Is the Traumatic Impact of Cancer Overestimated in Children With Cancer?
In a study reported in the Journal of Clinical Oncology, Phipps et al found no evidence of increased post-traumatic stress disorder (PTSD) or post-traumatic stress symptoms (PTSS) in children with cancer and observed a heightened sense of perceived growth related to cancer events in these children. The investigators noted, “Although childhood cancer remains a significant and challenging event, these findings highlight the capacity of children to adjust, and even thrive, in the face of such challenge.”
Study Details
In the study, children with cancer (n = 255) treated at St. Jude Children’s Research Hospital and demographically matched peers without cancer (n = 101) from regional schools were assessed for PTSD using structured diagnostic interviews by both child and parent reports and survey measures of PTSS and psychological benefit/growth by child report.
The cancer and control groups were balanced for age (median, 12.7 and 12.1 years), sex (52% and 56% male), race (73% and 72% white), and parent participant (mother for 83% and 89%); there were more children from high socioeconomic status backgrounds (49.5% vs 27.5%) and fewer low-status children (22% vs 40%) in the control group (P < .01).
In the cancer group, 38% of children had solid tumors, 24% acute lymphocytic leukemia, 17% brain tumor, 13% Hodgkin disease/non-Hodgkin lymphoma, and 6% other leukemia. Time since diagnosis was < 6 months in 25%, 6 months to 1.99 years in 25%, 2 to 4.99 years in 25%, and > 5 years in 25%. The time since the most stressful event for cancer patients and controls, as identified by the children, was within past year for 39% and 43%, 1 to 2 years for 14% and 14%, 2 to 5 years for 25% and 20%, and > 5 years for 23% and 23%.
Effect of Greater Time Since Diagnosis
Cancer was identified as a traumatic event by 52.6% of patients, with no differences according to demographic or disease characteristics. Cancer was reported as their most traumatic event by > 50% patients who were at < 5 years from diagnosis vs 23.8% of those at ≥ 5 years from diagnosis (P < .001); the corresponding percentages for parents’ ratings of their child’s most traumatic event were > 75% vs 47.6% (P < .001).
No Increase in PTSD
Child interviews using the Clinician-Administered PTSD Scale for Children and Adolescents (CAPSCA) identified one child (0.4%) meeting criteria for full PTSD in the cancer group, but the case did not result from a cancer event. Seven patients in the cancer group (2.8%) met criteria for lifetime PTSD, with events being cancer-related in two cases.
No cases of current (P = .9) or lifetime PTSD (P = .2) were observed in controls, but rates did not differ significantly from cancer patients. By parent report, 1.6% of children with cancer met current criteria and 5.9% met lifetime criteria for PTSD, but these rates did not differ significantly from controls (0% and 2.0%, all P > .1).
Lower PTSS Level
On the University of California, Los Angeles, PTSD Reaction Index for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition), PTSS levels were nonsignificantly lower in children with cancer compared with controls when referring to their most traumatic event (P = .067).
PTSS levels in the cancer group when referring specifically to cancer-related events were significantly lower than levels in the control group when referring to their most stressful event (P = .002). When analysis was limited to events meeting DSM-IV A1 criteria for PTSD, the lower PTSS level in the cancer group was more highly significant (P < .001).
Greater Perceived Growth
Use of the Benefit Finding/Burden Scale for Children to assess benefit/perceived growth associated with a stressful event showed that perceived growth in the cancer group was significantly higher when referring to most stressful event (P = .045) and when referring to a cancer event in the cancer group (P < .001) but not when referring to a noncancer event in the cancer group. When analysis was limited to events meeting DSM-IV A1 criteria for PTSD, the only difference between groups was greater perceived growth in the control group for most stressful event compared with noncancer events in the cancer group (P = .014).
The investigators concluded: “These findings suggest no evidence of increased PTSD or PTSS in youths with cancer…. Not only do children with cancer report low levels of PTSS (resilience), but they also report higher levels of perceived benefit (growth) than do their peers, and the perception of benefit is greater for cancer-related than non-cancer-related stressors. There may be unique elements of the childhood cancer experience that contribute to these outcomes, but to the extent that the diagnosis and treatment of cancer provide an exemplar of randomly occurring childhood adversity, the capacity of children to adjust, and even thrive, in the face of major life challenges should not be underestimated.”
Sean Phipps, PhD, of St Jude Children’s Research Hospital, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by a National Institutes of Health grant and the American Lebanese-Syrian Associated Charities. The study authors reported no potential conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
