Survivor Study Research Articles

Natural Course of Posttraumatic Stress Disorder: A 20-Month Prospective Study of Turkish Earthquake Survivors

Natural Course of Posttraumatic Stress Disorder: A 20-Month Prospective Study of Turkish Earthquake Survivors

Pharmacotherapy to prevent PTSD: Results from a randomized controlled proof‐of‐concept trial in physically injured patients

Acute physical injury is frequently associated with mental health sequelae, which then accentuate disability and worsen functional outcomes. A pharmacological prevention approach to this problem has been proposed. This proof-of-concept study was a double-blind, randomized controlled trial of 14 days of the beta-blocker propranolol (n = 17), the anxiolytic anticonvulsant gabapentin (n = 14), or placebo (n = 17), administered within 48 hours of injury to patients admitted to a surgical trauma center. Of 569 accessible, potentially eligible subjects, 48 (8%) participated. Outcomes assessments were conducted at 1, 4, and 8 months postinjury. Although well tolerated, neither study drug showed a significant benefit over placebo on depressive or posttraumatic stress symptoms. Implications are discussed for future pharmacological prevention studies in survivors of acute traumatic injury.

Does Compensation Status Influence Treatment Participation and Course of Recovery from Post-Traumatic Stress Disorder?

We reviewed the empirical literature to examine how seeking compensation and/or being awarded compensation for posttraumatic stress disorder-related disability are associated with participation in mental health treatment and course of recovery. The search for relevant literature was conducted using the PubMed, PsycINFO, Medline, and PILOTS databases and yielded seven studies on veterans and five on motor vehicle accident survivors. The literature indicates that veterans who are seeking or have been awarded compensation participate in treatment at similar or higher rates than do their non-compensation-seeking counterparts. Veteran treatment outcome studies produced either null or mixed findings, with no consistent evidence that compensation-seeking predicts worse outcomes. Studies of motor vehicle accident survivors found no association between compensation status and course of recovery. Recommendations to strengthen future research in this area are provided, including using clear and consistent definitions of compensation status that differentiate compensation-seeking status from award status.

Post-diagnosis statin use and breast recurrence sites in early stage breast cancer survivors

To the Editor, We read the article by Kwan et al. [1] in which they showed an inverse association between post-diagnosis, lipophilic statin use and risk of breast cancer recurrence in a prospective cohort study of early stage breast cancer survivors. However, information related to the specific recurrence sites were not discussed in their study. Evidence from animal models suggests that activation of osteoclastmediated bone resorption is an essential step in the process of bone metastasis [2]. Bisphosphonates are class of agents most frequently used to reduce skeletal-related events in patients with bone metastases by inhibiting osteoclast activity through inhibition of mevolanate pathway. Relationship between statins and nitrogen-containing bisphosphonates has been established. Both drugs interfere with the same metabolic pathway. Both exert their activity in the mevalonate pathway This pathway leads to cholesterol synthesis and to protein prenylation, adding a lipid chain to transpeptidases such as Ras and Ras-like transpeptidases in the osteoclast membrane which in turn leads to activation of osteoclasts [3]. Furthermore, some studies showed that bisphosphonates might reduce or prevent the incidence of bone metastases by inhibiting tumour-induced osteoclastic resorption of bone when they are used as an adjuvant treatment of breast cancer [4, 5]. Therefore, we suggest that post-diagnosis, lipophilic statin use may reduce bone metastases more than other recurrence sites in early stage breast cancer survivors.

Health profiles of older women cancer survivors

Cancer survivors diagnosed at 65 years or older represent an understudied population in cancer survivorship research. Therefore, the purpose of this descriptive analysis was to look at the health profiles and interpersonal relationships of older women survivors of cancer. This is a descriptive, cross-sectional study of older women cancer survivors who represented a subset of respondents from a larger mailed study that surveyed long-term cancer survivors treated at The University of Texas M.D. Anderson Cancer Center. Focusing on breast cancer, the most common antecedent diagnosis, we compared survivors of breast cancer with age-matched survivors of other cancer types. We identified 213 survivors of breast cancer and compared them with 314 age-matched female survivors of other cancers as well as age-matched female representatives of the general population. Few distinctions were found between breast cancer survivors and survivors of other cancers in terms of health effects and both groups reported very good interpersonal relationships. Breast cancer survivors report generally similar long-term outcomes with age-matched survivors of other cancers. Information derived from breast cancer survivor studies may be broadly applicable to survivors of other cancers, at least in the older populations.

Medical Assessment of Adverse Health Outcomes in Long-term Survivors of Childhood Cancer

Improved survival of children with cancer has been accompanied by multiple treatment-related complications. However, most studies in survivors of childhood cancer focused on only 1 late effect. To assess the total burden of adverse health outcomes (clinical or subclinical disorders ["adverse events"]) following childhood cancer in a large cohort of childhood cancer survivors with long-term and complete medical follow-up. Retrospective cohort study of 1362 five-year survivors of childhood cancer treated in a single institution in the Netherlands between 1966 and 1996. All survivors were invited to a late-effects clinic for medical assessment of adverse events. Adverse events occurring before January 2004 were graded for severity in a standardized manner. Treatment-specific prevalence of adverse events (according to severity) at end of follow-up and relative risk of high or severe burden of disease (> or =2 severe or > or =1 life-threatening or disabling adverse events) associated with various treatments. Medical follow-up was complete for 94.3% of survivors (median follow-up, 17.0 years). The median attained age at end of follow-up was 24.4 years. Almost 75% of survivors had 1 or more adverse events, and 24.6% had 5 or more adverse events. Furthermore, 40% of survivors had at least 1 severe or life-threatening or disabling adverse event. A high or severe burden of adverse events was observed in 55% of survivors who received radiotherapy only and 15% of survivors treated with chemotherapy only, compared with 25% of survivors who had surgery only (adjusted relative risks, 2.18 [95% confidence interval, 1.62-2.95] and 0.65 [95% confidence interval, 0.46-0.90], respectively). A high or severe burden of adverse events was most often observed in survivors of bone tumors (64%) and least often in survivors of leukemia or Wilms tumor (12% each). In young adulthood, a substantial proportion of childhood cancer survivors already has a high or severe burden of disease, particularly after radiotherapy. This underscores the need for lifelong risk-stratified medical surveillance of childhood cancer survivors.

Late recurrence in survivors of childhood and adolescent cancer: A report from the Childhood Cancer Survivor Study (CCSS)

9534 Background: An increasing percentage of childhood cancer patients are surviving their disease, but limited research suggests that late recurrences may impact overall survival. The goal of this study is to estimate late recurrence rates for the most common pediatric cancers and to determine additional risk factors for late recurrence. Methods: CCSS is a retrospective cohort study of five-year survivors of childhood cancer diagnosed before 21 years of age, between 1970 and 1986 at one of 26 consortium centers. Late recurrence was defined as first recurrence occurring > five years post-diagnosis. Recurrences were determined by self-report questionnaire or by confirmation through medical record, death certificate or pathologic review. Probability of late recurrence was calculated using cumulative incidence. Adjusted hazard ratios (HR) were obtained using Cox proportional hazards regression. Results: In 12,948 survivors with no recurrence = five years from diagnosis, 670 (5.2%) subjects had a first recurrence > five years after their primary diagnosis. Late recurrences ranged from 5 to 28.9 years from diagnosis (median 7.9 years). Cumulative incidence varied by diagnosis ( table ). In multivariate analysis, significant risk factors for increased late recurrence included a primary diagnosis of Ewing's sarcoma or CNS tumors (HR of 2.3 and 2.7 respectively vs. leukemia survivors), age = 10 years at diagnosis (HR 1.4 vs. age < 10 years), chemotherapy exposure (HR 1.5 vs. none), and radiation exposure (HR 1.4 vs. none) (p < 0.001 for all). At the time of last follow-up, 51.6% of subjects with a late recurrence had died versus 6.4% of those with no history of recurrence. Conclusions: Late recurrences occur in survivors of childhood cancers with a significant risk of mortality. This emphasizes the importance of long-term survivor follow-up into adulthood, particularly for adolescents and patients with Ewing's sarcoma and CNS tumors. [Table: see text] No significant financial relationships to disclose.

Diabetes mellitus among cancer survivors

Cancer and cancer treatments are associated with diabetes mellitus in some patients. The purpose of this review is to look at the association and potential impact of diabetes mellitus on the health profiles of a large cohort of cancer survivors. This is a descriptive, cross-sectional study of long-term cancer survivors who reported that they have diabetes. Of 8,559 respondents to a mailed survey, 696 (8.1%) reported diabetes mellitus (DM). We analyzed the responses to discern the potential impact of demographics, cancer type, or disease treatments on glycemia as well as the potential impact of DM on socioeconomic parameters (education, family and work). Survivors of gynecological cancer, chronic leukemia, or gastrointestinal cancer reported DM most frequently, although no statistical correlations could be demonstrated for DM and specific cancer types. The frequency of DM was higher among survivors than in the general U.S. population. Cancer survivors with DM were more likely to report that cancer affected their overall health (42.3 vs. 34.3%) and ability to work. They also reported more health problems. Diabetes mellitus affects a minority of long-term cancer survivors and may have an impact on their physiologic and psychosocial well-being. Systematic assessment for DM is suggested for all cancer survivors because DM appears to be an important co-morbidity for this growing segment of our population.

Long-term health consequences of atomic bomb radiation: RERF Life Span Study

Abstract. To determine the possible late health effects of atomic-bomb radiation, Radiation Effects Research Foundation (RERF) has been conducting mortality follow-up on a fixed cohort of 120,000 members (Life Span Study cohort or LSS cohort) since 1950. Through record linkage with local cancer registries in Hiroshima and Nagasaki, RERF has also been conducting cancer incidence studies of atomic bomb survivors since 1958. The central finding of the study is an increase in cancer risk. Besides the increase in leukemia risk, increase in risks of solid cancers such as cancers of the breast, lung and colon have also been demonstrated. Radiation-induced leukemia occurred 2 to 3 years after exposure, reached its peak within 6 to 8 years after the bombing, and has since declined steadily. However, radiation-related solid cancer began to appear at later years and the risk still remains to be present, even today. An increase of solid cancer risk appears to be larger for those exposed as children than those exposed as adults. However, since a majority of those exposed as children are still alive and risk estimates for them are uncertain at this stage, it is essential to continue their follow-up. Recently, the LSS also demonstrates an excess risk of death from non-cancer diseases, largely from cardiovascular, digestive and respiratory diseases. Further investigation is of absolute necessity in order to determine whether or not the excess was caused by atomic bomb radiation.

Follow-up of long-term cancer survivors in the Nordic countries

Cancer survivors are at increased risk of developing different co-morbid conditions. With an increasing number of long-term cancer survivors in the Nordic countries, the need for recommendations for long-term follow-up has become necessary. However, at present there are no general guidelines for follow-up in the Nordic countries. Three steps of follow-up should be distinguished and the objectives associated with each: 1) Follow-up research done as clinical studies in cancer survivors and as registry-based epidemiological investigations. Whenever possible these approaches should be combined with translational research relating clinical observations with findings from biological material for increased understanding of pathophysiology and aetiology. Such investigation has to provide evidence-based knowledge of late effects associated with the malignancy itself and its treatment. The Nordic countries have excellent possibilities for conducting such follow-up research; 2) Creation of guidelines, in an attempt to put results from research into clinical practice, should take the local situation and resources into consideration. Provision of an individualized Survivorship Care Plan is a first step; 3) Implementation of guidelines into daily health care. Guidelines have little influence on long-term cancer care if they do not reach the practitioners and convince them to comply. There is a need for well-planned follow-up to manage and reduce possible treatment-related morbidity and mortality in cancer survivors. The Nordic countries provide excellent possibilities for relevant research, but lack, so far evidence-based guidelines. In agreement with the initiatives of ASCO the development of Survivor Care Plans is the first step to improve on this situation.

Employment and Cancer: Findings from a Longitudinal Study of Breast and Prostate Cancer Survivors

We discuss how cancer affected the employment of almost 800 employed patients who participated in a longitudinal study. The greatest reduction in patients' labor supply (defined as employment and weekly hours worked) was observed 6 months following diagnosis. At 12 and 18 months following diagnosis, many patients returned to work. Based on these and other findings related to patients' employment situations, we suggest 4 areas for future research: 1) collection of employment information in cancer studies; 2) research into racial and ethnic minority patients and employment outcomes; 3) interventions to reduce the effects of cancer and its treatment on employment; and 4) investigations into the influence of employment-contingent health insurance on cancer treatment and recovery.

Follow-up study of long-term survivors of osteosarcoma in the prechemotherapy era

Follow-up study of long-term survivors of osteosarcoma in the prechemotherapy era

Hormone Replacement Therapy in Breast Cancer Survivors

It is well known that women with breast cancer who undergo therapies beyond the surgical intervention (adjuvant chemotherapy, hormone therapy, or both) often suffer from the lack of estrogen, manifesting as climacteric symptoms in either treated premenopausal or postmenopausal women. Although HRT (hormone replacement therapy) is traditionally viewed as a contraindication in women with a history of breast cancer, more women are willing to receive HRT for symptom relief. No observational or retrospective study in breast cancer survivors (whether in pre- or postmenopausal women) has shown an increased risk of tumor recurrence or increased mortality associated with HRT use. Nevertheless, because these studies are retrospective and different in terms of lymph node status, estrogen receptor (ER) status, and type of HRT used, firm conclusions on potential HRT use cannot be safely drawn. The few prospective studies appear controversial possibly due to differences in the studies' design. A potential scheme for possible HRT use in selected breast cancer survivors with severe climacteric symptoms is suggested. The duration of HRT use is debatable because there is insufficient evidence at present. However, the available data suggest that 3-year and possibly 5-year HRT use may be safe. In summary, while HRT cannot currently be recommended as first-line therapy, it may still be of benefit in the management of selected early stage breast cancer survivors with refractory climacteric symptoms after a well-informed decision and an individualized risk benefit discussion.

UNDERSTANDING ESTIMATION OF TIME AND AGE EFFECT-MODIFICATION OF RADIATION-INDUCED CANCER RISKS AMONG ATOMIC-BOMB SURVIVORS

In radiation risk assessment based on follow-up data, estimation of the excess relative cancer rate involves evaluation of effect-modification by time-related factors such as age at exposure, time since exposure, and attained age. Because these variables are collinear, the regression coefficients purportedly measuring effect-modification of the radiation-related excess relative rate by time and age factors generally differ from the individual effects of these factors. For example, depending on whether it is an age-at-exposure/attained-age effect-modification model or an age-at-exposure/time-since-exposure model which is used, the regression coefficient for the effect of changes in age at exposure on the excess relative rate per Gray measures the combined effects of changes in both age at exposure and time since exposure, or of age at exposure and attained age, respectively, rather than the individual effect of changes in age at exposure, which is of interest for scientific purposes. Such insights should be integrated when reporting and interpreting estimates for time-related risk modification in cohort studies of radiation-exposed populations. Cancer incidence data for the Life Span Study of atomic-bomb survivors are used for illustration in parallel to theory. In summary, model coefficients for time-since-exposure, age-at-exposure, and attained-age effects on radiation-induced cancer risks among atomic-bomb survivors and in other cohort studies estimate combined effects (estimable combined effects are explicated). An appropriate unequivocal display of results for effect-modification is suggested. Goodness of fit appears unreliable for sorting out the most significant effect-modifiers. For example, a model including only one of the effect-modifiers may provide a fit similar to a model including the other two effect-modifiers, even when only the latter are actually related to effect-modification. Also, due to collinearity between these effect-modifier variables, all three models with two of the effect-modifiers necessarily show equivalent fits.

Cardiac status predicts quality of life in Hodgkin’s disease survivors

9029 Background: Long-term survivors of Hodgkin’s disease (HD) treated with mediastinal radiotherapy suffer from a variety of subclinical cardiac abnormalities including valvar defects and findings suggestive of restrictive cardiomyopathy. Their clinical importance has not been definitively demonstrated in longitudinal studies, but they may be related to the reduced quality of life reported by many HD survivors. Methods: The overlapping participants in two independent studies of HD survivors were identified in order to form a longitudinally studied cohort. In the first study, 48 survivors of childhood and young adulthood HD were evaluated by multiple cardiac testing modalities and quality-of-life assessment including the SF-36, a mean of 16 years after diagnosis. In the second performed about 5 years later, 511 survivors took part in a survey study, which also included the SF-36 instrument. A total of 23 patients participated in both studies and formed the current study population. Correlations were performed between key cardiac abnormalities uncovered during the first study and the physical component score (PCS) of the SF-36 measured in the second study, and the changes in PCS during the time between the 2 studies. Results: Average PCS was 44.05 at time of the second study, about 6.0 points lower than at time of cardiac testing. Maximum oxygen consumption correlated with PCS at time 2 (r=0.50, p=0.029). Univariate regression suggested that for every unit decrease in maximum oxygen consumption, the PCS decreased by 0.45 units. The higher the baseline PCS, the greater the negative change in PCS. Left ventricular fractional shortening correlated with PCS at time 2 (r=−0.579, p=0.0094) but not change in PCS. Conclusions: The study suggests that objective measures of reduced cardiac function are predictive of future quality of life in HD survivors. These results however need to be verified in a larger longitudinal study that allows for multivariate analysis. No significant financial relationships to disclose.

Long-term outcomes in patients with stage IV neuroblastoma

Aim of Study Long-term outcome studies in survivors with stage IV neuroblastoma (NB) are sparse. This review evaluates late complications and long-term outcomes in stage IV NB survivors. Methods A retrospective review of stage IV NB survivors was performed to analyze outcomes, including long-term morbidity, recurrence, and survival. Main Results Of 153 patients with stage IV NB, 52 (34%) survived (male-female, 26:26). Age at diagnosis was 29.1 ± 31.7 months in survivors. Eighteen were 1 year or younger and 34 were older than 1 year compared with 10 nonsurvivors 1 year or younger and 91 older than 1 year ( P = .0003, Fisher's Exact test). Primary tumor sites were adrenal (35), retroperitoneal (11), mediastinal (3), pelvic (2), and no primary with tumor metastases identified (1). Ten survivors had favorable and 16 had unfavorable histology compared with 1 favorable and 18 unfavorable in nonsurvivors ( P = .01). Four survivors had MYCN amplification (≥10 copies) and 2 deletions of 1p and 11q. Sites of metastasis in survivors and nonsurvivors were similar. Treatment in survivors included surgery in 51 (75% [39/51] complete tumor resection [CTR]); chemotherapy, 50; radiation, 17; stem cell transplantation, 20; and bone marrow transplant, 1. In nonsurvivors, 13 (25%) of 53 ( P ≪ .0001) had CTR, 18 stem cell transplantation, and 12 bone marrow transplant. Six patients had tumor recurrence but survived (mean, 9.3 ± 8.3 years; range, 6 months–24 years). Recurrence was local (1), distant (2), and both (3) and was treated by resection, chemotherapy, and radiation. The mean age of survivors was 12.4 ± 8.3 years (range, 2-34 years). In all stage IV cases, event-free survival was 30% and overall survival was 34%. Long-term complications occurred in 23 (44%) survivors, including endocrine disturbances (7), orthopedic (5), cataracts (2), adhesive bowel obstruction (2), hypertension (1), bronchiolitis (1), blindness (1), peripheral neuropathy (1), nonfunctioning kidney (1), cholelithiasis (1), and thyroid nodule (1). Conclusion Only 34% of patients with stage IV NB survived despite aggressive multimodal therapy. Age of younger than 1 year, favorable pathology, CTR, and no recurrence were the only statistically significant factors that favored survival. Forty-four percent of survivors experienced late morbidity, and tumor recurred in 6 (11.5%) of 52. Patients should be monitored for tumor recurrence and long-term sequelae. New methods of treatment are required to achieve better outcomes.

No reconciliation, but self‐searching in the sense of rapprochement: Hillel Klein's Holocaust research in Germany 40 years after

The paper is written from a personal perspective and in conjunction with the author's participation in editing Hillel Klein's book Überleben und Versuche der Wiederbelebung‐Psychoanalytische Studien mit Überlebenden der Shoah und mit ihren Familien in Israel und in der Diaspora [Survival and trials of revival‐ Psychodynamic studies of Holocaust survivors and their families in Israel and the diaspora] which appeared posthumously in 2003. The manuscript was originally written in English during the fi rst half of the 1980s. It consists of a revised version of his contributions to psychoanalytic Holocaust research, as well as further observations and a number of autobiographical features. It suggests that we see the symptom which relates to the traumatic past less as the sign of a pathology, and instead, through the linking of drives and objects, more as a sign of hope. The hope is that revival begins in recovering the world that was lost in the Holocaust, the world from before, which, as torn as it was, he still referred to as the ‘intact world’. He regarded rapprochement as one of the main therapeutic tools. Rapprochement does not build up absolutes, but leaves from the quantitative point of view room for encounter.

No reconciliation, but self-searching in the sense of rapprochement: Hillel Klein’s Holocaust research in Germany 40 years after

The paper is written from a personal perspective and in conjunction with the author's participation in editing Hillel Klein's book Uberleben und Versuche der Wiederbelebung-Psychoanalytische Studien mit Uberlebenden der Shoah und mit ihren Familien in Israel und in der Diaspora [Survival and trials of revival--Psychodynamic studies of Holocaust survivors and their families in Israel and the diaspora] which appeared posthumously in 2003. The manuscript was originally written in English during the first half of the 1980s. It consists of a revised version of his contributions to psychoanalytic Holocaust research, as well as further observations and a number of autobiographical features. It suggests that we see the symptom which relates to the traumatic past less as the sign of a pathology, and instead, through the linking of drives and objects, more as a sign of hope. The hope is that revival begins in recovering the world that was lost in the Holocaust, the world from before, which, as torn as it was, he still referred to as the 'intact world'. He regarded rapprochement as one of the main therapeutic tools. Rapprochement does not build up absolutes, but leaves from the quantitative point of view room for encounter.

Hearing loss among cancer survivors

Cancer therapies may cause hearing loss (HL) in some patients. The purpose of this study is to examine at risk factors for HL and its impact on the health of a large cohort of cancer survivors. This is a descriptive, cross-sectional study of long-term cancer survivors who reported that they have experienced HL as a result of their cancer. Of 3571 respondents who answered a mailed survey, 243 (6.8%) reported HL. We analyzed the responses to discern the potential impact of demographics, cancer type or disease treatments on hearing, as well as the potential impact of HL on socioeconomic parameters (education, family and work). Survivors of head and neck cancer, sarcoma and testicular cancer reported HL most frequently. Among the younger survivors, the frequency of HL was higher than age-matched persons from the general U.S. population. Cancer survivors with HL were more likely to report that cancer had affected their overall health (71 vs. 32%) and were unable to work. While cisplatinum exposure was noted more frequently in respondents with HL, no other treatments, including radiotherapy, were shown to have a significant impact on hearing. There were no differences with respect to age, gender or family dynamics. Hearing loss affects a minority of long-term cancer survivors and may have an impact on their education, ability to work and overall health.

P114 Ten-year breast cancer survival — At what cost in human and physical terms? A case-control study of long-term survivors of breast cancer and their physical and functional well-being: An updated multivariate analysis

P114 Ten-year breast cancer survival — At what cost in human and physical terms? A case-control study of long-term survivors of breast cancer and their physical and functional well-being: An updated multivariate analysis