Post-operative C-reactive protein as a strong independent predictor of long-term colorectal cancer outcomes: consistent findings from two large patient cohorts

BACKGROUND

Post-surgery blood-based biomarkers may be useful for guiding treatment and surveillance decisions among colorectal cancer (CRC) patients. However, most candidate biomarkers provide little if any predictive value beyond stage at diagnosis. We aimed to investigate the independent prognostic value of post-operative serum C-reactive protein (CRP), a highly sensitive biomarker of inflammation, for long-term CRC outcomes in two large patient cohorts.

MATERIALS AND METHODS

CRP levels were measured from serum samples of CRC patients collected ≥1 month post-surgery in the German DACHS (n = 1416) and the UK Biobank (n = 1149) cohorts. Associations of post-operative CRP with overall survival (OS) and CRC-specific survival (CSS) were assessed using Cox regression and presented as hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for key sociodemographic and clinical covariates.

RESULTS

In both cohorts, consistent strong dose-response relationships between post-operative CRP and both OS and CSS were observed. Adjusted HRs (95% CI) for CRP >10 versus <3 mg/l were 1.93 (1.58-2.35) and 2.70 (2.03-3.59) in the DACHS cohort, and 2.70 (1.96-3.71) and 2.61 (1.83-3.72) in the UK Biobank cohort, respectively. Associations between post-operative CRP and OS were particularly strong among younger patients (<65 years at diagnosis; P value for interaction by age <0.01).

CONCLUSIONS

Serum CRP determined a month or more after surgery may be useful as a strong independent prognostic biomarker for guiding therapeutic decisions and for surveillance of the course of disease of CRC patients, particularly those <65 years of age at diagnosis.

Artificial intelligence for detection of microsatellite instability in colorectal cancer-a multicentric analysis of a pre-screening tool for clinical application

BACKGROUND

Microsatellite instability (MSI)/mismatch repair deficiency (dMMR) is a key genetic feature which should be tested in every patient with colorectal cancer (CRC) according to medical guidelines. Artificial intelligence (AI) methods can detect MSI/dMMR directly in routine pathology slides, but the test performance has not been systematically investigated with predefined test thresholds.

METHOD

We trained and validated AI-based MSI/dMMR detectors and evaluated predefined performance metrics using nine patient cohorts of 8343 patients across different countries and ethnicities.

RESULTS

Classifiers achieved clinical-grade performance, yielding an area under the receiver operating curve (AUROC) of up to 0.96 without using any manual annotations. Subsequently, we show that the AI system can be applied as a rule-out test: by using cohort-specific thresholds, on average 52.73% of tumors in each surgical cohort [total number of MSI/dMMR = 1020, microsatellite stable (MSS)/ proficient mismatch repair (pMMR) = 7323 patients] could be identified as MSS/pMMR with a fixed sensitivity at 95%. In an additional cohort of N = 1530 (MSI/dMMR = 211, MSS/pMMR = 1319) endoscopy biopsy samples, the system achieved an AUROC of 0.89, and the cohort-specific threshold ruled out 44.12% of tumors with a fixed sensitivity at 95%. As a more robust alternative to cohort-specific thresholds, we showed that with a fixed threshold of 0.25 for all the cohorts, we can rule-out 25.51% in surgical specimens and 6.10% in biopsies.

INTERPRETATION

When applied in a clinical setting, this means that the AI system can rule out MSI/dMMR in a quarter (with global thresholds) or half of all CRC patients (with local fine-tuning), thereby reducing cost and turnaround time for molecular profiling.

Two new species of the Peronospora belbahrii species complex, Pe. choii sp. nov. and Pe. salviae-pratensis sp. nov., and a new host for Pe. salviae-officinalis

The downy mildew species parasitic to Mentheae are of particular interest, as this tribe of Lamiaceae contains a variety of important medicinal plants and culinary herbs. Over the past two decades, two pathogens, Peronospora belbahrii and Pe. salviae-officinalis have spread globally, impacting basil and common sage production, respectively. In the original circumscription of Pe. belbahrii, the downy mildew of coleus (Plectranthus scutellarioides) was ascribed to this species in the broader sense, but subtle differences in morphological and molecular phylogenetic analyses using two genes suggested that this pathogen would potentially need to be assigned to a species of its own. In the present study, Peronospora species causing downy mildew on members of the Mentheae, including clary sage (Salvia sclarea), meadow sage (S. pratensis), basil (Ocimum basilicum), ground ivy (Glechoma hederacea) and coleus (Plectranthus scutellarioides) were studied using light microscopy and molecular phylogenetic analyses based on six loci (ITS rDNA, cox1, cox2, ef1a, hsp90 and β-tubulin) to clarify the species boundaries in the Pe. belbahrii species complex. The downy mildew on Salvia pratensis is shown to be distinct from Pe. salviae-officinalis and closely related to Pe. glechomae, and is herein described as a new species, Pe. salviae-pratensis. The downy mildew on S. sclarea was found to be caused by Pe. salviae-officinalis. This is of phytopathological importance, because meadow sage thus does not play a role as inoculum source for common sage in the natural habitat of the former in Europe and Asia, while clary sage probably does. The multi-gene phylogeny revealed that the causal agent of downy mildew on coleus is distinct from Pe. belbahrii on basil, and is herein described as a new taxon, Pe. choii.

Lifestyle factors and risk of sporadic colorectal cancer by microsatellite instability status: a systematic review and meta-analyses

Introduction

The association of lifestyle factors with molecular pathological subtypes of colorectal cancer (CRC), such as microsatellite instability (MSI), could provide further knowledge about the colorectal carcinogenic process. The aim of this review was to evaluate possible associations between lifestyle factors and risk of sporadic CRC by MSI status.

Methods

PubMed and Web of Science were searched for studies investigating the association between alcohol, body mass index, dietary fiber, hormone replacement therapy (HRT), non-steroidal anti-inflammatory drugs, physical activity, red meat, smoking, or statin use, with MSI-high (MSI-H) and microsatellite stable (MSS) CRC. Meta-analyses were carried out to calculate summary relative risks (sRR).

Results

Overall, 31 studies reporting on the association between lifestyle factors and CRC according to MSI status were included in this review. Ever smoking was associated with MSI-H (sRR = 1.62; 95% CI: 1.40-1.88) and MSS/MSI-low CRC (sRR = 1.10; 95% CI: 1.01-1.20), but the association was significantly stronger for MSI-H CRC. The use of HRT was associated with a 20% decrease (sRR = 0.80; 95% CI: 0.73-0.89) in the risk of MSS CRC, but was not associated with MSI-H CRC. An increase in body mass index per 5 kg/m2 was equally associated with MSS and MSI-H CRC (sRR = 1.22, in both cases), but was statistically significant for MSS CRC only (95% CI: 1.11-1.34 and 0.94-1.58, respectively). Limited evidence for associations between other lifestyle factors and CRC by MSI status exists.

Conclusions

Lifestyle factors, such as HRT and smoking are differentially associated with the risk of MSI-H and MSS CRC. Further research on associations of lifestyle factors and CRC subtypes is necessary to provide a better understanding of the CRC disease pathway.

Covariation and phenotypic integration in chemical communication displays: biosynthetic constraints and eco-evolutionary implications

Chemical communication is ubiquitous. The identification of conserved structural elements in visual and acoustic communication is well established, but comparable information on chemical communication displays (CCDs) is lacking. We assessed the phenotypic integration of CCDs in a meta-analysis to characterize patterns of covariation in CCDs and identified functional or biosynthetically constrained modules. Poorly integrated plant CCDs (i.e. low covariation between scent compounds) support the notion that plants often utilize one or few key compounds to repel antagonists or to attract pollinators and enemies of herbivores. Animal CCDs (mostly insect pheromones) were usually more integrated than those of plants (i.e. stronger covariation), suggesting that animals communicate via fixed proportions among compounds. Both plant and animal CCDs were composed of modules, which are groups of strongly covarying compounds. Biosynthetic similarity of compounds revealed biosynthetic constraints in the covariation patterns of plant CCDs. We provide a novel perspective on chemical communication and a basis for future investigations on structural properties of CCDs. This will facilitate identifying modules and biosynthetic constraints that may affect the outcome of selection and thus provide a predictive framework for evolutionary trajectories of CCDs in plants and animals.

[Implementing an Organised Colorectal Cancer Screening Programme in Germany: Opportunities and Challenges]

BACKGROUND

Each year in Germany, about 65,000 people are diagnosed with colorectal cancer (CRC) and more than 25,000 people die of the disease. The majority of these cases could be avoided by a more effective screening programme. Recently, a law came into force that offers a great opportunity in this regard. It calls for introducing an organised CRC screening programme in Germany, which includes an invitation system as well as further measures for quality assurance and programme evaluation. To realise this opportunity, challenges of implementation need to be considered. The aim of this review article is to elaborate the challenges of an organised CRC screening in Germany in order to derive the need for action regarding successful implementation.

METHODS

This review article is based on a selective literature search, including current guidelines and recommendations.

RESULTS AND CONCLUSION

In the context of CRC screening, but also by colonoscopies performed for other indications (e.g., due to symptoms), precancerous lesions (adenomas) are detected and removed in a relevant proportion of the target population, which requires a surveillance examination after 3 or 5 years according to current recommendations. Therefore, an efficient invitation system for CRC screening should be designed to allow for a flexible interval depending on previous findings, which differs from mammography screening with its fixed interval. A prerequisite would be the standardised documentation of all colonoscopies irrespective of the indication, given that a substantial proportion of colonoscopies in Germany are performed outside of the screening program. Still, the work load regarding documentation could be less than for mammography screening. Another challenge in terms of organisation results from the parallel offer of 2 different screening tools (colonoscopy and faecal occult blood test). To realise the potential of an organised CRC screening, it seems important to devote sufficient time and resources for developing an efficient and feasible concept, while there might be interim options to avoid further delay regarding the initial invitation of the target population. Given that expertise from, amongst others, gastroenterology, epidemiology, clinical chemistry and health communication is required, an interdisciplinary approach appears essential.

Establishment of robust controls for the normalization of miRNA expression in neuroendocrine tumors of the ileum and pancreas

There is need to determine tissue-specific robust controls for normalization of microRNA expression to avoid false results and misinterpretation. The aim of this study was to evaluate the expression of different small RNAs in neuroendocrine tumors (NETs) and their suitability as normalizers in miRNA real-time PCR experiments. We investigated the expression of the nine small RNAs miR-93, miR-191, SNORD48, SNORD61, SNORD68, SNORD72, SNORD95, SNORD96a, and RNU6-2 in formalin-fixed, paraffin-embedded tissue samples of 25 ileal NETs by real-time PCR determining the most stable controls for expression normalization using four different algorithms. This analysis was expended to ten pancreatic NETs. Finally, five small RNAs were further tested as normalizers for miRNA-133a expression, which is known to be downregulated in metastases of ileal NETs, in ten matched pairs of ileal NETs and their metastases. Ranking of the expression results revealed the following order of stability from high to low: SNORD61 < SNORD95 < SNORD72 < SNORD96a < SNORD68 < miR-191 < miR-93 < RNU6-2 < SNORD48 for ileal NETs and SNORD95 < miR-93 < SNORD96a < SNORD61 < SNORD68 < SNORD72 < RNU6-2 < miR-191 < SNORD48 for pancreatic NETs. The determination of SNORD61 and SNORD95 for ileal NETs and SNORD95 and miR-93 for pancreatic NETs as good normalizers presents a useful tool for experiments involving the analysis of miRNA expression.

Performance of additional colonoscopies and yield of neoplasms within 3 years after screening colonoscopy: a historical cohort study

BACKGROUND AND STUDY AIMS

After screening colonoscopy, additional colonoscopies may be required for adenoma surveillance or diagnostic reasons. The aim of the present study was to explore their utilization and findings in routine practice.

PATIENTS AND METHODS

The study comprised an historical cohort of individuals participating in colonoscopy screening in 2006. Utilization and yield of neoplasms of additional colonoscopies performed in these individuals by the same physician ( < 6 months and 6 - 36 months after screening) between 2006 and 2009 were assessed using data of a colonoscopy quality assurance program in Bavaria, Germany. Screening including polypectomy, and short-term follow-up colonoscopy was assumed to have been completed within ≤ 6 months. Multivariate logistic regression was used to identify predictors of additional colonoscopy and advanced neoplasms (high risk adenoma or colorectal cancer [CRC]) among those with additional colonoscopy during the period of 6 - 36 months after screening.

RESULTS

A total of 51 301 individuals undergoing screening colonoscopy were included. Of these, 10.1 % (95 % confidence interval [CI] 9.8 % - 10.3 %) had an additional colonoscopy performed by the same physician between 6 and 36 months after screening. The percentages of those with additional colonoscopy were 5.7 % (95 %CI 5.5 % - 5.9 %), 18.6 % (95 %CI 17.8 % - 19.4 %), and 33.7 % (95 %CI 32.2 % - 35.2 %) after negative screening, low risk adenoma at screening, and high risk adenoma at screening, respectively. The overall findings were negative colonoscopy, low risk adenoma, high risk adenoma, and CRC in 68.6 % (95 %CI 67.3 % - 69.8 %), 24.1 % (95 %CI 23.0 % - 25.3 %), 6.7 % (95 %CI 6.0 % - 7.4 %), and 0.6 % (95 %CI 0.4 % - 0.8 %), respectively. Younger age, male sex, screen-detected adenomas, inflammatory bowel disease, and early repeat colonoscopy within 6 months were predictors of additional colonoscopy. Older age, male sex, screen-detected adenomas, and surveillance indications were associated with increased risk of advanced neoplasms at post-screening colonoscopy.

CONCLUSION

The results indicate frequent utilization of additional colonoscopies along with substantial adenoma yield in the first 3 years after screening colonoscopy.

Expression of oestrogen receptor β and prognosis of colorectal cancer

BACKGROUND

Previous studies suggest that sex steroids influence colorectal cancer (CRC) carcinogenesis. The oestrogen receptor β (ERβ) is the predominantly expressed ER in the colon and loss of ERβ in CRC has been associated with advanced cancer stages.

METHODS

Information on vital status by the end of 2009 was obtained for 1262 CRC patients recruited between 2003 and 2007. The ERβ expression was immunohistochemically measured and associations of ERβ scores with overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS) were evaluated using Cox proportional hazard models adjusted for prognostic factors, such as tumour stage and second primary tumours.

RESULTS

Of the 1101 tumour samples with successful measurement, 535 were ERβ negative (48.6%), 381 (34.6%) showed moderate and 185 (16.8%) showed high ERβ expression. Compared with high ERβ expression, lack of ERβ was associated with higher cancer stages as well as greater tumour extent. In multivariate analyses, ERβ negativity was associated with an increased hazard ratio for death (HR=1.61, 95% CI 1.09-2.40, P=0.02), death attributed to CRC (HR=1.54, 95% CI 0.99-2.39, P=0.06) as well as a poorer DFS (DFS HR=1.64, 95% CI 1.23-3.36, P=0.04). The associations were stronger in stage I-III patients (OS HR=2.20, 95% CI 1.28-4.06, P=0.007, DSS HR=2.38, 95% CI 1.20-5.39, P=0.02, respectively).

CONCLUSIONS

Lack of ERβ expression is associated with advanced cancer stages and independently associated with poor survival.

Benefit finding and post-traumatic growth in long-term colorectal cancer survivors: prevalence, determinants, and associations with quality of life

BACKGROUND

As research on quality of life of colorectal cancer (CRC) survivors has mainly focused on downsides of cancer survivorship, the aim of this study is to investigate benefit finding (BF) and post-traumatic growth (PTG) in long-term CRC survivors.

METHODS

Benefit finding, PTG, and quality of life were assessed 5 years after diagnosis in a population-based cohort of 483 CRC patients using the benefit finding scale, the post-traumatic growth inventory, and the EORTC QLQ-C30. Prevalence of BF and PTG, determinants of moderate-to-high BF and PTG, and the association between BF, PTG, and quality of life were investigated.

RESULTS

Moderate to high levels of BF and PTG were experienced by 64% and 46% of the survivors, respectively. Survivors with the highest level of education and with higher depression scores reported less BF and PTG. The PTG increased with increasing stage and self-reported burden of diagnosis. Quality of life only correlated weakly with PTG (Pearson's r=0.1180, P=0.0112) and not with BF (r=0.0537, P=0.2456).

CONCLUSION

Many long-term CRC survivors experience BF and PTG. As these constructs were not strongly correlated with quality of life, focusing solely on quality of life after cancer misses an important aspect of survivorship.

Association of genetic polymorphisms in ESR2, HSD17B1, ABCB1, and SHBG genes with colorectal cancer risk

The incidence rates and relative risks for colorectal cancer (CRC) are higher in men than in women. Sex steroids may play a role in this gender-associated difference in CRC risk. This study was conducted to explore the relationship of single nucleotide polymorphisms (SNPs) in steroid hormone signaling (ESR1, ESR2, PGR, NR1I2, and SHBG), phase I- and II-metabolizing enzyme (COMT, HSD17B1, CYP1A1, CYP17A1, CYP1A2, CYP1B1, CYP2C9, CYP3A4, CYP2C19, and GSTP1), and hormone transporter (ABCB1) genes with the risk of CRC in German women and men, separately. From the population-based DACHS study (South Germany), 47 putatively functional SNPs were genotyped in 1798 CRC cases (746 women and 1052 men) and 1810 controls (732 women and 1078 men). Significant allele dose-response associations were observed with ESR2_rs1255998, ESR2_rs928554, HSD17B1_rs605059, and ABCB1_rs2229109 in women (P trend=0.004, 0.05, 0.03, and 0.05 respectively) and with ABCB1_rs1045642, ABCB1_rs9282564, and SHBG_rs6259 in men (P trend=0.01, 0.03, and 0.02 respectively). The ESR2_rs1255998_G allele showed the most significant association with risk for CRC in women, with a per-allele odds ratio (OR) of 0.68 (95% confidence interval (CI) 0.52-0.88). This finding was replicated in an independent study from North Germany including 1076 female CRC cases and 1151 controls (OR=0.84, 95% CI 0.71-1.04), yielding a per-allele OR of 0.80 (95% CI 0.69-0.93, P trend=0.003) in the pooled sample. These findings implicate a role of ESR2 in the risk for developing CRC in women and suggest that HSD17B1, ABCB1, and SHBG genes may contribute to sex steroid-mediated effects on CRC development.

Should colorectal cancer screening start at the same age in European countries? Contributions from descriptive epidemiology

We assessed incidence and mortality of colorectal cancer (CRC) at various ages among women and men in 38 European countries. The ages at which defined levels of incidence and mortality were reached varied between 9 and 17 years between countries. This variation requires consideration in the definition of screening guidelines.

Hormone replacement therapy, body mass, and the risk of colorectal cancer among postmenopausal women from Germany

Previous studies have reported inconsistent results regarding the modifying effect of hormone replacement therapy (HRT) on the association of body mass index (BMI) and the risk of colorectal cancer (CRC) among postmenopausal women. We assessed the use of HRT and BMI in 208 postmenopausal women with histologically confirmed incident CRC and 246 controls in a population-based case–control study in Germany (DACHS study). Ever use of HRT was strongly associated with reduction of CRC risk (adjusted odds ratio 0.41, 95% confidence interval 0.25–0.67). Among nonusers of HRT, risk of CRC was strongly increased in women with BMI 27 to <30 kg m⁻² (2.76, 1.07–7.12) and obese women (3.30, 1.25–8.72), when compared with women with BMI <23 kg m⁻² (P for trend <0.01). BMI was not associated with risk of CRC among HRT users (P for interaction <0.01). In contrast to most other studies, a positive association of BMI and CRC risk was found among nonusers of HRT, but not among users of HRT. The reasons for the inconsistency of results regarding the potential risk modifying effect of postmenopausal hormones in the association of BMI with CRC remain inconclusive and require further study.

Gender differences in colorectal cancer: implications for age at initiation of screening

There is some variation regarding age at initiation of screening for colorectal cancer (CRC) between countries, but the same age of initiation is generally recommended for women and men within countries, despite important gender differences in the epidemiology of CRC. We have explored whether, and to what extent, these differences would be relevant regarding age at initiation of CRC screening. Using population-based cancer registry data from the US and national mortality statistics from different countries, we looked at cumulative 10-year incidence and mortality of CRC reached among men at ages 50, 55, and 60, and found that women mainly reached equivalent levels when 4 to 8 years older. The gender differences were remarkably constant across populations and over time. These patterns suggest that gender differentiation of age at initiation may be worthwhile to utilise CRC-screening resources more efficiently.

Does a negative screening colonoscopy ever need to be repeated?

BACKGROUND AND AIMS

Screening colonoscopy is thought to be a powerful and cost-effective tool to reduce colorectal cancer incidence and mortality. Whether and when colonoscopy with negative findings has to be repeated is not well defined. The aim of this study was to assess the long term risk of clinically manifest colorectal cancer among subjects with negative findings at colonoscopy.

PATIENTS

380 cases and 485 controls participating in a population based case-control study in Germany.

METHODS

Detailed history and results of previous colonoscopies were obtained by interview and from medical records. Adjusted relative risks of colorectal cancer among subjects with a previous negative colonoscopy compared with those without previous colonoscopy were estimated according to time since colonoscopy.

RESULTS

Subjects with previous negative colonoscopy had a 74% lower risk of colorectal cancer than those without previous colonoscopy (adjusted odds ratio (aOR) = 0.26 (95% confidence interval, 0.16 to 0.40)). This low risk was seen even if the colonoscopy had been done up to 20 or more years previously. Particularly low risks were seen for sigma cancer (aOR = 0.13 (0.04 to 0.43)) and for rectal cancer (aOR = 0.19 (0.09 to 0.39)), and after a negative screening colonoscopy at ages 55 to 64 (aOR = 0.17 (0.08 to 0.39)) and older (aOR = 0.21 (0.10 to 0.41)).

CONCLUSIONS

Subjects with negative findings at colonoscopy are at very low risk of colorectal cancer and might not need to undergo repeat colonoscopy for 20 years or more, if at all. The possibility of extending screening intervals to 20 years or more might reduce complications and increase the feasibility and cost-effectiveness of colonoscopy based screening programmes.

Biochemistry and biotechnological applications of Gluconobacter strains

The genus Gluconobacter belongs to the group of acetic acid bacteria, which are characterized by their ability to incompletely oxidize a wide range of carbohydrates and alcohols. The corresponding products (aldehydes, ketones and organic acids) are excreted almost completely into the medium. In most cases, the reactions are catalyzed by dehydrogenases connected to the respiratory chain. Since the reactive centers of the enzymes are oriented towards the periplasmic space, transport of substrates and products into, and out of, the cell is not necessary. Thus, rapid accumulation of incompletely oxidized products in the medium is facilitated. These organisms are able to grow in highly concentrated sugar solutions and at low pH-values. High oxidation rates correlate with low biomass production, which makes Gluconobacter strains interesting organisms for industrial applications. Modern fermentation processes, such as the production of L-sorbose (vitamin C synthesis) and 6-amino- L-sorbose (synthesis of the antidiabetic drug miglitol) are carried out with members of this genus. Other important products are dihydroxyacetone, gluconate and ketogluconates. The bacteria belonging to the genus Gluconobacter exhibit extraordinary uniqueness not only in their biochemistry but also in their growth behavior and response to extreme culture conditions. This uniqueness makes them ideal organisms for microbial process development.

An overview of endosymbiotic models for the origins of eukaryotes, their ATP-producing organelles (mitochondria and hydrogenosomes), and their heterotrophic lifestyle

The evolutionary processes underlying the differentness of prokaryotic and eukaryotic cells and the origin of the latter's organelles are still poorly understood. For about 100 years, the principle of endosymbiosis has figured into thoughts as to how these processes might have occurred. A number of models that have been discussed in the literature and that are designed to explain this difference are summarized. The evolutionary histories of the enzymes of anaerobic energy metabolism (oxygen-independent ATP synthesis) in the three basic types of heterotrophic eukaryotes those that lack organelles of ATP synthesis, those that possess mitochondria and those that possess hydrogenosomes--play an important role in this issue. Traditional endosymbiotic models generally do not address the origin of the heterotrophic lifestyle and anaerobic energy metabolism in eukaryotes. Rather they take it as a given, a direct inheritance from the host that acquired mitochondria. Traditional models are contrasted to an alternative endosymbiotic model (the hydrogen hypothesis), which addresses the origin of heterotrophy and the origin of compartmentalized energy metabolism in eukaryotes.

[How do parents adjust to a child with cancer? A clinical study of the psychosocial status of parents of children with cancer]

As chronic life-threatening diseases, cancer or leukemia in children generates an extreme situation for the family involved that can go on for years. Psychosocial care for all family members by a pediatric oncologist should be integrated into the treatment plan, as this is both helpful and necessary.

[Psychosocial consequences of cancer in a child for its parents and siblings]

Cancer in children leads to extreme situations not only for the child but for all members of the family. Fear of death quite often over years has severe psychosocial consequences for the sick child, its parents and siblings. Without sufficient help from the therapeutic team the family is usually not able, to cope with these problems.