Adaptive functioning and academic achievement in survivors of childhood acute lymphoblastic leukemia: A report from the Children's Oncology Group

Abstract

Purpose To characterize academic and adaptive skill outcomes in survivors of high‐risk B‐lineage acute lymphoblastic leukemia (HR B‐ALL). Methods Participants were 178 patients enrolled on a nontherapeutic clinical trial that aimed to characterize neurocognitive and functional outcomes (ie, academic achievement and adaptive skills) following treatment for childhood HR B‐ALL. Eligible patients were treated on Children's Oncology Group AALL0232 clinical trial that included two treatment randomizations: methotrexate delivery (high or escalating dose) and corticosteroid (dexamethasone or prednisone). Academic achievement and adaptive skills were evaluated at one time point, 8‐24 months after completing treatment. Results Multivariable logistic regression showed no significant association between treatment variables and outcomes after accounting for age at diagnosis, sex, and insurance status. In multivariable analyses accounting for sex and insurance status, survivors <10 years old at diagnosis had significantly lower scores in Math (P = .02). In multivariable analyses accounting for sex and age at diagnosis, scores for children with US public health insurance were significantly lower than those with US private or military insurance across all academic and adaptive skills (all P‐values ≤.04). Results from univariate analyses showed that boys had significantly lower scores than girls across all adaptive skill domains (all P‐values ≤.04). Conclusion Regardless of treatment randomization, survivors of HR B‐ALL <10 years at diagnosis are at risk for deficits in Math and overall adaptive functioning; overall adaptive skills for boys were significantly poorer. Screening and early intervention for patients at highest risk, particularly young patients and lower resourced families, should be prioritized.

Characterizing academic performance in pediatric acute lymphoblastic leukemia with population‐based achievement tests

“… 9 , 15 For example, Jacola and colleagues reported that survivors diagnosed prior to age 10 had lower math scores than survivors who were diagnosed at an older age. 10 Likewise, Harshman and colleagues showed that survivors diagnosed prior to the age of 5 years old had reduced academic achievement relative to those diagnosed after the age of 5. 14 By contrast, we observed no significant association between academic outcomes and age at diagnosis.…”

“…Our results are in line with previous literature showing that ALL survivors who were covered through public insurance were at higher risk of exhibiting neurocognitive difficulties. 10 , 16 Comparable metrics are applied to determine eligibility for US public health insurance coverage. We opted to use free/reduced lunch because it was collected at the same time as our outcome measures.…”

“…As with our study, survivors treated with chemotherapy only performed within normal limits on a validated neuropsychological measure of math achievement. 10 Replacing cranial radiation with chemotherapy‐only regimens has clearly been beneficial in reducing toxicity, 38 underscoring the importance of continued research on reducing the long‐term impact of cancer treatment.…”

“… 6 , 7 , 8 , 9 Current evidence is primarily predicated using psychological tests to assess survivors' performance, including the Wechsler Individual Achievement Test and the Wide Range Achievement Test. 6 , 8 , 10 , 11 While these tests are psychometrically robust, there are notable limitations regarding ecological validity, 12 , 13 as these measures are typically administered in a quiet testing space with a dedicated examiner. By contrast, most school activities occur while experiencing significant environmental distractions.…”

“…Recent work has highlighted the importance of socio‐economic status (SES) as a key consideration in academic performance. In the United States, SES can be approximated by utilization of public health insurance, 16 and recent studies have shown that ALL survivors on public health insurance had more academic difficulties than survivors on private insurance 10,15,16 . Identifying determinants of school performance in ALL survivors will broaden the scope and depth of our understanding of academic achievement following ALL.…”