Sexual health in adult survivors of childhood cancer: A Project REACH study.

BACKGROUND: Sexual dysfunction is a significant complication of treatment for many adult-onset cancers. However, comparatively less is known about sexual dysfunction in adult childhood cancer survivors (CCSs). Research has been limited by the exclusion of specific cancers (e.g., central nervous system [CNS] tumors) and the lack of validated measures, which makes it difficult to understand the nature and prevalence of sexual dysfunction in CCSs. METHODS: A total of 249 adult CCSs (aged 18-65 years) enrolled in Project REACH, a prospective cohort study, and completed measures of physical and mental health, including sexual dysfunction. Participants scoring ≤19 on the Female Sexual Function Index 6 or ≤21 on the International Index of Erectile Function 5 were classified as experiencing sexual dysfunction. Analyses examined the relationships between sexual dysfunction and demographic, disease, treatment, and health variables. RESULTS: A total of 78 participants (32%) experienced clinically significant sexual dysfunction. In univariate analysis, sexual dysfunction was significantly associated with CNS tumor diagnosis (odds ratio [OR], 2.56) and surgery (OR, 1.96) as well as with health variables such as fatigue (OR, 3.00), poor sleep (OR, 2.84), pain (OR, 2.04), depression (OR, 2.64), poor physical health (OR, 2.45), and poor mental health (OR, 2.21). Adjusted analyses found that CNS tumor diagnosis (p = .001) and health variables (p = .025) contribute significantly to sexual dysfunction in CCSs. CONCLUSIONS: Approximately one third of adult CCSs report clinically significant sexual dysfunction, which underscores a significant screening and treatment need. However, because available measures were developed for survivors of adult cancers, research to create a sexual health measure specifically for adult CCSs is necessary to better identify the sexual health concerns of this vulnerable population.

Evaluating SunSmart: a brief educational intervention promoting sun protection in young adult cancer survivors.

PURPOSE: Young adult cancer survivors (YACS) are at risk for secondary skin cancers but relevant interventions have not been validated in this population. To address this, we designed and tested SunSmart, a set of two educational videos designed to promote sun protection (SP). One provides SP education (Information) and the second combines SP education with content on negative appearance consequences of sun exposure (Information + Appearance). METHODS: One hundred ninety-three YACS (aged 18-35) were randomized to one of three groups: (1) Information, (2) Information + Appearance, or (3) control (sleep hygiene video). Participants completed measures on SP behaviors at baseline and follow-up. One-way ANCOVAs examined the intervention effect on follow-up SP behaviors controlling for baseline behaviors. RESULTS: The intervention did not significantly affect SP behaviors. However, secondary analyses limited to participants with the lowest baseline SP adherence found that the Information + Appearance group had significantly lower intentional sun exposure than the control group (p = 0.02) at follow-up. CONCLUSIONS: Contrary to hypotheses, the SunSmart intervention did not significantly improve sun protection in YACS, even when it presented information on negative appearance consequences of sun exposure. However, secondary analyses suggest SunSmart may be more effective in YACS with the lowest SP adherence. Future research is required to improve intervention efficacy with YACS (e.g., increased focus on secondary cancer risks). IMPLICATIONS FOR CANCER SURVIVORS: Despite their increased risk of secondary skin cancer, YACS in the current study reported significant sun exposure and inadequate SP. The need for development and validation of effective interventions to address these concerns remains.

Screening young adult cancer survivors for depression and anxiety with the Primary Care Evaluation of Mental Disorders (PRIME-MD): Comparisons with a structured clinical diagnostic interview.

OBJECTIVE: Survivorship guidelines recommend screening for depression and anxiety in young adult cancer survivors (YACS), but research validating measures in this population is limited. The current study aimed to examine use of the Primary Care Evaluation of Mental Disorders (PRIME-MD) to screen for depression and anxiety in YACS. METHODS: 249 YACS (aged 18-40, 50% male) completed PRIME-MD via Telephone Automated Computer Assisted Structured Interview and the Structured Clinical Interview for the DSM-IV (SCID) via in-person interview. SCID responses were scored to identify depressive and anxiety symptoms and diagnoses. PRIME-MD was scored to identify YACS reaching the symptom threshold (≥1 depressive or anxiety symptom) and diagnostic threshold for depressive or anxiety disorder. ROC analyses evaluated concordance of the PRIME-MD with the SCID. RESULTS: The PRIME-MD depressive symptom threshold had excellent discrimination compared to SCID depressive diagnosis (AUC = 0.83) with high sensitivity (86%) and specificity (81%). Similarly, the PRIME-MD depressive diagnosis threshold had excellent discrimination compared to SCID depressive diagnosis (AUC = 0.86) as well as high sensitivity (86%) and specificity (86%). No PRIME-MD threshold met sensitivity (≥0.85) and specificity (≥0.75) criteria for identifying SCID depressive symptoms, anxiety disorders, or anxiety symptoms. CONCLUSIONS: PRIME-MD has potential utility as a screening measure of depressive disorders in YACS. The PRIME-MD depressive symptom threshold may be particularly useful in survivorship clinics as it requires only two items be administered. However, PRIME-MD does not meet study criteria for a standalone screen for anxiety disorders, anxiety symptoms, or depressive symptoms in YACS.

Evaluating the Sleep Treatment Education Program (STEP-1): A single-session educational workshop addressing insomnia in cancer survivors.

Insomnia is a common late effect of cancer, affecting as many as 27% of cancer survivors. Although cognitive behavioral therapy for insomnia (CBT-I) is highly effective, treatment-associated burdens and limited availability of providers result in few survivors receiving this treatment. To address this gap, we developed the Sleep Treatment Education Program-1 (STEP-1), a single-session intervention addressing insomnia after cancer. As a preliminary evaluation of STEP-1's potential to improve survivors' insomnia, STEP-1 was delivered to a convenience sample of 34 cancer survivors as an educational workshop in person or by videoconference. Participants completed the Insomnia Severity Index (ISI) at the workshop and at 1-month follow-up; items assessing participants' intentions to implement program suggestions and satisfaction were also collected. At 1-month follow-up, mean insomnia symptoms on the ISI were significantly lower compared to baseline (9.73 vs 15.73; d = 1.38, P < .001); the reduction in mean ISI scores did not significantly differ between in-person and videoconference participants (5.82 vs 6.33; P = .78). These results, along with positive indicators of program engagement and satisfaction, support the potential efficacy of STEP-1 to meet survivors' needs for insomnia care. Particularly when delivered by videoconference, STEP-1 has the potential to dramatically improve access and uptake for insomnia treatment in cancer survivors. Results also more generally support development of low-intensity, self-management insomnia interventions for cancer survivors and potentially other populations.

Evaluating sensitive symptoms in young adult cancer survivors: acceptability of suicidal ideation and sexual health items across administration modes.

PURPOSE: Patient-reported outcomes (PROs) are essential for assessing potential late effects experienced by young adult cancer survivors (YACS), but stigma and social desirability bias may limit their effectiveness for assessing sensitive topics (e.g., suicidal ideation, sexual health). This study compared two methods of item administration to determine the optimal method for obtaining sensitive information in YACS. METHODS: Two hundred forty-four YACS (ages 18-40) were randomized to complete measures of suicidal ideation and sexual health (i.e., sensitive items) by paper survey or by telephone automated computer assisted structured interview (TACASI). Participants also provided information on acceptability of administration mode and sensitive items. RESULTS: The proportion of participants reporting symptoms did not significantly vary between paper and TACASI administration: respectively, 10% vs. 12% reported suicidal ideation and 55% vs. 58% reported sexual health concerns. The majority (≥ 78%) of participants reported feeling comfortable answering sensitive items on paper and TACASI and there were no significant differences in acceptability based on administration mode. Although participants endorsing sensitive symptoms were significantly more likely to feel upset answering sensitive items, the majority (93%) of participants experiencing symptoms still felt they were important to ask. CONCLUSIONS: Despite their potentially sensitive nature, questions about suicidal ideation and sexual health were highly acceptable to YACS across administration modes. Moreover, YACS almost universally endorse the importance of providers asking about these topics. IMPLICATIONS FOR CANCER SURVIVORS: Findings should bolster provider confidence that screening for suicidal ideation and sexual health concerns can and should be integrated into clinical care for YACS using paper or technology-assisted methods.

Validation of the Three-Item Insomnia Severity Index Short Form in Young Adult Cancer Survivors: Comparison with a Structured Diagnostic Interview.

Chronic insomnia affects ∼25% of young adult cancer survivors (YACS) but is often overlooked in routine follow-up. A recently introduced three-item version of the Insomnia Severity Index (ISI-3) was compared with a diagnostic interview (SCID-5) in 250 YACS (ages 18-40) to evaluate its validity in this population. The ISI-3 had good discrimination compared with the SCID-5 (area under the receiver operating characteristic curve = 0.88). Although no ISI-3 cutoff met study criteria for both sensitivity (≥0.85) and specificity (≥0.75), an ISI-3 cutoff of ≥4 had high sensitivity (94%) and moderate specificity (70%), and is recommended as the first step in a two-step screening procedure.

The Effect of Pediatric Cancer on Identity in Young Adult Survivors: Results from Project REACH.

Purpose: Living through cancer can have a profound effect on identity. Among those treated for adult-onset cancer, identifying as a cancer survivor is common and has been linked to positive mental and physical health outcomes. Although childhood is a critical period for identity formation, comparatively less is known about identity development after pediatric cancers. Methods: One hundred seventy young adults previously treated for pediatric cancer enrolled in Project REACH, a prospective cohort study, and completed self-report measures on effect of cancer on identity (e.g., cancer victim and survivor identity), frequency of thoughts of cancer, health outcomes (i.e., anxiety, depression, and health-related quality of life), and health behaviors (i.e., smoking, sun protection, exercise, and binge drinking). Results: The majority of participants identified as a survivor (n = 146, 85.9%), and survivor identity was linked to significantly higher anxiety (p = 0.01) and worse overall mental health (p = 0.04), but no other health outcomes or behaviors. Only 14 participants (8.2%) endorsed the victim identity, and they were significantly more likely to report binge drinking (p = 0.03) and worse overall mental health (p = 0.02) than nonvictims. Frequency of thoughts of cancer and effect of cancer on identity were also significantly associated with health outcomes (e.g., more frequent thoughts associated with higher anxiety). Conclusions: Our findings suggest that what is known about the relationship between identity and health outcomes after adult-onset cancer cannot be generalized to pediatric cancers, and that clinicians should not assume survivor identity is associated with better health outcomes in this group.

Validating the Patient-Reported Outcomes Measurement Information System Short Form v1.0-Anxiety 8a in a sample of young adult cancer survivors: Comparison with a structured clinical diagnostic interview.

BACKGROUND: The objective of this study was to validate the Patient-Reported Outcomes Measurement Information System Short Form v1.0-Anxiety 8a (PROMIS-A-SF) against a structured diagnostic interview in order to determine its accuracy and the most appropriate cutoff score for identifying anxiety disorders in young adult cancer survivors (YACSs). METHODS: Two hundred forty-nine YACSs aged 18 to 40 years (50% male) completed the PROMIS-A-SF and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). The SCID was used to determine whether participants met the criteria for an anxiety diagnosis. Receiving operator characteristic analyses were performed to determine the concordance of the PROMIS-A-SF and the SCID as well as cutoff scores with sensitivity (≥0.85) and specificity (≥0.75) appropriate for an anxiety screening measure. RESULTS: The PROMIS-A-SF was determined to have good overall discrimination in comparison with the SCID (area under the curve, 0.84). A PROMIS-A-SF t-score cutoff ≥ 53.2 (total predictive value, 67.9%) came closest to meeting the study criteria with a sensitivity of 88%, but the specificity was only 65%. In a hypothetical screening example, this cutoff led to moderate levels of missed cases (14%) and a significant proportion of clinical referrals that were unnecessary by SCID criteria (35%). Of the survivors referred for services according to these criteria, less than one-third (29%) would have a SCID anxiety diagnosis. CONCLUSIONS: The PROMIS-A-SF demonstrated moderately strong concordance with anxiety disorders measured by the SCID, but cutoff scores did not meet study criteria for clinical screening. Although it may not be appropriate as a standalone screener, the PROMIS-A-SF may be useful for assessing anxiety in YACSs when it is incorporated into clinical practice or when it is combined with other measures.

Culture and Sexual Medicine: A Road Map for Clinical Inquiry and Practice.

As the field of sexual medicine continues to grow, there has been increasing attention to the importance of the sociocultural components of the biopsychosocial model. Although important in all medical practice, culture and sexual health are particularly entwined, so engaging with sociocultural aspects of the patient experience as part of evaluation and treatment is necessary to optimize patient outcomes in this field. We invite clinicians to consider the importance of sexual health literacy, cultural humility, and support for patient volition as key aspects of moving care towards a model that embraces all aspects of the biopsychosocial model. The aim of the current paper is to provide readers with concrete steps and illustrative examples to help guide this process. Bober SL, Chevalier L. Culture and Sexual Medicine: A Road Map for Clinical Inquiry and Practice. J Sex Med 2021;18:1475-1478.

The Relationship Between Parental Accommodation and Sleep-Related Problems in Children with Anxiety.

OBJECTIVE: Sleep-related problems, defined as sleep patterns atypical for the child's developmental stage, are common in children with elevated anxiety symptoms and linked to significant mental and physical health consequences. Despite the consequences of sleep-related problems, it remains unclear how these problems are initiated and maintained in children with elevated anxiety symptoms. The current study examines the relationship between sleep-related problems and parental accommodation (e.g., co-sleeping) to determine whether higher levels of accommodation are associated with more frequent sleep-related problems in a sample of children with elevated anxiety symptoms. METHODS: Participants were 122 children aged 8 to 17 years old (M = 11.97, SD = 2.68; 57% female) and their parents who presented to a university-based anxiety specialty clinic for assessment and treatment. Children completed the Multidimensional Anxiety Scale for Children, and their parents completed the Children's Sleep Habits Questionnaire and Family Accommodation Checklist and Interference Scale. Multiple regression analyses were performed to examine variance in sleep-related problems explained by parental accommodation. RESULTS: Parental accommodation accounted for a significant amount of variance in sleep-related problems over and above child anxiety and age for both mother report (19%) and father report (15%). When individual accommodation items were examined, parental sleep accommodations (e.g., slept in my child's bed) and nonsleep accommodations (e.g., came home early) were significant predictors for mother-reported sleep-related problems, but only sleep accommodations (e.g., let my child sleep with the lights on) were significant for father-reported sleep-related problems. CONCLUSION: Parents of children with elevated anxiety symptoms and sleep-related problems engage in accommodation related to their child's sleep (e.g., co-sleeping). Future research elucidating the potential bidirectional and causal links between parental accommodation and sleep-related problems is a necessary step in adapting sleep treatments for this population.

Parent and child emotion and distress responses associated with parental accommodation of child anxiety symptoms.

OBJECTIVE: Parental accommodation contributes to the maintenance of child anxiety and related symptoms. The current study examines the contributions of parent and child factors to parental accommodation in a sample of anxious youth. METHODS: Sixty-four treatment-seeking youth (6-16 years) and their mothers, as well as a subset of fathers (N = 41) reported on parental accommodation, parental distress and emotion regulation, child psychopathology, child externalizing behaviors, and child intolerance of uncertainty. RESULTS: Parental accommodation was not related to parental distress or emotion regulation. Parents who viewed their child as being more symptomatic (e.g., anxious, externalizing, and intolerant of uncertainty) were more likely to engage in accommodation. For mothers, child anxiety and externalizing symptoms were notable predictors of accommodation. CONCLUSIONS: Parent perceptions of child symptomology is an important factor significantly related to accommodation behaviors. This finding can be used to inform programming designed to target parental responses to child anxiety and related disorders.