Do Australian adolescents' and young adults' experiences of cancer care influence their quality of life?

Guidelines for Caring for the Social Well-Being of Adolescents and Young Adults with Cancer in Australia

More than 1000 Australian adolescents and young adults (AYAs) are diagnosed with cancer annually. Many report unmet social well-being needs, which impact their mental health. Australian AYA cancer care providers lack guidance to address these needs well. We aimed to develop guidelines for caring for the social well-being of AYAs with cancer in Australia. Following the Australian National Health and Medical Research Council guidance, we formed a multidisciplinary working group (n = 4 psychosocial researchers, n = 4 psychologists, n = 4 AYA cancer survivors, n = 2 oncologists, n = 2 nurses, and n = 2 social workers), defined the scope of the guidelines, gathered evidence via a systematic review, graded the evidence, and surveyed AYA cancer care providers about the feasibility and acceptability of the guidelines. The guidelines recommend which AYAs should have their social well-being assessed, who should lead that assessment, when assessment should occur with which tools/measures, and how clinicians can address AYAs' social well-being concerns. A key clinician, who is knowledgeable about AYAs' developmental needs, should lead the assessment of social well-being during and after cancer treatment. The AYA Psycho-Oncology Screening Tool is recommended to screen for social well-being needs. The HEADSSS Assessment (Home, Education/Employment, Eating/Exercise, Activities/Peer Relationships, Drug use, Sexuality, Suicidality/Depression, Safety/Spirituality Assessment) can be used for in-depth assessment of social well-being, while the Social Phobia Inventory can be used to assess social anxiety. AYA cancer care providers rated the guidelines as highly acceptable, but discussed many feasibility barriers. These guidelines provide an optimal care pathway for the social well-being of AYAs with cancer. Future research addressing implementation is critical to meet AYAs' social well-being needs.

Disparities in Treatment Satisfaction and Supportive Care Receipt for Young Adult Oncology Patients on the Basis of Residential Location

PURPOSE:

Adolescent and young adult oncology programs are critical but exist primarily in academic centers, prompting potential disparities in care on the basis of patient residence. We studied the impact of residential location on supportive care receipt and treatment satisfaction in young adults (YAs) with cancer age 19-39 years treated at the University of Wisconsin Carbone Cancer Center (UWCCC).

METHODS:

YA patients with cancer age 19-39 years seen at UWCCC from March 30, 2019, to March 29, 2020, were sent a survey assessing supportive care receipt and satisfaction. Survey results were compared with retrospective chart review of YAs seen at UWCCC between April 1, 2011, and April 1, 2021. Data were categorized on the basis of residential location using distance from UWCCC and 2013 Rural-Urban Continuum Code (RUCC).

RESULTS:

Survey results were obtained for 145 YAs, including 29 from nonmetro RUCC (20.0%) and 81 living > 20 miles from UWCCC (55.9%). YAs from nonmetro locations had lower satisfaction with available treatments (79.3% v 91.4%, P = .005), and distant YAs living > 20 miles from UWCCC more frequently identified location as a barrier to supportive care receipt (35.6% v 15.8%, P = .02). Metro YAs more frequently listed fertility consultations as unavailable (38.0% v 16.0%, P = .04) in the survey despite chart review data showing higher rates of sexual health assessments (48.2% v 20.4%, P = .002) and fertility visits (29.6% v 18.5%, P = .18).

CONCLUSION:

We identified differences in both supportive care receipt and treatment satisfaction on the basis of residential location. These findings support the need for measures to successfully meet treatment and supportive care needs regardless of residential location.

Patterns and Predictors of Healthcare Use among Adolescent and Young Adult Cancer Survivors versus a Community Comparison Group

Simple Summary

Adolescent and young adult cancer survivors face several significant physical/mental health late effects following cancer treatment. These effects may be minimized through healthcare use tailored to young survivors’ needs. Using a cross-sectional study design, we examined the healthcare use of 93 adolescent/young adult cancer survivors (aged 15–39 years), relative to a comparison group of adolescents and young adults recruited from the local community (n = 183). Our cancer survivor group reported greater use of medical and mental health services, and medications during the past six months relative to the comparison group. Our cancer survivor group also reported less psychological distress, and similar work/study participation relative to the comparison group. Survivors who were female, diagnosed with brain/solid tumors and who had finished treatment more recently reported greater healthcare use. Future research is needed to determine whether the healthcare accessed by adolescent and young adult cancer survivors is appropriate and meets their needs.

Abstract

Healthcare use (HCU) during survivorship can mitigate adolescent and young adult (AYA) cancer survivors’ (aged 15–39 years) risk of medical and psychosocial late effects, but this is understudied. We surveyed 93 Australian AYA post-treatment cancer survivors (M_age = 22.0 years, SD = 3.5; 55.9% female) and a comparison sample of 183 non-matched AYAs (M_age = 19.7, SD = 3.2; 70.5% female) on their HCU, medication use, depression/anxiety, and general functioning. Relative to our comparison AYAs, a higher proportion of our survivor group reported medical HCU (community-delivered: 65.6% versus 47.0%, p = 0.003; hospital-delivered: 31.2% versus 20.3%, p = 0.044) and mental HCU (53.8% vs. 23.5%; p < 0.0001) in the past six months. A higher proportion of our survivors reported taking medications within the past six months than our comparison AYAs (61.3% vs. 42.1%, p = 0.003) and taking more types (p < 0.001). Vitamin/supplement use was most common followed by psychotropic medications. Our survivor group reported lower depression (p = 0.001) and anxiety symptoms (p = 0.003), but similar work/study participation (p = 0.767) to our comparison AYAs. Across groups, psychological distress was associated with higher mental HCU (p = 0.001). Among survivors, those who were female, diagnosed with brain/solid tumors and who had finished treatment more recently reported greater HCU. Future research should establish whether this level of HCU meets AYAs’ survivorship needs.

Determinants of social functioning among adolescents and young adults with cancer: A systematic review

OBJECTIVES

Survivors of adolescent and young adult (AYA) cancer report deficits in social functioning relative to healthy peers. Identifying factors related to their social functioning is critical to improve their long-term social outcomes. This review addressed: (1) How is social functioning defined and measured among studies of AYAs who have had cancer? (2) What factors have quantitatively/qualitatively are associated with/predictors of social functioning? and (3) What associated factors/predictors of social functioning are modifiable and amenable to intervention?

METHODS

A systematic review was conducted to identify publications from 2000 to 2021, meeting these criteria: (1) mean/median age at diagnosis/treatment 13-40, (2) assessed social functioning with a validated measure and included factors associated with/predictive of social functioning and/or qualitatively assessed young people's perceptions of factors related to their social functioning and (3) was peer-reviewed/published in English.

RESULTS

Thirty-seven publications were included. Definitions and measures of social functioning varied, and factors related to social functioning varied based on definition. Factors most commonly associated with decreased social functioning included treatment status (receiving or completed treatment), poor physical functioning, depression, negative body image, engaging in social comparisons, social/cultural stigma around cancer, and fatigue. Increased social functioning was most commonly associated with social support and the quality/age-appropriateness of care.

CONCLUSIONS

Social functioning is multidimensional construct for AYAs diagnosed with cancer and may not be adequately assessed with measures of adjustment or quality of life. Future studies should clarify how to optimally define and measure social functioning in this population, to ensure their functioning can be protected and promoted long-term.

A qualitative investigation assessing whether implementing a Teenage Young Adult information evening, within a radiotherapy department, would improve the information support and treatment pathway for 18-24-year-old cancer patients

INTRODUCTION

This study evaluated the current information services provided to 10 Teenage Young Adult (TYA) oncology patients within a single radiotherapy department through retrospective patient views. Additionally, the participants provided valuable perspectives on the aptness and merit of implementing a dedicated information evening within the radiotherapy department.

METHODS

Focus group sessions and open-ended questionnaires were used as the primary data collection tools for this study, producing rich and informative data. The transcriptions from the focus groups, along with the questionnaire responses were then analysed using coding techniques, resulting in 6 distinct themes.

RESULTS

The participants felt they received adequate information about their radiotherapy treatment and its side effects. However, participants did report some gaps within the service provision that need to be addressed to improve treatment pathways in future. Furthermore, the information was always supplied in paper format which was often undesirable to the cohort with a more interactive format preferred. The participants disclosed very strong feelings of being different to "usual cancer patients" and displayed a desire for more opportunities to meet other TYA patients to be provided within their pathway.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The findings of this study suggest that the implementation of a dedicated TYA open evening would improve the information support and treatment pathway for 18-24-year-old cancer patients. The evening could offer a wanted opportunity where TYA patients could meet each other and additionally, treatment information and age appropriate support information could be provided in a different and more suitable format than current paper-based literature.

A scoping review of literature: What has been studied about adolescents and young adults (AYAs) with cancer?

PURPOSE

To map, organize and analyze the articles published in the last five years about AYAs with cancer.

METHODS

CAPES database and Google Scholar were searched to identify relevant studies from 2015 to February 2020. Eligible articles included empirical or theoretical research, quantitative and/or qualitative studies, targeted AYAs with cancer, addressed different topics related to AYAs such as unmet needs, hospital challenges, interventions or tools based on evidence, as well as political and socioeconomic aspects.

RESULTS

Of the 161 articles analyzed, 74 (46%) discussed the health system, including hospital dynamics, treatment and interventions during treatment; 63 (39.1%) discussed aspects or interventions that influence the quality of life and mental health of AYAs with cancer; 14 (8.7%) discussed issues related to sexual health; and 10 (6.2%) addressed social, economic and demographic problems of AYAs with cancer. Three types of purposes have been identified in the articles: 118 (73.3%) investigated variables in areas related to AYAs with cancer, aiming to increase the understanding of the phenomenon and the needs of AYAs; 18 (11.2%) intervened on the needs of AYAs with cancer through pilot studies or evidence-based interventions; and 22 (13.7%) aimed to evaluate an intervention previously performed or to evaluate an intervention based on evidence.

CONCLUSION

There is still much to be researched within the last two categories. In the last three years, these categories have been growing gradually and on a small scale.

Identification of Evidence for Key Positive Psychological Constructs in Pediatric and Adolescent/Young Adult Patients with Cancer: A Scoping Review

Introduction: Children and adolescents/young adults (AYAs) with cancer are a vulnerable population susceptible to numerous late effects, such as fatigue and depression, which may diminish their long-term psychological, physical, spiritual, and emotional health. A well-rounded understanding of how positive psychological constructs affect the quality of care and treatment outcomes is therefore warranted.

Methods: We conducted a scoping review of 15 positive psychological constructs in children and AYAs with cancer. The primary research questions were (1) what is known about positive psychological constructs in children and AYAs with cancer; (2) what value is ascribed to these constructs by patients?

Results: Two hundred seventy-six articles were included after database search and screening. These studies were mostly observational or qualitative and conducted in North America. Constructs were often poorly defined, and measurement tools used to gather data were wide ranging. Numerous factors were correlated with increased or decreased expression of certain constructs, but overall themes were difficult to identify. Similarly, patients often spoke of what increased or decreased expression of a construct, with less emphasis on what they implicitly value.

Discussion: This scoping review found ample evidence for what increases or decreases expression of positive psychological constructs, but this evidence was observational and often conflicting. In the future, we recommend the development of a core set of psychological outcomes, with definitions and corresponding measurement tools. We further recommend an emphasis on randomized trials to more rigorously study how expression of constructs can be improved and what effect this has on the quality of life.

Quantifying the psychosocial impact of a weekend retreat on adolescent and young adult (AYA) oncology patients

OBJECTIVE

This study aimed to determine if AYA oncology patients experienced a quantifiable improvement in psychosocial outcomes after attending a weekend retreat with their peers.

METHODS

AYA oncology patients attended a weekend retreat. They completed the Functional Assessment of Cancer Therapy - General (FACT-G) before, 1 month after, and 6 months after the weekend retreat. Controls were age-matched oncology patients who did not attend the retreat.

FINDINGS

Retreat participants' scores did not significantly change over time; however, retreat participants' scores at 1-month follow-up were significantly higher than control group scores.

CONCLUSIONS

AYA oncology patients may experience transient improvement in psychological well-being after attending a retreat, but benefits may not be durable. Work remains needed to examine the impact of retreat attendance on specific aspects of psychosocial well-being. Implications for psychosocial oncology: Work is needed to decrease perceived attendance barriers for AYA oncology patients who have a low quality of life. Future retreat planners may consider modifying retreat activities and consider alternative retreat locations that appeal to campers with limited mobility, chronic pain, and/or other quality of life limitations. Additional study is needed to determine whether brief overnight or weekend retreats can be as effective as week-long camps in enhancing oncology patients' quality of life. Future researchers should compare changes in weekend retreat attendees' quality of life to changes in quality of life for a control group (e.g., via a waitlist control study design).

Adolescent and young adult oncology-past, present, and future

There are nearly 70,000 new cancer diagnoses made annually in adolescents and young adults (AYAs) in the United States. Historically, AYA patients with cancer, aged 15 to 39 years, have not shown the same improved survival as older or younger cohorts. This article reviews the contemporary cancer incidence and survival data through 2015 for the AYA patient population based on the National Cancer Institute's Surveillance, Epidemiology, and End Results registry program and the North American Association of Central Cancer Registries. Mortality data through 2016 from the Centers for Disease Control and Prevention's National Center for Health Statistics are also described. Encouragingly, absolute and relative increases in 5-year survival for AYA cancers have paralleled those of childhood cancers since the year 2000. There has been increasing attention to these vulnerable patients and improved partnerships and collaboration between adult and pediatric oncology; however, obstacles to the care of this population still occur at multiple levels. These vulnerabilities fall into 3 significant categories: research efforts and trial enrollment directed toward AYA malignancies, access to care and insurance coverage, and AYA-specific psychosocial support. It is critical for providers and health care delivery systems to recognize that the AYA population remains vulnerable to provider and societal complacency.

Fertility preservation in oncology patients: A literature review examining current fertility preservation techniques and access to oncofertility services in Australia

BACKGROUND

In Australia, between the years 2010 and 2014, over 4500 adolescents and young adults (15-25 years old) were diagnosed with cancer. Treatment regimens are often gonadotoxic and are well known to induce ovarian and testicular failure. Oncofertility is an emerging discipline in obstetrics and gynaecology which seeks to preserve and restore the reproductive future of cancer patients.

AIM

To perform a systematic literature review to assess the current fertility preservation techniques available to patients and examine access and uptake of fertility preservation in Australia.

MATERIALS AND METHODS

Electronic databases, including Medline, Cochrane Review, SCOPUS and CINHAL, were searched for peer-reviewed publications and national guidelines examining oncofertility practices from 2008 to July 2018. Three hundred and seventy-five articles were initially screened, with 158 articles for full text review and an additional five clinical guidelines were identified.

RESULTS

There is a paucity of Australian data on oncofertility with <50% of data included for analysis reflecting the Australian experience. The majority of primary research included retrospective papers with small cohort numbers. Key areas addressed included live birth outcomes, uptake of services and patient and physician perspectives on fertility preservation. Few articles sought to examine the positive and negative side effects of fertility preservation in oncology, social challenges of oncofertility and access to services worldwide.

CONCLUSION

Oncofertility is an emerging discipline which seeks to provide safe, efficient and effective fertility preservation options for young adults and adolescents diagnosed with cancer. A multi-disciplinary approach with collaborative communication with oncologists is key to providing this service within Australia.

Health-Related Quality of Life of Adolescents with Cancer During the First Year of Treatment

Purpose: Adolescents with cancer (aged 12-18 years) are at risk for impaired health-related quality of life (HRQoL). Little is known about this population during treatment. This study aimed to (1) determine the HRQoL of adolescents with cancer during the first year of treatment and compare them with age-matched peers and (2) obtain insight into cancer-specific HRQoL of adolescents during the first year of treatment. Methods: Participants were part of a larger study focused on routine monitoring of electronic reported outcomes in standard pediatric oncology care. Adolescents completed the pediatric quality of life inventory (PedsQL) 4.0 and the PedsQL Cancer Module 3.0. Mean generic HRQoL scale scores were compared between the groups using multivariate analysis of covariance. Cancer-specific item scores were dichotomized and percentages were calculated to determine the proportion of adolescents reporting presence or absence of problems. Results: A total of 73 (mean [M]_age  = 14.71, standard deviation [SD] = 1.85) adolescents with cancer (M_age = 14.71, SD = 1.85, M_{timesincediagnosis} = 3.51 months, SD = 2.8) and 268 healthy peers (M_age = 14.23, SD = 1.51) participated. Adolescents with cancer reported significantly lower generic HRQoL scores on all domains than their peers (p's <0.05, η² = 0.01-0.42). Most frequently reported cancer-specific HRQoL problems were pain (hurt joint/muscle, 42.9%), nausea (during medical treatments [47.1%]; food not tasting good [54.3%]; food and smells [61.4%]), worry (about relapse [45.7%]; about side effects [52.9%]), cognitive problems (paying attention [47.1%]), and physical appearance (not good looking [47.1%]). Conclusions: Adolescents with cancer showed impaired HRQoL during treatment on both physical and psychosocial domains. Close monitoring of physical and psychosocial symptoms during treatment is, therefore, important.

Understanding survivors' needs and outcomes: the role of routinely collected data

PURPOSE OF REVIEW

The number of cancer survivors is growing due to population ageing, earlier detection and more effective therapies. Routinely collected data (RCD), generally cancer registry data, has been used to investigate survivors' needs and outcomes. We reviewed uses of RCD since 2017, identifying novel findings and research directions.

RECENT FINDINGS

Survival is improving internationally but continues to vary between subgroups. Longitudinal survivor surveys suggest malignancy-specific temporal patterns in unmet needs and health-related quality-of-life (HRQoL). Unmet needs are a risk factor for future depression and depression predicts poorer HRQoL in all domains. Emerging evidence suggests links between posttraumatic stress and poor HRQoL and posttraumatic growth and improved HRQoL. Evidence for a link between cancer-related financial hardship and poor HRQoL is accumulating. Surveys and linkage studies continue to show poorer work outcomes in survivors. Among survivors of childhood and young adult cancers, large linkage studies demonstrate significant risk of late effects, including hospitalization, pregnancy and labour complications, and cardiac death.

SUMMARY

RCD plays a significant role in understanding survivors' needs and outcomes. New approaches which overlay different types of data - including detailed clinical and treatment data, biomarker data and nonhealth administrative data - have the potential to generate considerable new knowledge.

Clinical management of Australian adolescents and young adults with acute lymphoblastic and myeloid leukemias: A national population-based study

BACKGROUND

While several studies have examined the treatment of adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL), studies of acute myeloid leukemia (AML) are rare. Using national data for Australia, we describe (i) the number and type of treatment centers caring for AYAs, (ii) induction/first-line treatments, and (iii) survival outcomes.

PROCEDURE

National population-based study assessing treatment of 15- to 24-year-olds diagnosed with ALL or AML between 2007 and 2012. Treatment details were abstracted from hospital medical records. Treatment centers were classified as pediatric or adult (adult AYA-focused or other adult; and by AYA volume [high/low]). Cox proportional hazard regression analyses examined associations between treatment and overall, event-free, and relapse-free survival outcomes.

RESULTS

Forty-seven hospitals delivered induction therapy to 351 patients (181 ALL and 170 AML), with 74 (21%) treated at pediatric centers; 70% of hospitals treated less than two AYA leukemia patients per year. Regardless of treatment center, 82% of ALL patients were on pediatric protocols. For AML, pediatric protocols were not used in adult centers, with adult centers using a non-COG 7+3-type induction protocol (51%, where COG is Cooperative Oncology Group) or an ICE-type protocol (39%, where ICE is idarubicin, cytarabine, etoposide). Exploratory analyses suggested that for both ALL and AML, AYAs selected for adult protocols have worse overall, event-free, and relapse-free survival outcomes.

CONCLUSIONS

Pediatric protocols were commonly used for ALL patients regardless of where they are treated, indicating rapid assimilation of recent evidence by Australian hematologists. For AML, pediatric protocols were only used at pediatric centers. Further investigation is warranted to determine the optimal treatment approach for AYA AML patients.

Psychosocial Assessment Using Telehealth in Adolescents and Young Adults With Cancer: A Partially Randomized Patient Preference Pilot Study

BACKGROUND

Adolescent and young adults with cancer are at increased risk of psychosocial difficulties relative to their healthy peers. Current models of inpatient face-to-face psychosocial care might limit the capacity for clinicians to provide timely and personalized assessment and intervention for this group. Telehealth offers a promising alternative toward increasing access to the provision of evidence-based psychosocial assessment and treatment for adolescent and young adults with cancer.

OBJECTIVE

This pilot study aimed to assess the feasibility and acceptability for both patients and clinicians of providing a psychosocial assessment via telehealth to adolescents and young adults currently receiving treatment for cancer, relative to face-to-face delivery.

METHODS

We included patients who were aged 15-25 years, currently receiving treatment, could speak English well, and medically stable. Patients were recruited from oncology clinics or wards from 5 hospitals located across Sydney and Canberra, Australia, and allocated them to receive psychosocial assessment (Adolescent and Young Adult Oncology Psychosocial Assessment Measure) with a clinical psychologist or social worker through face-to-face or telehealth modalities using a partially randomized patient preference model. Patients completed a pre- and postassessment questionnaire comprising validated and purposely designed feasibility and acceptability indices, including the impact of technical difficulties, if patients had their own devices; number of patients who were content with their group allocation; self-reported preference of modality; Treatment Credibility and Expectations Questionnaire; and Working Alliance Inventory. Clinicians also completed a postassessment questionnaire rating their impressions of the acceptability and feasibility of intervention delivery by each modality.

RESULTS

Of 29 patients approached, 23 consented to participate (response rate: 79%). Participants were partially randomized to either telehealth (8/23, 35%; mean age 16.50 years, range 15-23 years; females: 4/8, 50%) or face-to-face (11/23, 62%; mean age 17 years, range 15-22 years; females: 8/11, 72%) conditions. Four participants withdrew consent because of logistical or medical complications (attrition rate: 17.4%). Most participants (6/8, 75%) in the telehealth group used their computer or iPad (2 were provided with an iPad), with minor technical difficulties occurring in 3 of 8 (37.5%) assessments. Participants in both groups rated high working alliance (Working Alliance Inventory; median patient response in the telehealth group, 74, range 59-84 and face-to-face group, 63, range 51-84) and reported positive beliefs regarding the credibility and expectations of their treatment group. Postassessment preferences between face-to-face or telehealth modalities varied. Most patients in the telehealth group (5/8, 63%) reported no preference, whereas 6 of 11 (55%) in the face-to-face group reported a preference for the face-to-face modality.

CONCLUSIONS

Telehealth is acceptable as patient comfort was comparable across modalities, with no significant technological barriers experienced. However, patients varied in their preferred interview modality, highlighting the need to tailor the treatment to patient preference and circumstances.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614001142628; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366609 (Archived by WebCite at http://www.webcitation.org/721889HpE).