European Journal of Oncology Nursing 17 (2013) 214e219

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European Journal of Oncology Nursing

journal homepage: www.elsevier.com/locate/ejon

The impact of cancer on the physical, psychological and social well-being of

childhood cancer survivors
H.C. William Li a, *, Violeta Lopez b, O.K. Joyce Chung a, Ka Yan Ho a, S.Y. Chiu c
a
School of Nursing, The University of Hong Kong, 4/F, William M.W. Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong
b
Research Centre for Nursing and Midwifery Practice, Nursing and Midwifery Practice, Australian National University, Australia
c
Paediatric Oncology Unit, Queen Mary Hospital, Hong Kong

a b s t r a c t
Keywords: Purpose: Notwithstanding the advances in medical treatment, childhood cancer survivors are at risk of
Cancer adverse physical, psychological and social effects of the cancer treatment. The purpose of this study was
Chinese children
to examine the impact of cancer and its treatments on the physical, psychological and social well-being
Physical
Psychological
of Hong Kong Chinese childhood cancer survivors.
Social Method: A total of 137 childhood cancer survivors (aged 9e16 years), who had their medical follow-up in
Survivors an oncology out-patient clinic were invited to participate in the study. Participants were asked to
respond to the standardized measures of depressive symptoms and self-esteem. Additionally, 15
participants from the group were selected for a semi-structured interview.
Results: The results revealed that more than half of the participants presented depressive symptoms.
Results also found that the mean depressive symptom scores for childhood cancer survivors were
statistically signicant higher than those of school children without cancer (p 0.01), while the mean
self-esteem scores for the survivors were statistically signicant lower (p < 0.01). Additionally, quali-
tative interviews indicated that cancer and its treatments have great impact on the daily life of childhood
cancer survivors.
Conclusion: The study reveals that cancer and its treatments have a great impact on the physical,
psychological and social well-being of survivors. It is essential for healthcare professionals to develop
appropriate interventions with the aim of promoting physical, psychological and social well-being for
these children. Most importantly, it is crucial to help them develop a positive view of the impact that the
cancer experience has upon their lives.
2012 Elsevier Ltd. All rights reserved.

Introduction
Recent advances in cancer treatment have resulted in an
increase in survival rates for childhood cancer (Li et al., 2010a; Stam
et al., 2006). In Hong Kong, there are approximately 150 newly
diagnosed cases of childhood cancer each year. The incidence of
childhood cancer is about 10 per 100,000 children (Hospital
Authority, 2009). According to the Childrens Cancer Foundation
(2010), the chance of a cure for most types of leukemia is about
70%, and more than 80% of Hong Kong children with lymphoma are
cured. Regrettably, a review of the literature reveals that a number
of childhood cancer survivors develop chronic health problems in
early adulthood, such as second malignancies, growth and endo-
crine dysfunction, and serious organ toxicities (Hudson et al., 2003;
* Corresponding author. Tel.: 852 91761546; fax: 852 287260799.
E-mail address: william3@hku.hk (H.C.W. Li).
Sharp et al., 2007). Langeveld et al. (2004) points out that both
chemotherapy and radiotherapy may have adverse effects on
normal body tissue, manifested months or even years after the
completion of treatment.
Cancer and its treatments may not only adversely affect the
physical well-being of childhood cancer survivors, but their
psychosocial well-being as well (Langeveld et al., 2004). Previous
studies indicate that radiotherapy, chemotherapy and surgical
intervention may have long-term effects on the psychosocial well-
being of survivors, which include increased depression and
decreased self-esteem (Essen et al., 2000; Stam et al., 2006; Zeltzer
et al., 2009). Previous studies from Western countries have found
that survivors had higher levels of depression and lower self-
esteem than healthy children (Essen et al., 2000; Michel et al.,
2010; Recklitis et al., 2006; Servitzoglou et al., 2008). The ndings
of these studies warrant special attention by healthcare
professionals.

1462-3889/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejon.2012.07.010
 H.C.W. Li et al. / European Journal of Oncology Nursing 17 (2013) 214e219 215

Helping childhood cancer survivors maintain healthy physical,
psychological and social well-being is one of the most vital
responsibilities of healthcare professionals (Bradwell, 2009;
Shepherd and Woodgate, 2010). Over the past decade, Western
studies have focused on developing and evaluating different
psychosocial interventions for childhood cancer survivors
(Andersen et al., 2009; Hudson et al., 1998, 2002; Kazak, 2005).
Interventions with cognitive, behavioral, psycho-educational, and
biological components showed benecial effects on psycho-social
well-being of childhood cancer survivors. Yet, a review of the
literature reveals that, so far, no similar study has been conducted
in the Hong Kong Chinese context. Whilst most local studies of
childhood cancer have focused on examining the experience,
psychological well-being and quality of life of family members or
caregivers (Wills, 2009; Wong and Chan, 2006; Yiu and Twinn,
2001), the impact of cancer, in particular the side effects of treat-
ment on the psychosocial well-being of survivors remain relatively
underexplored. Although children with cancer in Hong Kong will
receive regular medical follow-up after completing the entire
course of treatment in a hospital, most attention has been focused
on medical issues or treatment outcomes. There is thus a compel-
ling need for healthcare professionals in Hong Kong to provide
follow-up for survivors of childhood cancer, in particular to monitor
the side effects of treatment on their physical, psychological and
social well-being. Most importantly, it is crucial to develop and
evaluate appropriate interventions that can promote the physical,
psychological and social well-being of such survivors and help
them to live a healthier life. Before this can be achieved in Hong
Kong, the impact of cancer and its treatments on the physical,
psychological and social well-being of these survivors must be fully
understood. This study aimed to shed light on the impact of cancer
and its treatments on the physical, psychological and social well-
being of Hong Kong Chinese childhood cancer survivors. The
objectives of this study were:
(1) To assess the self-esteem and depressive symptoms of Hong
Kong Chinese childhood cancer survivors
(2) To compare the self-esteem and depressive symptoms between
healthy Hong Kong Chinese school children and childhood
Hong Kong Chinese childhood cancer survivors; (2) all children
should be aged 9e16 years; and (3) children should be able to speak
Cantonese and read Chinese. We excluded children with evidence
of second malignancies, and those with cognitive and learning
problems identied from their medical records. The demographic
and clinical characteristics of the participants are shown in Table 1.
Another similar age group of healthy Hong Kong Chinese school
children, originating from two previous studies (Li et al., 2010b,
2010c) was used for comparison purposes. The sample of healthy
school children comprised of 245 primary school students aged
9e12 (Li et al., 2010b) and 1555 secondary school students aged
12e16 (Li et al., 2010c).
Measures
The Center for Epidemiologic Studies Depression Scale for Children
(CES-DC)
The CES-DC comprises 20 fully standardized items to evaluate
depressive symptoms. The items consist of short and simple
statements in the rst person about the emotional, cognitive and
behavior related components of depressiveness. All items are
evaluated on a four-point Likert scale in relation to their incidence
during the last week, which were scored from 0 to 3 (0 not at
all, 1 a lttle, 2 sometimes, 3 a lot), with total possible
scores ranging from 0 to 60, with higher scores indicating greater
symptomatology. The cut-off point is xed at 16. A score of 16 or
greater indicates an individual demonstrating some depressive
symptoms.
The psychometric properties of the Chinese version of the CES-
DC have been empirically tested (Li et al., 2010b). The scale has good
internal consistency, with a Cronbach alpha coefcient reported of
0.82. Convergent validity was estimated by nding correlations
Table 1
Demographic and clinical characteristics of the participants: total (n 137) and sub-
group for qualitative interview (n 15).
Frequency (%)
Total Sub-group

cancer survivors Age (yrs)

9 17 (12.4) 2 (13.3)
(3) To examine how the effects of cancer and its treatments affect
10 19 (13.9) 1 (6.8)
childhood cancer survivors physical, psychological and social 11 19 (13.9) 3 (20.0)
well-being 12 16 (11.7) 2 (13.3)
13 16 (11.7) 3 (20.0)
14 18 (13.1) 2 (13.3)
15 17 (12.4) 0 (0)
Methods 16 15 (10.9) 2 (13.3)
Sex
A cross-sectional study was employed. Data collection was Male 70 (51.1) 9 (60.0)
conducted in one of the largest oncology outpatient clinics, located Female 67 (48.9) 6 (40.0)
Diagnosis
in an acute setting hospital in Hong Kong. There are around 150 to
Leukemia 78 (56.9) 7 (46.7)
180 cancer survivors, aged 9e16 years old, having follow-up in that Lymphoma 30 (21.9) 3 (20.0)
clinic each year. A convenience sample of 137 childhood cancer Brain tumor 13 (9.5) 2 (13.3)
survivors was recruited during a 10-month period from 2010 to Osteoarcomas 10 (7.3) 2 (13.3)
2011. The response rate was 93%, with 11 sets of parents choosing Kidney tumor 4 (2.9) 0 (0)
Germ-cell tumor 2 (1.5) 1 (6.7)
not to participate (without giving specic reasons). Types of treatment received
Surgery 5 (3.6) 1 (6.7)
Sample Chemotherapy 66 (48.2) 7 (46.6))
Bone Marrow Transplant 6 (4.4) 1 (6.7)
Mixed method 60 (43.8) 6 (40.0)
Hong Kong Chinese childhood cancer survivors going through
Time since treatment was completed
the medical follow-up procedures at the out-patient clinic and who 6e12 months 61 (44.5) 8 (53.3)
met the studys inclusion criteria were invited to participate in the 13e24 months 39 (28.4) 49 (26.7)
study. The denition of childhood cancer survivors was children 25e36 months 23 (16.8) 2 (13.3)
who had been diagnosed with cancer and were now at a minimum 37e48 months 9 (6.6) 1 (6.7)
48e60 months 3 (2.2) 0
six-month stage after the completion of the entire course of >60 months 2 (1.5) 0
hospital treatment. The inclusion criteria were the following: (1)
216 H.C.W. Li et al. / European Journal of Oncology Nursing 17 (2013) 214e219
between scores on the Chinese version of the CES-DC and state
anxiety scale for children. The results showed that there was
a strong positive correlation between the two scores (r 0.63).
Discriminant validity was estimated by nding correlations
between scores on the Chinese version of the CES-DC and Rosen-
bergs Self-Esteem Scale. The results showed that there was
a strong negative correlation between the two scores (r 0.52).
Rosenbergs Self-Esteem Scale (RSES)
The RSES was designed to measure self-esteem as a global
disposition (Rosenberg, 1965) and has been widely used with
adolescents (Byrne, 2000; Kim, 2003) and children (Phillips et al.,
2008). The RSES consists of 10 items, an example being I am able
to do things as well as most other people. Responses are rated
using a 4-point Likert scale ranging from 1 (strongly disagree) to 4
(strongly agree), with total possible scores ranging from 10 to 40.
Higher scores indicate higher levels of self-esteem.
The Chinese version of the RSES has been used with and chil-
dren (Li et al., 2010b). The internal consistency of the Chinese
version of the RSES was good, with a Cronbach alpha coefcient
reported of 0.84. Discriminant validity was estimated by nding
correlations between scores on the Chinese version of the RSES and
CES-DC. The results showed that there was a strong negative
correlation between the two scores (r 0.52). The results suggest
that the Chinese version of the RSES can be used as a self-report
assessment tool in measuring self-esteem of Chinese children.
Semi-structured interview
To obtain qualitative information about the impact of cancer and
its treatment on the physical, psychological and social well-being of
childhood cancer survivors, a one-to-one interview was conducted
with participants selected from the group. Because of childrens
age-linked cognitive development, the impact of cancer and its
treatments on psychosocial well-being may be different in younger
and older children. Therefore, 8 childhood cancer survivors from
each of the age group 8 to 12 and 13 to 16 were randomly selected
for the qualitative interview. However, one participant from the
13e16 year old age group could not be contacted prior to the home
visit despite several attempts and thus a total of 15 participants
were selected for the interview. The demographic and clinical
characteristics of this sub-group are shown in Table 1. The inter-
views were semi-structured and audio-taped. An interview guide
was used, and questions asked were: Can you tell me your child-
hood cancer experience? How does having had cancer impact your
life now? During the interview, probing technique was used to elicit
more comprehensive information. Repetition of original question
and non-directive supplementary questions, such as how is that?
or why do you feel that way? were used to encourage the
participants to provide more detailed responses.
Data collection procedures
This study was approved by the Ethics Committee of the
University of Hong Kong and the hospital ethics committee.
Written consent was obtained from the parents after they were told
the purpose of the study. They were given the option to participate
or refuse their childs involvement in the study. The children were
also invited to put their names on a special childrens assent form
and told that their participation was voluntary.
Childhood cancer survivors who underwent medical follow-up
in the out-patient clinic were invited to participate in the study.
After collection of the demographic data, all participants were
asked to respond to the Chinese version of the CES-DC and RSES.
After collection of quantitative data for all participants, 15 from
the group were randomly selected for a semi-structured interview,
which was conducted at their home. Each interview lasted
approximately 30e45 min. To ensure the dependability and cred-
ibility of the data, some strategies were used in this study. First, to
ensure the consistency in the conduct of interviews, a qualied
research nurse with pediatric experience conducted the interviews.
Second, to facilitate accurate interpretation of the data, eld notes
were recorded during and after interviews. Because the validity of
data may be affected by childrens eagerness to please their parents,
causing them to respond the way they think their parents want
them to respond, parents were encouraged not to stay with their
child during the interview.
Data analysis
The Statistical Package for Social Science (SPSS: Version 18; SPSS
Inc., Chicago, IL, USA) for Windows was used for quantitative data
analysis. Descriptive statistics were used to calculate the mean,
standard deviation, and range of the scores of the different scales. A
two-way between-groups analysis of variance (ANOVA) was con-
ducted to examine the mean differences of the depressive symp-
toms and self-esteem of childhood cancer survivors and school
children without cancer of the two age groups (9e12 and 13e16).
According to Piaget (1963), children at the ages of 9e12 and
13e16 are at the development stage of concrete operational and
formal operational stages, respectively.
Content analysis was used to analyse the interview data.
Content analysis is an objective and systematic procedure used to
draw conclusions by creating categories of data from verbatim or
unstructured data (Weber, 1990). After the interviews, the
recording tape was immediately transcribed in Chinese and then
translated into English by the research nurse. Transcription is
a process that converts oral conversation into written form with
dependability and credibility. The principal investigator reviewed
the transcriptions to ensure there were no omissions. Two
researchers were then carefully conceptualized the categories
according to the similarities of the dialogues. Subsequently, all the
transcribed interviews were sorted into different categories. Once
categories were identied, the data were read in their entirety and
coded for correspondence to the categories. Two researchers were
then reviewed the codes. It was found that differences in coding
primarily arose from slight variations in the wording of statements.
For further verication, peer debrieng was carried out. Peer
debrieng involves sessions with peers to review different aspects
of the inquiry. In this study, two nurse educators working in
university with experience in data analysis of structured interview
were consulted to review the codes and examine meaning until
consensus was reached.
Results
The results of the study showed that majority of the participants
(78.8%) were diagnosed with leukemia and lymphoma. About half
(44.5%) had completed the entire medical treatment within one
year, with only two going on for more than ve years. Results
revealed that 52.6% of the participants were at or above the CES-DS
cut-off of 16, indicating that, at least, they present some depressive
symptoms.
The mean scores on the CES-DC and RSES of childhood cancer
survivors and healthy school children are shown in Table 2. The
results of two-way between-groups ANOVA are shown in Table 3.
The results revealed that there were statistically signicant differ-
ences in mean CES-DC and RSES scores between the two groups,
with childhood cancer survivors scored lower on mean RSES, but
 H.C.W. Li et al. / European Journal of Oncology Nursing 17 (2013) 214e219 217

Table 2
Mean scores for the CES-DC and RSES of childhood cancer survivors and healthy school children listed by age groups.

Childhood cancer survivors Healthy school children

Aged 9e12 (n 71) Aged 13e16 (n 66) Total (n 137) Aged 9e12 (n 245) Aged 13e16 (n 1555) Total (n 1800)

M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)

CES-DC 16.92 (7.97) 15.83 (7.88) 16.39 (7.91) 13.15 (9.61) 13.16 (10.66) 13.16 (10.53)
RSES 24.99 (4.92) 26.56 (5.85) 25.74 (5.43) 27.96 (7.26) 27.82 (4.89) 27.84 (5.27)

CES-DC, the Center for Epidemiologic Studies Depression Scale for Children; RSES, the Rosenbergs Self-Esteem Scale.

higher on CES-DC. There was no statistically signicant difference experience. Nevertheless, most informants reported that the
in mean CES-DC and RSES scores between the two age groups family relationship was enhanced. One survivor said: After
(9e12 and 13e16). The interaction effect (age and children groups) remission, I take part in more activities with my family. I feel deeply
did not reach statistical signicance, indicating that there was no that my parents love me.
signicant difference in the effect of age on the depressive symp- For the school dimensions, most survivors reported that there
toms and self-esteem for healthy school children and childhood was some impact on their academic performance after remission
cancer survivors. and they have to pay extra efforts to keep up with their schoolwork.
A short interview was conducted to 15 participants selected
from the group. Based on the method of content analysis, tran- Discussion
scribed data were coded into four broad descriptive categories,
physical, psychological, social and school dimensions. Categories, Despite the fact that cancer survival rates are higher than ever
subcategories and quotations representing the central content of before, childhood cancer survivors are at risk of adverse physical
each category are presented in Table 4. In respect of the impact of and psychosocial effects of their treatment, severely damaging
cancer on physical well-being, most of the children reported that their psychosocial well-being. The aim of this study was to examine
fatigue and poor concentration were their major concerns, many the impact of cancer on the physical, psychological and social well-
informants saying they easily felt tired even with adequate rest. The being of Hong Kong Chinese childhood cancer survivors, an area of
most annoying issue related to a decreased attention span, which research that has been underrepresented in the literature.
caused them learning difculties at school and when studying at The results of this study revealed that more than half of the
home. One survivor said: I nd difculty in paying attention to participants were potentially at risk of depression, or at least pre-
what I am doing. In the past, I could study 6 h per day. After sented some depressive symptoms as measured by the CES-DC. In
recovery, I am easily distracted by other things. I could hardly comparison with previous studies (Li et al., 2010b, 2010c) using the
concentrate on my study. Similarly, another survivor said: I am same scale to measure depressive symptoms and self-esteem of
forgetting things so quickly and easily than before. Sometimes, I a similar age group of Hong Kong Chinese school children without
have to take time to recall of things that happened in the past. cancer, the results revealed that the mean depressive symptom
As for the psychological dimension, most informants reported scores of childhood cancer survivor were relatively higher than
that they are threatened by the possibility of cancer recurrence.
One survivor stated: I fear a cancer recurrence. Whenever the
Table 4
blood test showed some signs of recurrence, I would become
A presentation of category and statements included in each category.
paranoid. I could not bear another painful and threatening treat-
ment procedure. Category Sub-category Examples of statements
As for the social dimension, most survivors commented that Physical Fatigue After recovery, I need to sleep more than
their social bonding was weakened. One informant claimed: After before. I easily get tired.
Memory loss I need longer to pick up what others can
remission, I feel the age gap between my classmates. The main
pick up in an instant. My memory used to
reason is that I havent hung out with them for a long time. We be very good. It is much poorer now.
cannot understand each other as we have different growing Poor My attention span has been to shorten,
concentration I was easily distracted than ever before.
Activity I was a member of a football team at school.
Table 3 intolerance Now, I am no longer able to join the team
The results of two-way between-groups analysis of variance on CES-DC and RSES of because of the decrease in physical strength
childhood cancer survivors and healthy school children listed by age groups. and endurance.
Depressive symptoms (CES-DC) Self-esteem (RSES) Psychological Uncertainty I know there is a possibility of recurrent.
Its hard to know when will happen as life
F-value p-value Eta F-value p-value Eta is full of uncertainty.
squared squared Fear It has been a constant fear and worry because
Main effect I dont know when or whether the cancer
Age will come back or not.
9e12 Lower I am not satised with my performance.
13e16 0.32 0.57 <0.001 2.17 0.14 0.001 self-esteem I feel myself useless at times.
Children Social Better family After remission, I take part in more activities
Childhood cancer relationship with my family. I feel deeply that my parents
survivors love me. I nd out only then that I had cancer.
Healthy school 11.36 0.01* 0.006 18.96 <0.01* 0.01 Weakening I have lost some of my friends because I am
children social bonding no longer able to participate in some activities
Interaction effect with my physical constraints.
Age*Children 0.32 0.57 <0.001 3.10 0.08 0.002 School Academic The impact cancer had on me was on the
performance learning side. I had to make extra efforts in
CES-DC, the Center for Epidemiologic Studies Depression Scale for Children; RSES, order to catch up with my studies after
the Rosenbergs Self-Esteem Scale. my remission.
*p < 0.05.
218 H.C.W. Li et al. / European Journal of Oncology Nursing 17 (2013) 214e219
those of school children without cancer, while the mean self-
esteem scores of the survivor group were lower, irrespective of
age. Findings indicated that despite different age-linked cognitive
development in younger and older children, the impact of cancer
and its treatments on their psychosocial well-being (depressive
symptoms and self-esteem) were similar. Nevertheless, the nd-
ings are consistent with previous studies from the West (Essen
et al., 2000; Servitzoglou et al., 2008), showing that childhood
cancer survivors report greater symptomatology of depression and
lower self-esteem than healthy children.
In childhood cancer survivors, feelings of depression may drag
down self-esteem and even bring a higher risk of suicidal tenden-
cies (Recklitis et al., 2006). Although it cannot be assumed from this
cross-sectional study that there is a high risk of depression among
childhood cancer survivors, many previous studies conducted in
Western countries have revealed that childhood cancer survivors
are at high risk of depression (Michel et al., 2010; Recklitis et al.,
2006, 2010). For these reasons, the presentation of depressive
symptoms in such survivors cannot be overlooked or under-
estimated. It is essential for healthcare professionals to detect and
identify childhood cancer survivors with depressive symptoms at
an early point, and subsequently take appropriate interventional
steps to promote their psychosocial well-being.
To explore further the impact of cancer and its treatment on the
physical, psychological and social well-being of childhood cancer
survivors, qualitative interviews were conducted to 15 participants
randomly selected from the group. They were asked about their
experience of cancer, in particular how the disease and its treat-
ment had affected their daily life. For the impact of cancer on
physical well-being, fatigue, memory loss, poor concentration and
activity intolerance were the common issues reported by survivors.
The results of the interviews were concurred with previous survival
studies that cancer and its treatments have a long term adverse
effects on survivors physical well-being (Hudson et al., 2003;
Langeveld et al., 2004; Sharp et al., 2007).
As for the psychological dimension, the issues most frequently
talked about by children in the interviews were uncertainty and
fear. As there is no 100% guarantee that the cancer will not come
back, cancer recurrence and second malignancies became
a constant fear for the survivors. In the social dimension, owing to
the decrease in physical strength and endurance after remission,
some children complained that they could no longer participate in
some games as before. Additionally, because of their relatively low
body resistance and high susceptibility to infection, many parents
did not allow them near crowded public places, in particular during
the seasonal outbreak of inuenza, consequently affecting their
normal social life and weakening social bonds. One of the rare
positive effects that the cancer experience had on their lives,
however, was the enhancement of their family relationships. Most
childhood cancer survivors reported that they gained more
psychological support and encouragement from their parents and
siblings, which made them feel they were not alone. Apart from the
impact of cancer and its treatment on the physical, psychological
and social well-being, the issue most frequently talked by child-
hood cancer survivors in the interviews was related to academic
performance in school. In Hong Kong, academic achievement has
traditionally been valued above other forms of achievement in
Chinese society (Li and Chung, 2009). This may be due to the
common attitude, held by parents, and by most of the students, that
academic achievement is related to a better career and bright future
(Li et al., 2010c). Given this issue, many informants reported that
they were anxious about their academic performance, which they
claimed was signicantly affected by the cancer and its treatment.
As a result of suspension from school during the course of treat-
ment, a decreased attention span and excessive tiredness after
remission, they had to make extra efforts to catch up with their
studies.
It is important to note that all participants in this study were
able to provide full responses to the questionnaires, without
showing any particular difculty in understanding the questions.
Indeed, all questionnaires are user-friendly in that they are easy to
comprehend and quick to complete e it took around 20e25 min for
each child to ll in all questionnaires.
Implications for practice
Childhood cancer survivors are at risk of adverse physical and
psychological and social effects of the cancer treatment, resulting
from chemotherapy toxicities, radiation or secondary cancers. The
side effects may even last many years after completion of treat-
ment, severely affecting childrens psychosocial well-being.
Nevertheless, insufcient attention has been paid to the impact of
cancer and its treatment on the psychosocial well-being of child-
hood cancer survivors in Hong Kong. According to the World Health
Organization (1948), health has been dened as complete physical,
mental and social well-being and not merely the absence of disease.
Additionally, with reference to the position statement on holistic
care as stated by the Hospital Authority in Hong Kong (2000),
holistic care is dened as the care delivered to meet an integral,
independent individuals health needs including, physical,
psychological and social aspects. Therefore, ensuring physical
psychological and social well-being in childhood cancer survivors
should be a prime concern of healthcare professionals. It is crucial
for nurses to plan, develop and evaluate interventions that can
promote physical and psychosocial well-being for childhood cancer
survivors. There is evidence of the relationship between low self-
esteem and a higher rate of depression in children. Therefore,
helping children to develop positive self-esteem can be one way of
promoting their psychological well-being. Moreover, as self-esteem
is moderately stable over time, it can be a useful indicator for
screening those children who may exhibit psychosocial distress or
are at high risk of depression. On the other hand, this study reveals
that parents or family are the one who give most support to the
childhood cancer survivors, it is essential for nurses to educate
parents on how to lead their child engage in a healthy lifestyle, such
as having eating properly and taking regular exercise. Most
importantly, nurses should take one step forward to extend beyond
their role in collaborating with education sectors and school social
workers to provide psychosocial education and support to child-
hood cancer survivors so that they can go on their journey with
renewed hope and faith.
Study limitations
The use of convenience sampling and all data were collected in
one setting mean that the extent to which the results of this study
can be generalized is limited. Another limitation is that this study
did not report the socio-economic factors of the participants, which
may have an effect on their experience. Moreover, participant
group included children of varying time since cancer treatment was
completed which might inuence the results. Additionally, we did
not obtain information from parents on the psychosocial well-
being of their children, which might have further enhanced our
understanding of the impact of childhood cancer and its treatments
on the survivors.
Conclusion
Despite its possible limitations, this study has addressed a gap in
the literature by examining the impact of cancer and its treatments
 H.C.W. Li et al. / European Journal of Oncology Nursing 17 (2013) 214e219
on the physical, psychological and social well-being of Hong Kong
Chinese childhood cancer survivors. The study reveals that cancer
and its treatments have a great impact on the physical, psycho-
logical and social well-being of survivors. It is essential for
healthcare professionals to develop and evaluate appropriate
interventions with the aim of promoting physical, psychological
and social well-being for these children. Most importantly, it is
crucial to help them develop a positive view of the impact that the
cancer experience has upon their lives.
Conict of interest
None declared.
References
Andersen, B.L., Golden-Kreutz, D.M., Emery, C.F., Debora, L.T., 2009. Biobehavioral
intervention for cancer stress: conceptualization, components, and intervention
strategies. Cognitive and Behavioral Practice 16 (3), 253e265.
Bradwell, M., 2009. Survivors of childhood cancer. Pediatric Nursing 21 (4), 21e24.
Byrne, B., 2000. Relationship between anxiety, fear, self-esteem and coping strat-
egies in adolescence. Adolescence 35 (137), 215e301.
Childrens Cancer Foundation, 2010. Publications: Leaets. Cancer in Children.
Retrieved from. http://www.ccf.org.hk/public.php (on 13 August 2010).
Essen, L.V., Enskr, K., Kreuger, A., Larsson, B., Sjdn, P.O., 2000. Self-esteem,
depression and anxiety among Swedish children and adolescents on and off
cancer treatment. Acta Paediatrica 89, 229e236.
Hospital Authority, 2009. Hong Kong Cancer Stat 2007. Hong Kong Cancer Registry,
Hong Kong.
Hospital Authority, 2000. HA Policies: Position Statement on Holistic Care. Hong
Kong Special Administrative Region: Hospital Authority.
Hudson, M.M., Hinds, P.S., Tyc, V., Gattuso, J., Quargnenti, A., Srivastava, D.K., et al.,
1998. An educational intervention to improve health knowledge and behavior in
childhood cancer survivors. Journal of Pediatric Oncology Nursing 15 (2),
112e113.
Hudson, M.M., Mertens, A.C., Yasui, Y., Hobbie, W., Chen, H., Gurney, J.G., et al., 2003.
Health status of adult long-term survivors of childhood cancer: a report from
the childhood cancer survivor study. Journal of the American Medical Associ-
ation 290, 1583e2339.
Hudson, M.M., Tyc, V.L., Srivastava, D.K., Gattuso, J., Quargnenti, A., Crom, D.B., 2002.
Multi-component behavioral intervention to promote health protective
behaviors in childhood cancer survivors: the protect study. Medical and Pedi-
atric Onocology 39, 2e11.
Kazak, A.E., 2005. Evidence-based interventions for survivors of childhood cancer
and their families. Journal of Pediatric Psychology 30 (1), 29e39.
Kim, Y.H., 2003. Correlation of mental health problems with psychological
constructs in adolescence: nal results from a 2-year study. International
Journal of Nursing Studies 40, 115e124.
219
Langeveld, N.E., Grootenhuis, M.A., Voute, P.A., Haan, R.J., Bos, C.V.D., 2004. Quality
of life, self-esteem and worries in young adult survivors of childhood cancer.
Psycho-Oncology 13, 867e881.
Li, H.C.W., Chung, O.K.J., 2009. The relationship between childrens locus of control
and their anticipatory anxiety. Public Health Nursing 26 (2), 153e160.
Li, H.C.W., Chung, O.K.J., Chiu, S.Y., 2010a. The impact of cancer on childrens
physical, emotional, and psychosocial well-being. Cancer Nursing 33 (1), 47e54.
Li, H.C.W., Chung, O.K.J., Ho, K.Y.E., 2010b. Psychometric testing of the Chinese
version of the center for epidemiologic studies depression scale for children.
Journal of Advanced Nursing 66 (11), 2582e2591.
Li, W.H.C., Chan, S.L.P., Chung, O.K.J., Chui, M.L.M., 2010c. Relationships among
mental health, self-esteem and physical health in Chinese adolescents: an
exploratory study. Journal of Health Psychology 15 (1), 96e106.
Michel, G., Rebholz, C.E., von der Weid, N.X., Bergstraesser, E., Kuehni, C.E., 2010.
Psychological distress in adult survivors of childhood cancer: the Swiss child-
hood cancer survivor study. Journal of Clinical Oncology 28 (10), 1740e1748.
Phillips, D., Bodeld, E., Woodthorpe, K., Gimsley, M., 2008. Exploring the impact of
group work and mentoring for multiple heritage childrens self-esteem, well-
being and behaviour. Health & Social Care in the Community 16 (3), 310e321.
Piaget, J., 1963. The Origins of Intelligence in Children. Norton, New York.
Recklitis, C.J., Lockwood, R.A., Rothwell, M.A., Diller, L.R., 2006. Suicidal ideation and
attempts in adult survivors of childhood cancer. Journal of Clinical Oncology 24
(24), 3852e3857.
Recklitis, C.J., Diller, L.R., Najita, J., Robison, L.L., Zeltzer, L., 2010. Suicide ideation in
adult survivors of childhood cancer: a report from the childhood cancer
survivor study. Journal of Clinical Oncology 28 (4), 655e661.
Rosenberg, M., 1965. Society and Adolescent Self-image. Princeton University Press,
Princeton.
Servitzoglou, M., Papadatou, D., Tsiantis, I., Vasilatou-Kosmidis, H., 2008. Psycho-
social functioning of young adolescent and adult survivors of childhood cancer.
Support Care Cancer 16, 29e36.
Sharp, L.K., Kinahan, K.E., Didwania, A., Stolley, M., 2007. Quality of life in adult survivors
of childhood cancer. Journal of Pediatric Oncology Nursing 24 (4), 220e226.
Shepherd, E.J.W., Woodgate, R.L., 2010. Cancer survivorship in children and young
adults: a concept analysis. Journal of Pediatric Oncology Nursing 27 (2),
109e118.
Stam, H., Grootenhuis, M.A., Caron, H.N., Last, B.F., 2006. Quality of life and current
coping in young adult survivors of childhood cancer: positive expectations
about the further course of the disease were correlated with better quality of
life. Psycho-Oncology 15, 31e43.
Weber, R., 1990. Basic Content Analysis. Sage Publications, London.
Wills, B.S.H., 2009. Coping with a child with acute lymphocytic leukemia. Cancer
Nursing 32 (2), E8eE14.
Wong, Y.F.M., Chan, W.C.S., 2006. The qualitative experience of Chinese parents
with children diagnosed of cancer. Journal of Clinical Nursing 15, 710e717.
World Health Organization, 1948. Constitution of the World Health Organization
Basic Document. World Health Organization, Geneva.
Yiu, M.C.J., Twinn, S., 2001. Determining the needs of Chinese parents during the
hospitalization of their child diagnosed with cancer: an exploratory study.
Cancer Nursing 24 (6), 483e489.
Zeltzer, L.K., Recklitis, C., Buchbinder, D., Zebrack, B., Casillas, J., Tsao, J.C.I., et al.,
2009. Psychological status in childhood cancer survivors: a report from the
childhood cancer survivor study. Journal of Clinical Oncology 27 (14),
2396e2404.