Childhood Cancer’s Long Shadow: Anxiety and Depression Persist Into Adulthood

For a young child diagnosed with acute leukaemia, everything except survival is more or less put on hold for roughly two years. Treatment is relentless: the first year is spent largely in hospital around the clock, with chemotherapy delivered intravenously and into the central nervous system. While the child endures this ordeal, life outside the hospital walls races ahead, and friends grow, learn and play without them. New research from the Norwegian University of Science and Technology (NTNU) now shows that this early interruption of development may cast a shadow lasting decades, with nearly half of adult survivors of childhood cancer reporting clinically significant symptoms of anxiety or depression.

The study, published in the journal Current Oncology, examined 132 adults aged 18 to 40 who had survived childhood cancer. Participants were recruited through Oslo University Hospital and St. Olav’s Hospital in Trondheim, and they completed detailed questionnaires covering cognitive functioning, psychological symptoms and fatigue. The results were striking: 49 per cent showed clinical symptoms of depression, 41 per cent showed clinical symptoms of anxiety, and 43 per cent reported significant fatigue. In addition, 28 per cent reported difficulties with various cognitive functions at clinically relevant levels. The researchers found these prevalence rates to be substantially higher than those reported in some previous studies and far above those observed in healthy control groups.

The contrast with the general Norwegian population is stark. Around 7 to 10 per cent of Norwegian adults experience depression during their lifetime, and the lifetime prevalence of anxiety lies between 15 and 20 per cent. Against those baselines, the figures among childhood cancer survivors indicate that mental health problems are considerably more common in this group than in the wider population. Anna Franzén, a medical student at NTNU who participates in the Medical Student Research Programme, where the study forms part of a planned PhD trajectory, says it is surprising that so many survivors experience anxiety and depression. While it is well known that childhood cancer survivors face various health problems later in life, she notes that the sheer scale of mental health struggles among these adults is new knowledge, and that follow-up studies will be needed to understand how these difficulties develop over time.

Acute leukaemia, the disease at the centre of this research, is caused by the uncontrolled growth of immature blood cells that crowd out healthy blood cells. It is the most common form of cancer affecting children, and the vast majority of those affected are between two and five years old. The medical trajectory of the disease has changed dramatically over recent decades. Magnus Aasved Hjort, Associate Professor of Paediatric Oncology at NTNU and a consultant at the Department of Paediatric Cancer and Blood Disorders at the Children and Young People’s Clinic at St. Olav’s Hospital, points out that some decades ago every child who developed acute leukaemia died. Today, more than 90 per cent can be saved, a result he describes as a major medical success story. Yet that success has created a growing population of adult survivors whose long-term needs are only now coming into focus.

The very young age at which these children become seriously ill appears to be central to the long-term consequences. Franzén explains that the children are at a vulnerable stage in the development of their social, mental and cognitive skills when they are struck down. The researchers believe that chemotherapy itself is a significant cause of the problems that arise later in life, but the prolonged hospital stay also means that other important aspects of development are put on hold. Time that could have been spent learning to interact with other children in nursery or school is suspended. Time that should have been spent learning to play football or dance ballet, or beginning to read and write, is likewise deferred. Two years is a long time in the life of a young child, and the developmental milestones missed during treatment cannot simply be recovered once the disease is in remission.

Hjort describes the practical reality of trying to preserve some normality during treatment. Clinicians attempt to let children spend as much time as possible in nursery or school so that they can develop their social skills as much as possible, but the children’s weakened immune systems must always be taken into account, which limits how much ordinary life can be maintained. The result, he says, is that outside the hospital, life and friends race ahead while the child’s own development is effectively paused. This tension between protecting a vulnerable immune system and preserving social and cognitive development is one of the defining challenges of modern paediatric oncology, and the new findings suggest that its consequences may persist well into adulthood.

The cognitive dimension of the findings deserves particular attention. The 28 per cent of participants who reported clinically relevant difficulties described significant problems with concentration, attention, planning, initiating tasks and completing them. These executive functions, Franzén emphasises, are also extremely important for regulating emotions and thoughts. A person whose executive functioning is impaired may be less able to manage negative thoughts and therefore more vulnerable to developing anxiety and depression. In other words, the cognitive and psychological symptoms documented in the study may not be parallel problems but interconnected ones, with deficits in attention and self-regulation feeding directly into emotional distress.

The consequences of these cognitive difficulties extend beyond mental health. Franzén notes that they can affect functioning at school and at work, as well as financial independence, and that it has been documented that such impairments can reduce the quality of life of cancer survivors. An adult who struggles to concentrate, plan and complete tasks may find education and employment harder to sustain, compounding the psychological burden with practical and economic disadvantages. This chain of effects, running from intensive childhood chemotherapy through executive dysfunction to reduced adult functioning, illustrates why the researchers argue that surviving childhood cancer can come at a cost in later life, even when the disease itself has been decisively defeated.

For Hjort, the findings point to a clear gap in the Norwegian healthcare system. Today, children who have had cancer are followed up by a paediatric oncology department until they turn 18. After that, all follow-up within the specialist healthcare service ends, precisely at the point when the adult consequences documented in this study begin to manifest in full. He argues that what has been identified is a need for more follow-up so that these people have the opportunity to participate in society on an equal footing with others, and he believes that a dedicated late-effects clinic for childhood cancer survivors should be established in Norway.

International practice offers a model for what such lifelong care could look like. Hjort, who collaborates extensively with hospitals internationally, points to Sydney, where all children who have had cancer are offered follow-up at a specialised outpatient clinic for the rest of their lives. That, he says, is clearly how it should be in Norway as well. The study was funded by the Norwegian Cancer Society and is led by NTNU’s Department of Psychology, with Professor Trude Reinfjell as project leader. As survival rates for childhood leukaemia and related cancers continue to climb, the number of adults living with the late effects of treatment will only grow, and the research suggests that medicine’s next great challenge is not merely saving these young lives but supporting them for the decades that follow.

Subject of Research: Long-term mental health and cognitive outcomes in adult survivors of childhood leukaemia and non-Hodgkin lymphoma

Article Title: Nearly half of childhood cancer survivors experience symptoms of anxiety or depression as adults

Article References: Nearly half of childhood cancer survivors experience symptoms of anxiety or depression as adults. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: childhood cancer, leukaemia, cancer survivors, depression, anxiety, fatigue, executive function, chemotherapy, paediatric oncology, late effects, mental health, follow-up care