Assessing the health care needs of adolescent and young adult cancer patients and survivors

Authors


Abstract

BACKGROUND.

Improvements in cancer outcomes observed for the United States population as a whole are not experienced as such by adolescent and young adult (AYA) patients. The objective of this study was to identify important health and supportive care needs for AYA patients and survivors.

METHODS.

Forty oncology health professionals and 37 young adults (ages 18 years to 44 years; diagnosed between ages 15 years and 39 years) participated on a modified Delphi panel. Over 3 iterative rounds of mailed surveys, participants identified, rank ordered, and rated the importance of various items.

RESULTS.

Overall, there was general agreement among health care providers and young adult survivors, with some notable exceptions. Providers and young adult survivors agreed on the relative importance of having adequate health insurance and oncology care that addresses the unique developmental characteristics of this population. Compared with health professionals, young adults ranked the importance of opportunities to meet other young adult survivors at a relatively higher level, and they also ranked those opportunities higher than the importance of support from family and friends.

CONCLUSIONS.

These findings provide oncology professionals and young adults with insight into the others' values and perspectives. These findings also suggest areas in which to target investments of resources to promote quality health care and appropriate informational and supportive care services and to overcome the deficit in survival improvement that has occurred in young adults and older adolescents with cancer. Cancer 2006. © 2006 American Cancer Society.

Progress has been achieved in the treatment of cancer over the past 30 years, as evidenced by improvements in mortality and survival rates for the United States population as a whole. However, disparate outcomes exist for certain subpopulations. For example, from the early 1970s through the late 1990s, cancer incidence among adolescents and young adults (AYAs) aged 15 years to 29 years rose faster, on an annual basis, than that of cancer diagnosed in younger children and older adults.1 In addition, the annual rate of improvement in 5-year survival for older AYAs has been below average compared with the rest of the population (Fig. 1).2, 3

Figure 1.

Average annual percentage change (AAPC) in 5-year relative survival of patients diagnosed with invasive cancer, 1975 to 1998 (United States statistics from the Surveillance, Epidemiology, and End Results Program). Relative survival refers to all deaths, regardless of cause. Updated and modified from Hampton T. Cancer treatment's trade-off. JAMA. 2005;294;167–168.2

Identifying the health care needs of cancer patients requires an evaluation of the biologic and psychosocial contexts within which cancer is diagnosed and treated. Bleyer and Albritton3 have suggested that disparities in outcomes for AYAs may be attributable in part to the biology of young people at this stage of life and, thus, indicate treatment-related needs that may differ from those of pediatric or older adult patients. With regard to psychosocial adaptation, Rowland's4 developmental model of adaptation suggests that, although there are common disruptions of cancer (ie, altered interpersonal relationships, dependence-independence, goal achievement disruption, body-sexual image and integrity, and existential issues), the specific needs for patients to address these disruptions vary across different ages or developmental life stages.

Empirical studies of cancer patients have examined the extent to which patients report a universal set of needs. Most of those studies focus on needs as they relate to a specific type of cancer,5–8 type or location of treatment,9, 10 or time at which cancer was diagnosed.6, 10 They most often involve homogenous samples of older adult patients or samples inclusive of patients across a wide range of ages. Few have reported on posttreatment needs11 or the extent of unmet needs.12, 13 Among those studies and others,9, 14, 15 most rely on newly developed or standardized instruments to assess needs related to information, education, and communication and concrete services, like transportation or assistance with activities of daily living, patient care, and psychological support. In some instances, health or supportive care needs are inferred from standardized measures of physical health status and psychosocial outcomes.10, 11 None of those studies, however, assess needs as they relate to an age-specific population of AYA patients. Unlike comprehensive geriatric assessments, which have aided the oncology community in understanding quality-of-life issues and functional needs of older patients,16 no similar assessment of an AYA population has been reported.

To understand the unique characteristics and needs of AYA cancer patients, it is informative to elicit perspectives from 2 primary groups involved in their treatment and care: clinical oncology professionals and the patients/survivors themselves. The perspective of the patient/survivor is noticeably absent from the literature, yet their unique perspective as health care consumers is critical in the process of improving care. Thus, the objective of the current study was to elicit perspectives on health care needs from young adults diagnosed with cancer between ages 18 years and 40 years and from health care professionals who treat this cohort as part of their oncology practice.

MATERIALS AND METHODS

A variation on the Delphi method was used to meet the study objective. The Delphi method is a mixed qualitative-quantitative research tool that enables a panel of experts from a variety of settings to formulate a list of ideas, followed by the development of group consensus concerning the relative importance of those ideas.17, 18 An expert is defined as an individual who has demonstrated knowledge about a subject and an ability to articulate a broad perspective on an issue. In this study, the selection of health professionals was based on a known history of participating in the treatment of AYA cancer patients in either pediatric or adult health care settings and located in community-based clinics, private practices, or large academic medical centers. The young adult participants were identified through their active participation in organizations serving young adult oncology patients (ie, Fertile Hope, Planet Cancer, Young Survivors Coalition). Panel members participated by responding to a questionnaire, which consisted of several iterations or rounds. The questions included in each successive round depended on responses from the previous round. Consensus eventually was attained by rank ordering responses and quantifying attributions of importance. The study was approved by the Institutional Review Board of the University of Southern California.

Participants

The objective of assembling the Delphi panel for this study was to include individuals representing a diversity of experiences and backgrounds. To capture the desired breadth of ideas and concepts from such a group, it was essential that the participants be able to articulate their experiences as well as represent the views of others. The principal investigator (B.Z.) used a purposive snowball sample, identifying participants through his own network of health professionals, researchers, and advocacy organizations. These individuals also were asked to identify others who would have a particularly informed interest in the oncology care of AYAs.

Fifty-seven health professionals, including pediatric and adult oncologists, oncology nurses, social workers, psychologists, and patient advocates, were invited to participate. Twenty-one health professionals completed surveys in all 3 rounds, an additional 10 health professionals completed surveys in 2 of 3 rounds, and 9 more completed 1 survey. Forty-seven young adults between ages 18 years and 44 years who were diagnosed between ages 15 years and 39 years also were invited to participate. Of these, 18 young adults completed surveys in all 3 rounds, 7 completed surveys in 2 of 3 rounds, and an additional 12 completed 1 survey. Thus, in total, 40 health professionals and 37 young adults contributed the information that led to a general consensus on the priority needs of AYA patients and survivors. The self-reported demographic characteristics of the 2 groups are summarized in Tables 1 and 2.

Table 1. Participant Demographics: Health Professionals
VariableNo. of participants
Total n = 40Round 1 n = 29Round 2 n = 30Round 3 n = 35
  1. NA indicates data not available; AYAs, adolescents and young adults.

Health professionals
 Adult oncology physician12869
 Pediatric oncology physician3332
 Nurse106910
 Social worker7666
 Psychologist5445
 Other, patient advocate, academic3223
Practice site, second site
 Community or private practice 111311
 Academic or university health systemNA151118
 Other, eg, internet or missing data 344
Average no. years in oncologyNA18.4119.8518.20
Percentage of practice working with AYAsNA34.3335.8331.92
Table 2. Participant Demographics: Young Adults (N = 37)
 No. of participants
VariableRound 1 n = 29Round 2 n = 25Round 3 n = 26
  1. NA indicates data not available.

Cancer diagnosis
 Brain tumor332
 Breast cancer444
 Endometrial111
 Germ cell, testicular or ovarian434
 Sarcomas434
 Hodgkin lymphoma434
 Leukemia200
 Melanoma212
 Other334
 Unknown or missing data241
Average age at diagnosis (range), y22.93 (15–32)23.85 (15–32)22.68 (15–32)
Current age (range), y31.08 (19–44)31.40 (20–44)31.36 (20–44)

RESULTS

Because the procedures and survey questions for each iterative round depended on results from the previous round, both procedures and results are reported together.

Round 1

The objective of the first round was to generate ideas for the derivation of items to be evaluated by panelists in future rounds. An initial survey for health professionals and another for young adults consisted of open-ended questions. Health professionals were asked to respond to the following statements: 1) List what you believe are biomedical and/or psychosocial needs for young adult cancer patients at diagnosis and during treatment (including palliative and end-of-life care); 2) list what you believe are biomedical and/or psychosocial needs for young adults who are off-treatment survivors; and 3) describe or diagram an idea or vision of what optimal cancer care for young adults (ages 15–40 years) should be, from diagnosis through treatment, and into off-treatment survival or end-of-life. Young adults were asked to respond to similar statements with slightly different wording that reflected less clinical terminology.

One page was provided for responses to each question, with additional pages provided at the end of the questionnaire. When they received the completed surveys, the research team collated, sorted, and edited responses to achieve consistent wording within and across the health professional and young adult groups. They also separated items as they related to patients in treatment or to off-treatment survivors. Then, using constant comparative analysis,19 items were organized around 4 thematic categories: 1) biomedical needs (8 items for patients in treatment and 11 items for off-treatment survivors), 2) individual patient/survivor needs (14 and 13 items, respectively), 3) counseling and emotional support needs (11 items for each group), and 4) other psychosocial needs (12 items for each group).

Health professionals and young adults identified many common issues and needs in Round 1 that appeared subsequently in the Round 2 survey. However, items that appeared in the health professionals' Round 2 survey only reflected content mentioned by health professionals in Round 1. Similarly, only content mentioned by young adults in Round 1 appeared as survey items in their Round 2 survey. Thus, the 2 surveys were not entirely identical, so that panelists were not asked to respond to items that they or their colleagues had not identified as relevant in prior rounds.

Round 2

The objective of Round 2 was to identify dominant and most highly endorsed items for each of the thematic areas. A 13-page questionnaire was developed for Round 2 that consisted of all responses listed in Round 1 grouped into the 4 thematic categories described above. For Round 2, panelists were directed to 1) score the importance of each item, 2) rank order the 5 most important items within each category, and 3) add further items to the list, if necessary. Mean importance scores for each item were calculated for each group based on a 7-point Likert scale from 0 (not at all important) to 6 (critically important). Rank scores were calculated by tabulating the number of times an item was ranked first, second, third, fourth, or fifth and then awarding 5 points to an item for each time a respondent ranked it first, 4 points for each time a respondent ranked it second, and so on. Rank scores were then ordered to determine the 5 most highly ranked items within each content area and for each group of respondents.

Round 3

The objective of Round 3 was to gain a consensus on the ranking of the items for each thematic category. The 58 items that were included in the Round 3 questionnaire for health professionals were those in which either rank scores from Round 2 indicated that at least 1 group (physicians, nurses, psychosocial professionals) aggregately ranked the item in the top 5, or the mean level of importance for an item calculated in Round 2 was ≥4. The same was true for the young adult survey, which comprised 45 items.

For Round 3, a 6-page questionnaire was mailed to panelists. Qualifying items were organized under the headings ‘Biomedical Treatment-related Needs,’ ‘Counseling, Information, and Supportive Care Needs,’ and ‘Other Psychosocial Needs.’ Again, headings and items were categorized for patients on treatment and for off-treatment survivors, and respondents were asked to rank order items for each section. Tables 3 through 5 summarize the top 5 ranked needs for patients in treatment, as rated by respondents in the aggregate. Tables 6 through 8 summarize the top 5 ranked needs for off-treatment survivors. Values in the tables represent 1) the ranking of an item for each group as determined by the calculated rank score, and 2) the mean importance score for each item.

Table 3. Biomedical Treatment-Related Needs at Diagnosis and During Treatment*
Physicians n = 11Nurses n = 10Psychosocial professors n = 14Young adults n = 26Needs
RankImportance ScoreRankImportance ScoreRankImportance ScoreRankImportance Score
  • AYAs indicates adolescents and young adults; NI, not included in the young adult survey.

  • *

    Values in the table represent 1) the ranking of an item for each group as determined by the calculated rank score (Rank) and 2) the average importance of the item for each group based on a Likert scale from 0 (not at all important) to 6 (critically important) (Importance Score).

14.8935.3835.4225.6Treatment decisions that account for risks to fertility, athleticism, education, career development, and other quality-of-life issues
25.1124.7515.815.08Availability of a multidisciplinary team of providers who are knowledgeable about specifics of treatment for AYAs (in terms of appropriate and adequate dosing, tolerance for different drugs, developmental issues, etc.)
45.1145.2525.535.16Clinical trials and state-of-the-art treatment protocols designed specifically for cancers diagnosed in AYAs
34.3315.2574.7554.92Management of side effects and symptoms (hair loss, nausea, diarrhea, pain, constipation, fatigue, neuropathy, etc.)
54.8965.254565.36Fertility-preservation services, including pretreatment information and counseling, to address infertility risks and options for fertility preservation
63.6754.6254.42NI Treatment regimens that fit into AYA's lifestyles (scheduling around school or work, day care for AYAs with children, etc.)
7495.2565.3345.36Physicians who consider cancer as a possible diagnosis for AYAs
Table 4. Counseling, Information, and Supportive Care Needs at Diagnosis and During Treatment*
Physicians n = 11Nurses n = 10Psychosocial professors n = 14Young adults n = 26Needs
RankImportance ScoreRankImportance ScoreRankImportance ScoreRankImportance Score
  • AYAs indicates adolescents and young adults.

  • *

    Values in the table represent 1) the ranking of an item for each group as determined by the calculated rank score (Rank) and 2) the average importance of the item for each group based on a Likert scale from 0 (not at all important) to 6 (critically important) (Importance Score).

15.5615.754 (Tie)5.555.64Support from family and friends
35.3334.3815.3315.64Opportunities to meet other young adult cancer patients and/or survivors (ie, peer support programs or buddy systems linking AYAs to others with similar diseases at similar life stages/ages)
24.6724.8824.8324.72Individualized information (written and/or verbal) about their disease, treatment, possible side effects, and potential late effects of therapy
44.8944.2534.7534.76Specialized and developmentally-appropriate sources of information for AYAs, such as resource library, electronic information, Internet websites, or brochures
54.7855.1365.5885.12Psychological and behavioral risk assessment and counseling to manage distress (eg, anxiety, depression)
124.4493.884 (Tie)4.9245.24A community-based center or regional network of support programs that address age-appropriate developmental and psychosocial issues
Table 5. Other Psychosocial Needs at Diagnosis and During Treatment*
Physicians n = 11Nurses n = 0Psychosocial professors n = 4Young adults n = 26Needs
RankImportance ScoreRankImportance ScoreRankImportance ScoreRankImportance Score
  • NI indicates not included in the young adult survey.

  • *

    Values in the table represent 1) the ranking of an item for each group as determined by the calculated rank score (Rank) and 2) the average importance of the item for each group based on a Likert scale from 0 (not at all important) to 6 (critically important) (Importance Score).

1515.3815.6416.54Adequate health insurance coverage
35.673 (Tie)5.252 (Tie)5.4265.2To keep hopes and dreams alive
55752 (Tie)5.4245.4Ability to communicate with spouse/partner or a future spouse/partner about cancer history, side effects, and potential health risks
75.2224.632 (Tie)5.1825.12Reassurance that their physical and emotional responses to cancer are “normal”
94.563 (Tie)55 (Tie)4.7574.8To express feelings about mortality or other existential issues (such as, “Why did this happen to me?”)
44.7855.3885.17NI To maintain a sense of control.
24.4464.7574.534.48Ability to assume responsibility for their own health care and decision-making
105.3884.1384.5854.42To stay involved in social activities
85.1195.135 (Tie)5NI To manage uncertainty about the future
Table 6. Treatment and Long-term Health Care Needs for Off-treatment Survivors*
Physicians (N = 11)Nurses (N = 10)Psychosocial professors (N = 14)Young adults (N = 26)Needs
RankImportance ScoreRankImportance ScoreRankImportance ScoreRankImportance Score
  • AYAs indicates adolescents and young adults; NI, not included in the young adult survey.

  • *

    Values in the table represent 1) the ranking of an item for each group as determined by the calculated rank score (Rank) and 2) the average importance of the item for each group based on a Likert scale from 0 (not at all important) to 6 (critically important) (Importance Score).

15.3315.2515.1715.32On-going surveillance and assessment of long-term effects of cancer treatment
24.334534.924 (Tie)5.12Defined standards or evidence-based guidelines for follow-up care
44.563555.1725.20A system for transitioning care from oncologists to primary care providers who will adhere to plans developed by physicians who treat AYAs
34.4464.7525.3335.36Recognition among health care professionals that off-treatment survival is a new stage of patient care
74.5675.0045.004 (Tie)4.96A system that keeps survivors informed about changing treatment standards and long-term follow-up
64.8925.5074.75NI Symptom management (fatigue, pain, etc.)
74.675564.67NI Infertility treatment
54.2284.6375.0NI Cancer survivorship clinical trials
Table 7. Counseling, Information, and Supportive Care Needs for Off-treatment Survivors*
Physicians (N = 11)Nurses (N = 10)Psychosocial professors (N = 14)Young adults (N = 26)Needs
RankImportance ScoreRankImportance ScoreRankImportance ScoreRankImportance Score
  • *

    Values in the table represent 1) the ranking of an item for each group as determined by the calculated rank score (Rank) and 2) the average importance of the item for each group based on a Likert scale from 0 (not at all important) to 6 (critically important) (Importance Score).

15.2215.515.0815.24Individualized information (written and/or verbal) provided at completion of therapy detailing history of treatment, type of cancer, surgeries, chemotherapies and dosages, radiation sites and dosages, potential late effects, risks for recurrence or second cancers, and other survivorship issues
24.8935.2525.0835.04Information about sexuality, fertility, and reproductive risks/issues (including pregnancy safety, options for having a family, menopausal symptoms and genetic susceptibility or inheritability for family/offspring risks of cancer)
44.8954.6335.0825.24Opportunities to meet other survivors (through peer-support programs, survivor support groups)
64.7845.1345.5855.12Psychological and behavioral risk assessment and counseling to manage distress (anxiety, depression, posttraumatic stress symptoms)
35.4425.636565.44Support from family and friends
54.6764.6354.8374.68Assistance or encouragement to pursue social activities and relationships (eg, dating, going out with friends, sustaining relationships, finding a mate)
94.7895.1310544.76Financial assistance and benefits counseling (eg, disability benefits, Medicaid/Medicare, help paying outstanding medical bills)
Table 8. Other Psychosocial Needs for Off-treatment Survivors*
Physicians (N = 11)Nurses (N = 10)Psychosocial professors (N = 14)Young adults (N = 26)Needs
RankImportance ScoreRankImportance ScoreRankImportance ScoreRankImportance Score
  • NI-YA indicates not included in Young Adult Survey; NI-HP, not included in the health professionals survey.

  • *

    Values in the table represent 1) the ranking of an item for each group as determined by the calculated rank score (Rank) and 2) the average importance of the item for each group based on a Likert scale from 0 (not at all important) to 6 (critically important) (Importance Score).

1525.381 (Tie)5.6725.64Adequate health insurance
24.7815.131 (Tie)5.2715.40To get back to normal or find a new sense of normal
34.5635.2535.2535.24Ability to express and cope with feelings about cancer (including fears of recurrence, anger, sense of loss or grief, adverse physical effects, bad memories)
55.224 (Tie)4.8875.42NI-YA Assurance that the medical team has not abandoned them
64.44115.134 (Tie)564.64To become independently responsible for their own health care
94.784 (Tie)4.7584.58NI-YA To confront discrimination in work, insurance discrimination, or social stigma
74.2274.624 (Tie)5NI-YA To integrate cancer into self perception/self image
44.4465.2585.08NI-YA To cope with changes to one's life plans
84.6784.7565.2555.12To live with uncertainty
NI-HP NI-HP NI-HP 44.36Opportunities to get involved and “give back” to the cancer community

DISCUSSION

Overall, there appeared to be general agreement among health care providers and young adult survivors with regard to health and supportive care needs, along with some notable exceptions. Notable areas of agreement in terms of high priority biomedical health care needs for patients in treatment included 1) having adequate health insurance coverage; 2) a multidisciplinary approach to the delivery of oncology care; 3) treatment decisions that account for risks to the successful achievement of developmental tasks facing this population, such as education, family planning, career development and employment; and 4) clinical trials and state-of-the-art treatment protocols designed specifically for cancers diagnosed in AYAs. The highest priority areas with regard to health care needs for off-treatment survivors included 1) having adequate health insurance, 2) ongoing medical monitoring for long-term effects, 3) a system for transitioning care from oncologists to primary care providers, and 4) evidence-based guidelines for long-term follow-up care.

All groups recognized the severe importance of having adequate health insurance coverage. The young adults also identified the need for financial assistance and benefits counseling during posttreatment survivorship as a much higher priority than any of the health professional groups. This divergence suggests that young adults may be more cognizant of the stresses of ongoing financial liabilities following cancer treatment.

With regard to counseling, information, and supportive care needs for patients in treatment, health providers and young adults agreed on the following high priority needs: 1) individualized information about disease, treatment, side effects and late effects; 2) informational resources that are appropriate for the developmental stage/age of this population; 3) opportunities to meet other young adult cancer patients and/or survivors (through peer support programs or buddy systems linking AYAs to others with similar diseases at similar life stages/ages); and 4) support from family and friends. For off-treatment survivors, all groups agreed to the high priority of the following: 1) individualized information provided at completion of therapy detailing course of treatment, risks of recurrence and potential late effects, and other survivorship issues; 2) information about sexuality, fertility, and reproductive risks; 3) opportunities to meet other survivors; and 4) ability to express and cope with feelings about cancer, including the desire to return to normal or find a new sense of normal.

Although all groups recognized the importance of support from family and friends, young adults did not rate this need as highly as health care providers. Furthermore, more young adults ranked the relative importance of opportunities to meet other young people with cancer as greater than the importance of support from family and friends. Whereas 50% of young adults ranked support from family and friends as a top 5 need at diagnosis and during treatment, 100% of young adults ranked opportunities to meet other survivors as a top 5 need. Similarly, 62% of young adults ranked support from family and friends as a top 5 need for off-treatment survivors, but 96% of young adults ranked opportunities to meet other survivors as a top 5 need after the completion of treatment. For the most part, health care providers ranked support from family and friends at a relatively higher level than opportunities to meet other survivors both for patients in treatment and for off-treatment survivors.

From a developmental perspective, young adults may be suggesting that socially connecting with same-age peers who have a cancer history may be more beneficial than, or at least different from, the support received from family and friends. These benefits may be experienced as new coping skills learned from other patients and survivors and may manifest in the adoption of positive health behaviors. These young adults also may experience improved self-concept or emotional well-being as a result of making downward comparisons, a cognitive appraisal process by which an individual feels better about himself or herself after comparing his or her own situation with the situation of someone else who appears worse off.20, 21 Or, by being among others who have experienced similar situations, including social exclusion or stigmatization, young adult cancer survivors see in one another the potential to establish strong and meaningful friendships that may, in turn, promote psychological and social well-being.22, 23

Peer involvement is an important element in the lives of older adolescents and young adults. Thus, opportunities to meet others whom they can observe as sharing similar experiences can provide AYAs with a chance to address areas of concern, such as coping with uncertainty, forced dependence on others, social exclusion, body image, intimacy, sexuality and fertility, and career plans.24 Retreats and workshops for AYAs offer these opportunities. In addition, they promote a sense of group identity, which is an important and normal developmental task for this age group. Investigation of the influence of peer support on adjustment and coping for young adults with cancer appears to be a fertile area for future research.

The findings from this study reflect the views of experienced health care providers when it comes to the health care needs of AYAs. They also reflect the views and abilities of a select group of young adult cancer survivors who were able to communicate the needs of their peers who also have experienced cancer. The high level of agreement among providers and young adults in this study was surprising, in that adolescents and young adults often do not communicate their needs and concerns to their oncology care providers. However, the young adult panelists in this study were active in cancer-related settings and were involved in providing services, education, and advocacy. It is possible that their views were influenced by this work.

Thus, in evaluating the generalizability of the current study, potential biases and limitations of the Delphi method should be considered. First, there is a bias in that the views expressed were primarily those of the panelists. The extent to which the health care professionals in this study represent a universe of oncology care providers who treat AYAs is unknown. The same holds true for the young adult panel. That being said, the panel of health care professionals represents a wide swath of viewpoints, professional disciplines, and years of experience. With regard to the survivor participants, their views reflect a breadth and depth of experience as lived through their own cancer as well as through their own interactions with countless other AYA patients and survivors across the country. Of course, the views and needs of young adult patients and survivors who practice avoidance or choose to forget about their cancer experience are not included here. Yet, the empirical findings reported here are not meant to be definitive conclusions about AYA needs. The objective of the Delphi method is to generate ideas and hypotheses for applications in broader and more representative samples of survivors, not to test them. Our intention in conducting this research was to provide a working framework that would generate questions for further exploration and areas for potential intervention. Although the study highlighted needs specific to an AYA population, it did not evaluate the extent to which these needs are being met.

The current findings provide oncology professionals and young adult cancer survivors with insight into each others' values and perspectives. Pending future studies of the extent to which needs are or are not being met, these findings also suggest areas in which to target investments of resources to promote quality health care and develop appropriate informational and supportive care services. Future needs assessments of a more broadly representative sample of young adult patients and survivors ultimately will be needed to overcome the deficit in survival improvement that has occurred in young adults and older adolescents with cancer.

Ancillary