Southern California Pediatric and Adolescent Cancer Survivorship (SC-PACS): Establishing a Multi-Institutional Childhood, Adolescent, and Young Adult Cancer Survivorship Consortium in Southern California

Introduction Given their risk for late effects and early mortality, childhood/adolescent cancer survivors (CACSs) should receive longitudinal monitoring and care. The Southern California Pediatric and Adolescent Cancer Survivorship (SC-PACS) consortium was established in February 2017 to combine resources and expertise across seven participating survivorship programs. Its over-arching objective is to address the unique needs of its demographically diverse CACS population through collaborative survivorship research and care initiatives. The first SC-PACS study was an assessment of survivorship needs and evaluation of current services as reported by CACSs and their parents/primary care givers (PPCGs) receiving survivorship care at consortium sites. Methods As an initial investigation, a cross-sectional survey for CACSs and their parents/primary care givers was conducted. The goal was to enroll 10 CACSs and 10 PPCGs from each of the seven institutions (total of 140 participants). The eligibility criteria for CACSs were age ≥13 years at the time of enrollment, >2 years from the end of treatment, sufficient cognitive function to complete the survey, and English or Spanish language proficiency. For CACSs <13 years old, their PPCGs completed the survey. This was a convenience sample using frequencies and proportions to describe participant characteristics and survey responses, which were entered into a Research Electronic Data Capture (REDCap) database. Results Across the consortium, of the recruitment target of 140 participants (CACSs, n=70; PPCGs, n=70), 127 (90.7%) participants were enrolled. Of the 127 participants enrolled, 65 (51.2%) were CACSs and 62 (48.8%) were PPCGs. The majority of participants were female (51.2%), were Hispanic (62.2%), spoke English as the primary language at home (57.5%), and were diagnosed between one to four years of age (45.7%). Information considered most important by both CACSs and PPCGs was related to cancer diagnosis (90.8%) and future risks as a result of cancer treatment received (98.0%). Overall, 78% of CACSs and PPCGs found the survivorship information (treatment summary) useful, and 83% felt that they received the right amount of information about their cancer. Conclusion Our aim was to obtain baseline data that would characterize our CACS population, inform consortium priorities, and establish a collaborative research platform. The ultimate goal of the consortium is to develop a comprehensive survivorship care approach that addresses the most important needs of cancer survivors in our catchment area and promotes best practice interventions. Future plans are to expand the needs assessment survey to obtain a wider representation of the survivor population at SC-PACS institutions, helping create strategies to improve cancer-specific education, delivery of treatment summary, and access to community resources for this demographically and socioeconomically diverse population.


Methods
As an initial investigation, a cross-sectional survey for CACSs and their parents/primary care givers was conducted. The goal was to enroll 10 CACSs and 10 PPCGs from each of the seven institutions (total of 140 participants). The eligibility criteria for CACSs were age ≥13 years at the time of enrollment, >2 years from the end of treatment, sufficient cognitive function to complete the survey, and English or Spanish language proficiency. For CACSs <13 years old, their PPCGs completed the survey. This was a convenience sample using frequencies and proportions to describe participant characteristics and survey responses, which were entered into a Research Electronic Data Capture (REDCap) database.

Results
Across the consortium, of the recruitment target of 140 participants (CACSs, n=70; PPCGs, n=70), 127 (90.7%) participants were enrolled. Of the 127 participants enrolled, 65 (51.2%) were CACSs and 62 (48.8%) were PPCGs. The majority of participants were female (51.2%), were Hispanic (62.2%), spoke English as the primary language at home (57.5%), and were diagnosed between one to four years of age (45.7%). Information considered most important by both CACSs and PPCGs was related to cancer diagnosis (90.8%) and future risks as a result of cancer treatment received (98.0%). Overall, 78% of CACSs and PPCGs found the survivorship information (treatment summary) useful, and 83% felt that they received the right amount of information about their cancer.

Conclusion
Our aim was to obtain baseline data that would characterize our CACS population, inform consortium priorities, and establish a collaborative research platform. The ultimate goal of the consortium is to develop a comprehensive survivorship care approach that addresses the most important needs of cancer survivors in our catchment area and promotes best practice interventions. Future plans are to expand the needs 1 2 1 3, 4 5, 6 2 Introduction Due to remarkable progress in the treatment of cancer among children and adolescents, their aggregate fiveyear survival now exceeds 84% [1][2][3]. However, large cohort and population-based studies have documented the high burden of morbidity and mortality associated with cancer treatment at a young age [4][5][6][7][8][9][10]. These studies have included mostly non-Hispanic white participants and few racial and ethnic minorities [11][12][13][14].
These underrepresented populations of survivors may have different outcomes and needs that have been understudied to date. With the increasing diversity of the United States [15], cancer survivorship programs must ensure their childhood/adolescent cancer survivors (CACSs) are appropriately represented in research studies and have access to culturally competent care. The racial, ethnic, and sociocultural diversity of southern California's population makes it an ideal environment to gain insight into the most pressing concerns for CACSs living in this region and beyond.
Consequently, the Southern California Pediatric and Adolescent Cancer Survivorship (SC-PACS) consortium was established in February 2017 with the over-arching objective of addressing the unique needs of its demographically diverse CACS population through collaborative survivorship research and care initiatives. The demographic reach of the SC-PACS consortium encompasses Los Angeles, San Diego, and contiguous counties, a region accounting for approximately 40% of the California population.
The first SC-PACS study was an assessment of survivorship needs and evaluation of current services as reported by CACSs and their parents/primary care givers (PPCGs) receiving survivorship care at consortium sites. Our goal was to obtain baseline data that would characterize our CACS population, inform consortium priorities, and establish a collaborative research platform.

Materials And Methods
The consortium includes seven cancer treatment centers for children and adolescents, including Cedars  Table 1).
Formal transition program to adult survivorship program N/A X X X We conducted a multi-center, cross-sectional, survey-based study of CACSs and their PPCGs. The goal was to enroll 10 CACSs and 10 PPCGs from each of the seven institutions (total of 140 participants). The eligibility criteria for CACSs were age ≥13 years at the time of enrollment, >2 years from the end of treatment, sufficient cognitive function to complete the survey, and English or Spanish language proficiency. In this cohort, only the CACSs were surveyed. For CACSs < 13 years old, their PPCGs completed the survey. All participants provided written informed consent or assent. The study was approved by each site's Institutional Review Board (IRB) prior to enrollment of its first participant (Children's Hospital of Orange County In-House IRB #1709102).
Participants were approached during a clinic visit and given a paper questionnaire to complete prior to discharge. The questionnaire was intentionally created for the purpose of this study and was not adapted from a previous, validated tool. Survey items included demographics and 33 questions evaluating the importance and usefulness of health information gained during their survivorship clinic encounters. Feasibility was defined as enrollment of ≥80% of participants who were approached at each site. This was a convenience sample using frequencies and proportions to describe participant characteristics and survey responses, which were entered into a Research Electronic Data Capture (REDCap) database (Vanderbilt University, Nashville, TN).

Results
Across the consortium, of the recruitment target of 140 participants (CACSs, n=70; PPCGs, n=70), 127 (90.7%) participants were enrolled. At four sites, 20 participants were approached and enrolled; at two sites, 19 and 6 participants, respectively, were approached and enrolled; and at one site, 22 participants were approached and enrolled. A total of 65 (51.2%) participants were CACSs and 62 (48.8%) were PPCGs.
The majority of participants were female (51.2%), were Hispanic (62.2%), spoke English as the primary language at home (57.5%), and were diagnosed between one and four years of age (45.7%) (survivor characteristics are given in Table 2).   Table 3).  No, not at all 5  Overall, there were high levels of satisfaction with the information the survivorship program provided to both group of participants. Overall, 78% of CACSs and PPCGs found the survivorship information useful, and 83% felt that they received the right amount of information about their cancer. The greatest difference between the two groups was the degree of importance for psychosocial support. PPCGs valued access to peer or survivor support groups, and information on where to seek help for managing feelings and learning coping strategies, 29% and 22.8% more, respectively, compared to the CACSs.

Discussion
The SC-PACS consortium is a unique collaboration of institutions representing varied models of healthcare, including freestanding children's hospitals, comprehensive cancer centers, managed care organizations, and private institutions. This heterogeneity leverages the strengths of each model, allows testing of interventions in varied settings, and ensures generalizability of results. The ultimate goal of the consortium is to develop a comprehensive survivorship care approach that addresses the most important needs of cancer survivors in our catchment area and promotes best practice interventions.
The demographic reach of the SC-PACS consortium consists of 62% self-reported Hispanic/Latino and 8% Asian. Because of the remarkable racial, ethnic, and sociodemographic diversity of southern California, the SC-PACS consortium stands uniquely in its position for serving and studying the minority population of cancer survivors. We recognize that given this diversity, it may be necessary to expand eligibility criteria of future study participants to patients who are neither completely proficient in English or Spanish and provide questionnaires that can be translated to other languages to promote participation.
Given that this was a feasibility study, our team acknowledged that our small sample size could be insufficient to show statistical significance. Although participants were recruited if they met the eligibility criteria for the study, purposeful selection methods were not rigorously adhered to, thus opening the possibility of selection bias. It is possible that we reached out to CACSs and PPCGs who would be willing to participate and potentially give a more positive feedback.
The importance of building a partnership with other nearby pediatric cancer survivorship centers has been recognized to promote collaborations for research endeavors and educational forums. Another pediatric cancer survivor consortium is the Consortium for New England Childhood Cancer Survivors (CONNECCS). This group was formed in 2011, consisting of 12 academic pediatric oncology institutions, serving a predominantly non-Hispanic white population in the New England region. The successful inception and publications of CONNECCS helped identify challenges and potential strategies for smaller, developing consortia [16][17].
The development of a Consortium Membership Agreement detailing core elements such as membership, data use, and administrative functions was integral to solidifying the consortium, as was establishing a core coordinating center. Moreover, successful completion of our pilot study demonstrates the commitment and ability of member institutions to execute multi-center survivorship studies. Not unexpectedly, some sites encountered administrative delays in obtaining IRB approval, which resulted in two sites being unable to approach 20 participants during the study period. Importantly, however, at both these sites, 100% of the CACSs or PPCGs who were approached did participate. Moving forward, the consortium intends to utilize a central IRB to reduce regulatory burden and facilitate study activation at member sites. Future plans are to expand the needs assessment survey in order to obtain broader representation of the survivor population at SC-PACS institutions. This may, in turn, inform strategies to improve cancer-specific education, delivery of treatment summary, and access to community resources including psychosocial needs for this demographically and socioeconomically diverse population.

Conclusions
Collaborations with nearby southern California pediatric cancer survivorship centers have enabled us to actively promote research endeavors and educational forums. Through the needs assessment study, we obtained data that specifically characterized our CACS population and their multiple survivorship needs. Future plans are to expand the needs assessment survey in order to obtain broader representation of the survivor population at SC-PACS institutions. This may, in turn, inform strategies to improve cancer-specific education, delivery of treatment summary, and access to community resources including psychosocial needs for this demographically and socioeconomically diverse population. In-House (CHOC IH) IRB has APPROVED your submission. This approval is based on an appropriate risk/benefit ratio and a project design wherein the risks have been minimized. All research must be conducted in accordance with this approved submission. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

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Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.