Aug 3, 2020
Guest host, Dr. Anne Katz, PhD, RN, FAAN, a sexuality counselor and clinical nurse specialist at CancerCare Manitoba, discusses taboo topics and the unique challenges of life for adolescent and young adult patients with cancer and survivors with Dr. Brad Zebrack, PhD, MSW, MPH, a specialist in social work oncology at the University of Michigan's Rogel Cancer Center.
Transcript
Dr. Anne Katz: Welcome to the ASCO Daily News podcast. I'm Anne Katz, and I'm delighted to be the guest host of the podcast today to discuss the challenges faced by adolescents and young adults who are cancer survivors. I work at CancerCare Manitoba, where I counsel many such patients and survivors who experience sexual and relationship challenges.
I'm delighted to welcome Dr. Brad Zebrack, a specialist in social
work oncology at the University of Michigan Comprehensive Cancer
Center. Brad is a longtime colleague of mine and has helped
countless people navigate the unique challenges of living life as a
young cancer patient or survivor. My guest and I report no
conflicts of interest relating to issues discussed in the
podcast. Full disclosures relating to all Daily News podcasts
can be found on our episode pages. Brad, welcome, and thanks
for making the time for this today.
Dr. Brad Zebrack: Yeah. Thanks, Anne. Thanks for
the invitation to be here, especially when we get to talk about the
things that nobody likes to talk about, those taboo topics.
Dr. Anne Katz: Absolutely, love those taboo
topics.
And I love the people who are prepared to talk about them, that's the other thing. So you know, your research and clinical work has focused on helping countless adolescents and young adults navigate these unique challenges of living life as a patient or a survivor. What are you working on these days?
Dr. Brad Zebrack: So right now, I've got a project
going on at the University of Michigan Rogel Cancer Center in which
we're looking at teens and young adults who report using
reproductive health and fertility preservation services, as well as
those who report not having used those services, and to try and get
an idea of what some of the barriers and challenges are to help
promote and facilitate their use and benefit of those services. And
one of the things I really appreciated about the taboo article was
that it did touch upon the experience of sexual and gender
minorities, an issue that I think has really not been captured so
well in the clinical and research literature over the years as
attention to fertility preservation, oncofertility, has really come
to the fore. And I that's great. I think that's really
important.
But at least at the clinical level, I think a lot of young people
who are going through-- you know, one of the aspects of growing up
and being a teenager or young adult is identifying, being
comfortable, becoming comfortable with yourself, and becoming
comfortable with who you are, that notion of identity development.
So things like sex, sexuality, sexual identity, gender identity are
rather fluid and change for young people. So seeing that addressed
in that article I think helped to really attend to some of the
current knowledge and science that we now have a better
understanding of sex and gender identification in young people.
Dr. Anne Katz: So just to contextualize the
article that we're talking about, the ASCO Virtual Education
program will feature a presentation about the taboo topics in
adolescent and young adult oncology and strategies to help oncology
care providers managing the challenging conversations with this
population and that we have to be having with them. So the
corresponding article was just published in ASCO's Educational
Book, which is an amazing resource for oncology care providers. I
don't want to steal the author's thunder. And I really encourage
everybody to read this. But let's talk a little bit about these
taboo topics, specifically those that are not mentioned in the
article and that are so important for us to talk about. So Brad,
what do you think is one topic that's missing from this
article?
Dr. Brad Zebrack: Well, after I read the article,
one of the first things that jumped out to me was the issue about
religion and faith. And my experience and working with teens and
young adults and actually cancer patients of all ages is that, for
many, faith and religion is an asset. It's something that helps
them deal with the adversities of life.
And there's a whole body of literature around, particularly for
older adults and especially at the end of life, how being able to
rely on faith and rely on religion is really important and really
helpful to deal with these adversities. For young people, it's
different. Because again, just like sex and gender, like I was
talking about earlier, developing a religious identity and a faith
basis is also fluid and changing for young people.
I remember once talking to a young woman. She was 25 years old. She
was just a couple of years out of therapy for Hodgkin's
lymphoma.
And she was telling me about how growing up she was very involved
in her youth group, her church youth group, and how being part of
that youth group was so important and going to church and having a
strong basis and faith in her religion was important. But when
cancer hit, it was very disturbing to her, because she found
herself questioning her faith in God.
So questioning the faith was an existential challenge to her that
she found very distressing. And the fact that she was questioning
her faith was doubly distressing to her. So you know, I think that
any kind of distress like that for young patients is going to have
implications for their adherence to therapy and their ability to
cope with the myriad challenges that accompany a cancer diagnosis
and its treatment.
Dr. Anne Katz: I think that's a really good point.
And there's certainly literature that points to the role of faith
in women with breast cancer, particularly in women of color, and
how that friendship and those bonds that are created and really
helped people through the experience. So how do we talk, or how do
we ask or assess faith in young patients? Certainly, I'm kind of
out as a woman who is Jewish, I'm quite secular. But I'm pretty out
about it.
And it suddenly informs a lot of what I talk about particularly
regarding end of life issues. And I know that sometimes when I say
to somebody, yeah, I'm Jewish and my faith says whatever, often you
can actually see a little start. It's something that depressed
people are not really used to talking about. And why aren't we?
Dr. Brad Zebrack: Yeah, a couple of things. I
think in some ways health providers are not trained or prepared or
have the time to sit and listen with patients as they talk about
the different ways that cancer is affecting their life. Part of
this is just a function of our crazy health care system. Well,
you're up in Canada-- I'm down here in the US. And we certainly
have a lot of challenges down here in our system.
But you when you raised the question about how do we talk to the
young people, I think it's more about listening to them. I have
found in both my research as well as in my clinical work over the
years that just sitting down with cancer patients and asking them
to tell me about how is cancer affecting your life right now-- and
just to let them talk and let them talk. And you know, when I think
back to this young woman who was telling me about these faith
challenges that she was having, I was sitting down with young
people and just asking, how is cancer affecting your life right
now?
And they will share. And they will open up. And I think that
another key piece is to resist the desire to want to fix things for
young people.
I think it's just the listening and the ability for them to have
that opportunity to talk about it. And then particularly the other
thing I've done in this adolescent young adult space is to connect
young people with other young people. Having them then feel like
it's OK to have these conversations, whether it's in a retreat or a
workshop or a camp program or even a support group that just
involves other adolescents and young adults, just to be able to
facilitate a space where those young people can talk with each
other about some of these issues I have found to be very powerful
and even have some of the empirical evidence that shows that
participating in these programs and retreats really contributes to
improved ability to manage symptoms.
Dr. Anne Katz: So that's actually a perfect segue
way to something that I've been thinking about. I recently
participated as a speaker at a virtual conference for young adults
with cancer. And one of the questions I was asked was, if you have
sex with someone, do you have to quarantine or isolate for 14 days
afterwards, and other questions just about the isolation that I
think young people, particularly those who are not living in large
metropolitan areas, they may be the only person in their rural area
or perhaps small town that they know has cancer.
And that isolation and feeling different is really distressing for
them. So what would you tell a young man or woman who really feels
isolated? How do you advise them?
Dr. Brad Zebrack: So I think the first thing that
I know that they're going to do is they're going to go online. And
they're going to use their social media accounts and networks to
try and connect with others and find information as well as
support. So knowing that that's going to happen, I find that as a
health provider it's my responsibility to make sure that they, to
the best of their ability, can sort through all that information
and be able to distinguish resources and information that's going
to be helpful from resources and information that, in essence, is
snake oil and could potentially be harmful.
I think we're talking about engaging young people in ability for
them to develop some critical thinking, that when they're online
and they're looking at all these resources to do things like, well,
what's the source of the information that's coming at you? Is it a
reputable organization? Just to give them some of the concrete
skills-- so that they can sort through some of this stuff.
Because I think that the biggest current concern I have is that they're going to be out there in that world, and every piece of information is evaluated equally. And we know that that's not the case, that there are reputable sources. So I think on the provider side what we can be doing is developing resource lists. Social workers are very keen and trained to keep these lists updated and provide these reputable lists to young people, so we can guide them to where to find safe and reputable information and support online.
Dr. Anne Katz: Yeah. And I think maybe this is a
good place to put a plug in for organizations such as Teen Cancer
America and Stupid Cancer that have done so much for this
population in a relatively short period of time, where individuals
can find like-minded people, people who have been through the same
experiences. And so much of the work is done online anyway that
this could provide them with a good fit for education, for support,
and perhaps even for dating. And certainly I know of young couples
who have met through online fora such as this.
So let's get back to the article again. So the article deals with
sex. It deals with money, financial toxicity, certainly deals with
end of life and death issues. And you've certainly raised the topic
of faith.
Can we talk a little bit perhaps about trust, which I think
underlies everything that we as oncology care providers do? And was
it really addressed? It underlies I think a lot of what is said.
But how do we develop trust with these young people who often have
every reason not to trust us?
Dr. Brad Zebrack: Yeah, that's a great question,
Anne, and I'm glad you're bringing attention to that. Because
particularly for adolescents and young adults, cancer is a really
rare disorder. So when they start to experience symptoms and they
go to see a doctor, oftentimes what these young people experience
is, if they're reporting a pain in their leg, for example, the
doctor is not going to obviously jump to the first thing. Oh, you
have cancer.
So it may be written off as something like growing pains. So what
is a common experience amongst young people is that they're
reporting these symptoms. They're reporting these conditions, and
they're being minimized or discounted by a number of different
doctors and, for most of them, appropriately so.
But for those who ultimately get diagnosed with cancer, what
they've now experienced is a number of physicians, a number of
health care providers, who have discounted their experience. So now
that when they're told that they have cancer, many of them have now
developed a distrust of the health care system and a distrust of
doctors. And I think that work then needs to be done to re-engage
and reinforce that sense of trust amongst young people.
I think we're also in an era now where we're really hearing an
emergence, particularly from young people of color and persons of
color, that there's a whole other aspect of experiencing
discrimination and racism in institutions, whether it's health care
systems, educational systems and so on, which makes it doubly
imperative for us within the system to reinforce and encourage and
build trust with patients.
Dr. Anne Katz: So how do you build trust?
Dr. Brad Zebrack: Oh, boy. Again, I mean, the
first thing that comes to mind is listening; to just sit down and
spend some time listening to the concerns of our patients. Given
that we may have just given them a cancer diagnosis, given that we
may just have told them the prognosis of something say, like, high
risk leukemia, which maybe has a 50% or less prognosis for
long-term survival; I think we just need to then take a breath and
step back and let these young patients process this and listen to
them about their concerns about what aspects of their life they
think are now going to be impacted and where we may be able to
provide some support and assistance.
Dr. Anne Katz: So as you're talking about this and
as we were talking a little earlier about listening, I can hear
some of my oncology physician colleagues say, 'yeah, but I don't
have the time. I have x number of patients to see in x number of
hours. And I just don't have the time.'
And I think you and I both, as psychosocial providers, we have that
gift. We can. We can ask the question and sit for 20 minutes and
listen. And I think that that is just such a disgrace, honestly,
that physician colleagues, many of whom would like to talk, would
like to listen, just don't have the time to do it.
And then you'll end up in a situation where that is the young
person who is constantly calling. And then they get labeled as
being needy or difficult. And that carries through the rest of
their treatment, which is really, really sad, because they just
want information. They want support. And it sets them up for really
a long period of treatment where perhaps they are labeled.
Is there anything else that stands out for you from this article?
It certainly touches on gender and sexual minorities. It certainly
touches on some of these big issues. Is there perhaps, as we get to
the end of this, some of the subtleties that stand out for you,
particularly because of the body of research that you have provided
for us?
Dr. Brad Zebrack: Again, one of the reasons I so
appreciated the article because it was really elevating issues of
sex, money, death. Whether we want to talk with young patients
about this or not, these things are on their mind. And just now
when we were talking about physicians maybe feeling like they just
don't have the time to do all this engagement or to do all this
listening, and I guess what I would say to them is, but you don't
have to.
Addressing cancer requires a team whether you're working in a large
academic facility where you've got a team of collaborators,
including nurses and mental health professionals and therapists.
But even to the providers who are working in small community
settings that maybe don't have right hand availability to mental
health providers, I would encourage them to utilize the resources
that they have in their community and refer their patients out to
some of these other supportive services either in their community
or online because it does take a community to address these aspects
of cancer that are not just physical, but they're psychological.
They're social. They're faith-based. They're existential.
Even if you're assessing aspects of sleep, for example, or pain,
what we may think of these as physical symptoms of cancer, they
have psychological and social implications. And there are
evidence-based psychological and social interventions to help
address things like fatigue and pain. So again, we've got to think
about cancer care as a shared and collaborative approach and even
to draw upon our colleagues in adolescent medicine who have some of
that orientation to the human developmental aspects of young people
and how that's a whole other layer of experience.
But back to your question, death, sex-- you know, those of you who
might be Woody Allen movie fans, every movie he ever made -sex and
death were at the forefront. And young people are thinking these
things whether we ask them about it or not.
Dr. Anne Katz: Yeah. And I think further to your
point about needing a community, a village, a city to support these
young people is also recognizing that for the younger patient,
their family needs support. I can imagine nothing worse than being
the parent of an adolescent or young adult who has cancer. It is
more than life altering, right? It turns out our ideas of how life
is going to go completely on its head. And then for the perhaps the
young adult who's a little bit older, let's think about their
partner and what they go through when often they are really
ill-equipped to deal with these kinds of issues. Our patients are a
village in and of themselves, and we need to include their
supports.
And I think sometimes we perhaps view parents as infantilizing and
sort of getting in the way of some of the stuff that we have to do
and not allowing that adolescent or young adult to reach those
developmental milestones that they need to. And I think sometimes
it's really hard to sort of think beyond the patient and recognize
that their friends, their social circle are stunned, don't know
what to say. And often, friendships fall away.
Dr. Brad Zebrack: Yeah. That's such a great point,
Anne. Because again, when you think about the relatively few
adolescents and young adult patients that'll be seen in oncology
practices compared to tons of older adults, older people, they've
lived a life. And they've had experiences of dealing with
adversity. And every time you have an experience of adversity in
your life, you learn ways to cope. And then you can apply those
learnings to the next time that some other challenge comes up in
your life.
But for young people, they haven't had these experiences and these
abilities to build up sort of a set of coping skills. So when we
think about relationships, there's the proverbial couple walking to
the altar and getting married. And it's like, we're going to be
together til death do us part, right?
And I think the young people are thinking, well, the health
challenges and death, that's going to come later. That's later in
life. But when it hits them early in life, they really lack the
coping skills, the ability to communicate within a couple and
really oftentimes can benefit from some outside support, some
outside experience to help them negotiate those relationships.
Dr. Anne Katz: Yeah. So you know, it looks like we
have to wrap this up now. Certainly, I hope this has given some
food for thought to those who have listened to this podcast. It
really has been a pleasure to talk to you once again. Thank you so
much for sharing those valuable insights that I think can be
practiced changing and certainly life changing for those that we
serve. So thank you so much, Brad.
Dr. Brad Zebrack: Yeah. Well, thank you, Anne.
Thanks for the invitation and also for the great work that you've
done for years in providing support to this population as well.
Dr. Ann Katz: Thanks. And thank you to our
listeners for joining us for this episode of the ASCO Daily News
podcast. Please take a moment to rate and review this podcast on
Apple podcasts. Thank you.
Disclaimer:
The purpose of this podcast is to educate and to inform. This is
not a substitute for professional medical care and is not intended
for use in the diagnosis or treatment of individual conditions.
Guests on this podcast express their own opinions, experience, and
conclusions. The mention of any product, service, organization,
activity, or therapy should not be construed as an ASCO
endorsement.
COI Disclosures:
Dr. Anne Katz - No Relationships to Disclose
Dr. Brad Zebrack - No Relationships to Disclose