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Research Paper Childhood Cancer Psychological Effects

Research Paper Childhood Cancer Psychological Effects

















































There are about 15 million cancer survivors in the United States, many under the age of 21. In the last 30 years, there have been improved treatments and better supportive care. As a result, more than 80% of children treated for cancer are now surviving for 5 years or more after treatment.

However, they are at risk for having long-term and late side effects from cancer treatment. Late effects are conditions that continue or develop 5 or more years after a cancer diagnosis. Some late effects do not show up until many years after cancer treatment ends. It is important to be aware of the possible late effects linked with cancer and its treatment. It is also helpful to know the recommended screening that can help detect conditions earlier, when they may be most treatable.

Causes of late effects

Any cancer treatment may cause late effects, including chemotherapy, radiation therapy, surgery, and stem cell/bone marrow transplantation. A child’s risk of developing late effects depends on many factors:

Type and location of cancer

Area of the body treated

Type and dose of treatment

Child’s age when treated

Genetics and family history

Other health problems that existed before the cancer diagnosis

Types of late effects

Late effects can be physical or emotional. Below is a listing of specific late effects of childhood cancer. Not all survivors will develop all of these long-term side effects. It depends on the type of treatment a child had and their age when treated.

You might be concerned about late effects of cancer. Talk with a doctor to understand what the risks are and ways to manage them.

If you were treated for a childhood cancer or you have a child who no longer in treatment, then consult with a survivorship center of excellence. They are located at many National Cancer Institute Comprehensive Cancer Centers. Or, consult with follow-up care clinics listed at the Pediatric Oncology Resource Center and the National Children’s Cancer Society websites.

Researchers continue to make progress in preventing, managing, and treating late effects from childhood cancer. They provide a growing body of information to children and their families about this disease. Many suggestions below are from the clinical guidelines from the Children’s Oncology Group .

Emotional troubles. No matter what age a child is during treatment, long-term emotional effects may occur. This may include anxiety, depression, and fear of recurrence. Often, many survivors of childhood cancer avoid doctors and health care settings. This may harm their health as an adult.

Second cancers. Childhood cancer survivors have a slightly increased risk of having a second cancer. This is a different type of cancer that appears after the first cancer diagnosis. This is often also called a secondary cancer. Radiation therapy and some types of chemotherapy have the strongest links to secondary cancers. These include the drugs cyclophosphamide (Neosar), ifosfamide (Ifex), etoposide (Toposar, VePesid), daunorubicin (Cerubidine), and doxorubicin (Adriamycin). For example, children and teens who received radiation therapy for Hodgkin lymphoma have a higher risk of second cancers. Common secondary cancers include skin, breast, and thyroid cancers.

Reproductive and sexual development problems. Boys and girls are both at risk for these problems.

In boys, radiation therapy to the lower abdomen, pelvis, or testicles may cause infertility, the inability to father a child. Chemotherapy with alkylating agents, such as cyclophosphamide and ifosfamide, can also cause this. These treatments may also change levels of the male hormone, testosterone, which can affect puberty and sexual functioning. Learn more about fertility concerns and cancer treatment for men.

In girls, chemotherapy and radiation treatment to the abdomen, pelvis, or lower spine can affect the ovaries. This may cause infertility, which is the inability to conceive a child or maintain a pregnancy, irregular periods, and early menopause. These treatments also changes levels of the female hormone, estradiol, which can affect puberty and sexual functioning. Learn more about fertility concerns and cancer treatment for women.

For both boys and girls, radiation to the head can affect glands that regulate the male and female hormone levels. As a result, it could affect fertility.

Growth, development, and hormone problems. Cancer treatments may affect the endocrine system. This is a group of hormone-producing glands that controls body functions, such as growth, energy, and puberty.

Radiation therapy near the brain, eyes, or ears can affect the pituitary gland, which helps control growth and puberty. Children who received radiation therapy to these areas who have not reached adult height may have growth problems. In addition, they may reach puberty earlier or later than usual. Kids who have had radiation therapy to the pituitary gland also have a higher chance of being obese and overweight. An endocrinologist can test for these conditions and provide hormone treatments. An endocrinologist is a doctor who specializes in treating hormone problems.

Radiation treatment given to the muscles, bones, and soft tissues can lead to reduced or uneven growth and cause other health conditions. For example, it could lead to scoliosis, which is a sideways curving of the spine.

Steroid drugs called glucocorticoids, such as prednisone and dexamethasone (multiple brand names for both drugs), and methotrexate (multiple brand names) have direct effects on bone formation. This can lead to low bone mineral density, and when severe, can cause osteoporosis. This is a disease that causes weak bones and increases risk of bone fractures. However, most children regain their bone density after stopping these medications.

Children should receive regular check-ups to monitor their growth throughout puberty. Doctors can measure bone mineral density with x-rays. These tests determine whether a child needs dietary supplements, special foods, or exercise to improve bone density.

Learning and memory problems. Children who received radiation therapy to the brain or high doses of certain drugs may be more likely to have these problems. Survivors who are struggling with these issues can ask for referrals to school programs, state or county social services, and other services. These programs can help them assess their abilities and find appropriate accommodations.

Heart problems. Drugs called anthracyclines may cause heart problems, such as abnormal heart beat, weakness of the heart muscle, and congestive heart failure. These drugs include doxorubicin, daunorubicin, and idarubicin (Idamycin). Also, radiation to the chest, spine, or upper abdomen and bone marrow/stem cell transplants may increase the risk of heart late effects.

Childhood cancer survivors should visit their doctor yearly for follow-up care because heart conditions may not cause symptoms early on. They should have noninvasive tests that check how the heart is functioning about two years after treatment. These tests include an electrocardiogram (ECG or EKG) and an echocardiogram or a similar imaging tests. The Children’s Oncology Group provides clinical guidelines on how often a patient should continue to have these tests.

Lung and breathing problems. Certain types of chemotherapy, including bleomycin (Blenoxane), carmustine (BiCNU), and lomustine (CeeNU), may cause lung damage. Chest radiation and surgery to the chest or lungs may also cause lung problems. Children who received cancer treatment at a younger age have a greater risk of lung and breathing problems. Childhood cancer survivors should have a baseline test of lung function at least two years after treatment. Talk with your doctor about how often to repeat these tests.

Dental problems. Radiation therapy to the mouth, head, or neck may cause problems such as dry mouth, gum disease, and cavities. Chemotherapy, especially when given to a child whose adult teeth have not formed, may cause tooth development problems. Childhood cancer survivors should visit their dentist every 6 months for check-ups. Talk with your child’s dentist before and after treatment for guidance on reducing these potential late effects.

Digestive system. Abdominal or pelvic surgery and radiation therapy to the neck, chest, abdomen, or pelvis can affect the gastrointestinal system. Childhood cancer survivors should talk with their doctor if they have stomach pain or long-term constipation, diarrhea, heartburn, or nausea and vomiting.

Hearing problems. Radiation treatment to the head or brain may cause hearing loss. Some chemotherapy, such as cisplatin (Platinol) or carboplatin (Paraplatin), may also affect hearing. Younger children are at greater risk for these problems. All survivors of childhood cancer should have their hearing tested at least once after treatment by an audiologist. This is a medical professional who treats and manages hearing problems. A doctor should test a survivor who has hearing loss every year or as needed.

Vision and eye problems. High doses of radiation to the eye, eye socket, or brain may cause eye problems. This includes cataracts, or clouding of the eye lens, as well as other problems that can affect vision. Radioiodine treatment for thyroid cancer may result in increased tearing, and bone marrow/stem cell transplants increase the risk for dry eyes. An ophthalmologist should evaluate childhood cancer survivors who have had these treatments. An ophthalmologist is a doctor who treats eye diseases.

More Information

Cancer families

As traumatic as it can be to be diagnosed with cancer, it can be even more upsetting for the parent, spouse or other relative of the person who is ill, say psychologists.

Their research is leading to new information about families facing cancer and interventions for helping them cope. For parents of children with cancer, for example, the result can be post-traumatic stress symptoms even years after their children have recovered. For partners, cancer can mean the end of sex as they knew it as well as plans for having children together. And the relationship between cancer and family relationships also works the other way around, with marital status and long-term survivorship linked in surprising ways.

“Families know state-of-the-art medical care is important,” says APA President Carol D. Goodheart, EdD, an independent practitioner in Princeton, N.J. “What they often do not realize is that state-of-the-art psychological care is also available to ease the impact of cancer fears, procedures, side effects and treatment sequelae.”

When it’s a parent who has cancer, the impact on children typically varies according to their age and gender, says Bruce E. Compas, PhD, professor of psychology and human development and professor of pediatrics at the Vanderbilt-Ingram Cancer Center in Nashville, Tenn. In a 1994 paper published in Health Psychology (Vol. 13, No. 6: 507–15), Compas found that teenagers — especially adolescent girls — experienced the greatest distress.

Now Compas focuses on children with cancer. Halfway through a five-year grant from the National Cancer Institute, he is studying how parents communicate with children with cancer.

“Parents are faced with two challenges when a child has cancer,” he says. “One is to provide information, and the other is to provide emotional support at the same time they’re dealing with their own emotional difficulties.”

Through his research, he and his colleagues seek to identify effective communications strategies to help families cope.

The stress doesn’t end when treatment does. In a 2009 functional neuroimaging study published online in Pediatric Blood & Cancer. for instance, Compas and colleagues found memory problems and other cognitive deficits in survivors of childhood acute lymphocytic leukemia.

“Children survive now where they didn’t before, but they survive with long-term adverse effects,” says Compas. “We have to look at cancer as a chronic condition and understand the stresses and strains it puts on families for the long haul.”

Not surprisingly, the stress of a child’s cancer can result in serious stress symptoms for both the child and the parents, says Anne E. Kazak, PhD, director of the psychology department at the Children’s Hospital of Philadelphia. Immediately following a child’s cancer diagnosis, most parents experience acute stress symptoms, Kazak and colleagues found in a 2007 study published in Pediatric Blood & Cancer (Vol. 50, No. 2: 289–92). Some develop acute stress disorder.

“To be told your child has a life-threatening illness evokes a lot of feelings of helplessness, uncertainty and fear,” she says.

And that stress continues, says Kazak. In a 2005 study of parents with children in treatment, published in the Journal of Clinical Oncology (Vol. 23, No. 30: 7405–10), Kazak and fellow researchers found that all but one of the 171 parents studied had post-traumatic stress symptoms, such as intrusive thoughts, physiological arousal and avoidance.

To treat those symptoms, Kazak and her colleagues developed a one-day intervention called the Surviving Cancer Competently Intervention Program, which combines cognitive-behavioral therapy with family therapy approaches. In a randomized clinical trial published in 2004 in the Journal of Family Psychology (Vol. 18, No. 3: 493–504), they found that the intervention reduced symptoms for adolescent cancer survivors and their parents.

Now the researchers are developing a similar intervention to help families prevent post-traumatic stress symptoms from developing in the first place. In an initial randomized trial, published in 2008 in the Journal of Pediatric Psychology (Vol. 34, No. 8: 803–16), the intervention failed to show a significant impact, although participating parents offered positive feedback. The main reason the study didn’t go as well as hoped, the researchers believe, was the sheer difficulty in recruiting families into the study while they were coping with the shock of a new diagnosis. “We’re continuing to work on some adaptations of the intervention model we hope will make it more effective,” says Kazak, explaining that the researchers are now considering alternative research designs and changes to the timing of the intervention.

Sexuality and fertility

For couples, cancer treatment can bring sexual challenges, says Leslie R. Schover, PhD, a professor of behavioral science at the University of Texas’s M.D. Anderson Cancer Center in Houston.

In a 2009 study in the Journal of Sexual Medicine (Vol. 6, No. 1: 149–63), she and colleagues surveyed patients who had been treated for cancer at the center about whether they were experiencing sexual dysfunction and related problems following their treatment. After treatment, 49 percent of male respondents reported new erection problems following their cancer treatment, while 45 percent of female respondents reported vaginal dryness and a loss of desire. In addition, a third of respondents under age 50 wished that they had had a fertility consultation before their treatment.

Cancer patients and their partners aren’t getting the information they need about coping with these sex and fertility issues, says Schover.

“Oncologists are pushed more and more to spend less time with patients and already have so many things they have to explain,” she says. “Even the advanced care nurses and physician’s assistants in the clinics often don’t feel comfortable talking about reproductive health topics.”

Schover is working to close that gap. With funding from the National Cancer Institute, for example, she and a partner are developing a computerized education and counseling tool for women with cancer. Designed for use from the initial diagnosis to long-term survivorship, the multimedia tool covers sexuality, fertility and pregnancy. A new grant will fund a version for male patients.

Schover’s earlier research shows that this low-cost approach to helping couples cope with the physical problems that arise from cancer treatment is effective. An Internet-based prostate cancer program she helped develop significantly boosted couples’ sexual functioning and satisfaction, according to her not-yet-published data. “The improvements were not only quite significant but lasted for up to a year without losing significance,” she says.

Marital status’s impact

While cancer can strain marriages and other committed relationships, marital status itself is tied to cancer survival rates, says neuropsychologist Gwen C. Sprehn, PhD, an assistant professor of neurology at the Indiana University School of Medicine in Indianapolis.

In a 2009 study published in Cancer (Vol. 115, No. 21: 5108–16), Sprehn and her colleagues found that married cancer patients have higher survival rates than the never-married or divorced. But their most striking finding, she says, was that people undergoing separation while they were diagnosed had the lowest survival rates.

Drawing on registry data on almost 3.8 million Americans with cancer, the researchers found that only 45 percent of separated cancer patients were alive five years after diagnosis and just 37 percent after 10 years. The rates for married patients were 63 percent and 57 percent respectively.

Although the researchers aren’t sure of the mechanism, says Sprehn, they suspect that the stress of separation weakens the immune system. They suggest that patients try stress-relief strategies such as psychotherapy, social support exercise and sufficient sleep. “The last thing we would want is for people to feel like, ‘Not only do I have cancer and my marriage is falling apart, but I’m probably going to die sooner,’” says Sprehn. “Rather than that being the take-home message, we’d much rather view it as, ‘You may be more vulnerable, but there are things you can do to potentially reduce the impact of that vulnerability.’”

Rebecca A. Clay is a writer in Washington, D.C.

Further reading

The Help Fight Childhood Cancer project searched for a cure for a particular childhood cancer. The researchers have found that some of the promising compounds they identified also show an antidepressant capability.

The Help Fight Childhood Cancer project researchers have published a paper on serendipitous results they found from the drug candidate search run on World Community Grid. The project originally searched for candidate compounds that targeted specific proteins to help cure a childhood brain cancer called neuroblastoma. Some of the targeted proteins are also involved in several psychological disorders. They have found that some of the identified compounds show an antidepressant capability. Furthermore, additional research might lead to potential treatments for Huntington’s disease and Alzheimer’s disease. The paper was published in the journal Neurochemistry International.

Paper title: Effects of novel small compounds targeting TrkB on neuronal cell survival and depression-like behavior

Authors: Mayu Fukuda, Atsushi Takotori, Yohko Nakamura, Akiko Suganami, Tyuji Hoshino, Yutaka Tamura, Akira Nakagawara

Brain-derived neurotrophic factor (BDNF) and its high affinity receptor tyrosine kinase receptor B (TrkB) are involved in neuronal survival, maintenance, differentiation and synaptic plasticity. Deficiency of BDNF was reported to be associated with psychological disorders such as depression. Hence we examined proliferative effect of 11 candidate TrkB agonistic compounds in TrkB-expressing SH-SY5Y cells, via a hypothesis that some candidate compounds identified in our previous in silico screening for a small molecule targeting the BDNF binding domain of TrkB should activate TrkB signaling. In the present study, two promising compounds, 48 and 56, were identified and subsequently assessed for their ability to induce TrkB phosphorylation in vitro and in vivo. Likewise those seen in BDNF, the compounds mediated TrkB phosphorylation was blocked by the Trk inhibitor, K252a. Since BDNF-TrkB signaling deficiency is associated with the pathogenesis of depression and reactivation of this signaling by antidepressants is a cause of the pathogenic state recovery, the compounds were subjected to the assessment for forced swim test, which is a mouse model of depression. We found that compound 48 significantly reduced mouse immobility time compared with the control vehicle injection, suggesting the confirmation of hypothetical antidepressant-like efficacy of 48 compound in vivo. Thus, our present study demonstrated that compound 48, selected through in silico screening, is a novel activator of TrkB signaling and a potential antidepressant molecule.

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