sectional questionnaire survey in a population-based sample of long-term CCS-parents (survivors aged ≤16 years at diagnosis, ≥20 years at study, >5 years post-diagnosis) and in the SGP. Using the Impact of Event Scale-Revised, we measured PTSS regarding the most stressful event experienced, and computed probable cases of PTSD.

RESULTS

Participants included 663 CCS-parents (39.4% fathers) and 1035 individuals of the SGP (40.0% male), of which we identified 391 comparison-parents (41.2% fathers). Illness was most often indicated as stressful event (CCS-parents: 49.5%, comparison-parents: 27.6%, SGP: 25.3%). Prevalence of PTSS and PTSD (CCS-parents: 4.8%, comparison-parents: 6.7%, SGP: 5.6%) did not significantly differ. Lower education was associated with higher intrusion, avoidance, and hyperarousal in all samples (all P ≤ .003). Parents of children with a chronic illness reported higher intrusion (all P ≤ .004). We found no associations with cancer-related characteristics.

CONCLUSIONS

No increased risk for PTSS or PTSD was found among CCS-parents. Individuals with lower education and those with a chronically ill child might benefit from additional support to help manage and resolve the stress symptoms in the long term.

Current and coming challenges in the management of the survivorship population

With the widespread adoption of multimodality treatment, 5-year survival of children diagnosed with cancer has improved dramatically in the past several decades from approximately 60% in 1970 to greater than 85% currently. As a result, there are an estimated nearly half a million long-term survivors of childhood cancer living in the United States today. However, survivors have, on average, significantly greater serious medical and psychosocial late effects compared with the general population. In this review, we will discuss the current epidemiology of childhood cancer survivorship, including new methods to estimate the burden of late effects and genetic susceptibility toward late effects. We will also review the development of surveillance guidelines for childhood cancer survivors and early toxicity signals from novel agents now being tested and used increasingly to treat pediatric and adult cancers. We conclude with an overview of current models of survivorship care and areas for future research.

Social attainment in physically well-functioning long-term survivors of pediatric brain tumour; the role of executive dysfunction, fatigue, and psychological and emotional symptoms

The purpose of this cross-sectional study was to investigate long-term social attainment in physically well-functioning adult survivors of pediatric brain tumour (PBT) and identify demographic, medical, and psychological factors related to poor social outcomes, with a special focus on the significance of executive dysfunction. One hundred and fourteen PBT survivors and a healthy control group provided personal data on social outcomes, i.e., education, work, and government benefits, and completed questionnaires on executive function (EF), psychological and emotional difficulties, and fatigue. A significantly higher number of survivors compared to healthy controls reported having received educational adjustments and substantial government benefits, and significantly more survivors than controls were currently not engaged in regular employment/training. PBT survivors and healthy controls did not differ on educational level or living situation. The factors most strongly associated with poor social outcomes were self-reported executive dysfunction, difficulties with adaptive functioning, and fatigue. The findings show that physically well-functioning PBT survivors are at risk of poorer social outcomes and financial dependence in adulthood compared to their healthy peers, and underline the importance of investigating EF in short- and long-term follow-ups. Future rehabilitation efforts should focus more on compensatory strategies for executive dysfunction and improving EF skills.

Work-Related Medical Rehabilitation in Cancer: A Cluster-Randomized Multicenter Study

BACKGROUND

Current guidelines recommend rehabilitative measures to alleviate dis- turbances resulting from cancer and its treatment. To give cancer survivors further assistance in getting back to work, work-related medical rehabilitation is currently being tested in Germany. In this cluster-randomized, multicenter trial, we studied the efficacy of work-related medical rehabilitation compared with conventional medical rehabilitation (trial no. DRKS00007770 in the German Clinical Trials Registry).

METHODS

A total of 484 cancer survivors of working age who were candidates for rehabilitation were recruited and assigned at random to either the intervention group (IG; work-related medical rehabilitation) or the control group (CG). The primary end- point was self-assessed function in a role one year after the end of rehabilitation, as evaluated with the health-related quality of life questionnaire of the European Organisation for Research and Treatment of Cancer (EORTC QLQ-C30). Further endpoints included symptom and function scales, subjective ability to work, coping with illness, and return to work. Neither the medical personnel nor the subjects were blinded.

RESULTS

One year after the end of rehabilitation, data from 379 subjects who par- ticipated in the last follow-up survey were evaluated. The intervention and control groups did not differ significantly either in the primary endpoint of role function (IG = 60.8 vs. CG = 57.6 out of a maximum of 100 points; p = 0.204) or in any of the secondary endpoints. A last observation carried forward analysis yielded com- parable results. At 12 months, 28.5% of the subjects in the IG and 25.3% of those in the CG were still unable to work.

CONCLUSION

This study did not reveal any significant clinically relevant advantage of work-related medical rehabilitation at one year. Future studies should determine whether a second period of rehabilitation might be helpful and whether selected subjects might benefit from the assistance of case managers beyond the period of rehabilitation.

Social Inequalities Along the Childhood Cancer Continuum: An Overview of Evidence and a Conceptual Framework to Identify Underlying Mechanisms and Pathways

Inequalities in health according to social conditions are regarded as unnecessary and unjust. There is a large body of evidence on inequalities in adult cancer, observable throughout the societies on a national level as well as on a global scale. Socioeconomic influences on health matter at all ages including childhood, for which childhood cancer is the leading cause of disease related death in high-income countries (HICs). Substantial differences in the reported incidence of childhood cancers have been observed globally by socioeconomic development of a population. This is reflected in the higher incidence rates reported for HICs, particularly for acute lymphoblastic leukemia, and for cancer in infants (below 1 year), compared to low- and middle-income countries (LMICs). Considerable inequalities between populations and degree of socioeconomic development are also noted for survival from childhood cancer, with substantially lower survival rates seen in most LMICs compared to HICs. With respect to inequalities by socioeconomic position (SEP) within countries, findings of an association between SEP and childhood cancer risk are diverse and limited to studies from HICs. On the contrary, observations on social inequalities in survival within countries are accumulating and indicate that survival inequalities do not only concern resource-poor countries but also high-income populations including European countries. In turn, a childhood cancer diagnosis in itself may have implications on the parents' socioeconomic situation as well as on the later socioeconomic life after having survived the disease. The underlying mechanisms and causal pathways of these empirically demonstrated social inequalities are poorly understood, although it is of significant public health relevance for any actions or strategies to reduce childhood cancer-related inequity. We propose a conceptual framework on potential underlying mechanism and pathways specifically addressing social inequalities in childhood cancer and after childhood cancer to (i) illustrate potential pathways by which social determinants may create health inequities at different points of the childhood cancer continuum; (ii) illustrate potential pathways by which a childhood cancer diagnosis may impact the socioeconomic situation of the concerned family or the later life of a childhood survivor; and (iii) point out how major determinants may relate to each other.