Journal of Psychosocial Oncology

ISSN: 0734-7332 (Print) 1540-7586 (Online) Journal homepage: https://www.tandfonline.com/loi/wjpo20

Being a teenager and cancer patient: What do

adolescents and young adults with cancer find
valuable and challenging with their friends and
cancer peers?

Tharushi Kaluarachchi, Fiona McDonald, Pandora Patterson & Toby R. O.

Newton-John

To cite this article: Tharushi Kaluarachchi, Fiona McDonald, Pandora Patterson & Toby R. O.
Newton-John (2019): Being a teenager and cancer patient: What do adolescents and young
adults with cancer find valuable and challenging with their friends and cancer peers?, Journal of
Psychosocial Oncology, DOI: 10.1080/07347332.2019.1672847

To link to this article: https://doi.org/10.1080/07347332.2019.1672847

Published online: 14 Oct 2019.

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JOURNAL OF PSYCHOSOCIAL ONCOLOGY
https://doi.org/10.1080/07347332.2019.1672847

ARTICLE

Being a teenager and cancer patient: What do

adolescents and young adults with cancer find valuable
and challenging with their friends and cancer peers?
Tharushi Kaluarachchi, MClinPsycha , Fiona McDonald, PhDb , Pandora
Patterson, PhDb , and Toby R. O. Newton-John, PhDa
a
Graduate School of Health, University of Technology Sydney, Sydney, Australia;
b
Research, Evaluation & Social Policy, CanTeen Australia, Sydney, Australia

ABSTRACT KEYWORDS
Purpose: This study examined Adolescent and Young Adult adolescent and young
(AYA) cancer patients’ experiences with friends and cancer adult; cancer; cancer
friends (peers) throughout their cancer journey. friends; friends
Research approach: Qualitative, thematic analysis.
Participants: Twelve AYA diagnosed with cancer, treated
within the past five years.
Methodological approach: Individual semi-structured inter-
views, focusing on friend and peer experiences pre-/post-diag-
nosis, during and after treatment.
Findings: Overarching themes of ‘valued’ vs. ‘challenging’
aspects with friends and peers.
Interpretation: Friend and peer relationships were both valu-
able, but in different ways. Friends provided general support and
helped AYA feel like a normal teenager, while peers provided tar-
geted support and helped AYA feel like a normal teenager with
cancer. Peers had an intimate understanding of cancer, whereas
poor understanding by friends led to further challenges such as
avoidance and being dismissive. Peer relations were notably chal-
lenged by a premature confrontation with mortality. Friendships
evolved and changed throughout the cancer journey.

Introduction
Adolescents and Young Adults (AYA) with cancer, aged between 12 and
25 years, are often remarked to be “cancer’s lost generation”, with cancer
generally considered to be a disease affecting older adults.1 However, there
is growing recognition that AYA diagnoses occupy a unique place in the
spectrum of pediatric and adult cancers.2 While increasing cancer survival
rates for AYA are promising, the short-term and long-term impact of can-
cer poses a challenge which requires specialized attention, care and
resources.3–5

CONTACT Toby Newton-John, PhD toby.newton-john@uts.edu.au Graduate School of Health, University

of Technology Sydney, PO Box 123, Ultimo, NSW 2007, Australia.
ß 2019 Taylor & Francis Group, LLC
2 T. KALUARACHCHI ET AL.

AYA are in a unique transitional phase, with increased friend interac-

tions, gaining independence from parents, altering body image, exploring
one’s sexuality and developing personal values.6,7 Cancer is a significant
stressor on their development and psychosocial functioning, when their
lives are already in a state of constant change.4,8 Psychosocial support is
known to be a crucial unmet need for a substantial proportion of AYA
with cancer.9,10 Opportunities to meet peers—other AYA with cancer—and
support from friends were regarded high priority needs and a long-
term issue.11,12
While forming friendships and being accepted is a salient aspect of AYA
development,13 this is often incongruous with cancer, as significant illness
results in an increased dependency on family.14 For AYA with cancer,
strong friendship support is cited to be helpful to cope with the complexity
of normative development, whereby participating in typical AYA tasks min-
imizes the interference of cancer and maximizes their quality of life.15,16
Miedema et al.17 indicated that this may be due to the preservation of nor-
malcy. While social support is evidenced to be generally helpful, limited
research has addressed what it is that AYA consider important. To date,
this has only been addressed in a limited way by Woodgate,18 who found
that others “being there” was a key supportive element.
There has been a limited exploration of positive aspects of friendships,
with studies focusing more on the negative aspects of friendships with non-
cancer friends. A review of psychosocial support in AYA cancer survivors19
found that while AYA expressed satisfaction with family support, support
from friends was described as less satisfactory. Noted reasons in studies
include strained friendships and poor support prior to being diagnosed
with cancer, friends feeling sorry for them, avoiding them or drifting
away.17,19 AYA also lost friends due to misconceptions regarding cancer,
and erroneous beliefs regarding their ability to function.20 AYA also
expressed guilt and frustration in providing reciprocal support, in not
knowing how to be there for family and friends.16
Another aspect of changing social relationships in the context of cancer,
is connecting with other AYA with cancer at a similar life stage/age, here
on referred to as (cancer) peers. Friends and peers are at a similar life stage,
but differ in terms of peers having an experience with cancer. Support
received from peers has been deemed invaluable for helping AYA cope with
cancer, and more important than support received from family and
friends.12,21 Peers provided the opportunity to establish meaningful friend-
ships with others who have experienced similar isolating situations such as
social exclusion or stigmatization, and promoted a sense of group identity,
a normative developmental task for AYA.12,14 For older adolescents, these
peer relationships provided a chance to address any areas of concern related
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 3

to cancer, such as dependence and lack of autonomy, body image, fertility,

and future plans.22
In this youth transitional phase, where friendships are highly salient,
there are currently no studies specifically examining friends and peers, with
a major gap in exploring what may be difficult in peer relationships.
Therefore, this study focused on both the positive and negative friendship
experiences of AYA with cancer. The aim was to generate information
about their experiences to help AYA manage these key supportive
relationships.

Method
Participants
The sample comprised of AYA from CanTeen, The Australian
Organization for Young People Living with Cancer, aged between 12 and
25 years. Eligible participants were aged between 14 and 25 years, received
treatment in the past five years and were currently in any cancer stage.
Twelve young people (9 female and 3 male), aged 16–22 (M ¼ 18.8) partici-
pated in the study (see Table 1). Sampling was purposive, with CanTeen
staff identifying potential participants and gaining permission to provide
contact details to the researcher. Potential participants were contacted via
telephone and email to provide information and gain consent to partici-
pate. Participants younger than 18 years provided assent in addition to con-
sent provided by their parent/guardian. The study was approved by the
University of Technology Sydney Human Research Ethics Committee refer-
ence number: ETH18-2114.

CanTeen programs and services

CanTeen is a non-Government organization providing a range of services
to young people aged 12–25 years impacted by their own or a family mem-
ber’s cancer diagnosis, including those whose family member has died due
to cancer. These services include recreational and therapeutic programs
(multi-day overnight programs, weekly group programs, online group pro-
grams, recreation days and evenings), counseling (email, chat, telephone
and face to face), individual support, and an online platform where young
people can connect with each other. Additionally, a range of information
resources are available in hard copy and digitally. The young people
involved in this study will have accessed support services that were most
appropriate for their situation and they will have met other young people
with a cancer experience through these programs and services.
4 T. KALUARACHCHI ET AL.

Table 1. Cancer characteristics of the AYA.

Age at Time from Treatment
Participant ID Cancer Type Gender Diagnosis/Relapse Current Age to Interview
01 Brain Male 17 years 18 years 0 months
02 Brain Female 15 years 18 years 4 months
03 Brain Female 3,13 years 16 years 3 years
04 Brain Female 13 years 20 years 4 years
05 Brain Male 16 years 22 years 5 years
06 Bone Female 16 years 19 years 1.5 years
07 Bone Female 14 years 17 years 2 years
08 Bladder Female 16 years 19 years 6 months
09 Leukemia Female 15 years 17 years 1.5 years
10 Lymphoma Female 15 years 18 years 2.5 years
11 Lymphoma Female 19 years 19 years 1 month
12 HLH, GVHD Male 17 years 22 years 3 years
Hemophagocytic lymphohistiocytosis, Graft vs. Host Disease.

Data collection
Individual semi-structured telephone interviews were conducted by the first
author (TK), a Masters level psychologist with qualitative research skills training,
under the supervision of an experienced clinical psychology panel (FP, PP, TNJ).
The interview schedule was designed flexibly to facilitate participants sharing
their experiences. It broadly focused on their high school/educational experience,
friendships before and after diagnosis, during treatment and post-treatment (if
applicable) and their experiences with peers. Demographic questions included
questions about their age, gender and cancer diagnosis. Interviews ranged from
20 to 45 minutes, were recorded and transcribed verbatim.

Data analysis
Thematic analysis was used to identify, analyze and report themes within
the data.23 Thematic analysis was selected as the qualitative methodology
because of its suitability for analyzing health data, and capacity to generate
meaningful representations of clinical experiences.23,35
Each transcript was analyzed individually by the first author to develop
an initial list of codes, which were then grouped into potential themes.
Transcripts were then reexamined for material consistent with each theme.
Each theme was also reviewed to ensure that it appropriately represented
the content. To achieve greater validity, the transcripts and themes were
also examined by two other authors with post-graduate qualifications in
Psychology and considerable clinical experience working with individuals
with cancer. These authors had the responsibility of confirming that the
themes were appropriate, and discussions took place until consensus
was reached.
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 5

Table 2. Themes and subthemes.

Type of
Relationship Theme Cancer Stage Subtheme
Friends Valued Pre-diagnosis Connected
Diagnosis/Treatment Support and Understanding
Normal Teenager
Post-treatment Closer Relationships
Challenging Pre-diagnosis Difficulty in Friendships
Diagnosis/Treatment Lack of Understanding
Overly Supportive
Reminders
Cancer Effects
Post-treatment Cancer is Forgotten
Changing Relationships
Peers Valued Shared Cancer Experience
Advice
Shared Non-Cancer Interests
Challenging Mortality
Not Being Open
Practical Difficulties

Results
Data analysis elicited key subthemes in the data, which were broadly
grouped according to what was valued and what was challenging, with
friends and peers. For friends, these subthemes were then further clustered
according to cancer stage (Pre-diagnosis, Diagnosis/Treatment and Post-
treatment). Each theme and subtheme (Table 2) is discussed.

What is valued with friends?

Pre-diagnosis
Connected. Prior to being diagnosed, most participants felt connected to
their friends by partaking in normal social experiences and valuing their
friends for being non-judgmental and open, which allowed a participant
to “be myself around them, not really hide anything” (P10). School often
provided a shared context for fostering relationships.

Diagnosis/treatment
Support and understanding. During diagnosis and treatment, friends provid-
ing support and having an accurate understanding helped the participant
feel valued and aided in maintaining relationships. This was described as
friends providing a physical presence—by visiting them, buying small gifts
and food—and providing a space to be emotionally vulnerable, for partici-
pants to speak about their ability to cope, as well as understanding the
effects of cancer on the participant.
6 T. KALUARACHCHI ET AL.

“They seemed to understand that even if I went off the grid for a couple of weeks it
wasn’t because I was avoiding them and that they should stop inviting me. It was just
because I wasn’t feeling up for it in that moment.” (P02)

Normal teenager. A predominate goal for participants was to experience a

sense of normalcy by partaking in typical AYA tasks.
“I needed a time and place where I could forget about everything else that was going
on and just be a normal teenager.” (P02)

This was readily offered by being viewed in terms of their pre-cancer self
and being able to engage in pre-diagnosis activities—such as talking about
things unrelated to cancer and playing games—which provided a distrac-
tion from worrying about cancer, mortality and from cancer-related pain
and side effects.
“One day my friend came over and we chatted for like 4 hours and I just completely
forgot about the pain. He left and I was like Woah, I didn’t feel the pain until he had
gone.” (P11)

Friends speaking about their everyday experiences had a similar effect of

making participants feel like they were still involved in activities that they
were engaged in prior to having cancer.
“They would just talk about swimming or what other friends were doing, stuff that
was happening that I couldn’t attend, I still felt like I was involved.” (P08)

Post-treatment
Closer relationships. Upon entering the post-treatment phase, participants
reflected on their experiences. As a result of spending time together, friends
gaining insight and a more accurate understanding of their functional abil-
ity, friendships became closer.
“It showed me who my true friends were, who I stayed close with.” (P10)

What is challenging with friends?

Pre-diagnosis
Difficulty in friendships. While friendships were mostly stable for the major-
ity of participants prior to cancer, some experienced pre-diagnosis difficul-
ties such as bullying or describing themselves as socially “awkward”, which
impeded the formation of friendships.
“There were a couple of girls at the time, who had friends that didn’t like me and that
would influence them to be a little bit hurtful towards me.” (P09)
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 7

Diagnosis/treatment
Lack of understanding. During diagnosis and treatment, a poor understand-
ing of the physical impact of cancer led to friends having erroneous beliefs
regarding cancer. While friends were valued for promoting normalcy and
their identity as a teenager, this was not feasible when friends defined the
participant in terms of their cancer.
“They saw me as the girl getting too sick and thought they would catch it.” (P08)

A lack of understanding also led to friends speaking differently, distanc-

ing themselves or avoiding the participant altogether, due to not knowing
how to approach the fact that they have cancer.
“People don’t know how to approach you after you have had cancer … They try and avoid
that topic and I guess in saying that they avoid talking to you about anything as well.” (P04)

Some experienced other challenges, with friends being actively dismissive

of their cancer experience through ostracizing the participant, “they all sat
away from me” (P03) or verbally bullying them.
“I had some girls … that would go to school and say I was an attention
seeker … talking behind my back at school.” (P09)

Overly supportive. On the other hand, an overprovision of support and con-

cern from friends prompted participants to reflect on their situation and
worry about cancer. For others, being overly supportive—by excessively
publicizing on social media or being ingenuine—led to feeling invalidated.
“She would always post things on like Instagram, Snapchat like “trooper” and trying to
be supportive, but she would go over the top. It was to the point where she would be
like “oh look at me, I’m so supportive as a friend.” (P11)

Reminders. While participants appreciated hearing about their friend’s lives,

it also led them to appraise their experience by comparing themselves to
their friends. In a period of high stress and vulnerable physical health, par-
ticipants found it difficult to hear their friend talk about being sick with a
minor illness, as it reminded them of their experience with cancer.
“They would say I’m sick, and it’s like, I’m not well every day … I didn’t want to
know if they had a cold or anything. I was more worried about looking after
myself.” (P08)

Hearing about their friends’ lives also provided a reminder of the typical
AYA experiences that they were not taking part in and reinforced cogni-
tions of being unable to progress in life due to cancer.
“Hearing them talk was great and it was what I wanted but it kinda hurt, because I
was missing out and it was reminding me of that.” (P02)
8 T. KALUARACHCHI ET AL.

Cancer effects. Friendships were also affected from the participant’s side, as
fatigue reduced the ability and motivation to partake in normative tasks
and communicate with friends.
“I wouldn’t have the energy to message them or reply to messages, let alone leave the
house … It was a combination actually; it was a lack of energy and I was in a bad
place and had no motivation to do that.” (P02)

Post-treatment
Cancer is forgotten. Interestingly, while participants craved normalcy, they
did not want the impact of cancer to be forgotten following treatment. In
comparison, peers were reported to understand that cancer was an
ongoing journey.
“Cancer still affects me. Cause like with my friends, it’s kinda like it’s there but it’s
forgotten … Whereas with, my friends who are from CanTeen they understand that
it’s an ongoing process.” (P09)

Changing relationships. As a result of having cancer, and their friends pro-

gressing typically along the developmental trajectory, some with relatively
stable pre-diagnosis friendships experienced friends being more distant.
Those who experienced pre-diagnosis difficulties continued to struggle fol-
lowing treatment, experiencing bullying, and struggling to keep in contact
with friends, due to a lack of reciprocation.
“I still make an effort to ask if they want to go out anywhere … I’m still waiting for
them to reply back but I don’t know why I’m still clinging onto them, I think it’s
because I don’t have any other friends.” (P06)

What is valued with peers?

Shared cancer experience
All participants felt that connecting with peers provided an opportunity to
feel understood and receive support informed by personal experience. In
comparison to friends, due to their intimate understanding of cancer, peers
were able to better understand what was happening in the patient’s life.
“If you say oh I’m in the hospital, they would understand why more than somebody
else would … CanTeen friends understand better.” (P04)

Speaking about cancer-specific topics also reassured participants and fos-

tered a sense of normalcy in regards to having cancer. This included speak-
ing about hospital experiences, treatment effects on appearance, fertility
and sexuality, life afterwards, and other related topics such as coping and
mental health.
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 9

“Talking about life after treatment, the ups and downs of it. Just talking about your
mental health as well, do you think about these things, do you feel this way, or get
worked up really quickly, or physical appearances.” (P06)

A large part of speaking about these topics was injecting humor, often
morbid jokes. Participants preferred to speak to peers about these topics, as
humor about cancer was described to make their friends feel uncomfortable.
“We can joke and say things about cancer, that other people would say, why are you
saying that. We had it so we can talk about it, we can say whatever, it won’t matter
to us.” (P04)

Advice
Participants also valued their peer relationships in so far as being able to
ask them questions, tips and get practical advice in regards to topics related
to cancer, such as coping in hospital during treatment. For some partici-
pants, peer relations were purely valued for these interactions.
“I just wanted to see how they were doing it or how they got through every day. They
really wanted to hang out with someone, to do something other than that … like to
play a game.” (P01)

Shared Non-Cancer interests

For others, while mutual understanding of cancer was valued, the ability to
speak to peers without feeling pressured to speak about cancer allowed par-
ticipants to connect through common interests unrelated to cancer such as
music, school, relationships. This aided in normalizing their experience of
being a teenager with cancer.
“You kind of just meet people your age and you just talk about, like normal people
talk, like being teenagers … you don’t have to just bring up the fact that you’ve been
through cancer.” (P09)

What is challenging with peers?

Mortality
A vital aspect that was endorsed as being challenging in peer relationships,
was being concerned about peers undergoing cancer treatment
and relapsing.
“There’s a slight thing in the back of your head, like you’re worried for them, what if
they relapse and all that … So you’re sitting there and having fun and at the same time
low-key thinking like oh my gosh something can happen.” (P11)

For some participants, this ultimately led to dealing with the death of
peers who passed away due to cancer.
10 T. KALUARACHCHI ET AL.

“For me death, it’s hard for me to get around my head, because one minute they’re
there and the next they’re just gone.” (P09)

This premature confrontation of mortality led to a reflection of their

own mortality and the longevity of the relationship, which hindered their
ability to engage meaningfully in the relationship.
“I’ve experienced friends that had cancer that have passed so it’s kind of like a
triggering thing, brings down my mood. I want to be there for them and help them but
like yeah.” (P04)

Not being open

Another difficulty with forming peer relationships were some peers not
being open to speaking about the details of their experiences, which made
it difficult to relate to each other. Some peers were also not open to new
friendships due to typical AYA reasons such as having preexisting friend-
ship groups. On the participants’ side, they initially experienced difficulty
in opening up to others.

“At first it was a bit confronting … I think it was just my confidence, just opening up
about scary things that have happened.” (P08)

Practical difficulties
Participants also found it difficult to form relationships with peers during
camp programs due to socializing being structured by the program and a
physical inability to be around other people due to treatment,
which stopped them being able to meet peers face-to-face and form
relationships.

“I haven’t been able to go out to their events, because of the cancer I’ve got … I have
seizures and that doesn’t allow me to go into the water.” (P01)

Discussion
The present study explored AYA friendship experiences throughout the
cancer trajectory. Previous research had not explicitly looked at friends and
peers, instead grouping together multiple types of support such as friends,
peers, family, partners and healthcare workers,22,24 making it difficult to
determine the unique value of having friends and peers during a develop-
mental phase where friendships become more salient. Our findings indicate
that friends and peers are in fact integral parts of the AYA support net-
work with distinct and unique contributions.
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 11

Findings from previous studies19 indicated poor satisfaction with friends

relative to family, and it was also concluded that peer relationships were
more important than support from family and friends.12 However, present
findings indicated that friends and peers were both very important, but
also very different types of relationships. In line with previous literature,
peer experience with cancer was invaluable,24 allowing participants to feel
better understood, with more targeted support. In comparison, friends pro-
vided more general support and were reported to be emotionally closer,
creating a physical and emotional presence.18 The present study notably
found that friends could be overly supportive, in an excessive and ingen-
uine manner. A lack of understanding by friends presented further chal-
lenges, leading to an avoidance of the patient and dismissal of their
experience. Though previous studies noted avoidance, misunderstanding
and bullying,16,25 the consequences of these challenging processes on
friendships have not been adequately explored. The present study found
that in the midst of cancer, these challenges had significant implications for
the maintenance of friendships, often leading to the cessation of
friendships.9
Friends and peers were also vital in promoting a distinct sense of nor-
malcy. Friends allowed the participant to feel like a normal teenager, previ-
ously identified as a key part of coping with cancer.17 Interestingly, in this
study, seeking normalcy consequently led to reminders of missing out on
typical AYA tasks and cancer being disregarded by friends following treat-
ment. While it has been well established that peers have a mutual under-
standing of cancer experiences,22,26 this was notably found to normalize the
experience of cancer. This study importantly considered the presence of
nonspecific friendship elements in peer relationships, previously overlooked
in the literature—such as the use of humor (which plays a central role in
AYA socialization)27 and shared non-cancer interests—which fostered the
sense of being a normal teenager with cancer. In the face of dual stressors
of normative development and cancer, normalcy helped AYA to make
sense of their cancer experience and unify their identity as a teenager and
an individual with cancer.
While friendship is a reciprocal relationship, previous studies have
neglected the participant’s side of the relationship. Cancer-related fatigue
made it difficult to engage in social interactions.28,29 In addition to a phys-
ical inability to socialize, fatigue was found to reduce motivation to main-
tain relationships with friends. Previously unexplored, other participant
factors were found to make peer relationships challenging. A novel finding
of this study was that the premature confrontation of peer mortality and
fearing peer relapse impeded the ability to engage meaningfully. While peer
death is a non-normative event, rarely considered in the context of
12 T. KALUARACHCHI ET AL.

terminal illness, in general it has been cited to affect AYA’s concept of self,
propel them into adulthood and strain relationships.14,30,31 Further chal-
lenges were faced when initiating face-to-face peer relationships in camps
due to their physical health and AYA experiencing difficulty in opening up
about cancer. These aspects have vital implications for providing appropri-
ate peer services, to help AYA navigate confronting issues such as mortality
and speaking about their cancer experiences, and including alternate forms
of face-to-face or online interaction.
While the majority of previous research has not traced the impact of
cancer on friendships at different time points,32 this study found that par-
ticular friendship behaviors and characteristics were valued at crucial time
points in the trajectory. Pre-diagnosis values of being connected to friends
and having typical social experiences, were amplified during diagnosis/
treatment, such that participants valued being treated as their usual self
with extra support, which facilitated closer relationships. While studies are
generally biased toward more forthcoming, well-adjusted individuals,12,33 a
strength of this study was including participants who experienced strained
friendships prior to being diagnosed. While pre-diagnosis difficulties often
permeated into their experiences during cancer and following treatment,
even those with stable friendships dealt with challenges.
In terms of study limitations, these narratives are likely to have a degree
of both retrospective bias in the participants and interviewer bias from the
researcher. However, our deliberate use of open-ended questions and a
neutral interviewer stance were intended to mitigate these biases as far as
possible. In addition, the current sample was subject to selection bias by
CanTeen staff, and thus may be a limited representation of AYA with can-
cer in the general population. Given that a primary part of CanTeen is
facilitating peer contact, without this, AYA may have drawn on alternate
forms of support. Thus, it would be a beneficial comparison to examine
the experiences of AYA who are not a part of a cancer organization.
Finally, the study also lacked a holistic consideration of friendships, without
the perspective of the participants’ non-cancer friends. Future studies may
consider the friend of the AYA with cancer as a further point of interven-
tion, to develop understanding from both sides, which may aid in resolving
difficult aspects of friendships.

Implications for psychosocial oncology

 Friends and peers advocated a sense of normalcy in addition to support.
Assisting stable friendships has the potential to provide unique support
to cope with cancer, as well as in navigating the complexity of norma-
tive development.
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 13

 Service provision of connecting AYA with cancer should consider that

peer relationships were challenged by peer mortality and fearing relapse.
 Particular friendship characteristics and behaviors were valued at different time
points along the cancer trajectory, which calls for phase-specific intervention.
 Based on the findings, recommendations can be made to share with
AYA with cancer and those involved in their care such as friends, fam-
ily and healthcare and psychosocial providers, to maximize friendship
support, and to minimize potentially challenging social interactions.

Conclusion
Findings from this study expand on existing knowledge about AYA peer
and friend relationships throughout the cancer journey. It importantly fills
a gap in the literature regarding what AYA find challenging in peer rela-
tionships, which can be used to inform service provision that connects
AYA with cancer. These AYA perspectives provided a unique introspection
on characteristics valued at different time points in the cancer journey.
This has the potential for phase-specific intervention, for other AYA with
cancer—particularly for those who have been recently diagnosed—to be
informed of not only potential difficulties, but also the value of friendships
at different time points. The findings also raise questions as to what actions
can be taken by those involved in their care (including friends, family,
healthcare and psychosocial providers), such as a nursing staff-led program
highlighted by Olsen and Harder34, focused on facilitating communication,
support and education of the AYA’s social network. This would assist in
the initiation and preservation of friend and peer relationships to not only
provide incomparable support, but also aid in navigating the complexities
of normative development. Overall, these findings provide guidance for
prospective clinical care and the development of clinical guidelines—to
maximize AYA support and minimize potentially challenging social interac-
tions—while acknowledging the unique developmental context. It is appar-
ent that given friend and peer relationships are an inimitable part of the
AYA cancer experience—colored with valued and challenging aspects—
there needs to be a dual consideration of these AYA as a teenager and a
cancer patient.

ORCID
Tharushi Kaluarachchi http://orcid.org/0000-0002-9576-1229
Fiona McDonald http://orcid.org/0000-0003-4484-4929
Pandora Patterson http://orcid.org/0000-0002-1686-3252
Toby R. O. Newton-John http://orcid.org/0000-0003-4219-4985
14 T. KALUARACHCHI ET AL.

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