Understanding the Long-Term Mental Health Trajectory Among Survivors of Adolescent and Young Adult Cancer in the United States

Background: Over 2.1 million adult survivors of cancer diagnosed in adolescence and young adulthood (AYA, 15-39) in the United States. While the mental health burden during treatment has been well-documented, few have examined the long-term mental health trajectories of survivors of AYA cancer into later adulthood. The purpose of this study is to understand the prevalence and trajectories of middle-aged or older survivors of AYA cancer compared to those diagnosed as adults or without cancer.

Methods: We employed data from the Health and Retirement Study (HRS) to characterize mental health outcomes for U.S. adults over age 50 and longitudinal data to examine trajectories of mental health outcomes. The study started on 09/01/2023. HRS is a longitudinal, population-based national sample that (re-)interviews ~20,000 participants every two years since 1992 on topics related to health, employment, income, and others. Main Outcomes include lifetime prevalence of psychiatric issues; prescription medication for anxiety/depression; meeting criteria for Major Depressive Disorder using CIDI-SF scoring; depression symptoms using the CES-D measure; and anxiety symptoms using items from the Beck Anxiety Inventory.

Analysis: Cross-sectional logistic regressions were conducted in two steps to compare prevalence estimates of each dichotomous variable at each wave of HRS as a function of wave-specific cancer cohort. Models were design-adjusted for complex survey design features and, therefore, characterized mental health outcomes for between 23,531,981 and 103,921,980 U.S. adults > 50 (depending on the wave). Change in self-reported depression and anxiety symptoms as a function of age and wave-specific cancer cohort was modeled using mixed-effects growth models, with observations nested within respondents.

Results: 39,668 respondents (56% female; mean-age at HRS entry=59, 18-103; 19.46% Black/African American, 71.94% White/Caucasian, 8.60% Other race) were identified who reported having cancer as an AYA (n=374), developing first-time cancer diagnosis after study onset as adults (n=5,045), or never having cancer (n=34,249). Cross-sectional estimates revealed survivors of AYA cancer had the highest prevalence of lifetime psychiatric issues (16.36%-37.80%), prescription anxiety/depression medication (25.10%-33.78%), and meeting major depression criteria (13.13%-20.96%) versus other cohorts. Compared to adult cancer survivors, AYA cancer survivors had higher odds of lifetime psychiatric issues (in 4/14 waves), similar odds of taking anxiety/depression medications, and higher odds of meeting major depression criteria (in 3/7 waves). Linear mixed-effects growth models revealed age-dependent U-shaped trajectories for depression and anxiety symptoms but significantly higher grand mean levels of symptoms among AYA cancer survivors. A flattening of anxiety symptoms later in life was only observed for AYA cancer survivors.

Conclusions and Discussion: This cohort study is among the first that highlight the sustained mental health challenges confronting survivors of AYA cancer, revealing this cohort’s significantly higher level of mental health trajectories, i.e., depression and anxiety. Growth curve models revealed that while all participants exhibited a U-shaped trajectory of depression symptoms across the lifespan, AYA cancer survivors consistently reported higher levels of depressive symptoms, indicating an enduring impact of cancer-related stressors. Interestingly, anxiety symptoms among AYA survivors flattened over time, suggesting possible resilience.