Late Effects Screening of Acute Lymphoblastic Leukemia Survivors in the Military Healthcare System

Abstract

Introduction Pediatric acute lymphoblastic leukemia (ALL) survivors are a growing portion of the population with unique health screening needs. These survivors receive care within late effects oncology clinics and primary care clinics. Prior attempts to quantify compliance with follow-up recommendations have shown variable rates ranging from 28% to 73%. This study set out to assess rates of adherence to recommended health screening among pediatric ALL survivors within the U.S. DoD, identify potential risk factors contributing to patient compliance, and better define the prevalence of chronic health conditions. Materials and Methods This Institutional Review Board–approved, retrospective cohort study used data from the U.S. DoD MHS database and identified incident cases of pediatric ALL during 2007-2011 using a conservative case identification algorithm. Minimum duration of follow-up was instituted in order to ensure the entire study population had sufficient time for the assessment of each screening exam according to recommended guidelines. Rates of adherence to recommended screening measures were calculated across the full study follow-up period, and regression analyses assessed protective factors for compliance. Results One hundred and forty-four incident ALL cases were identified. During the follow-up period, 31.3% developed a new mental health diagnosis. In terms of recommended screening, 94.4% had an annual complete blood count for the entire study period, 90.3% had a liver function screening, 81.9% had an echocardiogram, 34% had a bone density scan, and 54.2% had a mental health visit. Adolescents were less likely to have a bone density scan (odds ratio [OR] 0.32, 95% CI, 0.11-0.95) or a mental health visit (OR 0.28, 95% CI, 0.11-0.7). Conclusion The MHS provides universal access to healthcare for all beneficiaries. In this population with universal access to care, there is increased compliance with screening recommendations. Our results reflect actual screening testing as opposed to general screening visits that have been previously reported in the literature. We also highlight the significant number of mental health diagnoses among pediatric ALL survivors.

Disparities in pediatric cancer survivorship care: A systematic review

“…Eleven studies (1 prospective, 10 retrospective) addressed potential disparities in survivorship care engagement associated with age at diagnosis among CCS 17,26,28–32,34,38 . The evidence primarily indicated that older age at diagnosis is associated with a disparity both in survivorship care and general care engagement among CCS, as reported in 6 studies 26,28,32,34,37 . However, some inconsistent results were found in six studies (low QOE) 17,27,30,32,37,38 …”

“…We screened 7945 citations for relevance, we screened 2760 publications as full text against the prespecified eligibility criteria, and we identified 22 studies (as reported in 61 individual publications) examining disparities in survivorship care for CCS 17–69 . Figure 1 presents the PRISMA flow diagram that visually depicts the number of studies that were both included and excluded at each stage of the review process and the reasons for exclusion.…”

“…29,52 Increased survivorship clinic attendance was associated with treatment intensity score of 2 (RR 1. Barakat, 2012 19 Benedict, 2021 20 Berg, 2016 21 Daly, 2019 23 McBride, 2011 27 Michel, 2011 28 Milam, 2015 29 Nathan, 2016 30 Oeffinger, 2004 31 Streefkerk, 2019 33 Welch, 2017 36 Zanetti, 2022 37 Zheng, 2016 38 Favors females:…”

“…In multivariable analysis, survivors of bone tumors (RR 3.89; CI 1.9, 7. May, 2017 26 McBride, 2011 27 Michel, 2011 28 Milam, 2015 29 Nathan, 2016 30 Oeffinger, 2004 31 Reppucci, 2017 32 Szalda, 2016 34 Zanetti, 2022 37 Zheng, 2016 were more likely to attend survivorship care, after adjusting for health beliefs (susceptibility, severity, benefits, barriers, health value, cues to action), demographics (sex, age at study, living in a relationship, education, employment, immigration status, language spoken), and medical variables (diagnostic category, treatment, SCT, relapse, medical report received, follow-up checklist received). 28 For each year increase in age at diagnosis, survivors were more likely (OR 1.12; CI 1.08, 1.16) to access survivorship care, after adjusting for socioeconomic status at diagnosis, socioeconomic status at survey, education, treatment intensity, sex, race/ ethnicity, age at survey, insurance.…”

“…17,19,21,23,[25][26][27][28][30][31][32][33]36,38 Across these studies, there was evidence that survivors who received less intense treatment (e.g., guided by the Intensity of Treatment Rating Scale 70 ) or single modality regimens were less likely to be engaged in survivorship care and general care 21,23,27,28,30,31,38 ; however, some conflicting evidence was identified, in which four studies did not find an association with treatment type or intensity (low QOE). 17,27,33,36 In total, 14 studies (1 prospective, 13 retrospective) reported on potential disparities by biologic sex, six of which reported that male sex was associated with lower survivorship engagement (compared to female sex) 19,21,27,29,30,33 ; however, six studies showed no association 20,23,28,31,[36][37][38] or a conflicting direction of effects 17 (low QOE). For example, a prospective study found that the odds of experiencing difficulty obtaining care in the prior year decreased for males (OR 0.59; CI 0.41, 0.85) compared to females, after adjusting for age at survey, marital status, employment status, age at diagnosis, cancer diagnosis, and radiation therapy exposure.…”