1. TABLE 1. Weighted Percentages of Characteristics of Women Applying for Welfare Benefits, described in total sample and by welfare program type (GA/TANF) E. Anne Lown a, Robert Goldsby b, Ann C. Mertens c, Rachael A. Korcha a, Thomas Greenfield a, Jason Bond a, John Whitton d, Leslie L. Robison e and Lonnie K. Zeltzer f a Alcohol Research Group, Emeryville, CA; b Pediataric Hemotology/Oncology, University of California, San Francisco, CA; c Emory University, Atlanta, GA; d Fred Hutchison Cancer Research Center, Seattle, WA; e St Jude Children’s Research Hospital, Memphis, TN; f Department of Pediatrics and DCPCR, Jonsson Cancer Center, David Geffen School of Medicine, University of California, Los Angeles, CA. Abstract Objective Objective: Stress and serious trauma are associated with later risky health behaviors such as heavy alcohol consumption. Childhood cancer in the family can be disruptive to all members, including siblings. Little is known about health behaviors among siblings of childhood cancer survivors, though recent research has documented considerable distress among this under-researched population. This study describes alcohol consumption patterns among the siblings of long-term survivors of pediatric cancer compared to their sister/brother survivor and healthy peers. The study evaluates demographic, mental health and severity of the cancer experience to explain associated risks for heavy drinking among siblings. Methods Methods: Data were collected from 3,034 adult siblings of pediatric cancer survivors, 10,398 survivors, and 5,712 controls from a national population-based survey. National data were weighted to reflect the distribution of siblings by gender, age and ethnicity to increase comparability of the samples. Results Results: In multivariate analyses, siblings were more likely to be current drinkers(OR adj =2.0), risky drinkers(OR adj =1.3), and heavy drinkers (OR adj =1.3) compared to a national sample. Compared to survivors, siblings were significantly more likely to be current drinkers (OR=1.7), risky drinkers (OR=1.5) and heavy drinkers (OR=1.5). Factors associated with heavy sibling drinking include being age 18 to 21, (OR adj =3.0), being male (OR adj =2.3), having a high school education or less (OR adj =2.4), and drinking initiation at a young age (OR adj =5.2). Controlling for the above drinking risk factors, additional risk factors for siblings’ heavy drinking include: worse general health (OR adj =2.0), being aged 8-18 when their sister or brother was diagnosed, depression (OR adj =2.1), anxiety (OR adj =1.9), and global psychiatric distress (OR adj =2.2). Surprisingly, severity of the sister’s or brother’s cancer diagnosis or survivor’s current health were not significant predictors of heavy drinking. Conclusions Conclusions: This large study provided a unique opportunity to examine the long term impact of childhood cancer on adult siblings compared to long-term survivors and a national sample of aged matched peers. Adult siblings of childhood cancer exhibited higher rates of current, risky and heavy alcohol consumption compared to both peers and survivors. As in other populations early age of drinking initiation appeared to be a strong predictor for later risky and heavy drinking. Screening for alcohol consumption should be instituted for siblings as well as for survivors. Cancer related stresses from the survivor’s diagnosis and treatment do not appear to explain the heavier drinking. Research Implications Research Implications: Further studies should explore psychological distress, family and social factors that may better explain higher rates of risky and heavy drinking among siblings compared to national norms and survivors. Clinical Implications: Screening for alcohol consumption should be initiated among adolescent siblings while their sister/brother survivor is being treated and through long-term follow-up care. Interventions among adolescents should be established to reduce risk for early drinking among siblings and survivors and provide education for those most at risk. Siblings N=3,034 Survivors N=10,398 National N=5,712 %% Gender b Female52.946.251.8 Race/ethnicity b White and Other Black Hispanic 94.4 2.3 3.3 90.3 4.5 5.2 66.5 18.3 15.2 Age at interview b 18-21 22-26 27-31 32-48 49-56 17.6 22.3 23.2 36.3 0.6 24.1 30.0 23.3 22.5 0.0 9.4 12.0 13.0 49.2 16.4 Household Income a b lt 10K 10-20K 20,001-40K 40,001-60K gt 60K 4.8 8.1 24.8 24.9 37.4 9.2 13.8 30.1 21.9 25.1 12.8 14.8 29.0 18.3 25.1 Adjusted OR b Sibling vs. Survivor Adjusted OR b Siblings v. Peers OR adj (95%CI) Current Drinker1.7 (1.5, 1.9) *** 2.0 (1.7, 2.3 )*** Risky Drinking, NIAAA daily/weekly limit1.5 (1.3, 1.6) *** 1.3 (1.1, 1.6 )*** Heavy drinking, 5+/6+1.5 (1.3, 1.8) *** 1.3 (1.0, 1.6) * b Odds Ratios have been adjusted for age, race, gender and educational level * p <.05, ** p <.01, *** p <.001 Research Questions 1) Do siblings drink more heavily than cancer survivors and controls from a US National sample? 2) What general factors contribute to heavy drinking in siblings? 3) What factors related to the cancer increase risk for heavy drinking in siblings? Key Variables Dependent variable : Heavy Drinking is defined as being 5 or more drinks per occasion for women and 6 or more drinks per occasion for men during one month in the past year. Independent variables: Sibling stressors include: cancer diagnosis and sister/brother’s current health status. Mental health is measured using the Brief Symptom Inventory which assesses 3 subscales for depression, anxiety and somatization and the overall Global Severity Index (GSI). Methods This study employed data from two studies, the Childhood Cancer Survivor Study (CCSS) and the National Alcohol Study (NAS). The CCSS is a NCI funded cohort study childhood cancer survivors diagnosed between 1970 and 1986 and who have survived five or more years after diagnosis. The survivor response rate was 82% and included 10,398 who were ages 18-48 along with a comparison group of 3,034 nearest age siblings who were randomly selected from the list of participating survivors. The sibling response rate was 80.4%. Of those 3,034 were aged 18 to 56. Data for this study comes from the baseline survey collected between 1995 and 1996. The NAS collected data from U.S. adults between 9/1999 to 6/2001 using random digit dial techniques and CATI in English or Spanish. NAS participants were selected to match the CCSS age range of 18-56 (N=5,712). NAS had a 58% completion rate. The NAS data were weighted by age, race and gender to match the sibling sample. RESULTS *Siblings of childhood cancer survivors are at risk for heavy drinking. *Young age, being male, less education, and early initiation of drinking are risk factors for adult heavy drinking in siblings. *Older age of sibling at the cancer diagnosis is associated with heavy drinking. *Sibling poor general health, depression, anxiety and general mental health distress are associated with heavy drinking. *Stressors such as severity of sister/brother’s health and type of cancer diagnosis are NOT associated with heavy drinking.DISCUSSION Heavy alcohol consumption in this population may represent prolonged distress among siblings of childhood cancer survivors. This study represents the first detailed documentation of alcohol consumption in a large sample of siblings of childhood cancer survivors compared to survivors and general population controls. Future studies should use longitudinal measures to sort out the temporal sequence of stressors and subsequent mental health and health behaviors in this population. Table 1. Demographics by Dataset a Differences are significant between survivors and NAS/peers. b Differences are significant between survivors and siblings. Graph 2: Sibling Mental health distress is associated with heavy drinking Graph 1. Percentage of Heavy Drinkers by Dataset Table 2: Adjusted odds ratio for each drinking pattern for siblings compared to survivor Work on this study was supported by grants from the U.S. National Institutes on Health, National Institute on Alcohol Abuse and Alcoholism (P50 AA05595) through the National Alcohol Research Center, and supported by grant U24 CA55727 (L.L. Robison, Principal Investigator) from the National Cancer Institute, Bethesda, MD. Table 3: Multivariate model examining factors associated with heavy drinking (5+ women/6+ men). Model includes well known risk factors for heavy drinking OR adj =1.9* Total Population N=2,261 Sibling Heavy Drinking Siblings aged 18-56OR adj (95% CI) a Sibling Age at sister/brother’s cancer diagnosis (ref=Before birth-7 years) 8 to 13 14-18 19-36 2.2 (1.3-3.7) ** 2.0 (1.2-3.4) ** 0.9 (0.5-1.6) Was Sibling Younger or Older than Survivor? Older v Younger1.2 (0.8, 1.7) Was the sister/brother survivor a heavy drinker? Yes v No1.8 (1.1, 2.9) * Survivor age at Diagnosis (ref=5-9) 0-4 10-14 15-21 1.4 (1.0, 1.9) 0.7 (0.5, 1.1) 0.4 (0.3, 0.7) ** General Health Fair/Poor v Excellent/Very Good/Good2.0 (1.2, 3.2) ** Depression Abnormal v Normal2.1 (1.4, 3.4) ** Anxiety Abnormal v Normal1.9 (1.1, 3.4) * Somatization Abnormal v Normal0.9 (0.5, 1.9) GSI Score Abnormal v Normal2.6 (1.5, 4.5) ** Cancer Diagnosis (ref=Leukemia) Central Nervous System Hodgkin disease Non-hodgkin Lymphoma Wilms Tumor Neuroblastoma Sarcoma Bone 1.1 (0.7, 1.6) 0.7 (0.4, 1.1) 1.1 (0.7, 1.8) 0.6 (0.3, 1.0) * 1.2 (0.7, 2.0) 0.7 (0.4, 1.2) 0.9 (0.5, 1.2) Survivor Health Status (ref=no condition) Grade 1-mild Grade 2-moderate Grade 3-severe Grade 4-life-threatening Grade 5-fatal 1.1 (0.8, 1.6) 1.0 (0.7, 1.5) 0.9 (0.6, 1.3) 1.1 (0.6, 1.8) 1.5 (0.6, 3.9) Sibling Health Status (ref=no condition) Grade 1-mild Grade 2-moderate Grade 3-severe Grade 4-life-threatening 1.2 (0.9, 1.7) 1.3 (0.9, 2.0) 0.9 (0.4, 1.9) 1.1 (0.3, 3.8) * p <.05, ** p <.01, *** p <.001 a Odds Ratios have been adjusted for age, race, gender, education and age of first drink * p <.05, ** p <.01, *** p <.001 Table 4: An examination of individual risk factors for heavy drinking. Total PopulationCCSS Siblings N=3,034 Adjusted Odds Ratio Age at interview (ref=32-56) 18-21 22-26 27-31 3.0 (2.0-4.4) *** 2.8 (2.0-4.1) *** 1.7 (1.1-2.5) * Race/ethnicity (ref=White and other) Black, non-Hispanic Hispanic 0.4 (0.1-1.7) 1.0 (0.5-2.1) Gender Male v Female2.3 (1.7-3.0) *** Education (ref=College Graduate+) High school or less Some college/vocational 2.4 (1.7-3.5) *** 1.7 (1.2-2.4) ** Age of first drink (ref=21+) Le 14 15-16 17-20 5.2 (2.5-10.3) *** 3.5 (1.8-6.9) *** 2.1 (1.1-4.2) * OR adj =2.6** OR adj =2.1** OR adj =0.9