Some adolescent cancer survivors may require more comprehensive mental health screening

Most adolescent survivors of childhood cancer have no reported psychological symptoms, but an analysis led by St. Jude Children’s Research Hospital found that those who do often have multiple symptoms and distinct symptom profiles. The findings, which appear today in the Journal of Clinical Oncology, highlight strategies to improve mental health screening and interventions.

“Historically, mental health symptoms in childhood cancer patients were studied in isolation,” said first and corresponding author Tara Brinkman, Ph.D., an assistant member of the St. Jude Department of Epidemiology and Cancer Control. “This research shows that psychological symptoms typically occur together in adolescent cancer survivors rather than in isolation. That raises hope that with more robust screening efforts and identification of appropriate treatments we can help to prevent behavioral, emotional and social symptoms in adolescence from becoming chronic problems that persist into adulthood.”

The study included 3,893 adolescent survivors of childhood cancer who were enrolled in the federally funded Childhood Cancer Survivor Study (CCSS) and were treated between 1970 and 1999 at one of 31 medical centers. All had survived at least five years and were 12 to 17 years old when their parents or guardians completed the questionnaires used in this analysis. The study focused on behavioral, emotional and social symptoms. The CCSS is headquartered at St. Jude.

Researchers found that like adolescents in the general population, most adolescent survivors of childhood cancer were well adjusted with no significant reported psychological symptoms. “One of the primary take-home points is that most survivors had no significant psychological symptoms,” Brinkman said.

However, such symptoms, when they were reported, occurred together, never in isolation. Researchers also found survivors had distinct symptom profiles that often corresponded with their cancer treatments or the late effects of treatment.

For example, 31 percent of survivors treated with brain irradiation had reported symptoms of depression, anxiety, social withdrawal, peer conflict and attention problems compared to 9 percent of survivors who received other treatments. In contrast, headstrong behavior and attention problems were reported in 16 percent of survivors treated without brain irradiation but that combination of symptoms was not reported in survivors who received brain irradiation. A small percentage of survivors from both treatment groups had more global symptoms that combined headstrong behavior and inattention with anxiety, depression and social withdrawal.

The findings underscore the need for more robust screening. “Screening survivors for attention problems alone might miss symptoms of anxiety, depression or headstrong behavior, which means missed treatment opportunities,” Brinkman said.

She noted that adolescents with untreated attention problems and headstrong behavior are at risk for substance abuse as adults, and survivors with those symptoms may benefit from substance abuse prevention efforts during adolescence. In addition, while stimulant medication is recommended for adolescents with attention problems, survivors who also have anxiety may benefit from alternative therapies.

Certain late effects of cancer treatment, including obesity, cancer-related pain and scarring, were associated with a significantly increased risk for reported psychological symptoms regardless of whether survivors had received brain irradiation. For example, survivors with hearing loss or other sensory impairments were up to 2.5 times more likely than survivors without the impairment to have reported symptoms of anxiety, depression, inattention, social withdrawal and peer conflict or to have global symptoms that also included headstrong behavior.

“This study highlights an opportunity to improve the quality of life for the growing population of childhood cancer survivors and underscores the need for robust screening that includes survivor- and parent-reported symptoms,” Brinkman said. “These symptoms tend to persist into adulthood if they are not successfully treated in adolescence.”

The senior author is Kevin Krull, Ph.D., a member of the St. Jude Epidemiology and Cancer Control department. The other authors are Chenghong Li, Cara Kimberg, Stefanie Vuotto, Deokumar Srivastava, Leslie Robison and Gregory Armstrong, all of St. Jude; Kathryn Vannatta, Nationwide Children’s Hospital, Columbus, Ohio; Jordan Marchak, Emory University School of Medicine, Atlanta; Jin-Shei Lai, Northwestern University, Evanston, Ill.; Pinki Prasad, Louisiana State University, Baton Rouge; and Chongzhi Di, Fred Hutchinson Cancer Research Center, Seattle.

The study was supported in part by grants (CA55727, CA21765) from the National Cancer Institute, part of the National Institutes of Health; and ALSAC.