Consistent with previous literature, 24, 25
adult survivors of childhood cancer demonstrated low rates of engagement in protective health behaviors. Less than half of all survivors reported regular physical activity, and a similarly low percentage reported regular engagement in sun protection behaviors. Neurocognitive impairment, which was identified in over 20% of survivors, increased the risk of not engaging in these health behaviors. Survivors who reported problems with task efficiency were less likely to engage in regular physical activity, even when controlling for current BMI and prior history of physical activity. However, given the cross sectional nature of this study, it is unclear as to whether regular physical activity has a positive impact on these neurocognitive functions, or whether individuals with impairment in these neurocognitive functions have difficulty managing social circumstances in a manner to facilitate a regular exercise schedule. Certainly, good neurocognitive function can enhance one’s ability to structure daily life events, and thereby enhance opportunities for healthy behaviors. Alternatively, regular exercise has been demonstrated to improve neurocognitive functions in elderly adults.26, 27
An additional finding consistent with the existing literature on adult survivors of childhood cancer is the low rate of health care utilization in this cohort.4
Only 30% of the cohort reported receiving survivor focused care (either general or risk-based), while nearly 12% reported receiving no health care at all. Although the overall rate of health care mirrors the rate of health insurance coverage, other factors are predictive of utilization even when controlling for insurance coverage and household income. Survivors who report organizational problems were less likely to receive dental care.
Neurocognitive and emotionally-related factors were also associated with increased health care utilization. These findings were present even when controlling for insurance status and household income. Survivors with impaired task efficiency were 20% more likely to report receiving general survivor care. This increased survivor care may result from the recognition that neurocognitive symptoms are a relatively common late effect of cancer therapy. Such symptoms may, in fact, be brought to light during the course of general survivor care, and patients who recognize these symptoms may be more likely to seek out care related to their general survivorship status. Alternatively, neurocognitive symptoms may co-occur with other late effects of central nervous system targeted therapies (e.g. endocrinopathies) that cause survivors to seek survivor focused care. Such an association may also explain why survivors reporting memory problems were more likely to report receiving a colonscopy. Somatization is a condition associated with emotionally exaggerated experiences of physical symptoms, and can impact behavior independent of other emotional symptoms.28
Thus, it is not surprising to find this symptom pattern predictive of increased engagement in adherence to recommendations for an echocardiogram. Survivors who reported use of anti-depressant medication were also more likely to receive risk-based survivor care. Obviously, patients treated with antidepressants are more likely to already be connected to health care providers who monitor their medication prescription.
An unexpected finding in this study was the strong and pervasive risk associated with obesity. Not only were those survivors in the obese category at greater risk for not meeting recommended levels of physical exercise, they were also less likely to report receiving proper dental care, as well as receiving recommended bone density, mammogram, and skin exams. This pattern of behavior and lack of adherence to recommended medical examination, combined with the obese status, places these individuals at particularly high risk for future undetected chronic disease. The psychology literature identifies obesity as being associated with depression and social withdrawal,29, 30
which may account for these general maladaptive behavior patterns. Such a pattern may warrant a multipronged approach to preventive interventions, including social engagement, behavioral therapy, and psychopharmacology, when necessary.
There are several limitations inherent in this study. First, neurocognitive impairment and emotional symptoms were assessed through survivor self-report. Given the long-term status of the survivor cohort, some survivors may not be aware of the presence of limited neurocognitive functioning and, as such, the association with health behaviors and health care utilization may have been underestimated. Still, self-report questionnaires are a reliable and valid procedure for the identification of neurocognitive and emotional functioning, and the specific measures used in this study have been validated in cancer survivor cohorts. A related limitation extends to the self-report nature of data collected on health behaviors and health care utilization. Self-report of such behaviors is not inherently problematic, however, report by individuals who may truly have neurocognitive problems may be (e.g. survivors with memory problems being asked to recall health care utilization practices). Although this may account for the increased likelihood of reporting colonoscopy in patients with memory problems, most associations with neurocognitive impairment were focused on task efficiency and organization problems and, thus, the potential impact of this limitation appears small. An additional limitation is the lack of information on the knowledge of long-term follow-up guidelines on the part of the survivors or their primary care physicians. This information was not available, though its impact on adherence would certainly be worthy of future research efforts.
In summary, the findings of the current study demonstrate an association between neurocognitive and emotional functioning and engagement in health behaviors and health care utilization. Survivors who develop neurocognitive impairment, regardless of the reason for the impairment, are at increased risk for reduced physical activity and are more likely to receive general survivor care. Survivors with symptoms of emotional dysfunction, as evidenced by either current symptoms or use of antidepressant medication, are at more likely to receive risk-based survivor care, echocardiograms, and bone density exams. Perhaps the more pervasive predictive variable is current BMI, which is associated with increased risk for non-adherence to multiple health-related behaviors.
The results of this study warrant recommendations for future investigations and health care practices. The demonstrated association between task efficiency and reduced physical activity should be explored in a prospective therapeutic trial. Since more physical activity is associated with less neurocognitive impairment in our model, perhaps interventions aimed at increased exercise can improve neurocognitive skills in those survivors with impairment, similar to what has been demonstrated in the literature on aging adults. The association between emotional functioning and health care utilization also warrants consideration. Increased emotional problems were related to enhanced health care utilization. This pattern reinforces the importance of assessing and intervening for emotional status in long term survivors of childhood cancer. Such monitoring is not only important for improving general quality of life, but may help to identify survivors at risk for poor adherence to prescribed health behaviors and health screening exams.