Psychiatric Sequelae May Persist For Childhood Cancer Survivors

A minority of adults who survived cancer as children report having suicidal feelings, although less than half of them were depressed, a new study found. The increase in suicidality was largely associated with physical health problems and shows the need for a multidisciplinary approach to care for these patients, concluded the paper in the August 20 Journal of Clinical Oncology.

“The association with physical health and pain is important because these represent potentially treatable conditions for which survivors may seek follow-up care,” wrote Christopher Recklitis, Ph.D., M.P.H., director of the Office of Research of the Perini Family Survivors' Center at the Dana-Farber Cancer Institute in Boston, and colleagues.

“Our research gives empirical underpinnings to our clinical experience,” said Recklitis in an interview with Psychiatric News. “This is a group that is struggling.”

Suicidal thinking in this population may arise from a mix of preexisting conditions, struggles with the aftereffects of illness and treatment, and current physical functioning, he said.

“When kids get sick, it dislodges them from their typical life courses—this was not supposed to happen,” he said.“ Families and communities help them get back to normal, but later symptoms make them feel like being dislodged from life again. They've been hit twice, 'sucker-punched by life.' ”

Study participants included a convenience sample from the Perini center of 110 men and 126 women who had survived childhood cancer, ranging in age from 18 to 64. Their average age at diagnosis was 10 years, and an average of 18 years had passed since they learned they had cancer. Twenty-nine (12.8 percent) of the 226 participants reported suicide attempts, current suicidal ideation, or both.

Depression was not always associated with suicidality, the researchers said. Only 11 of the 209 suicidal respondents had Beck Depression Inventory scores of 16 or above, the threshold for clinically significant depression.

“Screening for depression alone may not be adequate,” said Recklitis and colleagues.

Younger age at cancer diagnosis, longer time since diagnosis, and cranial radiation treatment were significantly associated with suicidality, they found.

The researchers have raised an important issue for clinicians, but it should be placed in perspective, Jimmie Holland, M.D., the Wayne Chapman Chair in Psychiatric Oncology at Memorial Sloan-Kettering Cancer Center in New York, told Psychiatric News.

For one thing, she said, people with cancer typically go through periods of hopelessness and may tell themselves: “Well, if things get really bad, I can always kill myself,” without intending to carry out the thought. While such moments may be transitory, they might well be recalled when answering a screening question.

The effects of radiation treatment are more complex, she said. Because leukemia can spread to the brain, cranial radiation was formerly used as a preventive measure. However, radiation to the head and neck can lead to thyroid or pituitary problems that affect growth and sexual development. A child who received radiation treatment may fail to enter or complete puberty. Menarche may be advanced or delayed in some girls, depending on the site irradiated.

Furthermore, cranial radiation caused cognitive deficits that lowered IQ scores and reduced patients' self-esteem, said Holland. Cranial radiation was replaced with systemic treatments in the 1970s, except for rare, high-risk cases in which lower doses are now given.

Now that they are adults, survivors require special attention when it comes to managing their care, Recklitis said.

Pediatric oncologists aren't expert in dealing with adult patients, he said, and internists may not be knowledgeable about pediatric cancer treatments.

Adult survivors of childhood cancers are not very common, so primary care physicians see very few and are not familiar with their needs, said Recklitis. Some may fail to order routine screening tests for these patients, assuming that another physician has done so. Sometimes the patient must become the conduit of information between his or her doctors.

“Someone needs a comprehensive view of the person,” Recklitis stated.

“There is a need to organize the whole medical system to handle the problems of cancer survivors,” Holland stressed. Survivors' clinics are more common now, but cancer survivors of all ages need an annual evaluation of their psychological, social, and physical status.

An abstract of “Suicidal Ideation and Attempts in Adult Survivors of Childhood Cancer” is posted at<www.jco.org/cgi/content/abstract/24/24/3852>.▪