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

  • Emily CrochetEmail author
  • Vida L. Tyc
  • Mingjuan Wang
  • Deo Kumar Srivastava
  • Kristi Van Sickle
  • Paul C. Nathan
  • Wendy Leisenring
  • Todd M. Gibson
  • Gregory T. Armstrong
  • Kevin Krull



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.


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.


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.


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.


Childhood cancer Psychosocial oncology Late-effects Posttraumatic stress 



This work was supported by the National Cancer Institute (CA55727, G.T. Armstrong, Principal Investigator). Support to St. Jude Children’s Research Hospital also provided by the Cancer Center Support (CORE) grant (CA21765, C. Roberts, Principal Investigator) and the American Lebanese-Syrian Associated Charities (ALSAC).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethics Approval

All procedures performed involving human participants were in accordance with the ethical standards of the participating institutions and/or national research committees, and with the 1964 Helinski declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Institutional Review Boards at all participating institutions with participants providing informed consent. This analysis was approved by the Institutional Review board at St. Jude Children’s Research Hospital. FWA000047775.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

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ESM 1 (DOCX 53 kb)


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Emily Crochet
    • 1
    Email author
  • Vida L. Tyc
    • 1
  • Mingjuan Wang
    • 2
  • Deo Kumar Srivastava
    • 2
  • Kristi Van Sickle
    • 1
  • Paul C. Nathan
    • 3
  • Wendy Leisenring
    • 4
  • Todd M. Gibson
    • 2
  • Gregory T. Armstrong
    • 2
  • Kevin Krull
    • 2
  1. 1.Florida Institute of TechnologyMelbourneUSA
  2. 2.St. Jude Children’s Research HospitalMemphisUSA
  3. 3.The Hospital for Sick Children, Department of PediatricsUniversity of TorontoTorontoCanada
  4. 4.Fred Hutchinson Cancer Research CenterSeattleUSA

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