Chronic Health Conditions, Smoking Contribute to Worse Health-Related Quality of Life Among Adult Survivors of Childhood Cancer

Risk factors associated with declining health-related quality of life for adult survivors of childhood cancer, such as physical inactivity and chronic health conditions, should be targets of surveillance and intervention.

For adult survivors of childhood cancer experiencing declining health-related quality of life (HRQOL), chronic health conditions are associated with a decline in physical HRQOL, and current smoking and emotional and neurocognitive impairment were associated with a decline in mental HRQOL, according to a study published in JAMA Network Open. Interventions targeting modifiable risk factors may be needed to prevent poor HRQOL in this population.

Though the 5-year survival rate for childhood cancer has increased to more than 85%, this progress is tempered by adverse consequences of treatment and premature mortality. By 50 years of age, nearly 100% of survivors develop chronic health conditions, impacting HRQOL.

Researchers sought to identify risk factors for suboptimal and declining HRQOL that could be targeted in future interventions during follow-up care appointments.

They conducted a prognostic study to describe the prevalence of future suboptimal and declining HRQOL over time and to examine the performance of models developed to predict suboptimal and declining HRQOL. They also aimed to identify sociodemographic, lifestyle, and health state factors associated with future suboptimal and declining HRQOL.

The study included 4755 adults from the Childhood Cancer Survivor Study diagnosed between January 5, 1970, and December 31, 1986, who completed baseline and 2 follow-up and time 2 surveys. Participants included patients who had been diagnosed and treated for childhood cancer at younger than 21 years of age at institutions in the United States and Canada. HRQOL was operationalized using the Medical Outcomes Study 36-item Short Form Health Survey Physical and Mental Component Summary and classified by optimal or suboptimal at each point.

The analysis included 4755 adults (mean [SD] age at time 0, 24.3 [7.6] years; 2623 [55.2%] women). Between time 1 and time 2, 285 of 3294 survivors (8.7%) were found to have declining PCS and 278 of 3294 (8.4%) were found to have declining MCS.

Additionally, 5.3% to 6.3% of survivors reported persistently suboptimal HRQOL. The researchers identified risk factors associated with PCS decline, including female sex, family income less than $20,000 compared with $80,000 or more, presence of chronic health conditions, and depression.

Risk factors associated with MCS decline included physical inactivity, unemployment compared with full-time employment, current compared with never smoking cigarettes, depression, somatization, impaired task efficiency, and impaired organization. The authors of the study hope these findings can help guide the design of future interventions to prevent HRQOL decline.

“The implications of this work allow clinicians to speak to cancer survivors about the likelihood of maintaining poor or worsening HRQOL in the presence of specific risk factors or, more importantly, how alterations or elimination of risk factors might help improve HRQOL over time,” the authors wrote.

They encourage surveillance of these risk factors within the context of follow-up care appointments. When the presence of these factors is identified, they note that recommendations for referral to appropriate interventions are warranted.

“Given the growing number of cancer survivors, there continues to be an urgent need to identify those survivors who are at greatest risk and implement novel research toward improving their HRQOL,” the authors concluded.

The study has some limitations. The risk prediction model for HRQOL developed and validated in this study was based on the CCSS cohort alone. Validation by an external cohort was not possible as a comparable cohort was not available at the time of the study.

Additionally, researchers found that participants who completed both the time 1 and time 2 questionnaires were more likely to be women and non-Hispanic White, have a college graduate or post-graduate educational level, and to have higher annual household income. Therefore, the findings may not be generalizable to a larger, more diverse population. They encourage additional research with a more diverse sample of survivors.


Schulte F, Chen Y, Yasui Y, et al. Development and validation of models to predict poor health-related quality of life among adult survivors of childhood cancer. JAMA Netw Open. 2022;5(8):e2227225. Published August 17, 2022. Accessed August 18, 2022.