Young Adults with Cancer - An Outpatient Clinics Role in Supporting Care Equity

Vulnerable Cancer Populations: Who are they?  

  Close your eyes and consider an image of a cancer patient who experiences inequity in the Canadian health care system. Did you imagine a young adult as vulnerable to health disparities? Hovsepyan et al (2023) suggest “adolescents and young adults face poorer survival rates than children and adults” (p.2). Young adults with cancer face many challenges in their health journey including inability to work, attend school, build relationships, coping skills, understanding of health teaching, mental health challenges, and adopting healthy behaviour (Berkman et al., 2024). They also have more side effects, financial challenges and a higher likelihood of not following through with care. Further, young adult cancer survivors face potential for recurrence, new cancer, physical impairment, psychological strain, and chronic condition (Cancer Care Ontario, 2023). These risks are compounded by economic inequities background, and race (Berkman et al., 2024; Hovsepyan et al., 2023). In fact, these socioeconomic and behavioral factors result in less comprehensive care and worse long-term outcomes for this age group (Berkman et al., 2024). Erica et al., (2024) outlines, “young adults have not seen the same level of improvement compared to children and older adult survival rates in the last several decades (p. 4007).  

Why is a Multilevel Approach to Care Valuable to this Conversation?  

This approach considers how two or more upstream socio-ecological factors can change overall health and wellbeing (Baumgartner, 2024). According to Pearson (2021), an ecological model considers “individual, interpersonal, institutional, community, and public policy factors” (Ecological models, Para 1). Thus, it is a comprehensive approach to patient care that aligns to the social determinant of health outlined by the Government of Canada. These Determinants of Health (DOH) are named by the Canadian government as, “the broad range of personal, social, economic and environmental factors that determine individual and population health” (social and economic influences on Health, Para 1). In addition, it aligns with the WHO’s consideration for a comprehensive approach to health care (Schramme, 2023). In Ontario, the province supports the WHO’s opinion that social determinants play a significant role in health outcomes.  

These frameworks can also allow the health provider to find specific actions that can be taken within their scope of control to improve care for the individual and similar distinct groups. Finally, organizations and government policy makers can be guided to consider opportunities that are relevant for their communities. A visualization of this structure is presented in Table 1. 

Table 1                                                                                                                                         Ontario’s Perspective on Social Determinants Related to Health

The Survivorship Model: An Ecological Approach to Assisting Young Adults with Cancer 

With the individual or patient at the center of the framework, survivorship highlights the positive impact of interpersonal, organizational, and community support (Berkman et al., 2024). Vitalization presented in table 2 and table 3. 

Table 2 

Clinical and Sociodemographic factors of Cancer Survivorship for Young Adults 

Table 3 

Ecological Approach to Survivorship for Young Adults 

Things Cancer Centers Can Consider Supporting for Young Adults 

The focus of these strategies is associated with outpatient acute care management of cancer care patients falling into the young adult category. 

 

Individual Factors  

  • Consider making primary nurses and routine physician visit spaces less clinical and more inviting and relaxed.  

  • Support a model which allows the patient to have the same nurse and physician for each clinic visit. Consistency in the care model allows for developing a relationship. 

  • Create education aligned specifically to this age group and make them easy to read.  

  •  Normalize difficult topics of conversation (i.e., sexual healthy body image). 

  • Find sponsorship to aid with parking, transportation fees or other financial support related to care. 

  • Allow the patient to connect to psychosocial support to discuss any topic with no cap on appointments. 

  • Create comfortable spaces in the chemo suites and throughout the clinic. Patient and family education rooms, private office space, and nutritional areas. 

  • Encourage young adults to complete My Voice and My Symptoms matters provincial surveys. 

  • Work to develop a fulsome discharge plan that includes clinic visits and educational tools around what happens after acute care is over. Ensure they are aware of future risks for their health. Consider a discharge summary report to primary care provider outlining these ongoing health considerations and recommended future testing. 

  • Work to ensure young adults have a community care provider prior to discharge from the unit. 

Interprofessional influences on Individual Factors  

  • Hire and support a social worker dedicated to the cancer clinic to allow direct referral by nursing, physicians and patients. 

  • Offer education for staff around the unique challenges for these patients  

  • Physicians can consider pediatric and adult care models  

  • Ensure psychosocial supports are available and everyone is aware to refer patients 

  • Teach staff how to discuss uncomfortable topics.  

  • Allow appointment times for relationship building, in environments that are comfortable for the young adult. 

Organizational influences on Individual factors  

  • Have a clear transition plan for young adult cancer survivors by building discharge packages for primary care providers, offering clinic visits prior to discharge which focus on cancer survivorship.  

  • Patient navigation position aligned to checking in with high-risk individuals one or two times after discharge to see how young adults are coping.  

  • Patient navigator to help young adults in accessing community, organizational or provincial financial aid. Provide time for helping young adults with the required paperwork to relieve the burden. 

  • Provide a clear pathway for follow-up with young adults moving from acute care to survivorship. These may include what and when follow-up tests or diagnostics are needed. An outline of potential long term chronic illnesses and when to follow up with their care provider. Also, which supports are available in the community for psychosocial supports for young adult cancer survivors. 

  • Provide resources to allow for education and transition planning. This may include human health resources and education tools. 

  • Consider reduced parking fees or no parking fees for cancer patients. 

  • Establish community partnerships to allow access to all available tools for young adults. To also allow for continuity of care for survivorship and support a hub and spoke model of care.  

  • Participate in regional working groups focused on cancer care. 

  • Provide funding for staff education and training. 

  • Provide resources for nutrition, and psychosocial care for the patient. 

  • Implement an organizational electronic health information system which allows clinicians easy access to patient health history, test results and diagnostics. 

  • Review the Cancer Care 6 plan for Ontario and create goals for the outpatient clinic that align to the young adult. 

  • Look at provincial funding options to support resources needed for the unit goals. 

  • Create unit goals using unit huddles focused on patient care. 

Community influences on Individual factors  

  • Attend integrated patient related regional cancer care meetings to connect with community partners 

  • Hospital to connect with community partners to get help for young adults who may not have support for finances, nutrition support, and transportation to appointments. 

  • Establish transition plan, in collaboration with community partners to support specific patient needs after discharge from clinic.  

  • Offer community networking opportunities. 

Policy Factors 

  • Cancer center leadership routinely takes part in Regional Cancer Meetings 

  • Cancer clinic reviews Cancer Care Ontario Plan 6 and aligns organizational goals to the Provincial objectives. 

  • Data metrics are tracked and  

  • Regional centers bring feedback to provincial level planning groups 

  • Organizational policies align to Cancer Care Ontario standards of practice and specific system care guidelines. 

Final Thoughts 

It is difficult to imagine how devastating cancer would be at any age but even more so for someone with their entire life ahead of them. Many young adults in Ontario are facing demanding situations including isolation, a feeling of hopelessness, having difficulty finding a job, and paying their bills. The long-term complications of being a young adult cancer survivor are different from their mature counterparts. The journey does not end with survival, rather they face lifelong challenges and risks that mature cancer patients do not even have to consider.  

Outpatient cancer clinic care should include both curative and long-term survivorship strategies for young adults. In collaboration with community, regional and provincial partners, clinic teams can understand resources available to support care. These community teams can aid the clinic staff to develop long term survivorship plans. Which will create better long-term outcomes for the young adult cancer survivors.  

References  

Amy M. Berkman, Andrea C. Betts, Melissa Beauchemin, Susan K. Parsons (2024). Survivorship after adolescent and young adult cancer: models of care, disparities, and opportunities.Journal of the National Cancer Institute. 16(9), 1417-1428. https://doi.org/10.1093/jnci/djae119 


Government of Canada (2024, July 18). Social determinants of Health and health inequalities. https://www.canada.ca/en/public-health/services/health-promotion/population health/what-determines-health.html 

Hovsepyan S, Hoveyan J, Sargsyan L, Hakobyan L, Krmoyan L, Kamalyan A, Manukyan N, Atoyan S, Muradyan A, Danelyan S, Tamamyan G, Bardakhchyan S and Papyan R (2023) The unique challenges of AYA cancer care in resource-limited settings. Front. Adolesc. Med. 1:1279778. http://doi.org/10.3389/fradm.2023.1279778  

Karches, K., DeCamp, M., George, M., Prochaska, M., Saunders, M., Thorsteinsdottir, B., & Dzeng, E. (2021). Spheres of influence and strategic advocacy for equity in medicine. Journal of General Internal Medicine, 36(11), 3537-3540.https://doi.org/10.1007/s11606-021-06893-4 

Olsen, E.R., Olson, A. Driscoll, M. Bliss, D. Z. (2024). Psychosocial factors affecting wellbeing and sources of support of young adult cancer survivors: A scoping review. Nursing Reports 14, 4006-4021. https://doi.org/10.3390/nursrep14040293 

Ontario Health (2024, October). Resource guide to Ontario health’s social determinants of health framework. https://www.ontariohealth.ca/sites/ontariohealth/files/Social-Determinants-of- Health%E2%80%93FNIMui-Resource-Guide.pdf 

Schramme, T. (2023). Health as complete well-being: The WHO definition and beyond. Public Health Ethic, 16(3) 210-218. https://doi.org/10.1093/phe/phad017 

 

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