Ann C Mertens

Publications (118)1093.21 Total impact

• Article: Predictors of risk-based medical follow-up: a report from the childhood cancer survivor study.

  Jeanne R Steele, Melanie Wall, Nicholas Salkowski, Pauline Mitby, Toana Kawashima, Mark W Yeazel, Melissa M Hudson, Leslie L Robison, Ann C Mertens
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  ABSTRACT: PURPOSE: The purpose of this study is to conduct an intervention study designed to assess the effectiveness of using a newsletter to increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications. METHODS: Survivors participating in the Childhood Cancer Survivor Study who were at least 25 years of age and at risk of cardiovascular disease, breast cancer, or osteoporosis related to previous cancer treatment were randomly assigned to receive a newsletter featuring brief health risk information or a newsletter including an insert providing more comprehensive health risk information. A follow-up survey distributed 24 months after the newsletter intervention assessed predictors of medical follow-up. RESULTS: Overall, there were no differences found among the groups in terms of access to a treatment summary, medical follow-up, discussion of childhood cancer health risks, and medical screening for the targeted health behaviors. One exception, indicating borderline significance was that women at risk for osteoporosis who received the newsletter insert were more likely to have discussed their risk with a doctor than those who only received the brief information (10.1 % vs. 4.0 % p = 0.05). Discussion of breast cancer (OR = 2.15; 95 % CI = 1.74-2.66), heart disease (OR = 5.54; 95 % CI = 4.67-6.57) and osteoporosis (OR = 10.6; 95 % CI = 8.34-13.47) risk with physician significantly predicted report of undergoing screening for targeted behavior in previous 2 years as did physician access to treatment summary. CONCLUSIONS: More detailed content in a newsletter had minimal effect on recommended screening. However, survivor's discussion of cancer-related risks with one's doctor significantly influenced participation in health screening. These results highlight the integral role of communication in health behavior. IMPLICATIONS FOR CANCER SURVIVORS: This study is designed to assess communication strategies that increase medical follow-up in pediatric cancer survivors at risk of selected treatment complications. The results are of great importance not only to the pediatric oncology community but also the broad range of adult oncology medical specialties who are directly involved in the long-term medical care of this ever increasing population of cancer survivors.
  Journal of Cancer Survivorship 04/2013; · 2.63 Impact Factor
• Article: Absolute Risk Prediction of Second Primary Thyroid Cancer Among 5-Year Survivors of Childhood Cancer.

  Stephanie A Kovalchik, Cécile M Ronckers, Lene H S Veiga, Alice J Sigurdson, Peter D Inskip, Florent de Vathaire, Charles A Sklar, Sarah S Donaldson, Harald Anderson, Parveen Bhatti, Sue Hammond, Wendy M Leisenring, Ann C Mertens, Susan A Smith, Marilyn Stovall, Margaret A Tucker, Rita E Weathers, Leslie L Robison, Ruth M Pfeiffer
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  ABSTRACT: PURPOSEWe developed three absolute risk models for second primary thyroid cancer to assist with long-term clinical monitoring of childhood cancer survivors. PATIENTS AND METHODS We used data from the Childhood Cancer Survivor Study (CCSS) and two nested case-control studies (Nordic CCSS; Late Effects Study Group). Model M1 included self-reported risk factors, model M2 added basic radiation and chemotherapy treatment information abstracted from medical records, and model M3 refined M2 by incorporating reconstructed radiation absorbed dose to the thyroid. All models were validated in an independent cohort of French childhood cancer survivors.ResultsM1 included birth year, initial cancer type, age at diagnosis, sex, and past thyroid nodule diagnosis. M2 added radiation (yes/no), radiation to the neck (yes/no), and alkylating agent (yes/no). Past thyroid nodule was consistently the strongest risk factor (M1 relative risk [RR ], 10.8; M2 RR, 6.8; M3 RR, 8.2). In the validation cohort, 20-year absolute risk predictions for second primary thyroid cancer ranged from 0.04% to 7.4% for M2. Expected events agreed well with observed events for each model, indicating good calibration. All models had good discriminatory ability (M1 area under the receiver operating characteristics curve [AUC ], 0.71; 95% CI, 0.64 to 0.77; M2 AUC, 0.80; 95% CI, 0.73 to 0.86; M3 AUC, 0.75; 95% CI, 0.69 to 0.82). CONCLUSION We developed and validated three absolute risk models for second primary thyroid cancer. Model M2, with basic prior treatment information, could be useful for monitoring thyroid cancer risk in childhood cancer survivors.
  Journal of Clinical Oncology 11/2012; · 18.37 Impact Factor
• Article: Radiation-related risk of basal cell carcinoma: a report from the Childhood Cancer Survivor Study.

  Tanya C Watt, Peter D Inskip, Kayla Stratton, Susan A Smith, Stephen F Kry, Alice J Sigurdson, Marilyn Stovall, Wendy Leisenring, Leslie L Robison, Ann C Mertens
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  ABSTRACT: Basal cell carcinoma (BCC) is the most common malignancy in the United States. Ionizing radiation is an established risk factor in certain populations, including cancer survivors. We quantified the association between ionizing radiation dose and the risk of BCC in childhood cancer survivors. Participants in the Childhood Cancer Survivor Study who reported a BCC (case subjects, n = 199) were matched on age and length of follow-up to three study participants who had not developed a BCC (control subjects, n = 597). The radiation-absorbed dose (in Gy) to the BCC location was calculated based on individual radiotherapy records using a custom-designed dosimetry program. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between demographic and treatment factors, therapeutic radiation dose, and surrogate markers of sun sensitivity (skin and hair color) and the risk of BCC. A linear dose-response model was fitted to evaluate the excess odds ratio per Gy of radiation dose. Among case subjects, 83% developed BCC between the ages of 20 and 39 years. Radiation therapy, either alone or in combination with chemotherapy, was associated with an increased risk of BCC compared with no chemotherapy or radiation. The odds ratio for subjects who received 35 Gy or more to the skin site vs no radiation therapy was 39.8 (95% CI = 8.6 to 185). Results were consistent with a linear dose-response relationship, with an excess odds ratio per Gy of 1.09 (95% CI = 0.49 to 2.64). No other treatment variables were statistically significantly associated with an increased risk of BCC. Radiation doses to the skin of more than 1 Gy are associated with an increased risk of BCC.
  CancerSpectrum Knowledge Environment 07/2012; 104(16):1240-50. · 14.07 Impact Factor
• Article: Risk of Salivary Gland Cancer After Childhood Cancer: A Report From the Childhood Cancer Survivor Study.

  Houda Boukheris, Marilyn Stovall, Ethel S Gilbert, Kayla L Stratton, Susan A Smith, Rita Weathers, Sue Hammond, Ann C Mertens, Sarah S Donaldson, Gregory T Armstrong, Leslie L Robison, Joseph P Neglia, Peter D Inskip
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  ABSTRACT: PURPOSE: To evaluate effects of radiation therapy, chemotherapy, cigarette smoking, and alcohol consumption on the risk of second primary salivary gland cancer (SGC) in the Childhood Cancer Survivor Study (CCSS). METHODS AND MATERIALS: Standardized incidence ratios (SIR) and excess absolute risks (EAR) of SGC in the CCSS were calculated using incidence rates from Surveillance, Epidemiology, and End Results population-based cancer registries. Radiation dose to the salivary glands was estimated based on medical records. Poisson regression was used to assess risks with respect to radiation dose, chemotherapy, smoking, and alcohol consumption. RESULTS: During the time period of the study, 23 cases of SGC were diagnosed among 14,135 childhood cancer survivors. The mean age at diagnosis of the first primary cancer was 8.3 years, and the mean age at SGC diagnosis was 24.8 years. The incidence of SGC was 39-fold higher in the cohort than in the general population (SIR = 39.4; 95% CI = 25.4-57.8). The EAR was 9.8 per 100,000 person-years. Risk increased linearly with radiation dose (excess relative risk = 0.36/Gy; 95% CI = 0.06-2.5) and remained elevated after 20 years. There was no significant trend of increasing risk with increasing dose of chemotherapeutic agents, pack-years of cigarette smoking, or alcohol intake. CONCLUSION: Although the cumulative incidence of SGC was low, childhood cancer survivors treated with radiation experienced significantly increased risk for at least 2 decades after exposure, and risk was positively associated with radiation dose. Results underscore the importance of long-term follow up of childhood cancer survivors for the development of new malignancies.
  International journal of radiation oncology, biology, physics 07/2012; · 4.59 Impact Factor
• Article: Prevalence and predictors of risky and heavy alcohol consumption among adult siblings of childhood cancer survivors.

  E Anne Lown, Ann C Mertens, Rachael A Korcha, Wendy Leisenring, Melissa M Hudson, Thomas K Greenfield, Leslie L Robison, Lonnie K Zeltzer
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  ABSTRACT: OBJECTIVE: To describe alcohol consumption patterns and risk factors for risky and heavy alcohol use among siblings of childhood cancer survivors compared with survivors and national controls. METHODS: Secondary analysis of prospectively collected data from two national surveys was performed including a cohort of 3034 adult siblings of childhood cancer survivors (age 18-56 years) and 10,398 adult childhood cancer survivors, both from the Childhood Cancer Survivor Study, plus 5712 adult participants from the population-based National Alcohol Survey. Cancer-related experiences, self-reported current health, and mental health were examined in relation to alcohol consumption patterns including heavy and risky drinking. RESULTS: Adult siblings of childhood cancer survivors were more likely to be heavy drinkers (OR(adj)  = 1.3; 1.0-1.6) and risky drinkers (OR(adj)  = 1.3; 1.1-1.6) compared with controls from a national sample. Siblings were also more likely to drink at these two levels compared with survivors. Factors associated with heavy drinking among siblings included being 18-21 years old (OR(adj)  = 2.9; 2.0-4.4), male (OR(adj)  = 2.3; 1.7-3.0), having a high school education or less (OR(adj)  = 2.4; 1.7-3.5), and drinking initiation at a young age (OR(adj)  = 5.1; 2.5-10.3). Symptoms of depression, (OR(adj)  = 2.1; 1.3-3.2), anxiety (OR(adj)  = 1.9; 1.1-3.3), and global psychiatric distress (OR(adj)  = 2.5; 1.5-4.3) were significantly associated with heavy alcohol use. CONCLUSIONS: Siblings of children with cancer are more likely to be risky and heavy drinkers as adults compared with childhood cancer survivors or national controls. Early initiation of drinking and symptoms of psychological distress should be identified during early adolescence and effective sibling-specific interventions should be developed and made available for siblings of children with cancer. Copyright © 2012 John Wiley & Sons, Ltd.
  Psycho-Oncology 06/2012; · 3.34 Impact Factor
• Article: Childhood Cancer Survivor Study participants' perceptions and knowledge of health insurance coverage: implications for the Affordable Care Act.

  Elyse R Park, Anne C Kirchhoff, Jennifer P Zallen, Joel S Weissman, Hannah Pajolek, Ann C Mertens, Gregory T Armstrong, Leslie L Robison, Karen Donelan, Christopher J Recklitis, Lisa R Diller, Karen A Kuhlthau
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  ABSTRACT: Childhood cancer survivors face long-term health consequences, and comprehensive health insurance is critical. However, childhood cancer survivors may face barriers in accessing medical services due to being uninsured or underinsured. Little is known about the quality of survivors' health insurance coverage, and improving health insurance within the context of changes mandated by the 2010 Affordable Care Act requires understanding survivors' coverage. The current study explored adult childhood cancer survivors' quality of health insurance coverage. From 9/09 to 2/10, we conducted in-depth, semistructured qualitative interviews with 39 adult participants from the Childhood Cancer Survivor Study, a cohort of 5-year survivors of cancers diagnosed before age 21. Interviews were recorded and transcribed; content analyses were conducted by two coders (kappa = 0.88) using NVivo 8. Most insured survivors reported satisfaction with the quality of their coverage; however, they expressed low expectations. Almost half reported annual out-of-pocket costs exceeding $2,000, yet most felt fortunate to simply have coverage. One third of insured survivors had difficulty obtaining coverage, and many had difficulties understanding how to utilize it. Most uninsured survivors minimized their need for care. Worry about future health care costs seemed inevitable among insured and uninsured survivors. Almost all participants lacked knowledge about existing health insurance-related laws. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Insured survivors had low coverage expectations, and uninsured survivors avoided care. Childhood cancer survivors will likely benefit from assistance in how to access and utilize the new health care reform provisions (e.g., Medicaid expansion, expansion of parents' insurance, and mandatory primary care coverage).
  Journal of Cancer Survivorship 05/2012; 6(3):251-9. · 2.63 Impact Factor
• Article: Cancer prevention and screening practices of siblings of childhood cancer survivors: a report from the Childhood Cancer Survivor Study.

  David Buchbinder, Ann C Mertens, Lonnie K Zeltzer, Wendy Leisenring, Pam Goodman, E Anne Lown, Melissa A Alderfer, Christopher Recklitis, Kevin Oeffinger, Gregory T Armstrong, Melissa Hudson, Leslie L Robison, Jacqueline Casillas
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  ABSTRACT: To compare the skin and breast/cervical cancer prevention/screening practices of adult siblings of childhood cancer survivors with controls and to identify modifying factors for these practices. Cross-sectional, self-report data from 2,588 adult siblings of 5+ year survivors of childhood cancer were analyzed to assess cancer prevention/screening practices. Two age, sex, and race/ethnicity-matched samples (N = 5,915 and N = 37,789) of the Behavioral Risk Factor Surveillance System participants served as the comparison populations. Sociodemographic and cancer-related data were explored as modifying factors for sibling cancer prevention/screening practices through multivariable logistic regression. Compared with controls, siblings were more likely to practice skin cancer prevention behaviors: use of protective clothing [OR, 2.85; 95% confidence interval (CI), 2.39-3.39], use of shade (OR, 2.11; 95% CI, 1.88-2.36), use of sunscreen (OR, 1.27; 95% CI, 1.14-1.40), and wearing a hat (OR, 1.77; 95% CI, 1.58-1.98). No differences were noted for breast/cervical cancer screening including mammography and Pap testing. Having less than a high school education and lack of health insurance were associated with diminished cancer prevention/screening behaviors. Survivor diagnosis, treatment intensity, adverse health, chronic health conditions, and second cancers were not associated with sibling cancer prevention/screening behaviors. Siblings of cancer survivors report greater skin cancer prevention practices when compared with controls; however, no differences were noted for breast/cervical cancer screening practices. Access to care and lack of education may be associated with decreased cancer prevention/screening behaviors. Interventions are needed to address these barriers. Research should be directed at understanding the impact of the cancer experience on sibling health behaviors.
  Cancer Epidemiology Biomarkers &amp Prevention 05/2012; 21(7):1078-88. · 4.12 Impact Factor
• Article: Risky health behavior among adolescents in the childhood cancer survivor study cohort.

  James L Klosky, Carrie R Howell, Zhenghong Li, Rebecca H Foster, Ann C Mertens, Leslie L Robison, Kirsten K Ness
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  ABSTRACT: To report the prevalence and comparison of cancer-linked health behaviors and identify risk factors associated with unhealthy behavior among adolescent siblings and cancer survivors. The Child Health and Illness Profile--Adolescent Edition (CHIP--AE) was completed by 307 survivors and 97 sibling controls 14-20 years of age. Risky behavior ranged from 0.7% to 35.8% for survivors and 1.0% to 41.2% for siblings. Comparisons of sexual behavior, tobacco, alcohol, or illicit drug use utilizing continuous data revealed no differences between groups. Categorically, survivors were less likely to report past smokeless tobacco use or current use of beer/wine or binge drinking (p-values range from .01 to .04). Survivors with better mental health were at lower risk for poor behavioral outcomes. Adolescent survivors engage in risky health behaviors at rates generally equivalent to their siblings. Aggressive health education efforts should be directed toward this high-risk population.
  Journal of Pediatric Psychology 03/2012; 37(6):634-46. · 2.91 Impact Factor
• Article: Chemotherapy and thyroid cancer risk: a report from the childhood cancer survivor study.

  Lene H S Veiga, Parveen Bhatti, Cécile M Ronckers, Alice J Sigurdson, Marilyn Stovall, Susan A Smith, Rita Weathers, Wendy Leisenring, Ann C Mertens, Sue Hammond, Joseph P Neglia, Anna T Meadows, Sarah S Donaldson, Charles A Sklar, Debra L Friedman, Leslie L Robison, Peter D Inskip
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  ABSTRACT: Although ionizing radiation is an established environmental risk factor for thyroid cancer, the effect of chemotherapy drugs on thyroid cancer risk remains unclear. We evaluated the chemotherapy-related risk of thyroid cancer in childhood cancer survivors and the possible joint effects of chemotherapy and radiotherapy. The study included 12,547 five-year survivors of childhood cancer diagnosed during 1970 through 1986. Chemotherapy and radiotherapy information was obtained from medical records, and radiation dose was estimated to the thyroid gland. Cumulative incidence and relative risks were calculated with life-table methods and Poisson regression. Chemotherapy-related risks were evaluated separately by categories of radiation dose. Histologically confirmed thyroid cancer occurred in 119 patients. Thirty years after the first childhood cancer treatment, the cumulative incidence of thyroid cancer was 1.3% (95% CI, 1.0-1.6) for females and 0.6% (0.4-0.8) for males. Among patients with thyroid radiation doses of 20 Gy or less, treatment with alkylating agents was associated with a significant 2.4-fold increased risk of thyroid cancer (95% CI, 1.3-4.5; P = 0.002). Chemotherapy risks decreased as radiation dose increased, with a significant decrease for patients treated with alkylating agents (P(trend) = 0.03). No chemotherapy-related risk was evident for thyroid radiation doses more than 20 Gy. Treatments with alkylating agents increased thyroid cancer risk, but only in the radiation dose range less than 20 Gy, in which cell sparing likely predominates over cell killing. Our study adds to the evidence for chemotherapy agent-specific increased risks of thyroid cancer, which to date, were mainly thought to be related to prior radiotherapy.
  Cancer Epidemiology Biomarkers &amp Prevention 01/2012; 21(1):92-101. · 4.12 Impact Factor
• Article: Congenital anomalies in the children of cancer survivors: a report from the childhood cancer survivor study.

  Lisa B Signorello, John J Mulvihill, Daniel M Green, Heather M Munro, Marilyn Stovall, Rita E Weathers, Ann C Mertens, John A Whitton, Leslie L Robison, John D Boice
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  ABSTRACT: Children with cancer receive mutagenic treatments, which raises concern about the potential transmissibility of germline damage to their offspring. This question has been inadequately studied to date because of a lack of detailed individual treatment exposure assessment such as gonadal radiation doses. Within the Childhood Cancer Survivor Study, we performed a retrospective cohort analysis of validated cases of congenital anomalies among 4,699 children of 1,128 male and 1,627 female childhood cancer survivors. We quantified chemotherapy with alkylating agents and radiotherapy doses to the testes and ovaries and related these exposures to risk of congenital anomalies using logistic regression. One hundred twenty-nine children had at least one anomaly (prevalence = 2.7%). For children whose mothers were exposed to radiation or alkylating agents versus neither, the prevalence of anomalies was 3.0% versus 3.5% (P = .51); corresponding figures were 1.9% versus 1.7% (P = .79) for the children of male survivors. Neither ovarian radiation dose (mean, 1.19 Gy; odds ratio [OR] = 0.59; 95% CI, 0.20 to 1.75 for 2.50+ Gy) nor testicular radiation dose (mean, 0.48 Gy; OR = 1.01; 95% CI, 0.36 to 2.83 for 0.50+ Gy) was related to risk of congenital anomalies. Treatment with alkylating agents also was not significantly associated with anomalies in the children of male or female survivors. Our findings offer strong evidence that the children of cancer survivors are not at significantly increased risk for congenital anomalies stemming from their parent's exposure to mutagenic cancer treatments. This information is important for counseling cancer survivors planning to have children.
  Journal of Clinical Oncology 12/2011; 30(3):239-45. · 18.37 Impact Factor
• Article: Risk factors for smoking among adolescent survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.

  Lisa S Kahalley, Leslie A Robinson, Vida L Tyc, Melissa M Hudson, Wendy Leisenring, Kayla Stratton, Ann C Mertens, Lonnie Zeltzer, Leslie L Robison, Pamela S Hinds
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  ABSTRACT: Few studies have examined risk factors for smoking among adolescent survivors of childhood cancer. The present study reports on the rate of smoking and identifies factors associated with smoking in a sample of adolescent survivors from the Childhood Cancer Survivor Study (CCSS). Participants included 307 adolescent survivors and 97 healthy siblings (ages 14-20) who completed a self-report survey of health, quality of life, and health behaviors. Smoking rates did not differ significantly between survivor and sibling groups (ever smokers: 28% vs. 33%, recent smokers: 10% vs. 9%, respectively). Ever smoking was significantly associated with peer smoking, smokers in the household, binging, suicidal behavior, and no history of CRT. There were significant interactions of peer smoking with gender and CRT for ever smoking and with binging for recent smoking. Recent smoking was more likely for survivors with other household smokers (RR=2.24, CI=1.21-4.16), past suicidality (RR=1.89, CI=1.00-3.56), and no CRT (RR=2.40, CI=1.12-5.17). Among survivors with few smoking friends, ever smoking was more likely for survivors with no CRT (RR=4.47, CI=1.43-13.9), and recent smoking was more likely among survivors who binged (RR=3.37, CI=1.17-9.71). Despite the health risks associated with survivorship, nearly one in three adolescent survivors of childhood cancer has smoked. Exposure to other smokers, in particular, appears to increase the likelihood of smoking for some survivors. Providing smoking cessation programs targeted to family members, helping survivors choose non-smoking friends, and teaching ways to resist smoking influences from peers may be important pathways for smoking prevention with adolescent survivors.
  Pediatric Blood & Cancer 05/2011; 58(3):428-34. · 1.89 Impact Factor
• Article: Impact of insurance type on survivor-focused and general preventive health care utilization in adult survivors of childhood cancer: the Childhood Cancer Survivor Study (CCSS).

  Jacqueline Casillas, Sharon M Castellino, Melissa M Hudson, Ann C Mertens, Isac S F Lima, Qi Liu, Lonnie K Zeltzer, Yutaka Yasui, Leslie L Robison, Kevin C Oeffinger
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  ABSTRACT: Lack of health insurance is a key barrier to accessing care for chronic conditions and cancer screening. The influence of insurance type (private, public, none) on survivor-focused and general preventive health care in adult survivors of childhood cancer was examined. The Childhood Cancer Survivor Study is a retrospective cohort study of childhood cancer survivors diagnosed between 1970 and 1986. Among 8425 adult survivors, the relative risk (RR) and 95% confidence interval (CI) of receiving survivor-focused and general preventive health care were estimated for uninsured (n = 1390) and publicly insured (n = 640), compared with for the privately insured (n = 6395) Uninsured survivors were less likely than those privately insured to report a cancer-related visit (adjusted RR, 0.83; 95% CI, 0.75-0.91) or a cancer center visit (adjusted RR, 0.83; 95% CI, 0.71-0.98). Uninsured survivors had lower levels of utilization in all measures of care in comparison with privately insured. In contrast, publicly insured survivors were more likely to report a cancer-related visit (adjusted RR, 1.22; 95% CI, 1.11-1.35) or a cancer center visit (adjusted RR, 1.41; 95% CI, 1.18-1.70) than were privately insured survivors. Although publicly insured survivors had similar utilization of general health examinations, they were less likely to report a Papanicolaou test or a dental examinations Among this large, socioeconomically diverse cohort, publicly insured survivors utilize survivor-focused health care at rates at least as high as survivors with private insurance. Uninsured survivors have lower utilization of both survivor-focused and general preventive health care.
  Cancer 05/2011; 117(9):1966-75. · 4.77 Impact Factor
• Article: Increasing rates of breast cancer and cardiac surveillance among high-risk survivors of childhood Hodgkin lymphoma following a mailed, one-page survivorship care plan.

  Kevin C Oeffinger, Melissa M Hudson, Ann C Mertens, Stephanie M Smith, Pauline A Mitby, Debra A Eshelman-Kent, Jennifer S Ford, Judith K Jones, Sharmila Kamani, Leslie L Robison
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  ABSTRACT: Hodgkin lymphoma (HL) survivors face substantially elevated risks of breast cancer and cardiovascular disease. They and their physicians are often unaware of these risks and surveillance recommendations. A prospective one-arm study was conducted among a random sample of 72 HL survivors, ages 27-55 years, participating in the Childhood Cancer Survivor Study (CCSS) who were at increased risk for breast cancer and/or cardiomyopathy and had not had a screening mammogram or echocardiogram, respectively, within the prior 2 years. A one-page survivorship care plan with recommendations for surveillance was mailed to participants. In addition, survivors' primary physicians were contacted and provided patient-specific information and a web-based Virtual Information Center was made available for both survivors and physicians. Outcomes were assessed by telephone 6 months after the intervention. The survivor participation (62/72; 86%) and 6-month retention (56/61; 92%) rates were high. Tension and anxiety, measured by the Profile of Mood States, did not increase following risk notification; 91% of survivors described their reactions to receiving the information in positive terms. At 6 months, 41% of survivors reported having completed the recommended mammogram; 20% reported having an echocardiogram (females 30%, males 10%). Only 29% of survivors visited the website. Nine physicians enrolled, and none used the study resources. A mailed, personalized survivorship care plan was effective in communicating risk and increasing compliance with recommended medical surveillance. Internet- and telephone-based strategies to communicate risk were not utilized by survivors or physicians.
  Pediatric Blood & Cancer 05/2011; 56(5):818-24. · 1.89 Impact Factor
• Article: Survival rates and race--clues to curing childhood cancer.

  Ann C Mertens
  Pediatric Blood & Cancer 03/2011; 56(3):333-4. · 1.89 Impact Factor
• Article: Auditory complications in childhood cancer survivors: a report from the childhood cancer survivor study.

  Kimberly Whelan, Kayla Stratton, Toana Kawashima, Wendy Leisenring, Susan Hayashi, John Waterbor, Julie Blatt, Charles A Sklar, Roger Packer, Pauline Mitby, Leslie L Robison, Ann C Mertens
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  ABSTRACT: Studies have found associations between cancer therapies and auditory complications, but data are limited on long-term outcomes and risks associated with multiple exposures. The Childhood Cancer Survivor Study is a retrospective cohort investigating health outcomes of long-term survivors (5+ years) diagnosed and treated between 1970 and 1986 compared to a randomly selected sibling cohort. Questionnaires were completed by 14,358 survivors of childhood cancer and 4,023 sibling controls. Analysis determined the first occurrence of four auditory conditions in two time periods: diagnosis to 5 years post-diagnosis, and ≥ 5 years post-diagnosis. Multivariable analyses determined the relative risks (RR) and 95% confidence interval (CI) of auditory conditions by treatment exposure. Five or more years from cancer diagnosis, survivors were at increased risk of problems hearing sounds (RR = 2.3; 95% CI: 1.8-2.8), tinnitus (RR = 1.7; 95% CI: 1.4-2.1), hearing loss requiring an aid (RR = 4.4; 95% CI: 2.8-6.9), and hearing loss in 1 or both ears not corrected by a hearing aid (RR = 5.2; 95% CI: 2.8-9.5), when compared to siblings. Temporal lobe and posterior fossa radiation was associated with these outcomes in a dose-dependent fashion. Exposure to platinum compounds was associated with an increased risk of problems hearing sounds (RR = 2.1; 95% CI: 1.3-3.2), tinnitus (RR = 2.8; 95% CI: 1.9-4.2), and hearing loss requiring an aid (RR = 4.1; 95% CI: 2.5-6.7). Childhood cancer survivors are at risk of developing auditory complications. Radiation and platinum compounds are determinants of this risk. Follow-up is needed to evaluate the impact of auditory conditions on quality of life.
  Pediatric Blood & Cancer 02/2011; 57(1):126-34. · 1.89 Impact Factor
• Article: Risk of second primary thyroid cancer after radiotherapy for a childhood cancer in a large cohort study: an update from the childhood cancer survivor study.

  Parveen Bhatti, Lene H S Veiga, Cécile M Ronckers, Alice J Sigurdson, Marilyn Stovall, Susan A Smith, Rita Weathers, Wendy Leisenring, Ann C Mertens, Sue Hammond, Debra L Friedman, Joseph P Neglia, Anna T Meadows, Sarah S Donaldson, Charles A Sklar, Leslie L Robison, Peter D Inskip
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  ABSTRACT: Previous studies have indicated that thyroid cancer risk after a first childhood malignancy is curvilinear with radiation dose, increasing at low to moderate doses and decreasing at high doses. Understanding factors that modify the radiation dose response over the entire therapeutic dose range is challenging and requires large numbers of subjects. We quantified the long-term risk of thyroid cancer associated with radiation treatment among 12,547 5-year survivors of a childhood cancer (leukemia, Hodgkin lymphoma and non-Hodgkin lymphoma, central nervous system cancer, soft tissue sarcoma, kidney cancer, bone cancer, neuroblastoma) diagnosed between 1970 and 1986 in the Childhood Cancer Survivor Study using the most current cohort follow-up to 2005. There were 119 subsequent pathologically confirmed thyroid cancer cases, and individual radiation doses to the thyroid gland were estimated for the entire cohort. This cohort study builds on the previous case-control study in this population (69 thyroid cancer cases with follow-up to 2000) by allowing the evaluation of both relative and absolute risks. Poisson regression analyses were used to calculate standardized incidence ratios (SIR), excess relative risks (ERR) and excess absolute risks (EAR) of thyroid cancer associated with radiation dose. Other factors such as sex, type of first cancer, attained age, age at exposure to radiation, time since exposure to radiation, and chemotherapy (yes/no) were assessed for their effect on the linear and exponential quadratic terms describing the dose-response relationship. Similar to the previous analysis, thyroid cancer risk increased linearly with radiation dose up to approximately 20 Gy, where the relative risk peaked at 14.6-fold (95% CI, 6.8-31.5). At thyroid radiation doses >20 Gy, a downturn in the dose-response relationship was observed. The ERR model that best fit the data was linear-exponential quadratic. We found that age at exposure modified the ERR linear dose term (higher radiation risk with younger age) (P < 0.001) and that sex (higher radiation risk among females) (P  =  0.008) and time since exposure (higher radiation risk with longer time) (P < 0.001) modified the EAR linear dose term. None of these factors modified the exponential quadratic (high dose) term. Sex, age at exposure and time since exposure were found to be significant modifiers of the radiation-related risk of thyroid cancer and as such are important factors to account for in clinical follow-up and thyroid cancer risk estimation among childhood cancer survivors.
  Radiation Research 12/2010; 174(6):741-52. · 2.68 Impact Factor
• Article: Inconsistent mammography perceptions and practices among women at risk of breast cancer following a pediatric malignancy: a report from the Childhood Cancer Survivor Study.

  Stephanie M Smith, Jennifer S Ford, William Rakowski, Chaya S Moskowitz, Lisa Diller, Melissa M Hudson, Ann C Mertens, Annette L Stanton, Tara O Henderson, Wendy M Leisenring, Leslie L Robison, Kevin C Oeffinger
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  ABSTRACT: Women treated with chest radiation for a pediatric cancer have low mammography screening rates despite their high risk for breast cancer. This study characterized the relationship between perceptions of mammography and screening practices. A cross-sectional survey was administered to 523 women in North America who were treated with chest radiation before 21 years of age. Women with inconsistent mammography perceptions and practices were identified using the Pros and Cons of Mammography for perceptions and Transtheoretical Model stages of adoption for prior and intended screening practices. Classification and regression tree (CART) analysis was used to identify barriers to and facilitators of screening among women with positive and negative perceptions. Nearly one-third of the cohort had inconsistent perceptions and practices: 37.4% had positive perceptions and were not having mammograms; 27.6% had negative/neutral perceptions and were having mammograms. Regardless of perceptions, a recent physician's recommendation for mammography, age ≥ 40, and interest in routine health care were universally associated with mammography practices. For women with positive perceptions and a physician's recommendation, barriers to screening included high acceptance coping, low active-planning coping, and high internal health locus of control. For women with negative perceptions, acknowledging the importance of asymptomatic screening was associated with mammography.
  Cancer Causes and Control 10/2010; 21(10):1585-95. · 2.88 Impact Factor
• Article: Morbidity and mortality in long-term survivors of Hodgkin lymphoma: a report from the Childhood Cancer Survivor Study.

  Sharon M Castellino, Ann M Geiger, Ann C Mertens, Wendy M Leisenring, Janet A Tooze, Pam Goodman, Marilyn Stovall, Leslie L Robison, Melissa M Hudson
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  ABSTRACT: The contribution of specific cancer therapies, comorbid medical conditions, and host factors to mortality risk after pediatric Hodgkin lymphoma (HL) is unclear. We assessed leading morbidities, overall and cause-specific mortality, and mortality risks among 2742 survivors of HL in the Childhood Cancer Survivor Study, a multi-institutional retrospective cohort study of survivors diagnosed from 1970 to 1986. Excess absolute risk for leading causes of death and cumulative incidence and standardized incidence ratios of key medical morbidities were calculated. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of risks for overall and cause-specific mortality. Substantial excess absolute risk of mortality per 10,000 person-years was identified: overall 95.5; death due to HL 38.3, second malignant neoplasms 23.9, and cardiovascular disease 13.1. Risks for overall mortality included radiation dose ≥ 3000 rad ( ≥ 30 Gy; supra-diaphragm: HR, 3.8; 95% CI, 1.1-12.6; infradiaphragm + supradiaphragm: HR, 7.8; 95% CI, 2.4-25.1), exposure to anthracycline (HR, 2.6; 95% CI, 1.6-4.3) or alkylating agents (HR, 1.7; 95% CI, 1.2-2.5), non-breast second malignant neoplasm (HR, 2.6; 95% CI 1.4-5.1), or a serious cardiovascular condition (HR, 4.4; 95% CI 2.7-7.3). Excess mortality from second neoplasms and cardiovascular disease vary by sex and persist > 20 years of follow-up in childhood HL survivors.
  Blood 10/2010; 117(6):1806-16. · 9.90 Impact Factor
• Article: Stillbirth and neonatal death in relation to radiation exposure before conception: a retrospective cohort study.

  Lisa B Signorello, John J Mulvihill, Daniel M Green, Heather M Munro, Marilyn Stovall, Rita E Weathers, Ann C Mertens, John A Whitton, Leslie L Robison, John D Boice
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  ABSTRACT: The reproductive implications of mutagenic treatments given to children with cancer are not clear. By studying the risk of untoward pregnancy outcomes, we indirectly assessed the risk of transmission of germline damage to the offspring of survivors of childhood cancer who were given radiotherapy and chemotherapy. We did a retrospective cohort analysis, within the Childhood Cancer Survivor Study (CCSS), of the risk of stillbirth and neonatal death among the offspring of men and women who had survived childhood cancer. Patients in CCSS were younger than 21 years at initial diagnosis of an eligible cancer, were treated at 25 US institutions and one Canadian institution, and had survived for at least 5 years after diagnosis. We quantified the chemotherapy given to patients, and the preconception radiation doses to the testes, ovaries, uterus, and pituitary gland, and related these to the risk of stillbirth or neonatal death using Poisson regression analysis. Among 1148 men and 1657 women who had survived childhood cancer, there were 4946 pregnancies. Irradiation of the testes (16 [1%] of 1270; adjusted relative risk 0.8 [95% CI 0.4-1.6]; mean dose 0.53 Gy [SD 1.40]) and pituitary gland (17 [3%] of 510, 1.1 [0.5-2.4] for more than 20.00 Gy; mean dose 10.20 Gy [13.0] for women), and chemotherapy with alkylating drugs (26 [2%] of 1195 women, 0.9 [0.5-1.5]; ten [1%] of 732 men, 1.2 [0.5-2.5]) were not associated with an increased risk of stillbirth or neonatal death. Uterine and ovarian irradiation significantly increased risk of stillbirth and neonatal death at doses greater than 10.00 Gy (five [18%] of 28, 9.1 [3.4-24.6]). For girls treated before menarche, irradiation of the uterus and ovaries at doses as low as 1.00-2.49 Gy significantly increased the risk of stillbirth or neonatal death (three [4%] of 69, 4.7 [1.2-19.0]). Our findings do not support concern about heritable genetic changes affecting the risk of stillbirth and neonatal death in the offspring of men exposed to gonadal irradiation. However, uterine and ovarian irradiation had serious adverse effects on the offspring that were probably related to uterine damage. Careful management is warranted of pregnancies in women given high doses of pelvic irradiation before puberty. Westlakes Research Institute, National Cancer Institute, and Children's Cancer Research Fund.
  The Lancet 08/2010; 376(9741):624-30. · 38.28 Impact Factor
• Source

  Available from: John Whitton

  Article: Subsequent neoplasms in 5-year survivors of childhood cancer: the Childhood Cancer Survivor Study.

  Debra L Friedman, John Whitton, Wendy Leisenring, Ann C Mertens, Sue Hammond, Marilyn Stovall, Sarah S Donaldson, Anna T Meadows, Leslie L Robison, Joseph P Neglia
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  ABSTRACT: The occurrence of subsequent neoplasms has direct impact on the quantity and quality of life in cancer survivors. We have expanded our analysis of these events in the Childhood Cancer Survivor Study (CCSS) to better understand the occurrence of these events as the survivor population ages. The incidence of and risk for subsequent neoplasms occurring 5 years or more after the childhood cancer diagnosis were determined among 14,359 5-year survivors in the CCSS who were treated from 1970 through 1986 and who were at a median age of 30 years (range = 5-56 years) for this analysis. At 30 years after childhood cancer diagnosis, we calculated cumulative incidence at 30 years of subsequent neoplasms and calculated standardized incidence ratios (SIRs), excess absolute risks (EARs) for invasive second malignant neoplasms, and relative risks for subsequent neoplasms by use of multivariable Poisson regression. Among 14,359 5-year survivors, 1402 subsequently developed 2703 neoplasms. Cumulative incidence at 30 years after the childhood cancer diagnosis was 20.5% (95% confidence interval [CI] = 19.1% to 21.8%) for all subsequent neoplasms, 7.9% (95% CI = 7.2% to 8.5%) for second malignant neoplasms (excluding nonmelanoma skin cancer), 9.1% (95% CI = 8.1% to 10.1%) for nonmelanoma skin cancer, and 3.1% (95% CI = 2.5% to 3.8%) for meningioma. Excess risk was evident for all primary diagnoses (EAR = 2.6 per 1000 person-years, 95% CI = 2.4 to 2.9 per 1000 person-years; SIR = 6.0, 95% CI = 5.5 to 6.4), with the highest being for Hodgkin lymphoma (SIR = 8.7, 95% CI = 7.7 to 9.8) and Ewing sarcoma (SIR = 8.5, 95% CI = 6.2 to 11.7). In the Poisson multivariable analysis, female sex, older age at diagnosis, earlier treatment era, diagnosis of Hodgkin lymphoma, and treatment with radiation therapy were associated with increased risk of subsequent neoplasm. As childhood cancer survivors progress through adulthood, risk of subsequent neoplasms increases. Patients surviving Hodgkin lymphoma are at greatest risk. There is no evidence of risk reduction with increasing duration of follow-up.
  CancerSpectrum Knowledge Environment 07/2010; 102(14):1083-95. · 14.07 Impact Factor