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1.  Premature Carotid Artery Disease in Pediatric Cancer Survivors Treated With Neck Irradiation 
Pediatric blood & cancer  2009;53(4):615-621.
While carotid artery disease and strokes have been documented in adult cancer patients treated with neck irradiation, little information is available on pediatric patients. The purpose of this study is to determine if carotid disease is more prevalent among pediatric cancer survivors treated with neck irradiation than among healthy controls.
Thirty pediatric cancer survivors who received neck irradiation (2,000–6,660 cGy) and 30 healthy subjects underwent bilateral carotid ultrasounds. Study outcome measures were common carotid intima-media thickness (IMT) and plaque (present or absent). Multivariate methods were used to compare cases and controls and to identify risk factors related to carotid disease in childhood cancer survivors.
IMT was greater for cancer survivors than controls (0.46mm (SD 0.12) vs. 0.41mm (SD 0.06), P < 0.001). Plaque was present in 18% of irradiated vessels and 2% of non-irradiated vessels (P < 0.01). Among cancer survivors, IMT was positively associated with female gender (P < 0.05), nonwhite ethnicity (P < 0.01), positive family history of stroke/heart attack (P < 0.05), BMI (P < 0.001), total cholesterol (P < 0.01), cancer relapse (P < 0.001), and years off treatment (P < 0.0001). Plaque was positively associated with relapse (P < 0.05) and C-reactive protein (P < 0.01). There was no significant relationship between radiation dose at levels ≥2,000 cGy and IMT or plaque.
Carotid artery disease was more prevalent among cancer survivors treated with neck irradiation than among controls. Due to the high risk of stroke associated with advanced carotid disease, larger prospective studies are needed to better define disease risk in these long-term survivors.
PMCID: PMC4412314  PMID: 19533651
carotid artery disease; childhood cancer survivors; late effects; neck irradiation; radiation therapy
Pediatric blood & cancer  2013;60(9):1470-1477.
Parents of childhood cancer survivors (CCS) experience considerable distress related to their child’s cancer. However, little is known about cultural variation in this experience. We examine parental distress, specifically symptoms of posttraumatic stress (PTSS) and depression, comparing Hispanic and non-Hispanic parents of CCS.
79 Hispanic and 60 non-Hispanic parents of CCS (currently aged 14–25, off treatment ≥2 years) completed questionnaires assessing demographics, depression, PTSS, perceived stress, and child’s health status/quality of life (QOL). T-tests and chi-square statistics were used to compare differences in demographic characteristics between Hispanic and non-Hispanic parents and multivariable regression was used to determine independent risk factors associated with parental PTSS and depression.
Hispanic parents were significantly younger, had less education, lower incomes and reported significantly more PTSS and depressive symptoms than non-Hispanic parents (all p-values<0.0001). Among Hispanic parents, foreign birthplace predicted higher PTSS after controlling for other factors (p<0.001). Hispanic parents, regardless of birthplace, reported more depressive symptoms than non-Hispanic parents (US-born, p<0.05; foreign-born, p<0.01). For PTSS and depression, there were positive relationships with parental stress and negative relationships with the child’s psychosocial QOL. Hispanic and non-Hispanic CCS did not differ significantly on disease and treatment factors or health-related QOL.
Hispanic parents of CCS may be at greater risk for poorer mental health outcomes. Ethnic-specific factors (e.g., acculturation, immigration status and previous trauma) may influence parents’ responses and adjustment to their child’s cancer. Research is needed to determine how to meet the needs of the most vulnerable parents.
PMCID: PMC4118593  PMID: 23512267
3.  Perceived Positive Impact of Cancer Among Long-term Survivors of Childhood Cancer: a report from the Childhood Cancer Survivor Study 
Psycho-oncology  2011;21(6):630-639.
Investigations examining psychosocial adjustment among childhood cancer survivors have focused primarily on negative effects and psychopathology. Emergent literature suggests the existence of positive impact or adjustment experienced after cancer, as well. The purpose of this study is to examine the distribution of Perceived Positive Impact (PPI) and its correlates in young adult survivors of childhood cancer.
6,425 survivors and 360 siblings completed a comprehensive health survey, inclusive of a modified version of the Posttraumatic Growth Inventory (PTGI) as a measure of PPI. Linear regression models were used to examine demographic, disease and treatment characteristics associated with PPI.
Survivors were significantly more likely than siblings to report PPI. Endorsement of PPI was significantly greater among female and non-white survivors, and among survivors exposed to at least one intense therapy, a second malignancy or cancer recurrence. Survivors diagnosed at older ages and fewer years since diagnosis were more likely to report PPI. Income, education and marital/relationship status appeared to have varied relationships to PPI depending upon the subscale being evaluated.
The existence and variability of PPI in survivors in this study suggest that individual characteristics, inclusive of race, gender, cancer type, intensity of treatment, age at diagnosis and time since diagnosis, have unique and specific associations with different aspects of perceived positive outcomes of childhood cancer.
PMCID: PMC3697081  PMID: 21425388
Psychosocial; childhood cancer; trauma; event centrality; survivors
4.  Fatigue, Inflammation, and ω-3 and ω-6 Fatty Acid Intake Among Breast Cancer Survivors 
Journal of Clinical Oncology  2012;30(12):1280-1287.
Evidence suggests that inflammation may drive fatigue in cancer survivors. Research in healthy populations has shown reduced inflammation with higher dietary intake of ω-3 polyunsaturated fatty acids (PUFAs), which could potentially reduce fatigue. This study investigated fatigue, inflammation, and intake of ω-3 and ω-6 PUFAs among breast cancer survivors.
Six hundred thirty-three survivors (mean age, 56 years; stage I to IIIA) participating in the Health, Eating, Activity, and Lifestyle Study completed a food frequency/dietary supplement questionnaire and provided a blood sample assayed for C-reactive protein (CRP) and serum amyloid A (30 months after diagnosis) and completed the Piper Fatigue Scale and Short Form-36 (SF-36) vitality scale (39 months after diagnosis). Analysis of covariance and logistic regression models tested relationships between inflammation and fatigue, inflammation and ω-3 and ω-6 PUFA intake, and PUFA intake and fatigue, controlling for three incremental levels of confounders. Fatigue was analyzed continuously (Piper scales) and dichotomously (SF-36 vitality ≤ 50).
Behavioral (P = .003) and sensory (P = .001) fatigue scale scores were higher by increasing CRP tertile; relationships were attenuated after adjustment for medication use and comorbidity. Survivors with high CRP had 1.8 times greater odds of fatigue after full adjustment (P < .05). Higher intake of ω-6 relative to ω-3 PUFAs was associated with greater CRP (P = .01 after full adjustment) and greater odds of fatigue (odds ratio, 2.6 for the highest v lowest intake; P < .05).
Results link higher intake of ω-3 PUFAs, decreased inflammation, and decreased physical aspects of fatigue. Future studies should test whether ω-3 supplementation may reduce fatigue among significantly fatigued breast cancer survivors.
PMCID: PMC3341143  PMID: 22412148
6.  Estrogenic botanical supplements, health-related quality of life, fatigue, and hormone-related symptoms in breast cancer survivors: a HEAL study report 
It remains unclear whether estrogenic botanical supplement (EBS) use influences breast cancer survivors' health-related outcomes.
We examined the associations of EBS use with health-related quality of life (HRQOL), with fatigue, and with 15 hormone-related symptoms such as hot flashes and night sweats among 767 breast cancer survivors participating in the Health, Eating, Activity, and Lifestyle (HEAL) Study. HRQOL was measured by the Medical Outcomes Study short form-36 physical and mental component scale summary score. Fatigue was measured by the Revised-Piper Fatigue Scale score.
Neither overall EBS use nor the number of EBS types used was associated with HRQOL, fatigue, or hormone-related symptoms. However, comparisons of those using each specific type of EBS with non-EBS users revealed the following associations. Soy supplements users were more likely to have a better physical health summary score (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.02-2.70). Flaxseed oil users were more likely to have a better mental health summary score (OR = 1.76, 95% CI = 1.05-2.94). Ginseng users were more likely to report severe fatigue and several hormone-related symptoms (all ORs ≥ 1.7 and all 95% CIs exclude 1). Red clover users were less likely to report weight gain, night sweats, and difficulty concentrating (all OR approximately 0.4 and all 95% CIs exclude 1). Alfalfa users were less likely to experience sleep interruption (OR = 0.28, 95% CI = 0.12-0.68). Dehydroepiandrosterone users were less likely to have hot flashes (OR = 0.33, 95% CI = 0.14-0.82).
Our findings indicate that several specific types of EBS might have important influences on a woman's various aspects of quality of life, but further verification is necessary.
PMCID: PMC3234199  PMID: 22067368
7.  Prevalence and Predictors of Posttraumatic Stress Disorder in Adult Survivors of Childhood Cancer: a report from the Childhood Cancer Survivor Study 
Pediatrics  2010;125(5):e1124-e1134.
Recent studies have found that a subset of young adult survivors of childhood cancer report posttraumatic stress symptoms in response to their diagnosis and treatment. However, it is unclear if these symptoms are associated with impairment in daily functions and/or significant distress, thereby resulting in a clinical disorder. Furthermore, it is unknown whether this disorder continues into very long-term survivorship, including the 3rd and 4th decades of life. This study hypothesized that very long-term survivors of childhood cancer would be more likely to report symptoms of posttraumatic stress disorder, with functional impairment and/or clinical distress, compared to a group of healthy siblings.
Patients and Methods
6,542 childhood cancer survivors over the age of 18 who were diagnosed between 1970 and 1986 and 368 siblings of cancer survivors completed a comprehensive demographic and health survey.
589 survivors (9%) and 8 siblings (2%) reported functional impairment and/or clinical distress in addition to the set of symptoms consistent with a full diagnosis of Posttraumatic Stress Disorder (PTSD). Survivors had more than a four-fold risk of PTSD compared to siblings (OR=4.14, 95%CI: 2.08-8.25). Controlling for demographic and treatment variables, increased risk of PTSD was associated with educational level of high school or less (OR=1.51, 95% CI=1.16-1.98), being unmarried (OR=1.99, 95% CI=1.58-2.50), annual income less than $20,000 (OR=1.63, 95% CI=1.21-2.20), and being unemployed (OR=2.01, 95% CI=1.62-2.51). Intensive treatment was also associated with increased risk of full PTSD (OR=1.36, 95% CI 1.06 -1.74).
Posttraumatic stress disorder is reported significantly more often by childhood cancer survivors than by sibling controls. Although most survivors are apparently doing well, a subset report significant impairment that may warrant targeted intervention.
PMCID: PMC3098501  PMID: 20435702
childhood cancer; young adult
8.  Comorbidities, Therapy, and Newly Diagnosed Conditions for Women with Early Stage Breast Cancer 
To describe comorbidities in breast cancer patients at diagnosis and examine factors associated with self-reported comorbidities 30 month post-diagnosis.
941 of 1171 women had a medical record abstract and a follow-up survey in the Health, Eating, Activity and Lifestyle Study.
We compared our breast cancer cohort to a contemporaneous nationally-representative sample of age, race/ethnicity and education matched women without cancer (n=865). Breast cancer patients did not have substantially more comorbidities than women without breast cancer. Women with a hospital record of congestive heart failure significantly less often received chemotherapy or radiation following breast conserving surgery. In multivariate analysis, women who received chemotherapy alone (OR=3.2; 95% CI: 1.5–6.8), chemotherapy plus radiation (OR=1.9; 95% CI: 1.02–3.7) or radiation plus tamoxifen (OR=1.9; 95% CI: 1.1–3.2) were significantly more likely to report at least one new comorbid condition following breast cancer diagnosis than women who received no chemotherapy, tamoxifen or radiation. Overall, women who received adjuvant therapy were more likely to have new comorbidities.
Comorbidities were not substantially different in breast cancer patients than the non-cancer matched controls. Future research should focus on efforts to minimize comorbidities related to chemotherapy and other combination therapy.
PMCID: PMC2998176  PMID: 19437121
therapy; comorbidity; healthcare; disparities; heart disease; hypertension; diabetes
9.  Physical activity, long-term symptoms, and physical health-related quality of life among breast cancer survivors: A prospective analysis 
Many breast cancer survivors experience persistent physical symptoms of cancer and treatment that can decrease health-related quality of life (HRQOL). This prospective study investigated physical activity (PA), occurrence of physical symptoms, and HRQOL in a large, ethnically-diverse cohort of breast cancer survivors.
Survivors (n=545), on average 6 months post-diagnosis, were assessed in person or by mail at baseline (retrospective reports of pre-diagnosis PA), at 29 months post-diagnosis (post-diagnosis PA), and at 39 months post-diagnosis (pain, hormone symptoms, sexual interest/dysfunction, fatigue, physical subscales of HRQOL). Linear regression and analysis of covariance assessed the relationships between pre- and post-diagnosis PA and PA change after cancer with symptoms and HRQOL.
Greater pre-diagnosis PA was associated with better physical functioning at 39 months (βs 1.1–2.3; all p<.01) but was generally unrelated to symptoms. Greater post-diagnosis sports/recreational PA was related to less fatigue and better physical functioning (βs -.146, 2.21; both p < .01). Increased PA after cancer was related to less fatigue and pain and better physical functioning (all p<.01). Significant positive associations were found for moderate to vigorous and vigorous sports/recreation PA, not household activity. Results were similar for Hispanic and non-Hispanic White women.
Increased PA, especially after cancer, was consistently related to better physical functioning and to reduced fatigue and bodily pain, underscoring the need for PA promotion among survivors.
Implications for Cancer Survivors
Survivors may be able to decrease fatigue and bodily pain and be better able to pursue daily activities through increasing recreational PA after cancer.
PMCID: PMC2996230  PMID: 18648952
Physical Activity; Breast Cancer; Survivors; Long-term Effects; Quality of Life

Results 1-9 (9)