This article is more than 5 years old. Information may no longer be current.
Interventions crucial to offset negative impact of psychological symptoms on childhood cancer survivors
Click Here to Manage Email Alerts
Interventions are needed to address the interrupted psychosocial and psychological developments associated with cancer treatment and late effects among survivors of childhood cancer, according to a research paper published in the Journal of Clinical Oncology.
“As survival rates for childhood cancer continue to improve, efforts are being made to reduce treatment-related toxicities, which may yield positive effects for mental health outcomes,” Tara M. Brinkman, PhD, assistant member of faculty in the department of epidemiology and cancer control at St. Jude Children’s Research Hospital, told HemOnc Today. “There are a number of resources available to help survivors better understand the long-term health challenges they may face because of their disease and treatment, but it’s important to continue to educate survivors about these potential late effects and disseminate information about resources and sources of support.”
There are approximately 420,000 survivors of childhood cancer living in the United States. Although a majority of survivors are deemed psychologically healthy, multiple factors can affect quality of life and can increase risk for difficulties.
P sychological outcomes
Studies have found that survivors of childhood cancer are likely to develop mental health symptoms including anxiety, depression and suicidal thoughts. Several factors, including low income, lower education and unmarried status, could also contribute to poor physical and mental health.
“These adverse outcomes are more prevalent among survivors who had disease or treatment involving the central nervous system,” Brinkman said. “This includes brain tumor survivors and survivors who received intrathecal or high-dose IV chemotherapies, such as methotrexate.”
Late effects have been found to be associated with psychological adjustment. Survivors of CNS tumors are at high risk for poor adjustment related to CNS-directed therapy. In addition, survivors of bone tumors are at risk for psychosocial problems linked to physical immobility and pain on adjustment.
“If not appropriately treated, psychological symptoms in childhood and adolescence can place survivors at risk for continued or worsened mental health symptoms and engagement in risky health behaviors later in life,” Brinkman said.
Research for targeting psychological symptoms among survivors is limited due to small sample size, lack of comparison groups and heterogenous samples.
“However, results seem to suggest that tailored cognitive behavioral therapy can improve posttraumatic stress symptoms and anxiety as well as behavior problems in survivor of CNS tumors,” Brinkman and colleagues wrote in the report.
Impact on social outcomes
Survivors commonly experience difficulties in social interactions. Although it is important for survivors to develop relationships and independence from caregivers, late effects of treatment may hinder such relationships.
“In childhood, survivors are at risk for social difficulties through poor peer acceptance, isolation, and diminished leadership roles,” Brinkman said.
Further, large cohort studies have suggested that as these survivors age they have lower rates of marriage or cohabitation than other adults, according to Brinkman.
Psychosexual milestones also may be impacted.
Female survivors are likely to experience lower sexual function, interest, arousal and desire for sexual activity compared with their female siblings. Male survivors are also likely to experience less sexual activity compared with siblings, as well as experience a 2.6-fold higher relative risk for erectile dysfunction.
“Importantly, some data indicate no differences in risky sexual behaviors between adolescent survivors and siblings, suggesting more pronounced psychosexual difficulties may not emerge until young adulthood when the development of intimate relationships is a more salient social goal,” Brinkman and colleagues wrote.
Survivors also may seek to live independently; however, they are twice as likely to live dependent on someone else compared with their siblings. Risk factors associated with nonindependent living include CNS tumor diagnosis, poor physical functioning and cognitive problems.
Most intervention research has focused on social skills training among child and adolescent survivors of CNS tumors, but data have been limited due to discrepancies in outcomes and small sample size.
“Future work is needed to understand the long-term impact of these interventions as well as to promote social integration and independence among adults survivors of childhood cancer,” Brinkman and colleagues wrote.
Socioeconomic acquisition
Retaining an education and employment are important yet oftentimes missed opportunities for patients with cancer due to treatment and illness.
Neurocognitive deficits contribute to educational difficulties. Survivors of non-Hodgkin lymphoma, neuroblastoma and CNS tumors are at greatest risk for low educational achievement and not graduating high school.
“Enhancing educational opportunities and outcomes is critical for survivors of childhood cancer because success in the academic arena sets the stage for later vocational opportunities,” Brinkman and colleagues wrote.
Unemployment is 50% higher among survivors of cancer compared with the general population. Risk factors for unemployment include CNS tumor diagnosis, younger age at diagnosis and cancer-related late effects.
Unemployment can lead to lower household income and absence of health insurance for proper care.
Survivors with lower education and household income are at increased risk for not receiving recommended long-term follow-up care. In addition, survivors with financial burdens are more likely to defer care for a medical issue.
Other studies have indicated restrictive access to health insurance to also be assocaited with lower use of survivorship care and general preventative care.
“Despite risk of reduced vocational outcomes and associated financial and health consequences, we are unaware of interventions that have been developed/evaluated among survivors,” Brinkman and colleagues wrote.
Increased risky behavior
Both psychological symptoms and poor socioeconomic outcomes have been known to increase a survivor’s likelihood to engage in risky health behaviors including use of tobacco, illicit drugs and alcohol.
Smoking and other unhealthy habits have been linked to neoplasia, cardiac complications and pulmonary-related health problems.
Survivors who reported psychological distress or heavy alcohol consumption also are more likely to smoke compared with survivors with higher education and income.
Older age, depression and higher socioeconomic status has been linked to illicit drug use.
A study by the Swiss Childhood Cancer Survivor Study showed that survivors consumed more alcohol than the general population (22% vs. 12%). Predictors of risky alcohol consumption include psychological stress, limitations on activity and perceptions of poor health.
Diet and nutrition also can play a role in late effects of cancer survivors.
Further, many survivors of childhood cancer do not meet recommended dietary guidelines. Approximately 54% of survivors exceed daily caloric consumption requirements. Only 4% of survivors meet guidelines for vitamin D intake, 19% for sodium, 24% for calcium and 29% for saturated fat.
“Although empirical support for diet, nutritional and physical interventions among survivors remains in its nascency, preliminary evidence suggests that psychoeducational and physical activity interventions have the potential to improve these behaviors,” Brinkman and colleagues wrote.
Need for more research
Research is actively ongoing to determine which interventions can be most helpful to survivors of childhood cancer.
“For psychological disorders such as anxiety and depression, standard of care often includes psychotherapy, such as cognitive behavioral therapy with a licensed professional, and/or medication management under the supervision of a physician,” Brinkman said. “Some studies suggest short-term benefits of group social skills training for survivors of pediatric brain tumors. Educational interventions have been used to inform and increase survivors’ awareness of the risk of certain health behaviors such as drinking, smoking and excessive sun exposure.”
However, a number of factors have limited implementation and research for interventions.
“As these survivors age, they often move away from their primary treatment centers, making participation in research studies challenging,” Brinkman said. “We are trying to overcome some of these challenges by studying electronic and mobile health platforms for interventions.” – by Melinda Stevens
For more information:
Tara M. Brinkman, PhD, can be reached at Epidemiology and Cancer Control MS 735, Room S6047, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-3678; email: tara.brinkman@stjude.org.
Disclosures: Brinkman reports no relevant financial disclosures. One author reports research funding from Merck.
Click Here to Manage Email Alerts