Research highlights an alarming trend: Adolescent and young adult (AYA) cancer survivors (defined as age 15-39 at diagnosis) are facing significantly higher rates of suicide compared to their peers, particularly males diagnosed with thyroid, melanoma, and testicular cancer. These cancers are regarded as treatable and highly curable, but even so, AYA survivors may struggle with emotional and psychological scars for years following a cancer diagnosis.
This study underscores a critical gap in our understanding of how challenging survivorship can be and our responsibility to identify and address the mental health challenges of our AYA patients.
Unpacking Mental Health Challenges in AYA Cancer Survivors
AYA cancer survivors face multifaceted mental health challenges related to emotional health, social functioning, health-related behaviors, and cognition. Experiencing cancer during formative years disrupts important milestones like educational achievements, establishing autonomy, relationships, securing finances, and establishing a career path. Physical changes related to treatment, fear of recurrence, and a lingering sense of physical and emotional vulnerability can lead to profound identity struggles even after the cancer has been treated.
Developmental instability and insecurity, fueled by physical changes and challenges, emotional lability and regulation, and stunting of the progression of life stages contribute to the ever-common feeling of isolation . At a developmental stage in life where social connections shape future relationships, life goals, and experiences, cancer-associated isolation impacts the overall mental health of our young adult patients.
One potential explanation for the male survivor tilt noted in the JAMA study is that male patients may experience heightened stigma regarding mental health, often faced with societal pressure to "stay strong" or downplay their emotional needs. Data suggest mental illness goes untreated more often in men compared to women due to a of seeking care; depression and suicide remain leading causes of death among men in the U.S. While focusing on treating the cancer, the healthcare team may inadvertently pay less attention to mental health, leaving depression, anxiety, and even suicidal ideation unaddressed.
This calls to memory a patient who, months after completing treatment, admitted it was the first appointment he had attended sober. He had gotten through his diagnosis and treatment by using substances, a coping mechanism he had used for years prior to having cancer.
In of AYA cancer survivors (2015-2018) that assessed the incidence of substance use, misuse, and substance abuse disorders, AYA survivors were as likely or more likely than peers without cancer to report substance use problems, and only one in five survivors who experienced a substance use disorder received treatment. Paramount to improving AYA cancer care is counseling to not only reduce substance use but to improve recognition that patients may use substances to cope with diagnosis-associated psychological distress or health complications. These patients would greatly benefit from learning and applying coping skills to manage cancer-associated stress.
The expectation that patients and families go "back to normal" following a traumatic experience like cancer is unrealistic, and the reality needs to be acknowledged by all members of the healthcare team.
Another patient was well into survivorship when he contacted his social worker, moments from a suicide attempt and in need of emergent help. The mental health facility he had tried to get more information from had been unable to admit him and he was desperate for someone to acknowledge his situation and immediately connect him to supportive care.
If we take the psychological toll of cancer survivorship and compound it with systemic barriers -- including limited access to mental health services and insufficient training among healthcare providers to recognize and address mental health issues -- we shouldn't be surprised to find that we often come up short. There needs to be greater recognition of the many opportunities to bolster support for AYA cancer patients during and after treatment.
A Broken System and the Path Ahead
Our healthcare system is ill-equipped to meet the complex needs of AYAs with cancer who often experience psychological challenges at a personal, support system, and healthcare system level. Despite the growing number of AYA survivors and awareness that psychosocial care is paramount through the continuum of cancer diagnosis, treatment, and survivorship, mental health remains a neglected component of survivorship care. of AYA cancer survivors (age 15-25 at diagnosis) experience moderate-to-severe symptoms of anxiety and/or depression, and up to 50% experience clinically significant post-traumatic stress symptoms within 2 years of diagnosis.
Access to mental health professionals familiar with the challenges of AYA cancer survivorship is limited, and psychological distress screening tools are not consistently implemented. A more proactive approach to addressing this would require integration of mental health care into oncology practice, and standardizing psychosocial support during and after cancer treatment. Interventions focused on skills that guide patients with transition to survivorship, that promote effective coping mechanisms, and that address stigma associated with mental health seem to be an easy place to start.
Healthcare leaders and policymakers must prioritize funding and research to develop comprehensive, culturally and developmentally sensitive mental health interventions for this vulnerable population. We must shift our focus from not just ensuring our patients live but to equipping our AYA cancer survivors to thrive in a life beyond cancer.
lymphoma specialist and medical director of the Adolescent and Young Adult (AYA) Cancer Program, and social worker of the AYA Cancer Program, are both with the Mayo Clinic Comprehensive Cancer Center in Phoenix.