Brain tumors account for the majority of neoplasms in. Exploration of Morbidity in a Serial Study of Long-Term Brain Tumor Survivors: A Focus on Pain

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1 JOURNAL OF ADOLESCENT AND YOUNG ADULT ONCOLOGY Volume 4, Number 3, 2015 ª Mary Ann Liebert, Inc. DOI: /jayao Original Article Exploration of Morbidity in a Serial Study of Long-Term Brain Tumor Survivors: A Focus on Pain Trishana Nayiager, MSc, 1 JoAnn Duckworth, RN, 1 Eleanor Pullenayegum, PhD, 2 Anthony Whitton, MB, BS, 3 Robert Hollenberg, MD, 4 John Horsman, BSc, 5 William Furlong, MSc, 5 Rachel Spitzer, MD, 6 and Ronald Barr, MB, ChB, MD 1,7 Purpose: Children surviving brain tumors are frequently identified as having substantially decreased healthrelated quality of life (HRQL) in cross-sectional studies. This study explored the HRQL of a cohort of such survivors, who were recruited as adolescents and followed for a decade, in order to determine the trajectory of their morbidities. Method: Children diagnosed between January 1, 1985, and December 31, 1998, more than 2 years from diagnosis (N = 40), were recruited in 2000/2001 (T1) aged years. Health Utilities Index questionnaires (HUI2/3) were completed in 2000/2001 and again at 5 years (T2) and 10 years (T3), with 37 and 25 participants then aged and years, respectively. In addition to study subjects, parental proxies completed questionnaires at T1 and T2, while study subjects selected proxies at T3. Single attributes (domains/dimensions) of HRQL and details of pain were analyzed. Results: Cognition was the attribute compromised most often (T1 = 66.7% of participants, T2 = 62.2%, T3 = 60.0%). Pain was also reported frequently (T1 = 35%, T2 = 25%, T3 = 52%), and at T3 correlated moderately with HUI2 sensation (0.77) and HUI3 vision (0.44), speech (0.51), and ambulation (0.50). The lower median utility score for pain at T3 than at T1/T2 was a clinically important difference. Severe pain was identified in the lower extremities, back, upper extremities, and abdomen. Morbidity was observed also in emotion (worry HUI2 and unhappiness HUI3), sensation, and vision. Conclusion: Decreased HRQL in survivors of brain tumors in childhood is multifaceted. Pain is a prominent burden, along with morbidity in cognition, emotion, sensation, and vision. Further studies should explore pain and neurologic deficits, and potential opportunities for therapeutic intervention. Keywords: brain tumors, morbidity, survivors, children, pain Brain tumors account for the majority of neoplasms in the central nervous system (CNS), and are among the most common cancers of childhood and adolescence. 1 In Canada, the 5-year survival rate for children with these tumors has been estimated at 75% overall. 2 However, survivors are at high risk for long-term sequelae of the diseases and their treatments (surgery, radiotherapy and chemotherapy, including autologous hematopoietic stem cell transplantation), with a rate of chronic health conditions more than twofold greater than in survivors of other forms of cancer in childhood. 3 The perceived health of brain tumor survivors, as determined by self- or proxy-reported measures of health-related quality of life (HRQL), also reflects diminished overall HRQL 4,5 to an even greater extent than in survivors of other cancers, as reported by the Childhood Cancer Survivor Study. 6,7 Indeed, more than 90% of the survivors of CNS 1 Service of Hematology-Oncology, 4 Service of Surgery, McMaster Children s Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada. 2 Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada. 3 Department of Radiation Oncology, Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada. 5 Health Utilities, Inc., Dundas, Ontario, Canada. 6 Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, Ontario, Canada. 7 Division of Hematology-Oncology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada. 129

2 130 NAYIAGER ET AL. tumors in childhood reported a severe chronic medical condition at 25 years of follow-up. 8 Pain was the most prevalent symptom reported by more than 50% of all long-term survivors of cancer in childhood in the St. Jude Lifetime Cohort Study. 9 In cross-sectional studies of survivors of brain tumors in childhood and adult life, the most common morbidities are in emotion, cognition, and pain. 4,5,10 To the best of the authors knowledge, there has been limited exploration of the individual attributes (domains or dimensions) of HRQL in longitudinal studies, including the evaluation of pain experienced by survivors of brain tumors in childhood. In 2000/2001, a cohort of brain tumor survivors was established and they were followed over a decade, identifying a progressive decline in overall HRQL. 11 This study describes the outcomes of the single attributes that comprise overall HRQL, with a focus on pain. Patients and Methods Study participants The methods for recruiting study participants have been detailed previously. 11 In summary, children (<18 years of age) diagnosed with a malignant brain tumor at a single institution between January 1, 1985, and December 31, 1998, without evidence of progressive or relapsed disease, and at least 2 years from diagnosis at study entry, were eligible for participation (N = 59). The initial study assessment point occurred in 2000/2001 (n = 40, 68% participation), and assessments were repeated 5 years (n = 37, 93% participation) and 10 years (n = 25, 68% participation) later. Non-participants either declined or were lost to follow-up, the latter especially at the third time point. Demographic information and disease characteristics were collected at study entry, and disease status updates were collected at the subsequent time points. Individuals who participated at all three assessment points (n = 25) were considered the gold standard group. Ethics approval was received from the Hamilton Health Sciences/McMaster University Faculty of Health Sciences Research Ethics Board. Consent was obtained from participants at each study assessment point, and individuals who declined participation were not re-approached for participation at subsequent time points. Study measures HRQL was measured using the 40-item HUI23SIE-40Q and HUI23PIE-40Q questionnaires from the Health Utilities Index (HUI Ò ) family of instruments for self- and proxyassessments, respectively. These interviewer-administered questionnaires have a 1-week period of recall in the HUI2 (Mark 2) and HUI3 (Mark 3) systems, and have been used successfully in the assessment of survivors of cancers in childhood, including those who had CNS tumors. 4,5,12,13 HUI are generic, multi-attribute, preference-based instruments, developed at McMaster University, with established reliability and validity. 14 The attributes of health in HUI2 are sensation, mobility, emotion, cognition, self-care, pain, and fertility, each attribute having between three and five levels. The attributes in HUI3 are vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain, each attribute having five or six levels. The constructs for perceived emotion, cognition, and pain are different but complementary in HUI2 and HUI3. In HUI2, emotion is based on anxiety, in HUI3 on happiness. In HUI2, cognition is based on learning and remembering, in HUI3 on forgetfulness and solving dayto-day problems. In HUI2, pain is based on requirement for analgesics, in HUI3 on disruption of activities. Fertility was assumed to be unimpaired for the purposes of this study, and scored accordingly. The HUI system provides utility scores of morbidity for single attribute levels and for overall HRQL of multiattribute health states. Multi-attribute health states are defined as one level for each attribute of the HUI2 and HUI3 systems, based on responses about health status from the HUI questionnaires. HUI utility scores represent mean community preference scores. Scores for single attributes range from 0.0 (the most severe impairment) to 1.0 (no impairment). Overall HRQL scores are defined on scales such that dead = 0.00 and perfect health = The minimum HRQL score is on the HUI2 scale and on the HUI3 scale. Negative HRQL scores indicate states of health worse than being dead. 14 Clinically important differences in scores are q0.05 for single attributes and q0.03 for multi-attribute HRQL. 15,16 In addition, the responses to the questions (HUI constructs) provide contextual information to the utility scores. Based on the identification of a burden of pain in previous studies undertaken at the authors institution, 4,5 additional factors relating to pain were addressed at all three study assessment points. This included the location of pain using a simplified human figure (a line drawing). The intensity of pain was measured directly using a colored analogue scale (CAS) in which the intensity/brightness of red was mapped to a number ranging from 0 (no pain) to 10 (the worst pain ever experienced). 17 Statistical analysis Responses to questions and single attribute scores were summarized using measures of central tendency and dispersion. The proportion of individuals experiencing morbidity in each of the HUI2/3 attributes, as well as the median single attribute utility scores, were explored at each study assessment point. Lastly, a correlation matrix was created using Spearman s rho to evaluate relationships between variables at time point 3 that had the greatest morbidity reported among participants based on overall HRQL score. A p-value of < 0.05 was interpreted as a statistically significantresult.alldatawere managed using IBM SPSS Statistics for Windows v20. Results The demographics and disease characteristics of participants at each study assessment point have been presented in a previous report, 11 and are provided in Table 1. The responses of the participants to the HUI questionnaires form the basis of this study. The distribution of morbidity among the single attributes at each of the three study assessment points are shown in Tables 2 and 3. Sensation, emotion (worry), cognition (learning and memory), and pain (therapeutic intervention) as measured by HUI2, and vision, emotion (unhappiness), cognition (memory and problem solving), and pain (limitation of activity) as measured by HUI3, were the attributes in which morbidity was reported most frequently. The median single attribute utility score of 1.00, for all but cognition (HUI2 and HUI3) and pain at

3 Table 1. Patient and Disease Characteristics of Participants and Non-Participants at the Three Assessment Points of the Study 2000/ / /2012 Characteristic P, N = 40 NP, N = 19 P, N = 37 NP, N = 2 (excl. 1 died) P, N = 25 NP, N = 12 Age at diagnosis (years), mean (SD) Age at study point (years), mean (SD) Time from diagnosis (years), (mean SD) 8.59 (4.67) 6.94 (3.06) 8.37 (4.66) 8.85 (2.76) 8.24 (4.77) 8.64 (4.61) (4.23) a (3.33) (4.29) a (3.88) (4.07) a (4.80) 8.15 (4.27) 6.8 a (2.55) (4.2) 15.0 a (6.64) 19.7 (4.30) a (3.03) Disease characteristics Histology Astroglial tumors 25 (62.5%) 10 (52.6%) 24 (64.9%) 1 (50.0%) 15 (60.0%) 9 (75.0%) PNET/medulloblastoma 6 (15%) 7 (36.8%) 6 (16.2%) 0 (0%) 6 (24.0%) 0 (0%) Ependymoma 2 (5.0%) 2 (10.5%) 1 (2.7%) 1 (50%) 1 (4.0%) 0 (0%) Germ cell tumor 4 (10.0%) 0 (0%) 3 (8.1%) 0 (0%) 1 (4.0%) 2 (16.7%) Other 3 (7.5%) 0 (0%) 3 (8.1%) 0 (0%) 2 (8.0%) 1 (8.3%) Primary tumor site Cerebral hemisphere/basal 13 (32.5%) 4 (21.1%) 13 (35.1%) 0 (0%) 7 (28.0%) 6 (50.0%) ganglia Optic pathway 4 (10.0%) 1 (5.3%) 4 (10.8%) 0 (0%) 4 (16.0%) 0 (0%) Posterior fossa/cerebellum 16 (40.0%) 9 (47.4%) 14 (37.8%) 2 (100%) 11 (44.0%) 3 (25.0%) Brainstem 1 (2.5%) 3 (15.8%) 1 (2.7%) 0 (0%) 1 (4.0%) 0 (0%) Other 6 (15.0%) 2 (10.5%) 5 (13.5%) 0 (0%) 2 (8.0%) 3 (25.0%) Surgical procedures and treatment Extent of surgery None 1 (2.5%) 0 (0%) 1 (2.7%) 0 (0%) 1 (4.0%) 0 (0%) Biopsy only 4 (10.0%) 1 (5.3%) 3 (8.1%) 0 (0%) 2 (8.0%) 1 (8.3%) Partial resection 12 (30%) 7 (36.8%) 12 (32.4%) 0 (0%) 9 (36.0%) 3 (25.0%) Gross total resection 23 (57.5%) 11 (57.9%) 21 (56.8%) 2 (100%) 13 (52.0%) 8 (66.7%) Chemotherapy Yes 10 (25.0%) 4 (21.1%) 10 (27.0%) 0 (0%) 10 (40.0%) 0 (0%) No 30 (75.0%) 15 (78.9%) 27 (73.0%) 2 (100%) 15 (60.0%) 12 (100%) Radiotherapy Yes 22 (55.0%) 12 (63.2) 20 (54.1%) 1 (50.0%) 15 (60.0%) 5 (41.7%) No 18 (45.0%) 7 (36.8%) 17 (45.9%) 1 (50.0%) 10 (40.0%) 7 (58.3%) Patient outcome Disease status Stable/NED 31 (77.5%) 16 (84.2%) 35 (94.6%) 2 (0%) 24 (96.0%) 12 (100%) Progression/relapse 8 (20.0%) 3 (7.5%) 0 (0.0%) 0 (0%) 1 (4.0%) 0 (0%) Second malignant neoplasm 1 (2.5%) 0 (0.0%) 2 (5.4%) 1 (patient who died) 0 (0%) 0 (0%) Died 1 (in 2001) 2 (in 2000 and 2008) 0 (0%) 0 (0%) 0 (0%) 0 (0%) All values are shown as n (%) unless otherwise stated. a Estimated based on midway of assessment time point. P, participants; NP, non-participants; NED, no evidence of disease. 131

4 132 NAYIAGER ET AL. Table 2. The Frequency of Participants Reporting Morbidity and the Cohort Median for Each HUI2 Single Attribute Utility Score Across the Study Period HUI2 single attribute scores across time T1 2000/2001, n = 40 T2 2005/2006, n = 37 T3 2011/2012, n = 25 Sensation # with morbidity (%) 15/38 (39.5%) 15/34 (44.1%) 11/24 (45.8%) median (min, max) 1.00 (0.00, 1.00) 1.00 (0.61, 1.00) 1.00 (0.65, 1.00) Mobility # with morbidity (%) 6/40 (15.0%) 2/37 (5.4%) 7/25 (28.0%) median (min, max) 1.00 (0.34, 1.00) 1.00 (0.61, 1.00) 1.00 (0.34, 1.00) Emotion # with morbidity (%) 10/31 (32.3%) 12/35 (34.3%) 10/24 (41.7%) median (min, max) 1.00 (0.37, 1.00) 1.00 (0.60, 1.00) 1.00 (0.00, 1.00) Cognition # with morbidity (%) 26/39 (66.7%) 23/37 (62.2%) 15/25 (60.0%) median (min, max) 0.86 (0.66, 1.00) 0.86 (0.66, 1.00) 0.86 (0.86, 1.00) Self-care # with morbidity (%) 0/40 (0%) 0/37 (0%) 1/25 (4.0%) median (min, max) 1.00 (1.00, 1.00) 1.00 (1.00, 1.00) 1.00 (0.00, 1.00) Pain # with morbidity (%) 14/40 (35.0%) 9/36 (25.0%) 13/25 (52.0%) median (min, max) 1.00 (0.00, 1.00) 1.00 (0.42, 1.00) 0.88 (0.16, 1.00) assessment 3, reflects the fact that at least half of the participants experienced no burden of morbidity in the given single attribute (level 1). Pain was the only attribute, in both HUI2 and HUI3, to show a clinically important difference in median utility scores at T3 (lower) than at earlier time points. A review of the 25 subjects who contributed responses at all assessment points demonstrated that difficulties with cognition persisted over time at an individual level, with 13/ 15 (87%) subjects who reported cognitive morbidity at assessment point 3 also identifying morbidity at the previous Table 3. Frequency of Participants Reporting Morbidity and Cohort Median for Each HUI3 Single Attribute Utility Score Across the Study Period HUI3 single attribute scores across time T1 2000/2001, n = 40 T2 2005/2006, n = 37 T3 2011/2012, n = 25 Vision # with morbidity (%) 12/39 (30.8%) 14/35 (40.0%) 8/25 (32.0%) median (min, max) 1.00 (0.00, 1.00) 1.00 (0.38, 1.00) 1.00 (0.38, 1.00) Hearing # with morbidity (%) 1/40 (2.5%) 0/37 (0%) 1/24 (4.2%) median (min, max) 1.00 (0.48, 1.00) 1.00 (1.00, 1.00) 1.00 (0.86, 1.00) Speech # with morbidity (%) 5/39 (12.8%) 2/37 (5.4%) 2/25 (8.0%) median (min, max) 1.00 (0.82, 1.00) 1.00 (0.41, 1.00) 1.00 (0.41, 1.00) Ambulation # with morbidity (%) 4/40 (10.0%) 1/37 (2.7%) 3/25 (12.0%) median (min, max) 1.00 (0.16, 1.00) 1.00 (0.00, 1.00) 1.00 (0.16, 1.00) Dexterity # with morbidity (%) 1/39 (2.6%) 2/37 (5.4%) 3/25 (12.0%) median (min, max) 1.00 (0.45, 1.00) 1.00 (0.45, 1.00) 1.00 (0.00, 1.00) Emotion # with morbidity (%) 7/30 (23.4%) 8/36 (22.2%) 5/24 (20.8%) median (min, max) 1.00 (0.73, 1.00) 1.00 (0.33, 1.00) 1.00 (0.73, 1.00) Cognition # with morbidity (%) 26/39 (66.7%) 23/37 (62.2%) 15/25 (60.0%) median (min, max) 0.92 (0.32, 1.00) 0.92 (0.32, 1.00) 0.92 (0.32, 1.00) Pain # with morbidity (%) 14/40 (35.0%) 9/36 (25.0%) 13/25 (52.0%) median (min, max) 1.00 (0.00, 1.00) 1.00 (0.00, 1.00) 0.92 (0.00, 1.00)

5 SERIAL STUDY OF MORBIDITY IN SURVIVORS OF BRAIN TUMORS 133 FIG. 1. Frequency of participants reporting moderate or severe levels of morbidity at the 2011/2012 assessment point. two assessment points (HUI2 and HUI3). A similar although not as definitive trend was evident in vision (4/8 subjects reported decreased vision [HUI3] at all three assessment points), as well as sensation in HUI2 (5/11) and pain (5/13 in HUI2/3). While, as a group, emotion was noted to be affected commonly across the study period, morbidity in this attribute appeared to fluctuate over time at the subject level, as 0 and 1 subjects reported difficulties at all three study assessment points for HUI2 and HUI3, respectively. In the entire study cohort, no subject manifested seizures after completion of therapy, and none experienced a stroke at any time. The most common forms of moderate to severe morbidity at all time points were observed in cognition and pain (HUI3) and sensation (HUI2). Figure 1 depicts the frequency of individuals reporting moderate or severe morbidity at assessment point 3. Correlation matrices, shown in Tables 4 and 5, demonstrated a strong correlation between pain and sensation (HUI2) and a moderate correlation between pain and vision, speech, and ambulation (HUI3). Speech, in addition to pain, was also correlated strongly with ambulation and moderately with dexterity. A frequency table (Table 6) revealed that the reporting of moderate or severe comorbidities (level 3 or lower) was almost exclusively in participants reporting pain, though moderate or severe difficulties with emotion and cognition measured by HUI3 were balanced between those with and those without pain. In describing the experience of pain at the last assessment point, 7/13 (54%) participants recalled experiencing pain in q3 days in the week prior to the assessment. The most commonly reported areas of pain were (in descending order of frequency) the lower extremities, head, back, upper extremities, abdomen, and eyes. Nine participants (69%) reported experiencing pain in more than one location. The most severe areas of pain, as identified using the colored analogue scale, were the lower extremities (maximum score of 10.0), back (maximum score of 9.0), and upper extremities and abdomen (maximum scores of 8.0). Most participants (69%) reported that their pain could be managed with no intervention, limitation of activities, or non-prescription medications such as non-steroidal anti-inflammatory drugs. Pain was identified to limit activity in 4/13 (31%) participants. Discussion Diminished HRQL in survivors of brain tumors in childhood is multifaceted. This study demonstrated that pain is a prominent and persistent symptom in such a population who experience morbidity also in the attributes of cognition, emotion, and vision/sensation. Across the 10-year study period, at least 25% of participants reported pain at any assessment point, with an increase in prevalence and severity by the end of the study, emphasizing that pain is an ongoing burden in this cohort. Pain also appeared to interact with other single attributes, with moderate to strong correlations observed between pain and sensation, speech, vision, and ambulation. In a cross-sectional component of the St. Jude Lifetime Cohort Study, involving long-term (q10 years) survivors of a mix of cancers in childhood, almost 60% reported pain, and close to 90% reported multiple symptom classes. 9 Indeed, in that study, pain was significantly associated with impairment in the majority of HRQOL domains. By contrast, in the Childhood Cancer Survivor Study, pain was reported by 12 21% of survivors, least commonly in those who had had a CNS tumor. 18 Peripheral neuropathy, motor dysfunction, and neurosensory difficulties are common long-term morbidities described in survivors of CNS tumors, and are the result of tumor involvement and therapeutic interventions, including radiation and platinum-based chemotherapy. 19 It is postulated that the relationships observed between pain and physical functioning are manifestations of neurological complications. This is HUI2 single utility correlations Table 4. A Correlation Matrix (Spearman s Rho) Demonstrating the Relationship Between HUI2 Single Attributes at Assessment Point 3 Sensation result Mobility result Emotion result Cognition result Self-care result Pain result Sensation 1 Mobility 0.17 (0.43) 1 Emotion 0.35 (0.10) 0.13 (0.53) 1 Cognition (0.31) 0.29 (0.16) 0.00 (1.00) 1 Self-care* 0.33 (0.11) 0.41 (0.04) (0.43) 0.17 (0.43) 1 Pain 0.77 (<0.01) 0.20 (0.35) 0.38 (0.07) (0.25) 0.34 (0.10) 1 *Only one individual reported any difficulty with self-care; therefore correlation not considered.

6 134 NAYIAGER ET AL. Table 5. A Correlation Matrix (Spearman s Rho) Demonstrating the Relationship Between HUI3 Single Attributes at Assessment Point 3 Pain result Cognition result Emotion result Dexterity result Ambulation result Speech result Hearing* result Vision result HUI3 single utility correlations Vision 1 Hearing* (0.50) 1 Speech (0.34) (0.77) 1 Ambulation (0.99) (0.72) 0.78 (<0.01) 1 Dexterity (0.23) (0.77) 0.40 (0.048) 0.29 (0.16) 1 Emotion 0.04 (0.84) 0.36 (0.08) (0.47) (0.37) (0.47) 1 Cognition (0.08) 0.22 (0.30) 0.18 (0.40) 0.01 (0.97) 0.22 (0.29) 0.04 (0.85) 1 Pain 0.44 (0.03) 0.11 (0.60) 0.51 (<0.01) 0.50 (0.01) (0.99) 0.18 (0.40) (0.71) 1 *Only one individual reported any difficulty with hearing; therefore correlation not considered. Table 6. Frequency of Moderate/Severe Levels of Morbidity for Single Attributes in Participants With and Without Pain at Assessment Point 3 (2011/2012) Single attributes Moderate or severe level of morbidity Participants with pain Participants without pain HUI2 Sensation 4 0 Mobility 2 0 Emotion 5 0 Cognition 0 0 Self-care 1 0 HUI3 Vision 2 0 Hearing 0 0 Speech 1 0 Ambulation 2 0 Dexterity 1 0 Emotion 1 1 Cognition 2 0 in keeping with the observation that discomfort was reported commonly in the lower and upper extremities. Another possibility is that increased neurological morbidity (as demonstrated by difficulties in speech, vision, and sensation) may be associated with neurosensory changes, resulting in an increased perception of pain, as postulated by researchers exploring chronic pain in patients with a history of traumatic brain injury. 20,21 It was also observed that individuals with pain experienced the most severe comorbidities, aside from cognition, contributing to their notably diminished HRQL. This is in keeping with the St. Jude Lifetime Cohort Study that explored symptoms experienced by adult survivors of childhood cancers, and identified that pain and disfigurement in areas other than the back, head, and neck were the most commonly cited symptoms and were associated with decreased HRQL. 9 These considerations provide a measure of explanation for the heterogeneity in the prevalence, severity, and location of pain. Despite the frequency of pain reported by the present study cohort, it did not appear to be associated with a lower level of happiness (emotion as measured by HUI3), and most survivors identified that pain did not limit activity and could be controlled with no or minimal intervention. Nevertheless, it must be acknowledged that a functional element to pain was not explored in this study, and the relationship of pain to comorbidities raises the possibility of factors contributing to the maintenance of pain. Functional cognition, measured by self-reported abilities in memory, learning, and problem-solving skills, was identified as the most frequently compromised single attribute by overall frequency, as well as the prevalence in participants experiencing moderate to severe morbidity. The single attribute utility score was decreased but stable across time. It was also observed that individuals were consistent in reporting their cognitive compromise over the 10-year study period. This may appear surprising, given that many studies identify a decline in neurocognitive function over time based

7 SERIAL STUDY OF MORBIDITY IN SURVIVORS OF BRAIN TUMORS 135 on measures of IQ, particularly in individuals who received cranial irradiation therapy. 22,23 However, a longitudinal study by Palmer et al. of children diagnosed with medulloblastoma 24 demonstrated that a decline in neurocognitive ability over time is a result of the failure to acquire new skills and information, and not a loss of ability, and is in keeping with the observation of stable but decreased functional cognition seen in the present cohort of patients. In the present study, changes in neurocognitive ability with the use of a measure of perceived pain cannot be excluded. In addition to pain and cognition, vision (HUI3), sensation (HUI2 determined by a composite score that includes vision, hearing, and speech), and emotion (HUI2 and HUI3) were also identified often to be compromised, and so contributed to the declining overall HRQL utility score in a previous report. 10 Morbidity in vision/sensation appeared to be an ongoing issue for a subgroup of individuals. However, difficulty with emotion at an individual participant level fluctuated across time and may be explained, at least partially, by changes in life stage, particularly as survivors adjust to adult life The main limitation of this study is the small sample size, with attrition evident by the third assessment point. Although this is offset by an examination of the subjects who participated in all three assessments, it is hoped that the findings will prompt other investigators to undertake a longitudinal study of a greater number of survivors of brain tumors in early life, for it appears that pain is experienced frequently in this population. Given that pain is not as identifiable as physical limitations or as universally problematic as cognitive morbidity, clinicians providing care to such survivors should be aware of problems with pain, particularly in subjects with neurological complications. Further studies should be undertaken to characterize the type of pain experienced by this survivor population, as well as to explore areas for potential therapeutic intervention. Acknowledgments Funding for this study was received from Health Utilities Incorporated as a Student Grant. Author Disclosure Statement William Furlong has a proprietary interest in, and is an officer of, Health Utilities Incorporated (HUInc.) which distributes copyrighted HEALTH UTILITIES INDEX Ò (HUI Ò ) materials and provides methodological advice on the use of HUI. John Horsman is a paid consultant for HUInc. No competing financial interests exist for the remaining authors. References 1. Scheurer MR, Bondy ML, Gurney JG. Epidemiology of childhood cancer. In: Principles and practice of pediatric oncology. 6th ed. Pizzo PA, Poplack DG (Eds); Philadelphia, PA: Lippincott Williams and Wilkins; 2011; pp Canadian Cancer Society/National Cancer Institute of Canada. (2012). Canadian Cancer Statistics 2008, Toronto, Canada, Oeffinger KC, Mertens AC, Sklar CA, et al. Childhood Cancer Survivor Study. Chronic health conditions in adult survivors of childhood cancer. N Engl J Med. 2006;355(15): Barr RD, Simpson T, Whitton A et al. Health-related quality of life in survivors of tumours of the central nervous system in childhood a preference-based approach to measurement in a cross-sectional study. Eur J Cancer. 1999;35(2): Glaser AW, Furlong W, Walker DA, et al. Applicability of the Health Utilities Index to a population of childhood survivors of central nervous system tumours in the UK. Eur J Cancer. 1999;35(2): Hudson MM, Mertens AC, Yasui Y, et al. Health status of adult long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. JAMA. 2003;290(12): Ness KK, Mertens AC, Hudson MM, et al. Limitations on physical performance and daily activities among long term survivors of childhood cancer. Ann Int Med. 2005(9); 143: Armstrong GT, Liu Q, Yasui Y, et al. Long-term outcomes among adult survivors of childhood central nervous system malignancies in the Childhood Cancer Survivor Study. J Natl Cancer Inst. 2009;101(13): Huang LC, Brinkman TM, Kenzik K, et al. 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