Falling and rising in the vortex of cancer: children's adaptation with cancer: a qualitative study

BACKGROUND

Cancer is a considerable health problem worldwide and the second leading cause of death in children. It has many physical, psychological, and social consequences for children and their families. The ability to adapt to cancer plays a vital role in the recovery and quality of life of affected children. This study aimed to explain the adaptation of children with cancer to their disease.

METHODS

This qualitative study adopted the directed content analysis approach based on the Roy nursing model. The participants were nine children with cancer aged 6-18 years old, five family members, four nurses, one doctor, one teacher, and two charity association members, recruited by purposive sampling method. The information was collected via individual semi-structured interviews, a focus group discussion, and field notes. The data were analyzed simultaneously with data collection using the Elo and Kyngäs method. The study rigor was ensured based on the Guba and Lincoln criteria.

FINDINGS

Of the four categories of physical challenges, fragile self-concept, the difficulty of role transition, and disruption of the path to independence, the theme of Falling and rising in the cancer vortex was abstracted.

CONCLUSION

Based on the Roy model, the children in the present study were at the compensatory level of adaptation. This research demonstrates that the adaptation of children being treated for cancer is fragile and not constant. With each hospitalization and exacerbation of the disease, they made efforts to adapt to their disease using regulatory and cognitive subsystems. Paying attention to different stimulants and the effects of support systems on physical challenges, fragile self-concept, difficult role transition, and disruption of the path to independence for each child, as well as providing individualized care for these children, can help their adaptation to and healthy transition from the vortex of cancer. The Roy adaptation model was helpful and efficient for elucidating the adaptation of children with cancer. Providing care for children by healthcare specialists, especially nurses, should be theory-based and individualized.

Fostering resilience in adolescence and young adulthood: Considerations for evidence-based, patient-centered oncology care

Adolescence and young adulthood are times of growth and change. For adolescents and young adults (AYAs) who are diagnosed with cancer, the demands of illness may compound normal developmental challenges and adversely affect physical, emotional, and social health. Nevertheless, AYAs have a tremendous capacity for psychosocial adaptation and resilience. Informed by the Transactional Model of Stress and Coping, observational studies in AYA oncology suggest consistent individual, social, and existential resources that may promote resilience. To date, few interventions have been designed to examine whether resilience can be taught and whether doing so affects patient-centered outcomes. Findings point to the potential value of multicomponent programs that include various skills-building strategies, such as stress management, mindfulness, gratitude, and positive reappraisal coping, among others. New research directions include the need to evaluate delivery strategies to enhance participant adherence and retention (e.g., eHealth modalities, optimization studies) and to examine program effectiveness in community-based oncology practices (e.g., less resource-rich settings in which most AYAs receive care). Ultimately, this scholarship may inform, refine, and strengthen intervention science in resilience more broadly.

Feasibility pilot trial of a tailored medication adherence-promotion intervention for adolescents and young adults with cancer: Study design and protocol

BACKGROUND

Medication non-adherence is common among adolescents and young adults (AYAs) with cancer and associated with poor health outcomes. AYAs with cancer endorse multiple barriers to adherence that differ across individuals, suggesting that tailoring intervention content to an AYA's specific barriers may have the potential to improve adherence. The purpose of this manuscript is to report on ORBIT-guided Phase I design efforts to create the first tailored adherence-promotion intervention for AYAs with cancer and the study protocol for the ongoing Phase II pilot feasibility trial.

METHODS

Phase I design included qualitative interviews (n = 15 AYAs) to understand patient preferences for adherence-promotion care, development and refinement of a best-worst scaling exercise barriers tool (n = 5 AYAs), and development of intervention modules and a tailoring algorithm. In the ongoing Phase II pilot feasibility trial, AYAs (ages 15-24 years) with cancer currently taking oral chemotherapy or prophylactic medication will be recruited from three children's hospitals. Feasibility, acceptability, and usability will be assessed and these outcomes along with data on medication adherence will be used to inform the next phases of intervention development and testing.

CONCLUSIONS

If promising, this program of research ultimately has the potential to equip clinicians with additional strategies for supporting adherence among AYAs with cancer. NCT05706610.

Survival Trends Among Adolescents and Young Adults Diagnosed With Cancer in the United States: Comparisons With Children and Older Adults

PURPOSE

Although data from 1975 to 1997 revealed a gap in cancer survival improvement in adolescents and young adults (AYAs; 15-39 years) compared with children and older adults, more recent studies have reported improvements in AYA cancer survival overall. The current analysis provides an update of 5-year relative survival and cancer survival trends among AYAs compared with children and older adults.

METHODS

We obtained data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program for 17 regions to obtain recent (2010-2018) 5-year relative survival estimates by cancer type, stage, sex, and race/ethnicity by age group. In addition, we calculated 5-year relative survival trends during 2000-2014.

RESULTS

Across 33 common AYA cancers, AYAs and children had high 5-year relative survival (86%) and experienced similar survival improvements over time (average absolute change: AYAs, 0.33%; children 0.36%). Among AYAs, 73% of cancers had improvement in 5-year relative survival since 2000. Despite this overall progress, we identified cancers where survival was worse in AYAs than younger or older patients and cancers that have had either a lack of improvement (osteosarcoma and male breast) or decreases in survival (cervical and female bladder) over time. Furthermore, males had inferior survival to females for all cancers, except Kaposi sarcoma and bladder cancer, and non-Hispanic Black/African American AYAs experienced worse survival than other racial/ethnic groups for many cancers considered in this study.

CONCLUSION

Future studies should focus on identifying factors affecting survival disparities by age, sex, and race/ethnicity. Differences in biology, clinical trial enrollment, delivery of treatment according to clinical guidelines, and supportive and long-term survivorship care may account for the survival disparities we observed and warrant further investigation.

Understanding the Extent of Polypharmacy and its Association With Health Service Utilization Among Persons With Cancer and Multimorbidity: A Population-Based Retrospective Cohort Study in Ontario, Canada

Background: Cancer often co-occurs with other chronic conditions, which may result in polypharmacy. Polypharmacy is associated with adverse outcomes, including increased health service utilization. Objectives: This study examines the overall prevalence of polypharmacy (5 or more medications) among adults with cancer and multimorbidity, as well as the association of both minor polypharmacy (5-9 medications) and hyper-polypharmacy (10 or more medications) on high use of emergency room visits and hospitalizations, while controlling for age, sex, and type and stage of cancer. Methods: This retrospective longitudinal study used linked health administrative databases and included persons 18 years and older diagnosed with cancer between April 2010 and March 2013 in Ontario, Canada. Data on the number of health service utilizations at or above the 90th percentile (high users), was collected up to March 2014 and multivariate logistic regression was used to determine the impact of polypharmacy. Results: The prevalence of polypharmacy was 46% prior to cancer diagnosis, and 57% one year after diagnosis. Polypharmacy prior to and after cancer diagnosis increased with the level of multimorbidity, increasing age, but did not differ by sex. It was also highest in persons with lung cancer (52.4%) and those diagnosed with stage 4 cancer (51.3%). Minor polypharmacy increased the odds of being a high user of emergency rooms (1.16; 99% CI: 1.09-1.24) and hospitalizations (1.03; 0.98-1.09) and the odds of high use was greater with hyper-polypharmacy (1.41; 1.33-1.51) and (1.23; 1.17-1.29) respectively. Conclusion: Polypharmacy is highly prevalent and is associated with high health service utilization among adults with cancer and multimorbidity.

Financial burdens during the COVID-19 pandemic are related to disrupted healthcare utilization among survivors of adolescent and young adult cancers

PURPOSE

We examined whether financial burdens occurring during the COVID-19 pandemic impacted healthcare utilization among survivors of adolescent and young adult cancers.

METHODS

We surveyed survivors enrolled in a patient navigation program to obtain self-reports of delayed/skipped cancer care or other care, changes to medication obtainment, and changes to medication use since the COVID-19 pandemic began. Reported financial burdens were defined as financial toxicity in the past 4 weeks (COmprehensive Score for financial Toxicity [COST] ≤ median 21) and material hardships (range = 4-11) since March 2020. Adjusted logistic regression models calculated associations and effect modification by gender.

RESULTS

Survivors (n = 341) were mostly female (61.3%) and non-Hispanic White (83.3%). Nearly 20% delayed/skipped cancer care, 35.2% delayed/skipped other care, 19.1% changed medication obtainment, and 12.6% changed medication use. Greater material hardships were associated with delayed/skipped cancer care (odds ratio (OR) = 3.13, 95% CI = 1.44-6.81) and other care (OR = 2.17, 95% CI = 1.18-3.98), and changed medication obtainment (OR = 2.72, 95% CI = 1.43-5.18) or use (OR = 4.49, 95% CI = 2.05-9.80). Financial toxicity was associated with delayed/skipped other care (OR = 2.53, 95% CI = 1.31-4.89) and changed medication obtainment (OR = 1.96, 95% CI = 1.01-3.83) and medication use (OR = 3.73, 95% CI = 1.59-8.73). The association of material hardships and any changes in healthcare utilization was greater among female compared to male survivors.

CONCLUSION

Financial burdens experienced during the pandemic impeded survivors' ability to utilize necessary healthcare, with worse impacts among female survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Delayed or skipped healthcare may lead to an increased cancer mortality or severity of therapy-related conditions. Providing resources that enable survivors experiencing financial burdens to continue critical cancer and preventive care during the COVID-19 pandemic is a priority.

The Use of Virtual Reality Learning on Transition Education in Adolescents with Congenital Heart Disease

Improvement in congenital heart disease (CHD) outcomes has created a growing population of adolescents and young adults with unique health needs that require thoughtful transition planning and eventual transfer of care to an adult provider. Often, poor health literacy and limited resources can lead to interrupted care, which places them at risk for adverse health-related consequences. In 2019, the Wisconsin Adult Congenital Heart Disease transition program partnered with Stanford Virtual Heart (SVH), a virtual reality (VR) platform, to allow young adult patients to learn about their CHD in a clinic-based setting. We completed a single-center pilot study to evaluate these patients' experience and perceptions to using VR during their transition education. At an initial transition visit, we used an immediate post-VR experience survey, scored using Likert scales of 1-5 (1 = strongly disagree, 5 = strongly agree). Twenty-two patients (13 males) between the ages of 16 and 19 participated. Lesions included pulmonary stenosis, Tetralogy of Fallot, atrial and ventricular septal defect, coarctation, aortic stenosis, hypoplastic left heart syndrome, and patent ductus arteriosus. Likert averages were 4.7 for finding VR helped with understanding their heart lesion, 4.6 for finding VR helped with understanding their heart surgery, 4.7 for enjoying the VR heart simulation, and 4.6 for finding that it was a good use of time. This study demonstrates that adolescents enjoyed using SVH and found it helpful. Clinical implementation shows promise as a plausible adjunct tool for transition education.

Polypharmacy and medication fill nonadherence in a population-based sample of adolescent and young adult cancer survivors, 2008-2017

PURPOSE

We examined the association between polypharmacy-an established risk factor for nonadherence in the elderly-and medication fill nonadherence in a large national sample of adolescent and young adult cancer survivors (AYAs) in the USA.

METHODS

We pooled data (2008-2017) from the Medical Expenditure Panel Survey. We defined polypharmacy as ≥ 3 unique medications prescribed, based on self-report and pharmacy data, and medication fill nonadherence as self-reported delay or inability to obtain a necessary medication. We estimated prevalence of medication fill nonadherence among AYAs (age 18-39 years with a cancer history). We used logistic regression to estimate the association between (1) polypharmacy and medication fill nonadherence in AYAs, and (2) total number of medications prescribed and medication fill nonadherence, controlling for sex, number of chronic conditions, disability, and survey year.

RESULTS

AYAs (n = 598) were predominantly female (76.2%), age 30-39 years (64.9%), and non-Hispanic White (72.1%). Nearly half were poor (19.0%) or near-poor/low income (21.6%). One in ten AYAs reported medication fill nonadherence (9.75%). Of these, more than 70% cited cost-related barriers as the reason. AYAs with polypharmacy had 2.49 times higher odds of medication fill nonadherence (95%CI 1.11-5.59), compared to those without polypharmacy. Odds of medication fill nonadherence increased by 16% with each additional medication prescribed (AOR 1.16, 95% CI 1.07-1.25).

CONCLUSIONS

Polypharmacy may be an important risk factor for medication fill nonadherence in AYAs in the USA.

IMPLICATIONS FOR CANCER SURVIVORS

Improving AYAs' medication adherence requires eliminating cost-related barriers, particularly for those with polypharmacy.

How Do Adolescent and Young Adult Patients with Cancer Manage Their Chemotherapy-Related Symptoms at Home?

Chemotherapy can cause many distressing side effects, potentially impacting treatment completion and quality of life in adolescent and young adult (AYA) patients with cancer. To identify ways to help mitigate chemotherapy-related symptoms, we sought to elicit barriers and facilitators to managing symptoms experienced by AYAs with cancer through interviews. Qualitative thematic analysis identified three main domains: (1) managing chemotherapy symptoms (e.g., medication, home remedies), (2) anticipating and mitigating symptoms (e.g., management of symptoms at home, anticipatory guidance), and (3) knowing when to seek care (e.g., unexpected and unusual symptoms). This study elucidated that AYAs can successfully manage symptoms at home when given the proper guidance and this could be a focus of future efforts to improve outcomes in this population. The Clinical Trial Registration number is NCT04594096.

Have we made progress in taking care of adolescents and young adults with cancer? Results of a European multi-professional survey

BACKGROUND

It is well documented that traditional health care models do not meet the specific needs of Adolescents and Young Adults (AYA) cancer patients.

METHODS

We explore a map of the development of age-specific AYA cancer care across Europe, from the perspective of healthcare professionals with an interest in AYA care, in order to understand the specific challenges and map progress over time. An on-line survey was developed by international professional cancer organisations.

RESULTS

We had 377 respondents from 60 countries. The majority of respondents were physicians 298 (79%), a minority of survey respondents (39, 10.4%) work exclusively with AYA patients, most respondents declared substantial and routine clinical service collaborations to provide care and treatment to AYA with cancer. Policy for the multidisciplinary management of AYA cancer patients commonly appears in Europe now, and was reported by 234 (78.52%) respondents. Specific professional training for AYA cancer care is not uniformly available.

CONCLUSION

There is considerable opportunity for many organisations to work together in raising the profile of AYA cancer related issues, in providing education and in encouraging research and collaboration.

Facilitators and barriers to adherence to medical recommendations among adolescents with cancer: A systematic review

We aimed to systematically review barriers/facilitators of adherence among adolescents with cancer (aged 10-24 years), following a comprehensive approach to adherence that goes beyond medication-taking. Empirical studies published in English exploring determinants of adherence to medical recommendations among adolescents with cancer were identified in MEDLINE, PsycInfo, and Web of Science, up to October 2021. Records and full-text articles were reviewed by two independent reviewers, and results were classified according to the World Health Organization's (WHO) multidimensional adherence model. Eighteen studies were included. Despite heterogeneity in the definition and measurement of adherence, literature supported barriers/facilitators at patient, treatment, condition, healthcare team/system, and social/economic levels. Specifically, patient-related factors (i.e., psychological functioning and beliefs about disease and treatment) and social-related factors (i.e., family functioning) were major determinants of adolescent adherence. Few studies were conducted, and inconsistent findings were displayed for other dimensions (i.e., healthcare team/system, treatment, and condition-related factors). Adherence is a complex and multidetermined phenomenon. More research is needed to provide critical insights for policymakers and healthcare professionals in planning practices and interventions that effectively address meaningful barriers/facilitators of adolescents' adherence.

Better Together: acceptability, feasibility and preliminary impact of chronic illness peer support groups for South African adolescents and young adults

INTRODUCTION

Peer support can help navigate the isolation and psychological strain frequently experienced by youth living with chronic illness. Yet, data are lacking on the impact of providing support for youth living with mixed chronic conditions. We assessed the acceptability, feasibility and preliminary mental health impacts of a clinic-based peer support group for South African youth living with chronic illnesses, including HIV.

METHODS

This mixed-methods pilot study (September 2021-June 2022) enrolled 58 young patients, ages 13-24, at an urban hospital in Cape Town, South Africa. In-depth interviews elicited the perspectives of 20 young people in relation to their participation in the Better Together programme, a recurring clinic-based peer support group for patients with mixed chronic illnesses. Self-reported resilience, attitudes towards illness, stigma and mental health were captured via established measures. T-tests and multivariate analysis of variance compared psychosocial outcomes for 20 group participants and 38 control patients, controlling for socio-demographic characteristics at enrolment. Logistic regression analyses estimated the predicted probability of a positive depression or anxiety screening given peer group participation.

RESULTS

All interviewees valued being able to compare treatment regimens and disease management habits with peers living with different conditions. Adolescents living with HIV stated that understanding the hardships faced by those with other conditions helped them accept their own illness and lessened feelings of isolation. Compared to patients who did not participate in Better Together, those who attended ≥5 groups had statistically significantly higher individual-level resilience, a more positive attitude towards their illness(es), lower internalised stigma and a more positive self-concept. The probability of being screened positive for depression was 23.4 percentage points lower (95% CI: 1.5, 45.3) for Better Together participants compared to controls; the probability of a positive anxiety screening was 45.8 percentage points lower (95% CI: 18.1, 73.6).

CONCLUSIONS

Recurring, clinic-based peer support groups that integrate youth living with HIV and other chronic diseases are novel. Group sustainability will depend on the commitment of experienced peer leaders and providers, routine scheduling and transportation support. A fully powered randomised trial is needed to test the optimal implementation and causal mental health effects of the Better Together model.

Barriers to medication adherence among adolescents and young adults with cancer

BACKGROUND

Adherence promotion is a critical component of adolescent and young adult (AYA) cancer care, but predictors of nonadherence that could be targeted in intervention efforts remain largely unknown. The purpose of this multi-site longitudinal observational study was to examine the relationship between barriers and medication adherence among AYAs with cancer.

PROCEDURE

Sixty-five AYAs (ages 15-24 years; mean age = 18.97 years, SD = 2.51; Mmean time since diagnosis = 1.42 years, SD = 1.95) with newly diagnosed or relapsed cancer completed self-report measures of barriers and adherence at quarterly study visits and used an electronic adherence monitoring device for 12 months. Longitudinal mixed effects models were used to examine our primary hypothesis that greater barriers are related to lower adherence over time. Descriptive statistics were used to explore our secondary aim of describing the frequency and patterns of barriers endorsed by AYAs with cancer.

RESULTS

After controlling for covariates (time, medication type, race, ethnicity, diagnosis, time since diagnosis), a greater number of barriers was associated with lower electronically monitored (β = -5.99, p = .005) and self-reported (β = -1.92, p < .001) adherence. The specific barriers endorsed by AYAs differed across participants, and the majority of AYAs endorsed an entirely different pattern of barriers than any other AYA in the study.

CONCLUSION

Barriers are associated with nonadherence and may be a promising target for intervention. Individual variability across barriers, however, suggests that tailoring may be necessary, and a promising next step is to explore personalized approaches to adherence promotion.

Using immunotherapy and novel trial designs to optimise front-line therapy in adult acute lymphoblastic leukaemia: breaking with the traditions of the past

Multidrug chemotherapy has historically been the cornerstone of therapy for both children and adults with acute lymphocytic leukaemia. However, in the past decade, several novel immunotherapies have proven to be highly effective in the treatment of acute lymphocytic leukaemia, including the anti-CD22 antibody-drug conjugate inotuzumab ozogamicin, the CD3 × CD19 bispecific antibody blinatumomab, and two CD19-directed chimeric antigen receptor T-cell products. These agents are all approved in the USA as monotherapy for relapsed or refractory B-cell acute lymphocytic leukaemia. However, their use as single agents in the salvage setting might not be taking full advantage of their anti-leukaemia potential, because our ability to cure a patient is likely to be greatest when the most effective therapies are safety integrated into front-line treatment regimens. Several ongoing studies have yielded encouraging data with routine incorporation of inotuzumab ozogamicin or blinatumomab, or both, in patients with newly diagnosed acute lymphocytic leukaemia, and these approaches are emerging as new standards of care. In Philadelphia chromosome-positive acute lymphocytic leukaemia, chemotherapy-free regimens combining blinatumomab and a BCR-ABL1 tyrosine kinase inhibitor are changing acute lymphocytic leukaemia therapy, highlighting the potential for these novel agents to reduce-or perhaps eliminate-the need for chemotherapy in some subtypes. In this Viewpoint, we review promising data from ongoing clinical trials of novel immunotherapy-based combinations that are being explored in patients with newly diagnosed acute lymphocytic leukaemia. We also discuss the challenges of randomised studies in the rapidly evolving therapeutic landscape and argue for the ability of well designed, non-randomised studies to more rapidly advance the standard of care in acute lymphocytic leukaemia.

Impact of the insertion of the clinical pharmacist in the Allogeneic Hematopoietic Stem Cells Transplantation team

INTRODUCTION

Allogeneic Hematopoietic Stem Cells Transplantation (allo-HSCT) is capable of curing patients with neoplastic or non-neoplastic hematologic disorders or of prolonging their survival. This study assessed if the insertion of the clinical pharmacist in the allo-HSCT team modified the outcomes: transplantation-related mortality, grafting failure, incidence of Graft versus Host Disease, hospitalization time, time for grafting, number of readmissions, number of drug-related problems (DRPs), adherence and knowledge about pharmacotherapy.

METHODS

Interventional study with historical control carried out in an allo-HSCT unit, in which the intervention group (IG) included 33 individuals who received pharmacotherapy follow-up. Control Group (CG) consisted of 28 individuals.

RESULTS

A total of 250 DRPs were identified, 59 team's doubts were clarified, and 309 interventions were conducted in the IG. The DRPs mainly arose from safety (51.60%) and effectiveness (38.40%) problems. A mean of 9.36 (SD = 6.97) interventions per patient was obtained, mainly including dose reductions (19.09%), adjustments in administration time (18.12%), educational activities (15.21%) and drug removal (10.68%). Clinical significance of the interventions was considered high (75.7% extremely significant, very significant or significant), as well as their acceptability (89.7% accepted). Each patient attended a mean of 4.68 pharmaceutical consultations (SD = 1.91) after hospital discharge, presenting increase in knowledge (p = 0.0001) and in adherence (p = 0.0115). There was no evidence of differences between the groups in the other outcomes analyzed.

CONCLUSIONS

The pharmacotherapy follow-up allowed detecting several DRPs and performing interventions of high clinical relevance and acceptability, in addition to improving adherence and individualizing the pharmacotherapy.

Can pharmacotherapeutic follow-up after allogeneic hematopoietic stem cell transplantation improve medication compliance?

BACKGROUND

Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT) is currently one of the most effective therapies in onco-hematology. For the treatment of the disease and prevention of such complications, a complex pharmacotherapeutic regimen is employed. Non-compliance is prevalent among adolescents and young adults with chronic hematological diseases, being reported by up to 50% of the patients.

OBJECTIVE

To evaluate the results of pharmacotherapeutic follow-up on medication compliance and on the knowledge about pharmacotherapy of patients who underwent allo-HSCT.

METHODS

A single-arm, open-label and non-randomized intervention study developed in an allo-HSCT outpatient clinic. The participants attended pharmaceutical consultations and had their knowledge about pharmacotherapy and medication compliance measured by MedTake and Brief Medication Questionnaire (BMQ), respectively.

RESULTS

A total of 27 patients attended pharmaceutical consultations (4.81 consultations/patient; SD = 1.80). There was an improvement in medication compliance and in knowledge between the first and last consultations (p < 0.05). In the final consultation, 70.37% of the patients showed compliance, with a knowledge rate of 98.35% (SD = 3.63). Non-compliant individuals presented a greater tendency to hospital readmissions. There was no relationship between medication compliance and sociodemographic variables, graft-versus-host disease, and knowledge about pharmacotherapy.

CONCLUSIONS

Pharmacotherapeutic follow-up contributed to improving medication compliance. Knowledge about pharmacotherapy alone does not translate into behaviors, which corroborates the complexity of the biopsychosocial factors associated with medication compliance.

Comparing the effects of retro and forward walking on serum adiponectin levels in obese young adults

Objectives

Retro walking or backward walking expends greater energy and places less stress on joints compared with forward walking at a similar speed. This study conducted in obese young men was primarily aimed at comparing the effects of backward walking with forward walking on adiponectin levels. The secondary aim was to describe the effects of concomitant factors, namely C-reactive protein, body mass index (BMI), waist to height ratio, and waist to hip ratio, on adiponectin levels in obese young men.

Methods

In this randomized comparative study, 102 participants underwent either retro walking or forward walking treadmill training four times a week for 12 weeks before and after which adiponectin, C-reactive protein, BMI, waist to height ratio, and waist to hip ratio were measured. Comparison of the measured values before and after intervention and between the groups was done, and the influence of C-reactive protein, BMI, waist to height ratio, and waist to hip ratio on adiponectin levels was determined.

Results

Adiponectin levels were significantly increased (p < 0.001) and C-reactive protein, BMI, waist to height ratio, and waist to hip ratio were significantly decreased (p ≤ 0.001) post-intervention. The participants who underwent retro walking training showed a significantly higher change in C-reactive protein levels, BMI, and waist to hip ratio compared to the forward walking group (p < 0.001). Adiponectin levels were influenced by BMI (p < 0.001).

Conclusion

Retro walking training leads to a greater increase in adiponectin and reduction in C-reactive protein, BMI, waist to height ratio, and waist to hip ratio compared to forward walking, and adiponectin levels are influenced by BMI. Retro walking treadmill training can be preferentially used to decrease cardiovascular risk factors.

Adherence to Oral Chemotherapy in Acute Lymphoblastic Leukemia during Maintenance Therapy in Children, Adolescents, and Young Adults: A Systematic Review

Acute lymphoblastic leukemia (ALL) is the most common malignancy in children and young adults. Treatment is long and involves 2-3 years of a prolonged maintenance phase composed of oral chemotherapies. Adherence to these medications is critical to achieving good outcomes. However, adherence is difficult to determine, as there is currently no consensus on measures of adherence or criteria to determine nonadherence. Furthermore, there have been few studies in pediatric B-ALL describing factors associated with nonadherence. Thus, we performed a systematic review of literature on oral chemotherapy adherence during maintenance therapy in ALL following PRISMA guidelines. Published studies demonstrated various objective and subjective methods of assessing adherence without generalizable definitions of nonadherence. However, the results of these studies suggested that nonadherence to oral maintenance chemotherapy was associated with increased risk of relapse. Future studies of B-ALL therapy should utilize a uniform assessment of adherence and definitions of nonadherence to better determine the impact of nonadherence on B-ALL outcomes and identify predictors of nonadherence that could yield targets for adherence improving interventions.

Screening and assessment for cancer patients' psychosocial support needs: Development and validation of the psychosocial risk questionnaire

PURPOSE

Psychosocial factors can negatively influence the ability to cope with cancer-specific therapy. To identify high-risk patients and to offer need-based care concerning social issues, valid, reliable, and economic instruments are needed. This study aims to develop a tool assessing psychosocial support needs and analyze its psychometric properties.

METHODS

Based on an extensive literature search, items for the scale of psychosocial risks (PSR) were developed to assess the need for psychosocial support. Overall, N = 343 participants with cancer took part in the study to investigate the psychometric properties of the PSR. The factor structure was examined by using a principal component analysis. Correlations with criteria-related constructs determined the convergent validity. Cut-off scores for the PSR were selected based on receiver-operating characteristics and the calculation of Youden indices.

RESULTS

The principal component analysis suggests a two-factor structure: (1) Psychosocial support need to ensure medical and social care services, and (2) Support need for coping with problems. The predicted correlations confirm the convergent validity. Both scales showed excellent internal consistency (Ensure medical and social care services: Omega = 0.94) and (Coping with problems: Omega = 0.90).

CONCLUSION

The newly developed scale can provide helpful information regarding psychosocial support needs to professionals (psychotherapists, psychologists, physicians, and social workers) in the psycho-oncological field. Based on this information, specific and personalized interventions for cancer patients can be offered. The PSR is appropriate for assessing specific psychosocial needs to support cancer patients.

Metastasis patterns and prognosis in young breast cancer patients: A SEER database analysis

Background

There are few studies on young patients with metastatic breast cancer (MBC). This study aims to explore the metastasis pattern and prognosis of young patients with MBC.

Methods

A total of 6,336 MBC patients diagnosed in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2015 were selected. They were divided into two age groups: the younger group (≤40 years old) and the older group (>40 years old). χ² test was used to compare clinicopathological characteristics. Survival differences were compared by Kaplan–Meier analysis. Cox regression models were used to determine the prognostic factors affecting survival. Propensity score matching (PSM) was performed to balance the effects of baseline clinicopathological differences.

Results

Finally, 494 patients (7.8%) who are ≤40 years old and 5,842 patients (92.2%) who are >40 years old were included. In the younger group, the proportion of liver metastasis was significantly higher than that in the older group; the proportion of lung metastasis was significantly lower than that of the older group. Kaplan–Meier analysis showed that the younger group had the best prognosis and the older group had the worst. Youth is an independent protective factor for overall survival (OS). In the younger group, liver metastasis had the best prognosis among all metastatic sites, and the HER2-enriched subtype had the best prognosis among all subtypes.

Conclusions

The disease in young MBC patients is more aggressive but has a better prognosis, especially in liver metastases and the HER2-enriched subtypes.

Efficacy of a culturally tailored cognitive-behavioural intervention for Ethiopian children with haematological malignancies: study protocol for randomised controlled trial

Background

Paediatric cancer patients often experience anxiety and depression. Evidence suggests that cognitive-behavioural interventions may help reduce anxiety and depression in children undergoing cancer treatment. However, only a few studies evaluated its impact on the psychological well-being and quality of life of paediatric cancer patients globally. In Ethiopia, there has been no published study to date. Thus, this trial aims to evaluate the efficacy of a culturally tailored cognitive-behavioural intervention for Ethiopian children with haematological malignancies receiving chemotherapy.

Methods

A single-blinded, parallel-group, two-arm, repeated measure randomised controlled trial will be conducted. Eighty children aged 8 − 18 years with haematological malignancy receiving chemotherapy will be recruited and randomly assigned to experimental or control groups. The experimental group will receive five sessions of introducing cognitive-behavioural intervention, identifying and modifying maladaptive thoughts and behaviour, behavioural activation, practising deep breathing exercises, reassessing goals or treatment plans, and encouraging participants to maintain changes. Each session will be conducted face-to-face for 30–35 min a week. The control group will receive usual care. The outcomes will be measured at baseline, post-intervention, and one month after the intervention using the Revised Child Anxiety and Depression Scale and Paediatric Quality of Life Inventory Generic Core Score 4.0.

Discussion

The findings of this study will provide evidence to support the integration of culturally effective cognitive-behavioural intervention strategies into paediatric oncology practice and thus, add new knowledge to the literature and help improve the care of children with haematological malignancies receiving chemotherapy. If the cognitive-behavioural intervention is shown to be effective and culturally acceptable, it will provide evidence to include the intervention as a standard of care in paediatric haematology/oncology.

Trial registration

ClinicalTrials.gov NCT05270655. Registered on March 8, 2022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06768-x.

A Call to Action: Using and Extending Human-Centered Design Methodologies to Improve Mental and Behavioral Health Equity

Mental health disparities directly tie to structural racism. Digital mental health (DMH), the use of technologies to deliver services, have been touted as a way to expand access to care and reduce disparities. However, many DMH fail to mitigate the persistent disparities associated with structural racism that impact delivery (e.g., costs, dependable internet access)-and may even exacerbate them. Human-centered design (HCD) may be uniquely poised to design and test interventions alongside, rather than "for," marginalized individuals. In employing HCD methodologies, developers may proceed with a vested interest in understanding and establishing empathy with users and their needs, behaviors, environments, and constraints. As such, HCD used to mindfully address structural racism in behavioral health care may address shortcomings of prior interventions that have neglected to elevate the voices of marginalized individuals. We argue that a paradigm shift in behavioral health services research is critically needed-one that embraces HCD as a key methodological framework for developing and evaluating interventions with marginalized communities, to ultimately promote more accessible, useful, and equitable care. The current commentary illustrates practical examples of the use of HCD methodologies to develop and evaluate DMH designed with marginalized populations, while also highlighting its limitations and need for even greater inclusivity. Following this, calls to action to learn from and improve upon HCD methodologies will be detailed. Acknowledging potential limitations of current design practices, methodologies must ultimately engage representative voices beyond research participation and invest in their active role as compensated and true collaborators to intervention design.

Randomized Trial of a Supportive Psychotherapy for Parents of Adolescents and Young Adults With Hematologic Malignancies

BACKGROUND

Cancer regularly disrupts health and developmental trajectories in adolescents and young adults (AYAs). Parents have been shown to have a substantial impact on the health and cancer survivorship activities of AYA patients in the form of symptom management. However, no randomized controlled trial has evaluated a coping support intervention (CSI) program for parents of AYAs with cancer aged 18 to 40 years.

PATIENTS AND METHODS

From November 30, 2012, to August 29, 2016, parents of AYAs with hematologic malignancies were randomized in a phase III controlled trial (1:1 ratio, stratified sampling) to either the research-based CSI AYA-Parents group (CSI group; n=82) or the standard care (SC) group (n=70). CSI consisted of 5 sessions to achieve the enhancement of parental adaptive coping as the primary outcome (per the adaptive coping scale of the 28-item Brief COPE, a validated multidimensional self-assessment-questionnaire recommended for clinical cancer research). Measures of adaptive coping, depression, and mental health were collected at pre-CSI (measurement date T1), at the end of the intervention sessions (measurement date T2), and at follow-up (3 months). We calculated mean change scores in outcomes and estimated intervention effect sizes (Cohen's d) for changes from T1 to T2/T3, with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. All statistical tests were 2-sided.

RESULTS

In the intention-to-treat analysis, the CSI group significantly improved their adaptive coping compared with the SC group (95% CI, 0.30-2.54; P=.013; d=0.405), whereas adaptive coping in the SC group deteriorated. The CSI group also experienced a significant decrease in depressive symptoms and improved mental health with clinical significance (95% CI, -1.98 to -0.30; P=.008; d=0.433, and 95% CI, -0.19 to 3.97; P=.074; d=0.292, respectively). Sensitivity analyses confirmed the robustness of the main intention-to-treat analysis.

CONCLUSIONS

CSI improved effectively adaptive coping and depression in parents of AYAs with hematologic malignancies. It may represent a novel family-based approach in AYA oncology care.

Outcomes of Lymphoma Among American Adolescent and Young Adult Patients Varied by Health Insurance-A SEER-based Study

INTRODUCTION

Impacts of health insurance status on survival outcomes among adolescent and young adult (AYA, 15 to 39 years of age) patients with lymphoma in the United States are insufficiently known. This study aimed to clarify associations between health insurance status and overall survival (OS) estimates in this population.

MATERIALS AND METHODS

We examined 18 Surveillance, Epidemiology, and End Results registries in the United States and analyzed American AYA patients with lymphoma diagnosed during January 2007 and December 2016. Health insurance status was categorized, and Kaplan-Meier and multifactor Cox regressions were adopted using hazard ratio and 95% confidence interval. Probable baseline confounding was modulated by multiple propensity score.

RESULTS

A total of 21,149 patients were considered; ~28% were 18 to 25 years old, and 63.5% and 7.5% had private and no insurance, respectively. Private insurance rates increased in the 18 to 25 age group (60.1% to 6.1%, P<0.001) following the 2010 Patient Protection and Affordable Care Act (ACA), and lymphoma survival rates improved slightly 1 to 5 years postdiagnosis. Five-year OS rates decreased with age (93.9%, 90.4%, and 87.0% at 15 to 17, 18 to 25, and 26 to 39, respectively) and differed among insurance conditions (81.7%, 79.2%, 89.2%, and 92.0% for uninsured, Medicaid, insured, and insured/no specifics, respectively). Risk of death was significantly higher for those with Medicaid or no insurance than for those with private insurance in multiple propensity score-adjusted models (hazard ratio [95% confidence interval]=1.07 [1.03-1.12]), independent of stage at diagnosis.

CONCLUSIONS

No or insufficient insurance was linked to poor OS in our sample in exposure-outcome association analysis. Insurance coverage and health care availability may enhance disparate outcomes of AYAs with cancer. The ACA has improved insurance coverage and survival rates for out sample. Nevertheless, strategies are needed to identify causality and eliminate disparities.

A Support System for Adolescent and Young Adult Patients with Cancer at a Comprehensive Cancer Center

Cancer patients in adolescents and young adults (AYA) generation aged 15-39 years have various psychosocial needs during their treatment course such as school enrollment, finding employment, marriage, and fertility. It is difficult for medical professionals to gain experience related to providing medical care and consultation support to these kinds of AYA generation cancer patients. There is a need to provide information and establish both support and medical care systems that are able to meet the diverse needs unique to this generation. This review will explain how to launch an AYA support team (AST). We have worked and established the AST since 2016, which is medical care teams that provide support according to the life stage of each individual patient and build a multidisciplinary AYA generation patient support system. The team-building process consisted of two main projects: building and enlarging multidisciplinary team and establishing screening process of psychosocial needs of AYA generation patients. Multidisciplinary healthcare professionals got involved in the AST with already-existing patient support functions in our center: the patient support center, which is an outpatient department and the palliative care team, which is an inpatient interdepartmental team. The AST systematically finds patients in need of assistance and offers them support as a multidisciplinary team. The AST also established a procedure that systematically gathers information about the needs of patients by using a screening tool. In addition, the AST provides the following specialized services: reproductive medicine, supporting cancer patients with children, employment support, and peer support. The AST has been established and sophisticatedly worked. It can flexibly provide various psychosocial support services. This review will explain how to launch an AST.

Childhood acute lymphoblastic leukemia treatment in an academic hospital in Kenya: Treatment outcomes and health-care providers' perspectives

BACKGROUND

Early deaths and treatment nonadherence are major reasons for low childhood acute lymphoblastic leukemia (ALL) survival in low- and middle-income countries. This study assessed treatment outcomes of children presenting with ALL and evaluated perspectives of health-care providers (HCP) on ALL treatment at a Kenyan academic hospital.

METHODS

This was a combined retrospective medical records and cross-sectional questionnaire study. Treatment outcomes of 136 children diagnosed with ALL between 2010 and 2016 were collected. Questionnaires were completed by 245 HCP (response rate, 86%) between September and October 2016.

RESULTS

Childhood ALL treatment outcomes were death (30%), progressive or relapsed disease (26%), abandonment (24%), and event-free survival (20%). Of all deaths, 80% were early deaths (prior or during induction), whereas 20% occurred in remission. Probability of event-free survival at three years was 18%. Only 57% of HCP believed childhood ALL can be cured, with more doctors (96%) than other HCP (45%) believing in curability of ALL (P < 0.001). The majority of HCP (96%) thought that experienced doctors should put more time and effort into making parents understand the diagnosis and necessity to complete treatment. According to HCP, reasons for protocol nonadherence included parental financial difficulties (94%) and use of alternative treatment (79%).

CONCLUSIONS

Event-free survival for ALL in Kenya is low. The primary reason for treatment failure is early death from treatment-related complications. More efforts should be directed toward improving supportive care strategies. In the opinion of HCPs, improved communication with parents and supervision of junior staff will improve ALL treatment outcomes.

Specialist cancer services for teenagers and young adults in England: BRIGHTLIGHT research programme

Background

When cancer occurs in teenagers and young adults, the impact is far beyond the physical disease and treatment burden. The effect on psychological, social, educational and other normal development can be profound. In addition, outcomes including improvements in survival and participation in clinical trials are poorer than in younger children and older adults with similar cancers. These unique circumstances have driven the development of care models specifically for teenagers and young adults with cancer, often focused on a dedicated purpose-designed patient environments supported by a multidisciplinary team with expertise in the needs of teenagers and young adults. In England, this is commissioned by NHS England and delivered through 13 principal treatment centres. There is a lack of evaluation that identifies the key components of specialist care for teenagers and young adults, and any improvement in outcomes and costs associated with it.

Objective

To determine whether or not specialist services for teenagers and young adults with cancer add value.

Design

A series of multiple-methods studies centred on a prospective longitudinal cohort of teenagers and young adults who were newly diagnosed with cancer.

Settings

Multiple settings, including an international Delphi study of health-care professionals, qualitative observation in specialist services for teenagers and young adults, and NHS trusts.

Participants

A total of 158 international teenage and young adult experts, 42 health-care professionals from across England, 1143 teenagers and young adults, and 518 caregivers.

Main outcome measures

The main outcomes were specific to each project: key areas of competence for the Delphi survey; culture of teenagers and young adults care in the case study; and unmet needs from the caregiver survey. The primary outcome for the cohort participants was quality of life and the cost to the NHS and patients in the health economic evaluation.

Data sources

Multiple sources were used, including responses from health-care professionals through a Delphi survey and face-to-face interviews, interview data from teenagers and young adults, the BRIGHTLIGHT survey to collect patient-reported data, patient-completed cost records, hospital clinical records, routinely collected NHS data and responses from primary caregivers.

Results

Competencies associated with specialist care for teenagers and young adults were identified from a Delphi study. The key to developing a culture of teenage and young adult care was time and commitment. An exposure variable, the teenagers and young adults Cancer Specialism Scale, was derived, allowing categorisation of patients to three groups, which were defined by the time spent in a principal treatment centre: SOME (some care in a principal treatment centre for teenagers and young adults, and the rest of their care in either a children’s or an adult cancer unit), ALL (all care in a principal treatment centre for teenagers and young adults) or NONE (no care in a principal treatment centre for teenagers and young adults). The cohort study showed that the NONE group was associated with superior quality of life, survival and health status from 6 months to 3 years after diagnosis. The ALL group was associated with faster rates of quality-of-life improvement from 6 months to 3 years after diagnosis. The SOME group was associated with poorer quality of life and slower improvement in quality of life over time. Economic analysis revealed that NHS costs and travel costs were similar between the NONE and ALL groups. The ALL group had greater out-of-pocket expenses, and the SOME group was associated with greater NHS costs and greater expense for patients. However, if caregivers had access to a principal treatment centre for teenagers and young adults (i.e. in the ALL or SOME groups), then they had fewer unmet support and information needs.

Limitations

Our definition of exposure to specialist care using Hospital Episode Statistics-determined time spent in hospital was insufficient to capture the detail of episodes or account for the variation in specialist services. Quality of life was measured first at 6 months, but an earlier measure may have shown different baselines.

Conclusions

We could not determine the added value of specialist cancer care for teenagers and young adults as defined using the teenage and young adult Cancer Specialism Scale and using quality of life as a primary end point. A group of patients (i.e. those defined as the SOME group) appeared to be less advantaged across a range of outcomes. There was variation in the extent to which principal treatment centres for teenagers and young adults were established, and the case study indicated that the culture of teenagers and young adults care required time to develop and embed. It will therefore be important to establish whether or not the evolution in services since 2012–14, when the cohort was recruited, improves quality of life and other patient-reported and clinical outcomes.

Future work

A determination of whether or not the SOME group has similar or improved quality of life and other patient-reported and clinical outcomes in current teenage and young adult service delivery is essential if principal treatment centres for teenagers and young adults are being commissioned to provide ‘joint care’ models with other providers.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.

Understanding Adolescent and Young Adult 6-Mercaptopurine Adherence and mHealth Engagement During Cancer Treatment: Protocol for Ecological Momentary Assessment

BACKGROUND

Adolescents and young adults (AYAs) with cancer demonstrate suboptimal oral chemotherapy adherence, increasing their risk of cancer relapse. It is unclear how everyday time-varying contextual factors (eg, mood) affect their adherence, stalling the development of personalized mobile health (mHealth) interventions. Poor engagement is also a challenge across mHealth trials; an effective adherence intervention must be engaging to promote uptake.

OBJECTIVE

This protocol aims to determine the temporal associations between daily contextual factors and 6-mercaptopurine (6-MP) adherence and explore the proximal impact of various engagement strategies on ecological momentary assessment survey completion.

METHODS

At the Children's Hospital of Philadelphia, AYAs with acute lymphoblastic leukemia or lymphoma who are prescribed prolonged maintenance chemotherapy that includes daily oral 6-MP are eligible, along with their matched caregivers. Participants will use an ecological momentary assessment app called ADAPTS (Adherence Assessments and Personalized Timely Support)-a version of an open-source app that was modified for AYAs with cancer through a user-centered process-and complete surveys in bursts over 6 months. Theory-informed engagement strategies will be microrandomized to estimate the causal effects on proximal survey completion.

RESULTS

With funding from the National Cancer Institute and institutional review board approval, of the proposed 30 AYA-caregiver dyads, 60% (18/30) have been enrolled; of the 18 enrolled, 15 (83%) have completed the study so far.

CONCLUSIONS

This protocol represents an important first step toward prescreening tailoring variables and engagement components for a just-in-time adaptive intervention designed to promote both 6-MP adherence and mHealth engagement.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32789.

Prevalence of non-adherence and non-compliance during maintenance therapy in adults with acute lymphoblastic leukemia and their associations with survival

OBJECTIVES

Explore patient adherence and physician compliance to protocol guidelines during maintenance therapy, including the association with survival in adults with acute lymphoblastic leukemia (ALL).

METHODS

Blood counts, aminotransferase levels and prescribed 6-mercaptopurine (6MP)/methotrexate (MTX) doses were compared with the protocol guidelines to assess compliance. Non-adherence to the prescribed medication was confirmed in patients with unmeasurable 6MP metabolite levels and suspected in patients with low 6MP metabolites concurrent with aminotransferase and white blood cell count within normal ranges, while potential intermittent non-adherence was defined by >1.9 fold fluctuating 6MP metabolites.

RESULTS

Physicians' non-compliance with insufficient dose increments of 6MP/MTX despite white blood cell counts above the target level comprised a median of 20.1% (interquartile range 9.7-39.3%) of the observed time in maintenance therapy, yet no association to relapse was found (P = .17). Non-adherence to 6MP was confirmed in 9.8% (5 of 51 patients), suspected in an additional 9.8% (5 of 51 patients), and intermittent non-adherence was suspected in 52.6% (20 of 38 patients).

CONCLUSION

Although no association between non-compliance and leukemic relapse was found, likely due to lack of power, increased attention to this phase of ALL therapy is indicated.

Health Behavior and Associated Factors in Young Adult Cancer Patients

Objectives: Having cancer in young adulthood increases the risk of adverse long-term health effects. These risks can be influenced by one’s health behavior (HB). The aim of this study is therefore to investigate the presence of health behavior in adolescents and young adults (AYAs) and to identify associated factors.

Design: Young cancer patients (18–39 years old at time of diagnosis) were surveyed at baseline and 12 months later via online or as a paper-pencil version.

Methods: A spectrum of indicators for HB was assessed via seven items from the Questionnaire of Multiple Health Behavior (MHB). Multiple linear regression analyses were conducted to determine factors associated with patients’ HB indicators.

Results: Five-hundred and fourteen AYAs (75% women) reported the highest level of health-conscious behavior for “avoidance of consumption of nicotine,” “follow medical recommendations,” and “being considerate in road traffic.” Less health-conscious behavior was reported for “keeping an appropriate and balanced diet” and “physical activity.” Significant improvements from baseline to the follow-up were observed for “regularly attending health screening” (Hedges’ g = 0.44). The analyzed factors explained up to 10% of the HB indicators. Women reported significantly more health-conscious behavior than men in four out of seven HB indicators. Higher quality of life (QoL) was associated with more health behavior in three out of seven HB indicators.

Conclusion: Findings show a predominantly health-conscious lifestyle in AYA cancer patients, though we also found harmful behavior which needs to be better approached—e.g., through improving AYAs’ health education. AYA men should be particularly targeted in specific prevention and health promotion measures. Future work should identify other factors associated with HB to evaluate targets for intervention.

Disparities in Cancer Survival Among Adolescents and Young Adults: A Population-Based Study of 88 000 Patients

BACKGROUND

Adolescents and young adults (AYA, aged 15-39 years) diagnosed with cancer comprise a growing, yet understudied, population. Few studies have examined disparities in cancer survival in underserved and diverse populations of AYA.

METHODS

Using population-based data from the Texas Cancer Registry, we estimated 5-year relative survival of common AYA cancers and examined disparities in survival by race and ethnicity, neighborhood poverty, urban or rural residence, and insurance type. We also used multivariable Cox proportional hazards regression models to examine associations of race or ethnicity, neighborhood poverty, urban or rural residence, and insurance type with all-cause mortality.

RESULTS

We identified 55 316 women and 32 740 men diagnosed with invasive cancer at age 15-39 years between January 1, 1995, and December 31, 2016. There were disparities in relative survival by race and ethnicity, poverty, and insurance for many cancer types. Racial and ethnic disparities in survival for men with non-Hodgkin lymphoma (74.5% [95% confidence interval (CI) = 72.1% to 76.7%] White vs 57.0% [95% CI = 51.9% to 61.8%] Black) and acute lymphocytic leukemia (66.5% [95% CI = 61.4% to 71.0%] White vs 44.4% [95% CI = 39.9% to 48.8%] Hispanic) were striking, and disparities remained even for cancers with excellent prognosis, such as testicular cancer (96.6% [95% CI = 95.9% to 97.2%] White vs 88.7% [95% CI = 82.4% to 92.8%] Black). In adjusted analysis, being Black or Hispanic, living in high-poverty neighborhoods, and having Medicaid, other government insurance, or no insurance at diagnosis were associated with all-cause mortality in both women and men (all 2-sided P < .01).

CONCLUSIONS

Our study adds urgency to well-documented disparities in cancer survival in older adults by demonstrating persistent differences in relative survival and all-cause mortality in AYAs. Findings point to several areas of future research to address disparities in this unique population of cancer patients.

Associations between geographic residence and US adolescent and young adult cancer stage and survival

BACKGROUND

Multiple studies have indicated that place of residence can influence cancer survival; however, few studies have specifically focused on geographic factors and outcomes in adolescents and young adults (AYAs) with cancer. The objective of this study was to evaluate evidence for geographic disparities in cancer diagnosis stage and overall survival in AYAs and to examine whether stage mediated survival associations.

METHODS

National Cancer Database data on AYAs aged 15 to 39 years who were diagnosed with cancer from 2010 to 2014 were obtained. Residence in Metropolitan (metro), urban, or rural counties at the time of diagnosis was defined using Rural-Urban Continuum Codes. Distance between the patient's residence and the reporting hospital was classified as short (≤2.5 miles), intermediate (>12.5 to <50 miles), or long (≥50 miles). Logistic and Cox proportional hazards regression models were used for analyses.

RESULTS

The stage and survival analyses included 146,418 and 178,688 AYAs, respectively. The odds of a late versus early stage at diagnosis (stages III and IV vs I and II) were 1.16 (95% CI, 1.05-1.29) times greater for AYAs living in rural versus metro counties and 1.20 (95% CI, 1.16-1.25) times greater for AYAs living at long versus short distances to the reporting hospital. The hazard of death was 1.17 (95% CI, 1.05-1.31) and 1.30 (95% CI, 1.25-1.36) times greater for those living in rural versus metro counties, respectively, and for long versus short distances to the reporting hospital, respectively. Disease stage mediated 54% and 31% of the associations between metro, urban, or rural residence and residential distance categories and survival.

CONCLUSIONS

Rural residence and living long distances from the reporting hospital were associated with later stage diagnoses and lower survival in AYAs with cancer. Further research is needed to understand mechanisms.

LAY SUMMARY

Adolescents and young adults (AYAs) with cancer are a vulnerable population because cancer is of low suspicion in this population and may not be diagnosed in a timely manner. The authors evaluated evidence for geographic disparities in cancer stage at diagnosis and survival in the AYA population. The findings indicate that AYAs living in rural versus metropolitan US counties and those living farther from the diagnosis reporting hospital are more likely to be diagnosed at a later cancer stage, when it is generally less treatable, and have lower survival compared with AYAs living in metropolitan counties.

Individual prediction of nonadherence to oral mercaptopurine in children with acute lymphoblastic leukemia: Results from COG AALL03N1

BACKGROUND

Poor mercaptopurine (6MP) adherence (mean adherence rate < 90%) increases the relapse risk among children with acute lymphoblastic leukemia (ALL). 6MP adherence remains difficult to measure in real time. Easily measured patient-level factors could identify patients at risk for poor adherence.

METHODS

The authors measured 6MP adherence via electronic monitoring for 6 months per patient. Using data from month 3, they created a risk prediction model for 6MP nonadherence in 407 children with ALL (mean age, 7.7 ± 4.4 years); they used receiver operating characteristic analyses in the training set (n = 250) and replicated this in the test set (n = 157).

RESULTS

Age, race/ethnicity, 6MP dose intensity, absolute neutrophil count, 6MP ingestion patterns, and household structure were retained in the prediction model. The model yielded areas under the receiver operating characteristic curve (AUCs) of 0.79 (95% confidence interval [CI], 0.71-0.85) and 0.74 (95% CI, 0.63-0.85) in the training and test sets, respectively. The model performed better for those who were ≥12 years old (AUC, 0.79; 95% CI, 0.59-0.99) than those <12 years old (AUC, 0.70; 95% CI, 0.58-0.81). Using the predicted probability of nonadherence based on receiver operating characteristic analysis, the authors developed a binary risk classifier to classify patients with a high or low probability of nonadherence. The sensitivity and specificity of the binary risk classifier were 71% and 76%, respectively. Adjusted for clinical prognosticators, the risk of relapse was 2.2-fold higher (95% CI, 0.94-5.1; P = .07) among patients with a high probability of nonadherence in comparison with those with a low probability, as identified by the risk prediction model.

CONCLUSIONS

The risk prediction model identified patients with a high probability of nonadherence and could be used in real time to personalize recommendations and interventions in the clinic.

LAY SUMMARY

The vast majority of children with acute lymphoblastic leukemia, the most common childhood cancer, are cured. The treatment of acute lymphoblastic leukemia includes taking an oral chemotherapy medicine (mercaptopurine) for approximately 2 years. Children who miss doses of this medicine (specifically children who take the medicine less than 90% of the time that it is prescribed) are more likely to suffer leukemia relapse. The authors of this article have measured mercaptopurine adherence with electronic bottle caps to determine characteristics of patients that predict nonadherence, and they have created a prediction tool that could allow physicians to identify and intervene with patients at high risk of nonadherence.

Communication About Medication by Providers-Adolescent and Young Adult Version: Confirmatory Factor Analyses

OBJECTIVE

To replicate the factor structure of a patient-report measure of provider communication about key medication prescription information, the Communication about Medication by Providers-Adolescent and Young Adult (CAMP-AYA) Version. We evaluated whether the 15-item, two-factor structure identified previously could be replicated via confirmatory factor analysis, and we also examined fit of unidimensional and bifactor models. Associations of CAMP-AYA Total and Factor Scores with provider satisfaction and select patient and medication characteristics were also examined.

METHODS

Participants were 739 AYA (ages 18-25) who completed the CAMP-AYA, a provider satisfaction rating, and provided demographic and medication information.

RESULTS

The bifactor model was best fitting (χ2 [75] = 689.60, p < .0001; root mean squared error of approximation = 0.11, 90% CI [0.10, 0.11]; Comparative Fit Index = 0.98; Tucker-Lewis Index = 0.98; Standardized Root Mean Square Residual Index = 0.02). Internal consistency reliabilities for Total and Factor Scores were high (αs > .89) and Total and Factor Scores were associated with provider satisfaction (ps < .001). CAMP-AYA scores varied as a function of type of prescription (short vs. long term; new vs. refill), with higher scores reported in the context of long term (>30-day course) or refilled prescriptions (ps < .007) in most cases.

CONCLUSIONS

This study provides additional support for the reliability of the CAMP-AYA as a tool to assess AYA perceptions of provider key information coverage about medication prescriptions.

3 Dimensions of Treatment Decision Making in Adolescents and Young Adults With Cancer

BACKGROUND

Adolescents and young adults (AYAs) experience treatment nonadherence rates as high as 60%, which can increase the risk of cancer relapse. Involvement of AYAs in treatment decisions might support adherence to medical treatment.

OBJECTIVE

The aim of this study was to explore the involvement of AYAs, aged 15 to 20 years, in cancer treatment decision making (TDM).

METHODS

Using interpretive focused ethnography, we conducted interviews with 16 AYAs (total of 31 interviews) receiving cancer treatment within 1 year of diagnosis. Participants reflected on a major recent TDM experience (eg, clinical trial, surgery) and other treatment decisions.

RESULTS

Participants distinguished important major cancer treatment decisions from minor supportive care decisions. We identified 3 common dimensions related to AYAs' involvement in cancer TDM: (1) becoming experienced with cancer, (2) import of the decision, and (3) decision-making roles. The preferences of AYAs for participation in TDM varied over time and by type of decision. We have proposed a 3-dimensional model to illustrate how these dimensions might interact to portray TDM during the first year of cancer treatment for AYAs.

CONCLUSIONS

As AYAs accumulate experience in making decisions, their TDM preferences might evolve at different rates depending on whether the decisions are perceived to be minor or major. Parents played a particularly important supportive role in TDM for AYA participants.

IMPLICATIONS FOR PRACTICE

Clinicians should consider the AYAs' preferences and the role they want to assume in making different decisions in order to support and encourage involvement in their TDM and care.

Daily text message assessments of 6-mercaptopurine adherence and its proximal contexts in adolescents and young adults with leukemia: A pilot study

BACKGROUND

This pilot study explored the feasibility and acceptability of implementing text-based assessments of oral chemotherapy adherence in adolescents and young adults (AYA) with leukemia.

METHODS

AYA prescribed maintenance 6-mercaptopurine (6MP) received daily text message surveys and utilized an electronic pill bottle for 28 days. Text surveys assessed 6MP adherence and contextual associates (eg, mood). Feasibility was defined by recruitment/retention rates, survey completion rates, cost, and technical issues. After the 28-day period, AYA completed an acceptability survey. Secondary analyses compared text survey and electronic pill bottle adherence rates, and explored the daily associations between contextual factors and 6MP nonadherence.

RESULTS

Eighteen AYA enrolled (M age = 18, range 15-22) and completed study procedures (100% recruitment and retention rates). Adherence survey completion rates were high (M = 88.9%), the technology cost was $204.00, and there were few technical issues. AYA reported high satisfaction with the surveys and perceived them as a helpful medication reminder. While not significantly correlated, survey and electronic pill bottle adherence data converged on the majority of days (>90%). Exploratory analyses showed that AYA were more likely to miss a dose of 6MP on weekends (OR = 2.33, P = .048) and on days when their adherence motivation (OR = 0.28, P = .047) and negative affect (OR = 3.92, P = .02) worsened from their own typical functioning.

CONCLUSIONS

For AYA with leukemia, daily text-based surveys are a feasible and acceptable method for delivering medication adherence assessments, and may operate as a short-term intervention. To develop personalized mobile health interventions, findings also highlighted the need to study time-varying predictors of 6MP nonadherence.

Identifying and Meeting the Needs of Adolescents and Young Adults with Cancer

PURPOSE OF REVIEW

Adolescents and young adults (AYAs) with cancer are a vulnerable population with unique needs that are under-recognized and often overlooked by healthcare providers. This review focuses on identifying and meeting some of those needs including adherence to treatment, financial implications, impact on fertility and intimacy, issues with work/school, isolation, challenges with re-entry, and long-term side effects and survivorship.

RECENT FINDINGS

Survival rates have not improved in adolescents and young adults with cancer at the same rate as in children and older adults (the so called "AYA gap"). Restricted or delayed access to care and inconsistent cancer treatment and follow-up care contribute to this. Importantly, fertility preservation options have broadened and efforts to provide age appropriate counseling prior to treatment have improved. Additionally, AYAs face a variety of psychosocial issues while dealing with a cancer diagnosis during critical developmental years, and yet data pertaining to the successful identification and management of these issues is lacking. As a result, there has been recent increasing awareness that this patient population warrants strong advocates, additional research, and requires age group specific resources to be successful in navigating their cancer experience during treatment and into survivorship care. Members of the healthcare team should familiarize themselves with the unique needs of AYA cancer patients to provide optimal patient care. In order to build upon early progress, this group calls for additional study particularly when it comes to barriers to enrollment for AYA-specific research (including clinical trials), recognizing psychosocial needs (both during and after treatment), transition planning for returning to life after cancer, and managing long-term effects of treatment (including neuro cognitive changes). In addition, access to financial resources and appropriate mental health support needs to be improved.

Psychosocial Pre-Transplant Screening With the Transplant Evaluation Rating Scale Contributes to Prediction of Survival After Hematopoietic Stem Cell Transplantation

There is no standard in hematopoietic stem cell transplantations (HSCT) for pre-transplant screening of psychosocial risk factors, e.g., regarding immunosuppressant non-adherence. The aim of this prospective study is to explore the predictive value of the pretransplant psychosocial screening instrument Transplant Evaluation Rating Scale (TERS) for mortality in a 3-year follow-up. Between 2012 and 2017 61 patients were included and classified as low (TERS = 26.5-29) and increased-risk group (TERS = 29.5-79.5). Both groups were compared regarding mortality until 36 months after transplantation and secondary outcomes [Medication Experience Scale for Immunosuppressants (MESI); incidence/grade of GvHD]. The increased-risk group (n = 28) showed significantly worse cumulative survival in the outpatient setting (from 3 months to 3 years after HSCT) [Log Rank (Mantel Cox) P = 0.029] compared to low-risk group (n = 29) but there was no significant result for the interval immediately after HSCT until 3 years afterwards. Pre-transplant screening with TERS contributes to prediction of survival after HSCT. The reason remains unclear, since TERS did not correlate with GvHD or MESI. The negative result regarding the interval immediately after HSCT until 3 years could be caused by the intensive in-patient setting with mortality which is explained rather by biological reasons than by non-adherence.

Reasons for missed chemotherapy appointments in retinoblastoma patients undergoing chemotherapy: A report from a Tertiary Care Hospital from India

Background

Delays in chemotherapy due to missed‐appointments can lead to sub‐optimal outcomes in any cancer. Missed appointments or delayed follow up are an important concern in the treatment of pediatric cancers as it compromises the patient's health and overall outcomes.

Aim

This study was conducted to understand the reasons responsible for missed‐appointments in Retinoblastoma (RB) patients scheduled for daycare based chemotherapy.

Methods

We prospectively recorded the causes for missed‐appointments in RB patients from February 2018 to September 2018. A delay of more than 48‐hours from the pre‐scheduled date of chemotherapy was categorized as a “missed‐appointment.”

Results

Out of 870 scheduled visits of patients with RB for chemotherapy to our center, there were 122 (14%) instances of missed‐appointments during the study period. There were 40 instances (4.6%) where the patient had missed‐appointments (possibly avoidable reasons). These 40 instances occurred in 33 patients who had a median age of 29 months (IQR 22.5‐51.5 m) with 22 males. Six patients lived within 100 km of the treating center, 12 lived between 100 and 500 km, and 15 patients lived beyond 500 km. The median length of delay was 13.75 days (IQR‐7‐20.75 days). Twenty‐seven patients used a train as a means of transport, and 10 used the state‐bus. The main cause of delay was the illness of other family members (52.5%) followed by financial issues (27.5%), transport‐related problems (10%), and absence of an adult to accompany (10%).

Conclusion

Causes for missed‐appointments for chemotherapy in RB patients were multifactorial and included the illness of other family members, financial issues, distance/transport‐related problems, and no caregiver to accompany. The future study with a large sample size with a multicenter design is needed to confirm the results of the current study and to know the deficiency in the improvement of the follow‐up RB patients.

Pediatric Psychosocial Standards of Care in action: Research that bridges the gap from need to implementation

OBJECTIVE

To describe innovative models of psychosocial care delivery that align with published Standards of Psychosocial Care of Children with Cancer and their Families, in efforts to bridge the divide between research and practice.

METHODS

The Mattie Miracle Cancer Foundation, in partnership with the American Psychosocial Oncology Society reviewed 22 letters of intent and 13 full grants and awarded small grants to researchers with high quality projects that aimed to implement any of the published 15 Standards of Care. For three of the highest rated funded research projects, we describe the Standard implemented, the novel research design and implementation strategies, and how the research findings might inform the development, implementation, and dissemination of effective solutions for bridging Standard-to-practice gaps.

RESULTS

The first study presented is an innovative eHealth intervention for parents of children with cancer designed to improve family functioning and decrease symptoms of acute distress, anxiety, and posttraumatic stress. The second study addresses the acceptability and feasibility of using daily text message assessments of oral chemotherapy adherence in adolescents and young adults with leukemia, and the third creates a blueprint for providing psychosocial services to siblings, including ways to overcome common implementation barriers.

CONCLUSIONS

Several themes emerged from the studies presented, including (1) attention to barriers to previous attempts at implementation; (2) technology's role in delivering care; (3) the need for stakeholder involvement; and (4) consideration for multi-pronged solutions that address heterogeneity in care settings. Next steps for integrating the Standards of Psychosocial Care into clinical practice are discussed.

Urinary GC-MS steroid metabotyping in treated children with congenital adrenal hyperplasia

BACKGROUND

Treatment of children with classic congenital adrenal hyperplasia (CAH) is a difficult balance between hypercortisolism and hyperandrogenism. Biochemical monitoring of treatment is not well defined.

OBJECTIVE

Cluster analysis of the urinary steroid metabolome obtained by targeted gas chromatography-mass spectrometry (GC-MS) for treatment monitoring of children with CAH.

METHODS

We evaluated 24-h urinary steroid metabolome analyses of 109 prepubertal children aged 7.0 ± 1.6 years with classic CAH due to 21-hydroxylase deficiency treated with hydrocortisone and fludrocortisone. 24-h urinary steroid metabolite excretions were transformed into CAH-specific z-scores. Subjects were divided into groups (metabotypes) by k-means clustering algorithm. Urinary steroid metabolome and clinical data of patients of each metabotype were analyzed.

RESULTS

Four unique metabotypes were generated. Metabotype 1 (N = 21 (19%)) revealed adequate metabolic control with low cortisol metabolites (mean: -0.57z) and suppressed androgen and 17α-hydroxyprogesterone (17OHP) metabolites (-0.79z). Metabotype 2 (N = 23 (21%)) showed overtreatment consisting of a constellation of elevated urinary cortisol metabolites (0.62z) and low metabolites of androgens and 17OHP (-0.75z). Metabotype 3 (N = 32 (29%)) demonstrated undertreated patients with low cortisol metabolites (-0.69z) and elevated metabolites of androgens and 17OHP (0.50z). Metabotype 4 (N = 33 (30%)) presented patients with treatment failure reflected by unsuppressed androgen- and 17OHP metabolites (0.71z) despite elevated urinary cortisol metabolites (0.39z).

CONCLUSION

Metabotyping, which means grouping metabolically similar individuals, helps to monitor treatment of children with CAH using GC-MS urinary steroid metabolome analysis. This method allows classification in adequately-, over-, or undertreated children as well as identification of patients with treatment failure.

Evaluating Perspectives of a Smartphone Medication Application in the Adolescent and Young Adult Oncology Population: A Qualitative Study

Purpose: Medication adherence research involving adolescent and young adult (AYA) oncology patients has consisted of small, retrospective studies demonstrating poor adherence rates. Technology plays an active role in attempt to improve medication adherence. There is a growing body of literature investigating the role of smartphone applications (apps). We hypothesized a medication phone app, MedActionPlan Pro (MPP), leads to perceived improvement in medication adherence. Methods: Thirty AYA oncology patients actively receiving treatment (AYA defined as 15-30 years) at Nationwide Children's Hospital were enrolled. Participants downloaded the MPP app on their smartphone for 3 months, during which time participants were provided text messages and alerts to encourage medication adherence. Post-app use, participants completed semi-structured interviews. Interviews were audio-recorded, transcribed, and independently coded to determine consensus thematic content. Results: Thirty AYA oncology participants (16 male), median age 17.5 (range: 15-30 years), participated in the study, with 22 participants (55% male) with a median age of 18 years (range: 15-30 years) participated in the final qualitative survey interview. Participants reported positive views about app utilization and perceived improved medication adherence. Additional themes included perceived decreased forgetfulness, improved organization, and identified customization for medications within the app was most important to AYAs. Conclusion: AYA oncology patients reported improvement in perceived medication adherence utilizing MPP and identified several features they thought would lead to improved medication adherence. These findings, integrated with previous literature, support the further need to investigate the utility of medication adherence apps that fit the unique needs of AYA oncology patients.

Internet-delivered insomnia intervention improves sleep and quality of life for adolescent and young adult cancer survivors

BACKGROUND

Insomnia is common among adolescent and young adult (AYA) cancer survivors. Cognitive-behavioral therapy for insomnia (CBT-I) is considered the gold standard treatment. Standard CBT-I was designed for adults and not adapted to the unique medical, psychosocial, and developmental needs of AYA cancer survivors, which can exacerbate their insomnia. Further, the vast majority of cancer centers do not have a behavioral sleep medicine expert on staff. Our study objective was to examine the efficacy of an Internet-delivered CBT-I program that was tailored for AYA cancer survivors (NCT03279055).

PROCEDURE

Twenty-two AYA cancer survivors (mean age 20.4; range 14-25) with insomnia enrolled in an automated CBT-I program modified for AYA cancer survivors following stakeholder feedback. Participants were blood cancer (54.5%) and solid tumor (45.5%) survivors, an average of 9.7 years postdiagnosis. Sleep health, fatigue, and quality of life were assessed at baseline and at two follow up timepoints (8 and 16 weeks postbaseline).

RESULTS

Significant improvements in insomnia severity, daytime sleepiness, fatigue, and quality of life were reported at both follow up timepoints. However, most participants (72.7%) did not complete all of the six study sessions, with a mean completion rate of 3.2 sessions. Participants who completed at least two sessions reported better sleep (insomnia severity index total score) than those who did not.

CONCLUSIONS

An Internet-delivered insomnia intervention adapted for AYA cancer survivors was efficacious. This has important implications for access to evidence-based clinical care for this growing population. Future efforts should study stepped care models of care and ways to improve treatment adherence.

The association of health status and cancer history of young adult survivors of childhood cancer with parental accompaniment to survivorship clinic visits

PURPOSE

Adult childhood cancer survivors are frequently accompanied by a parent to survivorship clinic. From clinical evaluations among young adult survivors of childhood cancer we aimed to (1) investigate the association between accompaniment and the survivors' health complexity; and (2) determine whether accompaniment is associated with adherence to recommended surveillance tests and follow-up in clinic.

METHODS

This was a cross-sectional study of all patients ≥ 18 years old at their first visit to the regional Yale Childhood Cancer Survivorship Clinic from 2003 to 2018. Patients underwent standardized evaluations for medical, neurocognitive, and emotional late effects of therapy; individuals accompanying patients were documented.

RESULTS

The 168 patients were a median of 12.0 (range: 0-17.9) years at diagnosis and 22.7 (range: 18.1-39.9) years at evaluation, and 45.8% were accompanied by a parent. In multivariable analyses, 18.0-24.99 years vs. 25.0-39.99 years at visit (OR = 3.43, p = 0.022) and central nervous system (CNS) tumor diagnosis (OR = 6.09 vs. leukemia/lymphoma diagnosis, p = 0.010) were significantly associated with parental accompaniment. Accompaniment was not associated with number and severity of medical late effects, neurocognitive impairment, or emotional distress. Accompaniment was not associated with completed surveillance tests or a clinic follow-up within 2 years.

CONCLUSION

Forty-six percent of survivors were accompanied by a parent, and accompaniment was not associated with survivor health status. Accompaniment was not associated with adherence to recommended surveillance tests or clinic follow-up.

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).

Adherence to e-mental health among youth: Considerations for intervention development and research design

E-mental health programmes have great potential to provide young people with access to mental health support. However, it is commonly reported that adherence to these programmes is low. Low adherence can be problematic, particularly if young people do not receive the full benefits of a programme. In a research trial setting, non-adherence to treatment recommendations can prevent researchers from drawing strong conclusions about effectiveness. Although adherence has been recognised as an issue in need of attention, many of the reviews available are focused on adults and lack clear direction towards what strategies to employ. This paper presents a broad review of the adherence literature, focusing on factors associated with improving adherence to e-mental health among youth. Our view on the key elements to improve adherence identified from the existing literature are presented, and key recommendations for e-mental health intervention design are provided. These include: developing and communicating adherence guidelines based on individuals’ needs and symptom severity, including customisable features to provide a tailored experience and promote a sense of agency, including engagement checks and adopting a user-centred approach by utilising strategies such as co-design. This paper provides guidance to intervention designers and researchers by outlining recommendations and considerations for intervention development and research design.

Adherence to Multiple Treatment Recommendations in Adolescents and Young Adults with Cancer: A Mixed Methods, Multi-Informant Investigation

Purpose: This mixed methods study sought to assess adolescent and young adult (AYA) adherence to three cancer treatment recommendations (medications, diet, physical activity), and determine the individual, family, and health system factors associated with suboptimal adherence. Methods: In Stage 1, 72 AYA-caregiver dyads completed a validated adherence interview and surveys about individual and family functioning. Matched providers (n = 34 who reported on 61 AYAs) completed global adherence ratings through survey. In Stage 2, a subset (n = 31) completed qualitative interviews. Results: Medication adherence was higher (M = 94.8%) than diet (M = 73.9%) and physical activity (M = 55.4%), although ≥50% demonstrated "Imperfect Adherence" for each subtask. Univariately, AYAs who missed a medication had more depressive symptoms, worse health-related quality of life (HRQOL), and more medication barriers; their families had more financial stress, worse family functioning, and lower self-efficacy. The odds of adhering to medications were lower with worse HRQOL (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.02-1.15) and family functioning (OR = 0.18; 95% CI, 0.04-0.91). The odds of adhering to physical activity and diet were lower with worse family functioning (OR = 0.09; 95% CI, 0.01-0.91) and more barriers (OR = 0.24, CI: 0.10-0.61), respectively. Qualitative themes further supported multilevel influences on AYA adherence. Conclusions: Adherence challenges were identified across medications, diet, and physical activity. Multilevel contextual factors were associated with suboptimal adherence, including poorer HRQOL and family functioning. Findings support the need to improve clinical adherence assessment and develop contextually tailored interventions.