James L. Klosky

Prospective Medical Assessment of Adults Surviving Childhood Cancer: Study Design, Cohort Characteristics, and Feasibility of the St. Jude Lifetime Cohort Study

To facilitate prospective medical assessment of adults surviving pediatric malignancies and advance knowledge about long‐term childhood cancer survivor health, St. Jude Childrens Research Hospital (SJCRH) is establishing a lifetime cohort of survivors.

Factors Influencing Familial Decision-Making Regarding Human Papillomavirus Vaccination

OBJECTIVE The purpose of this review is to summarize the research regarding Human Papillomavirus (HPV) vaccination uptake among families with adolescent/preadolescent daughters. METHODS Literature searches (utilizing PubMed and PsychInfo databases) were conducted and research examining psychological and environmental factors which relate to HPV vaccine uptake and intentions was reviewed. RESULTS Factors such as physician recommendations, perceptions of the beliefs of peers and significant others, history of childhood immunizations, and communication with adolescents regarding sexual topics appear to influence HPV vaccination outcomes. CONCLUSIONS Although primary prevention of cervical and other cancers is available for preadolescent and adolescent girls, rates of HPV vaccine uptake are low. Future interventions should target vaccine intent and physician/family communication as a means to increasing HPV vaccination.

Cumulative alkylating agent exposure and semen parameters in adult survivors of childhood cancer: a report from the St Jude Lifetime Cohort Study

BACKGROUND Few data define the dose-specific relation between alkylating agent exposure and semen variables in adult survivors of childhood cancer. We undertook this study to test the hypothesis that increased exposure to alkylating agents would be associated with decreased sperm concentration in a cohort of adult male survivors of childhood cancer who were not exposed to radiation therapy for their childhood cancer. METHODS We did semen analysis on 214 adult male survivors of childhood cancer (median age 7·7 years [range 0·01-20·3] at diagnosis, 29·0 years [18·4-56·1] at assessment, and a median of 21·0 years [10·5-41·6] since diagnosis) who had received alkylating agent chemotherapy but no radiation therapy. Alkylating agent exposure was estimated using the cyclophosphamide equivalent dose (CED). Odds ratios (ORs) and 95% CIs for oligospermia (sperm concentration >0 and <15 million per mL) and azoospermia were calculated with logistic regression modelling. FINDINGS Azoospermia was noted in 53 (25%) of 214 participants, oligospermia in 59 (28%), and normospermia (sperm concentration ≥15 million per mL) in 102 (48%) participants. 31 (89%) of 35 participants who received CED less than 4000 mg/m(2) were normospermic. CED was negatively correlated with sperm concentration (correlation coefficient=-0·37, p<0·0001). Mean CED was 10 830 mg/m(2) (SD 7274) in patients with azoospermia, 8480 mg/m(2) (4264) in patients with oligospermia, and 6626 mg/m(2) (3576) in patients with normospermia. In multivariable analysis, CED was significantly associated with an increased risk per 1000 mg/m(2) CED for azoospermia (OR 1·22, 95% CI 1·11-1·34), and for oligospermia (1·14, 1·04-1·25), but age at diagnosis and age at assessment were not. INTERPRETATION Impaired spermatogenesis was unlikely when the CED was less than 4000 mg/m(2). Although sperm concentration decreases with increasing CED, there was substantial overlap of CED associated with normospermia, oligospermia, and azoospermia. These data can inform pretreatment patient counselling and use of fertility preservation services. FUNDING US National Cancer Institute, American Lebanese Syrian Associated Charities.

Physical performance limitations among adult survivors of childhood brain tumors.

Young adult survivors of childhood brain tumors (BTs) may have late effects that compromise physical performance and everyday task participation. The objective of this study was to evaluate muscle strength, fitness, physical performance, and task participation among adult survivors of childhood BTs.

Fatigue, vitality, sleep and neurocognitive functioning in adult survivors of childhood cancer: A Report from the Childhood Cancer Survivor Study

Long‐term survivors of childhood cancer are at risk for fatigue, sleep problems, and neurocognitive impairment, although the association between these outcomes has not been previously examined.

Risky Health Behavior Among Adolescents in the Childhood Cancer Survivor Study Cohort

OBJECTIVE To report the prevalence and comparison of cancer-linked health behaviors and identify risk factors associated with unhealthy behavior among adolescent siblings and cancer survivors. METHODS The Child Health and Illness Profile--Adolescent Edition (CHIP--AE) was completed by 307 survivors and 97 sibling controls 14-20 years of age. RESULTS Risky behavior ranged from 0.7% to 35.8% for survivors and 1.0% to 41.2% for siblings. Comparisons of sexual behavior, tobacco, alcohol, or illicit drug use utilizing continuous data revealed no differences between groups. Categorically, survivors were less likely to report past smokeless tobacco use or current use of beer/wine or binge drinking (p-values range from .01 to .04). Survivors with better mental health were at lower risk for poor behavioral outcomes. CONCLUSIONS Adolescent survivors engage in risky health behaviors at rates generally equivalent to their siblings. Aggressive health education efforts should be directed toward this high-risk population.

Posttraumatic Stress and Psychological Growth in Children With Cancer: Has the Traumatic Impact of Cancer Been Overestimated?

PURPOSE To examine posttraumatic stress disorder and posttraumatic stress symptoms (PTSD/PTSS) in children with cancer using methods that minimize focusing effects and allow for direct comparison to peers without a history of cancer. PATIENTS AND METHODS Children with cancer (n = 255) stratified by time since diagnosis, and demographically matched peers (n = 101) were assessed for PTSD using structured diagnostic interviews by both child and parent reports, and survey measures of PTSS and psychological benefit/growth by child report. RESULTS Cancer was identified as a traumatic event by 52.6% of children with cancer, declining to 23.8% in those ≥ 5 years from diagnosis. By diagnostic interview, 0.4% of children with cancer met criteria for current PTSD, and 2.8% met lifetime criteria by self-report. By parent report, 1.6% of children with cancer met current criteria and 5.9% met lifetime criteria for PTSD. These rates did not differ from controls (all Ps >.1). PTSS levels were descriptively lower in children with cancer but did not differ from controls when all were referring to their most traumatic event (P = .067). However, when referring specifically to cancer-related events, PTSS in the cancer group were significantly lower than in controls (P = .002). In contrast, perceived growth was significantly higher in the cancer group when referring to cancer (P < .001). CONCLUSION These findings suggest no evidence of increased PTSD or PTSS in youths with cancer. Although childhood cancer remains a significant and challenging event, these findings highlight the capacity of children to adjust, and even thrive, in the face of such challenge.

Factors influencing long-term follow-up clinic attendance among survivors of childhood cancer

IntroductionAttendance at long-term follow-up clinic is necessary for survivors of childhood cancer to facilitate education about cancer-related health risks, early detection of treatment-related morbidity, and implementation of health-promoting interventions. Despite the need for continued care, barriers to clinic attendance exist. The purpose of this prospective study was to identify the demographic, medical, and logistic factors impacting clinic attendance and long-term follow-up care among survivors of childhood cancer.MethodsAdherence to clinic attendance was monitored among 941 long-term childhood cancer survivors scheduled for evaluation. Patients were classified as “attenders” or “non-attenders” based on the outcome of their first scheduled clinic appointment over a one year period. Social work staff contacted non-attenders by telephone to determine reasons for missed appointments.ResultsNearly 15% of survivors were classified as non-attenders. Univariate findings revealed that older age, lower SES, being non-white, less medically insured, traveling by car, living shorter distance from clinic, having a scheduled social work consultation, and entering or exiting survivorship clinic were associated with clinic non-attendance (all p values < 0.05). The final multivariate model indicated that non-whites (OR = 1.88, 95% CI = 1.19–2.97), patients without insurance (OR = 2.36, 95% CI = 1.98–3.79), those traveling by car (OR = 12.74, 95% CI = 3.97–40.86), and those who have not experienced secondary cancer events (OR = 1.76, 95% CI = 0.94–3.28) were more likely to be non-attenders. Work or school conflicts were the primary reasons cited for missed appointments.Discussion/conclusionsDespite mechanisms designed to reduce financial burdens associated with attending survivorship clinic at our institution, demographic, medical, and logistic barriers exist which impact participation in long-term follow-up.Implications for cancer survivors and providersThese results highlight the importance of developing tailored outreach strategies for survivors of childhood cancer at-risk for clinic non-attendance, particularly among underserved populations.

SPERM CRYOPRESERVATION PRACTICES AMONG ADOLESCENT CANCER PATIENTS AT RISK FOR INFERTILITY

To assess sperm cryopreservation among males newly diagnosed with cancer aged 13 years and older, attending oncologists assigned infertility risk (yes/no) to patients and reported whether their patients engaged in sperm cryopreservation. Only 28.1% of informed at-risk patients banked sperm. Utilization of sperm banking was significantly associated with a diagnosis of central nervous system (CNS) malignancy or non-CNS solid tumor diagnosis, higher socioeconomic status, and not being a member of an Evangelical religious group. These results suggest that sperm banking is underutilized among adolescent males newly diagnosed with cancer, and that strategies to increase the engagement in this fertility preservation method are needed.

The need for reproductive and sexual health discussions with adolescent and young adult cancer patients

Reproductive health consistently ranks as one of the most important issues cited by adolescent and young adult (AYA) cancer survivors. Most literature on AYA cancer populations neglects broader reproductive health issues such as unintended pregnancies, contraception use and sexually transmitted infections, which, for cancer patients and survivors with compromised immune systems, can facilitate a multitude of future health problems. Lack of attention coupled with traditional risk-taking behaviors of AYAs poses a significant health risk to patients and survivors, particularly if fertility status is unknown or inaccurately assessed. AYA oncology patients and survivors are vulnerable to reproductive health complications that should be addressed prior to, during and after treatment; however, there are currently no tracking systems or evidence-based guidelines to discuss this subject with patients and survivors. Further research is needed to identify physician practices, AYA preferences and strategies for communication that can pave the way to establishing guidelines to discuss in oncology settings.