Tthanks to advances in treatments, so are children’s chances of surviving cancer higher than ever before. But the trauma patients experience as they deal with the disease can pose a lifelong risk to their mental health, according to one recent analysis published in JAMA Pediatrics.
The meta-analysis of 52 clinical trials measured the prevalence and severity of mental disorders in more than 20,000 young cancer survivors. Overall, cancer survivors in childhood, adolescents, and young adults were 57% more likely to develop depression, 29% more likely to develop anxiety, and 56% more likely to develop psychotic disorders in the years following cancer. treatment compared to their siblings or healthy members of treatment. a control group.
“Young cancer survivors suffer from numerous late effects,” said Joel Milam, a professor in the department of epidemiology and biostatistics at the University of California Irvine and co-director of the Southern California Center for Young Adult Cancer Survivorship Research, who was not involved in the study. “Much of the focus has historically been on medical late effects, such as a higher risk of cardiovascular disease or [cancer] repetition. That there are also mental health implications is not at all surprising.”
Many patients diagnosed with cancer at a young age deal with tremendous amounts of grief, says Jeanelle Folbrecht, a pediatric adolescent young adult psychologist and director of the Adolescent Young Adult Program at the City of Hope Clinical Research Center in Los Angeles.
“[It’s] not just sadness about a shortened life, because many people survive it, but sadness about what their life would have been like,” says Folbrecht, who was not involved in the study. “Grief over the loss of their physical abilities, their ability to pursue their career choice, their ability to participate in recreational activities or sports.”
The isolating impact of a cancer diagnosis
In particular, the new analysis found that children, adolescents and young adults who survive cancer have an increased risk of depression many years later, while their risk of anxiety tends to decrease after treatment. Folbrecht said the difference could lie in the severe, acute anxiety patients often experience during cancer treatment, while depression may develop as patients mature and become better able to process the trauma they’ve experienced.
Adolescent patients diagnosed with cancer between the ages of 12 and 18 are at the highest risk of suffering from major depression as adults, according to the study. For Folbrecht, herself the mother of a young cancer survivor, this makes sense.
“They see on social media their peers achieve the milestones they wanted to achieve — prom, graduating from high school, going to college, graduating from college, getting married, building a career, having kids,” she said.
In contrast, many cancer patients miss such milestones, experience them on a different timeline, or face limitations such as disabilities or infertility. Moreover, Folbrecht said, there are many “being kicked out of school or away from their friends or isolated because they may be immunocompromised, and their friends don’t know how to interact with them and lose weight,” further contributing to depression.
Young people who had had cancer were also significantly more prone to developing psychotic disorders compared to their peers, according to the analysis. Cyrus Ho, an assistant professor in the Department of Psychological Medicine at the National University of Singapore and the study’s principal investigator, hypothesizes that this finding may be explained by the two-way relationship between mental and physical health.
“Cancer and psychiatric illnesses like depression, anxiety — they have common immunological pathways. They’re all chronic inflammation and this can even result in a cascade of changes,” Ho said. “I do think there is a two-way relationship. So people with cancer are more likely to have psychiatric disorders, and people with psychiatric disorders may have an increased risk of cancer.” However, larger, “causative cohort studies” are needed to investigate this theory, Ho said.
Both Milam and Folbrecht had some hesitation in associating cancer in general with a higher likelihood of psychotic disorders, as psychotic symptoms can depend heavily on the type of cancer, the intensity of treatments such as chemotherapy or radiation, and the type of medication patients receive. The study did report a higher rate of psychosis in people with cancers of the central nervous system, but does not mention specifics about drugs.
Milam pointed out that some cancer patients could suffer “cognitive impairment due to the treatments they receive. Some of those neurocognitive disorders are also lifelong.” In addition, a patient’s genetic background could increase their predisposition to psychotic disorders, Folbrecht said.
The study also found that factors such as education, income level and level of social support may influence an individual cancer patient’s risk level of developing mental disorders. As expected, a lower level of education, income or social support are all associated with an increased risk of mental health problems. These factors can often be a measure of socioeconomic status, Milam said, serving as an “indicator of the overall supportive environment one has.” Many cancer survivors also have problems entering or re-entering the labor marketwith a further impact on their financial stability.
Despite increased risks of depression, anxiety and psychotic disorders, the meta-analysis found no significantly increased risk of suicide. For Folbrecht, this finding speaks to the unique experiences of young cancer patients.
“Even as my young adult [patients] do not live for themselves, they live to avoid the grief of their relatives. So they want to live because they don’t want their relatives to grieve,” she said.
Ainsley Ryan Lee, the lead author of the meta-analysis, said more research is needed to answer questions such as how the mental health of young cancer patients continues to develop over longer trajectories and which demographics could benefit most from psychosocial intervention.
Cancer care for the ‘whole person’
Despite the significant mental health burden faced by young cancer survivors, many still lack access to psychosocial supportive care. “There are far more pediatric oncologists than psychosocial clinicians” at nearly every pediatric cancer center, said Abby Rosenberg, chief of pediatric palliative care at the Dana-Farber Cancer Institute. While most patients “will have an assigned social worker, the extent to which that person can provide real, comprehensive, longitudinal mental health is completely different depending on where you are,” she said.
Milam adds that young adults in particular are underserved, saying many are “lost in menopause” when they get older and no longer have pediatric care. Because of the relative rarity of cancer in children, physicians providing care to adults are often unfamiliar with the specific needs of young cancer survivors, Milam said. “Chances are they won’t get all the screening tests they need, let alone the psychosocial support they need,” he said.
To improve access to psychosocial support, Rosenberg has developed a skills-based coaching program for young cancer patients. Called PRISM, which stands for Promoting Resilience in Stress Management, the program teaches patients tools to manage stress, set goals, reframe experiences, and find moments of gratitude.
“We wanted to create a basic, comprehensive supportive care program that would teach everyone resilience — whether you were already in need or not — because we knew that the cancer experience, if it wasn’t stressful now, would become stressful at some point,” said Rozenberg.
In a small, randomized clinical trial where the PRISM intervention was introduced during cancer treatment, PRISM recipients reported improved psychosocial outcomes two years later.
“If you administer it during cancer treatment in adolescents and young adults, it seems to work,” says Rosenberg. “They report a higher level of their own sense of resilience, they report more hope, and they report fewer mental health problems and a better quality of life.”
PRISM is one of the few interventions with clinically proven efficacy that exists. However, it is currently limited to research environments, which Rosenberg says is “a huge problem… the reason we haven’t made it publicly available is the scalability issue.” Rosenberg has developed an app version of PRISM and is preparing for future clinical trials with the goal of finding the balance between app-based and live coaching that can still be effective.
Rosenberg says studies like the meta-analysis are important because they represent a step toward both normalizing the inevitable stress associated with a cancer diagnosis and the importance of reducing it.
“It would be great if we could systematically recognize that there is a whole human being in front of us who has just been diagnosed with cancer, and that we need to think about all of their needs,” she said.