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\begin{document}

\title{Implementing Screening for Eating Disorders in Adolescents and Young
Adults with a History of Cancer}



\author[1]{Aarti Kamat}%
\author[2]{Jessica Van Huysse}%
\author[1]{Emily Walling}%
\affil[1]{University of Michigan Hospital}%
\affil[2]{University of Michigan Department of Psychiatry}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Background} Eating disorders are prevalent in the adolescent and
young adult population, with 2.7\% of adolescents effected. The American
Academy of Pediatrics recommends yearly screening for eating disorders
in adolescents. Even with this recommendation, eating disorders often go
underdiagnosed. AYAs with cancer possess several risk factors for eating
disorders that may place them at an even higher risk, including
receiving weight-altering therapies and having their weight/nutrition
emphasized. Since these patients see their oncology team frequently,
oncology clinics are opportune settings for eating disorder screening.
This describes a single-institution study to implement screening for
eating disorders in AYA patients in an oncology clinic.
\textbf{Procedures} During regularly scheduled oncology visits, eligible
patients were given the SCOFF questionnaire. Patients with an oncologic
diagnosis aged 13 and older were screened. Patients with known eating
disorders and patients receiving cytotoxic therapy were excluded. The
questionnaire was scored by a study team member. Patients with a
positive screening were referred to adolescent medicine.
\textbf{Results} 163 eligible patients filled out the SCOFF
questionnaire with 11 positive results (6.75\%). \textbf{Conclusions}
Our results demonstrate that eating disorder screening was successfully
implemented in our pediatric oncology clinic. With a rate more than
double than the general population, we observed that AYA patients with a
history of cancer are indeed at a higher risk for eating disorders and
should undergo routine screening. Since these patients have frequent
oncology appointments, oncology clinics should implement screening for
eating disorders. Further studies are needed to develop appropriate
screening methods for on therapy patients.%
\end{abstract}%



\sloppy


\textbf{Implementing Screening for Eating Disorders in Adolescents and
Young Adults with a History of Cancer}

Aarti Kamat MD\textsuperscript{a,b} Jessica Van Huysse
PhD\textsuperscript{c}, Emily Walling MD, MPHS\textsuperscript{a,b}

a - CS Mott Children's Hospital, Division of Pediatric
Hematology/Oncology

b - University of Michigan Medical School

c -- University of Michigan Department of Psychiatry

Corresponding Author:

Aarti Kamat

Address: 1540 E Hospital Dr, Ann Arbor MI, 48109

Phone: 248-767-6716

e-mail: aartimich@gmail.com

Word Count

Abstract: 249

Main Text: 1921

Number of Tables: 1

Running Title: Implementing Screening for Eating Disorders in AYAs

Keywords: Eating Disorders, Adolescents, Psychosocial care

Abbreviation Key:\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
AYA & Adolescent and Young Adult\tabularnewline
\midrule
\endhead
NIH & National Institutes of Health\tabularnewline
NCI & National Cancers Institute\tabularnewline
MA & Medical Assistant\tabularnewline
SLE & Systemic Lupus Erythematosus\tabularnewline
AAP & American Academy of Pediatrics\tabularnewline
\bottomrule
\end{longtable}

\textbf{Abstract}

\textbf{Background}

Eating disorders are prevalent in the adolescent and young adult
population, with 2.7\% of adolescents effected. The American Academy of
Pediatrics recommends yearly screening for eating disorders in
adolescents. Even with this recommendation, eating disorders often go
underdiagnosed. AYAs with cancer possess several risk factors for eating
disorders that may place them at an even higher risk, including
receiving weight-altering therapies and having their weight/nutrition
emphasized. Since these patients see their oncology team frequently,
oncology clinics are opportune settings for eating disorder screening.
This describes a single-institution study to implement screening for
eating disorders in AYA patients in an oncology clinic.

\textbf{Procedures}

During regularly scheduled oncology visits, eligible patients were given
the SCOFF questionnaire. Patients with an oncologic diagnosis aged 13
and older were screened. Patients with known eating disorders and
patients receiving cytotoxic therapy were excluded. The questionnaire
was scored by a study team member. Patients with a positive screening
were referred to adolescent medicine.

\textbf{Results}

163 eligible patients filled out the SCOFF questionnaire with 11
positive results (6.75\%).

\textbf{Conclusions}

Our results demonstrate that eating disorder screening was successfully
implemented in our pediatric oncology clinic. With a rate more than
double than the general population, we observed that AYA patients with a
history of cancer are indeed at a higher risk for eating disorders and
should undergo routine screening. Since these patients have frequent
oncology appointments, oncology clinics should implement screening for
eating disorders. Further studies are needed to develop appropriate
screening methods for on therapy patients.

\textbf{Introduction}

Eating disorders are prevalent in the adolescent and young adult (AYA)
population. It is difficult to ascertain the true prevalence of eating
disorders in adolescents, as estimates vary greatly -- ranging anywhere
from 1-22\% in the literature depending on the source and specific
eating disorder diagnosis.\textsuperscript{1} According to the mental
health section of the National Institutes of Health (NIH), the overall
prevalence of eating disorders in adolescents is
2.7\%.\textsuperscript{2} Risk factors for the development of an eating
disorder include underlying psychiatric conditions, stressful life
events, family history of eating disorders, and underlying chronic
illnesses (especially those with steroid-dependent
treatments).\textsuperscript{1,3,4} Eating disorders have a high rate of
morbidity and mortality, especially the longer they go undiagnosed, and
impact all aspects of patients' mental and physical
well-being.\textsuperscript{1,3} When undiagnosed, eating disorders can
cause adverse and/or fatal electrolyte derangements, cardiac arrythmias,
and cardiomyopathy. Emotionally, eating disorders are associated with
depression, anxiety, and suicidal ideation.\textsuperscript{1,3,5} Early
identification and intervention are key in limiting the morbidity
associated with eating disorders.\textsuperscript{1,3} The American
Academy of Pediatrics (AAP), therefore, recommends yearly screening for
eating disorders in the general adolescent
population.\textsuperscript{3} Even with this recommendation, eating
disorders in the general population often go underdiagnosed and
undertreated.\textsuperscript{4}

Adolescent and young adult (AYA) cancer survivors (those who have had or
had cancer ages 15-39 years per the National Cancers Institute (NCI)
definition) possess several of the general risk factors for eating
disorders -- including coping with chronic underlying diseases and
stressful life events. During treatment, AYA patients are also exposed
to weight and appetite-altering therapies and often have their weight
and nutrition emphasized, all of which may impact body image. Currently,
however, there is a lack of data regarding the development or incidence
of eating disorders in the AYA patient population. Additionally, there
is no standard for routinely screening for eating disorders in oncology
clinics. Patients with cancer, even when off-therapy, often see their
oncology team monthly or every few months, typically more frequently
than their primary care providers, therefore, oncology clinic is an
opportune setting to screen patients and identify eating disorders
early.

The purpose of this quality-improvement project was to implement a
standardized process for screening AYA oncology survivors for eating
disorders in oncology clinics using a validated questionnaire. We
postulated that AYAs with cancer have an increased risk for eating
disorders compared to their healthy peers, as they are exposed to
weight-altering therapies, face consistent scrutiny over their weight
and nutrition, and may be at risk for maladaptive coping strategies,
such as disordered eating behaviors, in the face of a significant
life-altering disease.

\textbf{Methods}

This was a single-institution quality improvement project conducted at a
tertiary pediatric cancer center. The study team, consisting of a
pediatric hematology/oncology fellow and attending, partnered with an
eating disorder specialist in the adolescent medicine department for
guidance on an appropriate screening process. This allowed the team to
create a pipeline to the adolescent medicine team for patients with a
positive screening for further management.

Participants

Participants included patients with an oncology diagnosis aged 13-39
years and older who were treated with chemotherapy. Participants were
excluded if they were receiving cytotoxic chemotherapy, those receiving
targeted therapy post-active treatment were allowed. Patients on active
therapy were excluded to eliminate confounding factors that could
iatrogenically alter weight or appetite (ex: chemotherapy-induced nausea
or vomiting, change to taste perception, and weight- altering
medications). Similarly, patients on maintenance therapy that included
steroids due to the known side-effects of increased appetite and weight,
making it difficult to truly assess for an eating disorder.

Procedures

There are several questionnaires that are utilized in primary care
offices that are validated screening devises for eating disorders. The
SCOFF questionnaire (Table 1) is an easy-to-use tool that can be
implemented in outpatient settings.\textsuperscript{3,5} The
self-administered questionnaire consists of 5 yes/no questions designed
to screen for both restrictive and binge-eating habits. Patients receive
a point for each question answered ``yes.'' A score of 2 or greater is
considered a positive screening.\textsuperscript{3,5}

At check-in for their scheduled oncology appointments, participants were
given a one-time SCOFF questionnaire by the clinic medical assistant
(MAs) to complete prior to their appointments. Patients were identified
prior to their appointments and the study team entered a note to
indicate to the MAs which patients were eligible for screening. An
informational sheet was provided to participants regarding the
questionnaire. Questionnaires were then scored by a member of the
research team. If a participant scored 2 or above, they were referred to
the Adolescent Medicine clinic for further resources and discussion and
their oncology providers were notified. All screenings were destroyed
and not made part of the permanent medical record. Participants were
aware that they would be referred to adolescent medicine should they
screen positive. Screenings were collected from September 2022 to June
2023. Participants were only screened one time each during this time
frame.

\textbf{Results}

During the 9-month screening period, 163 patients filled out the SCOFF
questionnaire. Of the 163 patients screened, 11 had positive results
(6.75\%). All 11 patients received referrals to adolescent medicine.
6/11 patients were female, 4/11 male, and 1/11 was non-binary. Ages of
patients who were positive ranged from 14-24 years.

\textbf{Discussion}

Our findings demonstrate that screening for eating disorders is feasible
in oncology clinics -- as over 150 patients were successfully screened
in only a 9-month period. With a 6.75\% positive screening rate, our
findings are also consistent with prevalence data in the general
population and over two times higher than the general AYA population
when compared to the NIH's prevalence data - confirming that oncology
survivors are at a higher risk and indeed should be screened for eating
disorders. Since early recognition is key for the treatment of eating
disorders and limiting the long-term morbidity, it is especially
important to screen oncology patients, particularly if they are not
regularly seeing their primary care physician.\textsuperscript{1,3} The
SCOFF questionnaire is an accessible, feasible, and time-efficient tool
for patients to use and for providers to interpret. We found that it was
simple for the clinic medical assistants to pass out the questionnaire
to the designated patients. This screening process was widely accepted
by both the adolescent patients as well as the oncology providers.

It is well documented that adolescents with childhood trauma and adverse
childhood events, including coping with a chronic disease, are at
increased risk of developing an eating
disorder.\textsuperscript{4}Adolescents with chronic health conditions,
including oncology patients, experience a loss of normalcy and autonomy
during a time when they are seeking independence and developing a
sense-of-self. Fixation on eating and weight loss lends a sense of
structure, predictability, and security.\textsuperscript{6} Indeed, this
has been reported in other adolescents with chronic conditions, such as
systemic lupus erythematosus (SLE), diabetes mellitus, and chronic
hypertension.\textsuperscript{5,7,8} One review of patients with
juvenile SLE patients demonstrated an association between SLE and
anorexia nervosa. In this review, it was suggested that these patients
developed anorexia due to the chronic use of steroids and the subsequent
body-image issues secondary to steroid-related body
changes.\textsuperscript{7} They also develop eating disorders because
of an emphasis on weight and nutrition, as both these factors can impact
prognosis, with adhering to a stricter diet ultimately having the
opposite effect and leading to an eating disorder.\textsuperscript{7}

Adolescent patients with diabetes mellitus are at 2-3 times higher risk
than the general population to develop an eating disorder, with a
prevalence anywhere between 15-40\%.\textsuperscript{8} This is the case
as patients with diabetes must adhere to a strict medication regimen
that emphasizes portion and weight control, leading to food
preoccupation.\textsuperscript{8,9} Underdosing or skipping insulin
doses entirely is commonly used as a form of weight loss among these
patients, as this both helps patient lose weight and gives them a sense
of independence and control over their
treatment.\textsuperscript{8,9}The same has been noted in adolescent
patients with chronic hypertension due to the emphasis on lifestyle
modification, including diet and exercise.\textsuperscript{5}

The above supports our hypothesis that AYA oncology patients are at high
risk for the development of eating disorders given several similar
characteristics with patients with SLE, diabetes, and chronic
hypertension -- including treatment with weight-altering therapies,
emphasis on weight and nutrition, stringent treatment regimens, and
significant stress - and therefore should be routinely screened.

Though the NCI has designated AYA patients as those 15 years and over
and the AAP defines adolescence as beginning at 11 years, we elected to
starting the screening age at 13 years. Starting at the onset of the
teenage years seemed reasonable as we did not want to miss patients
under 15 -- they are certainly at risk -- but did not think starting at
11 was appropriate as our and adolescent medicine team, who was
evaluating patients with a positive screening, does not accept patients
as young as 11.

One other consideration when implementing screening for eating disorders
in this patient population is how to respond to a positive result. Our
institution is fortunate to have a dedicated adolescent medicine clinic
with specific expertise in managing eating disorders. Other facilities
without an adolescent medicine team should find other resources and/or
the oncology team will need to be comfortable with subsequent follow up,
workup, and management for potential eating disorders. In this
situation, oncology providers can refer to social work for resources or
refer the patient back to their general pediatrician.

An important limitation to this study to note is that AYA oncology
patients receiving active therapy were excluded. There is currently a
lack of data regarding the prevalence of eating disorders in the AYA
oncology population. This initiative only screened AYA oncology
survivors who were not receiving active therapy. We also excluded
patients who were currently receiving steroids as these are known to
affect appetite and body habitus. AYA patients receiving active
chemotherapy have several factors that could affect their weight and
appetite -- nausea with chemotherapy, a change in taste, medication side
effects resulting in weight gain/loss - and are therefore tricky to
screen for eating disorders as their answers on questionnaires may be
influenced by from their treatment.

An important next step in preventing eating disorders in AYA cancer
patients on active therapy is to develop an appropriate screener that
accounts for these confounding factors. Adequate nutrition is a
necessity for patients who are actively receiving chemotherapy as this
allows for a better tolerance for intensive therapies. Severe cases of
eating disorders can also cause significant electrolyte derangements,
limiting the ability to give certain chemotherapies. Additionally,
variations in weight also impacts the dosing of chemotherapy and may
lead to subtherapeutic treatment. The presence of an eating disorder
also portends other psychosocial issues, which can worsen patients'
overall quality of life and survival. For these reasons and knowing that
on-therapy AYA patients carry risk factors for developing eating
disorders, it would be in active oncology patients' best interests to
develop a method for eating disorder screening.

\textbf{Conclusions}

Adolescents and young adults with a history of cancer are at a higher
risk than the general adolescent population for developing eating
disorders and should undergo routine screening per general adolescent
guidelines. Screening was feasible in our pediatric oncology clinic, and
results were higher than the prevalence of eating disorders in the
general AYA population. Though AYA patients see their oncology providers
primarily for disease surveillance in the post treatment period, it is
important to remember that they also continue to experience general AYA
issues. Since these patients may not visit their primary care physicians
as often as their oncology team, oncology clinics should implement
screening for eating disorders in off therapy patients. Further studies
are needed to develop appropriate screening methods for on therapy
patients.

\textbf{Conflict of Interest Statements:}

The authors have no conflicts of interest.

\textbf{References:}

1. Laurie L. Hornberger,~Margo Lane,~Cora C. Breuner,~Elizabeth M.
Alderman,~Laura K. Grubb,~Makia Powers,~Krishna Kumari
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FRCPC,~Meredith Loveless,~Seema Menon,~Lauren Zapata,~Liwei Hua,~Karen
Smith,~James Baumberger; Identification and Management of Eating
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2. National Institute of Mental Health (2023, January 1).~\emph{Eating
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3. Ellen S. Rome,~Sarah E. Strandjord; Eating Disorders.~\emph{Pediatr
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