Bridget M. Kuehn

March 17, 2016

CHICAGO — Young people with cancer are just like old people with cancer — except they tend to have a lot less money, to be more interested in sex, may still live with their parents, or are raising little children of their own.

These and other unique needs of adolescent and young adult patients make palliative care especially important, according to speakers here at the Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA).

But many of these patients are currently not receiving such care, they added.

Cancer patients aged 15 to 39 years often fall into a gap between pediatric and adult oncology. For these patients, treatment and palliative care programs geared to their unique needs are lacking, according to speaker David Hui, MD, of the University of Texas MD Anderson Cancer Center, in Houston.

Clinically, cancers that affect this age group are often aggressive and are driven by genetics, Dr Hui noted. Younger patients face many years of coping with consequences of cancer treatment. Their psychosocial needs are different, because they are in a period of life transition. Many are single, and others have young families. They may be in school or starting a career.

"Cancer hits, and it changes the trajectory of their life," Dr Hui said.

Palliative care can help these patients to address some of the physical, psychological, and practical challenges of cancer during adolescence and young adulthood, said Eric Prommer, MD, University of California, Los Angeles. The National Comprehensive Cancer Network offers a guideline that can be useful for meeting the needs of this population, he said.

"Palliative care fits in for these patients very well," Dr Prommer said. "When you first encounter these patients, you want to think prevention."

He explained that palliative care teams should start by assessing the youth's support system, and they should use tools to assess the patient's stress and coping ability. Friends or fellow cancer patients or survivors are often very important sources of support for this age group, Dr Prommer noted. Support groups, online communities, and patient retreats can all be valuable sources of support for young cancer patients.

Younger patients may also be less financially secure than older adult patients, Dr Hui noted. Some may rely on a parent, but others may be unable to pay their bills or support their own children because they are unable to work, he said.

"They have a lot fewer resources to address their needs," he added.

It is also important to understand what is important to patients in this age group and to encourage flexibility in the treatment of these patients, Dr Prommer said.

"What appears irrational [such as missing appointments or skipping medication] might be rational to the [adolescent or young adult with cancer]," he said.

For example, Mary Buss, MD, of Beth Israel Deaconess Medical Center, in Newton, Massachusetts, said one of her patients, a married father in his late 30s who has melanoma, sometimes runs out of pain medication and winds up in a pain crisis.

"He constantly says, 'I just want a day off,' " Dr Bruss said. "He's never off from being a cancer patient. He tries, and he winds up in a crisis."

Being flexible can help, Dr Prommer commented. For example, scheduling treatment around important social events, such as a prom or a child's recital, can improve adherence to treatment and reduce missed appointments.

"Avoid a punitive tone," he emphasized. He explained that youth often respond negatively to clinicians they feel are cold or patronizing.

Palliative care for adolescent and young adult patients should also address the patient's long-term needs, said Kelly Cooke, DO, of ProHealth Care, in Eagle, Wisconsin. Patients should be asked about sexuality and whether they would like to take steps to preserve their reproductive capacity, such as by freezing eggs or sperm prior to treatment. Often, these conversations, which can be uncomfortable for patients and clinicians, take multiple tries, she said.

"We need to ask," Dr Cooke said. "Some patients get chemotherapy without being asked about reproduction."

She further explained that adolescence and young adulthood are critical periods for mental health and development. Youth are trying to become independent of their parents and establish themselves as adults. Many mental conditions, such as schizophrenia and bipolar disorder, emerge during this period of life. Clinicians should be vigilant for signs that a patient is developing a serious mental health problem.

"We can encourage coping and identify maladaptive behaviors," Dr Cooke said.

Dr Prommer said that counseling about alcohol and other substance use is also important for this age group. Ultimately, building long-term and supportive relationships with adolescent and young adult cancer patients is important, because, later in life, many will require additional care for a second malignancy and relapse.

"For this age group, we are there for the long haul," Dr Cooke said.

No relevant financial relationships have been disclosed.

Annual Assembly of the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA): FR453, presented March 11, 2016.


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