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Original Investigation
June 25, 2020

Association of Exercise Intolerance With Emotional Distress, Attainment of Social Roles, and Health-Related Quality of Life Among Adult Survivors of Childhood Cancer

Author Affiliations
  • 1Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, Tennessee
  • 2Section of Cardiology, Baylor College of Medicine, Houston, Texas
  • 3Department of Pediatrics, University of Tennessee Health Science Center, Memphis
  • 4Division of Epidemiology and Community Health, University of Minnesota, Minneapolis
  • 5Division of Cardiology, The University of Texas, MD Anderson Cancer Center, Houston
  • 6Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
  • 7Division of Radiology Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston
  • 8Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
JAMA Oncol. Published online June 25, 2020. doi:10.1001/jamaoncol.2020.2054
Key Points

Question  Is exercise intolerance associated with perceived well-being among adult survivors of childhood cancer?

Findings  In this cross-sectional study of 1041 adult survivors of childhood cancer, exercise intolerance, after accounting for lifestyle, treatment, and chronic health condition, was associated with emotional distress, attainment of social roles, and health-related quality of life. Specifically, anxiety, unemployment, and self-reported physical health were more prevalent in survivors with exercise intolerance when compared with those without exercise intolerance.

Meaning  Data from this study suggest that exercise capacity among adult survivors of childhood cancer is associated with emotional health, ability to participate optimally in social roles, and health-related quality of life; improving exercise capacity may be factors in these other important indicators of health.

Abstract

Importance  Exercise intolerance is associated with increased risk for morbidity and mortality in childhood cancer survivors. However, an association between exercise intolerance and psychosocial outcomes has not been fully explored.

Objective  To examine the associations between exercise intolerance and emotional distress, attainment of social roles, and health-related quality of life in childhood cancer survivors.

Design, Setting, and Participants  A cross-sectional study including 1041 adult survivors of childhood cancer and 286 community controls in the St Jude Lifetime Cohort was conducted at St Jude Children’s Research Hospital. The study was performed from April 1, 2012, to March 15, 2020.

Exposures  Exercise intolerance was defined as relative peak oxygen uptake less than 85% of age- and sex-estimated levels from maximal cardiopulmonary exercise testing.

Main Outcomes and Measures  Emotional distress was measured with the 18-item Brief Symptom Inventory-18, which includes overall Global Severity Index and depression, anxiety, and somatization subscales. Participants with T scores greater than or equal to 63 were classified as having elevated levels of distress. Social attainment was evaluated using patient-reported educational, employment, and marital status. Health-related quality of life was examined with the Medical Outcomes Survey Short Form-36. Participants with T scores less than or equal to 40 were classified as reporting poor health-related quality of life.

Results  Of the 1041 participants, 528 were women (50.7%). The prevalence of exercise intolerance among survivors (mean [SD] age, 35.5 [9.2] years) was higher than that among controls (age, 34.5 [10.0] years) (survivors: 634 [60.9%] vs controls: 75 [26.2%], P < .001). After adjusting for age at diagnosis and cardiopulmonary exercise testing, sex, race/ethnicity, smoking, physical activity, and exercise intolerance were associated with an increased risk for anxiety (prevalence rate ratio [PRR], 1.95; 95% CI, 1.20-3.16), somatization (PRR, 1.86; 95% CI, 1.23-2.80), and unemployment (PRR, 1.76; 95% CI, 1.23-2.52); an inverse association was noted with having a college degree (PRR, 0.67; 95% CI, 0.50-0.88). Exercise intolerance was associated with an increased the risk for scoring less than or equal to 40 on the physical component summary of the Medical Outcomes Survey Short Form-36 (PRR, 3.69; 95% CI, 2.34-5.84). These associations persisted when either cancer treatment exposures or chronic health conditions were added to the model.

Conclusions and Relevance  The findings of this study suggest that exercise intolerance is independently associated with emotional distress, attainment of social roles, and health-related quality of life of long-term survivors of childhood cancer. The results also suggest that improving physiologic capacity may benefit general health and wellness, as well as emotional health, ability to participate in social roles, and health-related quality of life.

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