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

Adolescence and young adults (AYAs) with cancer between 15 and 39 years of age are complex and vulnerable as a result of the intersection of disease and developmental stage [1]. AYAs are in various challenging situations related to physical and cognitive development, identity, body image, autonomy, and employment [2, 3]. Nearing the end of or having completed high school, young people turn their attention to employment, further formal education, and establishing an independent living situation and intimate relationships with peers [4]. Young adults are in a phase of life marked by change and upheaval [5]. In addition to providing high quality treatment, when considering support based on these unique characteristics and developing age-specific supportive care resources, it is important to understand their supportive care needs and associated factors.

Previous studies in the United States and Australia showed that AYAs with cancer have unmet information, service and supportive care needs [4, 6‐13]. According to a systematic review conducted by Galán et al. [14], the most common needs for AYA cancer survivors are “individualized information and advice”, “counseling and psychological support” and “social support, and social relationship”. AYA cancer survivors tend to seek social support from their families and friends, not their doctors [14]. These results are different from those reported studies on adults [15]. Hoekstra et al. [15] found that being able to talk about impact of the disease, getting medical help for problems not related to cancer and obtaining information about their illness from their doctors were all key factors for adults. Moreover, support and access to specialists (e.g. psychologists) is highly valued by young people [14] but is not common in older cancer survivors. Unmet information and service needs for AYAs with cancer were associated with sex, age, age of first diagnose, race, performance status (PS), marital status, chemotherapy, depression, anxiety and QOL [4, 7‐10, 12, 13]. Though psychological distress, impaired physical functioning, cognitive dysfunction and financial hardship occur during treatment and many years after, supportive care needs could change during the transition process from active treatment to survivorship [16]. It is important to investigate the factors associated with unmet needs in order to consider the support of AYA cancer patients.

AYAs with cancer are 2.5% of all cancer patients in Japan [17]. As it’s relatively low rate compared to the other generations, little is known about their unmet needs and associations between various sociodemographic, medical and psychosocial variables and unmet needs among AYAs with cancer in Japan. Therefore, the current study aimed (1) to describe unmet supportive care needs among AYAs with cancer in Japan, and (2) to identify its associated factors.

To our knowledge, this study is the first report to assess unmet supportive care needs among Asian young adult cancer patients. Miyashita et al. [22] reported unmet information needs and they were related to QOL in young breast cancer survivors (18–45 years of age at diagnosis and 21–64 years of age at the time of the survey) in Japan. Satisfaction with overall communication with medical professionals was the most unmet information need, which was related to QOL. Those results and our study may lay a foundation for future intervention studies for Japanese young adults with cancer. Our findings are consistent with previously reported findings [23‐25]. Sender et al. [23, 24] found that young adult cancer patients most often reported their psychological supportive care needs. Hall et al. [25] showed the top five moderate/high needs reported by young adult cancer survivors. Those items were ‘Fears about the cancer spreading’, ‘Uncertainty about future’, ‘Concerns about the worries of those close to you’, ‘Anxiety’ and ‘Worry that treatment is beyond your control’ in the psychological domain, and ‘Lack of energy’ in the physical and daily living domain. They were also in the top ten unmet needs and seven items of the top ten unmet needs belonged to the psychological domain in our study. Unmet psychological needs of young adult cancer patients are as high as Japanese patients over 40 years of age [26, 27], and should be examined.

Poor social support was associated with higher levels of unmet total supportive care needs and three domains. A cross-sectional study has demonstrated that AYAs with cancer report greater challenges in social functioning compared with the general AYA population [8]. AYAs with cancer frequently report difficulties in maintaining or making new social relationships because of the long-term effects of treatment or feeling anxious concerning fitting into their peer group again [28, 29]. Husson et al. [30] found that AYAs with cancer who had low social functioning reported more physical symptoms and higher levels of distress, and they perceived themselves to receive less social support. We also found that single patients and patients who don’t have any children had more unmet needs in several items of psychological needs, physical and daily living needs, and health system and information needs. Social support and social functioning are key issues in terms of development of supportive care programs and services.

Our finding that patients who had experiences of change in work/school life after a cancer diagnosis was more likely to have unmet supportive care needs is also important and there is no study that reports association between unmet needs and experience of change in work/school life after a cancer diagnosis. Previous studies showed that work-related issues resulted in distress [31], and the ability to return or to maintain occupational and educational pursuits after a cancer diagnosis has been demonstrated to improve the QOL of patients with cancer, reducing social isolation and increasing self-esteem [32, 33]. Work-related issues are one of the major topics in studies on cancer survivors. It is necessary for employers, companies and schools to understand their situations and cooperate. As the Japanese government has been focusing on improving the circumstances of the working population and children [34], it is expected to improve their occupational and educational status. Though higher levels of unmet supportive care needs was associated with higher psychological distress and lower QOL in this study, it might be possible to improve psychological distress and QOL by maintaining occupational and educational status after a cancer diagnosis among young adults with cancer.

Although the number of patients undergoing chemotherapy was small, we examined the relationship between the presence or absence of chemotherapy and unmet supportive care needs as an exploratory study. Their unmet supportive care needs were much higher than those without chemotherapy. This finding suggests that healthcare professionals need to be more careful if patients undergoing chemotherapy have physical, psychological or information problems. The association between other treatments and supportive care needs could not be examined, because there was no data on other treatments. Gupta et al. [35] found that patients who had completed active cancer treatment tended to rate receiving information about diagnosis, cancer and fertility as more important than those who were on active treatment. However, service needs were similar in both groups. Few studies have examined the differences in needs between patients under treatment, those who have completed treatment, and the type of treatment. Further research is needed as supportive care needs could change during the transition process from active treatment to survivorship [16].

This study has some limitations. First, we didn’t have data on participation rate or refusal rate, because a web-based survey company recruited potential participants from a pool of registered people and we got the data from those who responded with interest. However, this study enabled a national survey among young adults with cancer in spite of relatively low prevalence. Second, there is a gender imbalance in that more women than men participated. According to the data of the Cancer Registry of Japan in 2016 and 2017, there are more female than male cancer patients over 20 years old and 80% of patients in the 20–39-year-old group are female [36]. Furthermore, the male-female ratio of registrants aged between 20 and 39 during the study period was approximately 1:2, and more female than male cancer patients were registered in the database (75.6%; 776 female). A gender imbalance in our study might occur due to differences in cancer incidence and gender differences in registrants. Third, 40% of the participants had uterine cancer. According to the data of the Cancer Registry of Japan, the prevalence of uterine cancer in patients aged 20–29 is 9%, and that in patients aged 30–39 is 13% [36]. It is unclear why the study participants had more uterine cancer compared to prevalence. From the distribution of cancer sites in the participants, it is considered that there may be a selection bias. We should be careful about generalizing the results. Fourth, there was no participant aged under 20 years probably because parents’ consent was needed in order to participate this survey if they were under 20 years old. It is necessary to clarify unmet needs among Japanese adolescents with cancer by other methods. Finally, the cross-sectional design provides no information on causal relationships.

This survey demonstrated that 76.7% of Japanese young adult patients with cancer reported having at least one unmet supportive care needs. The prevalence was relatively high in the psychological domain and low in the sexual domain. In a multiple regression analysis, perceived poorer PS, experience of change in work/school life after a cancer diagnosis and poor social support were associated with total needs. The findings suggest potential opportunities for intervention in addressing psychological needs rather than physical and information needs. And our study would lay a foundation for future intervention studies to improve their psychological adjustment and QOL.