Unmet Survivorship Care Needs of Adolescent and Young Adult Cancer Survivors

Neighborhood factors associated with late effects among survivors of adolescent and young adult cancer

PURPOSE

The purpose of this study is to evaluate the associations between neighborhood income, education, and neighborhood racial composition (measured as a low percentage of white residents) and risk of developing cardiovascular diseases (CVD), diabetes (DM), and severe depression among survivors of AYA cancer and matched non-cancer peers.

METHODS

Two-year survivors of AYA cancers diagnosed at age 15-39 yrs at Kaiser Permanente Southern California (diagnosed 2000-2012) and individually matched (1:13) non-cancer subjects were included. The development of CVD, DM, and severe depression was ascertained via electronic health records. Neighborhood characteristics were obtained from census-based geocoded data. Cox regression evaluated associations between neighborhood characteristics and the health outcomes of interest among both the cancer survivors and the non-cancer comparison cohort and effect modification by cancer survivor status on these relationships.

RESULTS

Among cancer survivors (n = 6774), living in mostly non-white neighborhoods, was associated with risk of CVD (hazard ratio (HR) = 1.54 (95% CI 1.00-2.36)), while lower education level (HR = 1.41 (95% CI 1.02-1.94)) was associated with risk of severe depression. None of the neighborhood characteristics were associated with risk of DM. Effect modification was found for neighborhood education and risk of DM and severe depression.

CONCLUSION

When jointly considered, cancer survivors who resided in the most disadvantaged neighborhoods were at the highest risk of developing these health outcomes compared to other subgroups.

IMPLICATIONS FOR CANCER SURVIVORS

Our findings may inform screening strategy and addressing social determinants of health among AYA cancer survivors.

The Growing Burden of Cancer in Adolescent and Young Adults in Asia: A Call to Action

Recent estimates suggest that the lower middle income countries in Asia carry the heaviest burden of cancer among adolescents and young adults (AYAs) (defined as age 15-39 years). A larger proportion of the population in Asia is aged 15-39 compared with the developed countries. This age group is different from the pediatric or the adult group in terms of physical, social, psychological, and financial needs. Cancer incidence, disability, survivorship needs, financial toxicity, psychosocial issues, and so on are underestimated in this group, and available literature is scarce. Global data show an increasing trend of adult-onset cancers such as colorectal, breast, pancreas, and lung in the AYA population. Data suggest that the disease biology and prognosis are different in this group; however, further research is needed. An ESMO/SIOPE/SIOP Asia survey on the care of AYA cancer patients in Asia found a suboptimal availability of AYA specialized centers in the region and identified several unmet needs including lack of training, clinical trials, and high rates of treatment abandonment. There is an urgent need for cancer care systems in Asia to develop specialized services to be able to cater to this growing burden. Training and research in this area also need to be upscaled with the goal of establishing a sustainable infrastructure and quality services to ensure that this vulnerable group receives appropriate care. Management guidelines and national health policies should consider giving special attention to this group as the World Health Assembly reinforces the inclusion of children and adolescents in cancer control programs.

Do discussions of financial burdens decrease long-term financial toxicity in adolescent and young adult cancer survivors?

PURPOSE

This study aims to evaluate the associations between patient-provider cost discussions with patient-reported out-of-pocket (OOP) spending and long-term financial toxicity (FT) among adolescent and young adult (AYA; 15-39 years old) cancer survivors.

METHODS

Using a cross-sectional survey, we assessed the themes and quality of patient discussions with providers about financial needs and general survivorship preparation, quantified patients' levels of FT, and evaluated patient-reported OOP spending. We determined the association between cancer treatment cost discussion and FT using multivariable analysis. In a subset of survivors (n = 18), we conducted qualitative interviews and used thematic analysis to characterize responses.

RESULTS

Two hundred forty-seven AYA survivors completed the survey at a mean of 7 years post treatment and with a median COST score of 13. 70% of AYA survivors did not recall having any cost discussion about their cancer treatment with a provider. Having any cost discussion with a provider was associated with decreased FT (β = 3.00; p = 0.02) but not associated with reduced OOP spending (χ2 = 3.77; p = 0.44). In a second adjusted model, with OOP spending included as a covariate, OOP spending was a significant predictor of FT (β =  - 1.40; p = 0.002). Key qualitative themes included survivors' frustration about the lack of communication related to financial issues throughout treatment and in survivorship, feeling unprepared, and reluctance to seek help.

CONCLUSION

AYA patients are not fully informed about the costs of cancer care and FT; the dearth of cost discussions between patients and providers may represent a missed opportunity to reduce costs.

The relationship between unmet cancer care needs and self-rated health among adolescents and young adults with cancer

BACKGROUND

Adolescents and young adults (AYA) with cancer face unique psychosocial challenges that often impact their outcomes, including self-rated health. To date, few studies have focused on AYA cancer survivors' multidimensional unmet needs of cancer care in relation to their health status.

METHODS/PROCEDURE

This study surveyed 324 AYA cancer survivors in a cross-sectional design using the Cancer Needs Questionnaire - Young People (CNQ-YP). In addition to descriptive statistics and bivariate correlations, multinomial logistic regressions were used for analysis.

RESULTS

AYA cancer survivors' daily life needs were found to be significantly and negatively associated with self-rated health, OR = 0.910, 95% CI 0.843, 0.983, p < 0.01, and OR = 0.888, 95% CI 0.818, 0.966, p < 0.01. In addition, the unmet work needs were significantly and positively associated with participants' self-rated health, OR = 1.207, 95% CI 1.003, 1.452, p < 0.05.

CONCLUSIONS

Moving beyond simply describing the unique psychosocial needs confronting AYA cancer survivors, this study empirically identified two specific dimensions of unmet needs of AYA cancer survivors that were significantly correlated to their SRH, both of which should be considered in future service and intervention research to support AYAs with cancer.

Clinical Relevance and Implementation Considerations of Physical Activity in Young Adult Cancer Survivorship: An Expert Consensus Study

Significance: Elevated survival rates in young adult cancer survivors (YACS) are accompanied by high morbidity levels resulting in an array of unmet needs limiting full life potential. Physical activity (PA) improves physical, psychological, and social aspects of health after a cancer diagnosis. There are no standardized PA guidelines tailored to YACS. Therefore, there is a critical need to understand areas of clinical relevance/agreement on PA use and implementation in young adult (YA) survivorship care. Aim: To identify expert consensus areas on the assessment, prescription, and implementation of PA in YA survivorship care; identify areas of clinical relevance and endorsement of PA as a health optimization strategy in YA survivorship care. Methods: A four-round modified Delphi study of international multidisciplinary experts (Round I/II n = 18; Round III n = 57, Round IV n = 45) in exercise oncology, symptom management, survivorship care, youth cancer care was conducted. Qualitative content analysis, descriptive statistics (% agreement, standard deviation, mean), and inter-rater reliability (Kappa) were calculated. Results: Experts reached a consensus on clinical providers needed to assess, refer, and provide PA interventions, the need for guidelines, and essential care delivery system components to foster the integration of PA integration in YA survivorship care as a health optimization activity. Conclusions/Implications: Cancer care integration models should optimize the unique preferences, strengths, and developmental stage of YA affected by cancer. The study adds to the existing literature on multidisciplinary teams needed to provide clinical expertise and organizational support to foster PA integration into YA survivorship care.

Impacts of the Early COVID-19 Pandemic Among a National Sample of Adolescent and Young Adult Cancer Survivors in the United States

Purpose: Adolescent and young adult cancer survivors (AYAs) experience early-onset chronic conditions and disrupted psychosocial development. We report prevalence of disruptions in care delivery and social support during the early wave of the pandemic in a national sample of AYAs in the United States. Materials and Methods: We used data from the population-based National Health Interview Survey (NHIS; July-December 2020), which allows for nationally representative estimates, and included questions related to COVID-19. We identified 61 AYAs diagnosed with cancer between ages 15 and 39 years and not currently receiving cancer treatment and 244 age- and sex-matched controls. We compared the proportion of AYAs and controls reporting delayed care due to the pandemic, not getting needed care due to the pandemic, and changes in social and emotional support. Results: AYAs were predominantly non-Hispanic White (61.3%) and female (58.8%), with a median age at diagnosis of 28 years (interquartile range [IQR] 21-31 years). Fewer AYAs were employed (52.1% vs. 71.5%), and more lived in poverty (32.0% vs. 12.4%) and felt depressed daily (9.9% vs. 3.0%, all p < 0.05). The proportion of AYAs reporting delayed care (39.8% vs. 15.3%) and not getting needed care (31.7% vs. 10.4%) due to the pandemic was more than double that of controls (both p < 0.01). One in five AYAs experienced less social and emotional support compared to the prior year, although not significantly different from controls (21.6% vs. 12.4%, p = 0.10). Conclusions: The pandemic disrupted AYAs' care and exacerbated their psychosocial challenges. Providers and health systems should prioritize reconnecting AYAs to affordable and comprehensive care.

The Perceived Impact of COVID-19 on the Mental Health Status of Adolescent and Young Adult Survivors of Childhood Cancer and the Development of a Knowledge Translation Tool to Support Their Information Needs

Background

Adolescent and young adult (AYA; 13 to 39 years) survivors of childhood cancer may be especially vulnerable to physical health and mental health concerns during the pandemic. We investigated the impact of COVID-19 on the mental health status of AYA survivors (Aim 1) and shared tailored, evidence-based health-related information on COVID-19 (Aim 2).

Methods

Between May and June 2020, participants completed a cross-sectional online survey assessing their cancer history, current mental health status, and their COVID-19 information needs.

Results

Ninety-four participants (78 females, 13 males, 2 non-binary) with a mean age of 26.9 years (SD = 6.2) were included in the final sample. Participants reported residing from 10 countries and 94% identified as White. Nearly half of the participants (49%) described their mental health status as worse now than before the pandemic. Thirty-nine participants (41%) that indicated their current mental health status was tied to fears/worries about their past cancer and treatment experienced a higher level of anxiety and PTSS than those who did not report the same. Most participants (77%) had not received any information related to the potential risks of COVID-19 and expressed an interest in receiving this information. In response, an infographic detailing recommended strategies for coping with mental health problems in the pandemic, along with preliminary study findings, was developed.

Discussion

AYA survivors reporting their mental health status was linked to their past cancer experienced poorer mental health. There is a value to educating survivors on their potential health risks, but accounting for their perceived mental health vulnerabilities should be considered when disseminating knowledge. The use of an infographic is a unique contribution towards the development of innovative and personalized means of sharing health education to this vulnerable yet resilient group. This research on the mental health status of AYA survivors very early in the pandemic informs continued initiatives investigating the rapidly changing nature of how COVID-19 may impact AYA survivors today and in the future.

Adolescent and Young Adult (AYA) Cancer Survivorship Practices: An Overview

Worldwide, more than 1.2 million adolescents and young adults (AYAs; those aged 15-39 years) are diagnosed with cancer each year. Although considerable variability exists according to cancer site and stage of disease, the 5-year relative survival at the time of diagnosis has been estimated at >80% for all AYA patients with cancer combined. Extensive survivorship research in recent decades has focused on patients diagnosed with cancer as children (<15 years) and older adults (>39 years), yet few studies to date have reported outcomes specifically for patients diagnosed as AYAs. With increasing incidence and improving survival for many tumor types, leading to the majority of AYA patients with cancer becoming long-term survivors, there is a critical need for research efforts to inform the survivorship care of this growing population. This article describes the population of AYA cancer survivors according to their epidemiology and late and long-term effects, the challenges and models of AYA survivorship care, as well as future opportunities for research and healthcare.

"Every day is just kind of weighing my options." Perspectives of young adult cancer survivors dealing with the uncertainty of the COVID-19 global pandemic

Purpose

We explored adolescent and young adult cancer survivor (AYA) experiences with COVID-19 to understand the impact of living through a pandemic, unmet needs, and coping strategies.

Methods

AYAs were recruited nationally, completed an online survey, and attended one of six online focus groups. We used qualitative content analysis to analyze focus group data.

Results

Thirty-nine AYAs completed the survey, and 24 also participated in the focus groups. In the survey, AYAs responded that COVID-19 increased anxiety about their health or their family’s health, feelings of isolation, and worries about job security. Overarching focus group themes included AYA behavioral responses to the pandemic similar to their peers, the added burden of cancer, and unexpected advantages of a cancer history. When discussing the added burden of cancer, subthemes included difficulties and delays in medical care, mental health stressors, and compounding uncertainty. Unexpected advantages of a cancer history included relying on coping strategies developed during active treatment and resiliency from practicing social distancing during treatment.

Conclusions

AYAs have struggled in the early pandemic in ways similar to their peers but with compounding uncertainty regarding their unknown risk due to cancer history. Healthcare providers and systems can better support AYAs by providing additional psychosocial supports, developing strategies to triage good candidates for telehealth, and providing information about cancer survivor-specific risks for COVID-19.

Implications for Cancer Survivors

Our findings indicate a need for psychosocial supports that address managing anxiety and uncertainty. AYAs may be able to draw on their cancer experiences to navigate the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11764-021-01069-9.

Psychological adaptation and recovery in youth with sarcoma: a qualitative study with practical implications for clinical care and research

OBJECTIVES

This study explored factors that play a role in psychological adaptation and recovery of young people with sarcoma.

DESIGN

Qualitative study.

SETTING

National Health Service hospitals in the UK.

METHODS

Using purposive sampling, participants were recruited for semistructured interviews over the telephone or face to face in order to answer questions about how cancer impacted various domains of their life. Data were analysed using a framework approach.

RESULTS

Thirty participants, aged 15-39 years with primary sarcoma diagnosis provided in-depth accounts of their experience. Emerging themes from the interviews were grouped into two overarching themes that relate to one's adaptation to illness: individual level and environmental level. The qualitative nature of our study sheds light on meaningful connections between various factors and their role in one's psychological adaptation to sarcoma. We devised a visual matrix to illustrate how risk and protective factors in adaptation vary between and within individuals.

CONCLUSIONS

This study demonstrates that young people with sarcoma report an array of both positive and negative factors related to their illness experience. The route to recovery is a multifactorial process and a one-size-fits-all approach to psychosocial care proves inadequate. We propose that moving beyond the latent constructs of resilience and psychopathology towards a dynamic model of psychological adaptation and recovery in this population can result in optimisation of care. We offer some recommendations for professionals working with young people with sarcoma in clinic and research.

Adherence to cardiomyopathy screening guidelines among adolescent and young adult cancer survivors exposed to chest radiation and/or anthracyclines

PURPOSE

Cancer survivors are at risk for late effects from therapeutic exposures, including cardiovascular complications. To improve outcomes among adolescents and young adults (AYA) with cancer, the National Comprehensive Cancer Network (NCCN) released guidelines for screening services (based on the Children's Oncology Group Long-Term Follow-Up [LTFU] guidelines) for survivors of AYA cancer. To better understand survivorship care gaps, we conducted a baseline evaluation of cardiomyopathy screening among survivors of AYA cancers.

METHODS

Members of Kaiser Permanente Southern California diagnosed with cancer between ages 15 and 39 from 2000 to 2010 with at least 5-year survival after diagnosis who were exposed to chest radiation and/or anthracyclines were included. We calculated the Prevention Index ([PI], proportion of person-time covered by receipt of preventive services relative to the total person-time eligible) to evaluate adherence to recommended cardiomyopathy screenings based on the LTFU through 2016. Predictors for screening were evaluated in multivariable logistic regression.

RESULTS

Among 479 survivors recommended for cardiomyopathy screening, 28 received at least one screening, and the mean PI was 2.38% (SD = 13.05%, median = 0.00%). Compared to stage I, survivors of stage II (odds ratio [OR] = 5.56 [1.05-29.46]) and stage III/IV cancer (OR = 6.08 [1.10-33.54]) were more likely to receive cardiomyopathy screening.

CONCLUSIONS

Cardiomyopathy screening among survivors was low around the time when NCCN AYA oncology guidelines were released.

IMPLICATIONS FOR CANCER SURVIVORS

Our study highlights significant room for improvement for adherence to cardiomyopathy screening recommendations among survivors of AYA cancer. Attention is needed to ensure that recommended cardiomyopathy screenings are met for better management of cardiomyopathy late effects.

The impact of COVID-19 on the cancer care of adolescents and young adults and their well-being: Results from an online survey conducted in the early stages of the pandemic

BACKGROUND

Because of the global spread of coronavirus disease 2019 (COVID-19), oncology departments across the world have rapidly adapted their cancer care protocols to balance the risk of delaying cancer treatments and the risk of COVID-19 exposure. COVID-19 and associated changes may have an impact on the psychosocial functioning of patients with cancer and survivors. This study was designed to determine the impact of the COVID-19 pandemic on young people living with and beyond cancer.

METHODS

In this cross-sectional study, 177 individuals, aged 18 to 39 years, were surveyed about the impact of COVID-19 on their cancer care and psychological well-being. Participants also reported their information needs with respect to COVID-19. Responses were summarized with a content analysis approach.

RESULTS

This was the first study to examine the psychological functioning of young patients and survivors during the first weeks of the COVID-19 pandemic. A third of the respondents reported increased levels of psychological distress, and as many as 60% reported feeling more anxious than they did before COVID-19. More than half also wanted more information tailored to them as young patients with cancer.

CONCLUSIONS

The COVID-19 pandemic is rapidly evolving and changing the landscape of cancer care. Young people living with cancer are a unique population and might be more vulnerable during this time in comparison with their healthy peers. There is a need to screen for psychological distress and attend to young people whose cancer care has been delayed. As the lockdown begins to ease, the guidelines about cancer care should be updated according to this population's needs.

Cognitive Mechanisms in Adolescent and Young Adult Cancer Patients and Survivors: Feasibility and Preliminary Insights from the Cognitions and Affect in Cancer Resiliency Study

This cross sectional pilot study assesses the feasibility of conducting online research into cognitive mechanisms in adolescent and young adult cancer populations. Twenty-one participants, aged 18-39 years, answered questionnaires about mental defeat, rumination, cancer worry, anxiety, and experience participating in such research. Seven participants scored in the clinical range for anxiety. Cancer-related worry was common. Rumination and mental defeat were positively associated with anxiety. The participants reported the length and type of questions to be appropriate and not distressing. Findings may inform future research into cognitive mechanisms, which could aid the development of psychosocial interventions for young cancer patients.

Adolescent cancer survivors' experiences of supportive care needs: A qualitative content analysis

Supportive care is an important strategy that can help cancer survivors manage changes and problems during their follow-up care. Identifying patients' care needs is one of the primary steps of the nursing process to plan effective nursing interventions. The aim of this study was to explore adolescent cancer survivors' supportive care needs. Purposeful sampling was adopted to select 49 participants from hospitals to participate in face-to-face, semistructured interviews. The qualitative content analysis method was conducted for data analysis. Ten subcategories and four main categories - empathetic care, information about survival period, instrumental support, and cooperation in care - were extracted from the data. These four categories formed a major theme, "supportive care", as the primary healthcare need. This study highlights that supportive care should be developed collaboratively by family and healthcare providers to meet the needs of adolescent cancer survivors. Survivors' strengths and limitations should be identified, and then supportive care can be provided, such as giving appropriate information, enabling survivors to access supportive networks, and improving survivors' confidence and autonomy with their self-management.

Health-related quality of life in adolescents and young adults with cancer - Including a focus on economic evaluation

Health-related quality of life (HRQL) is an amalgam of three elements - the opportunities that a person's health status affords, the constraints that it places upon the person and the value that a person places on his/her health status. HRQL measures are specific, for example for a disease, or generic with broad applicability. The latter include preference-based measures that can be used to generate quality-adjusted life years and so contribute to economic evaluation. Measures of HRQL in adolescents and young adults (AYAs) with cancer may fail to capture some important dimensions, for example sexual health. However, the use of HRQL measures in this population has identified burdens of morbidity according to disease, treatment status and duration of follow-up. There are few economic evaluations of the treatment of cancer in AYAs but preliminary evidence suggests that this is a cost-effective undertaking. Opportunities abound to include measurement of HRQL in routine clinical care.

Understanding and Improving Survivorship Care for Adolescents and Young Adults with Cancer

Purpose: To explore and highlight the opportunities and challenges that underlie the development of survivorship care for adolescent and young adult cancer. Methods: A multimethod approach was used, with perspectives of survivors, relatives, and health care professionals elicited through an online survey, focus group, and semistructured interviews. Results: Four themes were identified using thematic analysis: adjusting to life after cancer, transition to community-based care, ongoing change and reform of health care, and supporting survivorship services. Adolescents and young adults (AYAs) and their families struggled with the transition from active treatment, which was complicated by ongoing disease/treatment impacts and a collective dearth of knowledge and resources on how to support AYAs during this time. Limited confidence and communication in patient-general practitioner relationships complicated the transition to community-based care, with treatment summaries and survivorship care plans an underused resource. A growing movement toward integrated, holistic, and equitable survivorship care was identified, but progress has been fragmented and under-resourced. Further research, funding, and advocacy are needed to support ongoing survivorship initiatives. Conclusions: Although some survivorship concerns are common across age groups, others are specific to AYAs' developmental stage, emphasizing the need for integrated, age-appropriate, and targeted survivorship services for AYAs. The transition from active treatment to longer term survivorship presents challenges for ongoing clinical care and support; change is needed at individual, service, and system levels to provide quality, sustainable, and integrated care to AYA cancer survivors.