Establishment of a Lifetime of Cohort of Adults Surviving Childhood Cancer

Establishment of a Lifetime of Cohort of Adults Surviving Childhood Cancer

Childhood cancer predisposes to health risks that may not become apparent until many years after completion of therapy. The SJLIFE protocol is designed to establish a lifetime cohort of childhood cancer survivors treated at St. Jude Children's Research Hospital to facilitate evaluation of health outcomes in aging adults surviving pediatric cancer.

The study focuses on the following Primary and secondary objectives:

• To establish a lifetime cohort of childhood cancer survivors treated at St. Jude Children's Research Hospital to facilitate evaluation of health outcomes in aging children and adults surviving pediatric cancer.
• To estimate the prevalence, cumulative incidence, and latency of selected late treatment complications following predisposing therapeutic exposures in children and adults surviving pediatric cancer.
• To identify treatment, demographic, and psychosocial / behavioral related predictors of adverse health outcomes.
• To develop risk profiles for adverse health outcomes across the age spectrum to guide development of clinical screening guidelines and risk-reducing interventions.
• To identify factors that may be protective against the development of specific late treatment complications.
• To generate data for a series of future hypothesis-driven trials
• To serve as a source for the collection of samples from child and adult volunteers for future SJLIFE research.
• To collect health outcomes data on a community control population for comparison purposes.
• Characterize longitudinal social determinants of health (SDOH) to examine how living conditions, social integration, and structural inequality interact with personal social integrations/support to influence health.

SJLIFE will be implemented in progressive stages with specific objectives to permit knowledge gained in each phase to inform content/format/study design of subsequent stages. The planned stages of the study include 1) Pre-Recruitment Study, 2) Barriers to Participation Survey, 3) Pilot Study of Recruitment Strategies, 4) Pilot Studies of High-Risk Survivor Cohorts, 5) Cross-Sectional Study of 10-year survivors, and 6) Prospective Lifetime Cohort Study.

Stage I entailed telephone interviews with a random sampling of potentially eligible survivors to obtain subjective feedback regarding barriers and facilitators to SJLIFE recruitment and participation. The random sample included thirty alumnus survivors representing a broad representation of race, gender, attained age, years from diagnosis and primary diagnostic groups. The interview content comprised assessment of interest, decision-making factors, and barriers to participation, current

In Stage 2, the Barriers to Participation Survey will be distributed to a random sampling of 500 patients representative of the potentially eligible cohort by age, race, sex, geographic distribution, primary diagnosis and time from diagnosis; 200 patients will be randomly selected up front to receive follow-up communication by telephone if they fail to return completed surveys. Information obtained from responses to the questionnaire will inform a subsequent randomized recruitment trial and provide insight regarding retention procedures.

In Stage 3, a pilot study was undertaken to assess feasibility and potential pitfalls in recruitment for the Lifetime Cohort. Introductory letters were sent to 300 alumni survivors, with a broad representation across targeted diagnostic groups, to invite their participation in the Lifetime Cohort. Recruitment approaches will be informed by the findings of the Barriers to Participation Survey. Parameters assessed were related to feasibility include 1) accuracy of contact information in hospital system (need for tracing of potentially eligible research participants); 2) number of eligible participants actively or passively declining study participation; and 3) reasons for declining participation. The pilot study provided insight regarding the need for implementing procedures to track potential study participants who are "lost to follow-up" or incentives to recruit and retain study participants.

In Stage 4, pilot studies were undertaken in groups of survivors identified by SJLIFE investigators to be at high risk for cancer-related morbidity based on specific demographic, diagnostic, therapeutic, or genetic/familiar factors. In addition to utilizing data collected from the risk-based evaluations performed in the Cross-Sectional study these individuals had more extensive assessment beyond the screening recommendations outlined in the COG Guidelines to determine the frequency and more thoroughly characterize the extent specific treatment complications, as well as define the need for further study. Knowledge gained in these pilot studies provided important preliminary results that were used to develop proposals for extramural funding for further study of the identified vulnerable populations.

In Stage 5, a cross-sectional study of the cohort of 10 or more year alumnus survivors was undertaken using a risk-based assessment as recommended by the COG Guidelines. The first year of the study targeted accrual of survivors with a diagnosis of acute lymphoblastic leukemia, Hodgkin lymphoma, and acute myeloid leukemia who were 30 years or older. The second year targeted enrollment of survivors of central nervous system tumors, Wilms' tumor and other bone/soft tissue sarcomas. The third year targeted accrual of the remaining diagnostic subtypes. The prevalence of late treatment complications detected by risk-based screening provided important information regarding the appropriateness of the COG Guidelines recommendations in at risk survivor populations after specific therapeutic exposures. A group of five- year survivors treated through 2012, survivors from underrepresented populations and those treated on novel agents continue to be recruited for their first SJLIFE visit.

In Stage 6, information gained from the evaluations of survivors enrolled in the cohort provided compelling support for the potential benefits and knowledge to be gained by prospective and systematic evaluations of all cohort members. In addition, evaluation of participants earlier in survivorship (i.e., before 10 years from diagnosis) was perceived to enhance opportunities to characterize the pathophysiology of emerging late onset treatment-related toxicities. Therefore, the cohort was expanded by changing the eligibility from +10 years of survival and +18 years of age to 5+ years from cancer diagnosis regardless of age. As part of the expansion of the SJLIFE study, participants now undergo systematic organ function evaluations (e.g., echocardiography, pulmonary function testing, audiological testing, ophthalmologic evaluation, neurocognitive assessment, bone mineral density testing). In addition, all participants will undergo a comprehensive psychosocial assessment by a licensed social worker and receive, as needed, assistance with referrals to community providers and resources for ongoing care. Adult participants who meet additional recommendations for follow-up are offered participation in breast imaging, fertility assessment, and colonoscopy. In general, most survivors have evaluations scheduled to occur within a 4 to 6 year interval.

Several activities optimize communication with participating survivors about research activities involving the Lifetime Cohort. A newsletter will be distributed on a semi-annual basis for the purpose of 1) maintaining contact through periodic mailings (which include an address correction request from the post-office that can identify individuals who have moved from their last known address and may require additional tracing to re-establish contact); 2) providing an update on the status of the project; and 3) maintaining and enhancing the relationship with participants and 4) educating survivors about selected topics of health-related importance. In addition, a website will be developed that will serve as a resource that updates the progress of Lifetime Cohort activities and serves as a resource for SJLIFE visit planning.

Non-first degree relatives or friends of St. Jude patients or former St. Jude patients will be invited to participate as controls in this study during the time of the child's St. Jude clinic visit. Employees who request to be in the study may volunteer if they are not a SJLIFE study team member or not supervised by a SJLIFE study team member.

As part of SJLIFE initiative a group of study subjects who are not survivors of childhood cancer (community controls) will be recruited. These controls will serve as a comparative group to the aging survivors in SJLIFE cohort for assessing health-related, psychosocial, and quality of life outcomes.

Control enrollment to this protocol is expected to average 200-300 participants/year: with an estimated targeted accrual of 1500.

Survivor Inclusion Criteria:

• Patient will have a diagnosis of childhood malignancy (or neoplasm requiring similar therapy) that was treated or followed at St. Jude Children's Research Hospital.
• Patient will be at least five years from diagnosis.
• Patient is willing to participate at any level of study
• Patient is willing to comply with the guidelines of St. Jude domiciliary care facilities
• Patient or legally authorized representative must sign informed consent for study participation.

Control Participant Inclusion Criteria:

• ≥5 years of age
• Non-first degree relatives or friends of St. Jude patients or former patients or SJCRH employees/affiliates who are not SJLIFE study team members, or family members of SJLIFE study team, or supervised by a SJLIFE study team members, or any volunteer not associated with St. Jude.
• Participant does not have a diagnosis of childhood malignancy or childhood neoplasm requiring similar therapy (i.e., diagnosed <21 years of age).
• Participant is not currently pregnant or lactating.
• Patient is willing to comply with the guidelines of St. Jude domiciliary care facilities.
• Patient must sign informed consent for study participation.

Gait and Mobility Lab Assessment Inclusion Criteria:

• Enrolled participant in the SJLIFE study.
• At-risk for long lasting difficulties with walking or other aspects of mobility.
• Participant is not currently pregnant.
• Participant or their designee signs informed consent for Gait and Mobility Lab Assessment participation.

Survivor/Control Exclusion Criteria:

• Patient or control subject refuses to participate at any level of study

Gait and Mobility Lab Assessment Exclusion Criteria:

• Prospective participant or their designee declines participation in the Gait and Mobility Lab Assessment.