Quality of life, self-esteem and worries in young adult survivors of childhood cancer.

This study assessed quality of life, self-esteem and worries in young adult survivors of childhood cancer compared to a group of young adults with no history of cancer. The impact of demographic, medical and treatment factors and self-esteem on survivors' quality of life and worries was studied. Participants were 400 long-term survivors (LTS) of childhood cancer (age range 16-49 years, 45% female) who had completed treatment an average of 16 years previously and 560 persons (age range 16-53 years, 55% female) with no history of cancer. All participants completed the MOS-24 (Medical Outcome Study Scale), a Worry questionnaire consisting of three scales (cancer-specific concerns, general health concerns, present and future concerns), and the Rosenberg Self-Esteem Scale. Small to moderate differences were found in mean MOS-24 scores between the LTS group and controls (range effect sizes -0.36-0.22). No significant difference was found in the mean self-esteem scores between LTS and controls. Female LTS had more cancer-specific concerns than male LTS. In several related areas of general health, self-image and dying, the LTS group reported less worries than controls, but LTS worried significantly more about their fertility, getting/changing a job and obtaining insurance's. Multiple linear regression analysis revealed that female gender, unemployment, severe late effects/health problems and a low self-esteem were predictors of worse quality of life in survivors. In addition, age at follow-up, unemployment, years since completion of therapy and a low self-esteem were associated with a higher degree of survivors' worries. Quality of life and the level of self-esteem in LTS of childhood cancer is not different from their peers. Although many LTS worried not more or even less about health issues than their peers, they often are concerned about some present and future concerns. The investigated factors could explain poor quality of life and worries only to a limited extent. Further research exploring determinants and indices of quality of life and worries in LTS is warranted.

Long-term cause-specific mortality among five-year survivors of childhood cancer.

BACKGROUND: The purpose of our study was to assess long-term cause-specific mortality of 5-year childhood cancer survivors. PROCEDURE: The study population consisted of 1,378 patients who had been treated for childhood cancer in The Netherlands between 1966 and 1996 and survived at least 5 years; follow-up was complete for 99% of survivors. Cause-specific mortality was compared with general population rates to assess relative and absolute excess risks of death (standardized mortality ratio (SMR) and AER). RESULTS: After a median follow-up of 16.1 years, 120 patients had died. The overall SMR was 17-fold (95% CI: 14.3-20.6) increased compared to the general population. Our cohort experienced an excess of 7 deaths per 1,000 person-years. Patients who received combined modality treatment and were treated for at least one recurrence experienced the highest risk of death (SMR = 92.3; AER = 37.0 per 1,000 person-years). The SMR appeared to stabilize at an about 4 to 5-fold increased risk of death after 20 years of follow-up. Only after more than 20 years of follow-up excess mortality due to other causes than the primary cancer exceeded mortality from the primary childhood cancer (2.3 vs. 0.3/1,000 patients/year). The SMR for all causes other than primary cancer was 5.4 in 25-year survivors. The overall risks of death strongly decreased with increasing attained age, with an SMR of 1.6 (n.s.) and an AER of 0.3 per 1,000 person-years for survivors of 30 years or older. CONCLUSIONS: The first primary cancer contributes most to the absolute excess risk of death in 5-year survivors of childhood cancer, but after 25 years childhood cancer mortality is negligible. Relative risk of death due to other causes is still significantly increased after 25 years of follow-up.

Posttraumatic stress symptoms in adult survivors of childhood cancer.

BACKGROUND: Previous research suggests that posttraumatic stress disorder (PTSD) is present in survivors of childhood cancer. The aim of the current study was to explore posttraumatic stress symptoms in a sample of young adult survivors of childhood cancer. In addition, the impact of demographic, medical and treatment factors on survivors' posttraumatic stress symptoms was studied. PROCEDURE: Participants were 500 long-term survivors of childhood cancer. The median age at follow-up was 24 years (age range, 16- 49 years, 47% female). To assess symptoms of posttraumatic stress, all participants completed the Impact of Event Scale (IES), a self-report instrument consisting of two subscales, intrusion and avoidance. RESULTS: Twelve percent of this sample of adult survivors of childhood cancer had scores in the severe range, indicating they are unable to cope with the impact of their disease and need professional help. Twenty percent of the female survivors had scores in the severe range as compared with 6% of the male survivors. Linear regression models revealed that being female, unemployed, a lower educational level, type of diagnosis and severe late effects/health problems were associated with posttraumatic stress symptoms. CONCLUSIONS: The results indicate that, although the proportion of survivors reporting symptoms is well within the proportions found in the general population, a substantial subset of survivors report symptoms of posttraumatic stress. This finding supports the outcomes reported previously that diagnosis and treatment for childhood cancer may have significant long-term effects, which are manifested in symptoms of posttraumatic stress. The investigated factors could explain posttraumatic stress symptoms only to a limited extent. Further research exploring symptoms of posttraumatic stress in childhood cancer survivors in more detail is clearly warranted. From a clinical perspective, health care providers must pay attention to these symptoms during evaluations in the follow-up clinic. Early identification and treatment of PTSD symptoms can enhance the quality of life for survivors of childhood cancer.

Educational achievement, employment and living situation in long-term young adult survivors of childhood cancer in the Netherlands.

This paper investigated educational achievement, employment status, living situation, marital status and offspring in 500 Dutch long-term young adults survivors of childhood cancer (age range, 16-49 years, 47% female). The results were compared with a reference group of 1092 persons with no history of cancer (age range, 15-33 years, 55% female). The impact of demographic and medical characteristics on psychosocial adjustment was studied. All participants completed a self-report questionnaire. The results showed that, although many survivors are functioning well and leading normal lives, a subgroup of survivors were less likely to complete high-school, to attain an advanced graduate degree, to follow normal elementary or secondary school and had to be enrolled more often on learning disabled programs. The percentage of employed survivors was lower than the percentage of employed controls in the comparison group, but more survivors were student or homemaker. Survivors had lower rates of marriage and parenthood, and worried more about their fertility and the risk of their children having cancer. Survivors, especially males, lived more often with their parents. Cranial irradiation dose

No excess fatigue in young adult survivors of childhood cancer.

Clinical reports suggest that many survivors of childhood cancer experience fatigue as a long-term effect of their treatment. To investigate this issue further, we assessed the level of fatigue in young adult survivors of childhood cancer. We compared the results with a group of young adults with no history of cancer. The impact of demographic, medical and treatment factors and depressive symptoms on survivors' fatigue was studied. Participants were 416 long-term survivors of childhood cancer (age range 16-49 years, 48% of whom were female) who had completed treatment an average of 15 years previously and 1026 persons (age range 16-53 years, 55% female) with no history of cancer. All participants completed the Multidimensional Fatigue Inventory (MFI-20), a self-report instrument consisting of five scales (general fatigue, physical fatigue, mental fatigue, reduced activity, reduced motivation) and the Center for Epidemiologic Studies Depression Scale (CES-D). Small differences were found in the mean scores for the different dimensions of fatigue between the long-term survivors and controls (range effect sizes -0.34 to 0.34). Women experienced more fatigue than men. Logistic regression revealed that being female and unemployed were the only demographic characteristics explaining the various dimensions of fatigue. With regard to medical and treatment factors, diagnosis and severe late effects/health problems were associated with fatigue. Finally, depression was significantly associated with fatigue on all subscales. Our clinical practice suggests a difference in fatigue in young adult childhood cancer survivors and their peers. This could not be confirmed in this study using the MFI-20. The well known correlation between fatigue and depression was confirmed in our study. Further research is needed to clarify the undoubtedly complex somatic and psychological mechanisms responsible for the development, maintenance and treatment of fatigue in childhood cancer survivors.

Quality of life in young adult survivors of childhood cancer.

In recent years the necessity of measuring quality of life in childhood cancer survivors has been stressed. This paper gives an overview of the results of studies into the quality of life (QL) of young adult survivors of childhood cancer and suggest areas for future research. The review located 30 empirical studies published up to 2001. The results are described in terms of the following QL dimensions: physical functioning (QL, general health), psychological functioning (overall emotional functioning, depression and anxiety, self-esteem), social functioning (education, employment, insurance, living situation, marital status and family), and sexual functioning. Factors related to survivors' QL are reported: demographics and illness- and treatment related variables. Although the literature yields some inconsistent findings, a number of clear trends can be identified: (a) most survivors reported being in good health, with the exception of some bone tumour survivors; (b) most survivors function well psychologically; (c) survivors of CNS tumours and survivors of acute lymphoblastic leukaemia (ALL) are at risk for educational deficits; (d) job discrimination, difficulties in obtaining work and problems in obtaining health and life insurance were reported; (e) survivors have lower rates of marriage and parenthood; (f) survivors worry about their reproductive capacity and/or about future health problems their children might experience as a result of their cancer history. There is a need for methodological studies that measure QL among survivors of childhood cancer more precisely by taking into account the effects of the severity of the cancer and the long-term impact of different treatments. Additional data are needed to help us understand the needs of survivors and to identify those subgroups of survivors who are at greatest risk for the adverse sequelae of the disease and its treatment.

'I don't have any energy': The experience of fatigue in young adult survivors of childhood cancer.

Although it is speculated that fatigue occurs equally in adults, children and adolescents with cancer, little research exists to substantiate this view. Evidence that fatigue continues after treatment is limited in both the adult and paediatric oncology literature. Due to the current lack of knowledge, more information on the phenomenology of fatigue of childhood cancer survivors is desirable. Therefore a study was conducted to explore the concept of fatigue from a survivor's perspective. A semi-structured interview was conducted with a purposeful sample of 35 long-term survivors of childhood cancer who reported feeling extremely fatigued. The topics which were covered during the interview included the nature, onset and pattern of fatigue, sleep rest pattern, what helps with fatigue and what does not help, and the impact of fatigue on their daily life. Most survivors who were diagnosed with cancer in their adolescence identified fatigue as a significant side-effect of the treatment. The majority of survivors who were toddlers or preschooler at the time of cancer treatment mentioned that, as far as they could recall, they had suffered from fatigue their entire life. The course of fatigue during the day differed among the survivors, although the majority reported to be fatigued when waking up in the morning. None of the survivors reported sleep problems. Many survivors slept 9 hours or more. Fatigue was defined by all respondents as having a negative impact on their daily lives. Findings revealed that fatigue is a serious problem for some young adult survivors of childhood cancer and affects many aspects of quality of life.

[Late sequelae of oncologic treatment in children]. / Late gevolgen van oncologische behandeling bij kinderen.

The risk of late effects of cancer treatment in children is higher than that after treatment during adulthood. The late effects of chemotherapy are proportional to the dosage and those of irradiation to the size of the radiation field, fractionation and dose. Irradiation may lead to impaired growth of bone and soft tissues, cranial irradiation to pituitary deficiencies, alopecia and impaired cognitive function, irradiation of the neck to altered thyroid function, thoracic irradiation to diminished pulmonary function and cardiovascular morbidity, radiation therapy of the abdomen to infertility in females, impaired renal function and chronic enteritis. Chemotherapy-induced damage is more organ-specific. Well-known cardiotoxic agents are the anthracycline derivatives. Restricted pulmonary function is seen after treatment with bleomycin and nitrourea derivatives. Several antineoplastic agents are gonadotoxic in men. Nephrotoxic agents are cisplatin and ifosfamide. The cumulative relative risk of developing a second primary neoplasm is 3,8-6,9 after a follow-up period of 25 years. Alkylating agents and the topoisomerase inhibitors are known to increase the risk of haematologic malignancy, while radiation therapy is associated with bone, soft tissue, thyroid, breast, brain and gastrointestinal malignancies.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) ameliorates chemotherapy-induced neutropenia in children with solid tumors.

Neutropenia is one of the risk factors for severe therapy-related morbidity in childhood malignancies. We have studied the potential of GM-CSF to shorten the neutropenic period after normal-dose chemotherapy in children who were treated for solid tumors. Patients with osteosarcomas, with Ewing sarcomas, or with rhabdomyosarcomas received 10 daily subcutaneous doses GM-CSF (Leucomax, 5 micrograms/kg) after a course of normal-dose chemotherapy in an open-label study. Because these patients were treated with different combinations of chemotherapeutic agents, they were randomized before each pair of identical courses of chemotherapy to receive GM-CSF after the first or after the second course. Fourteen such combinations could be evaluated in eight patients. The results show that GM-CSF significantly reduced the mean duration of the chemotherapy-induced neutropenia (mean reduction +/- SEM in days: 2.2 +/- 0.6, P = .003). There was no significant difference between the mean number of days with fever in either group. GM-CSF was well tolerated by all patients. We conclude that GM-CSF reduced the mean neutropenic period in children with solid tumors who were treated with standard-dose chemotherapy.

Treatment of isolated testicular recurrence of acute lymphoblastic leukemia without radiotherapy. Report from the Dutch Late Effects Study Group.

BACKGROUND: The isolated recurrence of testicular leukemia in boys with acute lymphoblastic leukemia (ALL) is considered to be an ominous sign, heralding generalized recurrence. In general, treatment is comprised of systemic retreatment and local radiotherapy to one or both affected tests. METHODS: In this study, the authors report five boys with a late isolated testicular recurrence of ALL during sustained bone marrow remission, in whom radiotherapy had been omitted. High dose methotrexate was included in the treatment regimen. RESULTS: No further recurrences occurred after cessation of therapy. The follow-up period ranged from 1-15 years (median, 8 years). CONCLUSIONS: These cases show that there is a subpopulation of boys with recurrence of testicular leukemia who can be treated without radiotherapy. Therefore, the authors propose a treatment regimen for boys with late isolated recurrence of testicular leukemia in which conventional reinduction maintenance treatment is given in combination with high dose methotrexate. Radiotherapy should be withheld until subsequent testicular recurrence occurs.

An increased loading dose of ondansetron: a north european, double-blind randomised study in children, comparing 5 mg/m2 with 10 mg/m2.

A North European, randomised, double-blind study, comparing a loading-dose of ondansetron of 5 mg/m2 with 10 mg/m2, administered intravenously before highly emetogenic chemotherapy, was carried out in 187 chemotherapy-naïve children. In the first 24 h, both groups received further ondansetron intravenously at a dose of 5 mg/m2 8-hourly. Thereafter, ondansetron was given at an oral dose of 4 or 8 mg depending on the surface area of the child, three times a day and continued for at least 3 days after the last day of chemotherapy. There was no difference in the control of emesis between the two groups. Ondansetron provided good control of emesis and nausea on day 1 with 71-72% of patients experiencing two or fewer emetic episodes (complete or major responders) and 90-86% of patients reporting nausea as none or mild. There was also no difference in the efficacy of the treatment arms in the control of emesis and nausea on subsequent days of the study period. Both anti-emetic regimens were well-tolerated.

Electronic identification with injectable transponders in pig production: results of a field trail on commercial farms and slaughterhouses concerning injectability and retrievability.

A nationwide electronic system for the identification of all pigs is a means to achieve a tighter control of livestock and meat in the Netherlands. In order to examine the use of electronic identification transponders, two field trails were performed. Transponders supplied by three separate companies were tested on pigs on commercial farms. In phase 1, each device was examined on separate farms and in phase 2, the three devices were tested on each farm. A total of 3,436 and 5,947 transponders from the different suppliers were injected in the base of the ear at weaning in phase 1 and 2 on seven and five farms, respectively. The following aspects were examined: technical labour for injection and reading, readability of the transponders, impact on tissues at the injection site, and retrieval of the transponder after slaughter. After instruction the farmer was well able to inject a transponder in a restrained piglet. The results show that in phases 1 and 2 1.6% to 7.3% of the transponders were unreadable at retrieval in the slaughter line, which is significantly (p < 0.05) higher than the required maximum loss of 1%. The 1.6% failure rate in phase 1 involved transponders from a single supplier. Loss of identification was associated with rejection after injection, expulsion during inflammation and technical failure. Three weeks after injection on average 0.6% of the piglets had an observable inflammation and at the time of retrieval pus was found around, on average, 1.2% of the transponders. An average of between 37% and 88% of the transponders were retrieved in the slaughter line from the base of the ear in phases 1 and 2. The other transponders were retrieved medial or caudal to this position. This positional variation meant that it was not consistently possible to remove the transponder from the carcass within the required 4 second time period. It was concluded that the systems should be improved before recommending their introduction on a large scale, because the variation in readability and location is too high.

Effects of injecting electronic transponders into the auricle of pigs.

Electronic transponders (3 x 18 mm) were injected into the base of the auricle of 69 10-day-old pigs, 111 four-week-old pigs and 24 six-month-old pigs, to examine the procedure of injection in the auricle, the tissue reaction and the ease of removal from the carcase. The injection was difficult in the 10-day-old pigs, but was easier at four weeks. One of the 204 transponders were lost and five of them appeared to be broken. Only one gilt showed some exudate around the transponder. The transponders could easily be removed when the pigs were slaughtered by cutting off the ear. The position of the transponder was significantly (P < 0.05) more ventral in the animals injected at 10 days old than in those injected at four weeks. The mean thickness of the connective tissue capsule around the transponders increased at first (P < 0.1) and then decreased when they were injected into 10-day-old pigs but decreased (P < 0.1) from shortly after injection in the pigs injected at four weeks old. After five months, the capsule in the animals injected at 10 days old was on average significantly (P < 0.01) thinner than in those injected at four weeks.