# Background
The Canadian Partnership for Cancer (CPAC) reports that approximately 7,600 Canadians aged 15 to 39 years are diagnosed with cancer every year 1 Although the most frequent cancers in adolescent and young adults (AYAs) are thyroid cancer, breast cancer, Hodgkin lymphoma, non-Hodgkin lymphoma, testicular cancer and melanoma, all tumour groups present in young adults. 1 While there has been an increase in the age-standardized incidence rate of cancer for the AYA population, most AYAs diagnosed with cancer in Canada will survive their disease today. 1 AYAs diagnosed with cancer face unique challenges during and after their cancer diagnosis. Ferrari et al state that, "AYA patients seem to be in a sort of no-man's land, halfway between the two different worlds of pediatric and adult medical oncology and bearing the brunt, in terms of inclusion in clinical trials and quality of professional care, of the lack of integration between these two worlds." 2 Besides differences in tumour biology, limited progress in survival, lower clinical trial participation rates, and insufficient awareness of cancer symptoms among patients and professionals, AYA cancer patients have distinct psychosocial and supportive care needs compared with pediatric and adult cancer populations. 3 Late adolescence and young adulthood is a developmentally complex period of life, during which individuals are working to establish their own identity, develop a positive body image and sexual identity, detach from their parents, increase their involvement with peers, find a life partner, make decisions about higher education and careers, and possibly have their own family. 4 A cancer diagnosis can temporarily or permanently derail these plans.
In recognition of the lack of information about AYAs diagnosed with cancer in Canada and the obligation to address their unmet needs, a Canadian framework for the care and support of AYAs with cancer was jointly published by CPAC and the Adolescent and Young Adults with Cancer National Network in 2019. 5 The purpose of this framework was to articulate a national vision for high quality care and survivorship support of AYAs diagnosed with cancer and to provide specific individual-, service-, and system-level key actions to achieve the vision. Thus, the framework inspired the development of this provincial guideline, which endeavors to align its recommendations with the frameworks four strategic priorities to:
- Integrate an AYA-centered experience throughout care and survivorship; - Deliver interdisciplinary, integrated and comprehensive care and survivorship support that address the unique needs of AYAs with cancer; - Increase access to cutting-edge approaches to care and survivorship support for AYAs with cancer; and, - Drive evidence-based improvements for AYAs with cancer. This guideline has been developed as a supportive care guideline and not as a treatment guideline. The purpose of the guideline is to increase awareness of unique issues in AYA oncology and to recommend standards of care and interventions unique to the AYA population. Fundamentally, this guideline describes the optimal safe and high-quality care for all Albertan AYAs with cancer. Specific Guideline Resource Unit treatments or clinical procedures at the patient level are the domain of the Provincial Tumour Teams and treating teams. Operationalization of these guidelines is the domain of the AYA Oncology Steering Committee and treating teams and will likely look different across healthcare facilities.

# Guideline Questions
In AYAs diagnosed with cancer: 

# Search Strategy
PubMed database was searched for relevant studies, guidelines, and consensus documents. The specific search strategies, search terms, and search results, are presented in Appendix A. Evidence tables are available upon request. Online resources from oncology-based health organizations and guideline developers were also systematically searched, and relevant frameworks, care manuals, and guidelines from the following organizations were considered in the development of our recommendations: Canadian Partnership Against Cancer (CPAC), CanTeen Australia, Clinical Oncology Society of Australia (COSA), and the National Comprehensive Cancer Network (NCCN).

# Target Population
This guideline's recommendations are applicable to AYAs who have been diagnosed with cancer. We defined this population as persons aged 15 to 39 years, which is in line with The Canadian Framework for the Care and Support of Adolescents and Young Adults. 5 However, we recognize that based on their development status, persons chronologically less than 15 and older than 39 years may be best served through the recommendations of this guideline.

# Target Audience
This guideline is directed at healthcare professionals who are involved in the care of AYAs who have been diagnosed with cancer, as well as for AYAs with cancer and their families and caregivers.  c) Using a shared decision-making process, healthcare professionals should inform AYAs and discuss the potential risks and benefit for AYAs and their families to participate in clinical trials, as well as enrollment on tumour banking and biologic protocols. 5,11,12 Discussions and decisions about participation in research and clinical trials should be documented in the patient care plan. 5,11 (Level of Evidence: V, Strength of Recommendation: A)
- Refer to Alberta Clinical Trials and ClinicalTrials.gov databases for a list of current clinical studies being conducted in Alberta and around the World. ) Developmentally-appropriate care should be delivered and/or supported by a multidisciplinary team populated with age-and disease-specific medical and psychosocial experts able to effectively communicate and provide evidence-based care. 5,13  - Refer to the Children's Oncology Group (COG) 24 and National Comprehensive Cancer Network (NCCN) 6 for published recommendations for late effect screening in AYA cancer survivors.
f) Treating clinicians should work with patients to identify potential factors contributing to nonadherence with treatment regimens. 8 It is recommended that adherence assessment and monitoring occur at every clinic visit. 25,26 (Level of Evidence: V, Strength of Recommendation: A) g) All AYAs should be provided access to systematic and standardized symptom management for side effects related to cancer treatment. 6 (Level of Evidence: V, Strength of Recommendation: A) (4) Oncofertility a) All AYAs with cancer that require treatment that could compromise future fertility must be informed of the likely risk and options to protect or preserve fertility before treatment begins. 27 (Level of Evidence: V, Strength of Recommendation: B)
- Discussion can occur simultaneously with staging and the formulation of a treatment plan and should be documented in the medical record. 28 Appendix B provides common examples of effect of radiotherapy and systemic therapy on fertility. - Involving family members in these discussions may be beneficial.
- If the clinician is unable to discuss risks and treatment options, a referral to a colleague, or an AYA oncology specialist should be initiated for further discussion, or a referral directly to the fertility clinic may be completed.
b) Referral to a fertility clinic should be offered to AYAs as soon as possible following diagnosis 27 unless the risk of infertility from the cancer or treatment is 0 percent and documented. (Level of Evidence: V, Strength of Recommendation: B)
Guideline Resource Unit c) A discussion and/or referral related to fertility should be considered when the patient returns for follow up after completion of therapy and/or if pregnancy is being considered. 28  a) All AYAs should receive psychosocial screening as part of the new patient intake process. 30 When indicated, a full psychosocial assessment is recommended. The goal of this process is to identify, assess, support, and intervene to address common concerns associated with having cancer during the AYA years. While there are numerous scales to assess psychosocial outcomes in cancer, few have been specifically validated for AYAs with cancer. 31 Screening should include practical issues (housing, transport, finances), and for educational, family/social, emotional, physical, sexual, spiritual, and informational concerns. 30,32,33 b) Based on results from the psychosocial screening and/or initial comprehensive assessment, healthcare professionals should: (Level of Evidence: V, Strength of Recommendation: B)
- Provide AYAs and their families with information about psychosocial supports and services. 6,8
- Provide information about and encourage the use of about peer support to assist AYAs establishing and maintaining relationships with their peers, as well as other AYAs with cancer through mediums such as face-to-face meetings, camp and retreat programs, online support groups, and social networking opportunities. 5,6,8,34 - Address any physical/medical issues that may impact psychosocial wellbeing, including alcohol and drug use during treatment, the impact of treatment on fertility, sexuality and sexual function, physical function, and appearance. 6,8,16,35 - AYAs experiencing coping, transition, mood or other mental health issues, should be referred early to a psychosocial clinician (social worker, psychologist, or spiritual care provider) and/or psychiatrist. 6 - Refer AYAs to a social worker and/or occupational therapist to ensure they have access to the full range of educational, vocational, and employment support services for which they are eligible. 6,34,36 - Refer AYAs experiencing challenges with their spirituality/faith to faith-based resources or activities, including to spiritual care providers. 6,8 c) Healthcare professionals should routinely reassess the psychosocial supports of their AYA patients as they are likely to change over the patient cancer experience. 5,  - Intervention for consequences of cancer and treatment (e.g., medical problems, symptoms, emotional distress, financial and social concerns). - Coordination of care between primary care providers and specialists to ensure that all the survivor's health needs are met. 53 - Survivorship care planning. 54 - A consistent primary care physician for ongoing primary healthcare, health maintenance, and treatment of intercurrent illness. 6,51,55 - Assessment of sexuality and fertility related to the cancer and treatment should be considered part of routine follow up care. 6,56,57 - Offer of referral to an occupational therapy or a vocational specialist who can support reentering the workforce or returning to school. 34,36,58 c) Develop and provide to AYA cancer survivors and key healthcare professionals an individualized survivorship plan that includes 6,8 (Level of Evidence: V, Strength of Recommendation: B):
- Summary of treatment received.
- Information regarding follow-up care, surveillance, and screening recommendations.
- Information on post-treatment needs, including information regarding treatment-related effects and health risks when possible. - Delineation regarding roles of oncologists, primary care physicians in survivorship care and the timing of transfer if appropriate. - Healthy lifestyle recommendations (e.g., smoking cessation, physical activity).

# (7) Palliative Care
Alberta Health Services (AHS) adopts the World Health Organization (WHO) definition of palliative care that is, "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." 59 a) Clinicians caring for AYAs should screen for those who may benefit from an early, integrated palliative approach to care. Early, systematic integration of palliative care into standard oncology practice is recommended.  Opportunities for screening include: symptom burden and patient concern, transitions points in care or indicators of advanced disease trajectory, requests from patient or family/caregiver for palliative care services or information, and based on clinical judgement. 63  - Symptom, distress, and functional status management (e.g., pain, dyspnea, fatigue, sleep disturbance, mood, nausea, or constipation). - Exploration of understanding and education about illness and prognosis.
- Clarification of treatment goals.
- Assessment and support of coping needs.
- Assistance with medical decision making.
- Coordination with other care providers.
- Provision of referrals to other care providers as indicated. c) All AYAs should be given the opportunity to participate in Advance Care Planning as a part of routine care, started early in a longitudinal relationship with a healthcare provider and revisited when the health or wishes of the AYA change.  
Healthcare professionals referring to this appendix should exercise independent clinical judgment in the context of case-specific circumstances to frame discussions about fertility risk related to cancer treatment, including whether there is potential for recovery of fertility over time.

# Radiation Therapy
Temporary sterilization can occur in females of reproductive age at single-fraction doses to the ovary of 1.7-6.4 Gy with permanent sterilization occurring after 3.2-10 Gy. The effect of fractionated RT on ovarian function is shown in Table 1. Ovarian damage is also associated with whole abdomen dosages of 20-30 Gy (primary or premature secondary ovarian failure), as is direct or scattered irradiation from the spinal part of craniospinal irradiation. In males, multiple small fractions of radiation therapy are more toxic to spermatogenesis than a large, single fraction. Table 2 summarize the fractionated dose-related effect of spermatogenesis and Leydig cell function. In addition to testicular irradiation, the testes may be affected (transient elevation in FSH and oligospermia) by scatter from abdominal RT (>20 Gy). 

# Systemic Therapy
The tables below list patients as being at high risk (>70%), intermediate risk (30-70%), or low risk (<30%) of infertility based on different types of systemic therapy. iii Very low risk can be considered <10%. This classification, while not precise, acts a critical starting point to promote uniform discussions with patients and families. iv 

# Development and Revision History
This guideline was reviewed and endorsed by the Alberta Provincial Tumour Teams. Members include surgical oncologists, radiation oncologists, medical oncologists, dermatologists, nurses, pathologists, and pharmacists. Evidence was selected and reviewed by a working group comprised of members from the Alberta Provincial Tumour Teams and a Knowledge Management Specialist from the Guideline Resource Unit. A detailed description of the methodology followed during the guideline development process can be found in the Guideline Resource Unit Handbook.
This guideline was originally developed in 2020. In 2023, the guideline was revised to include Appendix B: Fertility Risk Classification.

# Levels of Evidence

# I
Evidence