Psychosocial outcomes and service use among young adults with cancer

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.

Prevalence and risk of psychological distress, anxiety and depression in adolescent and young adult (AYA) cancer survivors: A systematic review and meta-analysis

BACKGROUND

Adolescent and young adult (AYA) cancer survivors (CS) face unique psychosocial challenges, which may affect their mental health. However, there are inconsistencies in AYA definitions and varying prevalence data on psychological distress, anxiety, and depression. We aimed to synthesize published literature on prevalence, risk, longitudinal changes, and predictors for these outcomes and estimate pooled prevalences.

METHODS

We searched for observational studies published in English before June 1 2022, in PubMed, PsycINFO, Scopus, and Web of Science. Two researchers extracted independently information on study characteristics, prevalence, and risk. The pooled prevalence (PP) of psychological distress, anxiety, and depression was estimated using random-effects models. Geographical region, treatment status, and assessment instruments were considered in stratified meta-analyses.

RESULTS

Sixty-eight studies were included in the systematic review and 57 in the meta-analyses. We estimated an overall prevalence of 32% (n = 30; 4226/15,213 AYAs; 95% CI, 23%-42%; I2  = 99%) for psychological distress, 29% for anxiety (n = 24; 2828/8751 AYAs; 95% CI, 23%-36%; I2  = 98%), and 24% (n = 35; 3428/16,638 AYAs; 95% CI, 18%-31%; I2  = 98%) for depression. The range of PP of psychological distress varied across geographical regions, treatment status, and assessment instruments. The PP of anxiety varied significantly across continents, while no variations were seen for depression. Studies found higher risks for psychological distress, anxiety, and depression in AYAs compared to older cancer survivors or cancer-free peers.

CONCLUSIONS

Our research found that one in three AYA-CS experience psychological distress or anxiety and one in four are affected by depression, highlighting the need for specialized psychological services for AYA-CS in oncology settings and AYA-focused interventions.

Health-related quality of life in adolescents and young adults with and without cancer, using propensity score matching

PURPOSE

To assess health-related quality of life (HRQOL) among adolescents and young adults (AYAs) with and without cancer, using Andersen's behavioral model of health services use.

METHODS

We used a cross-sectional, matched case-control design; data were from the Texas Behavioral Risk Factor Surveillance System for 2015-2019. AYAs aged between 18 and 39 years and with cancer were matched to controls using propensity score matching to control for predisposing and enabling factors. Chi-square tests were used to compare differences in need for care, health practices, and health services utilization between AYAs with cancer and controls without cancer. Multiple logistic regression models were used to compare HRQOL outcomes.

RESULTS

The final study sample consisted of 276 AYAs diagnosed with cancer and 828 controls after propensity score matching. The AYAs with cancer were more likely to have chronic comorbidities, smoke, and avoid health services utilization because of cost in comparison with the matched controls. Multiple logistic regressions showed significant differences in HRQOL between AYAs with cancer and controls: AYAs with cancer were more likely to have worse general health (OR = 2.488; 95% CI, 1.305-4.741) and worse perceived cognitive function (OR = 2.070; 95% CI, 1.076-3.919).

CONCLUSION

AYAs with cancer experience more chronic comorbidities, smoking, financial barriers to health service, and worse HRQOL than do AYAs without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Age-appropriate tailored surveillance and survivorship supports/resources are needed for AYAs with cancer.

The Needs of Adolescents and Young Adults with Chronic Illness: Results of a Quality Improvement Survey

Adolescent and young adults (AYAs) with chronic illnesses cope with complex issues that require unique psychological support and healthcare services to reduce psychosocial difficulties, improve disease management, and facilitate positive transitions to adult care. Engaging patients and caregivers can help providers understand the specific needs of this population and identify the perceived areas of support. The purpose of this quality improvement initiative is to assess the needs of AYAs with chronic medical conditions at a large government research hospital. Eighty-nine AYA patients (age = 23.5 years; range 13–34) with neurofibromatosis type 1, cancer, primary immunodeficiencies, or sickle cell disease, and a sample of caregivers (n = 37, age = 52 years; range: 41–65), completed an anonymized survey that assessed their preferences for a wide range of informational and service-related needs. The results indicate an overwhelming desire for information about general health and wellbeing and disease-specific medical knowledge. The most endorsed item was the need for more information about an individual’s medical condition (72%), which was a primary concern across disease, racial, and gender groups. Demographic and disease-specific needs were also identified. Thus, providing information to AYA patients and caregivers is a critical and largely unmet component of care, which requires the development and implementation of targeted educational and psychosocial interventions.

Interprofessional spiritual care education in pediatric hematology-oncology: A pilot study

BACKGROUND

Evidence and clinical guidelines call care team members to address the spiritual well-being of pediatric patients, especially adolescents and young adults (AYA), with cancer and blood disorders. However, the lack of relevant training in generalist spiritual care has been a key barrier. Therefore, we aimed to improve clinicians' capabilities by utilizing the Interprofessional Spiritual Care Education Curriculum (ISPEC) to close this gap in pediatric hematology-oncology. A model of interprofessional spiritual care entails that all team members attend to patients' spirituality by employing generalist spiritual care skills and collaborating with spiritual care specialists such as chaplains.

METHODS

Interdisciplinary team members providing care for AYA with cancer and blood disorders were recruited to participate in interprofessional spiritual care education. Our intervention combined an evidence-based online curriculum and in-person discussion groups. Pretest-posttest study examined changes in participants' skills and practices to identify, address, and discuss spiritual concerns. Surveys were conducted at baseline and at 1, 3, and 6 months after the intervention.

RESULTS

Participants (n = 21) included physicians, advanced practice providers, nurse coordinators, and psychosocial team members. We observed positive changes in participants' ability (36%, P < 0.01), frequency (56%, P = 0.01), confidence (32%, P < 0.01), and comfort (31%, P = 0.02) providing generalist spiritual care baseline versus one month, with significant gains maintained through six months (Omnibus P < 0.05).

CONCLUSIONS

Utilizing ISPEC, interprofessional spiritual care education has a strong potential to develop pediatric hematology-oncology team members' capabilities to attend to the spiritual aspect of whole-person care and thus contribute to the well-being of AYA with cancer and blood disorders.

Psychosocial and Biological Outcomes of Immersive, Mindfulness-Based Treks in Nature for Groups of Young Adults and Caregivers Affected by Cancer: Results from a Single Arm Program Evaluation from 2016-2021

The COVID-19 pandemic has left many individuals suffering from “connection deficit disorder” given changes to the way we work, go to school, socialize, and engage in daily activities. Young adults affected by cancer between the ages of 18–39 have known this connection deficit long before the pandemic. Being diagnosed and treated for cancer during this time can significantly disrupt engagement in important educational, career, social, and reproductive pursuits, and contribute to increased stress, anxiety, depression, and other negative outcomes. Experiencing meaningful connection—with nature, with peers who understand, and with oneself, may help assuage this adverse effect of disconnect. A single arm within-subjects program evaluation was conducted to examine outcomes following participation in immersive, multi-night, mindfulness-based treks in nature in a sample of young adults (n = 157) and caregivers (n = 50) affected by cancer from 2016–2021. Pre to post-trek changes included significant (p < 0.001) self-reported improvements in feeling connected to nature (d = 0.93–0.95), peers (d = 1.1–1.3), and oneself (d = 0.57–1.5); significant (p < 0.001) improvements on PROMIS Anxiety (d = 0.62–0.78), Depression (d = 0.87–0.89), and Sleep Disturbance (d = 0.37–0.48) short forms; and significant (p < 0.05) changes in pro-inflammatory biomarkers (d = 0.55–0.82). Connection-promoting experiences like this have the potential to improve health and wellbeing in this population and serve as a model for others.

Assessment of the Promoting Resilience in Stress Management Intervention for Adolescent and Young Adult Survivors of Cancer at 2 Years: Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Adolescents and young adults (AYAs) with cancer have a high risk of poor psychosocial outcomes. The Promoting Resilience in Stress Management (PRISM) intervention is one of few psychosocial interventions targeting younger people with cancer that has demonstrated efficacy in a randomized clinical trial.

OBJECTIVE

To explore 2-year trajectories of patient-reported well-being among AYA cancer survivors. The hypothesis was that AYAs who initially responded to PRISM would report sustained positive changes.

DESIGN, SETTING, AND PARTICIPANTS

This secondary analysis of data from a single-center, parallel, phase 2 randomized clinical trial was conducted from January 2015 to October 2016. Eligible participants were English-speaking AYAs between ages 13 and 25 years with cancer treated at a single, quaternary children's hospital in the US. Participants were randomly assigned (1:1) to PRISM or usual care. Data were analyzed between March 2021 and June 2021.

INTERVENTION

PRISM is a brief, skills-based coaching program targeting 4 resilience resources (stress management, goal setting, cognitive reframing, and meaning making).

MAIN OUTCOMES AND MEASURES

Patient-reported cancer-related quality of life (QoL) (PedsQL scale), hope (Hope scale), resilience (Connor-Davidson Resilience scale), and psychological distress (Kessler-6 scale) were collected at baseline, 6, 12, and 24 months. Data from AYAs who remained alive at 24 months were analyzed. Improvement was defined as a positive change in instrument scores between baseline and 6 months (ie, the end of the PRISM program) and used linear mixed effects regression to assess changes over time.

RESULTS

A total of 57 AYAs were included in analysis at 24 months (62% of 92 randomized). Twenty-six participants (46%) were female; 36 (63%) were between ages 13 and 17 years; and 20 (35%) identified as part of a racial or ethnic minority group (4 [7%] Asian, 11 [19%] Hispanic or Latino, 16 [28%] mixed race or other). PRISM was associated with improved QoL, hope, resilience, and distress between baseline and 6 months, and these associations were sustained for QoL over 12 months (β = 7.4; 95% CI, 0.8 to 14; P = .03) and hope throughout the study period (12 months: β = 6.2; 95% CI, 2.7 to 9.6; P < .001; 24 months: β = 4.6; 95% CI, 1 to 8.3; P = .01). Of those whose scores improved between baseline and 6 months, PRISM participants more commonly reported sustained improvements in QoL (16 of 21 participants [76%] vs 8 of 17 [47%]), hope (14 of 24 participants [58%] vs 6 of 14 [43%]), resilience (9 of 18 participants [50%] vs 4 of 14 [29%]), and distress (14 of 19 participants [74%] vs 6 of 19 [32%]) at 24 months compared with usual care.

CONCLUSIONS AND RELEVANCE

These results suggest that PRISM was associated with sustained improvements in psychosocial outcomes as reported by adolescents and young adults. Those who responded to PRISM in the first 6 months reported continued well-being 2 years later.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02340884.

Cancer survivorship care for young adults: a risk-stratified, multicenter randomized controlled trial to improve symptoms

PURPOSE

Young adult (YA) cancer survivors have high rates of adverse health and psychosocial outcomes. This risk-stratified, multicenter, randomized controlled trial (RCT) compared a self-management survivorship intervention to usual care in YA survivors with symptoms of cancer-related distress, insomnia, fatigue, pain, and/or depression.

METHODS

Eligibility included age 18-39 at diagnosis with an invasive malignancy in the previous 1-5 years. Baseline assessment determined "high need" participants, with 2-5 elevated targeted symptoms. We randomized high need participants to intervention or usual care and offered intervention participants a survivorship clinic visit, which included mutually decided action plans for symptoms. Follow-up calls at 1 and 3 months after the clinic visit reviewed action plan progress. Outcomes compared rates of improved symptoms for intervention vs usual care at 6 months and 12 months.

RESULTS

N = 344 completed baseline assessment, with n = 147 (43%) categorized as high need and randomized. Of n = 73 randomized to the intervention, n = 42 (58%) did not attend their survivorship clinic visit. In intent-to-treat analyses, aggregate symptom scores did not differ between arms, though distress improved for 46% in the intervention arm at 6 months compared to 18% in usual care (p = 0.03) among those with elevated distress at baseline.

CONCLUSIONS

Distress improved for YAs who received self-management survivorship care. However, the study demonstrates a need for alternative strategies for providing YA survivorship care.

TRIAL REGISTRATION

NCT02192333 IMPLICATIONS FOR CANCER SURVIVORS: While YA survivors demonstrate some improved distress when provided survivorship care, to make care accessible and effective, they require options such as remote delivery of care.

The Needs and Care Experiences of Adolescents and Young Adults Treated for Cancer in Adult Surgery Clinics: A Qualitative Study

Purpose: Adolescents and young adults (AYAs) with cancer hospitalized in adult surgery clinics are an overlooked group of patients. They are a minority hospitalized among elderly surgical patients, and the surroundings and care are designed with older patients in mind. A growing body of research focuses on AYAs' experiences of cancer care. However, studies exploring care experiences in terms of in-patient surgery treatment are still needed. Hence, the purpose of the study was to explore the needs and care experiences of AYAs, 15-29 years of age, treated for cancer in adult surgery clinics. Methods: This qualitative study was based on semistructured interviews with 15 AYAs with cancer from seven surgery clinics at Rigshospitalet, Copenhagen University Hospital, Denmark. Data were analyzed and interpreted using inductive content analysis. The Danish Data Protection Agency approved the study (project no.: 05617). Results: Three themes were identified: (1) being the black sheep - experiences of being young in an adult environment, (2) the significant nurse - experiences of the essential relationship between AYAs and the nurses, and (3) the wounded body - experiences of how the physically changed body affects the mind. Conclusions: Our findings showed that the psychosocial needs of AYAs with cancer hospitalized in adult surgery clinics were not being adequately met. Initiatives are needed to improve the psychological and social well-being of this vulnerable patient group, while hospitalized for treatment in surgery clinics.

Promoting physical activity in young adult cancer survivors using mHealth and adaptive tailored feedback strategies: Design of the Improving Physical Activity after Cancer Treatment (IMPACT) randomized controlled trial

INTRODUCTION

Despite the health benefits of physical activity for cancer survivors, nearly 60% of young adult cancer survivors (YACS) are physically inactive. Few physical activity interventions have been designed specifically for YACS.

PURPOSE

To describe the rationale and design of the IMPACT (IMproving Physical Activity after Cancer Treatment) trial, which tests the efficacy of a theory-based, mobile physical activity intervention for YACS.

METHODS

A total of 280 physically inactive YACS (diagnosed at ages 18-39) will be randomized to a self-help control or intervention condition. All participants will receive an activity tracker and companion mobile app, cellular-enabled scale, individual videochat session, and access to a Facebook group. Intervention participants will also receive a 6-month mobile intervention based on social cognitive theory, which targets improvements in behavioral capability, self-regulation, self-efficacy, and social support, and incorporates self-regulation strategies and behavior change techniques. The program includes: behavioral lessons; adaptive goal-setting in response to individuals' changing activity patterns; tailored feedback based on objective data and self-report measures; tailored text messages; and Facebook prompts encouraging peer support. Assessments occur at baseline, 3, 6, and 12 months. The primary outcome is total physical activity min/week at 6 months (assessed via accelerometry); secondary outcomes include total physical activity at 12 months, sedentary behavior, weight, and psychosocial measures.

CONCLUSIONS

IMPACT uniquely focuses on physical activity in YACS using an automated tailored mHealth program. Study findings could result in a high-reach, physical activity intervention for YACS that has potential to be adopted on a larger scale and reduce cancer-related morbidity. ClinicalTrials.gov Identifier: NCT03569605.

Unmet supportive care needs and associated factors among young adult cancer patients in Japan

Background

Young adult cancer patients often face unique challenges and have potential unmet needs. This study aimed (1) to describe unmet supportive care needs among young adults with cancer in Japan, and (2) to identify its associated factors.

Methods

In a cross-sectional web-based survey, 206 young adults with cancer were assessed for supportive care needs. Multiple regression analysis examined whether demographics, clinical variables and social support were associated with unmet supportive care needs.

Results

A total of 206 patients (180 female) with a mean age of 33.7 years (SD = 4.3, range: 22–39) participated. One hundred and fifty-eight participants (76.7%) reported at least one unmet supportive care needs. The top 20 unmet needs included 9 of the 10 psychological needs, 3 of the 5 physical and daily living needs, 8 of the 11 health system and information needs and 1 of the 5 sexuality needs. Multiple regression analysis revealed that perceived poorer PS, experience of change in work/school after a cancer diagnosis and poor social support were significantly associated with higher supportive care needs. The total score of supportive care needs was significantly associated with both psychological distress and QOL.

Conclusions

More than 70% of young adult cancer patients reported unmet supportive care needs and most of those were psychological needs. The findings suggest potential opportunities for intervention in addressing psychological needs rather than physical and information needs.

A Narrative Literature Review and Environmental Scan of Self-management Education Programs for Adolescent and Young Adult Survivors of Childhood Cancer

Self-management education programs (SMEPs) have demonstrated a measurable benefit in enhancing self-efficacy, increasing health knowledge, and improving both health behaviors and physical symptoms associated with underlying conditions in multiple chronic disease populations. Adolescent and young adult (AYA) survivors of childhood cancer, defined as individuals ages 15 to 39 years, are at a high risk for adverse health outcomes due to late complications from previous cancer treatments, knowledge deficits of their risks, and complex socioeconomic challenges associated with transitional periods in their lives. We performed a literature review and environmental scan to systematically survey and interpret relevant SMEPs to identify opportunities for their development specific to the AYA population. Despite evidence existing for the importance of self-management and general educational messages for survivors of childhood cancer, very few evidence-based interventions have been developed for the AYA population. Most SMEPs for cancer survivors are geared towards individuals with cancer in adulthood. Among the limited interventions directed at survivors of childhood cancer, they are focused on individual health behaviors, such as physical exercise, mental health, nutrition, or self-efficacy. Given the ever-growing technological footprint in our daily lives, mobile health (mHealth) applications may be the most efficacious means of delivering self-management education to this specific population. As content is developed through mHealth applications as well as other platforms, they will need to be rigorously evaluated, given their potential to compliment survivor-focused care.

Peace of mind among adolescents and young adults with cancer

OBJECTIVE

Adolescents and young adults (AYAs) with cancer have high rates of psychological distress and unmet support needs. Peace of mind is an important construct among older cancer patients and parents of children with cancer but has not been explored in AYAs. We sought to evaluate the extent to which AYAs with cancer experience peace of mind and to identify factors associated with greater peace of mind.

METHODS

We surveyed 193 AYAs with cancer aged 15 to 29 years within 12 weeks of diagnosis; 137 patients completed the same measures again 4 and 12 months after diagnosis. Patients were asked to report peace of mind, measured using items from the Functional Assessment of Chronic Illness, Spiritual Well-being scale (FACIT-Sp); anxiety and depression, using the Hospital Anxiety and Depression Scale (HADS); and experiences surrounding medical communication and decision making.

RESULTS

Mean scores for peace of mind were 3.59 at diagnosis (range 1-5, standard deviation 0.84), with similar scores at 4 (3.53, P = .34) and 12 (3.59, P = .94) months. In a multivariable model adjusted for age and gender, patients who reported receiving high-quality information about their cancer had greater peace of mind at diagnosis (β = .25, P = .03), whereas those who reported holding a passive role in treatment decision making (β = -.47, P < .0001) or who had anxiety (β = -.64, P = .0003) or depression (β = -.51, P = .04) had lower peace of mind.

CONCLUSION

Peace of mind did not improve significantly over time for AYAs with cancer. While high-quality communication may be associated with heightened peace of mind, further study is needed to clarify relationships between peace of mind and other psychological variables.

Survivorship needs of adolescent and young adult cancer survivors: a concept mapping analysis

PURPOSE

Adolescents and young adults (AYAs) with cancer are known to have complex medical and psychosocial needs throughout treatment; however, information is lacking about the challenges AYA survivors face after treatment has ended. Focus groups were conducted using a concept mapping framework to better understand the most important issues these patients face in transitioning to survivorship and how prepared they felt to face them.

METHODS

AYAs diagnosed between 18 and 39 years old and at least 2 years post-treatment participated in one of six focus groups based on age group and follow-up status. Using a concept mapping design, participants provided important issues during the transition to survivorship and appraised them on three core areas of interest.

RESULTS

Analyses revealed salient themes shared across age and follow-up group status, particularly related to the psychosocial, emotional, and cognitive effects of treatment. Differential concerns included those related to patients' developmental concerns-namely, finding a new identity, financial burden of treatment, and fertility concerns after treatment.

CONCLUSIONS

AYA cancer survivors continue to have a myriad of issues beyond the immediate treatment phase. Despite a complex list of challenges, these issues largely remained unaddressed by their oncology provider and left patients feeling overwhelmingly ill-prepared to manage their transition to survivorship.

IMPLICATIONS FOR CANCER SURVIVORS

AYA cancer survivors have many unaddressed concerns as they transition out of active cancer treatment, largely related to developmental issues they are facing. Survivorship care for these patients would benefit from care planning that takes these unique concerns into account.

Long-term complications in adolescent and young adult leukemia survivors

Adolescents and young adults (AYAs) with cancer, defined by the National Cancer Institute as having been diagnosed between the ages of 15 and 39 years old, have not benefited from the same improvements in quality of outcomes and survival that have been seen for individuals diagnosed in childhood or as older adults. Although is leukemia composed of a diverse group of diagnoses, leukemia AYA survivors share unique vulnerabilities with other AYA diagnostic groups. They will spend the majority of their lives as survivors, with clear evidence of adverse medical conditions, health care requirements, and social and psychological needs that differ not only from their peers but also, from the needs of other cancer survivor populations. Furthermore, they share a developmental stage of life in which careers, finances, and family concerns are uniquely impacted by the cancer diagnosis and treatment. Leukemia in AYAs typically presents with higher-risk biologic features, and treatment requires multiagent chemotherapy, including alkylating agents, anthracyclines, high-dose steroids, frequently intrathecal chemotherapy, and sometimes, cranial radiation. Thus, AYAs have significant risks for long-term complications, subsequent malignancies, and accelerated development of usual age-related comorbid conditions, such as cardiovascular disease and dyslipidemias. AYAs require specialized health care monitoring, surveillance for late effects, and periodic evaluation of psychosocial, health behavior, and life goal outcomes.

Through our eyes: A photovoice intervention for adolescents on active cancer treatment

RESEARCH APPROACH

Photovoice, a participatory action research methodology, is a novel and promising intervention for adolescents with cancer. Photovoice was used as an intervention for eliciting and addressing the psychosocial needs of adolescents on active cancer treatment.

PARTICIPANTS

Six adolescents, aged thirteen to seventeen years old, who were on active treatment or had completed treatment in the three months prior to recruitment participated in a seven-week photovoice group that took place from March to May 2017. Methodological Approach: Each of the seven sessions was recorded and later transcribed. A content analysis was used to identify themes that were analyzed using an integrated framework developed earlier. The framework broadly categorized the themes into six domains: (i) physical changes, (ii) psychosocial impacts, (iii) short-term social impacts, (iv) long-term social impacts, (v) impacts on holistic well-being, and (vi) informational needs.

INTERPRETATION

Photovoice is an effective intervention for eliciting and addressing the psychosocial needs of adolescents on active cancer treatment.

"When I Needed It": Evaluation of the Use and Timing of Sharsheret's Thriving Again Program for Young Breast Cancer Survivors

Approximately 11% of all new breast cancer cases in the USA occur in women aged 45 years or younger. In 2011, CDC funded seven organizations to develop or enhance programs for young breast cancer survivors (YBCS). This paper analyzed program evaluation data collected by one of these organizations to gain a more nuanced understanding of how recipients used the newly developed program and resources for YBCS. Sharsheret's Thriving Again program was evaluated through a web-based survey of survivorship program participants. The evaluation asked questions about participant demographics, use of the kit's survivorship care plan (SCP), satisfaction with the timing of survivorship kit receipt, and factors related to survivors' use of additional Sharsheret programs. We conducted bivariate analyses of survey responses and calculated chi-square statistics for significance testing. Of the 163 women who responded to the survey, 43% were diagnosed with breast cancer at or before age 45 and 69% were of Jewish descent. The majority of women who used the SCP found it helpful to facilitate cancer treatment (94%), follow-up (85%), or discussions with providers (91%). A total of 75% of women who received the SCP kit while either recently diagnosed or undergoing treatment were satisfied with the timing of receipt. Survey respondents found the Thriving Again program and survivorship kit beneficial and indicated timing preferences for when to receive resources and support. Supporting the self-efficacy of cancer survivors may improve survivors' quality of life and is an important aspect of survivorship programs.

Adult self-image and well-being after testicular cancer: The role of agency and meaning

OBJECTIVE

Cancer during young adulthood can limit the extent to which one adopts an adult self-image. However, the relationship of adult self-image to cancer-related adjustment remains unexplored. The current study examines relationships of adult self-image and social/emotional well-being and job-related problems in young testicular cancer survivors. Factors thought to facilitate future-oriented goals (i.e. agency and meaning) are examined as intermediary processes.

DESIGN

Testicular cancer survivors (N = 171) between the ages of 18 and 29 completed questionnaire measures of adult self-image, agency, sense of meaning and indicators of adjustment.

MAIN OUTCOME MEASURES

Social and emotional well-being were measured by the Functional Assessment of Cancer Therapy-General. Job problems were assessed using the EORTC's testicular cancer supplement (EORTC QLQ-TC26).

RESULTS

Path model results revealed direct associations of survivors' adult self-image with social (β = .20, p < .05), but not emotional well-being (β = .14, p < .01). Both agency and meaning mediated the relationship of adult self-image and well-being indicators. Finally, the relationship between adult self-image and job problems was only significant for those who were employed or in school (β = -.19, p < .05).

OUTCOMES

Assessment of adult self-image might be useful in identifying risk for poor adjustment. Interventions that target agency and meaning might facilitate developmental goals.

Spending on Hospital Care and Pediatric Psychology Service Use Among Adolescents and Young Adults With Cancer

Objective

To examine the relationship between need-based pediatric psychology service use and spending on hospital care among adolescents and young adults (AYAs) with cancer.

Methods

Billing data were obtained from 48 AYAs with cancer receiving need-based pediatric psychology services and a comparison cohort of 48 AYAs with cancer not receiving services. A factorial analysis of covariance examined group differences in spending for hospital care. Pending significant findings, a multivariate analysis of covariance was planned to examine the relationship between need-based pediatric psychology service use and spending for inpatient admissions, emergency department (ED) visits, and outpatient visits.

Results

Spending for hospital care was higher among AYAs receiving need-based pediatric psychology services than in the comparison cohort (p < .001, ωPartial2 = .11). Group differences were driven by significantly higher spending for inpatient admissions and ED visits among AYAs receiving need-based pediatric psychology services.

Conclusions

The behavioral and psychosocial difficulties warranting need-based pediatric psychology services may predict higher health care spending.

Survivorship Care Planning for Young Adults After Cancer Treatment: Understanding Care Patterns and Patient-Reported Outcomes

PURPOSE

Young adult survivors (YAS) of cancer experience late effects of treatment similar to older adult survivors (AS). Online health tools such as Internet-based survivorship care plans (SCPs) can provide access to information about late effects and symptom management, but little is known about SCP patterns of use among YAS.

METHODS

An Internet-based cross-sectional survey was completed over 24 months. Participants were individuals diagnosed with cancer between 18 and 39 years (YAS, n = 611) or 40-60 years (AS, n = 1742), who were 2-20 years postdiagnosis, and who created an Internet-based SCP. Demographics, treatment-related variables, satisfaction with SCP, communication of SCP, and patient-reported late effects (fatigue, neurocognitive, sexual, cardiovascular, pulmonary, or second cancers) were collected.

RESULTS

YAS were primarily female (71%), Caucasian (78%), college educated (65%), and generated the SCP without assistance (76%). YAS reported satisfaction with content (93%) and shared content with providers (71%). A higher proportion of YAS than AS were male (29% vs. 17%, p < 0.001), lived internationally (23% vs. 17%, p = 0.003), and endorsed oncologist-led survivorship care (47% vs. 41%, p = 0.001). YAS reported concerns about neurocognitive performance (56%) and fatigue (50%). Overall, YAS reported equivalent or fewer late effects than AS across all domains.

CONCLUSIONS

YAS report high satisfaction with the online SCP, as well as a high symptom burden, although the latter were reported less than for AS.

An exploratory study of social problems experienced by ambulatory cancer patients in Japan: Frequency and association with perceived need for help

OBJECTIVE

Little is known about the social problems experienced by cancer patients in non-Western countries. The aims of this study were (1) to explore the characteristics and frequencies of social problems in cancer outpatients, as well as their associations with the need for help, and (2) to take the initial steps to develop an instrument for the assessment of cancer-related social problems in Japan.

METHODS

A cross-sectional group of 109 patients completed the Social Problem Checklist and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. Participants rated the levels of the problem severity and the need for help on each item. Factor structure, internal consistency, and construct validity were also assessed.

RESULTS

In total, 72.5% of the participants encountered ≥1 problem, and 33% experienced ≥1 serious problem. The amount of help needed tended to be lower than problem severity, especially for family and social life issues. The most common reason for not needing help, as reported by approximately 40% of patients who experienced problems, was the preference for self-management. A 3-factor model was extracted that included financial matters, medical information, and family and social life. Excellent internal consistencies for each factor and convergent correlations between the relevant subscales of European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Social Problem Checklist were confirmed.

CONCLUSIONS

A substantial proportion of participants had cancer-related social problems, but they had ambivalent help-related needs. Interventions that enhance the patient's abilities for self-care could be essential to help cancer outpatients manage social problems in Japan.

The Experience of Adolescents and Young Adults Treated for Cancer in an Adult Setting: A Review of the Literature

The purpose of this review is to explore the literature on the experience of adolescents and young adults (AYAs) having cancer treatment in an adult setting, rather than on a specialist adolescent cancer unit. The integrative review method was used to explore the current literature. Primary research on the topic was located systematically and then synthesized into a thematic narrative. The experience of AYAs undergoing treatment in an adult setting was generally negative. This can be attributed to three themes: feeling isolated in the adult setting; the lack of empathy from staff working in the adult setting; and the inappropriateness of the adult environment for this age group. As many AYAs with cancer will continue to have treatment in adult settings, staff working in this environment should be aware of the negative experience of this cohort and the impact this can have on a vulnerable group of patients. Staff could consider simple ways of improving the AYA experience, such as connecting AYA patients with their peers to reduce isolation; adapting their approach to take account of the unique emotional needs of this age group; and considering ways of making the environment more welcoming and age-appropriate.

Masculine norms about emotionality and social constraints in young and older adult men with cancer

Beliefs that men should restrict their display of emotions, or restrictive emotionality, might contribute to adjustment to cancer and this might be sensitive to social receptivity to disclosure. The present research examined relationships of restrictive emotionality, social constraints, and psychological distress in young adults with testicular cancer (N = 171; Study 1) and older men with prostate cancer (N = 66; Study 2). Study 1: positive associations were observed for social constraints and restrictive emotionality with depressive symptoms. Social constraints moderated the relationship, such that high restrictive emotionality was associated with higher depressive symptoms in those with high constraints. Study 2: only social constraints (and not restrictive emotionality) was positively associated with depressive symptoms and cancer-related intrusive thoughts. The social constraints × restrictive emotionality interaction approached significance with depressive symptoms, such with high social constraints low restrictive emotionality was associated with higher depressive symptoms compared to those with less constraints. No significant associations were found for intrusive thoughts in either study. Findings demonstrate unique relationships with psychological distress across the lifespan of men with cancer given perception of constraints and adherence to masculine norms about emotionality.

Barriers to follow-up care among survivors of adolescent and young adult cancer

PURPOSE

Though the need for risk-based follow-up care for survivors of adolescent and young adult (AYA) cancer has been documented, survivors often report forgoing recommended care due to cost. We sought to understand whether additional barriers to follow-up care exist for AYA survivors.

METHODS

We recruited survivors who were diagnosed with cancer between the ages of 15 and 39 using the Utah Cancer Registry (UCR). Overall, 28 survivors participated in 6 focus groups held between March and May 2015 in Salt Lake City and St. George, UT. Focus group discussions focused on the reasons survivors may or may not attend recommended medical visits after completing therapy.

RESULTS

Survivors reported myriad barriers to follow-up medical visits, including lack of clear provider recommendation, fear of recurrent cancer diagnosis, wishing to move on with life, competing life responsibilities due to work and children, and not perceiving the need for a visit due to lack of symptoms.

CONCLUSIONS

Though cost likely plays a major part in follow-up care adherence for survivors of AYA cancer, in our focus groups, participants indicated there were many other psychosocial and logistic barriers to care. Such factors play an important role in the day-to-day lives of survivors and are critical in medical decision-making.

IMPLICATIONS FOR CANCER SURVIVORS

Several factors impede follow-up care adherence for survivors of AYA cancer that are amenable to interventions, including clearer provider recommendations, flexible appointment times, and childcare availability in clinics.

Non-oncology physician visits after diagnosis of cancer in adolescents and young adults

PURPOSE

Health care needs of adolescents and young adults (AYAs) with cancer are probably different from other age groups. Studying their non-oncology physician visits in the first years after diagnosis may provide insight into the specific health problems AYA patients experience and thereby help to improve care for these patients.

METHODS

Seven hundred seventy-four AYAs identified from a Canadian provincial registry diagnosed with cancer between ages 15 and 24 years in 1991/2001 were included, matched by birth year and sex to ten controls. Based on provincial health insurance plan records, we determined the number of family physician and non-cancer specialist visits in the 5 years after diagnosis (for patients) or inclusion (for controls).

RESULTS

The percentage of patients visiting a non-cancer specialist decreased from 96 to 49 % over the 5-year period. The percentage visiting a family physician decreased from 96 to 84 %. Visits in all years were significantly higher than among controls. In the first year after diagnosis, many patients visited a non-cancer specialist or a family physician for neoplasm-related health problems (77 and 55 %, respectively). In addition, family physicians were also consulted for general age-specific problems, such as genitourinary symptoms

CONCLUSIONS

In the first years after diagnosis of cancer in AYAs, both non-cancer specialist and family physician visits are common, although non-cancer specialist visits are less common and decline considerably faster than in younger children.

IMPLICATIONS FOR CANCER SURVIVORS

The specific pattern of physician visits of this age group calls for care that is tailored to their specific needs.

Exploring gender and identity issues among female adolescent and young adults who connect in an anonymous platform

There has been an increased usage of online cancer support groups as a resource for health-related information and social support. This work analyzes message blog posts from an anonymous online support community to better understand issues related to gender and identity among female adolescent and young adults. This work sheds further light into the nuances of gender and identity issues including motherhood and reproductive issues, physical appearance, and romantic relationships. Specifically, findings reveal that female adolescent and young adults experience issues pertaining to infertility, feeling like a bad mom, hair loss, scarring, dating, and intimacy. These findings of this work offer further guidance about how healthcare providers and caregivers can attempt to meet the needs of female adolescent and young adults.

Cancer-related information needs and cancer's impact on control over life influence health-related quality of life among adolescents and young adults with cancer

OBJECTIVE

Adolescents and young adults (AYAs) diagnosed with cancer between 15 and 39 years of age often report need for greater amounts of cancer-related information and perceive that cancer has had a negative impact on control over their life. We examined whether unmet information need and perceived control over life are associated with health-related quality of life (HRQOL).

METHODS

We examined data from 484 AYA cancer survivors recruited from population-based cancer registries in 2007-2008. Participants completed surveys a median of 11 months after diagnosis. Multivariable linear regression analyses estimated associations of unmet cancer-related information needs and impact of cancer on control over life on HRQOL (SF-12).

RESULTS

Two-thirds of AYAs reported an intermediate or high level of unmet information need, and half (47%) reported a negative impact of cancer on control. Greater unmet information need was associated with lower overall mental and physical HRQOL and lower levels of all HRQOL subscales except vitality. A negative impact on control over life was associated with lower overall mental HRQOL as well as lower HRQOL across all subscales except general health perceptions (all p <0.05). In multivariable analyses, perceived control and unmet information need were independently associated with HRQOL (p-values for interaction >0.1).

CONCLUSIONS

Adolescent and young adult patients with cancer have high levels of unmet cancer-related information needs and perceived negative impact of cancer on control over life; both were independently associated with lower HRQOL. Addressing unmet information needs among AYA cancer survivors and finding ways to increase their sense of control may help improve HRQOL in this understudied population.

Examining the perceived social support and psychological symptoms among adolescents with leukemia

PURPOSE

The purpose was to determine the perceived social support and psychological symptoms of adolescents with leukemia.

DESIGN AND METHODS

The sample consisted of 70 adolescents with leukemia. The Brief Symptom Inventory (BSI), Multidimensional Perceived Social Support Scale (MPSSS), and a demographical data form were used for data collection.

RESULTS

Scores of the Global Severity Index, Positive Symptom Distress Index (PSDI), and Positive Symptom Total (PST) of the BSI were higher than those of the healthy adolescents with the same age in other studies. There was a negative relationship between the MPSSS and negative self-image, depression, anxiety, PSDI, and PST of the BSI.

PRACTICE IMPLICATIONS

It would likely be beneficial to increase adolescents' perceived social support in order to decrease psychological symptoms.

Cancer-Related Disclosure Among Adolescent and Young Adult Cancer Survivors: A Qualitative Study

Purpose: Adolescents and young adults (AYAs) employ self-disclosure in normative social interactions and in promoting identity development. Disclosure is associated with numerous psychological and physical benefits. Little research has examined how AYA cancer survivors diagnosed during adolescence disclose their cancer history. Methods: Using a qualitative design, this study explored cancer-related disclosures among survivors (N=26) 16-24 years old at study (M=19.6 years), 14-18 years old at diagnosis (M=15.6 years), and currently at least 6 months post-treatment (M=3.2 years). Semi-structured interview guides were developed and used. Disclosure-related topics included survivorship communications and others' responses to AYAs' disclosure of their cancer experiences. Results: Grounded theory and thematic content analysis guided analyses, with an inductive data-driven approach. Three themes and eight subthemes emerged: "it depends" decision-making processes (don't ask/don't tell, shared experience, relationship potential), perceptions of others' responses (perceived apprehension, positive responses), and methods of disclosure (verbal, written, behavioral). No thematic differences were found by gender or age, although females reported greater frequency of disclosures. Conclusion: Disclosure emerged as a nuanced and complex process. "It depends" decision-making processes were most frequently endorsed, consistent with developmental complexities of this age group. This reflects social and psychological changes and highlights unique challenges for AYA survivors. This also reflects the importance of peers and social interactions as variables that influence disclosure. In the context of AYA cancer survivorship, understanding ways in which disclosure may bolster or hinder social support can assist survivors, clinicians, and families navigate survivorship. Implications for future research are discussed.

The relationship between posttraumatic stress and posttraumatic growth among adolescent and young adult (AYA) cancer patients

OBJECTIVE

Theories of posttraumatic growth suggest that some degree of distress is necessary to stimulate growth; yet, investigations of the relationship between stress and growth following trauma are mixed. This study aims to understand the relationship between posttraumatic stress symptoms and posttraumatic growth in adolescent and young adult (AYA) cancer patients.

METHOD

165 AYA patients aged 14-39 years at diagnosis completed standardized measures of posttraumatic stress and posttraumatic growth at 12 months following diagnosis. Locally weighted scatterplot smoothing and regression were used to examine linear and curvilinear relationships between posttraumatic stress and posttraumatic growth.

RESULTS

No significant relationships between overall posttraumatic stress severity and posttraumatic growth were observed at 12-month follow-up. However, curvilinear relationships between re-experiencing (a posttraumatic stress symptom) and two of five posttraumatic growth indicators (New Possibilities, Personal Strengths) were observed.

CONCLUSION

Findings suggest that re-experiencing is associated with some aspects of posttraumatic growth but not others. Although re-experiencing is considered a symptom of posttraumatic stress disorder, it also may represent a cognitive process necessary to achieve personal growth for AYAs. Findings call into question the supposed psychopathological nature of re-experiencing and suggest that re-experiencing, as a cognitive process, may be psychologically adaptive. Opportunities to engage family, friends, cancer survivors, or health care professionals in frank discussions about fears, worries, or concerns may help AYAs re-experience cancer in a way that enhances their understanding of what happened to them and contributes to positive adaptation to life after cancer.

Efficacy of an internet-based cognitive-behavioral intervention for long-term survivors of pediatric cancer: a pilot study

PURPOSE

Long-term survivors of pediatric cancer have an increased risk of post-traumatic stress symptoms (PTSS) and dysfunctional anxiety. However, there is a lack of evidence-based psychotherapy tailored to the needs of this target group. In this single-arm pilot study, an Internet-based psychological intervention ("Onco-STEP") for adolescent and young adult survivors was developed, and its efficacy in reducing PTSS and anxiety was evaluated.

METHODS

Former patients of pediatric cancer older than 15 years manifesting clinically relevant PTSS or anxiety were eligible. The cognitive-behavioral treatment consists of ten writing sessions and comprises two modules: the first aiming to reprocess the traumatic cancer-related experiences and the second aiming to build coping strategies with current cancer-related fears. Treatment was delivered via written messages on a secure Internet platform. Outcomes were assessed by the Post-traumatic Stress Diagnostic Scale, the Hospital Anxiety and Depression Scale, and the Fear of Progression/Relapse Questionnaire.

RESULTS

A total of 20 participants completed the intervention (mean age 27.3 ± 4.8 years at study; 13.8 ± 4.7 years since diagnosis; 70 % female). PTSS, anxiety, and fear of progression/relapse significantly declined at the end of the intervention, with pre-post effect sizes of 0.63, 0.74, and 0.48. In addition, we found a significant decrease in symptoms of depression. Except for the improvement in depression, all effects were sustained 3 months after the end of treatment.

CONCLUSIONS

The results show that the intervention is efficacious in reducing symptoms of post-traumatic stress and anxiety. Onco-STEP is a promising new way to treat young adult long-term survivors of pediatric cancer with late psychological effects. Future efforts need to focus on investigating specific evidence of the intervention in a randomized controlled trial.

Psychosocial outcomes in young adults with cancer: emotional distress, quality of life and personal growth

This study aimed at assessing the psychosocial adjustment, specifically the emotional distress, quality of life (QOL) and personal growth, in a sample of 36 Portuguese young adults with cancer and 435 healthy controls. Cancer patients scored significantly lower than controls in the role, cognitive and social domains of QOL and in personal growth. Cancer patients scored significantly lower than off-treatment survivors in the role domain of QOL and personal growth. Cancer patients revealed QOL and personal growth difficulties. These issues need to be considered in the psychosocial intervention within adolescents and young adults' oncology care.

Changes among US Cancer Survivors: Comparing Demographic, Diagnostic, and Health Care Findings from the 1992 and 2010 National Health Interview Surveys

Background. Differences in healthcare and cancer treatment for cancer survivors in the United States (US) have not been routinely examined in nationally representative samples or studied before and after important Institute of Medicine (IOM) recommendations calling for higher quality care provision and attention to comprehensive cancer care for cancer survivors. Methods. To assess differences between survivor characteristics in 1992 and 2010, we conducted descriptive analyses of 1992 and 2010 National Health Interview Survey (NHIS) data. Our study sample consisted of 1018 self-reported cancer survivors from the 1992 NHIS and 1718 self-reported cancer survivors from the 2010 NHIS who completed the Cancer Control (CCS) and Cancer Epidemiology (CES) Supplements. Results. The prevalence of reported survivors increased from 1992 to 2010 (4.2% versus 6.3%). From 1992 to 2010, there was an increase in long-term cancer survivors and a drop in multiple malignancies, and surgery remained the most widely used treatment. Significantly fewer survivors (<10 years after diagnosis) were denied insurance coverage. Survivors continue to report low participation in counseling or support groups. Conclusions. As the prevalence of cancer survivors continues to grow, monitoring differences in survivor characteristics can be useful in evaluating the effects of policy recommendations and the quality of clinical care.

Receipt of psychosocial care among cancer survivors in the United States

PURPOSE

Given the importance of psychosocial care for cancer survivors, this study used population-based data to characterize survivors who reported a discussion with health care provider(s) about the psychosocial effects of cancer and who reported using professional counseling or support groups (PCSG) and tested associations between receipt of psychosocial care and satisfaction with care.

PATIENTS AND METHODS

We examined survivors of adult cancers from the 2010 National Health Interview Survey (N = 1,777). Multivariable logistic regression models examined factors associated with receipt of and satisfaction with psychosocial care.

RESULTS

Most survivors (55.1%) reported neither provider discussions nor use of PCSG; 31.4% reported provider discussion only, 4.4% reported use of PCSG only, and 8.9% reported both. Non-Hispanic blacks (v non-Hispanic whites), married survivors, survivors of breast cancer (v prostate or less prevalent cancers), those treated with chemotherapy, and survivors reporting past research study/clinical trial participation were more likely to report provider discussion(s) (P < .01). Hispanics (v non-Hispanic whites), survivors age 40 to 49 years (v ≤ 39 years), survivors of breast cancer (v melanoma or less prevalent cancers), those diagnosed ≤ 1 year ago (v > 5 years ago), survivors treated with radiation, and past research participants were more likely to report use of PCSG (P < .05). Survivors reporting any psychosocial care were more likely to be "very satisfied" with how their needs were met (P < .001).

CONCLUSION

Many survivors do not report a discussion with providers about the psychosocial effects of cancer, which reflects a missed opportunity to connect survivors to psychosocial services. These data can benchmark the success of efforts to improve access to cancer-related psychosocial care.