Adiposidade em pacientes tratados por câncer na infância: entendendo a fisiopatologia da obesidade

As childhood cancer treatment has become more effective, survival rates have improved, and a number of complications have been described while many of these patients reach adulthood. Obesity is a well-recognized late effect, and its metabolic effects may lead to cardiovascular disease. Currently, studies concerning overweight have focused on acute lymphocytic leukemia and brain tumors, since they are at risk for hypothalamic-pituitary axis damage secondary to cancer therapies (cranial irradiation, chemotherapy, and brain surgery) or to primary tumor location. Obesity and cancer have metabolic syndrome features in common. Thus, it remains controversial if overweight is a cause or consequence of cancer, and to date additional mechanisms involving adipose tissue and hypothalamic derangements have been considered, comprising premature adiposity rebound, hyperinsulinemia, leptin regulation, and the role of peroxisome proliferator-activated receptor γ. Overall, further research is still necessary to better understand the relationship between adipogenesis and hypothalamic control deregulation following cancer therapy.Os avanços do tratamento contra o câncer infantil têm resultado no aumento da sobrevida e das complicações, à medida que os pacientes atingem a maioridade. A obesidade é um evento reconhecido, e seus efeitos metabólicos levam à doença cardiovascular. Atualmente, o estudo da obesidade tem enfocado a leucemia linfocítica aguda e os tumores cerebrais, já que ambos têm risco para lesões hipotalâmicas, secundárias às terapias (irradiação cranial, quimioterapia, e cirurgia) ou à localização do tumor. Obesidade e câncer têm em comum fatores para síndrome metabólica. Entretanto, a relação de causa e efeito entre obesidade e câncer permanece controversa, sendo que são considerados outros mecanismos envolvendo o tecido adiposo e lesões hipotalâmicas, como o rebote precoce de adiposidade, hiperinsulinemia, regulação da leptina, e o papel do receptor ativado por proliferadores de peroxissoma γ. Concluindo, mais estudos são necessários para entender a relação entre adipogênese e descontrole hipotalâmico em sobreviventes de câncer.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Universidade Federal de São Paulo (UNIFESP) Divisão de Endocrinologia Pediátrica Departamento de PediatriaUniversidade Estadual de Campinas Faculdade de Ciências Médicas Divisão de Endocrinologia PediátricaUNIFESP, Divisão de Endocrinologia Pediátrica Depto. de PediatriaSciEL

Psychological Well-Being, Self-Esteem, Quality of Life and Gender Differences as Determinants of Post-Traumatic Growth in Long-Term Knee Rotationplasty Survivors: A Cohort Study

: Rotationplasty (RP) is a special surgical technique for bone tumors of the lower limb and is the chosen procedure for children under 6 with bone sarcoma in the distal femur. Leg reconstruction results in an unusual aspect of the limb potentially giving life-long emotional outcomes, especially considering the young age of most RP patients. Although the high level of the quality of life of these patients has been previously reported, aspects related to long-term psychological well-being, self-esteem and life satisfaction, particularly regarding the gender, procreation and parenting, have never been explored. The aim of this study was to assess the general degree of psychological well-being of RP patients, with specific reference to gender, procreation and parenting. Twenty long-term RP survivors of high-grade bone sarcoma participated in the study. They were administered the following validated questionnaires: HADS for psychological well-being (degree of anxiety and depression), Temperament and Character Inventory (TCI), RSES for self-esteem, SF-36 for quality of life, SWLS extended to life satisfaction, and ABIS for body image integration. Data on education, marriage, employment and parenthood were gathered. All the scores obtained were very close to normal references. The only gender difference was found for the TCI Cooperativeness scale, which was higher in women than in men. A satisfactory psychological well-being in terms of both self-esteem and integration of the prosthetic joint limb into one's body image, with relatively limited amount of anxiety/depression, good quality of life, and good temperament and character traits, was found. No major gender differences were reported

Pediatric DXA: clinical applications

Normal bone mineral accrual requires adequate dietary intake of calcium, vitamin D and other nutrients; hepatic and renal activation of vitamin D; normal hormone levels (thyroid, parathyroid, reproductive and growth hormones); and neuromuscular functioning with sufficient stress upon the skeleton to induce bone deposition. The presence of genetic or acquired diseases and the therapies that are used to treat them can also impact bone health. Since the introduction of clinical DXA in pediatrics in the early 1990s, there has been considerable investigation into the causes of low bone mineral density (BMD) in children. Pediatricians have also become aware of the role adequate bone mass accrual in childhood has in preventing osteoporotic fractures in late adulthood. Additionally, the availability of medications to improve BMD has increased with the development of bisphosphonates. These factors have led to the increased utilization of DXA in pediatrics. This review summarizes much of the previous research regarding BMD in children and is meant to assist radiologists and clinicians with DXA utilization and interpretation

Being young with a cancer experience : health-related quality of life with special focus on independence and sexuality

The increased survival rates for persons with a cancer experience from childhood imply that health care professionals working in different areas of the health care sector will encounter young persons with a cancer experience. It is therefore of importance to investigate perceptions of health and life situation including health-related quality of life (HRQoL) among young persons with such experience. Previous research in the area shows a somewhat varying picture and independence and sexuality have not been studied to a ‎large extent, still aspects relevant for young people. The overall aim for this thesis was to investigate self-reported HRQoL with special focus on independence and sexuality ‎among young persons treated for cancer during childhood. Study I is a methodological study, studies II-IV primarily have a cross-sectional design while study III also include longitudinal data. Two samples of survivors after childhood cancer were included, for studies I-III a national Swedish cohort consisting of persons 4-6 years after diagnosis (n=63, aged 12-22) and for study IV, a sample of adolescents and young adults (≥‎5 years after diagnosis) (n=133, aged 16-25). An age- matched comparison group was included in studies I-III (n=257). In study I, a Rasch- analysis was performed to assess the psychometric properties of the instrument KIDSCREN-27, studies II-III had a quantitative approach and were based on semi- structured interviews and self-reported questionnaires and study IV on written online focus group discussions which were analysed with qualitative inductive content analysis. The psychometric evaluation of KIDSCREEN-27 (study I) indicated that the instrument is acceptable to use among young persons with a cancer experience. Further, the overall results from study II and III revealed that the majority of survivors report satisfactory levels of HRQoL, similar or higher than a comparison group. A small group reported lower levels of HRQoL which corresponded to findings from the semi- structured interviews (study II). The survivors rated their independence as higher 5 years after diagnosis compared to the time at diagnosis and higher compared to the comparison group (study III). The analysis of the written online focus groups (study IV) resulted in one main category, Sex as a given part of life, with four generic categories: Sex considered to be good, Feeling insecure and falling behind, Relating sex to a stable relationship and Physical concerns. The majority had positive experiences of sex without any experiences of sexual problems. However, thoughts and worries included limited sexual experiences, feeling insecure, being behind peers and physical concerns such as vaginal dryness and erectile dysfunction. Experiences and concerns were sometimes related to the cancer experience but most often not. The findings of the thesis illustrate that the majority of those with a cancer experience from childhood get along well in terms of self-reported HRQoL focusing on independence and sexuality. However, a small group seem to be in need of extra support, displayed by lower ratings of HRQoL and sexual matters such as worrying thoughts and physical concerns. Registered nurses are suggested to take an active role in the care of young persons with a cancer experience. By tailoring the follow-up care in concordance to the needs and desires from these persons, the health and life situation for this group can be improved. Continued research, in a longer time perspective, is suggested in the areas of sexuality and sexual function

Marriage and Divorce in Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study

In this report from the Childhood Cancer Survivor Study (CCSS), we described marriage and divorce rates in survivors of childhood cancer, as compared to a sibling control group and the general U.S. population. We also sought to identify patient and treatment characteristics that were associated with survivor marital status. This study included 8,930 five-year survivors of childhood malignancy and 2,855 sibling controls participating in the CCSS. Data on marital status, sociodemographic factors, and current health status were obtained from questionnaires; detailed disease and treatment histories were available from medical records. Marital status of the U.S. population was obtained from the 2002 Current Population Survey of the U.S. Census. We found that survivors were more likely to have never married than both sibling (odds ratio [OR] = 1.79; 95 % CI = 1.65-1.94; p \u3c 0.0001) and population controls (OR = 2.29; 95 % CI = 2.19-2.38; p \u3c 0.0001), with persistence of trends across age and gender strata. Once married, survivors divorced at rates equivalent to controls. In adjusted analysis, we found that several survivor characteristics predicted never-married status, including treatment involving cranial radiation (OR = 2.41; p \u3c 0.0001), CNS tumor diagnosis (OR = 2.05; p \u3c 0.0001), history of growth hormone deficiency (OR = 2.02; p \u3c 0.0001), and unemployment secondary to disability (OR = 1.78; p = 0.0001). Survivor characteristics predictive of divorce included unemployment (OR = 1.91; p \u3c 0.0001, for unemployed or disabled), lower educational achievement (OR = 1.74; p \u3c 0.0001, for non-college graduates), and psychological distress (OR = 1.60; p \u3c 0.0001). This study confirms prior reports of lower marriage rates in survivors of childhood cancer, providing further evidence that this population struggles with psychosocial adjustment to adult life

Cross Cultural Adaptation and Validation of a Self-Reporting Tool to Assess Health-Related Quality of Life for Egyptians with Extremity Bone Sarcomas in Childhood or Adolescence

Validated self-reporting tools are required to evaluate the functional outcome and health-related quality of life (HRQOL) for Egyptians who had extremity bone sarcomas in their childhood or adolescence. Thus, we pursued cross-cultural adaptation and validation of the pediatric Toronto Extremity Salvage Score (pTESS) and Toronto Extremity Salvage Score (TESS) to assess the physical function of children and adult survivors following surgeries of extremity bone sarcomas. Modified versions of pTESS and TESS, which contain additional mental domains, were developed to allow the evaluation of HRQOL using a specific instrument for childhood bone cancer. The internal consistency of the original pTESS and TESS as well as their modified versions was assessed with Cronbach\u27s alpha. The intraclass coefficients (ICC) were calculated for test-retest reliability, and the correlations between scores of the generic Pediatric Quality of Life Inventory (PEDSQL 4.0) and each of the pTESS and TESS scores were used to confirm convergent validity. Exploratory Factor Analysis (EFA) was only feasible for pTESS-leg; therefore, the construct validity of the remaining versions was assessed by calculating the average inter-item correlation coefficients. The pTESS/TESS scores were also compared based on various patients’ characteristics. In a total sample of 233 included participants, 134 responded to pTESS leg, 53 to TESS-leg, 36 to pTESS-arm, and only 10 to TESS-arm. All versions of pTESS and TESS showed excellent internal consistency (Cronbach’s alpha \u3e 0.9), good test-retest reliability (ICC \u3e0.8), moderate to strong correlations with PEDSQL, and acceptable average inter-item correlation coefficients (≥0.3). Based on the scree plot, 3 factors were extracted for pTESS-leg in which all mental items were loaded on a separate factor with acceptable factor loadings (\u3e0.4). Using the original versions of pTESS/TESS-leg only, adults showed significantly higher scores than younger participants. In the large group representing limb salvage surgery in lower extremities, those who were still receiving chemotherapy, had done primary surgery within only one year, or had tumors located in the tibia showed significantly inferior pTESS/TESS scores. In conclusion, the culturally adapted pTESS and TESS are shown to be valid and reliable self-reporting tools for assessing the functional outcome in Egyptians affected with extremity bone sarcomas. The added mental domains enabled the assessment of the overall health status of this particular population. Future studies should evaluate the ability of pTESS and TESS to track progress over time and include more participants, especially those with upper extremity tumors