242 Seminars in Oncology Nursing, Vol 31, No 3 (August), 2015: pp 242-250

PSYCHOSOCIAL INTERVENTIONS
FOR ADOLESCENTS AND YOUNG
ADULTS WITH CANCER
CELESTE R. PHILLIPS AND LORIE L. DAVIS

OBJECTIVES: To summarize and evaluate the studies published since 2007 on

psychosocial interventions designed for adolescents and young adults (AYA)
with cancer.
DATA SOURCES: PubMed, Ovid, and PsycINFO.
CONCLUSION: Our review confirms that the development and evaluation of
psychosocial interventions for AYA is still in its infancy. Only five studies
were identified and these generally had small samples and limited results.
IMPLICATIONS FOR NURSING PRACTICE: It is important for nurses to assess the
needs of AYA. Incorporating creative ways for AYA to express their needs and
self-reflect seems to be critically important and may help AYA cope positively
with the cancer experience.
KEY WORDS: Adolescents, young adults, cancer, psychosocial interventions,
review

C
ancer is 2.9 times more likely to occur
in adolescents and young adults (AYA)
ages 15 to 29 than in younger chil-
dren.1 Although medical advance-
ments in pediatric oncology have improved the
Celeste R. Phillips, PhD, RN, CPONÒ: Assistant
Professor, Indiana University School of Nursing, Indi-
anapolis, IN. Lorie L. Davis, MSN, RN, OCNÒ: Doctoral
Student, Indiana University School of Nursing, Indian-
apolis, IN.
Address correspondence to Celeste R. Phillips, PhD,
RN, CPONÒ, 1111 Middle Dr., NU 425E, Indiana Uni-
versity School of Nursing, Indianapolis, IN 46202.
e-mail: cephilli@iu.edu
Ó 2015 Elsevier Inc. All rights reserved.
0749-2081/3103-$36.00/0.
http://dx.doi.org/10.1016/j.soncn.2015.05.004
survival rates of young children, AYA with cancer
have not seen the same improvement.2 Over the
past decade, there has been growing international
attention on addressing the specific needs of AYA
with cancer.3-6 AYA not only have unique medical
needs, but they also have many unique emotional,
social, spiritual, and physical needs. Recent
research suggests that AYA are inadequately
served by current support services.7-9
Despite the growing international attention, there
are few psychosocial interventions designed specif-
ically for AYA with cancer. In 2009, Seitz and col-
leagues,10 in a systematic review of peer-reviewed
articles reporting on psychological or psychosocial
interventions for adolescents with cancer between
1988 and 2007, found only four such studies. These
studies had small sample sizes (n ¼ 14 to 78), and
only one, a small pilot study (n ¼ 21), reported

significant improvement compared with a waitlist
control group. We sought to update findings from
the previously published review by conducting a
systematic review of psychosocial interventions de-
signed for AYA with cancer published since 2007
and by summarizing and evaluating these studies.
METHODS
Search Strategy
To identify relevant studies addressing interven-
tions for AYA with cancer, the following databases
were searched: PubMed, Ovid, and PsycINFO. In
addition to the database search, reference lists of
all relevant studies and review articles were
scanned for further references that met the inclu-
sion criteria.
The inclusion criteria were: (1) full-length, peer-
reviewed articles published between January 2008
and December 2014; (2) a study sample of AYA can-
cer patients between the ages of 10 and 29; (3) En-
glish language; (4) uncontrolled or controlled
trials; and (5) measurement of psychosocial
outcome variables. Exclusion criteria were: case
studies, editorials, abstracts, dissertations, and
studies focused on adolescent survivors of child-
hood cancers. Although the National Cancer Insti-
tute defines AYA as being between 15 and 39, for
this review we narrowed the age range to 15 to
29 years. This reflects the age range most commonly
considered the AYA cancer population by the
oncology community and also narrows the develop-
mental span for psychosocial interventions.11
Reference lists and abstracts for identified arti-
cles were scanned for their relevance. Using the
key words: adolescents, young adults, cancer,
and interventions, a total of 242 articles were iden-
tified; however, 233 were eliminated because they
did not meet the inclusion criteria. Full copies of
the nine articles that seemed to meet the inclusion
criteria were obtained. After reading these nine,
four were excluded because, for example, they
used study samples of adolescent survivors of child-
hood cancer or gave descriptions of the interven-
tion protocol but did not describe results.
Data Organization
Data from the remaining five eligible articles were
abstracted and organized into four separate
tables by one person and verified by a second
person. Table 1 focuses on: year published;
country of origin; population; sample size; sample
UPDATED PSYCHOSOCIAL INTERVENTIONS 243
characteristics including age, gender, and ethnicity;
type of study design; and theoretical framework.
Table 2 includes an overview of the interventions
with abstracted data addressing: behavior(s)
encouraged: mode of delivery (ie, route and inter-
vener, if applicable): timing of delivery: duration:
a description of the intervention: and a descrip-
tion of the control group. Table 3 describes the
methodological quality of the studies. Articles
were critiqued according to the following salient
features: randomization and processes descri-
bed (yes/no or not applicable for randomized,
randomization processes described, and blinding),
power analysis (yes/no reported), length of follow-
up, attrition, and the number of participants in
each arm that completed all measures. Table 4 dis-
plays the outcome variables of interest, measures
used, and significant findings.
RESULTS
The search produced only five studies that met
our inclusion criteria.12-16 One study included a
sample of AYA who ranged from 9 to 20 years of
age,16 which was slightly outside our pre-
specified age range of 10 to 29. We decided to
include this article because the majority of the
sample (78%) met this criterion (L. Wu, personal
communication, March 2015).
As shown in Table 1, three of the studies were
conducted in the United States12,14,15 and one in
Taiwan.16 One international study was conducted
in the United States, Canada, and Australia.13
Four studies were conducted with AYA,12,13,15,16
and one study focused on the adolescent/family
dyad.14 Ages of AYA ranged from 9 to 29. Three
studies included fewer than 100 partici-
pants.12,14,16 The average age of research partici-
pants was not explicitly reported in one study13;
instead, the percentage of participants in stratified
age groups was reported. In the four other studies,
mean age ranged from 13.2 to 17.3 years.12,14-16
Gender was reported in all studies and females
comprised from 31% to 45% of the samples.
Ethnicity was reported in four studies, and in
those studies from 50% to 75% of the samples
were White.12-15 All studies were randomized
controlled trials; however, three were pilot
studies.12,14,16 Theoretical frameworks were re-
ported in only three of the reviewed studies.13,15,16
As shown in Table 2, behavioral modification for
active/effective coping, self-efficacy, and control
 244
C.R. PHILLIPS AND L.L. DAVIS
TABLE 1.
Sample Demographics

Sample Characteristics
Gender Ethnicity Theoretical
Study Country Population N Age* (yrs) (% female) (% white) Design Framework

Jones (2010)12 US Adolescents (aged 12-18) 65 14.8 36.9 75.3 RCT/pilot Not specified
with solid tumors
Kato (2008)13 US/Canada/ Adolescents/young adults 371 13-14, 35.3%; 32.3 56.6 RCT Self-regulation Model of
Australia (aged 13-29) with 15-16, 30.7%; Health and Illness; Social
malignancies including 17-18, 21.3%; Cognitive Theory;
acute leukemia, 19-29, 12.7% Learning Theory
lymphoma, and sarcoma
Lyon (2014)14 US Adolescent (aged 30 dyads 16.3 40 50 RCT/pilot Not specified
14-20)/family dyads
with a cancer diagnosis
Robb (2014)15 US Adolescents/young adults 113 17.3 42.5 58.4 RCT Haase’s Resilience in
(aged 11-24) undergoing Illness Model (RIM);
stem cell transplant Robb’s Contextual
Support Model of Music
Therapy (CSM-MT)
Wu (2013)16 Taiwan Children/adolescents/ 58 14.1 (con) 44.8 (con.) Not RCT/pilot Lazarus’ Transactional
young adults with 13.2 (exp) 31 (exp.) reported theory
cancer (aged 9-20)

Abbreviations: RCT, randomized controlled trial; con, control; exp, experimental.

*Mean age reported unless otherwise specified.
 TABLE 2.
Overview of Interventions

Timing of Intervention Brief Description

Study) Behavior Encouraged Delivery Mode Delivery Duration (min) of Intervention Control Group
12
Jones (2010) Effective coping, CD-ROM During active cancer Not reported Interactive multimedia Attention control
self-efficacy, treatment CD-ROM to educate (Handbook with
and control or off treatment adolescents about their similar information)
cancer. Seven TV screens
(like a network station) that
represented 7 different
adolescent-related topics.
Games also included to
enhance learning
Kato (2008)13 Adherence to treatment Video game play During active 60 Video game designed to Attention control
regimens and other via mini-computer cancer treatment increase adherence and (Video game with
behavioral outcomes (ie, promote positive self-care similar play structure
self-efficacy and control.) behaviors. Participants and controller
asked to play the games for interface)
at least 1 hour per week
during the 3-month study
period; game content
engineered to address
issues such as destroying
cancer cells and managing
common treatment-related
adverse effects such as

UPDATED PSYCHOSOCIAL INTERVENTIONS

bacterial infections,
nausea, and constipation
Lyon (2014)14 Communication Face-to-face trained During active 60 A family-centered advanced Treatment as usual
about treatment or certified facilitator cancer treatment care planning intervention;
preferences 3 weekly sessions in a
dydactic format. The
foundation for sessions
included: engaging the
participant in end-of-life
questions; respecting
choices; and expressing
medical, personal,
emotional, and spiritual
needs
Robb (2014)15 Active engagement Face-to-face During stem 60-90 (J. Haase, AYA development of a Attention control
and coping board-certified cell transplant personal) therapeutic music video to (Audiobooks)
skills/strategies music therapist communication, provide predictability,
March 2015) autonomy support, and

245
(Continued )
 246 C.R. PHILLIPS AND L.L. DAVIS

were the most common behaviors encouraged by

the interventions and were addressed in four of
the reviewed studies.12,13,15,16 Another behavior
Control Group

encouraged included communication about treat-

Treatment as
ment preferences.14 Face-to-face contact as the
mode of delivery for the intervention was used in
usual
three studies.14-16 An interactive, asynchronous
CD-ROM or video game play was used in two
directly targeted Resilience

cognitive and/or behavioral

studies.12,13 Individuals who administered the
provide information about

effective skills to manage

sessions conducted over

completed within 1 week

modification; 3 modules;
in Illness Model risk and

identification and use of

treatment management
intervention program to

intervention varied across the studies and included

physical symptoms via

relationship support; 6

3 weeks; components
Brief Description
of Intervention

the participant themselves, music therapists, and

Modules 1-3 were

Psycho-educational
protective factors

trained research assistants or certified instruc-

and to facilitate

tors/facilitators. The delivery of the intervention

occurred during active cancer treatment in all of
the reviewed studies. The duration of the interven-
tion sessions was 60 minutes in two of the reviewed
studies13,14 and ranged between 60 and 90 minutes
in two studies.15,16 One study did not report the
Duration (min)

duration of the intervention.12 The descriptions of

the interventions showed that the psychosocial in-
terventions for AYA with cancer were rather com-
60-90

plex and had a wide variety of different elements.

Studies compared the intervention to treatment
as usual or to an attention control group.
Timing of Intervention

As shown in Table 3, all studies were random-

TABLE 2.
(Continued)

ized, although only two included a description of

cancer treatment
Delivery

the randomization process and details on blind-

ing.13,15 Three studies included a power anal-
During active

ysis,13,15,16 and all included a baseline assessment

before intervention or control. The follow-up as-
sessments commonly occurred from 1 to 3 months
post-intervention.12-14,16 Attrition was reported for
all of the reviewed studies and ranged from 4.91%16
trained research
Delivery Mode

to 59%,15 although all patients were accounted for

at the end of all studies.
Face-to-face

assistant

As shown in Table 4, there was an average of 5.4

outcome variables (excluding feasibility, accept-
ability) measured across the reviewed studies.
Coping12,15,16 and quality of life12-14 were the
most common outcome variables that were explic-
Behavior Encouraged

itly identified and measured across the reviewed

studies. Only one of the reviewed studies demon-
strated positive, significant findings among the
Effective coping
and symptom
management

research variables of interest.15 The other four

studies reported mixed findings relative to these
factors.12-14,16

DISCUSSION
Wu (2013)16
Study)

Our updated review confirms that little

advancement has been made in intervention sci-
ence for AYA with cancer since the last review
 UPDATED PSYCHOSOCIAL INTERVENTIONS 247

that Completed all Measures

was published.10 We identified five intervention
No. of Patients in Each arm

studies published since 2008 – taken together

Intervention: n ¼ 17 dyads
with the last review published10 only nine inter-

Control: n ¼ 13 dyads
Intervention: n ¼ 164
vention studies have been conducted with AYA
Intervention: n ¼ 35

Intervention: n ¼ 37

Intervention: n ¼ 29
with cancer since 1988 and only two have been
Control: n ¼ 140
Control: n ¼ 30

Control: n ¼ 30

Control: n ¼ 29
large randomized controlled trial studies,13,15
Furthermore, these few studies generally had
small samples and limited results, which serves
as a call to action for more intervention develop-
ment and evaluation for this underserved cancer
population.
17% attrition (intervention)
21% attrition (control)

Strengths
Attrition

Despite the few studies found in this updated

4.91% attrition

review, several strengths were identified among

59% attrition
8% attrition

7% attrition

the studies. First, two studies included samples

outside of the United States, including Australia,
Canada, and Taiwan.13,16 Second, although
three studies had small sample sizes (n ¼ 58 to
T2: 3 months post-intervention

T2: 3 months post-intervention

T3: 3 months post-intervention

65), these studies were identified as pilot

T2: 1 month post-intervention
T3: 100 days post-transplant

studies.12,14,16 Pilot studies are very important in

Length of Follow-up

the development and evaluation of interventions,

T2: After 6th session

and the pilot studies described here had fairly

Methodological Quality

reasonable sample sizes to evaluate the accept-

T3: 3 months
T1: Baseline

T1: Baseline

T1: Baseline

T1: Baseline

T1: Baseline

ability of the intervention and provided recom-

T2: 1 month
TABLE 3.

mendations for either improving the intervention

itself or its evaluation.12,14,16 Third, the average
number of participants among all of the reviewed
studies was much larger than the studies in the
Described/Requirement

previous published review (133.4 vs 32.3 partici-

Yes/20% attrition rate
Power Analysis

Yes/50 each group

Yes/65 each group

Yes/68 each group

pants). Fourth, all of the interventions were

feasible to implement during active treatment,
Not reported

which is important because this is a time when

cancer-related distress can be at its highest. Fifth,
three studies13-15 consisted of samples that were
#58% white, suggesting a good representation of
ethnicity. Sixth, four interventions12-15 were
Abbreviations: T1, Time 1; T2, Time 2; and T3, Time 3.
ii. Randomization Process Described

developed specifically based on the needs of AYA

with cancer (ie, through literature reviews, focus
groups, individual interviews, or advisory panels),
i. Randomized

which is particularly important when developing

iii. Blinding

age-appropriate interventions. Lastly, the attrition

rates for four of the studies were reasonable. Robb
iii. Not reported

iii. Not reported

ii. Not reported

ii. Not reported

ii. Not reported

and colleagues15 had a high attrition rate, but this

was because of the severity of the treatment and
iii. Yes

iii. Yes
ii. Yes

ii. Yes

disease within the sample.

i. Yes

i. Yes

i. Yes

i. Yes

i. Yes
i. No

Another unique strength identified was that

three of the studies were technology-based (ie,
Jones (2010)12

Robb (2014)15

interactive multimedia, video-game, and develop-

Lyon (2014)14
Kato (2008)13

Wu (2013)16

ment of a music video).12,13,15 Using techno-

Study)

logy and electronics has been regarded as highly

favorable to AYA.17 Additionally, the technology-
based interventions described here all provided
248 C.R. PHILLIPS AND L.L. DAVIS
TABLE 4.
Outcome Variables and Significant Findings
Outcome Variables
Study of Interest Measure
12
Jones (2010) 1. Control Multidimensional Health Locus of
Control Scale Form B (MHLC-B)
2. QOL Pediatric Oncology QOL Scale
(POQOLS)
3. Coping Style KIDCOPE
4. Self-efficacy Questionnaire developed for study
5. Cancer knowledge Questionnaire developed for study
6. Acceptability, use, Questionnaire developed for study
and satisfaction
Kato (2008)13 1. Treatment adherence Medication Adherence Scale (MAS);
Chronic Disease Compliance
Instrument (CDCI)
2. Antibiotic adherence MEMS-cap monitoring; 6-MP blood
assays
3. Self-efficacy Questionnaire developed for study
4. Knowledge Questionnaire developed for study
5. QOL Pediatric QOL– Generic Core Scale
Version 4.0; Functional Assessment
of Cancer Therapy- General
6. Stress Perceived Stress Scale
7. Control Multidimensional Health Locus of
Control Scale Form C
Lyon (2014)14 1. Anxiety Beck Anxiety Inventory
2. Depression Beck Depression Inventory
3. Pediatric QOL Pediatric QOL Inventory 4.0 Generic
Core Scales
4. Spiritual Well-being Spiritual Well-Being Scale of the
Functional Assessment of Chronic
Illness Therapy- Version 4
5. Satisfaction with intervention Satisfaction Questionnaire
6. Feasibility of intervention % eligible and enrolled, % attendance
at sessions, % retention at follow-
up, and % data completeness at
follow-up
Robb (2014)15 1. Illness-related distress McCorkle Symptom Distress Scale;
Mishel Uncertainty in Illness Scale
2. Coping-defensive Jalowiec Coping Scale-Revised:
Emotive & Evasive Subscales
3. Spiritual perspective Reed Spiritual Perspective Scale
4. Social integration Perceived Social Support-Health Care
Providers; Perceived Social
Support-Friends; Perceived Social
Support-Family
5. Family environment Family Adaptability/Cohesion Scale II;
Parent-Adolescent Communication
Scale; Family Strengths Scale
Significant Findings
Adolescents who received the
CD-ROM were significantly more
likely to increase their internal locus
of control scores (P ¼ 0.016);
however, no significant differences
were observed in regard to QOL,
coping, self-efficacy, or knowledge
Self-reported treatment adherence did
not differ significantly between
groups as measured by the MAS
and CDCI (group  time interaction,
P ¼ 0.503; P ¼ 0.78, respectively);
MEMS-cap monitoring showed a
16% increase in adherence in the
intervention group; A significantly
greater increase in cancer-related
knowledge and cancer-specific
self-efficacy was shown over time in
the intervention group (group  time
interaction of P ¼ 0.035 and
P ¼ 0.011, respectively); The
intervention group did not
demonstrate significant
group  time interactions for the
measures of adherence, stress,
control, or QOL
Adolescents’ anxiety decreased
significantly from baseline to
3 months post-intervention in both
groups (b ¼ 5.6; P ¼ 0.0212);
Total spirituality scores (b ¼ 8.1;
P ¼ 0.0296) were significantly
higher among the intervention
versus control group. 100%
attendance at all 3 sessions, 93%
retention at 3 months post-
intervention, 100% of families rated
intervention as worthwhile, and
adolescents’ rating as worthwhile
increased over time (65% to 82%).
At T2 the intervention group reported
significantly better courageous
coping (effect size, 0.505;
P ¼ 0.030); At T3 the intervention
group reported significantly better
social integration (effect size, 0.543;
P ¼ 0.028) and family environment
(effect size, 0.663; P ¼ 0.008);
Moderate non-significant effect
sizes for spiritual perspective (effect
size, 0.450: P ¼ 0.071) and
(Continued )
 UPDATED PSYCHOSOCIAL INTERVENTIONS 249

TABLE 4.
(Continued)

Outcome Variables
Study of Interest Measure Significant Findings

6. Coping-courageous Jalowiec Coping Scale-Revised: self-transcendence (effect size,

Confrontive Subscale, Optimistic
Subscale, Supportant Subscale
7. Hope-derived meaning Herth Hope Index: Expectancy/
Interconnectedness Subscales,
Positive Readiness Subscale
8. Outcomes Reed Self-Transcendence Scale;
Haase Resilience in Illness Scale
Wu (2013)16 1. Symptom severity Perceived Symptom Severity Scale
2. Coping Pediatric Cancer Coping Scale
3. Acceptability of the 4-item acceptability survey with
intervention Likert-type responses
0.424; P ¼ 0.088) were shown
No significant difference in coping
scores between groups;
intervention group reported
significantly lower scores in GI
problems (P ¼ 0.03) and pain
(P ¼ 0.02); most symptoms
decreased significantly over time
in both groups

Abbreviations: QOL, quality of life; MEMS, Medication Event Monitoring System.

elements to support self-efficacy, control, or au-
tonomy, which corresponds to fostering healthy
adolescent development.18
Limitations
Several limitations were also identified. First, fe-
males were somewhat underrepresented in all of
the studies. This is an important consideration
for future intervention studies because female
AYA have been identified as having greater
distress than male AYA.19,20 Second, few age-
appropriate theories were used to guide the devel-
opment or evaluation of these studies. Of the three
studies that used a theoretical framework, only
Robb and colleagues15 used a theory that was
age-appropriate. The other theories have most
commonly been evaluated with adult populations
and may not hold true for the adolescent experi-
ence. This limitation is likely caused by the lack
of well-developed and evaluated theories devel-
oped or tested for the adolescent population,
particularly with cancer. Third, only two studies
focused specifically on actively involving the
AYA in the development of effective coping skills
through self-reflection and communication of
their cancer experience. Robb and colleagues15
provided a structured creativity opportunity for
AYA to self-reflect, identify, and express what
was important to them through the development
of their own personalized music video. Wu and
colleagues16 also encouraged the AYA to self-
reflect on their treatment-related stressors,
discuss current coping styles, and then role-play
new coping techniques with a facilitator. Robb
and colleagues’ study was the only one that
demonstrated significant results on coping.
The fourth limitation was that all but one
study13 was underpowered (ie, #80%), suggesting
that researchers need to enhance their AYA
recruitment efforts and monitor the recruitment
process closely over the length of the grant period.
The fifth limitation was that the length of post-
intervention follow-up tended to be fairly short
(1 to 3 months). Therefore, it is unclear whether
or not these interventions had a long-term impact
on the AYA. The sixth limitation was the lack of
consistency in the outcome instruments used,
which made it difficult to compare results across
the studies. Lastly, most of the studies only used
self-report measures to evaluate the intervention.
In conclusion, this update review indicates
that the development and evaluation of age-
appropriate psychosocial interventions for AYA
with cancer is still in its infancy. However, we
are starting to finally see some larger randomized,
controlled trials with promising results that incor-
porate innovative technology, which is age-
appropriate and considered favorably by AYA.
Future research should focus on conducting
more multi-site studies to obtain larger sample
250 C.R. PHILLIPS AND L.L. DAVIS
sizes. Researchers will also need to overestimate
their targeted sample size because of the often se-
vere and complex nature of cancer to obtain
adequate power to detect differences. Secondly,
research should continue to develop interventions
based on the specific needs of AYA and to obtain
their feedback in the development and/or
improvement of these interventions. Additionally,
as more intervention studies are conducted inter-
nationally it will be important to evaluate cultural
differences so that efforts are made to support
these potential differences. Lastly, consistency in
instruments to evaluate outcomes will help future
comparison analyses.
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Although two of the reviewed interventions13,15
are ready for additional transitional research,
none are ready to be immediately translated into
clinical practice at this time. However, what can
be taken from this review is that it is extremely
important for nurses to evaluate and consider
the needs of AYA. Incorporating creative ways
for the AYA to express their needs and concerns
and to self-reflect on their experiences seems to
be critically important and may be a way for
nurses to help AYA cope positively with the cancer
experience.
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