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Prevalence and Predictors of Posttraumatic Stress Disorder in Adult Survivors of Childhood Cancer

Prevalence and Predictors of Posttraumatic Stress Disorder in Adult Survivors of Childhood Cancer A report from the Childhood Cancer Survivor Study. Margaret L. Stuber, M.D. Jonsson Cancer Center David Geffen School of Medicine University of California, Los Angeles. Co-Investigators.

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Prevalence and Predictors of Posttraumatic Stress Disorder in Adult Survivors of Childhood Cancer

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  1. Prevalence and Predictors of Posttraumatic Stress Disorder in Adult Survivors of Childhood Cancer A report from the Childhood Cancer Survivor Study Margaret L. Stuber, M.D. Jonsson Cancer Center David Geffen School of Medicine University of California, Los Angeles

  2. Co-Investigators • Kathleen Meeske, Children's Hospital, Los Angeles • Kevin Krull, St. Jude Children’s Research Hospital • Wendy Leisenring, Fred Hutchinson Cancer Research Center • Kayla Stratton, Fred Hutchinson Cancer Research Center • Anne E. Kazak, Children’s Hospital of Philadelphia • Marc Huber, SAS Consulting • Brad Zebrack, University of Michigan • Sebastian H. Uijtdehaage, UCLA • Ann C Mertens, Emory University • Leslie L. Robison, St. Jude Children’s Research Hospital • Lonnie K. Zeltzer, Jonsson Cancer Center, UCLA

  3. BackgroundThe childhood cancer survivor population • 5-year cancer survival in children across diagnostic groups is approximately 80% • Over 325,000 childhood cancer survivors now alive in United States, and growing • Functional and emotional outcomes of survivors as they enter adulthood a concern

  4. Some childhood cancer survivors report symptoms of Posttraumatic Stress Disorder (PTSD) many years after successful treatment PTSD symptoms are associated with functional impairment and emotional distress in young adult survivors of childhood cancer BackgroundPrevious studies of PTSD

  5. Study Aims • Compare the prevalence of PTSD in young adult childhood cancer survivors to a sibling control group • Examine the association of PTSD with demographic variables, including gender, ethnicity, level of education, employment, marital status, and income • Assess the association of PTSD with cancer-related variables

  6. Childhood Cancer Survivor Study • Retrospective cohort study • 26 centers: USA and Canada • Diagnosis 1970-1986 • < 21 years at diagnosis • Alive at 5 years • Selected cancer diagnoses

  7. Study Population Eligible n=20,691 Lost to Follow-up n=3,058 Contacted n=17,633 Declined or deceased n=3,276 Participants in Baseline Survey n=14,357 Participants in Follow-up 2003 n=11,576 Not invited to complete surveys of interest N=2,268 Completed surveys of interest n=9,308 Exclusions n=2,766 Currently under 18 Proxy reporter Eligible for Current Analysis n=6, 542

  8. Study Population *Statistically significant differences between groups at < 0.01

  9. Di Bone Soft-tissue 9% 9% CNS Neuroblastoma 11% 6% Wilms 10% Hodgkin 14% NHL Leukemia 8% 33% Study Population (n=6,542) Mean age at diagnosis = 8.2 years (range 0-20) Mean age at survey = 31.9 years (range 18-53)

  10. Composite dichotomous variable: PTSD • Self reported symptoms of PTSD using Foa PDS (reexperiencing, avoidance, hyper-arousal) • Self-report of emotional distress • (Brief Symptom Inventory) • Functional impairment (SF-36)

  11. Composite dichotomous variable: Intensity of treatment • Combined modality therapy • Radiation (TBI, cranial, mantle, pelvic, lung, abdomen) • Recurrence, transplant, high dose anthracycline or alkylating agent • Major surgery within two years of diagnosis (except nephrectomy)

  12. Prevalence of PTSD • N PTSD • Siblings 368 8 (2.2%) • Survivors 6542 589 (9.0%) • Odds ratio* = 4.36 • Odds ratio= 4.36 • 95% CI = 2.19-8.66 • P-value < 0.0001 • *(adjusted for age at interview, gender, within-family correlations)

  13. Prevalence of PTSD

  14. Results: Variables Statistically Significantly Associated with PTSD • Age at interview 30-39 yrs • Not employed • Education <high school • Personal Income <$20,000 • Single, never married • Intensive treatment 2.0 1.5 1.0 2.5 3.0 Odds Ratio (95% CI)

  15. Increased risk of PTSD by age at diagnosis by radiation exposure *Odds ratio were calculated using “No RT” as the reference

  16. Variables NOT associated with PTSD • Gender ( usually women report more symptoms) • Race/ethnicity • Year of diagnosis (not a “generational” effect) • Recurrence or second malignancy (except when combined into treatment intensity variable) • Age at diagnosis (except in interaction with CRT)

  17. Clinical Implications • Although most childhood cancer survivors are resilient, a subset meet full criteria for PTSD • Survivors are at significantly greater risk for PTSD than their siblings • Survivors with PTSD are generally not doing well with developmental tasks of young adults • More intense treatment increases risk of PTSD and functional difficulties

  18. Which came first, PTSD or poor function? • Because the diagnosis of PTSD included self-reported functional impairment and clinically significant distress, it is not surprising that these survivors were not doing well • Survivors were less likely to be married or employed and had lower income than siblings as a group, despite similar education • Perhaps marriage, employment, and higher income are protective

  19. Conclusions • While survivors of childhood cancer are at significantly higher risk of PTSD compared to siblings, only 9% are effected. • Younger age at cranial radiation and more intensive therapy are significant predictors of risk for PTSD. • While PTSD is associated with a spectrum of psychosocial outcomes, the relationship needs to be clarified.

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

  21. A Resource for Research • The Childhood Cancer Survivor Study is an NCI-funded resource to promote and facilitate research among long-term survivors of cancer diagnosed during childhood and adolescence. • Investigators interested in potential uses of this resource are encouraged to visit: • www.stjude.org/ccss

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