Key learning points:
- Teenagers are a distinct group in oncology care who face different challenges from adults
- Primary care nurses are well placed to support teenage cancer patients throughdepression
- A structured psychological assessment can be offered at key points in the care pathway to assess needs, identify coping strategies and inform interventions
In the UK, around 2,200 teenagers and young people per year are diagnosed with cancer.1 Adolescence is a time of physical, social and psychological change meaning teenagers and young adults are a distinct group in oncology care who face different challenges from adults.2 Adolescents may be particularly vulnerable to psychological distress. Research indicates that 18-32% of adolescents and young people with a cancer diagnosis may experience clinically significant symptoms of emotional distress, including depression and anxiety.3
It is suggested that the life-threatening diagnosis of cancer, the associated treatment, side effects and an interference with social life, education and employment are all associated with psychological strain and burden.4 Furthermore, this strain can have a long term impact on future psychosocial and life-course development if left untreated.3 Increasing clinicians’ knowledge in this area will enable them to provide effective care and support for adolescents and their families.5
Coping with cancer
It is important to understand the way that adolescents cope with cancer related distress in order to promote positive coping strategies. The literature suggests6 that adolescents cope with chronic illness, including cancer, in broadly three ways (see table 1).
There appears to be an association between the coping strategy chosen by the individual and the outcome they experience, with secondary control coping seeming to be the most adaptive. To investigate this, Compas et al (2014)7 compared self-reported descriptions of coping with symptoms of anxiety and depression in adolescents with a recent diagnosis of cancer. Their findings suggest that the use of strategies such as acceptance and positive appraisal are adaptive ways for adolescents to cope with cancer and minimise distress. Subsequently, there are implications here for the development of interventions for adolescents with cancer who also have a diagnosis of depression. To strengthen this claim the authors suggest that longitudinal research is needed to determine whether the effectiveness of different coping strategies change over time, in line with the patients’ cancer trajectory.
Depression is a broad condition with a wide range of symptoms meaning it affects people in different ways. It can be triggered by the cancer diagnosis or having treatment. However, it might be related to other events that have nothing to do with the cancer.8 Psychosocial risk factors in teenagers that increase their likelihood of becoming depressed include having an illness, being female, prior social and emotional problems, low self-esteem, poor body image, lack of social support, poor school performance and conflicts with parents.9,10
Specific to teenagers with cancer, the type of cancer the individual has can elevate their risk of becoming depressed. Cancers of the central nervous system are associated with greater levels of psychological distress. This may be due to the greater burden of neurocognitive deficits and the greater degree of social difficulties experienced by people diagnosed with brain tumours both during and after treatment11. Consequently, this highlights the need to offer appropriate, individualised psychosocial support.
Guidelines for managing and treating depression
Currently, no clinical guideline exists that focuses specifically on the diagnosis and treatment of depression in teenagers with cancer. There is also no guidance on the promotion of coping in this patient group. However, National Institute for Health and Clinical Excellence (NICE) provide best practice guidance on the diagnosis and management of depression for children and young people.12 A four tier approach to care is recommended (see diagram 1).
Tier one includes professionals that the young person may meet regularly in the community. These services should be involved in recognition, risk profiling and referral. Mild depression can also be managed at this level. However, teenagers with cancer spend extended periods in hospital and become isolated from such services.13 For that reason, primary care professionals are required to engage and work effectively with the wider multidisciplinary team to develop individualised care packages that take into account the views of the young person and their family.14 In particular, the inclusion of mental health professionals in the treatment team helps to address potential difficulties in adjustment after diagnosis.15 Teenagers with moderate to severe depression should be cared for by professionals with specific expertise in tiers two to four. This includes, for example, nurse specialists, occupational therapists and clinical psychologists.
Role of primary care nurses
As promoted in the NICE guidelines primary care professionals play a key role in the detection and management of depression in teenagers. This is supported by research in the cancer setting that highlights how well–placed nurses and support workers are to help teenagers cope with depression. One of the main ways they can do this is by facilitating social support. This can include:
- Nurturing the social support systems that the adolescent had in place pre-diagnosis.
- Temporarily taking on the role of the adolescent’s social support system where none currently exists.
Specifically, support workers and nurses can provide social support by offering friendship, building self-esteem and supporting positivity.16 As discussed, they may also have a role to play in enhancing secondary control coping by promoting the use of proven successful strategies such as acceptance and positive thinking.
Where depression is being treated with pharmacological agents, nurses and support workers have a number of potential roles including providing information, supporting and monitoring compliance, observing for side effects and monitoring efficacy. However, these roles are not delivered in isolation but within the context of a supportive relationship which both motivates and empowers the individual concerned.17
A diagnosis of cancer during adolescence can cause a significant amount of emotional distress potentially leading to clinical levels of depression and anxiety. All adolescents, young people and their families should be offered support and advice, with primary care nurses being central to this process. A structured psychological assessment can be offered at key points in the care pathway, including; at diagnosis, during treatment, end of treatment, follow-up in the event of relapse and during palliative care. The assessment should include an assessment of needs and coping skills and a consideration of the wider social and cultural context of the patient and their family.18 Consequently, understanding more about how teenagers cope with cancer related stress will enable commissioners to develop needs driven support services.
Cancer Research Campaign www.cancerresearchuk.org/about-cancer/coping-with-cancer/general-books-and-links/childrens-cancer-organisations
CLIC Sargent www.clicsargent.org.uk
Macmillan Cancer Support www.macmillan.org.uk/Cancerinformation/Cancertypes/Childrenscancers/Childrenscancers.aspx
Teenage Cancer Trust www.teenagecancertrust.org
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12. National Institute for Health and Care Excellence (NICE) Quality Standards [QS48] Depression in Children and Young People. London: NICE;2013 http://www.nice.org.uk/guidance/qs48/resources/guidance-depression-in-children-and-young-people-pdf
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14. Lanzkowsky, P. Psychosocial aspects of cancer for children and their families. In Lanzkowsky, P. ed. Manual of haematology and oncology. 5th Ed. London: Academic Press; 2011
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16. Corey A L, Haase J E, Azzouz F et al. Social support and symptom distress in adolescents/young adults with cancer. J Paediatr Onc Nurs 2008; 25: 275-284.
17. Laoutidis Z G, Mathiak K. Antidepressants in the treatment of depression/depressive symptoms in cancer patients: a systematic review and meta-analysis. BMC Psychiatry 2013; 13: 140.
18. National Institute for Health and Clinical Excellence (NICE) Improving Outcomes in Children and Young People with Cancer. London: NICE; 2005 www.nice.org.uk/guidance/csgcyp/evidence/improving-outcomes-in-children-and-young-people-with-cancer-manual-update-2
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