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Treatments for childhood cancer can impair pulmonary function. We assessed the potential impact of cigarette smoking on pulmonary function in 433 adult childhood cancer survivors (CCS) who received pulmonary-toxic therapy, using single breath diffusion capacity for carbon monoxide corrected for hemoglobin (DLCOcorr), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC). FEV1/FVC median values among current [1.00; interquartile range (IQR): 0.94–1.04] and former smokers (0.98; IQR: 0.93–1.04) were lower than those who had never smoked (1.02; IQR: 0.96–1.06; P = 0.003). Median FEV1/FVC values were lower among those who smoked ≥ 6 pack-years (0.99; IQR: 0.92–1.03) and those who smoked P = 0.005). Our findings suggest that CCSs have an increased risk for future obstructive and restrictive lung disease. Follow-up is needed to determine whether smoking imparts more than additive risk. Smoking prevention and cessation need to be a priority in this population. Cancer Epidemiol Biomarkers Prev; 23(9); 1938–43. ©2014 AACR.

PDF file - 77K, SJLIFE cohort showing final pulmonary function testing cohort.

PDF file - 57K, Frequency of demographic and treatment characteristics among SJLIFE participants who did or did not undergo PFT and non-participants exposed to pulmonary toxic therapy.

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PDF file - 62K, Pulmonary function among adult survivors of childhood cancer who were treated with toxic radiation and no chemotherapy.

There is ample evidence that Mental Health Courts (MHCs) are effective in reducing recidivism for participants who are mentally ill. This study will examine if MHCs are effective for the large number of clients with mental illness who abuse substances. Participants in Brevard County Florida’s Mental Health Court (N = 118) were examined for a history of substance arrests. Those with a substance history (n = 63) were compared to those without a substance history and examined for the outcome variables of days free before rearrest, severity of rearrest, and offense type (e.g., substance related, etc.). A history of substance arrests resulted in more rearrests for any offense at 1 year and more rearrests for a substance offense 3 years post-MHC, compared to participants without prior substance arrests. A survival analysis demonstrated that more MHC graduates without substance arrest history were able to remain arrest free in the community than those with substance arrest history. For those participants with a substance arrest history, graduating MHC was associated with less rearrests in general, less substance rearrests, and less severe rearrests than their non-graduating comparison group. Within the first 6 months of leaving MHC, the amount of substance arrests before they enter the program predicts the amount of substance offenses committed after they leave the program, and the association is much stronger in those who do not graduate MHC. Findings suggest that MHC has a significant impact even on those with co-occurring disorders. However, they are at greatest vulnerability to relapse with substances within the first 6 months after leaving MHC, suggesting greater substance-specific supports in the community for dually diagnosed participants may be beneficial.

Better communication between families, schools, communities, and clinicians is critical for improved skin cancer prevention initiatives for children and adolescents. Contributions from research in this area, as exemplified by the two studies in this special issue, will help shape priorities for future sun protection research and will be useful in generating evidence-based policy to support sun safety for children and reduce their future skin cancer risk.

PURPOSE: To examine the association between posttraumatic stress symptoms (PTSS), neurocognitive and psychosocial late-effects, health behaviors, and healthcare utilization in long-term survivors of childhood cancer. METHODS: Participants included individuals (N=6844; 52.5% female; mean [SD] age at diagnosis =7.6[5.8], at follow-up =34.9[7.5]) in the Childhood Cancer Survivor Study (CCSS). Follow-up included the Posttraumatic Stress Scale, Brief Symptom Inventory-18, Short-form 36 Health-related quality of life (HRQOL) survey, CCSS Neurocognitive Questionnaire, and questions about sociodemographics, physical health, health behaviors and healthcare utilization. Modified Poisson regression and multinomial logistic regression models examined associations between post-traumatic stress symptoms (PTSS) and neurocognitive, HRQOL, health behavior, and healthcare outcomes when adjusting for sociodemographics, disease, and treatment. RESULTS: Long-term survivors with PTSS (N= 995, 14.5%) reported more impairment in mental (relative risk [RR] 3.42, 95% confidence interval [CI] 3.05–3.85) and physical (RR=2.26, CI= 1.96–2.61) HRQOL. PTSS was also associated with increased impairment in task efficiency (RR=3.09, CI=2.72–3.51), working memory (RR=2.55, CI= 2.30–2.83), organization (RR=2.11, CI= 1.78–2.50) and emotional regulation (RR=3.67, CI=3.30–4.09). Survivors with PTSS were significantly more likely to attend cancer-specific health visits in the past 2-years (OR=1.89, CI=1.50–2.39), and showed greater likelihood of either high frequency (OR= 1.89, CI= 1.50–2.39) or complete lack of (OR=1.63, CI=1.32–2.01) primary care visits compared to survivors without PTSS. CONCLUSIONS: Survivors with PTSS reported significantly more psychosocial and neurocognitive late effects, and were more likely to engage in variable use of healthcare. IMPLICATIONS FOR CANCER SURVIVORS: PTSS is associated with additional challenges for a population vulnerable to adverse late effects. Inclusion of integrative services during follow up visits may benefit functional outcomes.

This study examined whether an intervention designed to reduce secondhand smoke exposure (SHSe) among children being treated for cancer had effects in the specific setting of a motor vehicle. The parents or guardians (n = 71) of children being treated for cancer were randomized to either a behavioral secondhand smoke (SHS) reduction program or a standard care control group. Parental reports of SHSe were collected over the course of 12 months. Younger children were exposed at baseline more than their older counterparts. The greatest initial declines in car exposure were observed among children ≤5 years old in the intervention group compared with same-aged peers in the control group. After the 3-month time point, the control group showed greater reductions in car exposure in comparison with the intervention group. Interventions that teach parents strategies to manage their smoking while driving in their personal vehicles may produce even greater reductions in child exposure and should be developed. Based on the age-specific results reported here, future studies should account for effects of child age and use setting-specific measures of SHS.

Introduction: The current study examined home and full (i.e., home plus car) smoking ban adop- tion as secondary outcomes to a randomized controlled trial targeting reduced secondhand smoke exposure (SHSe) for children under treatment for cancer. Methods: Families with at least 1 adult smoker who reported SHSe for their children (n = 119) were randomized to control or intervention conditions and followed for 1 year with 5 assessments. Both groups were advised of the negative health outcomes associated with SHSe; the interven- tion group provided more in-depth counseling from baseline to 3 months. Parents reported on household and car smoking behavior, demographic, psychosocial, and medical/treatment-related information. Results: Regardless of group assignment, there was an increase in home (odds ration (OR) = 1.16, p = .074) and full (OR = 1.37, p = .001) smoking ban adoption across time. Families in the interven- tion group were more likely to adopt a full ban by 3 months, but this difference was nonsignificant by 12 months. Married parents (OR = 2.33, p = .006) and those with higher self-efficacy for control- ling children's SHSe (OR = 1.11, p = .023) were more likely to have a home smoking ban; parents who reported smoking fewer cigarettes were more likely to adopt a home (OR = 1.62, p < .0001) or full (OR = 7.32, p = .038) ban. Conclusions: Smoking bans are in-line with Healthy People 2020's tobacco objectives and may be more feasible for parents with medically compromised children for immediate SHSe reduction. Furthermore, interventions targeting full smoking bans may be a more effective for comprehen- sive elimination of SHSe.

Few studies have examined adolescent reporting accuracy for secondhand smoke exposure (SHSe), and never for youth with cancer. SHSe reporting from adolescents being treated for cancer (Mage=14.92 years, SD=1.67) was examined against parent/guardian reports and urine cotinine among 42 adolescent–parent dyads. Number of days in hospital-based lodgings prior to assessment emerged as the strongest predictor of urine cotinine (β=−0.46, p=0.003) and adolescent SHSe reporting significantly predicted urine cotinine (β=0.37, p=0.011) beyond relevant demographic and contextual variables (overall R2=0.40, F(6, 35)=3.90, p=0.004). Findings support adolescents as accurate reporters of discrete SHSe occurrences.

Objectives To examine smoking restrictions in households of children with cancer and their effect on biological measures of children's secondhand smoke exposure (SHSe). Methods A sample of 135 parents of nonsmoking children with cancer who lived with a smoker completed structured interviews. Results Approximately 43% of families prohibited smoking in the home. Children living in homes that prohibited smoking had median cotinine levels that were 71% and 52% lower than did those from homes with no and partial restrictions. Conclusions Parents should be directed to completely ban all smoking from the home and car to best protect their children from SHSe.

Adolescent survivors of childhood cancer are more vulnerable to the consequences of health risk behaviors because of the late effects of their disease and its treatment. Decision making related to risk behaviors is important as they have reached an age during which initiation of substance use risk behavior is common.Factors associated with decision making and substance use behaviors (smoking, alcohol use, and illicit drug use) were identified among adolescent survivors of childhood cancer, the role of cognitive function was examined, and their rates of substance use behaviors were compared to a sample from the general population.A cohort of 243 adolescent survivors, ages 14-19 years, participated who were recruited from three cancer centers (St. Jude Children's Research Hospital, Hackensack University, and Long Beach Medical Center). A cross-sectional survey was used to assess cognitive and psychosocial factors for a presenting clinical profile to predict quality decision making and substance use behaviors. Validated measures using online data entry were obtained at the time of their annual visit for evaluation of late effects of treatment. Cancer and treatment factors were abstracted from the medical record. Eight factors (nine for substance use risk behavior) were examined in two regression models, quality decision making and substance use.In the model to predict poor-quality decision making for this cohort, gender and risk motivation (a surrogate for resiliency to social influence) were each significant predictors, with male gender and less resiliency each associated with poor decision making. Significant predictors of lifetime substance use were older presenting age, lower resiliency to social influence, poorer abstract ability (representing executive function impairment), history of current school problems, and negative substance use risk behavior modeling by household members and closest friend; CNS-associated late effects were only marginally associated. For current substance use, three factors remained significant in this cohort: older presenting age, lower resiliency, and negative risk behavior modeling.Study results characterize a presenting clinical profile for adolescent survivors with poor-quality decision making regarding substance use risk behaviors that will be helpful to health professionals counseling teen survivors about the impact of risk behaviors on disease-and treatment-related late effects.

This study assessed the prevalence of smoking restrictions among households of survivors of childhood and young adult cancer who smoke. It also examined the relationship between home smoking restrictions and motivation to quit smoking, as well as other smoking, psychosocial, and environmental factors.Participants included 374 smokers who were childhood or young adult cancer survivors (between the ages of 18 and 55 years) recruited from five cancer centers to participate in a randomized smoking cessation trial. Survivors completed baseline measures about the smoking restrictions in their households, their smoking behavior, and related psychological and environmental factors, which are the focus of the current manuscript.Almost 54% of survivors reported that smoking was prohibited in their households. Living with a nonsmoking partner, having a strict smoking policy at work, and not being nicotine dependent all increased the likelihood of having a total home smoking ban. Participants who were older, smoked more cigarettes per day over the prior week, and received prior chemotherapy were less likely to reside in households that adopted total bans.Findings suggest that socio-environmental factors and current smoking behaviors are associated with complete smoking restrictions in the homes of survivors. These factors should be considered when communicating with survivors about the importance of establishing strict smoking policies in their private residences.

Background Acute lymphoblastic leukemia (ALL) and brain tumor (BT) survivors are at risk for post-treatment IQ declines. The extent to which lower scores represent global cognitive decline versus domain-specific impairment remains unclear. This study examined discrepancies between processing speed and estimated IQ (EIQ) scores and identified clinical characteristics associated with score discrepancies in a sample of pediatric cancer survivors. Procedure Survivors (50 ALL, 50 BT) ages 12–17 years completed cognitive testing. The Wechsler Abbreviated Scale of Intelligence provided an untimed measure of general reasoning ability (EIQ). The age-appropriate Wechsler Intelligence Scale provided a Processing Speed Index (PSI) score. Scores were examined and compared. Results Survivors' PSI scores were lower than their EIQ scores (BT t(45) = 6.3, p

This study evaluated whether a self-administered stress management training (SSMT) could improve quality of life (QOL) and reduce distress among Hispanics receiving chemotherapy across multiple community clinical settings. Participants were randomized to receive SSMT (n = 106) or usual care (UCO) (n = 113). The primary outcome—QOL (SF-36) and secondary outcomes depression (CES-D), and anxiety (STAI) were assessed longitudinally over four chemotherapy cycles. Acculturation (BAS) and patients’ intervention adherence were assessed. About 63% of participants reported distress after the initial chemotherapy cycle. Hispanics with lower acculturation reported greater STAI-Trait scores (p = .003). No significant treatment effects on outcomes measures were observed for participants receiving SSMT. SSMT intervention techniques were reported useful and improved mental health scores were observed with patients on a psychotropic agent (p = .04). Hispanics experience an elevated level of distress, yet SSMT did not significantly improve primary outcomes. SSMT may be potentially effective when combined with a psychotropic agent. SSMT enhancing strategies are discussed.

Objective This randomized controlled trial tested the efficacy of parent-based behavioral counseling for reducing secondhand smoke exposure (SHSe) among children with cancer. It also examined predictors of smoking and SHSe outcomes.

Children with cancer are at greater risk for the negative consequences of secondhand smoke exposure, making the identification of predictors of exposure critical. The current study investigated the impact of parents' psychosocial variables (perceived stress and vulnerability, self-efficacy), as well as health-related and demographic variables, on children’s current exposure levels. Data were from 135 families whose children (M = 8.6 years old) lived with a smoker and were being treated for cancer. Self-efficacy was the consistent significant psychosocial predictor of exposure and the time since a child’s diagnosis was indicative of lower exposure when limiting the sample to only smoking parents ( n = 95). Both predictors of exposure have implications on motivation for behavioral change and may be suggestive of a teachable moment. Interventions may profit from tailoring programs to families based on these predictors of exposure, in particular for tobacco-based interventions for parents of medically compromised children, such as children with cancer.

Objectives To describe the psychological needs of adolescent survivors of acute lymphoblastic leukemia (ALL) or brain tumor (BT), we examined the following: (i) the occurrence of cognitive, behavioral, and emotional concerns identified during a comprehensive psychological evaluation and (ii) the frequency of referrals for psychological follow-up services to address identified concerns. Methods Psychological concerns were identified on measures according to predetermined criteria for 100 adolescent survivors. Referrals for psychological follow-up services were made for concerns previously unidentified in formal assessment or not adequately addressed by current services. Results Most survivors (82%) exhibited at least one concern across domains: behavioral (76%), cognitive (47%), and emotional (19%). Behavioral concerns emerged most often on scales associated with executive dysfunction, inattention, learning, and peer difficulties. Cranial radiation therapy was associated with cognitive concerns, χ2(1, N = 100) = 5.63, p

Background Few studies have examined risk factors for smoking among adolescent survivors of childhood cancer. The present study reports on the rate of smoking and identifies factors associated with smoking in a sample of adolescent survivors from the Childhood Cancer Survivor Study (CCSS). Procedure Participants included 307 adolescent survivors and 97 healthy siblings (ages 14–20) who completed a self-report survey of health, quality of life, and health behaviors. Results Smoking rates did not differ significantly between survivor and sibling groups (ever smokers: 28% vs. 33%, recent smokers: 10% vs. 9%, respectively). Ever smoking was significantly associated with peer smoking, smokers in the household, binging, suicidal behavior, and no history of CRT. There were significant interactions of peer smoking with gender and CRT for ever smoking and with binging for recent smoking. Recent smoking was more likely for survivors with other household smokers (RR = 2.24, CI = 1.21–4.16), past suicidality (RR = 1.89, CI = 1.00–3.56), and no CRT (RR = 2.40, CI = 1.12–5.17). Among survivors with few smoking friends, ever smoking was more likely for survivors with no CRT (RR = 4.47, CI = 1.43–13.9), and recent smoking was more likely among survivors who binged (RR = 3.37, CI = 1.17–9.71). Conclusions Despite the health risks associated with survivorship, nearly one in three adolescent survivors of childhood cancer has smoked. Exposure to other smokers, in particular, appears to increase the likelihood of smoking for some survivors. Providing smoking cessation programs targeted to family members, helping survivors choose non-smoking friends, and teaching ways to resist smoking influences from peers may be important pathways for smoking prevention with adolescent survivors. Pediatr Blood Cancer 2012; 58: 428–434. © 2011 Wiley Periodicals, Inc.

Background Post-treatment attention problems experienced by pediatric cancer survivors have been described as similar to symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD) experienced in physically healthy children. Accordingly, the objectives of this study were to: (a) estimate the rate of occurrence of ADHD and secondary ADHD (SADHD) in a sample of pediatric cancer survivors, (b) compare the rate of ADHD/SADHD among survivors to the prevalence of ADHD in the general population, and (c) examine clinical correlates of ADHD/SADHD in this sample.

The present study examines behavioral and psychosocial factors associated with smoking intentions and experimentation among adolescent survivors of pediatric cancer.Adolescent survivors of brain tumor and acute lymphoblastic leukemia (n = 99) provided information about their smoking histories and their intentions to smoke in the future. Behavior rating scales were completed by survivors, parents, and teachers.Past experimentation with smoking and higher levels of self-reported aggression were associated with intentions to smoke in the future (OR = 4.18, 95% CI 1.02-17.04, and OR = 1.08, 95% CI 1.01-1.15, respectively), while teacher-ratings of inattention in the classroom were negatively associated with intentions to smoke (OR = 0.94, 95% CI.88-.99), all p .05. Experimentation with smoking was more likely among older survivors (OR = 1.76, 95% CI 1.16-2.66, p .01) and those whose parents had divorced (OR = 4.40, 95% CI 1.21-16.06, p .05).A concerning minority of adolescent survivors have clear intentions to smoke, a behavior that adds to their overall health risk. Smoking intentions and experimentation are important precursors to regular smoking. Prevention efforts are needed to interrupt the progression from intentions and experimentation to established smoking and nicotine dependence in this medically vulnerable population.Assessment of an adolescent's history of parental divorce, past experimentation with smoking, and aggressive behavior will identify those survivors who are likely to consider smoking in the future. Screening for these characteristics will allow clinicians to be more vigilant in health promotion.

Introduction: Previous research has suggested that childhood cancer survivors initiate smoking at rates approaching those of healthy individuals, even though smoking presents unique risks to survivors. The present study explores whether the attentional and executive functioning (EF) deficits associated with cancer and treatment place survivors of childhood cancer at increased risk for smoking. Methods: Data from the Childhood Cancer Survivor Study were examined to identify concurrent and longitudinal correlates of tobacco use. We explored whether childhood attention problems and adulthood executive dysfunction were associated with smoking among adult survivors of childhood cancer. Results: Childhood attention problems emerged as a striking predictor of adult smoking nearly a decade later on average. Nearly half (40.4%) of survivors who experienced attention problems in childhood reported a history of smoking, a significantly higher rate of ever smoking, than reported by those without childhood attention problems (relative risk [RR] = 1.53, 95% CI = 1.31―1.79). Furthermore, they were nearly twice as likely to be current smokers in adulthood compared with those without childhood attention problems (RR = 1.71, 95% CI = 1.38―2.11). Similar associations were found between components of adult executive dysfunction and adult smoking. Discussion: Childhood cancer and treatment are associated with subsequent deficits in attention and EF. Early detection of these deficits will allow clinicians to identify patients who are at increased risk for smoking, an important step in promoting and maintaining health in this medically vulnerable population.

Tobacco use and exposure to secondhand smoke (SHS) are significant behavioral health problems that can result in a range of well-documented negative health consequences for children and adolescents (Gold et al., 1996; Prokhorov, Emmons, Pallonen, & Tsoh, 1996; US Department of Health and Human Services [USDHHS], 2000). The American Academy of Pediatrics (AAP) has issued a number of policy statements in the past 5 years that have identified tobacco prevention and cessation as well as SHS reduction as issues that are crucial to children’s health (AAP, 2001; Winickoff, Hillis, Palfrey, Perrin, & Rigotti, 2003b). Likewise, current national health objectives (Healthy People 2010) include reducing the initiation of tobacco use among children and adolescents, increasing cessation attempts by current smokers, and reducing the proportion of youngsters who are regularly exposed to tobacco smoke in the home (Centers for Disease Control and Prevention [CDC], 2004; USDHHS, 2000). The most recent US Surgeon General’s report has also brought the topic of children’s involuntary exposure to SHS to the national forefront once again (USDHHS, 2006). Although these are important health objectives for all children, they are especially important for children with a chronic illness, whose risks for tobacco-related health problems are magnified because of their vulnerable health status. Disease and treatment-related complications and toxicities that accompany many childhood chronic illnesses are likely to be exacerbated by cigarette smoking and exposure to SHS. High-risk groups include, but are not limited to children with medical conditions including asthma, cancer, cancer survivors, cystic fibrosis, diabetes, and those with elevated cardiovascular risk factors. There is a critical need to examine and evaluate tobacco prevention and control efforts for medically at-risk children and adolescents, as the estimates of morbidity and mortality attributable to tobacco use and SHS exposure in these vulnerable populations are likely significant. Investigators from a broad array of disciplines, with research agendas in tobacco control and health promotion, were invited to submit manuscripts for this special issue. Authors were selected that represented a balanced, yet broad cross-section of expertise in that they worked with children across different disease groups as well as healthy children. No forum has existed, to date, for the purpose of providing an exchange of information among researchers conducting tobacco-related studies with pediatric populations. Clearly, there are gaps in existing knowledge and a lack of focus on critical issues that could significantly advance the field. The articles presented in this special series provide a critical evaluation of the medical, psychological, behavioral, and public health aspects of tobacco control initiatives for children with chronic medical conditions and identify challenges for future pediatric tobacco control research. The goal of this issue was to expand tobacco control research efforts beyond the primary medical settings to medically at-risk children treated in specialty clinics. The articles in this series are organized around four content areas: (a) developmental and psychosocial aspects of cigarette smoking onset and prevention; (b) smoking cessation; (c) reduction of SHS exposure; and (d) outcomes/endpoints for tobacco trials and related measurement issues. This special issue provides evidence of scientific progress to date in these respective areas and also addresses future tobacco initiatives. Several recurrent

Although radiation therapy is a non-invasive and painless form of cancer therapy, distress reactions often occur among children and parents undergoing these procedures. This randomized 2 group clinical trial (N = 80) reports on the efficacy of a pediatric interactive-educational intervention regarding both parent and child distress outcomes. As predicted, parents in the intervention condition experienced greater reductions in trait anxiety, t(78) = 1.68, p < .05; and rated the intervention as significantly more effective in reducing pediatric procedural distress, as compared to parents in the control condition, t(78) = 1.74, p < .05. These findings suggest that interactive-educational interventions designed to reduce pediatric distress may generalize to parents, and highlight the importance of including parents in pediatric procedural interventions.

OBJECTIVES. The purpose of this work was to identify demographic, medical, and psychosocial variables that predict radiation therapy–related distress among pediatric patients with cancer. PATIENTS AND METHODS. Seventy-nine children between the ages of 2 and 7 years were consecutively enrolled in the study. Radiation therapy–related distress was measured by rates of anesthesia, observed behavioral distress, and heart rate. RESULTS. Younger age and higher observed behavioral distress predicted the use of anesthesia, higher baseline heart rate predicted lower initial observed behavioral distress, and prone treatment position was associated with increases in both observed behavioral distress and heart rate relative to baseline. CONCLUSIONS. Modifiable treatment and psychological variables directly relate to pediatric radiation therapy–related distress. Implementation of developmentally appropriate and cost-effective interventions to reduce procedural radiation therapy distress is warranted.

Childhood cancer survivors are at risk for health complications secondary to cancer treatment, and these late effects may be exacerbated by organ dysfunction, aging, and unhealthy behaviors. Despite their vulnerable health profiles, survivors engage in risky health behaviors at alarming rates, that are, in many instances, comparable to their peers who have never been treated for cancer. Tailored, lifestyle interventions that promote healthy behavioral practices and risk reduction strategies have been modestly effective across behaviors. This chapter will review prevalence, risk factors, and interventions that have been conducted to date with childhood cancer survivors in the areas of tobacco use, alcohol and illicit drug use, physical activity, nutrition, sun exposure, and risky sexual behavior. Recommendations for intervening with survivors in the healthcare setting to promote healthy behavior change will be provided.

Engaging in smoking is particularly risky for children and adolescents with chronic illness whose health status is already compromised because of disease- and treatment-related complications. Yet, some of these youngsters smoke at rates at least comparable to those of their healthy peers. To date, few randomized smoking-prevention and cessation trials have been conducted in children with chronic medical problems. In this review we report on the smoking rates among youngsters with chronic illness, identify specific disease- and treatment-related complications that can be exacerbated by smoking, examine risk factors associated with tobacco use among medically compromised youngsters, and review smoking interventions that have been conducted to date with pediatric populations in the health care setting. The following chronic illnesses are included in this review: asthma, cystic fibrosis, cancer, sickle cell disease, juvenile-onset diabetes, and juvenile rheumatoid arthritis. Objectives for a tobacco-control agenda and recommendations for future tobacco studies in chronically ill pediatric populations are provided. Finally, tobacco counseling strategies are suggested for clinicians who treat these youngsters in their practices.

Objective The purpose of this article is to review the role of behavioral research in disease prevention and control, with a particular emphasis on lifestyle- and behavior-related cancer and chronic disease risk factors—specifically, relationships among diet and nutrition and weight and physical activity with adult cancer, and tracking developmental origins of these health-promoting and health-compromising behaviors from childhood into adulthood. Method After reviewing the background of the field of cancer prevention and control and establishing plausibility for the role of child health behavior in adult cancer risk, studies selected from the pediatric published literature are reviewed. Articles were retrieved, selected, and summarized to illustrate that results from separate but related fields of study are combinable to yield insights into the prevention and control of cancer and other chronic diseases in adulthood through the conduct of nonintervention and intervention research with children in clinical, public health, and other contexts. Results As illustrated by the evidence presented in this review, there are numerous reasons (biological, psychological, and social), opportunities (school and community, health care, and family settings), and approaches (nonintervention and intervention) to understand and impact behavior change in children’s diet and nutrition and weight and physical activity. Conclusions Further development and evaluation of behavioral science intervention protocols conducted with children are necessary to understand the efficacy of these approaches and their public health impact on proximal and distal cancer, cancer-related, and chronic disease outcomes before diffusion. It is clear that more attention should be paid to early life and early developmental phases in cancer prevention.

Purpose/objectives To learn from female survivors of Hodgkin disease about their perceptions of their current health status and future health risks, self-care practices to prevent or diminish health risks, and what kind of breast health program could benefit them, including the most effective methods and optimal times for learning about breast health. Design Participatory research using focus groups. Setting Urban pediatric cancer center. Sample 1 African American and 19 Caucasian female survivors of Hodgkin disease aged 16-26 years, diagnosed at least two years before the start of the study, and treated with mantle radiation therapy. Participants were recruited during visits to an outpatient clinic. Methods Six open-ended questions were asked during three separate focus group sessions. Transcribed data were evaluated by content analysis techniques and analyzed to identify common themes. Main research variables Current health status and perceived health risks, current health practices, and effective methods and timing for breast health teaching. Findings Survivors reported feeling damaged by their cancer and its treatment and perceived that they were at risk for breast cancer. Self-care and risky behaviors also were reported. Internal influences (e.g., fear) and external influences (e.g., family) motivated survivors to participate in health promotion activities. Effective methods identified for learning about breast health included having access to other survivors, being respected as an adult, and having one-on-one staff teaching and peer support. The preferred timing of teaching varied, but survivors generally supported a gradual provision of information. Conclusions A positive listening environment is important for developing a breast health program for survivors. An essential first step is to create an opportunity for survivors to tell about their experiences with cancer, including its impact on their lives. Information regarding breast health must be provided in multiple formats during and after treatment if good practices are to be undertaken. Implications for nursing The provision of adequate information during and after therapy as well as peer counseling in a positive listening environment are important in helping survivors participate in health promotion activities.

Purpose This prospective, longitudinal study examined the effects of risk-adapted craniospinal irradiation (CSI) dose and the interactions of dose with age and time from diagnosis on intelligence quotient (IQ) and academic achievement (reading, spelling, and math) among patients treated for medulloblastoma (MB). Patients and Methods Patients received serial neurocognitive testing spanning from 0 to 6.03 years after diagnosis (median, 3.14 years). The multi-institutional study included 111 patients, who were 3 to 20 years of age at diagnosis (median age, 7.4 years), treated for MB with risk-adapted CSI followed by four cycles of high-dose chemotherapy (cyclophosphamide, cisplatin, and vincristine) with stem-cell support. High-risk patients (HR; n = 37) received CSI to 36 to 39.6 Gy and conformal boost treatment of the primary site to 55.8 to 59.4 Gy. Average-risk patients (AR; n = 74) received CSI to 23.4 Gy and conformal boost treatment of the posterior fossa to 36.0 Gy and primary site to 55.8 Gy. Results Multivariate modeling revealed statistically significant declines in mean IQ (−1.59 points/yr; P = .006), reading (−2.95 points/yr; P < .0001), spelling (−2.94 points/yr; P < .0001), and math (−1.87 points/yr; P = .003) scores for the entire group. The effects of risk-adapted radiation therapy on IQ, reading, and spelling were moderated by age, with the greatest rates of decline observed for the HR patients who were younger (< 7 years old) at diagnosis. Conclusion Young age at diagnosis was the most prominent risk factor for neurocognitive deficits among survivors of MB despite reductions in CSI dosing and efforts to limit the boost volume. Younger patients exhibited substantial problems with the development of reading skills.

Objective This study examines the relation between cognitive-motivational variables and self-reported health behaviours among adolescents. Design Cross-sectional survey of adolescents via questionnaires delivered in classrooms. Setting One large junior high school and two senior high schools located in the Memphis area. Method Data from 257 7th to 12th graders were used to determine their practice of health behaviours as well as their perceptions of health status and vulnerability, optimism and rebelliousness/risk taking. Results Adolescent males and females who were less rebellious and had better health perceptions reported healthier behavioural practices. A stronger significant inverse relationship between perceived vulnerability and health behaviour scores was found for females. Optimism was significantly and positively correlated with health behaviour scores only among females. Adolescents in lower grades obtained higher health behaviour scores than adolescents in higher grades. Males had higher rebelliousness scores than females. Demographic and cognitive- motivational variables accounted for 26 per cent of the variance in health behaviour scores. Conclusion Cognitive-motivational factors should be considered when designing health promotion programmes for adolescents.

For 303 children newly diagnosed with cancer, we investigated the prevalence of parental smoking and examined patients’ respiratory or pulmonary symptoms according to household smoking status. Results indicated that approximately 45 percent of patients came from households with at least one current parent smoker and 20 percent of current non-smoking parents reported past tobacco use. There was a trend for more patients from smoking households to experience respiratory problems than patients from non-smoking households ( p = .068). In conclusion, many patients are at risk for parental smoke exposure and associated health problems if they are continually exposed during therapy. Clinician-delivered interventions to reduce environmental smoke exposure are clearly warranted.

Background Improved cure rates for childhood cancer have produced a growing population of survivors at risk for late toxicities of chemotherapy and radiation therapy. Healthy behaviors can modify these risks. We initiated a controlled prospective trial to determine if a multi-component behavioral intervention could induce change in childhood cancer survivors' health knowledge, health perceptions, and practice of health-protective behaviors. Procedure Adolescent cancer survivors attending a long-term follow-up clinic were randomized to receive standard follow-up care or standard care plus the educational intervention. Baseline measures were obtained at randomization (T0) and repeated 1 year (T1) later during the survivors' annual check-up. Results Of 272 patients enrolled and randomized, 251 are evaluable at both time points. Treatment and control groups were similar in regards to diagnosis, gender, race, and age. The change in outcome measures over the year (T1−T0) was not significantly different between the two groups as assessed by a two-sample pooled t test. However, additional exploratory analyses indicated a significant gender difference in knowledge with female survivors in the intervention group having higher scores. In addition, patients who choose certain individual health goals, such as breast/testicular self-examination, showed improved practice of the health behavior. In addition, in a very exploratory analysis, a gender difference in response to the intervention was noted, with females exhibiting a greater improvement in knowledge scores than did males. Conclusions Although the multi-behavioral educational intervention did not induce change in health knowledge, perceptions, and behaviors of childhood cancer survivors for the treatment group as a whole, gender differences and specific health goal differences were found. These findings suggest that future interventions should be tailored to reflect gender differences and the nature of the health goal under assessment. Med Pediatr Oncol 2002;39:2–11. © 2002 Wiley-Liss, Inc.

Introduction Adolescents with cancer are susceptible to the health consequences associated with secondhand smoke exposure (SHSE) and tobacco use. The present study compared tobacco use, exposure, and risk factors between patients and population peers. Method Self-reported data on tobacco use, SHSE, and tobacco-related risk factors were drawn from a pediatric oncology hospital and the National Youth Tobacco Survey. Conditional logistic regression was used to estimate odds ratios for patients and control subjects. Results Patients were as likely to have tried tobacco and report home SHSE as control subjects. Patients were more likely to report car SHSE, less likely to report that SHSE is harmful, and less likely to report home smoking bans. Discussion Patients experienced SHSE, tobacco use, and tobacco-related risk factors at rates greater than or equal to control subjects. These results provide support for consideration of intervention targets, health status, and delivery mechanisms, particularly by health care providers, when developing comprehensive tobacco control strategies.

Background: Survivors of pediatric brain tumors (BT) and acute lymphoblastic leukemia (ALL) are at risk for neurocognitive late effects related to executive function. Procedure: Survivors of BT (48) and ALL (50) completed neurocognitive assessment. Executive function was compared to estimated IQ and population norms by diagnostic group. Results: Both BT and ALL demonstrated relative executive function weaknesses. As a group, BT survivors demonstrated weaker executive functioning than expected for age. Those BT survivors with deficits exhibited a profile suggestive of global executive dysfunction, while affected ALL survivors tended to demonstrate specific rapid naming deficits. Conclusion: Findings suggest that pediatric BT and ALL survivors may exhibit different profiles of executive function late effects, which may necessitate distinct intervention plans.

Treatments for childhood cancer can impair pulmonary function. We assessed the potential impact of cigarette smoking on pulmonary function in 433 adult childhood cancer survivors (CCS) who received pulmonary-toxic therapy, using single breath diffusion capacity for carbon monoxide corrected for hemoglobin (DLCOcorr), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC). FEV1/FVC median values among current [1.00; interquartile range (IQR): 0.94–1.04] and former smokers (0.98; IQR: 0.93–1.04) were lower than those who had never smoked (1.02; IQR: 0.96–1.06; P = 0.003). Median FEV1/FVC values were lower among those who smoked ≥ 6 pack-years (0.99; IQR: 0.92–1.03) and those who smoked

Tobacco use and exposure are preventable causes of morbidity and mortality. Whereas the impact of this public health issue is well described in adults with kidney disease, its role in the pediatric chronic kidney disease (CKD) population is largely unknown. This review discusses the prevalence of tobacco use and exposure in children with CKD, updates the reader on how tobacco affects the kidney, and presents intervention strategies relevant to this patient population.

Objectives: Elevated body mass index (BMI) has been reported in pediatric cancer survivors. It is unclear whether this is related to altered energy intake (via disordered eating), decreased energy expenditure (via limited exercise), or treatment-related direct/indirect changes. The aims of this study are to describe the occurrence of overweight and obesity, exercise frequency, and the extent of disordered eating patterns in this sample of survivors, and to examine relationships among BMI, eating patterns, exercise frequency, and demographic and disease and treatment-related variables to identify those survivors most at risk for overweight/obesity. Methods: This cross-sectional study recruited 98 cancer survivors (50 acute lymphoblastic leukemia [ALL], 48 brain tumor [BT]), aged 12 to 17 years and ≥12 months posttreatment from a large pediatric oncology hospital. Survivors completed health behavior measures assessing disordered eating patterns and physical activity. Clinical variables were obtained through medical record review. Univariate analyses were conducted to make comparisons on health behaviors by diagnosis, gender, treatment history, and BMI category. Results: Fifty-two percent of ALL survivors and 41.7% of BT survivors were classified as overweight/obese. Overweight/obesity status was associated with higher cognitive restraint (odds ratio = 1.0; 95% confidence interval = 1.0-1.1). Only 12% of ALL survivors and 8.3% of BT survivors met Centers for Disease Control and Prevention guidelines for physical activity. Males reported more physical activity, t(96) = 2.2, P < .05. Conclusions: Overweight/obese survivors may attempt to purposefully restrict their food intake and rely less on physiological cues to regulate consumption. Survivors should be screened at follow-up for weight-related concerns.

There is clearly a need to develop effective health promotion interventions for adolescent cancer survivors, given their increased susceptibility to adverse health risks if they practice unhealthy behaviors. Approaches typically used with healthy adolescents may not be highly effective with young cancer patients given their unique educational needs secondary to their cancer treatment experience. Interventions that capitalize on the perceptions of increased health vulnerability, characteristic of cancer survivors, may serve to enhance the impact of more traditional health education approaches. This strategy can be conceptualized from a theoretical model that focuses on the relationship between perceptions of health risk and behavior. The application of this approach as it relates to health promotion with adolescent cancer survivors will be illustrated with an intervention targeting tobacco-use prevention and cessation in this vulnerable population.

Survivors of childhood cancer are a growing and vulnerable population. Cure rates for pediatric cancers now exceed 60% and, by the year 2000, an estimated 1 of every 1,000 young adults will be a cancer survivor. Because this population is at increased risk for late medical and neoplastic complications that impact adversely on health-related quality of life, it is important to investigate methods to promote risk reduction by motivating survivors to practice health-promoting behaviors. With this background, we initiated a prospective, randomized, controlled feasibility study in which survivors attending a long-term follow-up clinic were randomized to receive standard care or standard care plus an educational intervention. Our objectives were to determine if the intervention would improve the survivors' knowledge about their cancer treatment and risks of late effects and increase their practice of health-protective behaviors. Since July 1995, 272 of 318 families (86%) approached about the study agreed to participate. Of these, 266 are evaluable for assessment of baseline knowledge and health behaviors. Demographic features, baseline knowledge, health perceptions and health behaviors did not differ among randomized groups. Assessment of the intervention's efficacy at changing health behaviors of survivors randomized to the intervention group will be available when the 1-year follow-up evaluations are completed for the study cohort. Our preliminary experience with this pilot study supports the feasibility of educational intervention research in a specialty clinic dedicated to monitoring long-term childhood cancer survivors. Int. J. Cancer Suppl. 12:138-142, 1999.

Testing the stress-response sequence model in paediatric oncology nursing¶The causes and intensity of role-related stress experienced by paediatric oncology nurses, the nurses’ ability to respond to the stressors, and the professional and personal consequences of those stressors for the nurses are issues of concern for administrators and staff. The concern evolves from the anticipated relationships among stressors, the ability to cope with role-related stressors, and the expected negative outcomes such as resignation. However, the relationships among these components have not been previously measured concurrently in paediatric oncology nurses. The primary purpose of this study was to test the complete stress-response sequence model in a sample of paediatric oncology nurses by obtaining concurrent measures of the model’s individual components: nurses’ stressors, reactions, mediators, and consequences. A total of 126 nurses completed six questionnaires (Stressor Scale for Paediatric Oncology Nurses, Perceived Stress Scale, Measure of Job Satisfaction, Organized Commitment Questionnaire, Group Cohesion Scale, and Intent to Leave) and a demographic sheet. The majority of participating nurses were married, worked full-time and had worked 5 or more years in oncology. Qualitative data were analysed using a semantic content analysis technique. Relationships among the components of the model were examined using a two-stage least squares technique. The components were only weakly associated and unable to explain significant variation in each other. The combined qualitative and quantitative data indicate that an important explanatory variable — role-related meaning — is missing in the content model.

We examined the relation between children's trait-dependent coping styles and situation-specific coping behaviors during invasive medical procedures. Children with cancer (N = 66) completed the Children's Behavioral Style Scale (CBSS), a measure of approach-avoidant coping styles, and the Procedural Coping Questionnaire (PCQ), an analogous measure of coping behaviors specific to invasive procedures developed for this study. Parents also completed a parent-report version of the PCQ, and both parents and children rated the severity of the child's distress before, during, and after the procedure. Factor analysis of thePCQ produced 3 distinct factors with adequate internal reliability (attention to sensory stimuli, cognitive strategies, preference for sedation), none of which were directly interpretable within the CBSS approach-avoidant framework. CBSS scores did not significantly predict procedural distress, although the higher total coping behavior scores on the PCQ were associated with greater distress, su...

The purpose of this survey was to examine the composition and function of pain services/teams at facilities that provide pain management services to pediatric oncology patients across the United States. A questionnaire was mailed to facilities identified by the 1994 Pain Facilities Directory as providing pain services to cancer patients. Thirty-five facilities that identified oncology patients as one of the primary pediatric populations treated at their institution were the focus of this study. Eight facilities that managed bone marrow aspirations and/or lumbar punctures for pediatric oncology patients also participated in a telephone interview regarding analgesia/sedation practices for procedure-related pain. Provision of direct patient care was a primary function of the pain services surveyed, although delivery of services varied across settings. Postoperative and chronic pain were the most frequent reasons for referral. Only 17% and 3% of facilities had established written standard guidelines for pharmacological and nonpharmacological approaches to pain management, respectively. Most facilities reported using a local anesthetic and conscious sedation to manage bone marrow aspiration and lumbar punctures. Implications from these findings and recommendations for provision of pediatric pain services are discussed.

We evaluated efficacy of a cognitive-behavioral therapy (CBT) intervention compared to a standard care condition (SCC) in 55 pediatric patients with central nervous system cancer, aged 6 to 18 years, undergoing magnetic resonance imaging (MRI). There were no significant differences between the CBT and the SCC groups on child, parent, or staff ratings of MRI distress, child self-reports of expected MRI distress, or observed behavioral distress. The CBT intervention was effective, however, in reducing distress during intravenous line (IV) insertion preceding the index MRI on the basis of staff but not child or parent ratings of distress. No significant differences in need for sedation were present between the CBT and the SCC groups. Positive changes in staff-patient interactions and improved patient education regarding the MRI were apparent. Discussion focuses on recommendations for future studies examining cognitive-behavioral interventions in pediatric patients.

PURPOSE AND METHODS: The current status of tobacco use among young cancer patients and the acute and chronic complications associated with tobacco use in these patients is reviewed. RESULTS AND CONCLUSION: Studies report that adolescent cancer survivors use tobacco as much as their peers who have never been treated for cancer, despite the adverse consequences of engaging in this unhealthy habit. Health care professionals have the opportunity and responsibility to incorporate tobacco counseling as a routine component of medical care delivery. Nurse/physician-delivered smoking interventions have been found to promote smoking cessation in adults, although little effort has been devoted to the development of similarly effective smoking interventions for pediatric cancer patients who smoke. Components of existing smoking prevention/cessation curricula from successful school-based interventions and physician-delivered smoking interventions can be adapted and tailored to pediatric cancer patients in medical settings. Smoking interventions that educate patients about their increased vulnerability to tobacco-related consequences, relative to their healthy peers, may have an enhanced impact. Guidelines for conducting a comprehensive assessment of tobacco use and implementing smoking interventions with pediatric cancer patients is provided. Strategies for modifying the cancer patient's perceived vulnerability to tobacco-related consequences is also discussed.

Investigated the prevalence of anticipatory nausea and vomiting (ANV) among 59 pediatric cancer patients who had routinely received ondansetron (Zofran) antiemetic therapy and determined patient- and treatment-related factors associated with ANV. Of the sample, 59% indicated at least mild ANV symptoms, suggesting that a significant number of patients report ANV and are bothered by it, despite the use of Zofran. These children were compared to those reporting no ANV symptoms. Most ANV symptomatology was consistent with a traditional classical conditioning model although cognitive processes may also play a role. Children with greater expectations of severe postchemotherapy vomiting and those who were more distressed by nausea and vomiting were more likely to experience ANV symptoms. Implications for psychological and pharmacological treatments of ANV are discussed.

BackgroundSmoking among cancer survivors increases the risk of late effects and second cancers. This article reports on Partnership for Health-2 (PFH-2)—an effort to develop an effective and scalable version of Partnership for Health (PFH), which was a previously tested peer-delivered telephone counseling program that doubled smoking cessation rates among childhood cancer survivors who smoke. ObjectiveThis paper presents results from a randomized controlled trial evaluating the effectiveness of PFH-2 in targeted and tailored Web-based versus print formats. The overall goal was to determine whether the intervention outcomes in these self-guided scalable formats approximate what was found in a more intensive telephone counseling program. MethodsThis study was a randomized controlled trial with a 15-month follow-up that included 374 smokers who were survivors of childhood or young adult cancers, recruited from five survivorship clinics. Participants were randomly assigned to a Web-based or print format of the PFH intervention; all had access to free pharmacotherapy. The website was designed to provide new content at each log-on, and a peer counselor moderated a forum/chat feature. The primary outcome was smoking status at 15 months post randomization. ResultsIn total, 58.3% (77/132) of Web participants logged on at least once (mean visits 3.25). Using multiple imputation methods for missing data, there were similar rates of cessation in the two arms (print: 20/128, 15.6%; Web: 33/201, 6.4%), and no differences in quit attempts or readiness to quit. The quit rates were equivalent to those found in our previous telephone counseling intervention. There were high rates of satisfaction with both of the PFH-2 interventions. ConclusionsThe print and Web formats yielded equivalent levels of success to those found with our telephone-delivered intervention and are comparable to other Internet treatment studies. This study provides important options for survivorship programs that may not have resources for interpersonal forms of cessation counseling. Efforts to increase patient use of the interventions may result in higher cessation rates. Trial RegistrationClinicaltrials.gov NCT00588107; http://clinicaltrials.gov/ct2/show/NCT00588107 (Archived by WebCite at http://www.webcitation.org/6K1gJtFEC).

Nutritional problems often result from malignancies and aggressive multimodal treatment. Early identification of reliable risk factors associated with malnutrition and need for nutritional support is necessary for development of preventative approaches. Nutritional and treatment-related characteristics were examined for 173 pediatric oncology patients referred for nutritional support and a comparison sample of 43 patients matched on treatment protocol and/or diagnosis who had never been referred for nutritional support. Abnormally low serum albumin levels, poor oral intake, mucositis, prior radiation therapy, and increased gastrointestinal toxicity were significantly more frequent among referred than non-referred patients. A discriminant function analysis indicated that poor oral intake was the single best predictor of need for nutritional support. Patients with solid tumors were more nutritionally depleted at the time of referral; all bone marrow transplant patients received nutritional support. Patients with central nervous system (CNS) tumors required nutritional support for longer time periods. We conclude that routine documentation of poor oral intake (i.e., observation of change in a child's eating patterns) is the most reliable indicator of children who eventually require nutritional support and who may benefit from interventions that could delay or prevent nutritional problems. Prophylactic interventions should be tailored to meet the specific needs of individual diagnostic groups.