Download Non-graduation after comprehensive school, and early retirement

Non-graduation after comprehensive school, and early retirement but not unemployment
are prominent in childhood cancer survivors - a Finnish registry-based study.
Ritva Ahomäki, Arja Harila-Saari, Jaakko Matomäki, Päivi M. Lähteenmäki
Turku University and Turku University Hospital, Department of Pediatrics, Karolinska University
Hospital, Stockholm Sweden and University of Oulu
Abstract
Background: Adverse neurocognitive and social outcomes play increasingly important role with
improving survival rates after childhood cancer. In order to assess these outcomes, we explored
the educational and vocational attainments of survivors in comparison to matched population
controls.
Subjects and Methods: Cancer survivors born from 1960 to 1992, aged below 16 at cancer
diagnosis (years 1964-2009), and alive in the beginning of the year of their 18th birthday (n=3243)
were identified from Finnish Cancer Registry, and age, sex and living place matched controls from
the Population Register Centre (n=16215). Data on educational achievements, yearly income,
employment status, and retirement were retrieved from Statistics Finland.
Results: The median (range) age at study was 28 (17-50) years. The proportion of those with no
education after comprehensive school was higher for all the diagnostic groups: brain tumor (BT)
(33.5% vs 23.0%), solid tumor (ST) (25.0% vs 21.4%), and leukemia/NHL (29.2% vs 23.1%) in
survivors than controls. Odds ratios for unemployment were not significantly elevated in any
survivor group compared to controls, but BT survivors were 14.8 (95% CI 10.4-21.0), ST survivors
2.2 (95% CI 1.5-3.0), and leukemia/NHL survivors 4.0 (95% CI 2.8-5.8) times more often retired
than their controls. Irradiation significantly increased the odds for being retired only in BT survivors.
Leukemia/NHL survivors treated after 1992 had lower risk for early retirement (OR 0.6, 95% CI 0.2
– 0.9) compared to those diagnosed earlier.
BT survivors had lower income level than controls (p<0.001), and irradiation (p<0.001) but not
gender (p=0.43) was associated with lower income level in survivors. ST survivors had a lower
income level (p=0.03) than their controls, and among them, females (p<0.001), those treated most
recently (p=0.002), and those with no irradiation (p=0.02) had lower income than the others.
Similarly, leukemia/NHL survivors had lower income than their controls (p<0.001), and this was
pronounced in females (p<0.001).
Conclusions: All survivors had higher frequencies than controls of not graduating from any further
education than comprehensive school. Cancer survivors had no increased risk for unemployment,
but risk for early retirement was significantly increased in each three survivor group. Also the level
of yearly income was significantly lower for all survivor groups than for their controls.
Key words: childhood, cancer, education, employment, income, retirement, survivor, registry
based study
Introduction
Improved survival rates during last decades have resulted in a growing population of children in the
education system who have survived childhood cancer. Learning difficulties and impaired
academic achievements have previously been shown to be evident after childhood cancer {{127
Bonneau,J. 2011;}}, {{248 Harila-Saari,A.H. 2007;}}, {{246 Lahteenmaki,P.M. 2008;}}. Need for
special tutoring at school has been shown for cancer patients {{353 Mitby,P.A. 2003;}}.
Acknowledged risk factors for impaired verbal or cognitive performance have been female gender,
younger age during cancer treatment, cranial irradiation, and shunt insertion or intrathecal
chemotherapy given before irradiation {{156 Di Pinto,M. 2012;}}, {{255 Shortman,R.I. 2014;}}, {{132
Lancashire,E.R. 2010;}}, {{137 Lorenzi,M. 2009;}}, {{248 Harila-Saari,A.H. 2007;}}, {{247
Lahteenmaki,P.M. 2007;}}, {{354 Koch,S.V. 2004;}}. Diminished white matter integrity has been
reported as one of the possible risk factors for impaired neurocognitive functioning, highlighted in
executive task performance {{152 Brinkman,T.M. 2012;}}, {{254 Reddick,W.E. 2014;}}. In a recent
review, the current knowledge on the background of cognitive problems is comprehensively
addressed {{355 Castellino,S.M. 2014;}}.
A previous Finnish registry-based study of brain tumor survivors showed that females and those
treated with irradiation had most decline in marks for all school subjects {{247 Lahteenmaki,P.M.
2007;}}. Hodgkin lymphoma (HL), neuroblastoma, osteosarcoma, and non-Hodgkin lymphoma
(NHL) survivors may have cognitive impairment compared with siblings but less than the survivors
of acute lymphoblastic leukemia (ALL) {{129 Kadan-Lottick,N.S. 2010;}}. Krull et. al reported HL
survivors having difficulties in memory functioning, and in learning new things {{159 Krull,K.R.
2012;}} but, on the contrary, Lähteenmäki et. al reported HL survivors having as good performance
in all academic subjects as population controls {{246 Lahteenmaki,P.M. 2008;}}.
These adverse outcomes play an important role as difficulties in neurocognitive functioning seem
to affect survivors' life increasingly over time {{169 Hawkins,M.M. 2006;136 Boman,K.K. 2009;}},
{{223 Armstrong,G.T. 2013;}}, {{254 Reddick,W.E. 2014;}}. In a Swiss population-based study,
upper secondary education was more prevalent in survivors than in controls but fewer survivors
achieved university degree (7,3-11%) and 5-8 % had only compulsory schooling {{124 Kuehni,C.E.
2012;}}. Adolescents with cancer have been reported to have risk for a delayed beginning of
occupational training and later graduation from vocational school {{126 Dieluweit,U. 2011;}}. Solid
tumor survivors are suggested having education and income parallel to general population but
brain tumor survivors make an exception with their overall poorer education and social outcomes
{{133 Boman,K.K. 2010;}}. In a population-based questionnaire study, Boman et al. found that
survivors of bone and CNS tumors had decline in general health status and cognition in their adult
life compared with general population {{136 Boman,K.K. 2009;}}. In the British Childhood Cancer
Survivor Study cohort, females and brain tumor survivors achieved a degree more seldom than
males and other solid tumor survivors {{132 Lancashire,E.R. 2010;}}.
Brain tumor survivors, especially females, are at risk for reduced income and employment {{134
Ellenberg,L. 2009;}}. In two reports from USA, full-time employment among childhood cancer
survivors was lower than national norms {{356 Crom,D.B. 2007;}} as well as that among siblings
{{357 Pang,J.W. 2008;}}. Similarly, in a Dutch meta-analysis, survivors of childhood cancer were
nearly twice as likely to be unemployed than healthy controls (OR 1.85, 95% CI 1.3-2.7) {{358 de
Boer,A.G. 2006;}} but this was explained by included studies from US as in European studies the
employment status did not significantly differ from controls. Declined physical health may be even
an eightfold risk factor for unemployment, depression and somatization, and memory impairment
may increase survivors' risk for unemployment in both sexes {{184 Kirchhoff,A.C. 2011;}}.
Nationwide analyses on such long-term social outcomes of childhood cancer survivors as fields of
highest education, employment, early retirement and yearly income have been a minor research
subject so far. The aim of this study was to explore Finnish childhood cancer survivors' educational
and vocational attainments compared with healthy controls based on nationwide registry sources.
Subjects and methods
Cancer survivors were identified from the Finnish Cancer Registry (FCR). The contents and
reliability of the FCR and other national registries have been presented in our earlier studies {{248
Harila-Saari,A.H. 2007;}}, {{247 Lahteenmaki,P.M. 2007;}}. The year of birth from 1960 to 1992,
cancer diagnosis at the age 0-16 years, and being alive at the year of 18th birthday were the
inclusion criteria for this study. For each cancer survivor, five age, sex and place of residence
matched controls as well as the parents of all survivors and controls were identified from the
Finnish Population Register Centre (PRC). The identification of patients and controls as well as the
record linkage procedures were performed on the basis of the personal identification code given to
each resident of Finland. Grades from graduation diploma of comprehensive school as well as
detailed information on subjects’ further education, employment, possible retirement, and yearly
income were collected from the Statistics Finland. Additionally, data on education of all parents
were retrieved from that registry. Basic education is free for all pupils. In addition to free tuition,
pupils receive free learning materials, school meals, school health and dental care and travel to
and from school. The National Board of Education is a key administration and development
agency in basic education and in general and vocational upper secondary education. The National
Board issues the national core curricula and some regulations concerning pupil assessment.
A description of the educational system in Finland is shown in Figure 1. The Finnish school report
at the end of each term during the comprehensive education has a scale of marks from 4 (failed) to
10 (best).
Insert Figure 1 about here
The data linkage was performed at the National Institute for Health and Welfare. Permits for
registry linkage were obtained from the Finnish Ministry of Social Affairs and Health and the PRC.
The clinical research review office of the South-West Finland Hospital District has approved this
study.
The outcome variables were analyzed separately in three survivor groups: brain tumors,
leukemias/non-Hodgkin lymphomas, and solid tumors. Since survivors and controls were matched,
comparisons between them were done using conditional logistic regression analysis for
dichotomous response variables, using GEE-method with cumulative logit link function for ordinal
response variables, using Gee-method with log link and normal distribution for income, and using
mixed models with matching group as a random effect for continuous variables. Parental education
level was controlled for in all analyses.
Within the survivors, logistic regression model was used to study the association between
background variables and binary response variables. When the response variable was ordinal,
cumulative logit models were used. Response variable “ income” was analyzed using generalized
linear model with normal distribution and log link. Linear models were used for other continuous
response variables. These analyses were controlled for parental education and year of birth.
Statistical analyses were done using SAS for Windows version 9.3. P- values below 0.05 were
considered as statistically significant.
Results
Altogether 3242 survivors of childhood cancer fulfilled the inclusion criteria. The description of the
study subjects is presented in Table 1
Insert Table1 about here
Brain tumor (BT) survivors
Grades of the qualification diploma at the end of comprehensive school, effect of ordinal response
variables and data on attending matriculation examination are presented in Table 2. Controls had
better grades in all analyzed school subjects (mother tongue, mathematics, first foreign language,
and sports). Lower proportion of BT survivors than their controls finalized the national matriculation
examination (27,3% vs 43,8%) taken at the end of upper secondary school. Males, those
diagnosed with BT before school-age, and irradiated survivors showed poorer results especially in
the first foreign language and in taking matriculation examination.
Statistics on the highest post-comprehensive school education are shown in Table 3. The
proportion of those with no education after comprehensive school is higher for survivors than
controls (33.5% vs 23.0%). Youngest age (<7 years) at treatment, cranial irradiation, and also
latest treatment era seemed to have effect on proportions of missing further education. No gender
difference was found in survivors' educational level.
The results on employment status, retirement and yearly income are presented in Table 4. Overall,
BT survivorship did not elevate the risk of being unemployed (p=0.27) but survivors were 14.8
times more often retired when compared with their controls. However, male survivors were 2.4
times more often unemployed than females, and those treated after 1999 were less often
registered as unemployed. The latter may be explained by still studying. Irradiation did not have
effect on employment status but it significantly increased the odds for being retired. Retirement
was significantly more common also for those treated at youngest age (<7years) or before 1990.
BT survivors had lower income level than controls (p<0.001), and irradiation but not gender was
associated with lower income level in survivors.
A description of entrances and admissions to different fields of education after comprehensive
school is given in Table 5. The fields of technology and especially services were most common
among those BT survivors who already had chosen their carrier. Especially higher degree tertiary
level and the highest level University degrees were clearly less common among survivors than
their age-matched controls.
Solid tumor (ST) survivors
ST survivors had poorer results than their controls only in sports at the end of comprehensive
school (Table 2). However, among survivors, girls were better than boys in mother tongue, first
foreign language and mathematics. Overall, significant difference was not found in the frequency of
taking matriculation examination between ST survivors and their controls, but among the ST
survivors, girls were significantly more often than boys finalizing this step.
The frequency for later non-graduation was higher in ST survivors than in their controls (Table 3),
and fewer survivors attended upper secondary school. Male survivors and those treated after 1999
were more often ungraduated than the other ST survivors.
The risk for unemployment was not elevated in ST survivors (p=0.85) (Table 4) However, ST
survivors had 2.2 times higher risk for early retirement than their controls and they had a lower
income level (p=0.03). Males, somewhat surprisingly survivors treated with irradiation, and those
treated before year 1990 had better yearly income than the others.
A description of entrances and admissions to different fields of education after comprehensive
school is given in Table 5. The fields the ST survivors had chosen resembled those of their controls
as did the levels of education.
Leukemia and NHL survivors
These survivors had lower grades in sports, first foreign language, and mathematics compared
with controls at the end of comprehensive school (Table 2). Among survivors, males had poorer
marks than females in mother tongue and the first foreign language. Youngest age (<7 years) at
diagnosis had effect on the marks in the first foreign language, and cranial irradiation in mother
tongue and sports. Regarding national matriculation examination, the controls had higher odds for
finalizing it(OR 1.6) than survivors. Among survivors, males and those with cranial irradiation
finalized it less often than the others (Table 2).
The frequency for later non-graduation was higher among survivors than in their controls (Table 3)Among survivors, this appeared to be more frequent for males, those treated at older age (>12
years) as well as for those treated more recently. Cranial irradiation seemed not to be an
explanatory factor in this survivor group.
The risk of unemployment was not elevated in leukemia/ NHL survivors compared with controls
(Table 4), but the odds for early retirement was 4 times higher in survivors than in controls. Female
survivors were more often retired than males (p=0.04) and their yearly income was significantly
lower than that of males (p<0.001). Survivors treated after 1992 had lower risk for early retirement
(OR 0.6, 95% CI 0.2 – 0.9).
A description of entrances and admissions to different fields of education after comprehensive
school is given in Table 5. Especially the field of “Health and Welfare” seemed to be chosen more
often by the survivors than their age and sex matched controls. From Table 3 one can see that
especially higher degree tertiary level education was less common among survivors than their
controls.
Insert Tables 2-5 about here
Discussion
We report here population based registry data on educational achievement, employment and
income in a large early cohort of Finnish childhood cancer survivors compared to matched
controls. All survivors had higher frequencies than controls of not graduating from any further
education than comprehensive school. Cancer survivors had no increased risk for unemployment,
but risk for early retirement was significantly increased in each three survivor group. Also the level
of yearly income was significantly lower for all survivor groups than for their controls.
Grades in qualification diploma at the end of comprehensive school
BT survivors had poorer grades than their controls in all analyzed school subjects, ST survivors
only in sports and Leukemia/NHL survivors in all other subjects except mother tongue. Lower
proportions of BT, and leukemia/NHL survivors than their controls finalized upper secondary school
and took the national matriculation examination, but no difference was found in ST survivors.
Consistent with previous studies, we found that brain tumor survivors performed worse than
controls in all academic subjects {{254 Reddick,W.E. 2014;}}, {{132 Lancashire,E.R. 2010;}}, {{137
Lorenzi,M. 2009;}}, {{247 Lahteenmaki,P.M. 2007;}},{{359 Reimers,T.S. 2003;}}. The long-term
survivors of brain tumors may have significant risk for adverse cognitive outcomes {{167
Armstrong,G.T. 2011;}}. Especially whole brain irradiation delivered at young age has been proved
problematic {{360 Packer,R.J. 1989;}}. Netson and co-workers have reported that cognitive
performance after low-grade gliomas and craniopharyngeomas may be preserved by conformal
irradiation, which highlights the fact that development in treatment techniques could possibly
diminish the burden of irradiation {{149 Netson,K.L. 2013;}}, though avoiding whole brain irradiation
will not be possible in all BT types. Among BT survivors, males, those diagnosed with BT before
school-age, and irradiated survivors showed poorer results especially in the first foreign language.
These results are also in keeping with previous studies except the finding on gender. However, the
gender effect at comprehensive school as well as attending upper secondary school with the
matriculation examination seems to be similar within the survivors than among the Finnish
population in general. The females do better at comprehensive school and attend more of the
upper secondary school
(www.minedu.fi/export/sites/default/pisa/2009/PISA09esite_-_ENG.pdf).
Our findings are in keeping with earlier reports where solid tumor survivors manage their education
as the control population. However, solid tumor survivors had lower grades in sports which may be
explained with late-effects of limb surgery and possibly vincristine (viite). Treatment associated
brain deformities, e.g leucoencephalopathy, that occur in Hodgkin lymphoma (HL) survivors due to
cardiac and pulmonary complications later in life have been suggested to be linked with cognitive
impairment {{159 Krull,K.R. 2012;}}, which was not supported by our findings. In our previous
study, HL survivors as well as Wilms tumor survivors had no differences in their academic
achievements compared to population controls {{246 Lahteenmaki,P.M. 2008;}}. A Canadian study
has presented that neuroblastoma survivors managed their educational training similarly to
controls {{137 Lorenzi,M. 2009;}}, and in a US study, osteosarcoma survivors were not likely to
have any neurocognitive sequelae {{119 Ottaviani,G. 2013;}}.
As in our previous studies on leukemia {{248 Harila-Saari,A.H. 2007;}} and NHL {{246
Lahteenmaki,P.M. 2008;}} survivors, the greatest decline was observed in grades for the first
foreign language, indicating impairment of verbal learning. Verbal cognitive abilities have been
found impaired also in ALL patients treated without irradiation {{217 Kunin-Batson,A. 2014;}}.
Interestingly, cranial irradiation did not anymore affect performance in this subject, which probably
reflects the decreased use of this treatment modality during most recent protocols.
Our findings regarding leukemia survivors are in keeping with the British results {{132
Lancashire,E.R. 2010;}} but not with those from Canada {{137 Lorenzi,M. 2009;}}. Canadian study
did not find decrease in the academical performance of leukemia survivors. Differencies in study
design may explain the discrepancies.
Limiting use and reducing the doses and volume of cranial irradiation while intensifying
chemotherapy have improved survival and reduced the severity of cognitive dysfunction, especially
in leukemia but still the prevalence of attention deficits remains as high as 67%, and up to 28% of
survivors experience deficits in other domains {{361 Conklin,H.M. 2012;}}. Systemic methotrexate
and corticosteroids have been linked with worse memory functioning {{136 Boman,K.K. 2009;}},
but in our previous study, mere chemotherapy affected scholastic achievements only in the
younger female leukemia patient group {{248 Harila-Saari,A.H. 2007;}}.. Prevalence of problems is
reported consistently higher in those receiving therapy for high risk ALL {{362 Waber,D.P.
2012;}},{{361 Conklin,H.M. 2012;}}.
Education after comprehensive school
In keeping with our results, in a Swiss questionnaire study 1049 adult childhood cancer survivors
{{124 Kuehni,C.E. 2012;}} aged 20 to 40 years, more survivors than controls had completed only
compulsory schooling (8.7% vs 5.2%; p <.001), and fewer survivors achieved a university degree
(7.3% vs 11%; p < .001). Differently from our results, in that Swiss study only a CNS tumor
diagnosis increased the likelihood that an individual would achieve compulsory schooling only. Our
results differed also from the results of a German study {{363 Zynda,A. 2012;}}, where 1476
survivors of childhood leukemia graduated at higher levels of school compared to the general
population, with 48.6% (female) versus 38.0% and 52.6% (male) versus 35.8% (p < 0.001).
Quite recently it has been found that white matter volume might be diminished especially in
children treated at younger age {{254 Reddick,W.E. 2014;}}. Irradiation therapy has been shown to
be associated e.g. with lower temporal lobe volumes and impaired memory functions {{223
Armstrong,G.T. 2013;}}. We found that treatment with irradiation affected graduation only in BT
survivors most probably reflecting the recent trend of diminishing cranial irradiation in leukemia.
We could, however, confirm the Swiss {{124 Kuehni,C.E. 2012;}} finding about older age at
diagnosis being a risk factor for non-graduation after compulsory schooling only for surviovors of
leukemia/NHL.
Previously there has been some references that females might be more susceptible to cognitive
and psychosocial late effects {{136 Boman,K.K. 2009;}},{{364 Holmqvist,A.S. 2010;}}.
Contradictory to these findings, we found that males had higher frequencies of non-graduation in
all three survivor groups in our study. This may, however, partly be a reflection of the Finnish
school system that seems in general to favour conscientious girls {{247 Lahteenmaki,P.M. 2007;}}.
Supporting our findings, it has been reported that chemotherapy-only protocols also may induce
cognitive challenges but, most interestingly, there has been implications that mild adverse effects
might be rehabilitated{{145 Bisen-Hersh,E.B. 2013;}},{{255 Shortman,R.I. 2014;}}. Zou et al. and
Moore et al. have shown changes in brain activations towards to those in healthy controls by using
remediating cognitive programs {{155 Zou,P. 2012;}} and results of computerised programs have
been somewhat encouraging {{150 Hardy,K.K. 2013;}}, {{234 Moore,I.M. 2012;}}. For brain tumor
and ALL survivors, cognitive therapy/problem solving techniques have shown that they may be
more effective than stimulant medication {{183 Hardy,K.K. 2011;}},{{135 Patel,S.K. 2009;}}.
Posttraumatic stress disorder occurs in around one fifth of brain tumor survivors and cognitive
variables may predict psychological adaptation better than medical factors {{160 Wenninger,K.
2013;}}. Contribution of various genetic polymorphisms may also have effect on cognitive
performance of survivors and it has been a hot topic for academic research lately {{146
Howarth,R.A. 2014;}}.
We found only one previous description on the fields of education that childhood cancer survivors
have chosen (DUMAS A 2015). That qualitative report was on 80 childhood solid tumor and
lymphoma survivors among whom females often chose health/child care and males white-collar
occupations. In our broader study population, the frequency of choosing the field of health and
welfare was remarkable in leukemia/NHL survivors and the field of services in BT survivors.
Employment, retirement and income
The odds for being unemployed was not elevated in any of our survivor group. Similarly, in a
German study on survivors of adolescent cancer, unemployment was not increased in general
{{126 Dieluweit,U. 2011;}}. However, a subgroup analysis showed that CNS tumor survivors had an
increased risk for lower employment and graduation from university. In a recent French study on
survivors of childhood leukemia, employment rate was good but among those currently employed,
the number of survivors in unstable employment was significantly higher than expected (Berbis J in
2015). Our results were contradictory to the findings among 213 Swedish survivors of childhood
ALL who were less often than controls employed (70% vs.82%, p = 0.019) at the age of 30 years
{{364 Holmqvist,A.S. 2010;}}. Furthermore, in a study concerning 1437 adult childhood cancer
survivors from USA, full-time employment was lower than national norms, except among nonirradiated survivors of hematologic malignancies {{356 Crom,D.B. 2007;}}. In the Childhood Cancer
Survivor Study (CCSS), 5.6% of survivors reported unemployment, compared with 1.2% of siblings
(OR 3.7; 95% CI 2.6, 5.1) {{357 Pang,J.W. 2008;}}. Similarly, in a Dutch meta-analysis, survivors of
childhood cancer were nearly twice as likely to be unemployed than healthy controls (OR 1.85,
95% CI 1.3-2.7), but this was explained by included studies from US. Apart from type of diagnosis
and country, predictors of unemployment were younger age, lower education or intelligence
quotient, female gender, motor impairment or epilepsy, and radiotherapy {{358 de Boer,A.G.
2006;}}. Declined physical health may be even an eightfold risk factor for unemployment and, in
addition, depression and somatization as well as memory impairment may increase survivors' risk
for unemployment in both sexes {{184 Kirchhoff,A.C. 2011;}}.
Our finding on low risk of unemployment is partly explained with the high levels of premature
retirement in each survivor group studied. Among BT survivors, irradiation, younger age at cancer
diagnosis, and earlier treatment era explained retirement. Earlier treatment era and female gender
but not irradiation explained it in leukemia/NHL survivors. Based on these findings, one could
assume that with current treatment protocols, the risk for premature retirement would be
diminished.
Regarding yearly income, our results showed significantly lower income than that of their controls
in each of the survivor groups. Gender was not a significant factor in BT survivors, and on the other
hand, irradiation significantly reduced the income only in BT survivors. Surprisingly, irradiated solid
tumor survivors had significantly better income than non-irradiated, which might be explained by
the fact that non-graduation was proportionally less common in irradiated survivors. In keeping with
our results, all diagnostic subcategories of cancer survivors had lower mean net salaries than the
comparison population also in a Swedish survey {{133 Boman,K.K. 2010;}}.
When viewing the strengths and limitations of this study, it should be noted that this is a nationwide
population analysis and it contains longitudinal data on survivors’ cognitive performance,
employment and possible retirement. Additionally, data in Finnish registries are reliable, as we
have public education system and wide range of mandatory population-based registries.
Weakness of this study might still be a quite small number of individuals in different tumor groups
that restricted detailed statistical analysis for various solid tumor groups.
Conclusion
To date there are only few longitudinal studies on childhood cancer survivors' educational and
socioeconomic outcomes. Proportions of survivors with no education after comprehensive school,
with premature retirement, and with low yearly income were significantly higher than those of
controls in all survivor groups. Irradiation seemed to be associated with lower marks at the end of
comprehensive school, with higher non-graduation, and with higher risk for early retirement in BT
survivors. Reassuring was that premature retirement was significantly less common during the
most recent treatment era. In the future, screening and follow-up of cognitive and psychosocial
performance of survivors more effectively might be essential, and there is a need for studies on
possibility of effective rehabilitation of the survivors.
Acknowledgements
This study was supported by grants from the Finnish Foundation for Pediatric Research, Childhood
cancer foundation Väre, the Finnish Cancer Association and the Cancer Association of South-West
Finland
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Berbis
Dumas
Legends for figures and tables:
Figure 1. Description of the Finnish education system.
Table 1. Description of the study subjects.
Table 2. Grades (mean, SD) at the end of comprehensive school, and proportions of those
finalizing matriculation examination at the end of upper secondary school.
Table 3. Statistics on highest post-comprehensive school education entrances leading to a
qualification or degree.
Table 4. Frequency and risk of unemployment and retirement, and mean annual income of
survivors compared with controls.
Table 5. Description of entrances and admissions to different fields of education after
comprehensive school.