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Tailored interventions needed to increase screening adherence of survivors of childhood cancers
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Multiple factors influence the adherence to screening recommendations among adult survivors of childhood cancers. Recent data from the Childhood Cancer Survivor Study suggest that it is particularly important for primary care physicians to discuss cancer, osteoporosis and heart disease with any patients they treat who are cancer survivors.
The analysis included participants from the study who were diagnosed and treated for pediatric cancer between 1970 and 1986. Participants were mainly women, white, unmarried college graduates who had an annual salary of $19,999 to $39,999 and despite having health insurance, had not visited an oncology clinic within the past two years.
Questionnaires were completed at baseline and throughout the study period. Participants were divided into two subsample groups on the basis of treatment exposure: a cardiac risk group (n=316) and a bone density risk group (n=324).
Results indicated that the participants in the cardiac risk group were more likely to follow the recommended echocardiogram schedule if they had more cancer-related visits (P=.01), discussed heart disease with a physician (P≤.001), had a sedentary lifestyle (P=.05) and had less health fears (P=.05).
Women included in the osteoporosis risk group who were more likely to adhere to the recommended bone density screening guidelines if they reported more cancer visits (P=.05), had a follow-up visit at an oncology clinic (P=.01), discussed osteoporosis with a physician (P≤.001) and had lower BMI (P=.05).
Only 4% of study participants reported going to a cancer center for follow-up and 7% reported visiting a cancer specialist for follow-up.
“Because most survivors are not followed-up in specialty clinics, this finding is particularly relevant for primary care physicians, who often lack knowledge about the unique health risks inherent in the treatment of childhood cancer,” the researchers wrote. – by Jennifer Southall
Cox CL. Arch Int Med.2009; 169:454-462.
What I found particularly interesting about this study was the conceptualization of the various factors that were displayed in the results section. These figures, adaptations of the Interaction Model of Client Health Behavior, allow the reader to see how cancer survivor characteristics (such as lifestyle, cancer-related side effects and motivation or 'locus of control') might interact with interventions, such as clinic visits, physician discussions or external educational efforts, to lead to a desired outcome. Somewhat analogous to graphics depicting biological pathways in cancer pathogenesis, the figures in this paper can help us to visualize targets in these behavioral pathways that we might address to positively influence the care of cancer survivors. The arrows in this study's diagrams that denote the directions of the pathways are descriptive of the patient behaviors in this study. However, we might imagine that creative interventions could influence the organization of these factors and the directions of the pathways between them in future studies.
I believe that these targets, particularly those that are patient-focused, will prove important because this study demonstrated that only 7% of the sample was followed up by a cancer specialist and only 4% followed up at a cancer center. Though one might try to increase the follow-up of survivors at cancer centers, the reality is that many of these patients will be seen mostly by primary care physicians who may lack knowledge about health risks from childhood cancer. We are left then with options that include a campaign to educate primary care physicians about cancer late effects (a worthwhile but massive undertaking) or efforts to educate and motivate survivors through provision of treatment summaries, guides, interventions or other means outside of office visits. At the same time, the authors point out that intrinsically motivated survivors in this study seemed less likely to adhere to guidelines, which might suggest that efforts to motivate and educate need to go hand in hand.
HemOnc Today Editorial Board member
Fellow, University of North Carolina, Chapel Hill, N.C.