Wendy L. Hobbie

Posttrauamatic stress disorder (PTSD) in young adult survivors of childhood cancer

Posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD) were assessed in young adult survivors of childhood cancer, including the role of four sets of variables in understanding PTSD in this population: demographic characteristics, disease and treatment factors, psychosocial and functional outcomes, and cancer‐related beliefs.

The medical consequences of cure.

As more children are now being cured of cancer, increasing attention needs to be focused on the long‐term sequelae of cancer therapy, principally late‐appearing second cancers and damage to organ systems. To this end, the authors have established an oncology follow‐up clinic specifically designed to examine former pediatric cancer patients who are likely to be cured. Patients receive a physical examination and appropriate organ function studies based upon initial diagnosis, pre‐existing conditions, treatment received, and any complications experienced during the course of therapy. The late effects noted among the first 200 such survivors examined reveal a high proportion of severe sequelae secondary to radiation therapy in early childhood. Second malignant neoplasms may also be related to alkylating agent chemotherapy and to genetic conditions. Although certain therapeutic practices have improved the outlook for these patients, and, in some cases, reduction in intensity of therapy has been found to be effective, increased survival and newer treatment modalities have made extended follow‐up increasingly necessary in order to detect and possibly prevent the occurrence of such late effects. Cancer 58:524‐528, 1986.

A revision of the intensity of treatment rating scale: Classifying the intensity of pediatric cancer treatment

We previously developed a reliable and valid method for classifying the intensity of pediatric cancer treatment. The Intensity of Treatment Rating Scale (ITR‐2.0) 1 classifies treatments into four operationally defined levels of intensity and is completed by pediatric oncology specialists based on diagnosis, stage, and treatment data from the medical record. Experience with the ITR‐2.0 and recent changes in treatment protocols indicated the need for a minor revision and revalidation.

Substance Use Risk Behaviors and Decision-Making Skills Among Cancer-Surviving Adolescents

The aims of this study were to compare decision making and substance use risk behaviors of a cohort of cancer-surviving adolescents to those of 2 earlier cohorts as well as adolescents in the US general population and to determine the relationship of decision making to substance use risk behaviors. This correlational study used a semistructured interview at the time of the annual clinic visit to obtain data. Teen cancer survivors (N = 76), ages 14-19 years, were recruited from 5 clinics within the United States. Adherence to quality decision-making skills reported by different cancer-surviving adolescent cohorts appears to remain the same over time. However, reported substance use risk behaviors by these teen survivor cohorts have decreased over time. The prevalence rates for lifetime use for the 2004 cohort of teen cancer survivors were 25%, 49%, and 16%, for cigarettes, alcohol, and marijuana use, respectively. These rates are somewhat lower than those in the US general population; yet, they are high given the health vulnerability of cancer-surviving adolescents. Poor-quality decision making was significantly associated with higher levels of substance use risk behaviors for these teen cancer survivors. In conjunction with the statistics related to higher health risks in this vulnerable group of teens, these findings support continued efforts in developing interventions for risk behavior counseling.

Prevalence of advanced bone age in a cohort of patients who received cis‐retinoic acid for high‐risk neuroblastoma

In the last decade, 13‐cis‐retinoic acid (13‐cis‐RA) has been added to the treatment of patients with high‐risk neuroblastoma. In survivors of neuroblastoma, short stature is consistently observed. Causes include growth hormone deficiency and poor growth of irradiated long bones. Within the survivorship program at CHOP, we have observed that a number of these patients also have advanced bone ages. Children treated with 13‐cis‐RA are at risk for advanced bone age that may dramatically impact their linear growth. Ongoing evaluation is necessary to examine the effect of 13‐cis‐RA on final adult height and to inform clinical practice in this cohort. Pediatr Blood Cancer 2011;56:474–476.

Survivors of childhood and adolescent cancer: A multidisciplinary approach: Third Edition

Because of the tremendous advances in childhood and adolescent cancer treatment, medical and psychosocial survivorship issues have gained more attention in the last decade. Health professionals are now more likely to encounter cancer survivors in their clinical practice and will be presented with the challenge of sifting through the emerging scientific knowledge and evidence-based practices. This volume, now in its second edition, aids in simplifying this task by providing an overview of the health issues in survivorship, and successfully integrates relevant information on the study of the delayed consequences, or Blate effects[, of cancer treatment. According to the 2003 reportChildhoodCancer Survivorship: Improving Care and Quality of Life (Institute of Medicine, National Research Council of the National Academies), approximately two thirds of childhood cancer survivors are likely to experience at least one late effect resulting from the disease process, treatment, or both. Most important for mental health workers, neurocognitive and psychological symptoms are among the most common of such late effects. These can have an impact on quality of life in a variety of settings, including academic achievement, work performance, and interpersonal relationships. When conducting a comprehensive mental health evaluation and treatment plan for these survivors, providers must carefully consider the potential physical and emotional impact of their childhood cancer experience. The editors have divided the volume into 22 chapters that provide an in-depth overview of late effects by organ system. They also address legal concerns, methodological problems in the study of childhood cancer survivors, and special issues related to the transition from adolescence to adulthood. Throughout the text, readers will find a highly organized chapter format, clinically useful tables, and impressive figures. Although the majority of this text focuses on medical late effects, the chapters relevant to psychiatry are well constructed. In Chapter 4, BCentral Nervous System Effects[, Nina Kadan-Lottick and Joseph Neglia address a wide range of central nervous system late effects, including paralysis, neuropathies, blindness, seizures, behavioral disturbances, diminished intellectual function, learning difficulties, school failure, and limited employability. This chapter carefully reviews the neurotoxic effects of radiation and chemotherapy, as well as the unique risks associated with central nervous system tumors. The authors discuss the variable impact of toxic andmetabolic insults depending on an individual_s stage of brain development. There is also emphasis on neural plasticity and capacity for recovery following brain insult. One of the most useful aspects of this section is a table addressing the domains of neurobehavioral function and screening questions to detect potential abnormalities. In Chapter 19, BPsychological Aspects of Long-term Survivorship[, Mary Rourke and Anne Kazak are careful to note that most survivors of childhood and adolescent cancer do not develop traditional psychological issues later in life. They also stress that many individuals will express the positive outcomes of the childhood cancer experience (e.g., stronger family relationships, greater sense of hope). The authors broadly define Bpsychological late effects[ as Bthe influence of cancer, treatment, and survivorship on survivors_ and their family members_ feelings, thoughts, behaviors and relationships[ (p. 295). The authors effectively present the research involving posttraumatic stress symptoms in survivors and their family members. This section is especially rich, and highlights the various developmental differences in survivors. For example, the child and adolescent survivors tend to experience traumatic reactions related to concrete events such as painful procedures, whereas young adult survivors may experience additional distress such as worry over late effects or infertility concerns. The emphasis on the family is also one of the strong points of the chapter. The authors note that Bnearly all families (99%) have at least one member who struggles with reexperiencing symptoms[ (p. 297). Here we are reminded that in treating this population it is important to also address the psychological needs of family members. In conclusion, this text is clear, concise, and full of useful information to better understand the unique needs of child and adolescent cancer survivors. Perhaps a child and adolescent psychiatrist who wishes to become more versed in this B O O K R E V I E W S Assistant Editor: Andres Martin, M.D., M.P.H.

Neurocognitive and family functioning and quality of life among young adult survivors of childhood brain tumors.

Many childhood brain tumor survivors experience significant neurocognitive late effects across multiple domains that negatively affect quality of life. A theoretical model of survivorship suggests that family functioning and survivor neurocognitive functioning interact to affect survivor and family outcomes. This paper reviews the types of neurocognitive late effects experienced by survivors of pediatric brain tumors. Quantitative and qualitative data from three case reports of young adult survivors and their mothers are analyzed according to the theoretical model and presented in this paper to illustrate the importance of key factors presented in the model. The influence of age at brain tumor diagnosis, family functioning, and family adaptation to illness on survivor quality of life and family outcomes is highlighted. Future directions for research and clinical care for this vulnerable group of survivors are discussed.

Engagement and experience with cancer-related follow-up care among young adult survivors of childhood cancer after transfer to adult care

PurposeYoung adult survivors (YAS) of childhood cancer require annual adult-focused, cancer-related follow-up given their risk for late effects of treatment. This study describes perception of and engagement with adult-focused, cancer-related follow-up care and general health care among YAS formally transferred to adult care from pediatric survivorship care.MethodsYAS transferred from pediatric survivorship care in the prior 1–5xa0years completed measures indicating engagement with cancer-related follow-up care, other health care utilization, content of communication by providers, quality of cancer-related care, and satisfaction with health care in the prior year.ResultsEighty YAS (M ageu2009=u200927.7xa0years, M time since diagnosisu2009=u200910.4xa0years) participated. Just over half of YAS surveyed (nu2009=u200944, 55xa0%) endorsed continuing cancer-related follow-up care since transfer. Those with cancer-related follow-up endorsed seeing subspecialty survivorship providers (nu2009=u200916, 44xa0%) and primary care providers (nu2009=u200922, 50xa0%) or utilizing a shared care model (nu2009=u20096, 14xa0%). About a third of YAS endorsed seeing subspecialists (nu2009=u200929, 36xa0%) or using other support services (nu2009=u200922, 27xa0%). YAS-perceived content of communication varied significantly depending on care model with less cancer-related content being discussed by primary care providers, though perceived quality of cancer-related care and satisfaction with health care was generally favorable.ConclusionsYAS report less than optimal engagement in cancer-related follow-up care and communication in their health care encounters.Implications for Cancer SurvivorsYoung adult survivors should receive anticipatory guidance about expectations for delivery and content of adult-focused cancer-related follow-up care.

Relationship between sleep problems and psychological outcomes in adolescent and young adult cancer survivors and controls

PurposeHow cancer history and distress relate to sleep outcomes of adolescents and young adults (AYAs) is unclear. The current study compares AYA cancer survivors to controls on indicators of sleep and fatigue; examines the concurrent association between psychological status, sleep, and fatigue; and investigates the lagged relationship between sleep and fatigue problems with psychological functioning.MethodsAYA cancer survivors (nu2009=u2009167) and controls (nu2009=u2009170), ages 16 to 30, completed measures at a survivorship clinic/primary care visit (time 1) and 2xa0months later (time 2). Participants completed questions about sleep quality, quantity, sleep medication use, self-reports of sleep problems, and fatigue in addition to measures of depression, anxiety, and posttraumatic stress symptoms (PTSS).ResultsThere were no differences in sleep quantity or quality between survivors and controls, but survivors reported significantly more fatigue. Within groups, AYAs with self-reported sleep and fatigue problems reported significantly higher depression, anxiety, and PTS symptoms. Controlling for baseline depression, sleep, and fatigue problems at time 1 significantly predicted depression at time 2 in survivors but not in controls.ConclusionThis study offers important insight into the psychological functioning of childhood cancer survivors and prospectively describes sleep and fatigue as risk factors for poor psychological functioning in survivors. These findings support screening for sleep problems in AYA survivors as these difficulties are closely related to mental health functioning.

Childhood Cancer Survivors Exposed to Total Body Irradiation Are At Significant Risk For Slipped Capital Femoral Epiphysis During Recombinant Growth Hormone Therapy

Childhood cancer survivors treated with cranial or total body irradiation (TBI) are at risk for growth hormone deficiency (GHD). Recombinant growth hormone (rhGH) therapy is associated with slipped capital femoral epiphysis (SCFE). We compared the incidence of SCFE after TBI versus cranial irradiation (CI) in childhood cancer survivors treated with rhGH.