Cancer and the adolescent: the Second Teenage Cancer Trust International Conference, Royal College of Physicians, London, England, March 2001

The Youth Project at the Istituto Nazionale Tumori in Milan

The paper describes the key issues of the Youth Project launched in 2011 at the pediatric oncology unit of the Istituto Nazionale Tumori in Milan dedicated to adolescents (over 15 years old) and young adults (up to 25 years old) with solid tumors. The Youth Project was developed within the pediatric oncology unit in the conviction that adolescent patients may benefit from the multidisciplinary team typical of the pediatric oncology setting, as well as the expertise in treating pediatric-type malignancies and enrolling patients in clinical trials. The project was an offshoot of existing activities, making no major changes to the hospital's organization and posing no major demands on the institution's administration and board. Patients are managed by the pediatric oncology staff, but they have access to particular services (e.g., regarding their psychosocial support, fertility preserving measures, access to care after completing therapy); dedicated, adequately equipped multifunctional rooms have been provided. The location of the pediatric unit within a cancer referral center and the cooperation with divisions dedicated to adults have played an important role in the project's creation.

Psychosocial challenges and resource needs of young adult cancer survivors: implications for program development

Young adult (YA) cancer survivors have specific needs because of their age and life stage. The authors investigated the challenges and resource needs of YA survivors, exploring the influence of age at diagnosis (i.e., diagnosis during childhood vs. young adulthood) and the diagnosis of a brain tumor. The authors conducted four focus groups with YA survivors (N = 22, age 18-35), treated for brain tumors or other cancers in childhood (mean age at diagnosis ± SD: brain, 10.7 ± 2.86; other cancers, 10.5 ± 3.51) or as YAs (brain, 23.5 ± 4.04; other cancers, 25.6 ± 4.10). Transcripts of audiotaped sessions were coded using thematic analysis. Common challenges across the groups included physical appearance, fertility, late effects, social relationships, and changing priorities. Childhood cancer survivors struggled with identity formation, social isolation, and health care transitions. Concerns specific to survivors diagnosed as YAs included financial independence and protecting parents. Childhood brain tumor survivors struggled with cognitive deficits, limited career options, and poor social skills, whereas brain tumor survivors diagnosed as YAs emphasized cognitive decline, loss of autonomy, and living with an incurable disease. Despite the unique challenges identified, all groups described similar resource needs including peer support, age-specific information, and having health care providers proactively raise salient issues. Young adult cancer survivors have many similar psychosocial and information needs regardless of age at or type of diagnosis that differ from those of pediatric and older adult survivors. With improved survival rates, the small number of YA in any one institution will grow. It will become increasingly important to create comprehensive, age-appropriate YA programs that address overlapping and unique needs of survivors at this life stage.

The challenge of access to care for soft tissue sarcomas bridging pediatric and adult age: the Italian pediatric oncology view

Synovial sarcoma and rhabdomyosarcoma are two high-grade soft tissue sarcoma subtypes that occur in adolescents and young adults. Managing these malignancies in patients in this age bracket poses various clinical problems, partly because different therapeutic approaches are sometimes adopted by pediatric and adult oncologists, even though they are dealing with the same condition. In this review, the doubts concerning how best to manage soft tissue sarcomas in patients between pediatric and adult ages lead up to a more general discussion of the issue of access to optimal cancer services for adolescents and young adults - a subset of patients acknowledged as being under-represented in clinical trials on therapies that may improve their outcome. The situation in Italy is described, along with action taken in an effort to bridge the gap and implement specific programs tailored to these patients.

Adolescents and young adults with cancer: An orphaned population

Adolescents and young adults (AYAs [15 to 29 years of age]) with cancer have a distinct cancer epidemiology, evolving hormonal milieu, maturing development, transitions in autonomy, increasing demands in education, entry into the workplace and family responsibilities. The prevalence of epithelial cancers in AYA patients represents a major shift from the embryonal cancers that predominate in early childhood. Thus, one would expect a specialized expertise to be required in caring for these patients, who typically fall between paediatric and oncology spheres of practice. Complex issues contribute to the lower survival rates noted for AYAs compared with those of younger patients, even with the same cancer. Cooperative group clinical trial participation has been crucial in advancing the excellent outcomes accomplished in paediatric oncology, yet participation by adolescents in clinical trials (either adult or paediatric) is typically low. There is increasing evidence that both appropriate location of care and access to specialists in paediatric or adult oncology contribute to favourable outcomes. Issues specific to AYA patients should be studied rigorously so that evidence-based approaches may be used to reduce waiting times, ensure prompt referral to appropriate centres, increase accrual to clinical trials, foster compliance, provide comprehensive supportive care and promote programs designed to enhance survivorship.

Starting an Adolescent and Young Adult Program: Some Success Stories and Some Obstacles to Overcome

Adolescent and young adult (AYA) patients seem to be in a sort of no-man's land, halfway between the two different worlds of pediatric and adult medical oncology and bearing the brunt, in terms of inclusion in clinical trials and quality of professional care, of the lack of integration between these two worlds. This article discusses the different organization models of care used in pediatric oncology (mainly family-focused) and in adult medical oncology (disease-focused). There is a growing awareness that these models are not ideally suited to the complex needs of AYA patients, which require a different, new, patient-focused multidisciplinary approach. A comprehensive, multipronged effort is required to bridge the gap in the care of AYA patients, with the ultimate challenge of creating a new discipline, AYA oncology. In this article, we review the experiences of AYA oncology programs in Europe, North America, and Australia, focusing on similarities and differences in strategy, as well as the major challenges and opportunities faced by these programs. Among the most important factors for the successful establishment of an AYA oncology service are the degree of engagement of both pediatric and adult medical oncologists, the philanthropic support of powerful charities, and the role of dedicated professionals across a range of disciplines in driving the development of services for AYA patients.

Psychological referral and consultation for adolescents and young adults with cancer treated at pediatric oncology unit

PURPOSE

Managing older adolescents and young adults with cancer is a challenge, both medically and psychosocially: it is important to assess these patients' psychological issues and the type of services they need when deciding who should treat these patients, and where.

METHODS

This study describes the pattern of psychological referral and consultation for older adolescents and young adults with cancer being treated at a pediatric oncology unit, as compared with the case of younger patients.

RESULTS

Between 1999 and 2006, 318 patients <15 (32% of the patients in this age group) and 117 >/= 15 years old (30%) were referred for psychological consultation. The number of interviews per patient was 2.8 for patients under fifteen and 7.8 for older patients. Younger patients were referred by all members of staff, while most older patients were referred by doctors, mainly because they had trouble adapting to the cancer's diagnosis and treatment. An ongoing, weekly, long-term psychotherapy was needed for 1% of patients <15 and 10% of those >/=15 years old.

CONCLUSIONS

Adolescents and young adults with cancer have specific psychological needs. While awaiting the full development of programs dedicated to these patients, they would seem to benefit from being treated in a multidisciplinary setting of the kind usually developed at pediatric units, fully integrating the psychological operators with the other staff members.

Participation of adolescents with cancer in clinical trials

Adolescent patients with cancer reside in a "no-man's land" between the world of pediatric oncology and that of "adult" medical oncology. As compared to younger and older patients, adolescents and young adults are under-represented on clinical trials. This relative lack of participation in clinical protocols has been associated to a lack of progress in survival improvement over the last years. One of the main reasons for the deficit in protocol enrolment and the worse outcome of adolescents (when compared in particular to children) is the lack of awareness by the public, community and healthcare systems that cancer may occur in this age group. However, physicians--inadequately trained or reluctant to care for adolescents--have important responsibilities. Most 15- to 19-year-olds diagnosed with cancer are treated at adult facilities, although two-thirds to three-fourths of their cancers are typical of those that occur in the pediatric age range. The best choice may be to treat them according to their type of tumor, not according to their age: "pediatric" tumors treated by pediatric oncologists, "adult" tumors by adult medical oncologists, regardless of the patient's age. This solution, however, is probably appropriate for the tumor, but not necessarily for the patient. Adolescents are neither old children nor young adults, and are very complicated individuals, with unique socio-psychological problems and needs, that may be addressed only by dedicated professionals, adequately trained and supported. The ultimate challenge is the development of a new discipline, adolescent/teenage and young adult oncology, devoted to the care of these patients.

Psychosocial issues in adolescents with cancer

Cancer in adolescents is uncommon and when it occurs raises a number of unique challenges for both the patient and their families. Adolescence is a period of time of significant physical and emotional changes and a diagnosis of cancer during this time has a major impact on their psychological and physical development. In this review we will look at the psychosocial issues facing adolescents who have cancer. We will address adolescent development, issues related to informed consent and assent, initial responses to the diagnosis of cancer, quality of life and the experience of the adolescent with cancer, psychological adjustment, support systems, body image issues, sexuality, education, hope, and treatment compliance.

Shifting perspectives: adolescent-focused oncology nursing research

PURPOSE/OBJECTIVES

To describe contextual features of the experience of adolescents with cancer in the United States; to relate these features to a different theoretical perspective, the Shifting Perspectives Model of Chronic Illness; and to derive implications from that model for conducting research with adolescents who have cancer.

DATA SOURCES

64 qualitative and quantitative studies and clinical anecdotes.

DATA SYNTHESIS

Unique features of adolescents with cancer related to person, disease, and treatment indicate that existing theories on adolescence do not adequately guide research efforts with this patient population, nor do they adequately assist in explaining study findings.

CONCLUSIONS

The Shifting Perspectives Model of Chronic Illness is useful in generating potentially important hypotheses about adolescents and their experiences with cancer and has the promise of guiding research design and method selection for studies involving adolescents with cancer. The model also highlights a moral responsibility for researchers who conduct studies with this patient population.

IMPLICATIONS FOR NURSING

Nurse researchers who use this model to guide their research will create a purposeful balance in methods that allows adolescents with cancer to choose the amount of time and detail they will give to illness-related or to wellness-related responses in studies, particularly those that rely on self-report methods.