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Background Cancer survivors develop other chronic medical conditions because of shared risk factors and delayed effects of cancer treatment. This study investigated trends in the prevalence of chronic diseases and estimated their population sizes among adult cancer survivors in the United States from 2002 to 2018. Methods Using 2002-2018 National Health Interview Survey data, this study calculated the age-sex-race/ethnicity-adjusted prevalences and estimated the population sizes for the following chronic conditions among cancer survivors: hypertension, diabetes, stroke, heart disease, chronic obstructive pulmonary disease (COPD)/asthma, hepatitis, arthritis, liver disease, kidney disease, and morbid obesity. This study also examined multiple chronic conditions (MCC; 3 or more health conditions). MCC trends were further examined by sociodemographic factors to identify high-risk populations. Parallel analyses were performed for participants without a cancer history to provide a reference. Results Among 30,728 cancers survivors, increasing trends were observed in the prevalence of hypertension, diabetes, kidney disease, liver disease, and morbid obesity, whereas decreasing prevalence trends were observed for ischemic heart disease, COPD, and hepatitis. Cancer survivors with MCC increased from 4.7 million in 2002 to 8.1 million in 2018 (the prevalence increased from 43.7% to 46.6%). The increase was more pronounced among survivors aged 18 to 44 years. Among adults without a cancer history, the MCC prevalence also increased, although more slowly than among survivors. Conclusions The number of adult cancer survivors in the United States with comorbid illnesses has increased substantially over the past 2 decades. Optimal management of comorbid conditions and aggressive interventions for risk reduction may benefit the cancer survivor population.

LAY SUMMARY Guidance on how to approach opioid decisions for people beyond active cancer treatment is lacking. This editorial discusses strategies from the general literature that can be thoughtfully tailored to cancer survivors to provide patient-centered pain and opioid care.

Background Research on cannabis use among those with a history of cancer is limited. Methods Prevalence of past-year cannabis use among individuals with and without a cancer history and predictors of use within these 2 groups were determined using data from the Population Assessment of Tobacco and Health study, a nationally representative, longitudinal survey conducted in the United States (waves 1-4; 2013-2018). Discrete time survival analyses were used to estimate baseline (wave 1) predictors (physical health status, mental health status, pain, and demographic variables) on past-year engagement with cannabis within individuals who reported a cancer diagnosis at wave 1 (n = 1022) and individuals who reported never having cancer at any wave (n = 19,702). Results At the most recent survey, 8% of cancer survivors reported past-year cannabis use, compared with 15% of those without a cancer history. Across 4 time points, an estimated 3.8% of cancer survivors engaged with cannabis, as compared to 6.5% of those without a cancer history. Across both groups, older age and having health insurance were associated with lower likelihood of engaging in cannabis use, whereas greater levels of pain were associated with higher likelihood of engaging in cannabis use. Among those without a cancer history, being female, White, and having better mental health status were associated with lower likelihood of engaging in cannabis use. Conclusions Although cannabis use prevalence is lower among cancer survivors, the reasons for use are not markedly different from those without a cancer history. Continued monitoring of use, reasons for use, and harms or benefits is warranted. Lay Summary Results from this study, which uses data from the Population Assessment of Tobacco and Health Study, indicate that cannabis use is generally increasing across cancer survivors and those without a history of cancer. Cancer survivors are using cannabis at slightly lower rates than those without a history of cancer. Factors related to pain seem to be more prevalent in cancer populations relative to the general population, and could be contributing to cannabis use within cancer survivor populations.

BACKGROUND Substance use can exacerbate cancer-related morbidity and mortality in adolescent/young adult (AYA) cancer survivors and place them at increased risk for adverse health outcomes. The objective of this study was to assess substance use, misuse, and substance use disorders [SUDs], as well as receipt of treatment for SUDs, among AYA cancer survivors. METHODS The authors used data from the National Survey of Drug Use and Health (2015-2018) to identify a nationally representative sample of AYAs aged 12 to 34 years. Outcomes assessed past-year tobacco, alcohol, marijuana, and illicit drug use; misuse of prescription opioids; SUDs; and SUD treatment. Multiple logistic regression was estimated to compare outcomes between 832 AYAs who reported a cancer history (survivors) and 140,826 AYAs who did not, adjusting sequentially for sociodemographic characteristics and health status. RESULTS In regressions adjusting for sociodemographic characteristics, survivors were more likely than a noncancer comparison group of peers to use alcohol (6% relative increase; P = .048) and illicit drugs (34% relative increase; P = .012), to misuse prescription opioids (59% relative increase; P < .001), and to have a marijuana (67% relative increase; P = .011), illicit drug (77% relative increase; P < .001), or prescription opioid (67% relative increase; P = .048) SUD. When further adjusting for health status, survivors were still 41% more likely (P < .001) to misuse prescription opioids than noncancer peers. Among those with SUDs, survivors were more likely than peers to receive treatment (unadjusted, 21.5% vs 8.0%; adjusted, P < .05). CONCLUSIONS AYA survivors were as likely as or more likely than noncancer peers to report substance use problems. These findings underscore the importance of interventions to reduce substance use and improve SUD treatment among AYA cancer survivors. LAY SUMMARY The authors assessed substance use, misuse, and substance use disorders, as well as the receipt of treatment for substance use disorders, among adolescent and young adult (AYA) cancer survivors. In a nationally representative AYA sample, cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than peers without cancer to experience substance use problems. In particular, survivors had a significantly higher rate of prescription opioid misuse than peers. However, only 1 in 5 AYA survivors who experienced substance use disorders received treatment. These findings underscore the importance of interventions toward reducing substance use and improving access to treatment among AYA survivors.

Background Spouses of cancer survivors are at an increased risk of poor mental health outcomes but are known to underuse supportive services. The objective of the current study was to determine how the health and health care use of cancer survivors were associated with depression and anxiety-related health care use in their spouses. Methods The current observational study used data from the Medical Expenditure Panel Survey to identify married individuals with a cancer-related medical event or disability ("cancer survivors"), and linked health and health care use data across spousal dyads. Spouses reporting a prescription for an antidepressant or antianxiety medication or any psychotherapy were flagged as having used mental health care. Correlates of use were assessed, with a focus on the health and health care use of the cancer survivor. Results Greater than 25% of the spouses of cancer survivors used mental health care over the approximately 2.5 years of follow-up. Controlling for their own predisposing, enabling, and need characteristics, spouses were found to be less likely to use mental health care if the cancer survivor reported more health conditions or elevated depressed mood compared with dyads in which the survivor reported low distress and depression. Spouses were nearly 3 times more likely to use mental health care if the cancer survivor themselves had used mental health care (odds ratio, 2.98; 95% confidence interval, 2.17-4.09). Conclusions The findings of the current study enhance understanding of how health outcomes are intertwined in families with cancer, and reinforce the importance of a family-centered approach to cancer care that facilitates psychosocial care. Lay summary The health and well-being of cancer survivors and their spouses are intertwined. The results of the current study demonstrated that this interrelationship extends to mental health care related to depression and anxiety. Spouses of cancer survivors were found to be less likely to receive mental health care when the survivor had more health care needs. Spouses were nearly 3 times more likely to receive care if the survivor also was receiving mental health care. Caregiving spouses may face more challenges finding the time, money, or energy to engage in their own self-care. However, providing supportive care to one partner may help the other partner access care as well.

To the authors' knowledge, few studies to date have examined associations between moderate to vigorous physical activity (MVPA) and sitting time with quality of life in cancer survivors compared with a cancer-free group. The current study examined differences in global mental health (GMH) and global physical health (GPH) across levels of MVPA and sitting among cancer survivors and cancer-free participants.Cancer Prevention Study II participants (59.9% of whom were female with an age of 77.8 ± 5.8 years) were grouped as: 1) survivors who were 1 to 5 years after diagnosis (3718 participants); 2) survivors who were 6 to 10 years after diagnosis (4248 participants); and 3) cancer-free participants (ie, no history of cancer; 69,860 participants). In 2009, participants completed MVPA, sitting, and Patient-Reported Outcomes Measurement Information System GMH/GPH surveys. Mean differences in GMH and GPH T scores across MVPA (none, 0 to7.5, 7.5 to15, 15 to22.5, and ≥22.5 metabolic equivalent [MET]-hours/week) and sitting (0 to3, 3 to6, and ≥6 hours/day) were assessed using multivariate generalized linear models.The mean GMH and GPH scores were statistically significantly higher in cancer-free participants compared with cancer survivor groups, although the differences were not clinically meaningful (mean difference of 0.52 for GMH and 0.88 for GPH). More MVPA was associated with higher GMH and GPH scores for all 3 groups (P for trend.001), and differences between the least and most active participants were found to be clinically meaningful (mean differences of ≥4.34 for GMH and ≥6.39 for GPH). Similarly, a lower duration of sitting was associated with higher GMH and GPH scores for all groups (P for trend.001), with clinically meaningful differences observed between the least and most sedentary participants (mean differences of ≥2.74 for GMH and ≥3.75 for GPH).The findings of the current study provide evidence of the importance of increased MVPA and decreased sitting for improved health in older adults with or without a prior cancer diagnosis.

BACKGROUND The objective of this study was to characterize chronic disease, health-related quality of life (HRQOL), emotional distress, and social attainment among long-term survivors of neuroblastoma. METHODS Chronic health conditions among 136 ≥10-year neuroblastoma survivors (median age, 31.9 years; range, 20.2-54.6 years) and 272 community controls (median age, 34.7 years; range, 18.3-59.6 years) were graded with a modified version of the Common Terminology Criteria for Adverse Events (version 4.03). HRQOL and emotional distress were assessed with the Medical Outcomes Study 36-Item Short Form Health Survey and the Brief Symptom Inventory-18. Log-binomial regression and logistic regression were used to compare the prevalence of chronic conditions and the frequency of reduced HRQOL, distress, and social attainment between survivors and controls. The cumulative burden approach was used to estimate multimorbidity. RESULTS By the age of 35 years, survivors had experienced, on average, 8.5 grade 1 to 5 conditions (95% confidence interval [CI], 7.6-9.3), which was higher than the average for controls (3.3; 95% CI, 2.9-3.7). Compared with controls, survivors had a higher prevalence of any pulmonary (P = .003), auditory (P

Background The number of head and neck cancer (HNC) survivors has been increasing because of improving survival in the United States. The aim of this study was to evaluate the incidence of respiratory disease diagnoses in HNC survivors in comparison with cancer-free individuals. A second aim was to investigate risk factors for respiratory disease among HNC survivors. Methods Patients with HNC diagnosed from 1996 to 2012 were identified in the Utah Cancer Registry (n = 1901). Up to 5 cancer-free individuals from the general population (n = 7796) were matched to each HNC survivor by birth year, sex, birth state, and follow-up time. Electronic medical records and statewide health care facility data were used to identify a disease diagnosis after the cancer diagnosis. Cox proportional hazards models were used to estimate the risks of respiratory diseases. Results The median follow-up times were 4.5 years for HNC survivors and 7.8 years for the general population cohort. The risks of respiratory infection (hazard ratio [HR], 1.63; 95% confidence interval [CI], 1.40-1.90), chronic obstructive pulmonary diseases and bronchiectasis (HR, 2.65; 95% CI, 2.13-3.29), and aspiration pneumonitis (HR, 6.21; 95% CI, 3.98-9.68) were higher among HNC survivors than the general population cohort more than 5 years after the cancer diagnosis. Age at diagnosis, baseline body mass index, sex, baseline smoking status, treatment modality, primary site, and stage were associated with the risk of adverse respiratory outcomes among HNC survivors. Conclusions The risk of adverse respiratory outcomes was much higher among HNC survivors than the general population cohort. Multidisciplinary care is needed to prevent the occurrence of adverse respiratory outcomes among HNC survivors.

Background Optimal risk-based survivor health care includes surveillance for late effects and education targeted at reducing or preventing risky health behaviors. Understanding the reasons for a lack of risk-based follow-up care is essential. Methods Adult participants from the Childhood Cancer Survivor Study were surveyed about having a cancer-related visit in the past 2 years and the likelihood of having a cancer-related visit in the future. Additional factors thought to be related to the primary outcomes were also assessed. Results Nine hundred seventy-five survivors completed the survey. Twenty-seven percent (95% confidence interval [CI], 24%-30%) had a cancer-related medical visit in the previous 2 years, and 41% (95% CI, 38%-44%) planned to have such a visit within the next 2 years. The likelihood of having had a cancer-related visit within the last 2 years was higher among survivors assigning greater importance to these visits (relative risk [RR], 1.2; 95% CI, 1.1-1.3), perceiving greater susceptibility to health problems (RR, 1.2; 95% CI, 1.1-1.3), having a moderate to life-threatening chronic health problem related to their cancer (RR, 2.1; 95% CI, 1.7-2.7), seeing a primary care provider for a cancer-related problem (RR, 1.3; 95% CI, 1.0-1.6), having a cancer treatment summary (RR, 1.3; 95% CI, 1.0-1.6), and endorsing greater confidence in physicians' abilities to address questions and concerns (RR, 1.2; 95% CI, 1.0-1.3). Conclusions Educational interventions improving awareness of treatment history and susceptibility to cancer-related late effects and corresponding risk-based care are likely to be beneficial for survivors of childhood cancers.

BACKGROUND Extant evidence links neighborhood walkability with obesity-related health in the general population. This association likely exists in cancer survivors, but research is limited. Furthermore, a disproportionate obesity burden in African American cancer survivors warrants subgroup-specific analyses. METHODS This study analyzed data from 2089 African American cancer survivors participating in the Detroit Research on Cancer Survivors (ROCS) cohort. On the basis of built environment data summarized within 1-km radial buffers around census block centroids, a multidimensional neighborhood walkability index (NWI) was constructed. Survivors' residential addresses at Detroit ROCS enrollment were geocoded, and addresses were linked to NWI scores via the census block of residence. At study enrollment, survivors reported height and weight; these data were used to calculate their body mass index (BMI). Associations between NWI quartiles and BMI overall and by cancer type, biological sex, and physical activity engagement were evaluated. RESULTS BMI was found to be inversely associated with increasing NWI quartile (P for trend < .01). This inverse relationship was observed in men (P for trend < .01) and in survivors reporting any regular physical activity (P for trend < .01). CONCLUSIONS This study's findings suggest that among African American cancer survivors, higher neighborhood walkability is associated with lower BMI. As health care systems in the United States increasingly consider the role of the neighborhood environment in their patients' health, these findings provide additional evidence supporting health systems' incorporation of neighborhood walkability as an obesity-related health indicator for this cancer survivor subgroup and potentially for cancer survivors from other vulnerable populations.

Background Although multiple co-occurring symptoms are a significant problem for cancer survivors, to the authors' knowledge little is known regarding the phenotypic characteristics associated with a higher symptom burden. The objectives of the current study were to evaluate the occurrence, severity, and distress associated with 32 symptoms and examine the phenotypic and stress characteristics associated with a higher symptom burden. Methods A total of 623 cancer survivors completed a demographic questionnaire, as well as measures of functional status, comorbidity, and global (Perceived Stress Scale) and cancer-related (Impact of Event Scale-Revised) stress. The Memorial Symptom Assessment Scale was used to evaluate symptom burden. Multiple linear regression analysis was used to determine the phenotypic characteristics associated with a higher symptom burden. Results The mean number of symptoms was 9.1 (±5.2). The most common, severe, and distressing symptoms were lack of energy, problems with sexual interest/activity, and hair loss, respectively. Poorer functional status, a higher level of comorbidity, and a history of smoking as well as higher Perceived Stress Scale and Impact of Event Scale-Revised scores were associated with a higher symptom burden. The overall model explained approximately 45.6% of the variance in symptom burden. Conclusions Although cancer survivors report a high number of co-occurring symptoms of moderate severity and distress, in the current study, no disease or treatment characteristics were found to be associated with a higher symptom burden. Clinicians need to assess for general and disease-specific stressors and provide referrals for stress management interventions. Future studies need to examine the longitudinal relationships among symptom burden, functional status, and level of comorbidity, as well as the mechanisms that underlie the associations between stress and symptom burden.

Background To the authors' knowledge, there is limited information regarding the long-term risk of congestive heart failure (CHF) among patients with follicular lymphoma, a prevalent non-Hodgkin lymphoma diagnosis among those aged >65 years, especially within the context of therapeutic exposures and preexisting comorbidities. Methods Using Surveillance, Epidemiology, and End Results-Medicare data from 1999 through 2013, the authors identified 6109 patients with follicular lymphoma who were diagnosed at age ≥66 years between January 1, 2000 and December 31, 2011, and a frequency-matched Medicare noncancer sample. Subdistribution hazards models assessed risks associated with new-onset CHF through December 31, 2013. Propensity score-matched models examined CHF risk in patients receiving anthracyclines when compared with matched noncancer controls. Results When compared with matched controls, patients with follicular lymphoma receiving anthracyclines at ages 66 to 75 years had a 1.7-fold (95% confidence interval, 1.4-fold to 2.1-fold) higher risk of new-onset CHF; patients diagnosed at age >75 years did not differ from noncancer controls with regard to CHF risk. Preexisting hypertension was associated with a 1.7-fold and 1.35-fold, respectively, increased hazard of CHF for each age group, independent of anthracycline exposure. Preexisting diabetes was associated with 1.5-fold increased hazard of CHF only in those patients aged 66 to 75 years. Patients with new-onset CHF had a 18% lower 10-year survival compared with those without CHF. Conclusions Patients with follicular lymphoma who were exposed to anthracyclines between the ages of 66 years and 75 years were found to be at an increased risk of new-onset CHF; preexisting hypertension and diabetes appeared to increase this risk. The findings of the current study support and inform the risk-based follow-up of vulnerable populations.

The American cancer survivor population is ever-growing, with necessary follow-up primarily accomplished in a high-touch fashion-adding to unsustainability and fragmentation of care. Given the complexities of the health care system processes needed to support survivorship, engineering approaches may best address performance deficits and facilitate the provision of patient-centered care. Such collaboration between health care and engineering is recommended for redesigning health care delivery systems. By using Systems Engineering Initiative for Patient Safety (SEIPS), a systems engineering model widely used to improve health care quality and delivery, the authors examine the work system to identify the barriers and facilitators to necessary care in the presence of a survivorship care plan and visit. Recommendations for future improvement include ensuring that care-planning processes are dynamic, clearly assigned, resilient, and integrated with electronic health record systems.

Background The Patient Protection and Affordable Care Act extends Medicaid coverage to millions of low-income adults, including many survivors of cancer who were unable to purchase affordable health insurance coverage in the individual health insurance market. Methods Using data from the 2011 to 2015 Behavioral Risk Factor Surveillance System, the authors compared changes in coverage and health care access measures for low-income cancer survivors in states that did and did not expand Medicaid. Results The study population of 17,381 individuals included adults aged 18 to 64 years, and was predominantly female, white, and unmarried. The authors found a relative reduction in the uninsured rate of 11.7 percentage points and a relative increase in the probability of having a personal physician of 5.8 percentage points. Stratifying by whether states expanded Medicaid by 2015, the authors found that relative gains in coverage and access were larger among those individuals residing in states with expanded Medicaid compared with those residing in nonexpansion states. Conclusions The results of the current study suggest that the Patient Protection and Affordable Care Act Medicaid expansion has improved coverage and access for cancer survivors. Cancer 2018;124:2645-52. © 2018 American Cancer Society.

BACKGROUND Infertility, poor semen quality, and gonadal dysfunction are well recognized long-term sequelae in male survivors of childhood acute lymphoblastic leukemia (ALL). However, few studies have investigated adult sexual functioning in these survivors. METHODS The authors studied 52 male survivors of childhood ALL at a median age of 28.5 years (range, 25-38 years) ≥ 10 years after diagnosis. In addition, 56 men without a history of cancer were recruited for an age-matched control group. The participants completed the Derogatis Interview for Sexual Functioning self-report. To analyze predictive factors for sexual dysfunction, variables assessing sociodemographic background, antileukemia treatment, testicular size, laboratory variables from current serum and semen samples, self-reported depressive symptoms, and self-reported physical functioning were included in multiple regression analyses. RESULTS ALL survivors had significantly poorer sexual functioning, as measured by the Derogatis Interview for Sexual Functioning self-report, compared with the control group. Survivors had a similar frequency of sexual fantasies, autoerotic acts, and full erection during these activities as the control group, but they had less frequent sexual activity with a sexual partner, poorer self-rated orgasms, and lower satisfaction with their sex life. Predictive factors for poorer sexual functioning were depressive symptoms, the absence of a relationship, and, to a lesser extent, testicular size as an indication of gonadal damage from childhood antileukemia therapy. Older survivors experienced a deeper decline in sexual functioning compared with men in the control group. CONCLUSIONS Decline in sexual functioning at an early adult age can be regarded as 1 of the late effects of childhood cancer. Monitoring these survivors' sexual health is indicated. Cancer 2016. © 2016 American Cancer Society.

BACKGROUND The extent to which cancer exacerbates or creates new health conditions is a long-standing, unanswered question. The current prospective study examined the short-term impact of cancer on the functioning, development of, and worsening of age-related health conditions among older adults who develop cancer compared with age-matched controls. METHODS Surveillance, Epidemiology, and End Results registry data were linked with Medicare Health Outcomes Survey (MHOS) data. A total of 921 eligible cases were Medicare beneficiaries with diagnosis of breast, colorectal, lung, or prostate cancer made between their baseline and follow-up MHOS. Using propensity score matching, 4605 controls without cancer were matched from the MHOS. Analysis of covariance and logistic regression were used to examine changes in physical functioning, activities of daily living, age-related conditions, and exacerbation of preexisting conditions for cases compared with controls. RESULTS Cancer groups demonstrated greater declines in activities of daily living and physical function compared with controls (mean, -1.53 [standard error, 0.14]), with the greatest change noted for patients with lung cancer (mean, -6.72 [standard error, 0.94]). Having a cancer diagnosis increased the risk of depression but did not increase the odds of developing arthritis in the hand and/or hip, urinary incontinence (except for prostate cancer), or vision and/or hearing problems. Having a cancer diagnosis also did not exacerbate the severity of arthritis or foot neuropathy. CONCLUSIONS The findings of the current study suggest that cancer is a stronger driver for declines in physical functioning and an increased risk of depression in older adults. Interventions are needed to decrease these risks. Clinicians need to prepare patients and families for changes in functioning levels and interventions that limit the declines for older patients with cancer are needed. Cancer 2016;122:1946–53. © 2016 American Cancer Society.

Background No prior study has measured or compared self‐reported and objectively measured physical activity trajectories in prostate cancer survivors before and after treatment. Methods Clinically localized prostate cancer patients treated with radical prostatectomy were recruited between 2011 and 2014. Of the 350 participants enrolled at the main site, 310 provided self‐reported physical activity at baseline before radical prostatectomy, and 5 weeks, 6 months, and 12 months after radical prostatectomy. A subset of participants (n = 81) provided objectively measured physical activity at all study time points by wearing an accelerometer for 7 days each. Changes in activity over time were compared using Friedman’s test. Agreement between self‐reported and objective measures was evaluated using Spearman’s rank correlation coefficient. Results Self‐reported moderate‐to‐vigorous physical activity was high at baseline (median, 32.1 min/day), followed by a decline at 5 weeks (median, 15.0 min/day) and a recovery at 6 and 12 months (median, 32.1‐47.1 min/day). In contrast, objectively measured moderate‐to‐vigorous physical activity was low at all 4 time points (median, 0.0‐5.2 min/day), with no overall change across study assessments (global P = .29). Self‐reported moderate‐to‐vigorous physical activity tended to be more closely related to objectively measured light‐intensity physical activity (ρ = 0.29‐0.42) than to objectively measured moderate‐to‐vigorous physical activity (ρ = 0.07‐0.27, P = .009‐.32). Conclusions In our population of prostate cancer survivors with critically low moderate‐to‐vigorous physical activity levels, self‐reported measures greatly overestimated moderate‐to‐vigorous physical activity and may have been more reflective of light‐intensity physical activity. Because cancer survivor guidelines are derived from self‐reported data, our findings may imply that intensities of physical activity below moderate, such as light intensity, still have health benefits., In a population of 81 prostate cancer survivors with critically low moderate‐to‐vigorous physical activity levels, self‐reported measure greatly overestimates moderate‐to‐vigorous physical activity and may be more reflective of light‐intensity physical activity. Because prostate cancer guidelines are derived from self‐reported moderate‐to‐vigorous physical activity, the findings imply that lower intensities of physical activity, such as light‐intensity physical activity, may still have health benefits.

BACKGROUND Young adult female cancer survivors have unmet reproductive concerns and informational needs that are associated with poorer quality of life. The purpose of this study was to examine the association between current reproductive concerns and moderate to severe depression among young survivors. METHODS This cross-sectional study included 200 female cancer survivors between the ages of 18 and 35 years who completed a Web-based survey measuring reproductive history, parenthood desires, reproductive concerns after cancer, and quality-of-life indicators. RESULTS The mean age of the participants was 28 years (standard deviation, 4.4 years), and almost two-thirds were diagnosed within 5 years of survey completion. A multivariate logistic regression analysis controlling for education, duration of survivorship, and social support revealed an association between experiencing reproductive concerns and moderate to severe depression (odds ratio for each 5-unit increase in the Reproductive Concerns After Cancer [RCAC] score, 1.30; 95% confidence interval, 1.06-1.60). Among those with moderate to severe depression, 23% had high RCAC scores, whereas 6% of those with minimal to mild depression did (P

BACKGROUND Physical activity after breast cancer diagnosis is associated with improved survival. The current study examined levels of and changes in physical activity after breast cancer diagnosis, overall and by race. METHODS Phase 3 of the Carolina Breast Cancer Study assessed both pre- and postdiagnosis physical activity levels in a cohort of 1735 women aged 20 years to 74 years who were diagnosed with invasive breast cancer between 2008 and 2011 in 44 counties of North Carolina. Logistic regression and analysis of variance were used to examine whether demographic, behavioral, and clinical characteristics were associated with activity levels. RESULTS Only 35% of study participants met current physical activity guidelines after diagnosis with breast cancer. A decrease in activity after diagnosis was reported by 59% of patients, with the average study participant reducing their activity by 15 metabolic equivalent task (MET) hours (95% confidence interval [95% CI], 12 MET hours-19 MET hours). After adjustment for potential confounders, when compared with white women, African American women were less likely to meet national physical activity guidelines after diagnosis (odds ratio, 1.38; 95% CI, 1.01-1.88) and reported less weekly postdiagnosis physical activity (12 MET hours vs 14 MET hours; P = .13). In adjusted stratified analyses, receipt of treatment was found to be significantly associated with postdiagnosis activity in African American women (P

BACKGROUND Sedentary behavior may independently contribute to morbidity and mortality among survivors of colorectal cancer. In the current study, the authors assessed whether a telephone-delivered multiple health behavior change intervention had an effect on the sedentary behavior of recently diagnosed colorectal cancer survivors. METHODS A total of 410 participants were recruited through the Queensland Cancer Registry and randomized to the health coaching (intervention) or usual-care (control) group. Eleven health coaching sessions addressing multiple health behaviors, including sedentary behavior, were delivered over a period of 6 months. Data were collected at baseline (before randomization), at 6 months, and at 12 months via a telephone interview. RESULTS At 12 months, there was a significant decrease noted in the hours per day of sedentary time in both the health coaching (−1.21; 95% confidence interval [95% CI], −1.71 to −0.70) and usual-care groups (−0.55; 95% CI, −1.06 to −0.05), but the between-group difference was not found to be statistically significant (−0.65; 95% CI, −1.37 to 0.06 [P = .07]). In stratified subgroup analyses, the multiple health behavior change intervention was found to have a significant effect on total sedentary time (hours/day) at 12 months in survivors of colorectal cancer who were aged > 60 years (−0.90; 95% CI, −1.80 to −0.01 [P = .05]), male (−1.33; 95% CI, −2.44 to −0.21 [P = .02]), and nonobese (−1.10; 95% CI, −1.96 to −0.25; [P = .01]). CONCLUSIONS Incorporating simple messages about limiting sedentary behaviors into a multiple health behavior change intervention was found to have modest effects on sedentary behavior. A sedentary behavior-specific intervention strategy may be required to achieve substantial changes in sedentary behavior among colorectal cancer survivors. Cancer 2014;120:2665–2672. © 2014 American Cancer Society.

There is a considerable body of evidence about the adverse effects of cancer and cancer treatments on employment, work ability, work performance, and work satisfaction among cancer survivors. There is also a growing consensus that cancer survivorship research needs to address the large variety of short-term and long-term work-related problems and that programs to support return to work and employment should be developed and integrated into the follow-up survivorship care of cancer patients. Cancer survivorship and employment can be considered from the perspective of the cancer survivor, the caregiver and the family, the employer and coworkers, the health care providers, and the community or society—elements that comprise many similarities but also differences between Europe and the Unites States and that may affect employment and return to work among cancer survivors in different ways. Previous research has specifically addressed the likelihood and timeliness of work return, including factors that promote and hinder return to work and work performance, and intervention studies and programs that focus on psychological, physical, pharmacologic, or multidisciplinary approaches to work. The area of work disability has emerged as an international field with research from areas throughout the globe. In this article, the authors provide an overview of the current state of scientific research in these areas and further provide a cancer survivorship and work model that integrates significant individual cancer-related, treatment-related, and work-related factors and outcomes. The report concludes with a discussion of European and American contributions and possible future directions for the enhancement of current efforts. Cancer 2013;119(11 suppl):2151-59. V C 2013 American Cancer Society.

BACKGROUND: The authors developed a framework for estimating and comparing the risks of various long-term complications on a common scale and applied it to 3 different techniques for craniospinal irradiation in patients with pediatric medulloblastoma. METHODS: Radiation dose-response parameters related to excess hazard ratios for secondary breast, lung, stomach, and thyroid cancer; heart failure, and myocardial infarction were derived from large published clinical series. Combined with age-specific and sex-specific hazards in the US general population, the dose-response analysis yielded excess hazards of complications for a cancer survivor as a function of attained age. After adjusting for competing risks of death, life years lost (LYL) were estimated based on excess hazard and prognosis of a complication for 3-dimensional conformal radiotherapy (3D CRT), volumetric modulated arc therapy (VMAT), and intensity-modulated proton therapy (IMPT). RESULTS: Lung cancer contributed most to the estimated LYL, followed by myocardial infarction, and stomach cancer. The estimates of breast or thyroid cancer incidence were higher than those for lung and stomach cancer incidence, but LYL were lower because of the relatively good prognosis. Estimated LYL ranged between 1.90 years for 3D CRT to 0.28 years for IMPT. In a paired comparison, IMPT was associated with significantly fewer LYL than both photon techniques. CONCLUSIONS: Estimating the risk of late complications is associated with considerable uncertainty, but including prognosis and attained age at an event to obtain the more informative LYL estimate added relatively little to this uncertainty. Cancer 2012. (c) 2012 American Cancer Society. (Less)

Every year in Canada and the United States, about 26,000 adolescent and young adults (AYA) between ages 15 and 29 years are diagnosed with cancer. Although the majority of AYA cancer patients will survive their primary cancer, many will develop serious health problems or die prematurely secondary to their curative cancer therapy. Much is known about the long-term health outcomes after adolescent cancer. In contrast, there remain substantial gaps in our understanding of the long-term outcomes after most young adult cancers. To optimize the health and quality of life of AYA cancer survivors and improve upon curative cancer therapy, it is essential to further investigate the long-term outcomes of this population. Before embarking upon this endeavor, it is important for the investigator and the funding agency to be cognizant about some of the unique challenges in research of AYA cancer survivors. To this end, the authors present a brief overview of some of the key research challenges, discuss the strengths and limitations of using available AYA cohorts and databases, and highlight potential future directions.

BACKGROUND: To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged

BACKGROUND: Recent attention has focused on the negative effects of chemotherapy on the cognitive performance of cancer survivors. The current study examined modification of this risk by catechol-O-methyltransferase (COMT) genotype based on evidence in adult populations that the presence of a Val allele is associated with poorer cognitive performance. METHODS: Breast cancer survivors treated with radiotherapy (n ¼ 58), and/or chemotherapy (n ¼ 72), and 204 healthy controls (HCs) completed tests of cognitive performance and provided saliva for COMT genotyping. COMT genotype was divided into Val carriers (Valþ; Val/Val, Val/Met) or COMT-Met homozygote carriers (Met; Met/ Met). RESULTS: COMT-Valþ carriers performed more poorly on tests of attention, verbal fluency, and motor speed relative to COMT-Met homozygotes. Moreover, COMT-Valþ carriers treated with chemotherapy performed more poorly on tests of attention relative to HC group members who were also Valþ carriers. CONCLUSIONS: The results suggest that persons treated with chemotherapy for breast cancer who also possess the COMT-Val gene are susceptible to negative effects on their cognitive health. This research is important because it strives to understand the factors that predispose some cancer survivors to more negative quality-of-life outcomes. Cancer 2010;000:000–000. V C 2010 American Cancer Society.

BACKGROUND: Young adult survivors of childhood brain tumors (BTs) may have late effects that compromise physical performance and everyday task participation. The objective of this study was to evaluate muscle strength, fitness, physical performance, and task participation among adult survivors of childhood BTs. METHODS: In-home evaluations and interviews were conducted for 156 participants (54% men). Results on measures of muscle strength, fitness, physical performance, and participation were compared between BT survivors and members of a population-based comparison group by using chi-square statistics and 2-sample t tests. Associations between late effects and physical performance and between physical performance and participation were evaluated in regression models. RESULTS: The median age of BT survivors was 22 years (range, 18-58 years) at the time of the current evaluation, and they had survived for a median of 14.7 years (range, 6.5-45.9 years) postdiagnosis. Survivors had lower estimates of grip strength (women, 24.7 ± 9.2 kg vs 31.5 ± 5.8 kg; men, 39.0 ± 12.2 kg vs 53.0 ± 10.1 kg), knee extension strength (women, 246.6 ± 95.5 Newtons [N] vs 331.5 ± 5.8 N; men, 304.7 ± 116.4 N vs 466.6 ± 92.1 N), and peak oxygen uptake (women, 25.1 ± 8.8 mL/kg per minute vs 31.3 ± 5.1 mL/kg per minute; men, 24.6 ± 9.5 mL/kg per minute vs 33.2 ± 3.4 mL/kg per minute) than members of the population-based comparison group. Physical performance was lower among survivors and was associated with not living independently (odds ratio [OR], 5.0; 95% confidence interval [CI], 2.0-12.2) and not attending college (OR, 2.3; 95% CI 1.2-4.4). CONCLUSIONS: Muscle strength and fitness values among BT survivors were similar to those among individuals aged ≥60 years and were associated with physical performance limitations. Physical performance limitations were associated with poor outcomes in home and school environments. The current data indicated an opportunity for interventions targeted at improving long-term physical function in this survivor population. Cancer 2010. © 2010 American Cancer Society.

In the last 40 years patients have become more involved in their health care as the doctor-patient relationship has shifted from a largely paternalistic model to an emphasis on patient autonomy.1-5 At the same time, there has been unprecedented growth in the amount of health information that is available to patients. Widespread access to communication technologies such as the internet has made health information almost ubiquitous.6, 7 This increased access is reflected in widespread health information seeking by lay individuals. For example, approximately 45% of people report looking for cancer information and approximately 39% of cancer patients seek cancer information on the internet. 6, 8 If patients' use of health information is increasing, it remains unclear how these phenomena will influence medical outcomes. Patient access to information may erode components of the doctor-patient relationship, however increased access may lead to more informed patients and improved shared decision making.9-12 Additionally, patient information seeking may produce adverse effects such as an increased demand for cancer related therapies and technologies. Increased patient access to medical information may also directly influence population health by influencing health behaviors and reducing disparities in information access.6, 7, 13 Theories suggest that access to health information may impact the diffusion and adoption of new medical technologies. Diffusion of innovation is a complex process that is influenced by factors as diverse as pricing, government regulation, patient, physician and technology characteristics, and physician interpersonal networks.14-21 Patterns of adoption of new technologies are also strongly influenced by exposure to information.15, 22 Physicians commonly encounter information in a professional context but there is evidence that media coverage influences physician attitudes about scientific discoveries and amplifies the impact of publications in the research community.23, 24 Patients may learn about novel therapies from sources such as the media and the internet. This phenomenon may be particularly important for cancer treatment when new therapies are rapidly developed and receive considerable media attention. Although several studies have demonstrated that people who look for health information have improved knowledge, engage in more cancer-prevention behaviors and take more active roles in decision making, little published work exists that examines the relationship between cancer information seeking and cancer treatment.25-27 In one study, 47% of patients referred for participation in a prominent phase I drug trial first learned about the trial from media sources and 51% of those patients subsequently contacted their doctor for more information.28 Here we report the results of a study examining the relationship between cancer patient information seeking and awareness about and use of novel targeted therapy for colon cancer. We focused on treatments with targeted therapy, bevacizumab (Avastintm) and cetuximab (Erbituxtm), because of their clinical importance, significant media coverage and recent FDA approval. We investigated awareness and use of targeted therapy in both on-label and off-label indications because we thought that there might be both positive and negative associations of information seeking on drug use. We hypothesized that there would be a relationship between information seeking and awareness of targeted therapies for all colon cancer patients because information on bevacizumab and cetuximab is widely available and would likely be encountered during treatment information seeking, regardless of whether targeted therapy would be indicated. Additionally, because treatment information seeking may lead patients to inquire about specific medications and subsequently receive those medications, we hypothesized that information seeking would be associated with the use of targeted therapy with a greater effect in patients for whom targeted therapy is approved by the FDA.