1. Health Perceptions, Behavior, and Medical Care Utilization: Links to Mortality in Adult Survivors of Childhood Cancer Cheryl L. Cox, RN, PhD Department of Epidemiology and Cancer Control

2. DISCLOSURES The authors have no financial or other interests to disclose

3. Mortality in adult survivors of pediatric malignancies Life expectancy reduced by 28% Mortality risk modified by: –era of treatment –type of treatment –diagnosis –demographic characteristics

4. Excess late mortality causes 15-fold ↑ in death from subsequent neoplasms 7-fold ↑ in cardiac deaths 9-fold ↑ in pulmonary deaths

5. New links to late mortality risk? Beyond cancer-related treatment? Beyond severity of chronic health conditions? What about health behavior, perceived health status, and health worries?

6. Sample Childhood Cancer Survivor Study –Retrospective cohort (n=20,691) –Diagnosed between 1970-1986 –Derived from 27 institutions in US and Canada

7. Sample Selection

8. Analysis Conditional logistic regression (all- cause and cause-specific mortality) –3 models Medical care Lifestyle and self-care behaviors Health concerns/worries Models adjusted for: –Race/ethnicity, sex, marital status, education, health insurance status, income, #/severity of chronic conditions

9. Sample Characteristics Cases (n=445) vs. Controls (n=7162): –Slightly older (30.5 vs. 28.8 years) –Less likely to be college grads (p=<0.001) –Less likely to be married (p=0.007) –More likely to have income <$20K (p=<0.001) –More likely to be African-American (p=0.03) –More likely to have grade 3 or 4 chronic health condition (p=<0.001)

10. Common causes of death Malignant neoplasm (42%) Cardiac (20%) Pulmonary (7%)

11. All-Cause Mortality

12. Medical care

13. Lifestyle and self-care behaviors Smoking Never 1.00 Past 0.95 (0.66–1.36)0.79 Current 1.03 (0.74–1.44)0.84 Alcohol consumption Never 1.00 Ever 0.61 (0.41–0.89)0.01 Drinks per month None 1.00 1 to 4 0.83 (0.59–1.15)0.26 5 + 0.75 (0.55–1.00)0.05 Physical activity 0 days per week 1.72 (1.27–2.34)<0.001 1 – 2 days per week 1.65 (1.17–2.31)0.004 3+ days per week 1.00 Testicular self-examination Regularly (once a month) 1.00 Occasionally 1.49 (0.76–2.94)0.25 Rarely or never 1.32 (0.72–2.42)0.36 Breast self-examination Regularly (once a month) 1.00 Occasionally 0.68 (0.45–1.03)0.07 Rarely or never 0.56 (0.35–0.91)0.02 BMI Underweight 2.58 (1.55–4.28)<0.001 Normal 1.00 Overweight 1.12 (0.84–1.50)0.43 Obese1.03 (0.71–1.49)0.88

14. Health worry and concern

15. Time to death

16. Cause-Specific Mortality

17. Medical care

18. Lifestyle and self-care behaviors

19. Health worry and concern

20. Limitations Inaccuracy in death certificates ↓N limits power - cause-specific mortality Changes in covariates since baseline Young age/short observation period inadequate to identify associations observed later in life (e.g., tobacco use) Findings may not generalize to more recently treated patients

21. Conclusions Behavior, self-reported health, worries/concerns, and medical care use impact mortality Clear trends between mortality and surveillance/lifestyle behaviors may emerge as predictive as observation continues These associations are established in the general population, but occur much earlier in childhood cancer survivors

22. Implications Increase awareness among community care providers Target specific demographic groups for risk-based care (African-Americans, low income) Interventions to support increased surveillance among survivors

23. Contributors Vikki Nolan, DSc (University of Memphis) Wendy Leisenring, ScD (Fred Hutchison Cancer Research Center) Yutaka Yasui, PhD (University of Alberta) Susan Ogg, MSN(St. Jude) Ann Mertens, PhD(Emory University) Joseph Neglia, MD(University of Minnesota) Kirsten Ness, PhD(St. Jude) Greg Armstrong, MD(St. Jude) Les Robison, PhD(St. Jude)