Neurologic morbidity and functional independence in adult survivors of childhood cancer.

OBJECTIVE: To examine associations between neurologic late effects and attainment of independence in adult survivors of childhood cancer treated with central nervous system (CNS)-directed therapies. METHODS: A total of 7881 survivors treated with cranial radiation therapy (n = 4051; CRT) and/or intrathecal methotrexate (n = 4193; IT MTX) ([CNS-treated]; median age [range] = 25.5 years [18-48]; time since diagnosis = 17.7 years [6.8-30.2]) and 8039 without CNS-directed therapy reported neurologic conditions including stroke, seizure, neurosensory deficits, focal neurologic dysfunction, and migraines/severe headaches. Functional independence was assessed using latent class analysis with multiple indicators (independent living, assistance with routine and personal care needs, ability to work/attend school, attainment of driver's license, marital/partner status). Multivariable regression models, adjusted for age, sex, race/ethnicity, and chronic health conditions, estimated odds ratios (OR) or relative risks (RR) for associations between neurologic morbidity, functional independence, and emotional distress. RESULTS: Among CNS-treated survivors, three classes of independence were identified: (1) moderately independent, never married, and non-independent living (78.7%); (2) moderately independent, unable to drive (15.6%); and (3) non-independent (5.7%). In contrast to 50% of non-CNS-treated survivors and 60% of siblings, a fourth fully independent class of CNS-treated survivors was not identified. History of stroke (OR = 2.50, 95% CI: 1.70-3.68), seizure (OR = 9.70, 95% CI: 7.37-12.8), neurosensory deficits (OR = 2.67, 95% CI: 2.16-3.31), and focal neurologic dysfunction (OR = 3.05, 95% CI: 2.40-3.88) were associated with non-independence among CNS-treated survivors. Non-independence was associated with emotional distress symptoms. INTERPRETATION: CNS-treated survivors do not attain full independence comparable to non-CNS-treated survivors or siblings. Interventions to promote independence may be beneficial for survivors with treatment-related neurological sequalae.

The role of body image dissatisfaction in the association between treatment-related scarring or disfigurement and psychological distress in adult survivors of childhood cancer.

OBJECTIVE: To examine the potential mediating role of body image dissatisfaction on the association between treatment-related scarring/disfigurement and psychological distress in adult survivors of childhood cancer. METHODS: Participants included 1714 adult survivors of childhood cancer (mean [SD] age at evaluation = 32.4 [8.0] years, time since diagnosis = 24.1 [8.1] years) enrolled in the St. Jude Lifetime Cohort Study. Survivors completed measures of body image, emotional distress, and posttraumatic stress symptoms (PTSS). Body image dissatisfaction (BID) was categorized into 2 groups (cancer-related and general) based on factor analysis. Using causal mediation analysis, we estimated the proportion of psychological distress associated with treatment-related scarring/disfigurement that could be eliminated by resolving BID through a hypothetical intervention. RESULTS: Among survivors with scarring/disfigurement of the head, a sizable proportion of the relative excess of psychological distress could be eliminated if BID was successfully treated (males: [cancer-related BID: depression: 63%; anxiety: 100%; PTSS: 52%]; [general BID: depression: 70%; anxiety: 100%; PTSS: 42%]; females: [cancer-related BID: depression: 20%; anxiety; 36%; PTSS: 23%]; [general BID: depression: 32%; anxiety: 87%; PTSS: 38%]). The mediating effect of BID was less pronounced for the association between scarring/disfigurement of the body and psychological distress for both males and females. CONCLUSIONS: Body image dissatisfaction mediates the association treatment-related scarring/disfigurement and psychological distress among adult survivors of childhood cancer, particularly among survivors with scarring/disfigurement of the head and male survivors. Successful treatment of body image dissatisfaction has the potential to eliminate a substantial proportion of psychological distress related to scarring/disfigurement among adult survivors of childhood cancer.

Impact of chronic disease on emotional distress in adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

BACKGROUND: The current study was performed to examine associations between childhood cancer therapies, chronic health conditions, and symptoms of emotional distress in adult survivors of childhood cancer. METHODS: Participants included 5021 adult survivors of childhood cancer (mean age, 32.0 years [standard deviation, 7.6 years] with a time since diagnosis of 23.2 years [standard deviation, 4.5 years]) who completed measures assessing symptoms of anxiety, depression, and posttraumatic stress. Cardiac, pulmonary, and endocrine conditions were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.03; grades 1-4). Structural equation modeling was used to examine hypothesized pathways between cancer treatment exposures, chronic health conditions, and symptoms of emotional distress. Multivariable models were used to estimate relative risks (RRs) for associations between chronic health conditions and distress. RESULTS: Survivors with cardiovascular, endocrine, or pulmonary conditions were found to have a significantly higher prevalence of emotional distress symptoms. In path analyses and multivariable models, significant effects were observed between endocrine (ß = .12 [P = .002] and RR, 1.3 [95% confidence interval (95% CI), 1.1-1.6]) and pulmonary (ß = .13 [P<.001] and RR, 1.4 [95% CI, 1.1-1.7]) conditions and depression, and between cardiac (ß = .13 [P = .001] and RR, 1.5 [95% CI, 1.2-1.8]) and pulmonary (ß = .15 [P<.001] and RR, 1.6 [95% CI, 1.3-2.0]) conditions and anxiety. All treatment-related chronic health conditions were found to be associated with posttraumatic stress symptoms (cardiac: ß = .09 [P = .004] and RR, 1.3 [95% CI, 1.2-1.5]; endocrine: ß = .12 [P<.001] and RR, 1.3 [95% CI, 1.2-1.5]; and pulmonary: ß = .13 [P<.001] and RR, 1.4 [95% CI, 1.2-1.6]). CONCLUSIONS: Chronic health conditions resulting from childhood cancer therapies contribute to emotional distress in adult survivors. Targeted mental health screening efforts in this at-risk population appear warranted. Therapeutic approaches should consider the complex interplay between chronic health conditions and symptoms of emotional distress. Cancer 2017;123:521-528. © 2016 American Cancer Society.

Understanding the Health Behaviors of Survivors of Childhood and Young-Adult Cancer: Preliminary Analysis and Model Development.

The current study presents preliminary correlational data used to develop a model depicting the psychosocial pathways that lead to the health behaviors of survivors of childhood and young-adult cancer. Data collected from a sample of 18- to 30-year-old cancer survivors (n = 125) was used to examine the relations among interpersonal support and nonsupport, personal agency, avoidance, depressive symptoms and self-efficacy as they related to health behaviors. The outcome measures examined included tobacco and alcohol use, diet, exercise, sunscreen use, medication compliance and follow-up/screening practices. Correlational analyses revealed a number of significant associations among variables. Results are used to inform the development of a health behavior model. Implications for health promotion and survivorship programming are discussed, as well as directions for future research.