Table 3. Central Nervous System Late Effects continued...
The CCSS has shown that adolescents who are long-term survivors of childhood cancer demonstrate significantly higher rates of inattention, social withdrawal, emotional problems, and externalizing problems than their siblings. Social withdrawal was associated with adult obesity and physical inactivity. As a result, these psychological problems may increase future risk for chronic health conditions and subsequent neoplasms and support the need to routinely screen and treat psychological problems after cancer therapy. In a study of 101 adult cancer survivors of childhood cancer, psychological screening was performed during a routine annual evaluation at the survivorship clinic at the Dana Farber Cancer Institute. On the Symptom Checklist 90 Revised, 32 subjects had a positive screen (indicating psychological distress), and 14 subjects reported at least one suicidal symptom. Risk factors for psychological distress included subjects' dissatisfaction with physical appearance, poor physical health, and treatment with cranial radiation. In this study, the instrument was shown to be feasible in the setting of a clinic visit because the psychological screening was completed in less than 30 minutes. In addition, completion of the instrument itself did not appear to result in distress on the part on the survivors in 80% of cases. These data support the feasibility and importance of consistent assessment of psychosocial distress in a medical clinic setting. However, further study is needed to evaluate the true prevalence of suicidality among a representative cohort of long-term childhood cancer survivors. (Refer to the PDQ summary on Adjustment to Cancer: Anxiety and Distress for more information about psychological distress and cancer patients.)
Post-traumatic stress after childhood cancer
Despite the many stresses associated with the diagnosis of cancer and its treatment, studies have generally shown low levels of post-traumatic stress symptoms and post-traumatic stress disorder (PTSD) in children with cancer, typically no higher than healthy comparison children. Patient and parent adaptive style are significant determinants of PTSD in the pediatric oncology setting.[65,66]
The incidence of PTSD and post-traumatic stress symptoms has been reported in 15% to 20% of young adult survivors of childhood cancer, with prevalence varying based on criteria used to define these conditions. Survivors with PTSD reported more psychological problems and negative beliefs about their illness and health status than those without PTSD.[68,69] A subset of adult survivors (9%) from the CCSS reported functional impairment and/or clinical distress in addition to the set of symptoms consistent with a full diagnosis of PTSD significantly more frequently than sibling control subjects. In this study, PTSD was significantly associated with being unmarried, having an annual income of less than $20,000, being unemployed, having a high school education or less, and being older than 30 years. Survivors who underwent cranial radiation therapy at younger than 4 years were at particularly high risk for PTSD. Intensive treatment was also associated with increased risk of full PTSD.