Multilevel Characteristics of Cumulative Symptom Burden in Young Survivors of Childhood Cancer

Importance

Symptom burden and its characteristics among survivors of pediatric cancers aged 8 to 18 years remain understudied.

Objective

To examine the prevalence of symptom burden among young childhood cancer survivors and identify associations with sociodemographic, clinical, and psychological resilience skills, and health-related quality of life (HRQOL).

Design, Setting, and Participants

A cross-sectional analysis using data collected from November 1, 2017, to January 31, 2019, in a survivorship clinic at a US-based comprehensive cancer center was conducted. Participants included 302 dyads of children aged 8 to 18 years who survived at least 5 years beyond diagnosis and their primary caregivers. Data analysis was performed from March 13, 2023, to February 29, 2024.

Exposures

Diagnosis, caregiver-reported family conflict, self-reported caregiver anxiety, neighborhood-level social vulnerability, and survivor-reported meaning and purpose.

Main Outcomes and Measures

Novel symptom-level burden, integrating the attributes of severity and daily activity interference using the pediatric version of the Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events, global cumulative symptom burden, and HRQOL using the EuroQol-5D. Multinomial logistic regression identified characteristics associated with symptom burden; linear regression assessed symptom burden and HRQOL associations.

Results

Among 302 survivors (mean [SD] age, 14.2 [2.9] years, mean [SD] time since diagnosis, 10.9 [2.9] years; 153 [50.7%] male), 186 (62.0%) had low, 77 (25.7%) moderate, and 37 (12.3%) high global cumulative symptom burden. Greater caregiver anxiety was associated with moderate (risk ratio [RR], 1.56; 95% CI, 1.09-2.24) global symptom burden. Greater neighborhood deprivation was associated with moderate global symptom burden (RR, 4.86; 95% CI, 1.29-18.26). Survivors with greater meaning/purpose were less likely to have moderate (RR, 0.42; 95% CI, 0.29-0.61) and high (RR, 0.27; 95% CI, 0.16-0.46) global symptom burden. The burden of individual symptoms displayed similar patterns. Low (Cohen d, -0.60; 95% CI, -0.87 to -0.32) and moderate/high (d, -0.98; 95% CI, -1.53 to -0.43) general pain, moderate/high numbness (d, -0.99; 95% CI, -1.69 to -0.29), and moderate/high worry (d, -0.55; 95% CI, -0.99 to -0.11) were associated with lower HRQOL.

Conclusions and Relevance

In this cross-sectional study of young childhood cancer survivors, symptom burden was prevalent. Caregiver anxiety and disparity-related neighborhood factors were associated with greater symptom burden, whereas meaning and purpose was a protective factor. Greater specific symptom burden contributed to poorer HRQOL. The findings suggest that interventions targeting resilience and neighborhood adversity may alleviate symptom burden and improve HRQOL.

Financial Hardship & Neighborhood Socioeconomic Disadvantage in Long-term Childhood Cancer Survivors

BACKGROUND

Long-term survivors of childhood cancer face elevated risk for financial hardship. We evaluate whether childhood cancer survivors live in areas of greater deprivation and the association with self-reported financial hardships.

METHODS

Cross-sectional analysis of data from the Childhood Cancer Survivor Study (CCSS) between 1970 and 1999, and self-reported financial information from 2017-2019. We measured neighborhood deprivation with the Area Deprivation Index (ADI) based on current zip code. Financial hardship was measured with validated surveys that captured behavioral, material/financial sacrifice, and psychological hardship. Bivariate analyses described neighborhood differences between survivors and siblings. Generalized linear models estimated effect sizes between ADI and financial hardship adjusting for clinical factors and personal socioeconomic status.

RESULTS

Analysis was restricted to 3,475 long-term childhood cancer survivors and 923 sibling controls. Median ages at time of evaluation was 39 [IQR 33,46] and 47 [39,59] years, respectively. Survivors resided in areas with greater deprivation (ADI ≥ 50: 38.7% survivors vs 31.8% siblings, P < .001). One quintile increases in deprivation were associated with small increases in behavioral (2nd quintile P = .017) and psychological financial hardship (2nd quintile P = .009; 3rd quintile, P = .014). Lower psychological financial hardship was associated with individual factors including greater household income ($60,000+ income, P < .001) and being single (P = .048).

CONCLUSIONS AND RELEVANCE

Childhood cancer survivors were more likely to live in areas with socioeconomic deprivation. Both neighborhood level disadvantage and personal socioeconomic circumstances should be evaluated when trying to assist childhood cancer survivors with financial hardships.

Using natural language processing to analyze unstructured patient-reported outcomes data derived from electronic health records for cancer populations: a systematic review

INTRODUCTION

Patient-reported outcomes (PROs; symptoms, functional status, quality-of-life) expressed in the 'free-text' or 'unstructured' format within clinical notes from electronic health records (EHRs) offer valuable insights beyond biological and clinical data for medical decision-making. However, a comprehensive assessment of utilizing natural language processing (NLP) coupled with machine learning (ML) methods to analyze unstructured PROs and their clinical implementation for individuals affected by cancer remains lacking.

AREAS COVERED

This study aimed to systematically review published studies that used NLP techniques to extract and analyze PROs in clinical narratives from EHRs for cancer populations. We examined the types of NLP (with and without ML) techniques and platforms for data processing, analysis, and clinical applications.

EXPERT OPINION

Utilizing NLP methods offers a valuable approach for processing and analyzing unstructured PROs among cancer patients and survivors. These techniques encompass a broad range of applications, such as extracting or recognizing PROs, categorizing, characterizing, or grouping PROs, predicting or stratifying risk for unfavorable clinical results, and evaluating connections between PROs and adverse clinical outcomes. The employment of NLP techniques is advantageous in converting substantial volumes of unstructured PRO data within EHRs into practical clinical utilities for individuals with cancer.

Financial hardship among siblings of long-term survivors of childhood cancer: A Childhood Cancer Survivor Study report

BACKGROUND

Siblings of children with cancer may experience adverse household economic consequences, but their financial outcomes in adulthood are unknown.

METHODS

A total of 880 siblings (aged 18-64 years) of adult-aged childhood cancer survivors were surveyed to estimate the prevalence of financial hardship by three established domains (behavioral, material, and psychological). For individual financial hardship items matching the contemporaneous National Health Interview Survey or Behavioral Risk Factor Surveillance System, siblings were compared with the general population by calculating adjusted prevalence odds ratios (ORs) to sample-weighted responses. Multivariable logistic regression models examined associations between sibling characteristics and each hardship domain and between sibling hardship and survivors' cancer/treatment characteristics.

RESULTS

Behavioral, material, and psychological hardship was reported by 24%, 35%, and 28%, respectively. Compared with national survey respondents, siblings were more likely to report worries about medical bills (OR, 1.14; 95% confidence interval [CI], 1.06-1.22), difficulty affording nutritious foods (OR, 1.79; 95% CI, 1.54-2.07), and forgoing needed medical care (OR, 1.38; 95% CI, 1.10-1.73), prescription medications (OR, 2.52; 95% CI, 1.99-3.20), and dental care (OR, 1.34; 95% CI, 1.15-1.57) because of cost. Sibling characteristics associated with reporting financial hardship in one or more domains included female sex, older age, chronic health conditions, lower income, not having health insurance, high out-of-pocket medical expenditures, and nonmedical/nonhome debt. No survivor cancer/treatment characteristics were associated with sibling financial hardship.

CONCLUSIONS

Adult siblings of childhood cancer survivors were more likely to experience financial hardship compared with the general population. Childhood cancer may adversely affect entire households, with potentially lasting implications.

Health-Related quality of life and DNA Methylation-Based aging biomarkers among survivors of childhood cancer

BACKGROUND

Childhood cancer survivors are at high risk for morbidity and mortality and poor patient-reported outcomes, typically health-related-quality-of-life (HRQOL). However, associations between DNA methylation (DNAm)-based aging biomarkers and HRQOL have not been evaluated.

METHODS

DNAm was generated with Infinium EPIC BeadChip on blood-derived DNA (median[range] for age at blood draw = 34.5[18.5-66.6] years) and HRQOL was assessed with age at survey (32.3[18.4-64.5] years) from 2,206 survivors in the St Jude Lifetime Cohort. DNAm-based aging biomarkers, including epigenetic age using multiple clocks (eg, GrimAge) and others (eg, DNAmB2M beta-2-microglobulin; DNAmADM: adrenomedullin), were derived from the DNAm Age Calculator (https://dnamage.genetics.ucla.edu). HRQOL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey to capture eight domains, and physical and mental component summaries (PCS and MCS). General linear models evaluated associations between HRQOL and epigenetic age acceleration (EAA, eg, EAA_GrimAge) or other age-adjusted DNAm-based biomarkers (eg, ageadj_DNAmB2M) after adjusting for age at blood draw, sex, cancer treatments, and DNAm-based surrogate for smoking pack-years. All P values were 2-sided.

RESULTS

Worse HRQOL was associated with greater EAA_GrimAge (PCS β[95%CI]=-0.18[-0.251,-0.11] years, P = 1.85 × 10-5; and four individual HRQOL domains), followed by ageadj_DNAmB2M (PCS: -0.08[-0.124,-0.037], P = .003; and three individual HRQOL domains), and ageadj_DNAmADM (PCS: -0.082[-0.125,-0.039], P = .002; and two HRQOL domains). EAA_Hannum (Hannum clock) was not associated with any HRQOL.

CONCLUSIONS

Overall and domain-specific measures of HRQOL are associated with DNAm measures of biological aging. Future longitudinal studies should test biological aging as a potential mechanism underlying the association between poor HRQOL and increased risk of clinically assessed adverse health outcomes.

Job lock among survivors of childhood cancer and their spouses post Affordable Care Act implementation: A Childhood Cancer Survivor Study brief report

It is unknown how common job lock (i.e., staying at job to maintain health insurance) remains among childhood cancer survivors after Affordable Care Act (ACA) implementation in 2010. We examined prevalence of and factors associated with job lock using a cross-sectional survey from the Childhood Cancer Survivor Study (3503 survivors; 942 siblings). Survivor, spousal, and any survivor/spouse job lock were more frequently reported by survivors than siblings. Survivor job lock/any job lock was associated with older age, low income, severe chronic conditions, and debt/inability to pay debt. Job lock remains more common among survivors than siblings after ACA implementation.

Natural language processing with machine learning methods to analyze unstructured patient-reported outcomes derived from electronic health records: A systematic review

OBJECTIVE

Natural language processing (NLP) combined with machine learning (ML) techniques are increasingly used to process unstructured/free-text patient-reported outcome (PRO) data available in electronic health records (EHRs). This systematic review summarizes the literature reporting NLP/ML systems/toolkits for analyzing PROs in clinical narratives of EHRs and discusses the future directions for the application of this modality in clinical care.

METHODS

We searched PubMed, Scopus, and Web of Science for studies written in English between 1/1/2000 and 12/31/2020. Seventy-nine studies meeting the eligibility criteria were included. We abstracted and summarized information related to the study purpose, patient population, type/source/amount of unstructured PRO data, linguistic features, and NLP systems/toolkits for processing unstructured PROs in EHRs.

RESULTS

Most of the studies used NLP/ML techniques to extract PROs from clinical narratives (n = 74) and mapped the extracted PROs into specific PRO domains for phenotyping or clustering purposes (n = 26). Some studies used NLP/ML to process PROs for predicting disease progression or onset of adverse events (n = 22) or developing/validating NLP/ML pipelines for analyzing unstructured PROs (n = 19). Studies used different linguistic features, including lexical, syntactic, semantic, and contextual features, to process unstructured PROs. Among the 25 NLP systems/toolkits we identified, 15 used rule-based NLP, 6 used hybrid NLP, and 4 used non-neural ML algorithms embedded in NLP.

CONCLUSIONS

This study supports the potential utility of different NLP/ML techniques in processing unstructured PROs available in EHRs for clinical care. Though using annotation rules for NLP/ML to analyze unstructured PROs is dominant, deploying novel neural ML-based methods is warranted.

Financial Hardship in Childhood Cancer Survivors Treated with Hematopoietic Cell Transplantation: A Report from the Childhood Cancer Survivor Study

Long-term survivors of childhood cancer are at risk for financial hardship. However, it is not known if HCT leads to an incremental change in financial hardship for survivors who received it versus those who did not. We examined financial outcomes among adult survivors of childhood cancer who had undergone HCT. Using a cross-sectional survey in the Childhood Cancer Survivor Study population between 2017 and 2019, self-reported financial hardship was compared between survivors who received HCT, survivors treated without HCT ("non-HCT"), and siblings and categorized into 3 domains: material hardship/financial sacrifices, behavioral, and psychological hardship. The standardized score of each domain of financial hardship was calculated by adding the item responses and dividing by the standard deviation among siblings. Multivariable linear and logistic regression were used to evaluate associations between sociodemographic characteristics, cancer diagnosis, post-treatment complications, and financial hardship among survivors. The mean adjusted score for each hardship domain was not significantly different between HCT survivors (n = 133) and non-HCT survivors (n = 2711); mean differences were .18 (95% confidence interval [CI], -.05 to .41) for material hardship/financial sacrifices, .07 (95% CI, -.18 to .32) for behavioral hardship, and .19 (95% CI, -.04 to .42) for psychological hardship. Within specific items, a higher proportion of survivors treated with HCT reported greater financial hardship compared to non-HCT survivors. HCT survivors also had significantly higher mean domain scores compared to sibling controls (n = 1027) in all domains. Household income and chronic health conditions, but not HCT, were associated with financial hardship among all survivors. Adult survivors of childhood cancer treated with HCT do not report greater overall financial hardship compared to non-HCT survivors but do report greater overall financial hardship compared to sibling controls. Surveillance and intervention may be necessary for all survivors regardless of HCT status.

Health-related quality of life profiles in adolescents and young adults with chronic conditions

PURPOSE

To assess health-related quality of life (HRQOL) among adolescents and young adults (AYAs) with chronic conditions.

METHODS

AYAs (N = 872) aged 14-20 years completed NIH's Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures of physical function, pain interference, fatigue, social health, depression, anxiety, and anger. Latent profile analysis (LPA) was used to group AYAs into HRQOL profiles using PROMIS T-scores. The optimal number of profiles was determined by model fit statistics, likelihood ratio test, and entropy. Multinomial logistic regression models were used to examine how LPA's HRQOL profile membership was associated with patient demographic and chronic conditions. The model prediction accuracy on profile membership was evaluated using Huberty's I index with a threshold of 0.35 for good effect.

RESULTS

A 4-profile LPA model was selected. A total of 161 (18.5%), 256 (29.4%), 364 (41.7%), and 91 (10.4%) AYAs were classified into Minimal, Mild, Moderate, and Severe HRQOL Impact profiles. AYAs in each profile had distinctive mean scores with over a half standard deviation (5-points in PROMIS T-scores) of difference between profiles across most HRQOL domains. AYAs who were female or had conditions such as mental health condition, hypertension, and self-reported chronic pain were more likely to be in the Severe HRQOL Impact profile. The Huberty's I index was 0.36.

CONCLUSIONS

Approximately half of AYAs with a chronic condition experience moderate to severe HRQOL impact. The availability of risk prediction models for HRQOL impact will help to identify AYAs who are in greatest need of closer clinical care follow-up.

Interventions with Social Integration Components Addressing Psychosocial Outcomes of Young- and Middle-Aged Adult Cancer Individuals: A Systematic Review

BACKGROUND

The majority of adult cancer patients/survivors encounter social challenges (e.g., obtaining social support, maintaining social relationships, feelings of social isolation). This systematic review summarizes intervention studies addressing social integration or social connectedness issues among young- and middle-aged cancer patients/survivors.

METHODS

We searched the PubMed, CINAHL, and Web of Science databases (January 2000-May 2021) to identify intervention studies that addressed social integration, social connectedness, social support, and social isolation for cancer patients/survivors in young- and middle-aged adulthood (18-64.9 years) through a randomized controlled trial (RCT). We categorized the interventions as technology-based, non-technology-based, and mixed-type (technology- and non-technology-based).

RESULTS

A total of 28 studies were identified. These interventions demonstrated improved social outcomes (e.g., increased social support, decreased loneliness), increased awareness of available cancer-related resources, and better patient-reported outcomes among patients/survivors versus controls. Specifically, the use of internet-based discussion sessions was associated with improved social cohesion and social support. Receiving social support from peers through networking sites was associated with improved physical activity. Additionally, implementing mixed-type interventions led to better social support from peer survivors, less fear of social interactions, and improved social connectedness.

CONCLUSIONS

Using existing technology- and/or non-technology-based platforms to facilitate social connectedness among cancer patients/survivors in young- or middle-aged adulthood can help them cope with stressful life circumstances and improve quality-of-life. Further interventions targeting social integration (e.g., social network interventions) are needed to improve the complex social integration challenges experienced by cancer patients and survivors.

Financial hardship in families of children or adolescents with cancer: a systematic literature review

Financial hardship in childhood cancer contributes to poor health outcomes and global disparities in survival, but the extent of the financial burden on families is not yet fully understood. We systematically reviewed financial hardship prevalence and individual components characterising financial hardship across six domains (medical, non-medical, and indirect costs, financial strategies, psychosocial responses, and behavioural responses) and compared characteristics across country income levels using an established theory of human needs. We included 123 studies with data spanning 47 countries. Extensive heterogeneity in study methodologies and measures resulted in incomparable prevalence estimates and limited analysis. Components characterising financial hardship spanned the six domains and showed variation across country income contexts, yet a synthesis of existing literature cannot establish whether these are true differences in characterisation or burden. Our findings emphasise a crucial need to implement a data-driven methodological framework with validated measures to inform effective policies and interventions to address financial hardship in childhood cancer.

Response-shift effects in childhood cancer survivors: A prospective study

BACKGROUND

Treatment-related late effects can worsen over time among cancer survivors. Such worsening health states may trigger changes in internal standards, values, or conceptualization of quality-of-life (QOL). This "response-shift" phenomenon can jeopardize the validity of QOL assessment, and misrepresent QOL comparisons over time. This study tested response-shift effects in reporting future-health concerns among childhood cancer survivors who experienced progression in chronic health conditions (CHCs).

METHODS

2310 adult survivors of childhood cancer from St. Jude Lifetime Cohort Study completed a survey and clinical assessment at two or more timepoints. Based on 190 individual CHCs graded for adverse-event severity, global CHC burden was classified as "progression" or "non-progression". QOL was assessed using the SF-36^TM eight domains and physical- and mental-component summary scores (PCS, MCS). A single global item measured concerns about future health. Random-effects models comparing survivors with and without progressive global CHC burden (progressors vs. non-progressors) evaluated response-shift effects (recalibration, reprioritization, reconceptualization) in reporting future-health concerns.

RESULTS

Compared with non-progressors, progressors were more likely to de-emphasize (or downplay) overall physical and mental health in evaluating future-health concerns (p-values<0.05), indicating recalibration response-shift, and more likely to de-emphasize physical health earlier rather than later in follow-up (p-value<0.05), indicating reprioritization response-shift. There was evidence for a reconceptualization response-shift with progressor classification associated with worse-than-expected future-health concerns and physical health, and better-than-expected pain and role-emotional functioning (p-values<0.05).

CONCLUSION

We identified three types of response-shift phenomena in reporting concerns about future health among childhood cancer survivors. Survivorship care or research should consider response-shift effects when interpreting changes in QOL over time.

Applying latent profile analysis to identify adolescents and young adults with chronic conditions at risk for poor health-related quality of life

The impact of chronic diseases on health-related quality of life (HRQOL) in adolescents and young adults (AYAs) is understudied. Latent profile analysis (LPA) can identify profiles of AYAs based on their HRQOL scores reflecting physical, mental, and social well-being. This paper will (1) demonstrate how to use LPA to identify profiles of AYAs based on their scores on multiple HRQOL indicators; (2) explore associations of demographic and clinical factors with LPA-identified HRQOL profiles of AYAs; and (3) provide guidance on the selection of adult or pediatric versions of Patient-Reported Outcomes Measurement Information System® (PROMIS®) in AYAs. A total of 872 AYAs with chronic conditions completed the adult and pediatric versions of PROMIS measures of anger, anxiety, depression, fatigue, pain interference, social health, and physical function. The optimal number of LPA profiles was determined by model fit statistics and clinical interpretability. Multinomial regression models examined clinical and demographic factors associated with profile membership. As a result of the LPA, AYAs were categorized into 3 profiles: Minimal, Moderate, and Severe HRQOL Impact profiles. Comparing LPA results using either the pediatric or adult PROMIS T-scores found approximately 71% of patients were placed in the same HRQOL profiles. AYAs who were female, had hypertension, mental health conditions, chronic pain, and those on medication were more likely to be placed in the Severe HRQOL Impact Profile. Our findings may facilitate clinicians to screen AYAs who may have low HRQOL due to diseases or treatments with the identified risk factors without implementing the HRQOL assessment.

Abstract 3503: Racial disparity and roles of social determinants of health in epigenetic age acceleration among survivors of childhood cancer

Our published studies demonstrated that epigenetic age acceleration (EAA) is significantly higher in childhood cancer survivors than non-cancer controls. Additionally, EAA is associated with germline genetics, cancer treatments, unfavorable health behaviors, and chronic health conditions. However, our previous studies were limited to non-Hispanic whites (NHW). We aimed to investigate and compare the EAA between non-Hispanic blacks (NHB) and NHW, and evaluate the contribution of social determinants of health (SDOH) to potential racial disparity in EAA. Methylation profiling was generated using Infinium EPIC BeadChips on blood derived DNA from 460 NHB and 2,052 NHW from the St. Jude Lifetime Cohort. EAA was estimated as the residual from the fit of a simple linear regression of epigenetic age (EA, using Levine’s clock) on chronological age (CA, i.e., age at DNA sampling). Cumulative doses of chemotherapy and region-specific radiation exposures were abstracted from medical records. Educational attainment was categorized into 3 levels (&lt; high school, high school, ≥ college). Personal income was categorized into 3 levels (none, &lt; $40,000 and ≥ $40,000). For socioeconomic area deprivation index (ADI), we considered &gt;75th percentile, 40th to 75th percentile, and &lt;40th percentile as high, moderate, and low deprivation, respectively. Multivariable linear regression evaluated associations of EAA with race and SDOH adjusting for sex and cancer treatments. Mediation analysis treated SDOH as mediators, EAA as an outcome, and race as an exposure. The Pearson r between EA and CA was 0.85 and 0.58, and the age slope of EA (i.e., annual change rate of EA) was 1.21 and 0.91, for NHW and NHB, respectively. EAA was much higher in NHB (mean, 5.31; sd, 7.21) than NHW (mean, -1.19; sd, 12.48) with significance in a multivariable regression model adjusting for sex and cancer treatment (NHB vs. NHW: β = 1.90, P = 9.24×10-5). EAA was also associated with educational attainment (high school vs. &lt;high school: β = -2.84, P = 3.22×10-5; college vs. &lt;high school: β = -3.75, P = 2.03×10-7) and ADI (moderate vs. low: β= 1.07, P = 0.026; high vs. low: β = 1.58, P = 2.26×10-3), but not personal income. Notably, after adjusting for SDOH, the association between EAA and race was moderately attenuated (β = 1.50, P = 8.37×10-3). Both educational attainment (15.5%) and ADI (21.4%) mediated the association between race and EAA. We found racial disparity in EAA, with both personal and geographic SDOH as mediators of the association between race and EAA. These data indicate that changes in the social support system at both a personal and community level are needed to reduce socioeconomic disadvantage (e.g., lower education and poor living conditions) and hence the biological aging trajectory. In addition, moderate correlation between EA and CA among NHB suggests that further refined measurement of EA for NHB survivors is needed.

Citation Format: Noel-Marie Plonski, Cheng Chen, Qian Dong, Na Qin, Nan Song, John Easton, Heather Mulder, Emily Walker, Geoffrey Neale, Jinghui Zhang, Kevin Krull, Kirsten K. Ness, Melissa M. Hudson, Leslie L. Robison, I-Chan Huang, Zhaoming Wang. Racial disparity and roles of social determinants of health in epigenetic age acceleration among survivors of childhood cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3503.

Abstract 4514: Variations of blood DNA methylation associated with cancer treatment exposures among childhood cancer survivors of African ancestry

We previously showed that cancer treatment associated DNA methylation (DNAm) signatures were present decades following the cancer diagnosis in childhood cancer survivors (CCS) of European ancestry (EA) and that treatment associated DNAm sites mediated the causal pathway from specific treatment exposures to increased risk of chronic health conditions (CHCs). This new analysis further evaluated and compared the treatment and DNAm associations in CCS of African ancestry (AA) from the St. Jude Lifetime Cohort Study. Cancer treatments were abstracted from medical records. DNAm was measured using MethylationEPIC BeadChip with blood-derived DNA. Among 370 AA CCS (53.2% female, median age at blood draw=31.2 [range=18.4-65.1] years), treatments included alkylating agents (54.6%), anthracyclines (48.6%), epipodophyllotoxins (29.2%), corticosteroids (33.0%), and vincristine (61.6%), and radiation therapy (RT) to brain (26.5%), chest (27.6%), abdomen (22.7%), and pelvis (21.6%). Epigenome-wide association study (EWAS) for each treatment, using multivariable linear regression adjusting for sex, age at blood draw, leukocyte cell subtype proportions, genotype principal components and DNAm principal components, showed little inflation with genomic control (GC) factor between 1.1 (brain-RT) and 1.2 (chest-RT). A total of 93 5′-cytosine-phosphate-guanine-3′ (CpG) was associated with one or more cancer treatments (GC-adjusted P&lt;9 × 10−8), including epipodophyllotoxins (n=46), alkylating agents (n=38), corticosteroids (n=3), anthracyclines (n=3), abdominal-RT (n=3), chest-RT (n=2), and pelvic-RT (n=1). A total of 60 differentially methylated regions (DMRs) was identified using DMRcate R package, including alkylating agents (n=28), epipodophyllotoxins (n=22), corticosteroids (n=3), abdominal-RT (n=4), chest-RT (n=2), and anthracyclines (n=1). A total of 39 CpGs from EWAS were nested within 21 DMRs. 92.1% (650/706) chemo-associated CpGs in EA were replicated in AA CCS, and 98.9% (86/87) chemo-associated CpGs in AA were replicated in EA CCS. In contrast, 66.7% (4/6) RT-associated CpGs in AA were replicated in EA CCS, and 71.7% (638/890) RT-associated CpGs in EA were replicated in AA CCS. Moreover, the four CpGs that partially mediated the effect of abdominal-RT on hypercholesterolemia in EA were not associated with abdominal-RT in AA CCS, further suggesting substantial difference in RT-associated CpGs as compared to chemo-associated CpGs between AA and EA CCS. Future studies by including a larger sample size of AA CCS are warranted to assess the difference in treatment-associated DNAm alterations and subsequent disparity in risk of treatment-related CHCs between AA and EA CCS. The DNAm sites can be used as predictors for risk management (treatment decision-making) and potential mechanistic targets for intervention for those at the greatest risk of CHCs.

Citation Format: Qian Dong, Sarmistha Das, Cheng Chen, John Easton, Heather L. Mulder, Emily Walker, Geoffrey Neale, Deo Kumar Srivastava, I-Chan Huang, Jinghui Zhang, Melissa M. Hudson, Leslie L. Robison, Kirsten K. Ness, Nan Song, Zhaoming Wang. Variations of blood DNA methylation associated with cancer treatment exposures among childhood cancer survivors of African ancestry. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4514.

Determinants of health-related quality-of-life in adult survivors of childhood cancer: integrating personal and societal values through a health utility approach

Background

Childhood cancer survivors are at elevated risk for poor health-related quality-of-life (HRQOL). Identification of potentially modifiable risk factors associated with HRQOL is needed to inform survivorship care.

Methods

Participants included 4294 adult childhood cancer survivors from the St. Jude Lifetime Cohort Study who completed a survey and clinical assessment at entry into the survivorship cohort (baseline) and follow-up (median interval: 4.3 years) between 2007 and 2019. The SF-6D compared utility-based HRQOL of survivors to an independent sample from the U.S. Medical Expenditures Panel Survey. Chronic health conditions (CHCs) were graded using modified Common Terminology Criteria for Adverse Events. General linear models examined cross-sectional and temporal associations of HRQOL with CHC burden (total and by organ-system), adjusting for potential risk factors.

Findings

Survivors reported poorer HRQOL compared to the general population (effect size [d] = -0.343). In cross-sectional analyses at baseline, significant non-demographic risk factors included higher total CHC burden (driven by more severe cardiovascular [d = -0.119, p = 0.002], endocrine [d = -0.112, p = 0.001], gastrointestinal [d = -0.226, p < 0.001], immunologic [d = -0.168, p = 0.035], neurologic [d = -0.388, p < 0.001], pulmonary [d = -0.132, p = 0.003] CHCs), public (d = -0.503, p < 0.001) or no health insurance (d = -0.123, p = 0.007), current smoking (d = -0.270, p < 0.001), being physically inactive (d = -0.129, p < 0.001), ever using illicit drugs (d = -0.235, p < 0.001), and worse diet quality (d = -0.004, p = 0.016). In temporal analyses, poorer utility-based HRQOL at follow-up was associated with risk factors at baseline, including higher total CHC burden (driven by cardiovascular [d = -0.152, p = 0.002], endocrine [d = -0.092, p = 0.047], musculoskeletal [d = -0.160, p = 0.016], neurologic [d = -0.318, p < 0.001] CHCs), public (d = -0.415, p < 0.001) or no health insurance (d = -0.161, p = 0.007), current smoking (d = -0.218, p = 0.001), and ever using illicit drugs (d = -0.217, p < 0.001).

Interpretation

Adult survivors report worse utility-based HRQOL than the general population, and potentially modifiable risk factors were associated with HRQOL. Interventions to prevent the early onset of CHCs, promote healthy lifestyle, and ensure access to health insurance in the early survivorship stage may provide opportunities to improve HRQOL.

Funding

The research reported in this manuscript was supported by the U.S. National Cancer Institute under award numbers U01CA195547 (Hudson/Ness), R01CA238368 (Huang/Baker), R01CA258193 (Huang/Yasui), R01CA270157 (Bhakta/Yasui), and T32CA225590 (Krull). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.

Emotional, behavioral, and physical health consequences of loneliness in young adult survivors of childhood cancer: Results from the Childhood Cancer Survivor Study

BACKGROUND

Young adults in the general population are at risk of experiencing loneliness, which has been associated with physical and mental health morbidities. The prevalence and consequences of loneliness in young adult survivors of childhood cancer remain unknown.

METHODS

A total of 9664 young adult survivors of childhood cancer (median age at diagnosis 10.5 years [interquartile range (IQR), 5-15], 27.1 years at baseline [IQR, 23-32]) and 2221 siblings enrolled in the Childhood Cancer Survivor Study completed a self-reported survey question assessing loneliness on the Brief Symptom Inventory-18 at baseline and follow-up (median follow-up, 6.6 years). Multivariable models evaluated the prevalence of loneliness at baseline only, follow-up only, and baseline + follow-up, and its associations with emotional distress, health behaviors, and chronic conditions at follow-up.

RESULTS

Survivors were more likely than siblings to report loneliness at baseline + follow-up (prevalence ratio [PR] 2.2; 95% confidence interval [CI], 1.7-3.0) and at follow-up only (PR, 1.4; 95% CI, 1.1-1.7). Loneliness at baseline + follow-up was associated with elevated risk of anxiety (relative risk [RR], 9.8; 95% CI, 7.5-12.7), depression (RR, 17.9; 95% CI, 14.1-22.7), and current smoking (odds ratio [OR], 1.7; 95% CI, 1.3-2.3) at follow-up. Loneliness at follow-up only was associated with suicidal ideation (RR, 1.5; 95% CI, 1.1-2.1), heavy/risky alcohol consumption (RR, 1.3; 95% CI, 1.1-1.5), and new-onset grade 2-4 chronic conditions (RR, 1.3; 95% CI, 1.0-1.7).

CONCLUSIONS

Young adult survivors of childhood cancer have elevated risk of experiencing loneliness, which is associated with future emotional distress, risky health behaviors, and new-onset chronic conditions.

Distinct DNA methylation signatures associated with blood lipids as exposures or outcomes among survivors of childhood cancer: a report from the St. Jude lifetime cohort

BACKGROUND

DNA methylation (DNAm) plays an important role in lipid metabolism, however, no epigenome-wide association study (EWAS) of lipid levels has been conducted among childhood cancer survivors. Here, we performed EWAS analysis with longitudinally collected blood lipid data from survivors in the St. Jude lifetime cohort study.

METHODS

Among 2052 childhood cancer survivors of European ancestry (EA) and 370 survivors of African ancestry (AA), four types of blood lipids, including high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC), and triglycerides (TG), were measured during follow-up beyond 5-years from childhood cancer diagnosis. For the exposure EWAS (i.e., lipids measured before blood draw for DNAm), the DNAm level was an outcome variable and each of the blood lipid level was an exposure variable; vice versa for the outcome EWAS (i.e., lipids measured after blood draw for DNAm).

RESULTS

Among EA survivors, we identified 43 lipid-associated CpGs in the HDL (n = 7), TC (n = 3), and TG (n = 33) exposure EWAS, and 106 lipid-associated CpGs in the HDL (n = 5), LDL (n = 3), TC (n = 4), and TG (n = 94) outcome EWAS. Among AA survivors, we identified 15 lipid-associated CpGs in TG exposure (n = 6), HDL (n = 1), LDL (n = 1), TG (n = 5) and TC (n = 2) outcome EWAS with epigenome-wide significance (P < 9 × 10^-8). There were no overlapping lipids-associated CpGs between exposure and outcome EWAS among EA and AA survivors, suggesting that the DNAm changes of different CpGs could be the cause or consequence of blood lipid levels. In the meta-EWAS, 12 additional CpGs reached epigenome-wide significance. Notably, 32 out of 74 lipid-associated CpGs showed substantial heterogeneity (P_het < 0.1 or I² > 70%) between EA and AA survivors, highlighting differences in DNAm markers of blood lipids between populations with diverse genetic ancestry. Ten lipid-associated CpGs were cis-expression quantitative trait methylation with their DNAm levels associated with the expression of corresponding genes, out of which seven were negatively associated.

CONCLUSIONS

We identified distinct signatures of DNAm for blood lipids as exposures or outcomes and between EA and AA survivors, revealing additional genes involved in lipid metabolism and potential novel targets for controlling blood lipids in childhood cancer survivors.

Dietary supplement use among adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort Study

BACKGROUND

Adult survivors of childhood cancer have poor adherence to nutrition guidelines and inadequate intake of dietary vitamins D and E, potassium, fiber, magnesium, and calcium. The contribution of vitamin and mineral supplement use to total nutrient intake in this population is unclear.

METHODS

We examined the prevalence and dose of nutrient intake among 2570 adult survivors of childhood cancer participating in the St. Jude Lifetime Cohort Study, and the association of dietary supplement use with treatment exposures, symptom burden, and quality of life.

RESULTS

Nearly 40% of the adult survivors of cancer survivors reported regular use of dietary supplements. Although cancer survivors who used dietary supplements were less likely to have inadequate intake of several nutrients, they were also more likely to have excessive intake (total nutrient intake ≥ tolerable upper intake levels) of folate (15.4% vs. 1.3%), vitamin A (12.2% vs. 0.2%), iron (27.8% vs. 1.2%), zinc (18.6% vs. 1%), and calcium (5.1% vs. 0.9%) compared with survivors who did not use dietary supplements (all p < 0.05). Treatment exposures, symptom burden, and physical functioning were not associated with supplement use, whereas emotional well-being and vitality were positively associated with supplement use among childhood cancer survivors.

CONCLUSIONS

Supplement use is associated with both inadequate and excessive intake of specific nutrients, but positively impacts aspects of quality of life among childhood cancer survivors.

Financial Hardship in Adult Survivors of Childhood Cancer in the Era After Implementation of the Affordable Care Act: A Report From the Childhood Cancer Survivor Study

PURPOSE

To estimate the prevalence of financial hardship among adult survivors of childhood cancer compared with siblings and identify sociodemographic, cancer diagnosis, and treatment correlates of hardship among survivors in the era after implementation of the Affordable Care Act.

METHODS

A total of 3,555 long-term (≥ 5 years) survivors of childhood cancer and 956 siblings who completed a survey administered in 2017-2019 were identified from the Childhood Cancer Survivor Study. Financial hardship was measured by 21 survey items derived from US national surveys that had been previously cognitively tested and fielded. Principal component analysis (PCA) identified domains of hardship. Multiple linear regression examined the association of standardized domain scores (ie, scores divided by standard deviation) with cancer and treatment history and sociodemographic characteristics among survivors.

RESULTS

Survivors were more likely than siblings to report hardship in ≥ 1 item (63.4% v 53.7%, P < .001). They were more likely to report being sent to debt collection (29.9% v 22.3%), problems paying medical bills (20.7% v 12.8%), foregoing needed medical care (14.1% v 7.8%), and worry/stress about paying their rent/mortgage (33.6% v 23.2%) or having enough money to buy nutritious meals (26.8% v 15.5%); all P < .001. Survivors reported greater hardship than siblings in all three domains identified by principal component analysis: behavioral hardship (mean standardized domain score 0.51 v 0.35), material hardship/financial sacrifices (0.64 v 0.46), and psychological hardship (0.69 v 0.44), all P < .001. Sociodemographic (eg,

CONCLUSION

Survivors of childhood cancer were more likely to experience financial hardship than siblings. Correlates of hardship can inform survivorship care guidelines and intervention strategies.

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Key Words Collapse

MESH Headings

• United States
• Adult
• Humans
• Child
• Neoplasms/therapy
• Cancer Survivors
• Patient Protection and Affordable Care Act
• Financial Stress
• Cost of Illness
• Survivors
• Surveys and Questionnaires

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Grants

• U24 CA055727 NCI NIH HHS

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Affiliation(s)

Paul C. Nathan The Hospital for Sick Children, Division of Hematology/Oncology, The University of Toronto, Toronto, Ontario, Canada
I-Chan Huang St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Yan Chen University of Alberta, Edmonton, School of Public Health Alberta, Edmonton, Alberta, Canada
Tara O. Henderson University of Chicago Comer Children's Hospital, Section of Pediatric Hematology, Oncology and Stem Cell Transplantation, Chicago, IL
Elyse R. Park Massachusetts General Hospital Cancer Center, Boston, MA
Anne C. Kirchhoff Huntsman Cancer Institute, Cancer Control and Population Sciences, University of Utah, Salt Lake City, UT
Leslie L. Robison St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Kevin Krull St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Wendy Leisenring Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA
Gregory T. Armstrong St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
Rena M. Conti Department of Markets, Public Policy and Law, Questrom School of Business, Boston University, Boston, MA
Yutaka Yasui St Jude Children's Research Hospital, Department of Epidemiology & Cancer Control, Memphis, TN
K. Robin Yabroff Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, GA

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Association of Modifiable Health Conditions and Social Determinants of Health With Late Mortality in Survivors of Childhood Cancer

IMPORTANCE

Associations between modifiable chronic health conditions (CHCs), social determinants of health, and late mortality (defined as death occurring ≥5 years after diagnosis) in childhood cancer survivors are unknown.

OBJECTIVE

To explore associations between modifiable CHCs and late mortality within the context of social determinants of health.

DESIGN, SETTING, AND PARTICIPANTS

This longitudinal cohort study used data from 9440 individuals who were eligible to participate in the St Jude Lifetime Cohort (SJLIFE), a retrospective cohort study with prospective clinical follow-up that was initiated in 2007 to characterize outcomes among childhood cancer survivors. Eligible individuals had survived 5 or more years after childhood cancer diagnosis, were diagnosed between 1962 and 2012, and received treatment at St Jude Children's Research Hospital were included in mortality estimates. A total of 3407 adult SJLIFE participants (aged ≥18 years) who completed an on-campus assessment were included in risk factor analyses. Vital status, date of death, and cause of death were obtained by linkage with the National Death Index (coverage from inception to December 31, 2016). Deaths occurring before inception of the National Death Index were obtained from the St Jude Children's Research Hospital Cancer Registry. Data were analyzed from June to December 2022.

EXPOSURES

Data on treatment exposures and causes of death were abstracted for individuals who were eligible to participate in the SJLIFE study. Information on modifiable CHCs (dyslipidemia, hypertension, diabetes, underweight or obesity, bone mineral deficiency, hypogonadism, hypothyroidism, and adrenal insufficiency, all graded by the modified Common Terminology Criteria for Adverse Events), healthy lifestyle index (smoking status, alcohol consumption, body mass index [calculated as weight in kilograms divided by height in meters squared], and physical activity), area deprivation index (ADI; which measures neighborhood-level socioeconomic disadvantage), and frailty (low lean muscle mass, exhaustion, low energy expenditure, slowness, and weakness) was obtained for participants.

MAIN OUTCOMES AND MEASURES

National Death Index causes of death were used to estimate late mortality using standardized mortality ratios (SMRs) and 95% CIs, which were calculated based on US mortality rates. For the risk factor analyses (among participants who completed on-campus assessment), multivariable piecewise exponential regression analysis was used to estimate rate ratios (RRs) and 95% CIs for all-cause and cause-specific late mortality.

RESULTS

Among 9440 childhood cancer survivors who were eligible to participate in the SJLIFE study, the median (range) age at assessment was 27.5 (5.3-71.9) years, and the median (range) duration of follow-up was 18.8 (5.0-58.0) years; 55.2% were male and 75.3% were non-Hispanic White. Survivors experienced increases in all-cause mortality (SMR, 7.6; 95% CI, 7.2-8.1) and health-related late mortality (SMR, 7.6; 95% CI, 7.0-8.2). Among 3407 adult SJLIFE participants who completed an on-campus assessment, the median (range) age at assessment was 35.4 (17.9-69.8) years, and the median (range) duration of follow-up was 27.3 (7.3-54.7) years; 52.5% were male and 81.7% were non-Hispanic White. Models adjusted for attained age, sex, race and ethnicity, age at diagnosis, treatment exposures, household income, employment status, and insurance status revealed that having 1 modifiable CHC of grade 2 or higher (RR, 2.2; 95% CI, 1.2-4.0; P = .01), 2 modifiable CHCs of grade 2 or higher (RR, 2.6; 95% CI, 1.4-4.9; P = .003), or 3 modifiable CHCs of grade 2 or higher (RR, 3.6; 95% CI, 1.8-7.1, P < .001); living in a US Census block with an ADI in the 51st to 80th percentile (RR, 5.5; 95% CI, 1.3-23.5; P = .02), an ADI in the 81st to 100th percentile (RR, 8.7; 95% CI, 2.0-37.6; P = .004), or an unassigned ADI (RR, 15.7; 95% CI, 3.5-70.3; P < .001); and having frailty (RR, 2.3; 95% CI, 1.3-3.9; P = .004) were associated with significant increases in the risk of late all-cause death. Similar associations were observed for the risk of late health-related death (1 modifiable CHC of grade ≥2: RR, 2.2 [95% CI, 1.1-4.4; P = .02]; 2 modifiable CHCs of grade ≥2: RR, 2.5 [95% CI, 1.2-5.2; P = .01]; 3 modifiable CHCs of grade ≥2: RR, 4.0 [95% CI, 1.9-8.4; P < .001]; ADI in 51st-80th percentile: RR, 9.2 [95% CI, 1.2-69.7; P = .03]; ADI in 81st-100th percentile: RR, 16.2 [95% CI, 2.1-123.7; P = .007], unassigned ADI: RR, 27.3 [95% CI, 3.5-213.6; P = .002]; and frailty: RR, 2.3 [95% CI, 1.2-4.1; P = .009]).

CONCLUSIONS AND RELEVANCE

In this cohort study of childhood cancer survivors, living in a Census block with a high ADI and having modifiable CHCs were independently associated with an increased risk of late death among survivors of childhood cancer. Future investigations seeking to mitigate these factors will be important to improving health outcomes and developing risk-stratification strategies to optimize care delivery to childhood cancer survivors.

Associations of Symptom Clusters and Health Outcomes in Adult Survivors of Childhood Cancer: A Report From the St Jude Lifetime Cohort Study

PURPOSE

To identify symptom clusters among adult survivors of childhood cancers and test associations with health-related quality of life (HRQOL) and physical and neurocognitive performance.

METHODS

This cross-sectional study included 3,085 survivors (mean age at evaluation 31.9 ± 8.3 years; mean years from diagnosis 28.1 ± 9.1) participating in the St Jude Lifetime Cohort Study. Survivors self-reported the presence of 37 symptoms capturing 10 domains (cardiac, pulmonary, sensory, motor/movement, nausea, pain, fatigue, memory, anxiety, and depression). The Short Form-36's Physical/Mental Component Summaries assessed HRQOL; the Physical Performance Test evaluated physical performance; and neurocognitive batteries tested attention, processing/psychomotor speed, memory, and executive function. Latent class analysis identified subgroups of survivors experiencing different patterns of symptom burden (ie, symptom clusters). Multivariable regression models identified risk of cluster membership and tested associations with health outcomes.

RESULTS

Four symptom clusters were identified including cluster 1 (prevalence 52.4%; low physical, somatization, and psychologic domains), cluster 2 (16.1%; low physical, moderate somatic, and high psychologic domains), cluster 3 (17.6%; high physical, moderate somatic, and low psychologic domains), and cluster 4 (13.9%; high in all three domains). Compared with cluster 1, survivors in cluster 4 were more likely to have less than high school education (odds ratio [OR], 7.71; 95% CI, 4.46 to 13.31), no insurance (OR, 1.49; 95% CI, 1.04 to 2.13), and exposure to corticosteroids (OR, 1.76; 95% CI, 1.02 to 3.03); survivors in cluster 3 were more likely to have received platinum agents (OR, 2.22; 95% CI, 1.34 to 3.68) and brain radiation ≥ 30 Gy (OR, 3.99; 95% CI, 2.33 to 6.86). Survivors in cluster 4 reported the poorest Physical Component Summary/Mental Component Summary scores (31.0/26.7) and physical and neurocognitive performance versus survivors in the other clusters (P < .001).

CONCLUSION

Nearly 50% of survivors had moderate to high multisymptom burden, which was associated with sociodemographic, treatment factors, HRQOL, and functional outcomes.

A Review of Patient-Reported Outcome Measures in Childhood Cancer

Patient-reported outcomes (PROs) are used in clinical work and research to capture the subjective experiences of childhood cancer patients and survivors. PROs encompass content domains relevant and important to this population, including health-related quality-of-life (HRQOL), symptoms, and functional status. To inform future efforts in the application of PRO measures, this review describes the existing generic and cancer-specific PRO measures for pediatric cancer populations and summarizes their characteristics, available language translations, content coverage, and measurement properties into tables for clinicians and researchers to reference before choosing a PRO measure that suits their purpose. We have identified often unreported measurement properties that could provide evidence about the clinical utility of the PRO measures. Routine PRO assessment in pediatric cancer care offers opportunities to facilitate clinical decision-making and improve quality of care for these patients. However, we suggest that before implementing PRO measures into research or clinical care, the psychometric properties and content coverage of the PRO measures must be considered to ensure that PRO measures are appropriately assessing the intended construct in childhood cancer patients.

Development and Validation of Models to Predict Poor Health-Related Quality of Life Among Adult Survivors of Childhood Cancer

IMPORTANCE

Risk prediction models are important to identify survivors of childhood cancer who are at risk of experiencing poor health-related quality of life (HRQOL) as they age.

OBJECTIVE

To develop and validate prediction models for a decline in HRQOL among adult survivors of childhood cancer.

DESIGNS, SETTING, AND PARTICIPANTS

This prognostic study included 4755 adults from the Childhood Cancer Survivor Study (CCSS) diagnosed between January 5, 1970, and December 31, 1986, who completed baseline (time 0 [November 3, 1992, to August 28, 2003]) and 2 follow-up (time 1 [February 12, 2002, to May 21, 2005] and time 2 [January 6, 2014, to November 30, 2016]) surveys. Data were analyzed from June 19, 2019, to February 2, 2022.

EXPOSURES

Sociodemographic, lifestyle, and emotional factors, and chronic health conditions (CHCs) were assessed at time 0 and time 1, and neurocognitive factors were assessed at time 1 to predict HRQOL at time 2 and a decline in HRQOL between time 1 and time 2. Impaired health states were defined as CHC grades 2 to 4 using the modified Common Terminology Criteria for Adverse Events, version 4.03, and mental and neurocognitive status as 1 SD or more below reference levels.

MAIN OUTCOMES AND MEASURES

Health-related quality of life was operationalized using the Medical Outcomes Study 36-Item Short Form Health Survey Physical (PCS) and Mental (MCS) Component Summary and classified by optimal (≥40) or suboptimal (<40) at each point (main outcome). A decline in HRQOL was defined as a change from optimal to suboptimal between time 1 and time 2. Multivariable logistic regression identified factors associated with HRQOL decline. The cohort was randomly split into training (80%) and test (20%) data sets for model development and validation; the area under the receiver operating characteristic curve was used to evaluate prediction performance.

RESULTS

A total of 4755 adults (mean [SD] age at time 0, 24.3 [7.6] years; 2623 [55.2%] women) were included in the analysis. Between time 1 and time 2, 285 of 3294 survivors (8.7%) had declining PCS and 278 of 3294 (8.4%) had declining MCS. Risk factors associated with PCS decline included female sex (odds ratio [OR], 1.67 [95% CI, 1.25-2.24]), family income less than $20 000 vs $80 000 or more (OR, 2.00 [95% CI, 1.21-3.30]), presence of CHCs (OR for neurological, 2.16 [95% CI, 1.51-3.10]; OR for endocrine, 2.25 [95% CI, 1.44-3.52]; OR for gastrointestinal tract, 1.89 [95% CI, 1.32-2.69]; OR for respiratory, 1.66 [95% CI, 1.06-2.59]; OR for cardiovascular, 1.53 [95% CI, 1.14-2.06]), and depression (OR, 1.79 [95% CI, 1.20-2.67]). Risk factors associated with MCS decline included unemployment vs full-time employment (OR, 1.68; [95% CI, 1.19-2.38]), current vs never cigarette smoking (OR, 2.03 [95% CI, 1.37-3.00]), depression (OR, 4.29 [95% CI, 2.44-7.55]), somatization (OR, 1.63 [95% CI, 1.05-2.53]), impaired task efficiency (OR, 1.90 [95% CI, 1.34-2.68]), and impaired organization (OR, 1.67 [95% CI, 1.12-2.48]). The areas under the receiver operating characteristic curve for the test models were 0.74 (95% CI, 0.67-0.81) for declining PCS and 0.68 (95% CI, 0.60-0.75) for declining MCS.

CONCLUSIONS AND RELEVANCE

In this prognostic study of adult survivors of childhood cancer who experienced declining HRQOL, CHCs were associated with a decline in physical HRQOL, whereas current smoking and emotional and neurocognitive impairment were associated with a decline in mental HRQOL. These findings suggest that interventions targeting modifiable risk factors are needed to prevent poor HRQOL in this population.

Self-Reported Health Outcomes of Children and Youth with 10 Chronic Diseases

OBJECTIVES

To identify pediatric patient-reported outcomes (PROs) that are associated with chronic conditions and to evaluate the effects of chronic disease activity on PROs.

STUDY DESIGN

Participants (8-24 years old) and their parents were enrolled into 14 studies that evaluated Patient-Reported Outcome Measurement Information System PROs across 10 chronic conditions-asthma, atopic dermatitis, cancer, cancer survivors, chronic kidney disease, Crohn's disease, juvenile idiopathic arthritis, lupus, sickle cell disease, and type 1 diabetes mellitus. PRO scores were contrasted with the US general population of children using nationally representative percentiles. PRO-specific coefficients of variation were computed to illustrate the degree of variation in scores within vs between conditions. Condition-specific measures of disease severity and Cohen d effect sizes were used to examine PRO scores by disease activity.

RESULTS

Participants included 2975 child respondents and 2392 parent respondents who provided data for 3409 unique children: 52% were 5-12 years old, 52% female, 25% African American/Black, and 14% Hispanic. Across all 10 chronic conditions, children reported more anxiety, fatigue, pain, and mobility restrictions than the general pediatric population. Variation in PRO scores within chronic disease cohorts was equivalent to variation within the general population, exceeding between-cohort variation by factors of 1.9 (mobility) to 5.7 (anxiety). Disease activity was consistently associated with poorer self-reported health, and these effects were weakest for peer relationships.

CONCLUSIONS

Chronic conditions are associated with symptoms and functional status in children and adolescents across 10 different disorders. These findings highlight the need to complement conventional clinical evaluations with those obtained directly from patients themselves using PROs.

Abstract 3764: Epigenome-wide association study of blood lipids among survivors of childhood cancer in the St. Jude Lifetime Cohort

Epigenetic studies of blood lipid traits have identified genes underlying lipid metabolism in the general population. However, investigation of this association has not been conducted in survivors of childhood cancer, a population with a much higher burden of dyslipidemia and other cardiometabolic conditions due to exposures of genotoxic cancer therapies. We performed epigenome-wide association studies (EWAS) to identify blood DNA methylation (DNAm) 5’-cytosine-phosphate-guanine-3′ (CpGs) associated with lipid concentrations, including high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC), and triglycerides (TG), for childhood cancer survivors from the St. Jude Lifetime (SJLIFE) cohort. DNAm was generated with blood derived DNA using Illumina MethylationEPIC BeadChip array. Adjusted M-value of DNAm for each CpG was calculated based on a linear regression of M-value against a set of covariates, including sex, age at DNA sampling, leukocyte subtype proportions, top four significant genetic principal components, and top four methylation principal components. In the exposure EWAS, a linear regression model was used for lipid levels prior to DNA sampling as an exposure variable and DNAm as an outcome variable, adjusting for cancer treatments, age at lipid measurement, BMI, cigarette smoking and lipid lowering medicine use. In the outcome EWAS, a linear regression model was used for DNAm as an exposure variable and lipid levels after DNA sampling as outcome variables, adjusting for cancer treatments, age at lipid measurement, BMI, smoking, lipid lowering medicine use, lipid levels measured at DNA sampling, age at DNA sampling, and polygenic risk score for specific lipid levels. Among survivors of European ancestry (N=2052), we identified 43 significant CpGs (P&lt;9×10-8) associated with HDL (n=7), TC (n=3) and TG (n=33) as exposures; and 106 CpGs associated with HDL (n=5), LDL (n=3), TC (n=4), and TG (n=94) as outcomes. Among survivors of African ancestry (N=370), we identified 3 CpGs associated with TG as an exposure, and 5 CpGs associated with LDL (n=1) and TC (n=4) as outcomes. A comparison of effect sizes of significant CpGs between survivors of European and African ancestry suggests moderate to substantial racial differences in epigenetic associations with lipid exposures (14/46 with I2&gt;50) and lipid outcomes (106/111 with I2&gt;50). Additionally, no overlap between CpGs associated with lipid exposures and lipid outcomes suggests that the DNAm levels of these CpGs could be either the cause or consequence of lipid levels. Examination of the EWAS catalog and recent literature, suggests that most of the lipid associated CpGs identified in our study are novel. Blood lipid associated CpGs may be epigenetic biomarkers for identification of survivors with higher risk of dyslipidemia and may inform potential drug targets for future interventions.

Citation Format: Qian Dong, Nan Song, Cheng Chen, Zhenghong Li, John Easton, Heather Mulder, Jinghui Zhang, Geoffrey Neale, Emily Walker, I-Chan Huang, Kirsten K. Ness, Melissa M. Hudson, Leslie L. Robison, Zhaoming Wang. Epigenome-wide association study of blood lipids among survivors of childhood cancer in the St. Jude Lifetime Cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3764.

Symptom profiles and health care utilization in long-term survivors of Survivors of Childhood Childhood Cancer Survivor (CCSS) study

e22024

Background: Physical and psychological symptoms co-occur among survivors of childhood cancer, and subgroups with high symptom burden may be at increased risk for problematic healthcare utilization (HCU). Methods: Childhood Cancer Survivor Study participants (N = 17,231; Mean [SD] age = 27.4 [5.98]; 79% non-Hispanic White; 48% female) self-reported sensory, motor, cardiac, respiratory, pain, gastrointestinal, fatigue, memory, depression, and anxiety symptoms at baseline evaluation and latent class analysis identified symptom profiles. Chronic health conditions (CHCs) at baseline (graded per CTCAE 1-2 [mild or moderate; reference] vs 3-4 [severe-life threatening or disabling). HCU (no health care, general care, oncology-focused, long-term follow-up, emergency room visit) for the past 2 years was assessed 6.3 median years after baseline. Logistic regressions examined associations between class membership and follow-up HCU, adjusted for sex, age, health insurance and CHCs. Results: Five symptom classes were identified: 1) Global symptoms (global; 7.7%); 2) emotional distress and pain (distress-pain; 13.3%); 3) neurologic and pain (neuro-pain; 10.6%); 4) cardiopulmonary and pain (cardio-pain; 5.3%); 5) non-elevated symptoms (norm; 63.1%). Bone tumor survivors had higher risk of falling into global, neuro-pain and cardio-pain groups (p’s < .001), and CNS tumor survivors had higher risk of falling into global and neuro-pain group (all p < .001) compared to leukemia survivors. Radiation, Grade 3-4 CHCs, female sex, and older age increased risk of global, distress-pain, neuro-pain and cardio-pain membership compared to norm (all p’s < .001). Oncology-focused care was more common in cardio-pain and global symptom groups, while long-term follow-up care was more common in neuro-pain and global groups (Table). All elevated symptoms groups were more likely to have emergency room visits compared to norm group. Conclusions: Adjusting for insurance, CHCs and older age, elevated symptoms are associated with future emergency room use. Pain is prevalent in all high symptom groups, and suggests an important intervention target.[Table: see text]

Longitudinal associations between psychosocial morbidity, chronic health conditions, quality of life, and mortality in adult survivors of childhood cancer

e24147

Background: Psychosocial late effects of childhood cancer are often studied in isolation despite high rates of co-morbidity. We examined patterns of psychosocial morbidity and their associations with subsequent chronic health conditions, quality of life, and mortality in adult survivors of childhood cancer. Methods: St. Jude Lifetime Cohort participants (n = 4,009; median[range] 30.6[18.0-64.8] years of age; 20.4[5.5-52.3] years from diagnosis; 51% female) completed baseline questionnaires. Latent class analysis characterized psychosocial morbidity using 18 individual indicators across four domains: functional independence (e.g., independent living), emotional health (e.g., depressive symptoms), health behaviors (e.g., alcohol use), and socioeconomic status (e.g., employment). Generalized linear models, adjusted for age, sex, and race/ethnicity, examined longitudinal associations between class membership at cohort entry and persistent/new onset Grade 2-4 chronic health conditions from baseline to follow-up (n = 2,355, median f/u = 5.8 years). In separate adjusted models, associations with persistently poor/worsening quality of life at follow-up [SF-36 t-score <40] (n = 2,276, median f/u = 5.7 years) were examined. Cox Proportional models were used to examine associations between class membership and all-cause mortality adjusting for age, sex, and race/ethnicity. Results: Four latent classes were identified: (1) functional non-independence (21%); (2) risky health behaviors (15%); (3) poor emotional health (14%); and (4) low psychosocial morbidity (49%). Survivors in the functional non-independence and poor emotional health classes had increased risk of persistent/new onset Grade 2-4 cardiac (RR = 1.23, 95% CI 1.09-1.40; RR = 1.16, 95% CI 1.04-1.31), pulmonary (RR = 1.28, 95% CI 1.14-1.42, RR = 1.15; 95% CI 1.02-1.29), neurologic (RR = 2.22, 95% CI 1.93-2.56; RR = 1.97, 95% CI 1.70-2.28), and musculoskeletal conditions (RR = 1.85, 95% CI 1.58-2.15; RR = 1.46, 95% CI 1.21-1.75) compared to low psychosocial morbidity. Each class of psychosocial morbidity was significantly associated with persistently poor/worsening quality of life from baseline to follow-up compared to low psychosocial morbidity. Compared to the low psychosocial morbidity class, functional non-independence (HR = 3.37, 95% CI 2.43-4.67), risky health behaviors (HR = 1.77, 95% CI 1.21-2.59), and poor emotional health (HR = 2.70, 95% CI 1.89-3.84) classes were associated with increased risk of all-cause mortality. Conclusions: Baseline psychosocial morbidities experienced by survivors of childhood cancer are associated with persistent and new onset chronic health conditions, poor/worsening quality of life, and mortality. Interventions targeting psychosocial late effects may mitigate adverse health outcomes in survivors.

Genome-wide association studies identify novel genetic loci for epigenetic age acceleration among survivors of childhood cancer

Background

Increased epigenetic age acceleration (EAA) in survivors of childhood cancer is associated with specific treatment exposures, unfavorable health behaviors, and presence of certain chronic health conditions. To better understand inter-individual variability, we investigated the genetic basis underlying EAA.

Methods

Genome-wide association studies of EAA based on multiple epigenetic clocks (Hannum, Horvath, PhenoAge, and GrimAge) were performed. MethylationEPIC BeadChip array and whole-genome sequencing data were generated with blood-derived DNA from participants in the St. Jude Lifetime Cohort Study (discovery: 2138 pre-existing and 502 newly generated data, all survivors; exploratory: 282 community controls). Linear regression models were fit for each epigenetic age against the allelic dose of each genetic variant, adjusting for age at sampling, sex, and cancer treatment exposures. Fixed-effects meta-analysis was used to combine summary statistics from two discovery data sets. LD (Linkage disequilibrium) score regression was used to estimate single-nucleotide polymorphism (SNP)-based heritability.

Results

For EAA-Horvath, a genome-wide significant association was mapped to the SELP gene with the strongest SNP rs732314 (meta-GWAS: β=0.57, P=3.30×10^-11). Moreover, the stratified analysis of the association between rs732314 and EAA-Horvath showed a substantial heterogeneity between children and adults (meta-GWAS: β=0.97 vs. 0.51, I²=73.1%) as well as between survivors with and without chest/abdominal/pelvic-RT exposure (β=0.64 vs. 0.31, I²=66.3%). For EAA-Hannum, an association was mapped to the HLA locus with the strongest SNP rs28366133 (meta-GWAS: β=0.78, P=3.78×10^-11). There was no genome-wide significant hit for EAA-PhenoAge or EAA-GrimAge. Interestingly, among community controls, rs732314 was associated with EAA-Horvath (β=1.09, P=5.43×10^-5), whereas rs28366133 was not associated with EAA-Hannum (β=0.21, P=0.49). The estimated heritability was 0.33 (SE=0.20) for EAA-Horvath and 0.17 (SE=0.23) for EAA-Hannum, but close to zero for EAA-PhenoAge and EAA-GrimAge.

Conclusions

We identified novel genetic variants in the SELP gene and HLA region associated with EAA-Horvath and EAA-Hannum, respectively, among survivors of childhood cancer. The new genetic variants in combination with other replicated known variants can facilitate the identification of survivors at higher risk in developing accelerated aging and potentially inform drug targets for future intervention strategies among vulnerable survivors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13073-022-01038-6.

Blood DNA methylation signatures are associated with social determinants of health among survivors of childhood cancer

Social epigenomics is an emerging field in which social scientist collaborate with computational biologists, especially epigeneticists, to address the underlying pathway for biological embedding of life experiences. This social epigenomics study included long-term childhood cancer survivors enrolled in the St. Jude Lifetime Cohort. DNA methylation (DNAm) data were generated using the Illumina EPIC BeadChip, and three social determinants of health (SDOH) factors were assessed: self-reported educational attainment, personal income, and an area deprivation index based on census track data. An epigenome-wide association study (EWAS) was performed to evaluate the relation between DNAm at each 5’-cytosine-phosphate-guanine-3’ (CpG) site and each SDOH factor based on multivariable linear regression models stratified by ancestry (European ancestry, n = 1,618; African ancestry, n = 258). EWAS among survivors of European ancestry identified 130 epigenome-wide significant SDOH–CpG associations (P < 9 × 10⁻⁸), 25 of which were validated in survivors of African ancestry (P < 0.05). Thirteen CpGs were associated with all three SDOH factors and resided at pleiotropic loci in cigarette smoking–related genes (e.g., CLDND1 and CPOX). After accounting for smoking and body mass index, these associations remained significant with attenuated effect sizes. Seven of 13 CpGs were associated with gene expression level based on 57 subsamples with blood RNA sequencing data available. In conclusion, DNAm signatures, many resembling the effect of tobacco use, were associated with SDOH factors among survivors of childhood cancer, thereby suggesting that biologically distal SDOH factors influence health behaviours or related factors, the epigenome, and subsequently survivors’ health.

Barriers and Opportunities for Patient-Reported Outcome Implementation: A National Pediatrician Survey in the United States

Purpose: To characterize pediatricians’ perceived barriers and areas of confidence in assessing patient-reported outcomes (PROs) in the U.S., and to test associations of these factors with implementing PRO assessment. Methods: Using a random sample from the members of American Medical Association, we recruited general pediatricians and pediatric subspecialists to complete a survey (July 2011 to December 2013). Perceived barriers and confidence in PRO assessment were compared by age, pediatric specialty (general pediatrics, seven subspecialties), practice settings (academic, private), and region of practice. Multivariable logistic regressions tested associations of demographic factors, barriers, and confidence factors with the implementation of PRO assessment. Findings: The survey was completed by 458 participants (response rate 48.5%); of these, 40.4%, 15.9%, 15.5%, and 8.1% were general pediatricians, cardiology, hematology/oncology, and pulmonary specialists, respectively. PRO assessment was implemented by 29.0% of the pediatricians. The top five barriers for PRO assessment included limited time/manpower (79.0%), limited training (77.4%), lengthy PRO instruments (76%), lack of meaningful cut-offs on PRO scores (75.5%), and unavailable PRO instruments (75.0%). Limited knowledge of PROs (OR 4.10; 95% CI 2.21, 7.60) and unavailability of PRO instruments (OR 1.87; 95% CI 1.01, 3.49) increased the odds of not implementing the assessment, whereas confidence in PRO assessments compatible with norms (OR 0.41; 95% CI 0.23, 0.72) and perceived benefit over clinical judgment alone (OR 0.53; 95% CI 0.31, 0.93) decreased the odds of not implementing the assessment. Interpretation: significant barriers to PRO assessment in pediatric settings suggest the need for providing training, resources, and practical guidance toward implementation. Patient or Public Contribution: healthcare service users contributed to this study by completing a survey and providing feedback about the barriers and areas of confidence in assessing PROs for pediatric populations.

Health utilities in pediatric cancer patients and survivors: a systematic review and meta-analysis for clinical implementation

PURPOSE

Health utility (HU) is a useful metric for evaluating cost and utility of cancer therapies or prioritizing healthcare resources. We conducted a meta-analysis to compare HUs in association with clinical parameters and identify missing cancer-related themes from the extant HU measures for pediatric cancer patients and survivors.

METHODS

Studies published in the PubMed, Embase, Web of Science, and Cochrane Library were identified. Meta-analyses were performed to estimate weighted means of HUs assessed by self- and proxy-responses. Mixed-effects meta-regressions were applied to compare HUs between cancer patients/survivors and general populations. Missing themes in the extant measures were identified based on established patient-reported outcomes frameworks.

RESULTS

Of 123 selected studies included pediatric cancer populations, 44% used the Health Utilities Index version 2 (HUI2), and 48% used version 3 (HUI3). Compared to general populations, cancer patients undergoing therapies for acute lymphoblastic leukemia (ALL) had 0.129 (95% CI - 0.183 to - 0.075) and brain tumor had 0.257 (95% CI - 0.354 to - 0.160) lower HUs per proxy-reported HUI3, whereas survivors of ALL had 0.028 (95% CI - 0.062 to 0.007) and brain tumor had 0.188 (95% CI - 0.237 to - 0.140) lower HUs per proxy-reported HUI3. Compared to general populations, cancer patients treated with multimodality therapy and survivors off therapy 2-5 years had significantly poorer HUs (p's < 0.05). Missing cancer-specific contents from the HU measures were identified.

CONCLUSION

Pediatric cancer patients and survivors had poorer HUs than general populations. It is important to select appropriate HUs for economic evaluations, and offer interventions to minimize HU deficits for particular cancer populations.

Racial and Ethnic Disparities in Health Outcomes Among Long-Term Survivors of Childhood Cancer: A Scoping Review

The five-year survival rate of childhood cancer has increased substantially over the past 50 yr; however, racial/ethnic disparities in health outcomes of survival have not been systematically reviewed. This scoping review summarized health disparities between racial/ethnic minorities (specifically non-Hispanic Black and Hispanic) and non-Hispanic White childhood cancer survivors, and elucidated factors that may explain disparities in health outcomes. We used the terms “race”, “ethnicity”, “childhood cancer”, “pediatric cancer”, and “survivor” to search the title and abstract for the articles published in PubMed and Scopus from inception to February 2021. After removing duplicates, 189 articles were screened, and 23 empirical articles were included in this review study. All study populations were from North America, and the mean distribution of race/ethnicity was 6.9% for non-Hispanic Black and 4.5% for Hispanic. Health outcomes were categorized as healthcare utilization, patient-reported outcomes, chronic health conditions, and survival status. We found robust evidence of racial/ethnic disparities over four domains of health outcomes. However, health disparities were explained by clinical factors (e.g., diagnosis, treatment), demographic (e.g., age, sex), individual-level socioeconomic status (SES; e.g., educational attainment, personal income, health insurance coverage), family-level SES (e.g., family income, parent educational attainment), neighborhood-level SES (e.g., geographic location), and lifestyle health risk (e.g., cardiovascular risk) in some but not all articles. We discuss the importance of collecting comprehensive social determinants of racial/ethnic disparities inclusive of individual-level, family-level, and neighborhood-level SES. We suggest integrating these variables into healthcare systems (e.g., electronic health records), and utilizing information technology and analytics to better understand the disparity gap for racial/ethnic minorities of childhood cancer survivors. Furthermore, we suggest national and local efforts to close the gap through improving health insurance access, education and transportation aid, racial-culture-specific social learning interventions, and diversity informed training.

Natural Language Processing and Machine Learning Methods to Characterize Unstructured Patient-Reported Outcomes: Validation Study

BACKGROUND

Assessing patient-reported outcomes (PROs) through interviews or conversations during clinical encounters provides insightful information about survivorship.

OBJECTIVE

This study aims to test the validity of natural language processing (NLP) and machine learning (ML) algorithms in identifying different attributes of pain interference and fatigue symptoms experienced by child and adolescent survivors of cancer versus the judgment by PRO content experts as the gold standard to validate NLP/ML algorithms.

METHODS

This cross-sectional study focused on child and adolescent survivors of cancer, aged 8 to 17 years, and caregivers, from whom 391 meaning units in the pain interference domain and 423 in the fatigue domain were generated for analyses. Data were collected from the After Completion of Therapy Clinic at St. Jude Children's Research Hospital. Experienced pain interference and fatigue symptoms were reported through in-depth interviews. After verbatim transcription, analyzable sentences (ie, meaning units) were semantically labeled by 2 content experts for each attribute (physical, cognitive, social, or unclassified). Two NLP/ML methods were used to extract and validate the semantic features: bidirectional encoder representations from transformers (BERT) and Word2vec plus one of the ML methods, the support vector machine or extreme gradient boosting. Receiver operating characteristic and precision-recall curves were used to evaluate the accuracy and validity of the NLP/ML methods.

RESULTS

Compared with Word2vec/support vector machine and Word2vec/extreme gradient boosting, BERT demonstrated higher accuracy in both symptom domains, with 0.931 (95% CI 0.905-0.957) and 0.916 (95% CI 0.887-0.941) for problems with cognitive and social attributes on pain interference, respectively, and 0.929 (95% CI 0.903-0.953) and 0.917 (95% CI 0.891-0.943) for problems with cognitive and social attributes on fatigue, respectively. In addition, BERT yielded superior areas under the receiver operating characteristic curve for cognitive attributes on pain interference and fatigue domains (0.923, 95% CI 0.879-0.997; 0.948, 95% CI 0.922-0.979) and superior areas under the precision-recall curve for cognitive attributes on pain interference and fatigue domains (0.818, 95% CI 0.735-0.917; 0.855, 95% CI 0.791-0.930).

CONCLUSIONS

The BERT method performed better than the other methods. As an alternative to using standard PRO surveys, collecting unstructured PROs via interviews or conversations during clinical encounters and applying NLP/ML methods can facilitate PRO assessment in child and adolescent cancer survivors.

If it's information, it's not "bias": a scoping review and proposed nomenclature for future response-shift research

BACKGROUND

The growth in response-shift methods has enabled a stronger empirical foundation to investigate response-shift phenomena in quality-of-life (QOL) research; but many of these methods utilize certain language in framing the research question(s) and interpreting results that treats response-shift effects as "bias," "noise," "nuisance," or otherwise warranting removal from the results rather than as information that matters. The present project will describe the various ways in which researchers have framed the questions for investigating response-shift issues and interpreted the findings, and will develop a nomenclature for such that highlights the important information about resilience reflected by response-shift findings.

METHODS

A scoping review was done of the QOL and response-shift literature (n = 1100 articles) from 1963 to 2020. After culling only empirical response-shift articles, raters characterized how investigators framed and interpreted study research questions (n = 164 articles).

RESULTS

Of 10 methods used, papers using four of them utilized terms like "bias" and aimed to remove response-shift effects to reveal "true change." Yet, the investigators' reflections on their own conclusions suggested that they do not truly believe that response shift is error to be removed. A structured nomenclature is proposed for discussing response-shift results in a range of research contexts and response-shift detection methods.

CONCLUSIONS

It is time for a concerted and focused effort to change the nomenclature of those methods that demonstrated this misinterpretation. Only by framing and interpreting response shift as information, not bias, can we improve our understanding and methods to help to distill outcomes with and without response-shift effects.

Transforming challenges into opportunities: conducting health preference research during the COVID-19 pandemic and beyond

The disruptions to health research during the COVID-19 pandemic are being recognized globally, and there is a growing need for understanding the pandemic’s impact on the health and health preferences of patients, caregivers, and the general public. Ongoing and planned health preference research (HPR) has been affected due to problems associated with recruitment, data collection, and data interpretation. While there are no “one size fits all” solutions, this commentary summarizes the key challenges in HPR within the context of the pandemic and offers pragmatic solutions and directions for future research. We recommend recruitment of a diverse, typically under-represented population in HPR using online, quota-based crowdsourcing platforms, and community partnerships. We foresee emerging evidence on remote, and telephone-based HPR modes of administration, with further studies on the shifts in preferences related to health and healthcare services as a result of the pandemic. We believe that the recalibration of HPR, due to what one would hope is an impermanent change, will permanently change how we conduct HPR in the future.

1446Forgoing needed medical care among long-term survivors of childhood cancer: Racial/ethnic-insurance disparities

Background

Among adult childhood cancer survivors, the relationship between race/ethnicity and health insurance status, as a contributor to disparities in healthcare utilization, is poorly understood.

Methods

We examined racial/ethnic-related disparities by insurance status in “forgoing needed medical care in the last year due to finances” using 3,964 adult childhood cancer survivors (3310 non-Hispanic/Latinx White, 562 non-Hispanic/Latinx Black, and 92 Hispanic/Latinx) participating in the St. Jude Lifetime Cohort Study (SJLIFE). Multivariable logistic regression analyses, guided by Andersen’s Healthcare Utilization Model, were adjusted for “predisposing” (age, sex, childhood cancer diagnosis, cancer treatment, surgery, and treatment era) and “need” (perceived health status) factors. Additional adjustment for income/education and chronic health conditions was considered.

Results

The risk of forgoing care was highest among non-Hispanic/Latinx Blacks and lowest among Hispanics/Latinxs for each insurance status. Among privately-insured survivors, relative to non-Hispanic/Latinx Whites, non-Hispanic/Latinx Blacks were more likely to forgo care (adjusted OR: 1.82, 95% CI: 1.30–2.54): this disparity remained despite additional adjustment for income/education (adjusted OR: 1.43, 95% CI: 1.01–2.01). In contrast, publicly-insured survivors, regardless of race/ethnicity, had similar risk of forgoing care as privately-insured non-Hispanic/Latinx Whites. All uninsured survivors had high risk of forgoing care. Additional adjustment for chronic health conditions did not alter these results.

Conclusions

The findings of this study show that provision of public insurance to all childhood cancer survivors may diminish racial/ethnic disparities in forgoing care that exist among the privately-insured and reduce the risk of forgoing care among uninsured survivors to that of privately-insured non-Hispanic/Latinx Whites.

Key messages

Providing publicly funded health insurance coverage to childhood cancer survivors can reduce disparities in forgoing medical care.

Online Platform to Assess Complex Social Relationships and Patient-Reported Outcomes Among Adolescent and Young Adult Cancer Survivors

PURPOSE

Social integration and relationship issues have been understudied among adolescent and young adult (AYA) cancer survivors. This study compared social relationships (social networks, support, and isolation) between AYA cancer survivors and noncancer controls, and identified social integration mechanisms through which the cancer experience influences patient-reported outcomes (PROs).

MATERIALS AND METHODS

One hundred two AYA cancer survivors and 102 age, sex, and race-matched noncancer controls from a national Internet panel completed an online survey to identify up to 25 of closest friends and relatives whom they have contacted within the past 2 years. Participants' interpersonal connections were used to create a social network index. The Duke-UNC Functional Social Support Questionnaire, UCLA Loneliness Scale, and PROMIS-29 Profile were used to measure social support, perceived isolation or loneliness, and PROs (physical functioning, pain interference, fatigue, anxiety, and depression domains), respectively. Path analysis tested effects of cancer experience on PROs using serial social relationship variables as mediators.

RESULTS

Compared with controls, survivors of lymphoma, leukemia, and solid tumor had better social networks; however, survivors of solid tumor and central nervous system malignancies had higher perceived loneliness (all P values < .05). Cancer experience was directly associated with poor PROs (P values < .05 for all domains except fatigue) and indirectly associated through the social network-support-loneliness pathway (all P values < .05). Survivors with higher loneliness had lower physical functioning and higher pain interference, fatigue, anxiety, and depression versus controls with lower loneliness (all P values < .05).

CONCLUSION

Compared with controls, survivors were more socially connected but experienced greater loneliness, which was associated with poorer PROs. Screening social integration issues during follow-up care and providing appropriate interventions are warranted.

Abstract 904: Epigenome-wide association study of dyslipidemia in survivors of childhood cancer: A report from the St. Jude lifetime cohort

Background: Epigenetic research of blood lipids has been conducted in the general population with some robust findings. However, there is lack of similar studies that explore epigenetic effects among childhood cancer survivors who have elevated risk of dyslipidemia. We aimed to utilize epigenome-wide approach to search for DNA methylation (DNAm) sites influencing lipid metabolism among survivors of childhood cancer.

Methods: Epigenome-wide methylation data were generated with Infinium EPIC BeadChip on blood derived DNA of survivors from the St. Jude Lifetime Cohort Study. Chemotherapy agents and region-specific radiation exposures were abstracted from medical records. Two forms of dyslipidemia, i.e. hypertriglyceridemia (HTG) or hypercholesteremia (HCL) were clinically assessed. Multivariable logistic regression was used to evaluate associations between each DNAm site with incident cases of HTG or HCL adjusting for age, sex, and cancer treatment exposures. Analysis was stratified by genetically determined races, i.e. survivors of European ancestry (EA) and survivors of African ancestry (AA). Significant DNAm sites were correlated with mRNA expression of the mapped genes using RNA sequencing data available for blood samples of 87 survivors.

Results: 2,052 EA (median age=34.7 years, 47.1% female, 26.6% HTG, 32.0% HCL) and 370 AA survivors (median age=32.1 years, 53.2% female, 15.9% HTG, 26.8% HCL) were included. Among EA survivors, six DNAm sites were associated with HTG risk at epigenome-wide significance level (P&lt;9×10-8): CPT1A (cg00574958, cg05325763, cg17058475, cg09737197), SLC43A1 (cg11376147), and LINC01934 (cg22050199). These DNAm sites were also associated with HCL with P value ranging from 1.9×10-4 to 2.1×10-7. There was no single DNAm site associated with HCL risk reaching over epigenome-wide significance level. Search of differentially methylated regions for HTG status identified one additional statistically significant (PFDR&lt;0.05) genomic region of chr1:120255941-120256112 encompassing PHGDH with three DNAm sites (cg16246545, cg14476101, cg26457483). Furthermore, DNAm of cg00574958 and cg14476101 located in CPT1A and PHGDH, respectively, were both inversely correlated with gene expression (CPT1A: r = -0.33, P=2.0×10-3; PHGDH: r=-0.46, P=9.1×10-6). In contrast, none of these DNAm sites showed associations with risk of HTG or HCL among AA survivors.

Conclusion: We identified one or more DNAm sites, residing in each of CPT1A, SLC43A1, and PHGDH genes, associated with dyslipidemia among EA survivors. Lack of associations among AA survivors may partially contribute to lower risk of dyslipidemia among AA survivors. The findings demonstrated epigenetic roles in dyslipidemia among survivors, suggesting epigenetic biomarkers for identification of survivors with higher dyslipidemia risk and new targets for future interventions.

Citation Format: Qian Dong, Nan Song, Yadav Sapkota, Yinan Zheng, I-Chan Huang, Deo Kumar Srivastava, John Easton, Heather Mulder, Geoffrey Neale, Emily Walker, Jinghui Zhang, Melissa M. Hudson, Leslie L. Robison, Zhaoming Wang. Epigenome-wide association study of dyslipidemia in survivors of childhood cancer: A report from the St. Jude lifetime cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 904.

Abstract 685: A social epigenomic investigation of racial disparity in pulmonary impairment among aging survivors of childhood cancer

Background: Prior research suggests that social determinants of health (SDOH) may influence health through an epigenetic mechanism. However, the social epigenomic approach has not yet been applied to childhood cancer survivors, a population at high risk for chronic health conditions. We aim to investigate how SDOH factors contribute to racial disparity in pulmonary impairment with survivors from the St. Jude Lifetime Cohort Study.

Methods: DNA methylation (DNAm) profile was generated with EPIC BeadChip using blood derived DNA. SDOH factors included educational attainment and personal income self-reported using a survey, and socioeconomic area deprivation index (ADI) geocoded using full home addresses. Clinically assessed pulmonary impairment included pulmonary diffusion deficits (PDD), restrictive pulmonary deficits (RPD) and obstructive pulmonary deficits (OPD). Epigenome-wide association study (EWAS) was performed to evaluate the association between DNAm at each CpG and each SDOH factor. Mediation analysis was conducted by treating each SDOH-associated CpG as a mediator, SDOH factor as an exposure, and specific pulmonary condition as the outcome. Genetically inferred races, i.e. survivors of European ancestry (EA) and African ancestry (AA), were considered.

Results: The study included 258 AA (median time from cancer diagnosis [MTD]=25.2 years, interquartile range [IQR]=19.9-32.1 years) and 1,618 EA survivors (MTD=27.3, IQR=21.1-33.7 years). Compared to EA survivors, AA survivors had lower educational attainment (P&lt;0.0001), lower personal income (P&lt;0.0001), and higher ADI (P&lt;0.0001). Compared to EA survivors, incidence of PDD (25.2% in AA vs 18.2% in EA, P=0.03) and RPD (14.2% in AA vs 7.5% in EA, P=0.002) were significantly higher in AA survivors, whereas OPD were comparable between groups (9.8% vs 13.1%, P=0.21). However, the racial disparity in PDD became nonsignificant after adjusting for SDOH. EWAS identified 130 SDOH-CpG associations at epigenome-wide significance (P&lt;9×10-8) including 88 for educational attainment, 23 for personal income, and 19 for ADI. Thirteen CpGs, commonly associated with all three SDOH factors, resided at pleiotropic loci featuring cigarette smoking genes, e.g. CPOX and AHRR among others. Three independent SDOH-associated CpGs (cg04180924, cg1120500, and cg27470486) had a significant combined mediation effect for educational attainment (%mediation = 48.9%), and a single mediator cg08064403 had a significant mediation effect for personal income (25.9%) and ADI (24.1%) on PDD risk.

Conclusions: DNAm signatures, many resembling the effect of tobacco use, are associated with educational attainment, personal income, and ADI. Our findings suggest that these DNAm are potential mechanistic mediators for the effects of SDOH factors on PDD risk. Through this mechanism, poor SDOH factors in AA survivors led to racial disparity in PDD.

Citation Format: Nan Song, Jin-ah Sim, Qian Dong, Yinan Zheng, Lifang Hou, Zhenghong Li, Chia-Wei Hsu, Haitao Pan, Heather Mulder, John Easton, Emily Walker, Geoffrey Neale, Carmen L. Wilson, Kirsten K. Ness, Kevin R. Krull, Deo Kumar Srivastava, Yutaka Yasui, Jinghui Zhang, Melissa M. Hudson, Leslie L. Robison, I-Chan Huang, Zhaoming Wang. A social epigenomic investigation of racial disparity in pulmonary impairment among aging survivors of childhood cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 685.

Forgoing needed medical care among long-term survivors of childhood cancer: racial/ethnic-insurance disparities

PURPOSE

To investigate racial/ethnic-related disparities by insurance status in "forgoing needed medical care in the last year due to finances" in childhood cancer survivors.

METHODS

Our study included 3310 non-Hispanic/Latinx White, 562 non-Hispanic/Latinx Black, and 92 Hispanic/Latinx survivors from the St. Jude Lifetime Cohort Study. Logistic regression analyses, guided by Andersen's Healthcare Utilization Model, were adjusted for "predisposing" (survey age, sex, childhood cancer diagnosis and treatment, and treatment era) and "need" (perceived health status) factors. Additional adjustment for household income/education and chronic health conditions was considered.

RESULTS

Risk of forgoing care was highest among non-Hispanic/Latinx Blacks and lowest among Hispanics/Latinxs for each insurance status. Among privately insured survivors, relative to non-Hispanic/Latinx Whites, non-Hispanic/Latinx Blacks were more likely to forgo care (adjusted OR: 1.82, 95% CI: 1.30-2.54): this disparity remained despite additional adjustment for household income/education (adjusted OR: 1.43, 95% CI: 1.01-2.01). In contrast, publicly insured survivors, regardless of race/ethnicity, had similar risk of forgoing care as privately insured non-Hispanic/Latinx Whites. All uninsured survivors had high risk of forgoing care. Additional chronic health condition adjustment did not alter these results.

CONCLUSIONS

Provision of public insurance to all childhood cancer survivors may diminish racial/ethnic disparities in forgoing care that exist among the privately insured and reduce the risk of forgoing care among uninsured survivors to that of privately insured non-Hispanic/Latinx Whites.

IMPLICATIONS FOR CANCER SURVIVORS

Under public insurance, childhood cancer survivors had low risk of forgoing care, at the similar level to privately insured non-Hispanic/Latinx Whites, regardless of race/ethnicity.

Financial hardship in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS)

10026

Background: The impact of childhood and adolescent cancer on the long-term financial outcomes of survivors is poorly understood. We compared financial hardship between survivors and siblings enrolled in the CCSS and identified survivors at elevated risk. Methods: Survivors treated for cancer at age < 21 years in 1970-1999 and siblings responded to a survey (23 binary-response questions) at age ≥26 years administered in 2017-2019. Principal component analysis with promax rotation extracted 3 factors with eigenvalues > 1 and KR-20 reliability coefficients > 0.7, retaining items with factor loadings > 0.4. These factors were behavioral hardship (8 items, e.g., forgone needed medical care), material hardship/financial sacrifices (8 items, e.g., problems paying medical bills) and psychological hardship (3 items, e.g., worry about having enough money to pay rent/mortgage). Factor scores were calculated by adding the item responses and dividing by their standard deviation. Multiple linear regression examined the association of sociodemographic and cancer treatment variables with factor scores. Results: Among 3349 survivors (49% male; median age [range] 40.2 [26.0-67.4] years) and 976 siblings (42% male, median age 46.5 [ 26.1-69.2] years), survivors were more likely to report being sent to debt collection (29.5 vs 21.4%), problems paying medical bills (20.0 vs 11.9%), foregoing needed medical care (13.3 vs 7.7%) and worry/stress about paying their mortgage (32.8 vs 23.2%) or having enough money to buy nutritious meals (25.0 vs 16.2%), all P < 0.001. Survivors reported greater hardship than siblings on all 3 factors: behavioral hardship (standardized mean score 0.51 vs 0.36), material hardship/financial sacrifices (0.63 vs 0.44), psychological hardship (0.69 vs 0.44), all P < 0.001. Behavioral hardship was increased by female gender (regression coefficient [ꞵ] 0.17, 95% CI 0.10-0.25), < high school (ꞵ 0.45, CI 0.12-0.79) or < college (ꞵ 0.18, CI 0.09-0.26) education, no (ꞵ 1.14, CI 0.93-1.35) or public (ꞵ 0.23, CI 0.10-0.35) health insurance, being divorced/separated (ꞵ 0.28, CI 0.10-0.46) and ≥250mg/m2 anthracycline chemotherapy (ꞵ 0.09, CI 0.00-0.19). The same variables were significantly associated with the other two hardship factors, but total body irradiation and cranial radiation also contributed to the risk of material hardship/financial sacrifices, and ≥8g/m2 cyclophosphamide equivalent dose and cranial radiation contributed to psychological hardship. Conclusions: Survivors of childhood and adolescent cancer are at elevated risk for financial hardship as compared to sibling controls. Those at highest risk can be defined using a combination of sociodemographic and treatment variables. This information can be used to inform targeted intervention strategies to reduce the risk of poor financial outcomes in this vulnerable population.

Determinants of symptom clusters and associations with health outcomes in childhood cancer survivors: A report from the St. Jude Lifetime Cohort (SJLIFE)

10046

Background: Childhood cancer survivors experience concurrent symptoms, but associations with health outcomes are unknown. We characterize symptom clusters among adult survivors of childhood cancer in SJLIFE and tests associations with health-related quality of life (HRQL) and clinically assessed physical and neurocognitive performance. Methods: This cross-sectional study includes survivors diagnosed when <18 years of age, ≥10 years off-therapy, and ≥18 years of age at evaluation. Survivors rated 37 symptoms over 10 domains (cardiac, pulmonary, sensory, motor, nausea, pain, fatigue, memory, anxiety, depression), representing 3 broader symptom groups (physical, somatic, psychological). They also underwent a rating of HRQL (SF-36 PCS/MCS) and testing of physical performance (quantitative sensory, motor, endurance, mobility) and neurocognition (processing speed, executive function, attention, memory problems). Latent class analysis determined survivors with distinct symptom burden. Polytomous logistic regression identified risk factors of symptom clusters; multivariable regression tested associations of symptom clusters with health outcomes. Results: Among 3,085 survivors, mean [SD] age at evaluation was 31.9 [8.3] years, time from diagnosis was 28.1 [9.1] years, 49.7% were female, 37.1% were treated for leukemia and 33.0% for solid tumors. Four groups of survivors with distinct symptom burden were found: Cluster 1 (52%, low prevalence in all 3 symptom groups); Cluster 2 (16%, low in physical, moderate in somatic, high in psychological); Cluster 3 (18%; high in physical, moderate in somatic, low in physiological); and Cluster 4 (14%, high in all 3 symptom groups). Compared to the lowest symptom burden (Cluster 1), survivors with highest burden (Cluster 4) were significantly more likely to be female (OR 2.5; 95%CI 1.9, 3.4), have below a high school education (OR 7.7; 95%CI 4.5, 13.3), no insurance (OR 1.5; 95%CI 1.1, 2.3) and previous exposure to corticosteroids (OR 1.8; 95%CI 1.0, 3.0). High physical, moderate somatic and low psychological symptom burden (Cluster 3) was associated with below high school education (OR 2.7; 95%CI 1.4, 5.0), exposure to platinum agents (OR 2.2; 95%CI 1.4, 3.7) and brain radiation ≥30Gy (OR 4.0; 95%CI 2.3, 6.9) in contrast to Cluster 1. Survivors in Cluster 4 had the poorest PCS, MCS, physical and neurocognitive outcomes vs in Clusters 2 or 3, whereas those in Cluster 1 had the best outcomes (F-values for 4 clusters: 291.4 [PCS], 269.2 [MCS], 61.5 [physical], 36.9 [neurocognitive], p-values <0.001; effect sizes for Clusters 4 vs 1: 0.4-2.0 [4 outcomes]). Conclusions: Nearly 50% of survivors belong to symptom clusters with ≥1 moderate/high burden groups, associated with the socio-demographic and treatment exposures. Survivors in the highest symptom burden cluster had the poorest HRQL and functional outcomes.

Predicting decreased health-related quality of life (HRQL) in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS)

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Background: This study examines temporal patterns in HRQL among adult survivors of childhood cancer, and socio-demographic, lifestyle and health status predictors of decline in HRQL. Methods: Adult survivors of childhood cancer (4755, 55.2% female, 86.9% non-Hispanic white) completed baseline (T0) and follow-up (T1 in 2003, T2 in 2014) surveys (median[SD] age 32.4[7.5] at T1, time since diagnosis to T1 23.0[4.5], T1-T2 interval 11.7[0.6] years). Socio-demographic (e.g., age, sex, educational attainment, annual family income), lifestyle (physical inactivity, smoking) and health status predictors were collected at T0 and T1. Chronic conditions graded ≥2 by CTCAE defined as presence, and mental and cognitive status with ≥1SD from norms defined as poor. SF-36 Physical and Mental Component Summary (PCS/MCS; mean 50/SD 10) at T1 and T2 classified HRQL as optimal (≥40) or suboptimal ( < 40). Multivariable logistic regression identified risk factors (T0, T1 or status change T0-T1) of decreased HRQL (i.e., optimal to suboptimal) using a backward selection method (p < 0.1), adjusting for sex, race, age at T1 and years between T1-T2. The sample was randomly split into training (80%) and test (20%) datasets to develop and validate prediction models; Area Under the ROC Curve (AUC) evaluated model performance. Results: From T1-T2, 8.1% and 8.3% of survivors reported decreased PCS and MCS. AUCs of training/test models were 0.75/0.74 for decreased PCS and 0.72/0.68 for decreased MCS. Risk factors at T0 or T1 predicting decreased PCS included female sex (OR 1.67, 95%CI 1.25-2.24), younger age (OR 1.04, 95%CI 1.02-1.06), < college/vocational education (OR 1.59, 95%CI 1.02-2.46), family income < $20,000 (OR 2.00, 95%CI 1.21-3.30), obesity (OR 1.97, 95%CI 1.32-2.92), chronic health conditions (neurologic OR 2.47, 95%CI 1.69-3.60; musculoskeletal OR 2.27, 95%CI 1.42-3.64; endocrinological OR 2.25, 95%CI 1.44-3.52; gastrointestinal OR 1.89, 95%CI 1.32-2.69; pulmonary OR 1.66, 95%CI 1.06-2.59; cardiovascular OR 1.53, 95%CI 1.14-2.06) and depression (OR 1.79, 95%CI 1.20-2.67). Risk factors at T0 or T1 predicting decreased MCS included unemployment (OR 1.68, 95%CI 1.19-2.38), smoking (OR 2.03, 95%CI 1.37-3.00), physical inactivity (OR 1.48, 95%CI 1.05-2.09), poor mental health (depression OR 4.29, 95%CI 2.44-7.55; somatization OR 1.63, 95%CI 1.05-2.53) and poor cognitive status (task efficiency OR 1.90, 95%CI 1.34-2.68; organization OR 1.67, 95%CI 1.12-2.48). Conclusions: Nearly 10% of childhood cancer survivors have significant late-onset decline in HRQL. Chronic health conditions predict decreased physical HRQL, whereas smoking, physical inactivity and poor mental health predict decreased mental HRQL. Interventions targeting modifiable lifestyle and health conditions should be considered to prevent decreased HRQL for childhood cancer survivors.

Persistent variations of blood DNA methylation associated with treatment exposures and risk for cardiometabolic outcomes in long-term survivors of childhood cancer in the St. Jude Lifetime Cohort

BACKGROUND

It is well-established that cancer treatment substantially increases the risk of long-term adverse health outcomes among childhood cancer survivors. However, there is limited research on the underlying mechanisms. To elucidate the pathophysiology and a possible causal pathway from treatment exposures to cardiometabolic conditions, we conducted epigenome-wide association studies (EWAS) to identify the DNA methylation (DNAm) sites associated with cancer treatment exposures and examined whether treatment-associated DNAm sites mediate associations between specific treatments and cardiometabolic conditions.

METHODS

We included 2052 survivors (median age 33.7 years) of European ancestry from the St. Jude Lifetime Cohort Study, a retrospective hospital-based study with prospective clinical follow-up. Cumulative doses of chemotherapy and region-specific radiation were abstracted from medical records. Seven cardiometabolic conditions were clinically assessed. DNAm profile was measured using MethylationEPIC BeadChip with blood-derived DNA.

RESULTS

By performing multiple treatment-specific EWAS, we identified 935 5'-cytosine-phosphate-guanine-3' (CpG) sites mapped to 538 genes/regions associated with one or more cancer treatments at the epigenome-wide significance level (p < 9 × 10-8). Among the treatment-associated CpGs, 8 were associated with obesity, 63 with hypercholesterolemia, and 17 with hypertriglyceridemia (false discovery rate-adjusted p < 0.05). We observed substantial mediation by methylation at four independent CpGs (cg06963130, cg21922478, cg22976567, cg07403981) for the association between abdominal field radiotherapy (abdominal-RT) and risk of hypercholesterolemia (70.3%) and by methylation at three CpGs (cg19634849, cg13552692, cg09853238) for the association between abdominal-RT and hypertriglyceridemia (54.6%). In addition, three CpGs (cg26572901, cg12715065, cg21163477) partially mediated the association between brain-RT and obesity with a 32.9% mediation effect, and two CpGs mediated the association between corticosteroids and obesity (cg22351187, 14.2%) and between brain-RT and hypertriglyceridemia (cg13360224, 10.5%). Notably, several mediator CpGs reside in the proximity of well-established dyslipidemia genes: cg21922478 (ITGA1) and cg22976567 (LMNA).

CONCLUSIONS

In childhood cancer survivors, cancer treatment exposures are associated with DNAm patterns present decades following the exposure. Treatment-associated DNAm sites may mediate the causal pathway from specific treatment exposures to certain cardiometabolic conditions, suggesting the utility of DNAm sites as risk predictors and potential mechanistic targets for future intervention studies.

Negligible Effects of the Survey Modes for Patient-Reported Outcomes: A Report From the Childhood Cancer Survivor Study

PURPOSE

This study compared the measurement properties for multiple modes of survey administration, including postal mail, telephone interview, and Web-based completion of patient-reported outcomes (PROs) among survivors of childhood cancer.

METHODS

The population included 6,974 adult survivors of childhood cancer in the Childhood Cancer Survivor Study who completed the Brief Symptom Inventory-18 (BSI-18), which measured anxiety, depression, and somatization symptoms. Scale reliability, construct validity, and known-groups validity related to health status were tested for each mode of completion. The multiple indicators and multiple causes technique was used to identify differential item functioning (DIF) for the BSI-18 items that responded through a specific survey mode. The impact of the administration mode was tested by comparing differences in BSI-18 scores between the modes accounting for DIF effects.

RESULTS

Of the respondents, 58%, 27%, and 15% completed postal mail, Web-based, and telephone surveys, respectively. Survivors who were male; had lower education, lower household income, or poorer health status; or were treated with cranial radiotherapy were more likely to complete a telephone-based survey compared with either a postal mail or Web-based survey (all P < .05). Scale reliability and validity were equivalent across the 3 survey options. One, 2, and 5 items from the anxiety, depression, and somatization domains, respectively, were identified as having significant DIF among survivors who responded by telephone (P < .05). However, estimated BSI-18 domain scores, especially depression and anxiety, between modes did not differ after accounting for DIF effects.

CONCLUSION

Certain survivor characteristics were associated with choosing a specific mode for PRO survey completion. However, measurement properties among these modes were equivalent, and the impact of using a specific mode on scores was minimal.

Change in Pain Status and Subsequent Opioid and Marijuana Use Among Long-Term Adult Survivors of Childhood Cancer

We evaluated pain status change and associations with subsequent opioid/marijuana use among 1208 adult survivors of childhood cancer. Pain status and opioid/marijuana were self-reported at baseline and follow-up evaluation (mean interval = 4.2 years). Over time, 18.7% of survivors endorsed persistent/increasing significant pain; 4.8% and 9.0% reported having used opioids and marijuana at follow-up. Persistent/increased (vs none/decreased) pain, persistent/increased (vs none/decreased) anxiety, and lack of health insurance increased odds of subsequent opioid use by 7.69-fold (95% confidence interval [CI] = 3.71 to 15.95), 2.55-fold (95% CI = 1.04 to 6.24), and 2.50-fold (95% CI = 1.07 to 5.82), respectively. Persistent/increased (vs none/decreased) depression increased odds of subsequent marijuana use by 2.64-fold (95% CI = 1.10 to 6.33).

Childhood Neurotoxicity and Brain Resilience to Adverse Events during Adulthood

OBJECTIVE

This study used childhood cancer survivors as a novel model to study whether children who experience central nervous system (CNS) injury are at higher risk for neurocognitive impairment associated with subsequent late onset chronic health conditions (CHCs).

METHODS

Adult survivors of childhood cancer (n = 2,859, ≥10 years from diagnosis, ≥18 years old) completed a comprehensive neurocognitive battery and clinical examination. Neurocognitive impairment was defined as age-adjusted z score < 10th percentile. Participants impaired on ≥3 tests had global impairment. CHCs were graded using the Common Terminology Criteria for Adverse Events v4.3 (grade 1, mild; 2, moderate; 3, severe/disabling; 4, life-threatening) and were combined into a severity/burden score by frequency and grade (none/low, medium, high, and very high). A total of 1,598 survivors received CNS-directed therapy including cranial radiation, intrathecal methotrexate, or neurosurgery. Logistic regression estimated the odds of neurocognitive impairment associated with severity/burden score and grade 2 to 4 conditions, stratified by CNS treatment.

RESULTS

CNS-treated survivors performed worse than non-CNS-treated survivors on all neurocognitive tests and were more likely to have global neurocognitive impairment (46.9% vs 35.3%, p < 0.001). After adjusting for demographic and treatment factors, there was a dose-response association between severity/burden score and global neurocognitive impairment, but only among CNS-treated survivors (high odds ratio [OR] = 2.24, 95% confidence interval [CI] = 1.42-3.53; very high OR = 4.07, 95% CI = 2.30-7.17). Cardiovascular and pulmonary conditions were associated with processing speed, executive function, and memory impairments in CNS-treated but not non-CNS-treated survivors who were impacted by neurologic conditions.

INTERPRETATION

Reduced cognitive/brain reserve associated with CNS-directed therapy during childhood may make survivors vulnerable to adverse cognitive effects of cardiopulmonary conditions during adulthood. ANN NEUROL 2021;89:534-545.