Young Cancer Survivors at Increased Lifetime Risk of Mental Health Disorders

Children, adolescents, and young adults with cancer (CAYAs) remained at increased risk for mental health disorders after the remission of their cancer, according to results from a systematic review and meta-analysis.

Compared with siblings and matched controls, survivors had a 57% increased lifetime risk of severe symptoms of depression or a disorder of depression (RR 1.57, 95% CI 1.29-1.92), a 29% increased risk of anxiety (RR 1.29, 95% CI 1.14-1.47), and a 56% increased risk of psychotic disorders (RR 1.56, 95% CI 1.36-1.80).

There was a nonsignificant trend for suicide mortality risk among young people with cancer as well (RR 1.63, 95% CI 0.78-3.40), reported Ainsley Ryan Yan Bin Lee, MBBS, of the National University of Singapore, and colleagues.

The findings "suggest that CAYAs may experience lasting psychological burden long into survivorship," Lee and colleagues wrote in JAMA Pediatrics. "However, longitudinal studies are needed to examine the trajectory and prognosis of psychological disorders and symptoms, particularly as issues may arise and progress over time."

They added that policymakers and healthcare professionals should be particularly conscious of vulnerable subgroups more likely to develop severe psychiatric and psychological comorbidities.

In an accompanying editorial, Abby R. Rosenberg, MD, MS, and Anna C. Muriel, MD, MPH, both of the Dana-Farber Cancer Institute in Boston, said the study "provides the most definitive answer to date" to the question of whether these survivors are at higher risk than their siblings or peers for depression, anxiety, suicide, or other mental health disorders.

The review and meta-analysis included 52 studies reporting on psychiatric disorders and symptoms of depression, anxiety, psychotic disorders (such as schizophrenia), and suicide mortality in CAYAs compared with controls without cancer.

The studies included patients with any solid or hematologic cancer -- those no older than 25 years who were in treatment or planned to receive any form of antineoplastic therapy and another group of cancer survivors in remission after a prior diagnosis of cancer when they were no older than 25 years.

In addition to analyzing the lifetime prevalence and risk of depression and anxiety, Lee and colleagues also looked at symptom severity and found that the mean severity of depression was elevated during treatment (standardized mean difference [SMD] 0.44, 95% CI 0.13-0.74) and among long-term survivors (SMD 0.18, 95% CI 0.02-0.33) compared with controls.

The mean severity of anxiety was also found to be elevated during treatment (SMD 0.16, 95% CI 0.03-0.20) but not among long-term survivors (SMD 0.07, 95% CI -0.07 to 0.22).

While the meta-analysis showed no significant increased risk of death by suicide, Lee and colleagues did note that a Nordic population-based registry study found that risk to be significantly elevated in CAYAs with central nervous system tumors (RR 1.49, 95% CI 1.08-2.05) and highest for CAYAs diagnosed between the ages of 15 and 19 years (RR 1.61, 95% CI 1.09-2.39).

Lee and colleagues also reported that survivors currently older than 25 years and those with lower income, less education, lack of current employment, and weaker social supports had higher risks of poor mental health.

The authors acknowledged several limitations to the study. For example, they noted that a dearth of longitudinal follow-up data meant they were unable to clarify when psychological outcomes presented and how they progressed.

Rosenberg and Muriel observed that the findings do raise the question of whether the risk of developing mental health issues are greater when patients undergo treatment or in the years following.

"There is evidence for both," they said, adding that while clinicians and investigators have long tried to identify and mitigate immediate and long-term risk factors, "the data, including those used in the present meta-analysis, are limited."

"Perhaps it is enough to say that intervention is needed both during treatment and for those whose psychological challenges persist into survivorship," Rosenberg and Muriel said.

Furthermore, they suggested the study's results offer the opportunity to "put the debate about survivors' mental health risks to rest."

"We can accept that these patients are more likely to suffer from clinically significant depression, anxiety, psychotic disorders, and -- in some cases -- are at higher risk of death by suicide," they said. "We can therefore devote our energies to determining how to meet the needs of each patient in real time, targeting those most at risk."

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