Quality Cancer Care for Adolescents and Young Adults: A Position Statement

Abstract

This consensus-based position statement on behalf of the LIVESTRONG Young Adult Alliance (Alliance) offers recommendations to enhance oncologic care of adolescent and young adult (AYA) patients with cancer.
In 2005 to 2006, the National Cancer Institute and the Lance Armstrong Foundation jointly sponsored the Adolescent and Young Adult Oncology Progress Review Group (PRG). The PRG report included the directive to develop standards of care for AYA patients with cancer and to disseminate these guidelines to the community. To this end, the Alliance convened a meeting of experts (clinicians, researchers, and advocates) in June 2009 and derived this position statement.
Quality care for AYAs depends on four critical elements: timely detection; efficient processes for diagnosis, initiation of treatment, and promotion of adherence; access to health care professionals who possess knowledge specific to the biomedical and psychosocial needs of this population; and research that will ultimately derive objective criteria for the development of AYA oncology care guidelines. Achieving quality care for AYAs will require assistance with management of disease and treatment effects; cognizance of the unique psychosocial context for AYA growth and development; assessment of and attention to cognitive, psychiatric, and psychosocial issues; facilitated transition to treatment care; and referral to age-appropriate information and support services.
Dissemination of recommendations stated here will raise awareness of the need for AYA-specific care guidelines and assist providers in the delivery of care that is responsive to the distinct needs of AYAs with cancer.

Full text

Quality Cancer Care for Adolescents and Young Adults: A
Position Statement
Brad Zebrack, Beth Mathews-Bradshaw, and Stuart Siegel
From the Standards of Care Task Force,
LIVESTRONG™ Young Adult Alliance, a
program of the Lance Armstrong Foun-
dation; Association of Oncology Social
Work, Philadelphia, PA; University of
Michigan Comprehensive Cancer
Center and School of Social Work, Ann
Arbor, MI; Science Applications Interna-
tional Corporation, McLean, VA; Child-
rens Hospital Los Angeles; and Keck
School of Medicine, University of
Southern California, Los Angeles, CA.
Submitted May 17, 2010; accepted
August 5, 2010; published online ahead of
print at www.jco.org on September 20,
2010.
The LIVESTRONG™ Young Adult Alli-
ance, a program of the Lance
Armstrong Foundation, provided fund-
ing and staff support for the Standards
of Care for Adolescents and Young
Adults with Cancer Meeting and this
resulting position paper.
The ideas and opinions expressed
herein are those of the authors and the
LIVESTRONG™ Young Adult Alliance.
Endorsement by the author’s or Alli-
ance member’s individual institutions is
not intended, nor should it be inferred.
Authors’ disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Corresponding author: Brad Zebrack,
PhD, MSW, MPH, 1080 S University,
Ann Arbor, MI 48109-1106; e-mail:
zebrack@umich
.edu.
© 2010 by American Society of Clinical
Oncology
0732-183X/10/2899-1/$20.00
DOI: 10.1200/JCO.2010.30.5417
ABSTRACT
Purpose
This consensus-based position statement on behalf of the LIVESTRONG Young Adult Alliance
(Alliance) offers recommendations to enhance oncologic care of adolescent and young adult (AYA)
patients with cancer.
Background
In 2005 to 2006, the National Cancer Institute and the Lance Armstrong Foundation jointly
sponsored the Adolescent and Young Adult Oncology Progress Review Group (PRG). The PRG
report included the directive to develop standards of care for AYA patients with cancer and to
disseminate these guidelines to the community. To this end, the Alliance convened a meeting
of experts (clinicians, researchers, and advocates) in June 2009 and derived this posi-
tion statement.
Results
Quality care for AYAs depends on four critical elements: timely detection; efficient processes for
diagnosis, initiation of treatment, and promotion of adherence; access to health care professionals
who possess knowledge specific to the biomedical and psychosocial needs of this population; and
research that will ultimately derive objective criteria for the development of AYA oncology care
guidelines. Achieving quality care for AYAs will require assistance with management of disease
and treatment effects; cognizance of the unique psychosocial context for AYA growth and
development; assessment of and attention to cognitive, psychiatric, and psychosocial issues;
facilitated transition to treatment care; and referral to age-appropriate information and sup-
port services.
Conclusion
Dissemination of recommendations stated here will raise awareness of the need for AYA-specific
care guidelines and assist providers in the delivery of care that is responsive to the distinct needs
of AYAs with cancer.
J Clin Oncol 28. © 2010 by American Society of Clinical Oncology
INTRODUCTION
The incidence of cancer in young people ages 15 to
30 years has steadily increased during the past 25
years.
1
In 2009, an estimated 62,000 people in the
United States between the ages of 20 to 39 years
old will have been diagnosed with invasive can-
cer.
2
Cancer is a leading cause of nonaccidental
death among adolescents and young adults in the
US.
3
Despite advances in cancer prevention, early
detection, and treatment over the past several de-
cades, survival rates and quality-of-life (QOL) out-
comes for adolescents and young adults (AYAs)
diagnosed with cancer have not improved to the
extent they have for younger children and older
adult cancer populations.
4-6
Progress in advancing
biomedical and psychosocial outcomes for AYAs
has been limited by a number of factors, including
suboptimal knowledge of and access to specialized
care, inconsistent referral practices, limited research
on cancer in this age group accompanied by limited
access to and participation in clinical trials, inconsis-
tency in treatment and follow-up care, and limited
psychosocial resources and services with an AYA-
specific focus.
1,6-11
The current lack of evidence-based guidelines
and standards of care specific to AYAs with cancer
results in health care providers, either appropriately
or perhaps inappropriately, treating AYAs based on
guidelines developed for the treatment of children
or older adults. Referral patterns are arbitrary and
usually based on the patient’s age—those under 18
are commonly referred to pediatric oncology spe-
cialists and those 18 or older are referred to adult
JOURNAL OF CLINICAL ONCOLOGY REVIEW ARTICLE
© 2010 by American Society of Clinical Oncology 1
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oncology specialists—and neither group has the majority of its pa-
tients in the AYA age range of 15 to 39. While prospective research and
data for this age group are sparse, retrospective analyses of disease-
specific protocols within this 15- to 39-year-old age range are begin-
ning to distinguish cancer biology and treatment responses in the AYA
population from that in older adults and children.
3-6,12-14
Further-
more, current institutional environments and care settings created for
the treatment of children or older adults with cancer are not fully
equipped to address the unique needs of a highly mobile AYA popu-
lation experiencing multiple demands such as work, school, raising
children, and assisting aging parents, all of which can be potential
barriers to optimal treatment adherence. To date, we lack state-of-the-
art therapies, protocols, and evidence-based practice guidelines for
AYAs diagnosed with cancer.
Recognizing the need to improve outcomes for AYAs across the
cancer control continuum, the National Cancer Institute (NCI) and
the Lance Armstrong Foundation jointly sponsored the Adolescent
and Young Adult Oncology Progress Review Group (AYAO PRG) in
2005 to 2006. This group reviewed the biologic, biomedical, and
psychosocial aspects of cancer diagnosis and treatment in the AYA
population and published imperatives for improving measurable out-
comes in a report entitled “Closing the Gap: Research and Care Im-
peratives for Adolescents and Young Adults with Cancer.”
15
The
LIVESTRONG™ Young Adult Alliance (Alliance), a coalition of 110
organizations representing clinicians, researchers, and patient advo-
cates, created a 5-year strategic implementation plan for the AYAO
PRG recommendations.
16
This implementation plan includes a strat-
egy to “Develop standards of care guidelines for AYAO programs and
patients, and [to] disseminate these guidelines to the community.”
16
To facilitate this effort, on June 7 to 8, 2009, the Alliance convened an
expert panel of 28 individuals representing cancer centers, aca-
demia, community-based care settings, and nonprofit service
agencies (Appendix, online only).
This position statement is the product of that collaboration. It is
a preliminary step toward enhancing care for AYAs by providing
consensus recommendations intended to supplement existing stan-
dards of care that apply to all oncology patients, such as the clinical
practice guidelines in oncology disseminated by the National Cancer
Comprehensive Network.
17
By putting forth these recommendations,
we hope to raise awareness of the need for evidence-based guidelines
for AYA care and, in the interim before development of those
guidelines, assist NCI-designated cancer centers, community can-
cer centers and hospitals, and private oncology practices in deliv-
ering optimal quality cancer care for AYAs. This position statement
reflects distinct needs related to the diagnosis, treatment, and care
of AYAs with cancer, as suggested by emergent research and clini-
cal observations.
18-22
SUMMARY OF RECOMMENDATIONS
The Alliance recommends the following: formulation of standards of
care for AYAs with cancer that ensure excellence throughout the
continuum of care from awareness and timely detection through
treatment, survivorship, or end of life care; access to and availability of
health professionals with the education, training, and experience nec-
essary for providing age-appropriate medical, psychosocial, and sup-
portive care services (a physician champion is essential); consider the
resources of the facility that provides care (eg, NCI-designated cancer
center vcommunity hospital); for facilities that cannot provide direct
access to AYA-specific care, locate and encourage facilitated access to
AYA-specific oncology care within the oncology community at-large;
develop and apply scientific standards to support efficacious treat-
ment protocols for AYA patients with cancer; promote awareness and
education for providers, particularly around need to increase partici-
pation of AYAs in clinical trials; and develop and implement strategies
Continuum of Care
Diagnosis and
Treatment Survivorship End-of-Life Care
Personnel, Components, and Services
AYA Champion
Pediatric Oncologist
Adult Oncologist
Oncology Specialists (radiation, surgery,
gynecology, etc)
Primary Care Provider
Patient/Peer Navigator
Mental Health Professionals (psychologist,
social worker)
Palliative Care Specialist
Religious/Spiritual Counsel/Chaplaincy
Legal Counsel
Peer Support
Community-Based Patient Service Organizations
Child Life Specialist (for patients with children)
Physical Therapist, Fitness Trainer, Coach
Nutritionist/Dietitian
Geneticist/Genetic Counselor
Reproductive Endocrinologist/Fertility Specialist
Sexual Health Specialist
Vocational Rehabilitation/Occupational Therapist
AYA-Trained Hospice Team
Fig 1. AYA cancer care personnel, components, and services. AYA, adolescents and young adults.
Zebrack, Mathews-Bradshaw, and Siegel
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for integrating the critical elements outlined in this consensus
statement into clinical practice in a way that allows for systemic
evaluation of measurable outcomes and advancements in care
based on these measurements.
PERSONNEL, COMPONENTS, AND SERVICES
Consistent with the Institute of Medicine’s report on quality cancer
care,
20
treating programs or institutions must have internal or adjunct
access to facilities, personnel, and services that enhance care for AYA
patients with cancer. Currently, AYA cancer care is delivered through
large academic institutions, NCI-designated cancer centers, free-
standing community cancer programs, ambulatory care clinics (eg,
radiation clinics and chemotherapy infusion units), medical oncology
groups, and individual practices. Wherever the location of care, it is
imperative that those treating AYA patients with cancer have access to
an appropriate knowledge base and expertise appropriate to each
AYA’s diagnosis. Oncology care providers who are educated to spe-
cific issues related to AYAs with cancer (eg, fertility preservation,
preventing social isolation, potentially differential responses to treat-
ment based on protocols selected) are better equipped to provide
tailored AYA oncology care. To expect every treatment setting, from
large institutions to private oncology practices, to possess all the per-
sonnel, facilities, and components needed for the best treatment of the
AYA patient with cancer is not realistic. The resources available to
these institutions vary enormously. Given this reality, providers and
treating institutions can reasonably be expected to have knowledge of
ancillary and supportive care opportunities for AYAs with cancer and
to provide referrals to appropriate sources within care networks or in
the broader community, as opposed to being expected to have an
AYA-specific specialist on staff.
There is, however, potential value in the identification of an AYA
champion—an oncology care provider who is available to other phy-
sicians and oncology care providers for the purposes of consultation
within institutions and communities and across oncology-related dis-
ciplines and departments. Ideally, this AYA champion would be edu-
cated to the specifics of AYA oncology as well as adult and pediatric
oncology issues. Practically, a more likely scenario is a model in which
an AYA champion is a specialist who collaborates and coordinates care
across different services (eg, pediatric oncology, adult oncology, gyne-
cology, urology, radiation oncology, surgery). To assure that the
unique needs of AYA patients are met, an AYA champion could,
Table 1. Critical Elements, Sample Strategies, and Outcome Measures for Improving Survival
Critical Element Sample Strategy Possible Outcome Measure
Early detection and
diagnosis
Educational programs for primary care physicians and nurse
practitioners that raise their awareness of cancer and cancer
risks in AYAs
Awareness of cancer risks in AYAs among primary care providers
Collaborations among health care and advocacy groups to improve
knowledge of AYA cancer in the medical community
AYA awareness and knowledge of cancer health risks and
preventive behaviors (eg, sun exposure, testicular self-exam,
breast self-exam)
Screening standards established and implemented
Timely referral, initiation
of treatment, and
adherence
Develop shared models of care for integration of primary and
oncology care
Length of time from symptom report to diagnosis
Apply existing quality control standards for the diagnosis and
treatment of all cancers to AYAs
Length of time of transition from primary care referral to
oncology care system
Monitor and assure adherence to treatment protocol Treatment adherence/compliance rates
Integrate age-appropriate psychosocial and supportive care
services
Quality control and outcomes standards
Genetic testing and counseling Determine prevalence of genetically related cancers in AYAs
Health care providers
knowledgeable of
biomedical and
psychosocial issues
specific to AYAs
Establish systems for referral and use of services either within
institutions or through community agencies that serve AYAs
Provider knowledge of differential impact of therapies on AYAs
as compared to pediatric and older adult populations
Provide access to an AYA champion and ancillary health care
providers knowledgeable about AYA needs
Number of clinical care programs with access to AYA-specific
multidisciplinary expertise
Provision of evidence-based treatment protocols for AYA patients Percent of all AYA patients who have accessed AYA-specific
expertise and services
Promote networking and training around utilization of evidence-
based protocols and clinical trial availability
Percent of AYA patients treated per available AYA-specific
protocol
Patient satisfaction
AYAO-specific research Develop evidence-based standards for best practices for AYA
cancer treatment
Proportion of AYA cancers for which AYA-specific clinical trials
have been developed
Develop treatment protocols and clinical trials for AYA-specific
cancers
Proportion and absolute number of AYA patients entered on
clinical trials
Establish venues for disseminating knowledge and education
about clinical trials
Availability of biospecimens and number of investigations utilizing
biospecimens in research
Coordinate collection, utilization, and analyses of biospecimens
according to best practices
Availability of program announcements or requests for
applications calling for AYA-specific biomedical, psychosocial,
and behavioral research
Perform longitudinal, prospective cohort studies to investigate
biomedical and psychosocial outcomes
Survival rates, quality of survival, and key determinants of these
outcomes
Conduct studies of health services utilization and cost-benefit
analyses
Use of health services; cost-benefit ratios
Abbreviations: AYAs, adolescents and young adults; AYAO, adolescent and young adult oncology.
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among other activities, seek to increase the availability and enrollment
of AYAs on clinical trials, promote multidisciplinary tumor board
discussions of AYA patients that include pediatric and medical oncol-
ogy representation, and provide access to age- or developmentally
appropriate psychosocial care (including supportive counseling and
peer support programs).
Figure 1 offers a graphic representation of recommended person-
nel, components, and services integral to AYA optimal care and sug-
gests when along a continuum of care these elements should be
activated. While many of these elements can be considered critical for
the care of cancer patients of any age, we suggest that due to AYAs’
unique physiology, cancer manifests differently in AYAs than in
Table 2. Critical Elements, Sample Strategies, and Outcome Measures for Improving QOL and Quality of Care Throughout the Cancer Care Continuum
Critical Element Sample Strategy Possible Outcome Measure
Assistance with
disease and
treatment effects
(ie, symptom
management,
fertility
preservation,
sexual
dysfunction, and
body image)
Patient education programs that provide AYAs with knowledge regarding
treatment options and the potential physical and QOL implications of
cancer therapy
Patient knowledge of treatment-related health risks
Provide access to a systematic and standardized symptom management,
pain control, and palliative care program
Treatment adherence
Inform reproductive-age patients of cancer-related fertility risks as early in
treatment planning as possible (per the ASCO guideline
24
) and refer as
needed to an appropriate fertility preservation specialist
Compliance with ASCO guidelines for addressing
fertility issues, including utilization of fertility
preservation
Provide knowledge of body image concerns (eg, hair loss, body
disfigurement, weight loss/gain) and access to practical resources to
address them (eg, wigs and prosthetics)
Referral patterns to appropriate and ancillary
supportive care services
Physical and mental health function, including pain
status and fatigue, and extent to which function
interferes with QOL
Cognizance among
providers of the
unique
psychosocial
context for AYA
growth and
development
Educational programs to increase provider knowledge of unique AYA issues
related to psychosocial, legal, financial, genetic testing, palliative care, etc
needs
Demonstrable knowledge of
psychological/developmental needs relevant to
adolescence and young adulthood
Create age-appropriate environments and policies (eg, access to same-age
peers, Internet access, flexible clinic hours around school and work, and
waiting rooms/lounges outfitted with age-appropriate media/materials)
Evidence of advanced clinical training specific to AYAs
Provide or refer to resources for developmentally appropriate end-of-life
care, including planning for death
Availability of AYA-appropriate patient education
materials and resources
Assessment of and
attention to
cognitive,
psychiatric, and
psychosocial
needs of AYA
patients
Clinical interview/psychosocial assessment evaluating social functioning (eg,
work, school, and relationships with family and friends), sexual health,
mental health status (including suicide assessment when indicated),
religion and spirituality, psychiatric symptoms, cognitive functioning, and
financial/legal issues
Utilization of mental health counseling, psychosocial
support, and supportive care services
Ongoing monitoring of cognitive, psychiatric, and psychosocial function, as
well as referral to resources to address identified needs
Psychosocial adaptation, HRQOL
Assess for substance use/abuse and refer to treatment, when indicated Referral patterns to appropriate psychosocial support
services
Promote AYAs’ knowledge and competence in medical decision-making and
involvement in self-care (self-efficacy)
Cancer-related self-efficacy
Promote communication between AYA patients and family members
(including spouses/partners, parents, young children) and between AYA
patients and health care providers
Provider-patient communication
Provide access to resources to develop advanced directives, wills, and/or
trusts
Possession of advanced directives
Referral to available
age-appropriate
resources during
treatment
Provide or refer patient to reputable community and Internet-based
educational and support resources
AYA utilization of mental health counseling/support
services
Establish relationships with community partners and agencies Linkages between treating institution/practice and
community-based agencies serving AYAs
Provide awareness, assessment, and support of practical issues while under
treatment, such as child care, transportation, and housing
Adherence to recommended treatment
Assist AYA patients in assessing the impact of their treatment plan on their
education/work/career plans
Adequate insurance coverage; financial needs
addressed
Assist with the navigation of financial and insurance issues when needed
Facilitation of
transition to
survivorship
Survivorship care plan available to patients and other appropriate health
providers
Possession of a survivorship care plan
Provide early education related to the transition of an adolescent from
pediatric to adult settings/providers
Health behaviors (cancer screening, use of sunscreen,
smoking, diet, etc)
Assist AYA survivors in developing appropriate self-management behaviors,
including health literacy, coping skills, and understanding of treatment
implications
Successful transition to adult settings and/or providers
Provide resources for managing co-morbidities and ongoing late effects Health services utilization (primary care, oncologic
care, specializations)
Provide lifetime access to portable treatment records HRQOL, self-efficacy, health literacy
Provide access to health insurance information Health insurance status
Abbreviations: QOL, quality of life; AYA, adolescents and young adults; ASCO, American Society of Clinical Oncology; HRQOL, health-related quality of life.
Zebrack, Mathews-Bradshaw, and Siegel
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children and older adults. The personnel listed in this document must
be cognizant of how this affects AYAs’ psychology and overall QOL,
and thus must be educated to administer biomedical and psychosocial
therapies or interventions appropriate to this population. The com-
panion manuscript “Adolescent and Young Adult Oncology Training
for Health Professionals: A Position Statement” addresses the ele-
ments of training and education that health professionals committed
to the care of AYAs should receive.
23
CRITICAL ELEMENTS, CLINICAL CARE STRATEGIES, AND
MEASURABLE OUTCOMES FOR IMPROVING AYAO CARE
Improvements in treatment outcomes, survival rates, and QOL for
this age-specific population depend on four critical elements: timely
detection; efficient processes for diagnosis, initiation of treatment, and
promotion of adherence; access to health care professionals who pos-
sess knowledge specific to the biomedical and psychosocial needs of
this population, including knowledge of the evidence-based treatment
protocols for achieving best outcomes for AYAs; and rigorous AYA-
specific research. Examples of clinical care strategies reflecting these
elements are summarized in Table 1, along with examples of suggested
outcome measures to demonstrate the effect of these AYA-specific
elements on survival.
IMPROVING QUALITY OF CARE AND QOL ACROSS THE CANCER
CARE CONTINUUM
As described elsewhere,
1,8,11
research has begun to identify the unique
impacts of cancer on QOL issues for AYAs. Thus, clinical care and
investigations of cancer’s impact on QOL and psychosocial outcomes
must take into account the stage of life at which cancer is diagnosed in
these young people.
To enhance QOL and quality of care for AYA patients with
cancer, providers must address the specific health and psychosocial
needs of AYAs. Doing so will require: assistance with the management
of disease and treatment effects, particularly fertility and body image
issues; cognizance of the unique psychosocial context for AYA growth
and development; assessment of and attention to cognitive, psychiat-
ric, and psychosocial effects and needs; facilitated transition to off-
treatment care; and referral to available age-appropriate information
and support services when indicated. Sample strategies for achieving
these objectives are summarized in Table 2.
24
Ultimately, the success
of clinical care strategies may be determined by observation and mea-
surement of the outcomes or competencies listed in Tables 1 and 2.
NEXT STEPS AND CHALLENGES
The recommendations set forth here are intended to be a first step
toward raising awareness of the need for guidelines of care in AYA
oncology. As next steps in an implementation strategy for developing
standards of care, the Alliance recognizes the need to test and validate
the extent to which recommendations proposed here in fact result in
improved survival and QOL outcomes. As clinical programs and new
models of care for treatment of AYA patients emerge, studies need to
derive objective evidence demonstrating the efficacy of critical com-
ponents and strategies that ultimately will form clinical care guide-
lines. Complex issues exist that make the creation of guidelines
challenging, including but not limited to the following: health systems
outside the US use different terminology and a narrower age range to
define the AYA oncology population; these facts, in addition to their
greater dedicated resources, make it difficult to apply their lessons
learned in the US;
25,26
the US health system consists of multiple tiers of
health care professionals, from general practitioners within the com-
munity to oncology specialists at large NCI-designated cancer centers,
making increased awareness of AYA oncology and the provision of
specialized care throughout the system difficult; the development of
systematic research methods and measurable outcomes depends on
the availability of funded research opportunities and settings, and all
in a time of limited resources and economic pressures; and the ability
to address research questions related to this age-specific population is
dependent on the accrual of sufficient numbers of AYA patients to
studies and clinical trials for statistical analyses to have analyz-
able power.
CONCLUSION
We set forth these recommendations for the oncology community to
stimulate interest and illustrate the need to enhance quality of care for
AYAs. Evidence-based guidelines for AYAO care will offer providers
objective criteria by which they can assess the quality of care provided
in their programs to this age-specific population. In the interim, health
care providers in all settings may improve treatment outcomes and
QOL for AYAs with cancer by adopting recommendations in this
position statement.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
The author(s) indicated no potential conflicts of interest.
AUTHOR CONTRIBUTIONS
Conception and design: Brad Zebrack, Beth Mathews-Bradshaw,
Stuart Siegel
Administrative support: Beth Mathews-Bradshaw
Provision of study materials or patients: Stuart Siegel
Collection and assembly of data: Brad Zebrack, Stuart Siegel
Data analysis and interpretation: Brad Zebrack, Stuart Siegel
Manuscript writing: Brad Zebrack, Beth Mathews-Bradshaw,
Stuart Siegel
Final approval of manuscript: Brad Zebrack, Beth Mathews-Bradshaw,
Stuart Siegel
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Acknowledgment
The authors/co-chairs wish to acknowledge the following members of the LIVESTRONG™ Young Adult Alliance for their contributions in
the preparation of this article: Kristin Bingen, Ashley Wilder Smith, Douglas Bank, Lindsay Beck, Debra Friedman, Daniel Indelicato, Rebecca
Johnson, Rebecca Morris, Stacy Sanford, Leonard Sender, Lauren Spiker, and Ronald Waldheger.
Appendix
In addition to the authors, participants at the Standards of Care for Adolescents and Young Adults with Cancer Meeting included:
Heidi Adams, Planet Cancer; Karen Albritton, Cook Children’s Medical Center; Yvette Colon, American Pain Foundation; Pat Fobair,
Stanford University; Nicole Grant, National Cancer Institute (NCI); Keren McCord, Oregon Health & Science University (OHSU); Raul
Mena, St. Joseph’s Hospital, Burbank, CA; Robert Mennel, Baylor College of Medicine; Sheila Santacroce, Yale Medical School; Elizabeth
Saylor, Ulman Cancer Fund for Young Adults; Ashley Wilder Smith, NCI; Debra Friedman, Vanderbilt University; Sylvie Aubin, McGill
University; Lindsay Beck, Fertile Hope; Archie Bleyer, St. Charles Medical Center; Kim Day, University Hospitals, Cleveland, OH; Kieron
Dunleavy, NCI; Joseph Flynn, Ohio State University; Brooke Hamilton-Leggin, NCI; Brandon Hayes-Lattin, Oregon Health & Science
University; Julie Larson, CancerCare; Stacy Sanford, Robert H. Lurie Comprehensive Cancer Center; Karla Wilson, Oncology Nursing
Society; and Nicholas Yeager, Ohio State University.
Zebrack, Mathews-Bradshaw, and Siegel
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