Behavioral and Social Adjustment in Adolescent Survivors of Childhood Cancer

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Behavioral and Social Adjustment in Adolescent
Survivors of Childhood Cancer

• A Report From the Childhood Cancer Survivor Study
• KAP Schultz, KK Ness, J Whitton, C Recklitis,
• B Zebrack, LL Robison, L Zeltzer, AC Mertens

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Background

• Adolescence is a time of transitions
• Cancer and related treatments pose unique
  challenges
• Issues may be different from those of young
  children and adults
• Adjustment issues may impact
• Identity formation
• School and/or career choice
• Relationships

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Background

• Few studies in adolescents
• Potential indicators of adult adjustment may have
  less applicability in adolescence
• Marital, career, insurance status
• Higher treatment intensity may be linked with
  diminished social adjustment
• Intrathecal methotrexate and cranial radiation
  may be risk factors

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Objectives

• To determine prevalence of behavioral and social
  adjustment difficulties in teenage survivors of
  childhood cancer
• To assess the impact of treatment factors and
  medical late effects on social skills

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Childhood Cancer Survivor Study

• Retrospective cohort study
• gt14,000 childhood cancer survivors
• 26 institutions in the U.S. and Canada
• Hypotheses related to sequelae of cancer
  treatment

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Study Overview

• Eligibility criteria
• Diagnosis 1970-1986
• Less than 21 yrs of age at diagnosis
• Leukemia, Lymphoma, CNS, Bone tumor, Wilms, NBL,
  Soft-tissue sarcoma
• 5 year survival

20,696 Eligible Lost
(n3058) Refused (n3204)
14,370 Participants 2,979 Ages 12-17
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Study Population
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Study Population by Diagnosis
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CNS Treatment
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CCSS Questionnaire

• Includes section on social behaviors
• 28 items modified from Child Behavior Checklist
  (CBCL/4-18)
• Completed by proxy

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Behavioral Adjustment Domains

• Depression/Anxiety
• Unhappy, worries too much
• Aggression
• Bullies, mean to others
• Inattention
• Difficulty concentrating
• Opposition/Defiance
• Cheats, tells lies

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Social Adjustment Domains

• Interpersonal Problems
• Has trouble getting along with other children
• Social Competence
• Presence of close friends

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Scoring

• Completed using 1 to 3 scale
• Scores determined by summing and dichotomizing
  the outcome
• Impairment defined as score more than 1.3 SD
  above the sibling mean

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Adjusted for current age, sex and race/ethnicity
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Adjusted for current age, sex and race/ethnicity
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Adjusted for current age, sex and race/ethnicity
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CNS Treatment
Adjusted for sex, current age, age at diagnosis,
and race/ethnicity
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CNS Treatment
Adjusted for sex, current age, age at diagnosis,
and race/ethnicity
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CNS Treatment
Adjusted for sex, current age, age at diagnosis,
and race/ethnicity
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Conclusions

• Most survivors function well
• Survivors of childhood cancer had more frequent
  difficulty with
• Depression/anxiety
• Inattention
• Interpersonal problems and social competence
• Few difficulties with aggression or
  opposition/defiance found

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Conclusions

• Specific risk factors include a history of
• Leukemia
• CNS tumors
• Neuroblastoma
• CNS-directed therapy/radiation

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Future Considerations

• Provide anticipatory guidance to families
  following treatment
• Utilize screening opportunities
• Assess impact of current therapies and
  anticipatory techniques on social outcomes

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CCSS Collaborating Institutions
University of Minnesota Denver Childrens
Hospital Childrens Hospital of
Pittsburgh Stanford University Dana-Farber Cancer
Institute Childrens National Medical Center M.D.
Anderson Cancer Center Memorial Sloan-Kettering
Cancer Center Texas Childrens Hospital University
of California, San Francisco Seattle Childrens
Hospital Toronto Hospital for Sick Children St.
Jude Childrens Research Hospital Childrens
Hospital of Columbus
Roswell Park Cancer Center Mayo Clinic Childrens
Health Care Minneapolis Childrens Hospital of
Philadelphia St. Louis Childrens
Hospital Childrens Hospital of Los Angeles UCLA
Medical Center Miller Childrens Hospital Long
Beach Childrens Hospital of Orange County Riley
Hospital for Children Indiana
Univ. UAB/Childrens Hospital of
Alabama University of Michigan Mott Childrens
Hosp. Childrens Medical Center of Dallas Fred
Hutchinson Cancer Research Center
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Acknowledgements

• Ann Mertens
• Kiri Ness
• John Whitton
• Christopher Recklitis
• Brad Zebrack
• Les Robison
• Lonnie Zeltzer
• Joe Neglia

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A Resource for Research

• The Childhood Cancer Survivor Study is an
  NCI-funded resource (U24 CA55727) to promote and
  facilitate research of long-term survivors of
  cancer diagnosed during childhood and
  adolescence.
• Investigators interested in potential uses of
  this resource are encouraged to visit
• www.cancer.umn.edu/ccss