Validation of a milk consumption stage of change algorithm among adolescent survivors of childhood cancer.

OBJECTIVE: To assess the construct validity of a milk consumption Stages of Change (SOC) algorithm among adolescent survivors of childhood cancer ages 11 to 21 years (n = 75). METHODS: Baseline data from a randomized controlled trial designed to evaluate a health behavior intervention were analyzed. Assessments included a milk consumption SOC algorithm and hypothesized theoretical and behavioral predictors of SOC. RESULTS: Compared with survivors who expressed no readiness to change, those expressing readiness to change behavior for both 2 and 4 daily servings of milk reported more frequent milk consumption (P < .001), greater dietary calcium intake (P = .006), and were more likely to meet age-specific recommendations for daily calcium intake (P = .01). CONCLUSIONS AND IMPLICATIONS: Results provide support for the construct validity of the milk consumption SOC algorithm relative to behavioral criteria. Research is needed to further examine algorithm validity with respect to theoretical predictors of SOC.

Improving short-term sun safety practices among adolescent survivors of childhood cancer: a randomized controlled efficacy trial.

INTRODUCTION: Skin cancer is one of the most common secondary neoplasms among childhood cancer survivors. However, little evidence exists for effective interventions to promote sun safety behaviors within this population. METHODS: This small-scale randomized controlled trial examined the efficacy of the Survivor Health and Resilience Education (SHARE) Program intervention, a multiple health behavior change intervention designed to increase sun safety practices among adolescent survivors of childhood cancer. Adolescent survivors of childhood cancer (11-21 years) were randomly allocated to a group-based behavioral intervention (n = 38) or wait-list control (n = 37). Self-reported sun safety behaviors were assessed using a valid, 8-item scale at baseline and 1-month post-intervention. RESULTS: Controlling for baseline sun safety, gender, and seasonal influences, intervention participants reported significantly more sun safety practices (e.g., using sunscreen, reapplying sunscreen regularly) at 1-month post-intervention than control participants (B = 2.64, 95% CI = 1.02, 4.27, p = 0.002). CONCLUSIONS: The results suggest that SHARE was efficacious in producing improvements in short-term self-reported sun safety practices among adolescent survivors of childhood cancer. Future research is needed to build upon this work by incorporating objective measures of sun safety behaviors and examining intervention durability. IMPLICATIONS FOR CANCER SURVIVORS: Behavioral interventions addressing lifestyle factors, including sun safety behaviors, among adolescent survivors of childhood cancer should be integrated into long-term care to reduce the risk for secondary malignancies and diseases.

Efficacy of the Survivor Health and Resilience Education (SHARE) program to improve bone health behaviors among adolescent survivors of childhood cancer.

PURPOSE: The purpose of this study is to test the efficacy of the Survivor Health and Resilience Education Program intervention--a manualized, behavioral intervention focusing on bone health behaviors among adolescent survivors of childhood cancer. METHODS: Participants were 75 teens aged 11-21 years, one or more years post-treatment, and currently cancer-free. Teens were randomized to a group-based intervention focusing on bone health or a wait-list control. Bone health behaviors were assessed at baseline and 1-month post-intervention. RESULTS: Controlling for baseline outcome measures and theoretical predictors, milk consumption frequency (p=0.03), past month calcium supplementation (p<0.001), days in the past month with calcium supplementation (p<0.001), and dietary calcium intake (p=0.04) were significantly greater at 1-month follow-up among intervention participants compared with control participants. CONCLUSIONS: The intervention had a significant short-term impact on self-reported bone health behaviors among adolescent survivors of childhood cancer. Research examining long-term intervention effectiveness is warranted.

Late effects in long-term survivors after treatment for childhood acute leukemia.

BACKGROUND: This is a report of late effects in childhood cancer survivors seen in the follow-up clinic of a single institution. MATERIALS AND METHODS: There were 324 acute leukemia survivors in the database of the Long Term Follow Up Clinic of Children's National Medical Center from January 1, 1997, through June 30, 2005. RESULTS: Of the 324 acute leukemia survivors, 228 were white, 48 black, 20 Hispanic, and 12 other. Their follow-up time was 0 to 25 years (mean 5.3 years). One or more adverse events occurred in 74.1% of the 324 survivors. Defective physical growth was most commonly reported, followed by disturbed neurocognitive function, emotional difficulties, cardiac abnormalities, hypertension, osteoporosis/osteopenia, fractures, and second neoplasms. More black and Hispanic children had acute myeloid leukemia, relapses, cardiac problems, and hypertension than white and other subjects. CONCLUSION: Childhood cancer survivors require lifelong monitoring, with prompt identification and treatment of adverse late effects.

Hypertension and prehypertension in long-term survivors of childhood and adolescent cancer.

BACKGROUND: Hypertension as a late effect following childhood and adolescent cancer has received little attention. Since obesity, a known risk factor for hypertension, is increased following some childhood cancers, it seems likely that significant numbers of survivors would have hypertension. PROCEDURES: The records of patients seen in the Long Term Follow Up Clinic of Children's National Medical Center were examined for a single institution, retrospective study of blood pressure in survivors of childhood and adolescent cancer. Of 103 consecutive survivors who attended the clinic from January 1 through June 30, 2004, 51 (49.5%) were female and 52 (50.5%) were male. Their mean age was 14.6 years. Systolic and diastolic blood pressures for children and adolescents under 18 years of age were evaluated for hypertension and prehypertensive according to standards for age, sex, and height. Blood pressures for adults 18 years of age and older were evaluated according to standard adult values. Children and adolescents were evaluated for obesity and overweight according to body mass index (BMI) standards for age and sex. Adults were evaluated according to standard adult values. RESULTS: Twenty-nine patients (28.2%) were hypertensive or prehypertensive, and 74 (71.8%) were normal. Thirty-eight patients (36.9%) were obese or overweight, and 65 (63.1%) were non-obese. Most Wilms tumor patients, 7 of 10 (70.0%), had hypertension or prehypertension, but only 4 of 10 (40.0%) were obese or overweight. CONCLUSION: Careful follow-up of their blood pressure status is warranted for long-term survivors of childhood and adolescent cancer, especially for those with an initial diagnosis of Wilms tumor.

Growth hormone deficiency after chemotherapy for acute lymphoblastic leukemia in children who have not received cranial radiation.

Chemotherapy-related growth failure is a significant problem in children with acute lymphoblastic leukemia (ALL) and other childhood cancers. Growth impairment after cranial radiation (CR) can result in diminished adult height, but growth failure following chemotherapy without CR is usually followed by catch-up growth and normal adult height.1 A retrospective review of 347 ALL survivors registered in our Long Term Follow Up (LTFU) Clinic, since 1997 revealed that 109 had received CR; 3, total body irradiation (TBI); and 235, neither CR nor TBI. For patients whose growth velocity slowed, growth hormone (GH) levels and pediatric endocrinology referrals were obtained. Among the 112 ALL survivors who had received some form of CR, 5 had significant growth failure with growth hormone deficiency (GHD). Among the 235 ALL survivors treated with chemotherapy without CR, 2 were diagnosed with growth failure and GHD. We report the two survivors of childhood ALL treated with chemotherapy without CR who required GH replacement due to absence of catch-up growth. A 15-year-old boy and a 12-year-old girl, off therapy for 9 and 6 years, respectively, were evaluated for decreased growth velocity and failure of catch-up growth. Peak GH responses to stimulation using arginine and clonidine were 3.4 and 3.0 ng/ml, respectively (normal >10 ng/ml). Other causes of growth failure were ruled out, and GH replacement therapy was instituted. Their chemotherapy had included methotrexate, 6 mercaptopurine, vincristine, adriamycin, cyclophosphamide, L-asparaginase, dexamethasone, cytarabine, 6 thioguanine, and intrathecal methotrexate. The growth of all children treated with intensive chemotherapy, regardless of whether CR was administered, should be closely monitored with measurement of standing height at 6 months intervals until growth is complete.

Multiple behavioral risk factors among adolescent survivors of childhood cancer in the Survivor Health and Resilience Education (SHARE) program.

BACKGROUND: Health-compromising behaviors among survivors of childhood cancer may increase their risks of cancer recurrence and the onset of chronic disease in adulthood. Regardless of whether such behaviors occur singly or in combination with one another, multiple behavioral risk factors must be identified and addressed early to promote better health outcomes within this special population. Adolescent survivors may be especially vulnerable, as reported rates of smoking and other risky behaviors are at or near levels of their healthy peers. The psychological literature suggests stress may play a role in risk behavior initiation and maintenance, including multiple behavioral risks, and that adolescent survivors are stress-prone. This report focuses on the prevalence and co-occurrence of three behavioral risk factors (cigarette use, insufficient physical activity, and non-adherence to sun protection recommendations) and describes stress-health behavior relationships in this special population. PROCEDURE: All patients in this study (n = 75) were adolescent survivors of childhood cancer and completed a baseline assessment of their health behaviors and stress as part of a randomized controlled trial of health promotion. RESULTS: Twenty-eight percent of the patients reported one of three risk factors, 12% reported two of three risk factors, and 7% reported all three risk factors. Non-adherence to sun protection was the single most common risk factor; physical inactivity and non-adherent sun protection were the most common co-occurring risk factors. Greater age and stress were significantly associated with the presence of more behavioral risk factors. CONCLUSIONS: The evidence suggests interventions to reduce multiple health-compromising behaviors in these patients are warranted, and that efforts to address these patients' personal and family stress levels are important as well.

Identifying, recruiting, and enrolling adolescent survivors of childhood cancer into a randomized controlled trial of health promotion: preliminary experiences in the Survivor Health and Resilience Education (SHARE) Program.

OBJECTIVE: To report on the identification, recruitment, and enrollment of adolescent survivors of childhood cancer into an ongoing randomized controlled trial (RCT) of health promotion. METHODS: A total of 244 adolescents were contacted by mail and telephone to assess their trial eligibility. Data were collected with respect to each adolescent's demographics and trial recruitment efforts (frequency and intensity of telephone call contact); exclusion and randomization status were tracked throughout. RESULTS: Thirty-one percent of adolescents were ultimately randomized in the trial and 69% were excluded from randomization (13% were ineligible, 33% refused to participate, 22% were unreachable or nonresponsive, that is, did not respond to trial mailings or telephone calls, and less than 1% were withdrawn prior to randomization). Among all eligible adolescents, the trial's consent rate was 49%. Adolescents excluded owing to refusal resided the farthest away from the intervention site and experienced the least amount of telephone call contact time. The primary reasons for trial refusal were lack of interest in health promotion (28%) and lack of time to participate (23%). CONCLUSIONS: Health promotion RCTs among adolescent survivors of childhood cancer may help prevent and control the onset and severity cancer-treatment-related late effects. However, trial success may be contingent upon tracing nonresponsive adolescents and reducing and eliminating barriers to participation.

Second neoplasms in survivors of childhood and adolescent cancer are often treatable.

PURPOSE: To estimate the incidence and types of second neoplasms in survivors of childhood and adolescent cancer, as well as the characteristics of those who developed second neoplasms. METHODS: Survivors who were under age 21 years at initial diagnosis, off therapy, and in remission for 2 years are referred to the Long Term Survivors' Clinic (LTSC) at Children's National Medical Center (CNMC). This review includes patients entered in the clinic database from January 1, 1997 to August 30, 2002. RESULTS: Twenty-three (2.3%) of 987 childhood cancer survivors followed in the LTSC had 26 (2.6%) second and third neoplasms. The mean age was 6.7 years at initial diagnosis, 20.3 years at diagnosis of the second neoplasm, and 20.5 years at diagnosis of the third neoplasm. Of 10 female and 13 male patients, 15 were white, six black, one Hispanic, and one Asian. All but two of the patients received radiation. Nineteen neoplasms, including seven thyroid carcinomas, six central nervous system tumors (three meningiomas), three basal cell carcinomas, two breast cancers, and one soft tissue sarcoma, occurred at sites within or contiguous to radiation sites. Five patients died, but the majority of neoplasms were treatable and most patients had good outcomes. CONCLUSION: Indefinite follow-up in a long-term survivors' clinic is indicated for adolescent and adult survivors of childhood cancer, with routine examination and screening for recurrence of the initial cancer as well as late effects, including second neoplasms.