Posttraumatic stress as a contributor to behavioral health outcomes and healthcare utilization in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

J Cancer Surviv. 2019 Dec;13(6):981-992. doi: 10.1007/s11764-019-00822-5. Epub 2019 Nov 5.


Purpose: To examine the association between posttraumatic stress symptoms (PTSS), neurocognitive and psychosocial late-effects, health behaviors, and healthcare utilization in long-term survivors of childhood cancer.

Methods: Participants included individuals (N = 6844; 52.5% female; mean [SD] age at diagnosis = 7.6 [5.8], at follow-up = 34.9 [7.5]) in the Childhood Cancer Survivor Study (CCSS). Follow-up included the Posttraumatic Stress Scale, Brief Symptom Inventory-18, Short-form 36 Health-related quality of life (HRQOL) survey, CCSS Neurocognitive Questionnaire, and questions about sociodemographics, physical health, health behaviors, and healthcare utilization. Modified Poisson regression and multinomial logistic regression models examined associations between posttraumatic stress symptoms (PTSS) and neurocognitive, HRQOL, health behavior, and healthcare outcomes when adjusting for sociodemographics, disease, and treatment.

Results: Long-term survivors with PTSS (N = 995, 14.5%) reported more impairment in mental (relative risk [RR] 3.42, 95% confidence interval [CI] 3.05-3.85), and physical (RR = 2.26, CI = 1.96-2.61) HRQOL. PTSS was also associated with increased impairment in task efficiency (RR = 3.09, CI = 2.72-3.51), working memory (RR = 2.55, CI = 2.30-2.83), organization (RR = 2.11, CI = 1.78-2.50), and emotional regulation (RR = 3.67, CI = 3.30-4.09). Survivors with PTSS were significantly more likely to attend cancer-specific health visits in the past 2 years (OR = 1.89, CI = 1.50-2.39), and showed greater likelihood of either high frequency (OR = 1.89, CI = 1.50-2.39) or complete lack of (OR = 1.63, CI = 1.32-2.01) primary care visits compared to survivors without PTSS.

Conclusions: Survivors with PTSS reported significantly more psychosocial and neurocognitive late effects, and were more likely to engage in variable use of healthcare.

Implications for cancer survivors: PTSS is associated with additional challenges for a population vulnerable to adverse late effects. Inclusion of integrative services during follow-up visits may benefit functional outcomes.

Keywords: Childhood cancer; Late-effects; Posttraumatic stress; Psychosocial oncology.

Publication types

  • Multicenter Study

MeSH terms

  • Adult
  • Cancer Survivors / psychology*
  • Child
  • Female
  • Health Behavior / physiology*
  • Humans
  • Male
  • Neoplasms / mortality
  • Neoplasms / psychology*
  • Outcome Assessment, Health Care
  • Patient Acceptance of Health Care / psychology*
  • Quality of Life / psychology*
  • Retrospective Studies
  • Stress Disorders, Post-Traumatic / complications*
  • Stress Disorders, Post-Traumatic / psychology
  • Surveys and Questionnaires
  • Treatment Outcome