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Recent observations have revealed the presence of strong C III] emission (EWC III] > 20 Å) in z > 6 galaxies, the origin of which remains unclear. In an effort to understand the nature of these line emitters, we have initiated a survey targeting C III] emission in gravitationally lensed reionization-era analogues identified in Hubble Space Telescope imaging of clusters from the Reionization Lensing Cluster Survey. Here, we report initial results on four galaxies selected to have low stellar masses (2-8 × 107 M☉) and J125-band flux excesses indicative of intense [O III] + H β emission (EW[O III]+H β = 500-2000 Å), similar to what has been observed at z > 6. We detect C III] emission in three of the four sources, with the C III] EW reaching values seen in the reionization era (EWC III] = 17-22 Å) in the two sources with the strongest optical line emission (EW[O III]+H β = 2000 Å). We have obtained a Magellan/FIRE (Folded-port InfraRed Echellette) near-infrared spectrum of the strongest C III] emitter in our sample, revealing gas that is both metal poor and highly ionized. Using photoionization models, we are able to simultaneously reproduce the intense C III] and optical line emission for extremely young (2-3 Myr) and metal-poor (0.06-0.08 Z☉) stellar populations, as would be expected after a substantial upturn in the star formation rate of a low-mass galaxy. The sources in this survey are among the first for which C III] has been used as the primary means of redshift confirmation. We suggest that it should be possible to extend this approach to z > 6 with current facilities, using C III] to measure redshifts of objects with IRAC excesses indicating EW[O III]+H β = 2000 Å, providing a method of spectroscopic confirmation independent of Ly α.

Strong [O iii]λλ4959,5007 + Hβ emission appears to be typical in star-forming galaxies at z > 6.5. As likely contributors to cosmic reionization, these galaxies and the physical conditions within them are of great interest. At z > 6.5, where Lyα is greatly attenuated by the intergalactic medium, rest-UV metal emission lines provide an alternative measure of redshift and constraints on the physical properties of star-forming regions and massive stars. We present the first statistical sample of rest-UV line measurements in z ∼ 2 galaxies selected as analogs of those in the reionization era based on [O iii]λλ4959,5007 equivalent width (EW) or rest-frame U - B color. Our sample is drawn from the 3D-HST Survey and spans the redshift range 1.36 ≤ z ≤ 2.49. We find that the median Lyα and C iii]λλ1907,1909 EWs of our sample are significantly greater than those of z ∼ 2 UV-continuum-selected star-forming galaxies. Measurements from both individual and composite spectra indicate a monotonic, positive correlation between C iii] and [O iii], while a lack of trend is observed between Lyα and [O iii] at EW[O iii] ≲ 1000 Å. At higher EW[O iii], extreme Lyα emission starts to emerge. Using stacked spectra, we find that Lyα and C iii] are significantly enhanced in galaxies with lower metallicity. Two objects in our sample appear comparable to z > 6.5 galaxies with exceptionally strong rest-UV metal line emission. These objects have significant C iv λλ1548,1550, He ii λ1640, and O iii]λλ1661,1665 emission in addition to intense Lyα or C iii]. Detailed characterization of these lower-redshift analogs provides unique insights into the physical conditions in z > 6.5 star-forming regions, motivating future observations of reionization-era analogs at lower redshifts.

Galactic-scale outflows regulate the stellar mass growth and chemical enrichment of galaxies, yet key outflow properties such as the chemical composition and mass-loss rate remain largely unknown. We address these properties with Keck/ESI echellete spectra of nine gravitationally lensed z ≃ 2-3 star-forming galaxies, probing a range of absorption transitions. Interstellar absorption in our sample is dominated by outflowing material with typical velocities of ∼-150 . Approximately 80% of the total column density is associated with a net outflow. Mass-loss rates in the low-ionization phase are comparable to or in excess of the star formation rate, with total outflow rates likely higher when accounting for ionized gas. On the order of half of the heavy element yield from star formation is ejected in the low-ionization phase, confirming that outflows play a critical role in regulating galaxy chemical evolution. Covering fractions vary and are in general non-uniform, with most galaxies having incomplete covering by the low ions across all velocities. Low-ion abundance patterns show remarkably little scatter, revealing a distinct "chemical fingerprint" of outflows. Gas-phase Si/Fe abundances are significantly supersolar ([Si/Fe] ≳ 0.4), indicating a combination of α-enhancement and dust depletion. The derived properties are comparable to the most kinematically broad, metal-rich, and depleted intergalactic absorption systems at similar redshifts, suggesting that these extreme systems are associated with galactic outflows at impact parameters conservatively within a few tens of kiloparsecs. We discuss implications of the abundance patterns in z ≃ 2-3 galaxies and the role of outflows at this epoch.

We present the first comprehensive evolutionary analysis of the rest-frame UV spectroscopic properties of star-forming galaxies at z ∼ 2-4. We match samples at different redshifts in UV luminosity and stellar mass, and perform systematic measurements of spectral features and stellar population modeling. By creating composite spectra grouped according to Lyα equivalent width (EW) and various galaxy properties, we study the evolutionary trends among Lyα, low- and high-ionization interstellar (LIS and HIS) absorption features, and integrated galaxy properties. We also examine the redshift evolution of Lyα and LIS absorption kinematics, and fine-structure emission EWs. The connections among the strengths of Lyα, LIS lines, and dust extinction are redshift independent, as is the decoupling of the Lyα and HIS line strengths, and the bulk outflow kinematics as traced by the LIS lines. Stronger Lyα emission is observed at higher redshift at fixed UV luminosity, stellar mass, SFR, and age. Much of this variation in the average Lyα strength with redshift, and the variation in Lyα strength at fixed redshift, can be explained in terms of variations in the neutral gas covering fraction and/or dust content in the ISM and CGM. However, based on the connection between Lyα and C iii] emission strengths, we additionally find evidence for variations in the intrinsic production rate of Lyα photons at the highest Lyα EWs. The challenge now is to understand the observed evolution of the neutral gas covering fraction and dust extinction within a coherent model for galaxy formation, and make robust predictions for the escape of ionizing radiation at z > 6.

The fraction of ionizing photons that escape from young star-forming galaxies is one of the largest uncertainties in determining the role of galaxies in cosmic reionization. Yet traditional techniques for measuring this fraction are inapplicable at the redshifts of interest due to foreground screening by the Lyα forest. In an earlier study, we demonstrated a reduction in the equivalent width of low-ionization absorption lines in composite spectra of Lyman break galaxies at z ≃ 4 compared to similar measures at z ≃ 3. This might imply a lower covering fraction of neutral gas and hence an increase with redshift in the escape fraction of ionizing photons. However, our spectral resolution was inadequate to differentiate between several alternative explanations, including changes with redshift in the outflow kinematics. Here we present higher quality spectra of three gravitationally lensed Lyman break galaxies at z ≃ 4 with a spectral resolution sufficient to break this degeneracy of interpretation. We present a method for deriving the covering fraction of low-ionization gas as a function of outflow velocity and compare the results with similar quality data taken for galaxies at lower redshift. We find an interesting but tentative trend of lower covering fractions of low-ionization gas for galaxies with strong Lyα emission. In combination with the demographic trends of Lyα emission with redshift from our earlier work, our results provide new evidence for a reduction in the average H I covering fraction, and hence an increase in the escape fraction of ionizing radiation from Lyman break galaxies, with redshift. © 2013. The American Astronomical Society. All rights reserved..

We analyze the redshift- and luminosity-dependent sizes of dropout galaxy candidates in the redshift range z ∼ 7-12 using deep images from the 2012 Hubble Ultra Deep Field (UDF12) campaign, which offers two advantages over that used in earlier work. First, we utilize the increased signal-to-noise ratio offered by the UDF12 imaging to provide improved measurements for known galaxies at z ≃ 6.5-8 in the HUDF. Second, because the UDF12 data have allowed the construction of the first robust galaxy sample in the HUDF at z > 8, we have been able to extend the measurement of average galaxy size out to higher redshifts. Restricting our measurements to sources detected at >15σ, we confirm earlier indications that the average half-light radii of z ∼ 7-12 galaxies are extremely small, 0.3-0.4 kpc, comparable to the sizes of giant molecular associations in local star-forming galaxies. We also confirm that there is a clear trend of decreasing half-light radius with increasing redshift, and provide the first evidence that this trend continues beyond z ≃ 8. Modeling the evolution of the average half-light radius as a power law, (1 + z)s, we obtain a best-fit index of over z ∼ 4-12. A clear size-luminosity relation is evident in our dropout samples. This relation can be interpreted in terms of a constant surface density of star formation over a range in luminosity of . The average star formation surface density in dropout galaxies is 2-3 orders of magnitude lower than that found in extreme starburst galaxies, but is comparable to that seen today in the centers of normal disk galaxies. © 2013. The American Astronomical Society. All rights reserved.

We present the 2012 Hubble Ultra Deep Field campaign (UDF12), a large 128 orbit Cycle 19 Hubble Space Telescope program aimed at extending previous Wide Field Camera 3 (WFC3)/IR observations of the UDF by quadrupling the exposure time in the F105W filter, imaging in an additional F140W filter, and extending the F160W exposure time by 50%, as well as adding an extremely deep parallel field with the Advanced Camera for Surveys (ACS) in the F814W filter with a total exposure time of 128 orbits. The principal scientific goal of this project is to determine whether galaxies reionized the universe; our observations are designed to provide a robust determination of the star formation density at z ≳ 8, improve measurements of the ultraviolet continuum slope at z ∼ 7-8, facilitate the construction of new samples of z ∼ 9-10 candidates, and enable the detection of sources up to z ∼ 12. For this project we committed to combining these and other WFC3/IR imaging observations of the UDF area into a single homogeneous dataset to provide the deepest near-infrared observations of the sky. In this paper we present the observational overview of the project and describe the procedures used in reducing the data as well as the final products that were produced. We present the details of several special procedures that we implemented to correct calibration issues in the data for both the WFC3/IR observations of the main UDF field and our deep 128 orbit ACS/WFC F814W parallel field image, including treatment for persistence, correction for time-variable sky backgrounds, and astrometric alignment to an accuracy of a few milliarcseconds. We release the full, combined mosaics comprising a single, unified set of mosaics of the UDF, providing the deepest near-infrared blank-field view of the universe currently achievable, reaching magnitudes as deep as AB ∼ 30 mag in the near-infrared, and yielding a legacy dataset on this field. © 2013. The American Astronomical Society. All rights reserved.

Background: The General Health Questionnaire (GHQ) - 12 was designed as a short questionnaire to assess psychiatric morbidity. Despite the fact that studies have suggested a number of competing multidimensional factor structures, it continues to be largely used as a unidimensional instrument. This may have an impact on the identification of psychiatric morbidity in target populations. The aim of this study was to explore the dimensionality of the GHQ-12 and to evaluate a number of alternative models for the instrument.Methods: The data were drawn from a large heterogeneous sample of cancer patients. The Partial Credit Model (Rasch) was applied to the 12-item GHQ. Item misfit (infit mean square >or= 1.3) was identified, misfitting items removed and unidimensionality and differential item functioning (age, gender, and treatment aims) were assessed. The factor structures of the various alternative models proposed in the literature were explored and optimum model fit evaluated using Confirmatory Factor Analysis.Results: The Rasch analysis of the 12-item GHQ identified six misfitting items. Removal of these items produced a six-item instrument which was not unidimensional. The Rasch analysis of an 8-item GHQ demonstrated two unidimensional structures corresponding to Anxiety/Depression and Social Dysfunction. No significant differential item functioning was observed by age, gender and treatment aims for the six- and eight-item GHQ. Two models competed for best fit from the confirmatory factor analysis, namely the GHQ-8 and Hankin's (2008) unidimensional model, however, the GHQ-8 produced the best overall fit statistics.Conclusions: The results are consistent with the evidence that the GHQ-12 is a multi-dimensional instrument. Use of the summated scores for the GHQ-12 could potentially lead to an incorrect assessment of patients' psychiatric morbidity. Further evaluation of the GHQ-12 with different target populations is warranted. [ABSTRACT FROM AUTHOR]

AIM: We aimed to describe and contrast the epidemiology of haematological malignancies among 0-14 and 15-24-year-olds in northern England from 1990 to 2002 and compare clinical trial entry by age group. PATIENTS AND METHODS: Incidence rates were examined by age, sex and period of diagnosis and differences were tested using Poisson regression. Differences and trends in survival were assessed using Cox regression. RESULTS: 1680 subjects were included comprising 948 leukaemias and 732 lymphomas. Incidence rates for acute lymphoblastic leukaemia were significantly higher for 0-14 compared to 15-24-year-olds, whilst Hodgkin lymphoma showed the reverse. No significant changes in incidence were observed. 60% of leukaemia patients aged 15-24 years entered trials compared to 92% of 0-14-year-olds. Survival rates were significantly lower and improved less markedly over time for 15-24 compared to 0-14-year-olds, particularly for leukaemia. CONCLUSIONS: Trial accrual rates need to be improved amongst 15-24-year-olds and a more structured follow-up approach adopted for this unique population. [ABSTRACT FROM AUTHOR]

Purpose: In England, health care policy promotes specialized age-appropriate cancer services for teenagers and young adults (TYA), for those aged 13-24 years at diagnosis. Specialist Principal Treatment Centers (PTCs) provide enhanced age-specific care for TYA, although many still receive all or some of their care in adult or children's cancer services. Our aim was to determine the patient-reported outcomes associated with TYA-PTC based care. Methods: We conducted a multicenter cohort study, recruiting 1114 TYA aged 13-24 years at diagnosis. Data collection involved a bespoke survey at 6,12,18, 24, and 36 months after diagnosis. Confounder adjusted analyses of perceived social support, illness perception, anxiety and depression, and health status, compared patients receiving NO-TYA-PTC care with those receiving ALL-TYA-PTC and SOME-TYA-PTC care. Results: Eight hundred and thirty completed the first survey. There was no difference in perceived social support, anxiety, or depression between the three categories of care. Significantly higher illness perception was observed in the ALL-TYA-PTC and SOME-TYA-PTC group compared to the NO-TYA-PTC group, (adjusted difference in mean (ADM) score on Brief Illness Perception scale 2.28 (95% confidence intervals [CI] 0.48-4.09) and 2.93 [1.27-4.59], respectively, p  = 0.002). Similarly, health status was significantly better in the NO-TYA-PTC (ALL-TYA-PTC: ADM -0.011 [95%CI -0.046 to 0.024] and SOME-TYA-PTC: -0.054 [-0.086 to -0.023]; p  = 0.006). Conclusion: The reason for the difference in perceived health status is unclear. TYA who accessed a TYA-PTC (all or some care) had higher perceived illness. This may reflect greater education and promotion of self-care by health care professionals in TYA units.

Early JWST observations have uncovered a population of red sources that might represent a previously overlooked phase of supermassive black hole growth 1-3 . One of the most intriguing examples is an extremely red, point-like object that was found to be triply imaged by the strong lensing cluster Abell 2744 (ref.  4 ). Here we present deep JWST/NIRSpec observations of this object, Abell2744-QSO1. The spectroscopy confirms that the three images are of the same object, and that it is a highly reddened (A V  ≃ 3) broad emission line active galactic nucleus at a redshift of z spec  = 7.0451 ± 0.0005. From the width of Hβ (full width at half-maximum = 2,800 ± 250 km s -1 ), we derive a black hole mass of M BH = 4 - 1 + 2 × 1 0 7 M ⊙ . We infer a very high ratio of black-hole-to-galaxy mass of at least 3%, an order of magnitude more than that seen in local galaxies 5 and possibly as high as 100%. The lack of strong metal lines in the spectrum together with the high bolometric luminosity (L bol  = (1.1 ± 0.3) × 10 45  erg s -1 ) indicate that we are seeing the black hole in a phase of rapid growth, accreting at 30% of the Eddington limit. The rapid growth and high black-hole-to-galaxy mass ratio of Abell2744-QSO1 suggest that it may represent the missing link between black hole seeds 6 and one of the first luminous quasars 7 ., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

The biographical disruption that occurs in adolescents and young adults following a cancer diagnosis can affect various important psychosocial domains including relationships with family and friends, sexual development, vocational and educational trajectories, and physical and emotional wellbeing. While there is evidence of the physical impact of cancer during this period, less is known about the impact on emotional wellbeing and especially on the barriers for young people accessing help and support. We aimed to obtain a more in-depth understanding of young people's experiences of their diagnosis, treatment, psychological impact, and range of resources they could or wanted to access for their mental health. We conducted an in-depth qualitative study using semi-structured interviews with 43 young people who had developed cancer aged 16 to 39 years and were either within 6 months of diagnosis or 3-5 years after treatment had ended. Framework analysis identified three themes: the emotional impact of cancer (expressed through anxiety, anger, and fear of recurrence); personal barriers to support through avoidance; and support to improve mental health through mental health services or adolescent and young adult treatment teams. We showed the barriers young people have to access care, particularly participant avoidance of support. Interrupting this process to better support young people and provide them with flexible, adaptable, consistent, long-term psychological support has the potential to improve their quality of life and wellbeing.

The identification of sources driving cosmic reionization, a major phase transition from neutral hydrogen to ionized plasma around 600-800 Myr after the Big Bang 1-3 , has been a matter of debate 4 . Some models suggest that high ionizing emissivity and escape fractions (f esc ) from quasars support their role in driving cosmic reionization 5,6 . Others propose that the high f esc values from bright galaxies generate sufficient ionizing radiation to drive this process 7 . Finally, a few studies suggest that the number density of faint galaxies, when combined with a stellar-mass-dependent model of ionizing efficiency and f esc , can effectively dominate cosmic reionization 8,9 . However, so far, comprehensive spectroscopic studies of low-mass galaxies have not been done because of their extreme faintness. Here we report an analysis of eight ultra-faint galaxies (in a very small field) during the epoch of reionization with absolute magnitudes between M UV  ≈ -17 mag and -15 mag (down to 0.005L ⋆ (refs.  10,11 )). We find that faint galaxies during the first thousand million years of the Universe produce ionizing photons with log[ξ ion  (Hz erg -1 )] = 25.80 ± 0.14, a factor of 4 higher than commonly assumed values 12 . If this field is representative of the large-scale distribution of faint galaxies, the rate of ionizing photons exceeds that needed for reionization, even for escape fractions of the order of 5%., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: It is well documented that traditional health care models do not meet the specific needs of Adolescents and Young Adults (AYA) cancer patients., Methods: We explore a map of the development of age-specific AYA cancer care across Europe, from the perspective of healthcare professionals with an interest in AYA care, in order to understand the specific challenges and map progress over time. An on-line survey was developed by international professional cancer organisations., Results: We had 377 respondents from 60 countries. The majority of respondents were physicians 298 (79%), a minority of survey respondents (39, 10.4%) work exclusively with AYA patients, most respondents declared substantial and routine clinical service collaborations to provide care and treatment to AYA with cancer. Policy for the multidisciplinary management of AYA cancer patients commonly appears in Europe now, and was reported by 234 (78.52%) respondents. Specific professional training for AYA cancer care is not uniformly available., Conclusion: There is considerable opportunity for many organisations to work together in raising the profile of AYA cancer related issues, in providing education and in encouraging research and collaboration., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Prof Dan Stark has received grant funding for AYA cancer research from the Teenage Cancer Trust, UK NIHR, UK ESRC and EU Horizon programmes.The other authors declare that there is no conflict of interest.

Objective: Adolescents and young adults (AYAs) diagnosed with cancer commonly experience elevated psychological distress and need appropriate detection and management of the psychosocial impact of their illness and treatment. This paper describes the multinational validation of the Distress Thermometer (DT) for AYAs recently diagnosed with cancer and the relationship between distress and patient concerns on the AYA-Needs Assessment (AYA-NA)., Methods: AYA patients (N = 288; 15-29 years, M age  = 21.5 years, SD age  = 3.8) from Australia (n = 111), Canada (n = 67), the UK (n = 85) and the USA (n = 25) completed the DT, AYA-NA, Hospital Anxiety Depression Scale (HADS) and demographic measures within 3 months of diagnosis. Using the HADS as a criterion, receiver operating characteristics analysis was used to determine the optimal cut-off score and meet the acceptable level of 0.70 for sensitivity and specificity. Correlations between the DT and HADS scores, prevalence of distress and AYA-NA scores were reported., Results: The DT correlated strongly with the HADS-Total, providing construct validity evidence (r = 0.65, p < 0.001). A score of 5 resulted in the best clinical screening cut-off on the DT (sensitivity = 82%, specificity = 75%, Youden Index = 0.57). Forty-two percent of AYAs scored at or above 5. 'Loss of meaning or purpose' was the AYA-NA item most likely to differentiate distressed AYAs., Conclusions: The DT is a valid distress screening instrument for AYAs with cancer. The AYA-POST (DT and AYA-NA) provides clinicians with a critical tool to assess the psychosocial well-being of this group, allowing for the provision of personalised support and care responsive to individuals' specific needs and concerns., (© 2021 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.)

Background: MicroRNAs from the miR-371~373 and miR-302/367 clusters, particularly miR-371a-3p, are promising biomarkers for blood-based diagnosis and disease monitoring of malignant germ cell tumors (GCTs) and are nearing clinical implementation. These biomarkers have superior sensitivity and specificity compared with current markers alpha-fetoprotein (AFP) and human chorionic gonadotropin (HCG). We explored patient acceptability of using circulating microRNAs to replace multiple serial computed tomography (CT) scans in malignant GCT follow-up., Patients and Methods: Two workshops involved interactive presentations and focus groups. Discussions were digitally recorded and transcribed verbatim. Qualitative thematic analysis of transcripts identified the key themes., Results: Prior to the workshops, potential participants expressed concern about the adoption of new blood tests due to personal experiences of the limitations of existing (AFP/HCG) markers. Twelve males (22-57 years of age; currently, 26-59 years of age) with a malignant GCT diagnosis participated; all were in follow-up. Three had experienced recurrence. Participants had cumulative exposure of between 1 and 15 CT scans. Data saturation was reached at the second workshop; five themes emerged underpinning preference for microRNA testing versus CT scans: (1) increased sensitivity and safety, (2) reduced financial costs, (3) reduced time for testing and results, (4) practicalities, and (5) reduced anxiety. However, some participants perceived an increased diagnostic capacity of CT scans versus blood testing., Conclusion: This first user consultation of circulating microRNA testing for future malignant GCT follow-up suggests high acceptability with potential patient and healthcare system benefits., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: Survival gains in teenagers and young adults (TYA) are reported to be lower than children and adults for some cancers. Place of care is implicated, influencing access to specialist TYA professionals and research.Consequently, age-appropriate specialist cancer care is advocated for TYA although systematic investigation of associated outcomes is lacking. In England, age-appropriate care is delivered through 13 Principal Treatment Centres (TYA-PTC). BRIGHTLIGHT is the national evaluation of TYA cancer services to examine outcomes associated with differing places and levels of care. We aimed to examine the association between exposure to TYA-PTC care, survival and documentation of clinical processes of care., Design: Prospective cohort study., Setting: 109 National Health Service (NHS) hospitals across England., Participants: 1114 TYA, aged 13-24, newly diagnosed with cancer between 2012 and 2014., Intervention: Participants were assigned a TYA-PTC category dependent on the proportion of care delivered in a TYA-PTC in the first year after diagnosis: all care in a TYA-PTC (ALL-TYA-PTC, n=270), no care in a TYA-PTC (NO-TYA-PTC, n=359), and some care in a TYA-PTC with additional care in a children's/adult unit (SOME-TYA-PTC, n=419)., Primary Outcome: Data were collected on documented processes indicative of age-appropriate care using clinical report forms, and survival through linkage to NHS databases., Results: TYA receiving NO-TYA-PTC care were less likely to have documentation of molecular diagnosis, be reviewed by a children's or TYA multidisciplinary team, be assessed by supportive care services or have a fertility discussion. There was no significant difference in survival according to category of care. There was weak evidence that the association between care category and survival differed by age (p=0.08) with higher HRs for those over 19 receiving ALL or SOME-TYA-PTC compared with NO-TYA-PTC., Conclusion: TYA-PTC care was associated with better documentation of clinical processes associated with age-appropriate care but not improved survival., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: In England, healthcare policy advocates specialised age-appropriate services for teenagers and young adults (TYA), those aged 13 to 24 years at diagnosis. Specialist Principal Treatment Centres (PTC) provide enhanced TYA age-specific care, although many still receive care in adult or children's cancer services. We present the first prospective structured analysis of quality of life (QOL) associated with the amount of care received in a TYA-PTC DESIGN: Longitudinal cohort study., Setting: Hospitals delivering inpatient cancer care in England., Participants: 1114 young people aged 13 to 24 years newly diagnosed with cancer., Intervention: Exposure to the TYA-PTC defined as patients receiving NO-TYA-PTC care with those receiving ALL-TYA-PTC and SOME-TYA-PTC care., Primary Outcome: Quality of life measured at five time points: 6, 12, 18, 24 and 36 months after diagnosis., Results: Group mean total QOL improved over time for all patients, but for those receiving NO-TYA-PTC was an average of 5.63 points higher (95% CI 2.77 to 8.49) than in young people receiving SOME-TYA-PTC care, and 4·17 points higher (95% CI 1.07 to 7.28) compared with ALL-TYA-PTC care. Differences were greatest 6 months after diagnosis, reduced over time and did not meet the 8-point level that is proposed to be clinically significant. Young people receiving NO-TYA-PTC care were more likely to have been offered a choice of place of care, be older, from more deprived areas, in work and have less severe disease. However, analyses adjusting for confounding factors did not explain the differences between TYA groups., Conclusions: Receipt of some or all care in a TYA-PTC was associated with lower QOL shortly after cancer diagnosis. The NO-TYA-PTC group had higher QOL 3 years after diagnosis, however those receiving all or some care in a TYA-PTC experienced more rapid QOL improvements. Receipt of some care in a TYA-PTC requires further study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The optimal treatment for advanced leiomyosarcoma is still debated. Given histotype-specific prospective controlled data lacking, this study retrospectively evaluated doxorubicin plus dacarbazine, doxorubicin plus ifosfamide, and doxorubicin alone as first-line treatments for advanced/metastatic leiomyosarcoma treated at European Organization for Research and Treatment of Cancer Soft Tissue and Bone Sarcoma Group (EORTC-STBSG) sites., Methods: The inclusion criteria were a confirmed histological diagnosis, treatment between January 2010 and December 2015, measurable disease (Response Evaluation Criteria in Solid Tumors 1.1), an Eastern Cooperative Oncology Group performance status ≤2, and an age ≥ 18 years. The endpoints were progression-free survival (PFS), overall survival (OS), and overall response rate (ORR). PFS was analyzed with methods for interval-censored data. Patients were matched according to their propensity scores, which were estimated with a logistic regression model accounting for histology, grade, age, sex, performance status, tumor site, and tumor extent., Results: Three hundred three patients from 18 EORTC-STBSG sites were identified. One hundred seventeen (39%) received doxorubicin plus dacarbazine, 71 (23%) received doxorubicin plus ifosfamide, and 115 (38%) received doxorubicin. In the 2:1:2 propensity score-matched population (205 patients), the estimated median PFS was 9.2 months (95% confidence interval [CI], 5.2-9.7 months), 8.2 months (95% CI, 5.2-10.1 months), and 4.8 months (95% CI, 2.3-6.0 months) with ORRs of 30.9%, 19.5%, and 25.6% for doxorubicin plus dacarbazine, doxorubicin plus ifosfamide, and doxorubicin alone, respectively. PFS was significantly longer with doxorubicin plus dacarbazine versus doxorubicin (hazard ratio [HR], 0.72; 95% CI, 0.52-0.99). Doxorubicin plus dacarbazine was associated with longer OS (median, 36.8 months; 95% CI, 27.9-47.2 months) in comparison with both doxorubicin plus ifosfamide (median, 21.9 months; 95% CI, 16.7-33.4 months; HR, 0.65; 95% CI, 0.40-1.06) and doxorubicin (median, 30.3 months; 95% CI, 21.0-36.3 months; HR, 0.66; 95% CI, 0.43-0.99). Adjusted analyses retained an effect for PFS but not for OS. None of the factors selected for multivariate analysis had a significant interaction with the received treatment for both PFS and OS., Conclusions: This is the largest retrospective study of first-line treatment for advanced leiomyosarcoma. In the propensity score-matched population, doxorubicin and dacarbazine showed favorable activity in terms of both ORR and PFS and warrants further evaluation in prospective trials., (© 2020 American Cancer Society.)

Background: Adolescents and young adults (AYAs) with cancer require dedicated management encompassing both adult and paediatric cancer services. Following a European survey, the European Society for Medical Oncology, the European Society for Paediatric Oncology and the Asian continental branch of International Society of Paediatric Oncology undertook a similar survey to assess AYA cancer care across Asia., Methods: A link to the online survey was sent to healthcare professionals (HCPs) in Asia interested in AYA cancer care. Questions covered the demographics and training of HCPs, their understanding of AYA definition, availability and access to specialised AYA services, the support and advice offered during and after treatment, and factors of treatment non-compliance., Results: We received 268 responses from 22 Asian countries. There was a striking variation in the definition of AYA (median lower age 15 years, median higher age 29 years). The majority of the respondents (78%) did not have access to specialised cancer services and 73% were not aware of any research initiatives for AYA. Over two-thirds (69%) had the option to refer their patients for psychological and/or nutritional support and most advised their patients on a healthy lifestyle. Even so, 46% did not ask about smokeless tobacco habits and only half referred smokers to a smoking cessation service. Furthermore, 29% did not promote human papillomavirus vaccination for girls and 17% did not promote hepatitis B virus vaccination for high-risk individuals. In terms of funding, 69% reported governmental insurance coverage, although 65% reported that patients self-paid, at least partially. Almost half (47%) reported treatment non-compliance or abandonment as an issue, attributed to financial and family problems (72%), loss of follow-up (74%) and seeking of alternative treatments (77%)., Conclusions: Lack of access to and suboptimal delivery of AYA-specialised cancer care services across Asia pose major challenges and require specific interventions., Competing Interests: Competing interests: CKL: Fees for Advisory Board from Amgen Asia. SB: Fees for Advisory Boards from Pfizer, Bayer, Lilly, Novartis, Isofol. LB: Fees for Advisory Board from Takeda. FAP: Fees from Roche, Astra Zeneca, Clovis and Ipsen. DS: Research support from the National Institute for Health Research, Cancer Research UK, the Teenage Cancer Trust, Pharmamar and AstraZeneca.

Objective: International recognition of the unique needs of young people with cancer is growing. Many countries have developed specialist age-appropriate cancer services believing them to be of value. In England, 13 specialist principal treatment centres (PTCs) deliver cancer care to young people. Despite this expansion of specialist care, systematic investigation of associated outcomes and costs has, to date, been lacking. The aim of this paper is to describe recruitment and baseline characteristics of the BRIGHTLIGHT cohort and the development of the bespoke measures of levels of care and disease severity, which will inform the evaluation of cancer services in England., Design: Prospective, longitudinal, observational study., Setting: Ninety-seven National Health Service hospitals in England., Participants: A total of 1114 participants were recruited and diagnosed between July 2012 and December 2014: 55% (n=618) were men, mean age was 20.1 years (SD=3.3), most (86%) were white and most common diagnoses were lymphoma (31%), germ cell tumour (19%) and leukaemia (13%)., Results: At diagnosis, median quality of life score was significantly lower than a published control threshold (69.7 points); 40% had borderline to severe anxiety, and 21% had borderline to severe depression. There was minimal variation in other patient-reported outcomes according to age, diagnosis or severity of illness. Survival was lower in the cohort than for young people diagnosed during the same period who were not recruited (cumulative survival probability 4 years after diagnosis: 88% vs 92%)., Conclusions: Data collection was completed in March 2018. Longitudinal comparisons will determine outcomes and costs associated with access/exposure to PTCs. Findings will inform international intervention and policy initiatives to improve outcomes for young people with cancer., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Home loans are the largest financial transaction consumers typically enter and the consequences from entering overpriced or unaffordable home loans can devastate individuals and entire communities. This article reviews how insights from research in experimental psychology can be utilized to protect consumers. Current policy relies too much on disclosures, which-among other limitations-can be undermined by verbal behaviors on the part of salespeople. In particular, salespeople such as mortgage brokers and lenders can exploit the fact that consumers do not know where to look for information on disclosure forms by violating conversational norms, introducing confirmation biases, and using dual tasks such as talking to consumers while they are reviewing forms. They can also exploit the fact that even consumers who know where to look can forget by part-set cuing consumers. They can even cause consumers who discover problematic terms to ignore them by providing the consumers with explanations. Policymakers need to be aware of these findings to design effective consumer-protection policies. The authors suggest alternatives for policymakers to consider.

Introduction: Adolescents and young adults (AYA) with cancer require dedicated clinical management and care. Little is known about the training and practice of European healthcare providers in regard to AYA and the availability of specialised services., Methods: A link to an online survey was sent to members of the European Society for Medical Oncology (ESMO) and the European Society for Paediatric Oncology (SIOPE). The link was also sent to ESMO National Representatives and circulated to other European oncology groups. Questions covered the demographics and clinical training of respondents, their definition of AYA, education about AYA cancer, access to specialised clinical and supportive care, research and further education. Data from Europe were analysed by region., Results: Three hundred tweenty two questionnaires were submitted and we focused on data from the 266 European healthcare professionals. Responses revealed considerable variation both within and between countries in the definition of AYA. Over two-thirds of respondents did not have access to specialised centres for AYA (67%), were not aware of research initiatives focusing on AYA with cancer (69%) and had no access to specialist services for managing the late effects of treatment (67%). The majority of the respondents were able to refer AYA patients to professional psychological support and specialised social workers. However, more than half had no access to an age-specialised nurse or specialised AYA education. Overall, 38% of respondents reported that their AYA patients did not have access to fertility specialists. This figure was 76% in Eastern Europe. Lack of specialised AYA care was particularly evident in Eastern and South-Eastern Europe., Conclusion: There is important underprovision and inequity of AYA cancer care across Europe. Improving education and research focused on AYA cancer care should be a priority., Competing Interests: Competing interests: DS: Research support from the National Institute for Health Research, Cancer Research UK, the Teenage Cancer Trust, Pharmamar and Astra-Zeneca. SB: Fees for Advisory Boards from Pfizer, Bayer, Lilly, Novartis, Isofol. FAP: Fees from Roche, Astra Zeneca, Clovis and Ipsen. ES, LB, SJ, KM, J-YD, GM, SE: No relevant disclosures to declare.

Background: The ICON6 trial showed that cediranib, an oral inhibitor of vascular endothelial growth factor receptors 1, 2, and 3, improved clinical outcomes for patients with platinum-sensitive relapsed ovarian cancer when it was used with chemotherapy and was continued as maintenance therapy. This study describes health-related quality of life (QOL) during the first year of treatment., Methods: Four hundred fifty-six women were randomly allocated to receive standard chemotherapy only, chemotherapy with concurrent cediranib, or chemotherapy with cediranib administered concurrently and continued as maintenance. Patients completed QOL questionnaires until disease progression every 3 weeks during chemotherapy and then every 6 weeks to 1 year. Patients alive with disease progression completed a QOL form 1 year after randomization. The primary QOL endpoint was the global score from the Quality of Life Questionnaire Core 30 (of the European Organization for Research and Treatment of Cancer) at 1 year, with the standard chemotherapy group compared with the concurrent-maintenance cediranib group., Results: The rate of questionnaire compliance was 90% at the baseline and 76% at 1 year and was similar across the 3 groups. The mean global QOL score at 1 year was 62.6 points for the standard chemotherapy group and 68.7 points for the concurrent-maintenance group (+4.5; 95% confidence interval, -2.0 to 11.0; P = .18). Sensitivity analyses suggested that this finding was robust to the effect of missing data, and the improvement became statistically significant after adjustments for self-reported diarrhea., Conclusions: The 6th study by the International Collaboration in Ovarian Neoplasm (ICON6) showed a significant improvement in progression-free survival with cediranib as concurrent and maintenance therapy. No QOL detriment with cediranib was found 1 year after treatment was commenced. The maintenance of QOL along with prolonged cancer control suggests that cediranib has a valuable role in the treatment of relapsed ovarian cancer. Cancer 2017;123:2752-61. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited., (© 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.)

Background: Principal Treatment Centres (PTC) were established to provide age-appropriate care as well as clinical expertise for children and young people with cancer. However, little is known about the effects of specialist treatment centres on survival outcomes especially for teenagers and young adults. This population-based study aimed to describe access to PTC and the associated trends in survival for 0-24 year olds accounting for stage of disease at presentation and treatment., Methods: Patients diagnosed from 1998-2009 aged 0-24 years were extracted from the Yorkshire Specialist Register of Cancer in Children and Young People, including information on all treating hospitals, followed-up until 31st December 2014. The six commonest cancer types were included: leukaemia (n = 684), lymphoma (n = 558), CNS tumours (n = 547), germ cell tumours (n = 364), soft tissue sarcomas (n = 171) and bone tumours (n = 163). Treatment was categorised into three groups: 'all', 'some' or 'no' treatment received at a PTC. Treatment at PTC was examined by diagnostic group and patient characteristics. Overall survival was modelled using Cox regression adjusting for case-mix including stage, treatment and other socio-demographic and clinical characteristics., Results: Overall 72% of patients received all their treatment at PTC whilst 13% had no treatment at PTC. This differed by diagnostic group and age at diagnosis. Leukaemia patients who received no treatment at PTC had an increased risk of death which was partially explained by differences in patient case-mix (adjusted Hazard Ratio (HR) = 1.73 (95%CI 0.98-3.04)). Soft tissue sarcoma patients who had some or no treatment at PTC had better survival outcomes, which remained after adjustment for patient case-mix (adjusted HR = 0.48 (95%CI 0.23-0.99)). There were no significant differences in outcomes for other diagnostic groups (lymphoma, CNS tumours, bone tumours and germ cell tumours). For leukaemia patients survival outcomes for low risk patients receiving no treatment at PTC were similar to high risk patients who received all treatment at PTC, implying a benefit for care at the PTC., Conclusion: This study demonstrates that for leukaemia patients receiving treatment at a PTC is associated with improved survival that may compensate for a poorer prognosis presentation. However, further information on risk factors is needed for all diagnostic groups in order to fully account for differences in patient case-mix.

The aims of this article are to describe the ongoing development of adolescent and young adult (AYA) cancer services within the European Union (EU), and to develop consensus on key areas within the field. This survey used an e-Delphi design. An initial survey was distributed via email to professionals working in Europe. A snowball sampling technique was used to promote distribution. Consensus was sought over three rounds from October 2012 to April 2015. Consensus was defined as >80% agreement ("agree" or "strongly agree"). Sixty professionals participated in round 1, 106 in round 2, and 61 in round 3. Twenty-six countries were represented across all rounds. Consensus was achieved for: the need for national policy guidance, the importance of patient choice, the validity of the International Charter of Rights for Young People, and some aspects of multi-disciplinary working. There was 75% agreement on a single definition of the patient age range within AYA cancer care. European professionals with expertise in AYA cancer care reached consensus on key elements of care for this group. The optimal AYA age range remained an elusive topic on which to agree. The broad engagement and interest in AYA cancer across the EU through the European Network for Cancer in Children and Adolescents (ENCCA) network was also demonstrated.

Purpose: To gather the perspectives of Teenagers and Young Adults (TYA) with cancer across Europe on the care they received and research priorities for TYA services., Methods: A questionnaire was designed by TYA oncology specialists in the United Kingdom and translated into 11 other European languages. It was disseminated to TYAs in various European countries with the help of collaborators in the European Network for Cancer in Children and Adolescents (ENCCA). Free text responses were analyzed using a thematic approach., Results: 301 participants representing 25 countries were entered into the analysis. Only 9% of the sample had experience of a ward solely for the use of TYAs. Two thirds of participants agreed with the need for TYA-specific services. Participants reported that important aspects of TYA care included access to psychological care, youth workers and physiotherapists, higher levels of staffing, and healthcare workers who understand the needs of TYAs and communicate effectively. The most frequently endorsed areas for future research were "monitoring after treatment," "communication between professionals and young people," "research about cancer," "fertility preservation," and "back to work/school.", Conclusion: European collaboration between TYA and professionals in delivering this project has been feasible. This study contributes to developing a healthcare culture that values the perspectives of service users. It has provided an insight into what TYAs perceive as important aspects of their care, how they think TYA care can be improved, and what they consider to be important areas for research.

Purpose: Survival of children and adolescents and young adults (AYAs) treated for cancer has increased with improved treatments. However, there is still an increased risk of second primary cancer (SPC) in the long term compared with the same-age population, especially related to treatments. The follow-up of this population and the prevention of SPC are important issues. Therefore, this study aimed to review the available literature on cancer risk factors (lifestyle and occupational exposures) in children and AYAs previously treated for cancer in order to identify interventions that might be implemented to improve healthy behaviors in this population., Methods: PubMed was searched using the following terms: "cancer[Tiab] AND young adult[Tiab] or teen[Tiab] or childhood[Tiab] AND prevention[Tiab] AND survivors[Meshterm].", Results: Twenty-seven articles were included. Children and AYA survivors of cancer have similar risk behaviors to their peers regarding tobacco, diet, and sun exposure. However, they have lower physical activity. Few studies on prevention strategies in this population were identified. Results of available studies remain inconclusive. No publications were found on occupational exposure and risk of second cancer., Conclusion: Children and AYAs treated for cancer are a population at risk and require specific effective prevention strategies.

The pattern of cancer seen in young people changes with increasing age, transitioning from childhood- to adult-type cancer in adolescence and the third decade. The risk factors, presentation and biology of cancer in young adults differ from those in the older adult population. Factors of particular significance in adolescents and young adults (AYAs) include genetic predisposition to adult-type cancer, diagnostic uncertainty, long-term morbidity and considerations of fertility. New systemic therapies are being introduced that can prolong life and even increase the chance of cure, but the impact on AYAs is uncertain, as these patients are often under-represented in clinical trials. Here, we discuss the management of AYAs with 3 of the most common cancers affecting adults, when they emerge in the AYA populations, and therefore are currently met by medical oncologists - breast cancer, colorectal cancer and melanoma., (© 2016 S. Karger AG, Basel.)

To design the services for adolescents and young adults (AYAs) with cancer, we need to understand the patterns of disease and the other clinical and managerial challenges of the patient group. Cancer occurring between the ages of 15 and 39 years is 4 times less rare than cancer occurring during the first 15 years of life and consists of 2% of all invasive cancer in Europe, about 66,000 patients in Europe each year. AYAs have a unique distribution of cancer types, including the peak in incidence of Hodgkin lymphoma (HL) or germ cell tumors. The relative improvement in the survival rate in AYAs has not kept pace with that achieved in younger children, especially for acute leukemia, non-HLs, Ewing tumors and rhabdomyosarcoma. Etiological factors are under-researched and remain largely hypothetical. In this unique group of illnesses, improving AYA cancer management involves bridging interfaces. Since this has begun, outcomes have also begun to improve. The local nature of these interfaces determines the age group considered as AYA. Specific skills are necessary in the clinical, biological and psychosocial domains. Services need support from policy, clinical and administrative professionals. National policy and supranational groups such as SIOPE and ESMO are in constructive collaboration to develop this further., (© 2016 S. Karger AG, Basel.)

Background: Although relatively rare, cancer in teenagers and young adults (TYA) is the most common disease-related cause of death and makes a major contribution to years of life lost in this age group. There is a growing awareness of the distinctive needs of this age group and drive for greater understanding of how outcomes can be improved. We present here the latest TYA survival trends data for the United Kingdom (UK)., Methods: Using national cancer registry data, we calculated five-year relative survival for all 15-24 year olds diagnosed with cancer or a borderline/benign CNS tumour in the UK during the periods 1992-1996, 1997-2001 and 2002-2006. We analysed trends in survival for all cancers combined and for eighteen specified groups that together represent the majority of TYA cancers. We compared our data with published data for Europe, North America and Australia., Results: Five-year survival for all cancers combined increased from 75.5% in 1992-1996 to 82.2% in 2002-2006 (P<0.001). Statistically significant improvements were seen for all disease groups except osteosarcoma, rhabdomyosarcoma, non-gonadal and ovarian germ cell tumours and ovarian and thyroid carcinomas. During the earliest time period, females had significantly better survival than males for five of the twelve non-gender-specific disease groups. By the latest period, only melanomas and non-rhabdomyosarcoma soft tissue sarcomas had differential survival by gender. Survival in the UK for the most recent period was generally similar to other comparable countries., Conclusion: Five-year survival has improved considerably in the UK for most cancer types. For some disease groups, there has been little progress, either because survival already approaches 100% (e.g. thyroid carcinomas) or, more worryingly for some cancers with poor outcomes, because they remain resistant to existing therapy (e.g. rhabdomyosarcoma). In addition, for a number of specific cancer types and for cancer as a whole males continue to have worse outcomes than females., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The 5-year survival of teenagers and young adults (TYAs; 13-24 years old) with cancer has continued to rise, but as a result more patients experience late effects of treatment, such as infertility. Advice regarding fertility preservation in relation to cancer is provided in numerous clinical practice guidelines, but the rigor of their development is unclear. Methods: A systematic search was undertaken for clinical practice guidelines regarding fertility preservation in TYAs with cancer. All guidelines were reviewed according to the Appraisal of Guidelines for Research and Evaluation (AGREE-II) criteria. Five out of 13 identified guidelines scored over 75% in the "rigor of development" section and were further appraised. Content, scope, and consistencies between recommendations were also examined. Results: All five of the reviewed guidelines encouraged oncologists to have discussions with their patients about potential fertility issues associated with treatment and available fertility preservation methods. The cryopreservation of sperm, oocytes, and embryos were all recommended as first-line interventions in postpubertal patients. Recommendations surrounding pre- or peripubescent adolescents were few, with many techniques only recommended as part of a clinical trial. The risk of subfertility associated with different treatment regimens was poorly described. Conclusions: The methodology and development of guidelines describing fertility preservation in TYA cancer patients varied greatly. Methodological quality did not clearly influence key recommendations. Those involved with the development of guidelines are encouraged to clearly define their development methods to allow users to be confident of the quality.

Background: Little aetiological epidemiological research has been undertaken for major cancers occurring in teenagers and young adults (TYA). Population mixing, as a possible proxy for infectious exposure, has been well researched for childhood malignancies. We aimed to investigate effects of population mixing in this older age group using an English national cancer dataset., Methods: Cases of leukaemia, lymphoma and central nervous system (CNS) tumours amongst 15-24 year olds in England (diagnosed 1996-2005) were included in the study. Data were obtained by ward of diagnosis and linked to 1991 census variables including population mixing (Shannon index); data on person-weighted population density and deprivation (Townsend score) were also used and considered as explanatory variables. Associations between TYA cancer incidence and census variables were investigated using negative binomial regression, and results presented as incidence rate ratios (IRR) with 95% confidence intervals (CI)., Results: A total of 6251 cases of leukaemia (21%), lymphoma (49%) and CNS tumours (30%) were analysed. Higher levels of population mixing were associated with a significant decrease in the incidence of CNS tumours (IRR=0.83, 95% CI=0.75-0.91), accounted for by astrocytomas and 'other CNS tumours'; however, there was no association with leukaemia or lymphoma. Incidence of CNS tumours and lymphoma was 3% lower in more deprived areas (IRR=0.97, 95% CI=0.96-0.99 and IRR=0.97, 95% CI=.96-0.98 respectively). Population density was not associated with the incidence of leukaemia, lymphoma or CNS tumours., Conclusions: Our results suggest a possible role for environmental risk factors with population correlates in the aetiology of CNS tumours amongst TYAs. Unlike studies of childhood cancer, associations between population mixing and the incidence of leukaemia and lymphoma were not observed.

Purpose: Little is known about the factors that influence the place of inpatient care for teenage and young adult (TYA) cancer patients. Recent guidelines have recommended centralization of care for this group to a small number of specialized centers. This study aimed to investigate the influence of geography and travel times on the likelihood of admission to an age-specialist center in England during cancer treatment for patients aged 15-24 at the time of diagnosis. Methods: Data for 6788 patients aged 15-24, diagnosed between 2001 and 2006 and treated as an inpatient in England between 2001 and 2009, were obtained from the National Cancer Data Repository. Eight TYA age-specialist centers were identified in England during this time period; road travel times to these centers were calculated using ArcGIS Network Analyst. Factors thought to affect the likelihood of admission, such as diagnostic group, gender, and age at diagnosis were modeled using logistic regression. Results: Overall, 66.9% of patients never received inpatient treatment at a TYA age-specialist center during the course of their treatment. Increasing travel time significantly reduced the likelihood of admission to a TYA age-specialist center after adjustment for case mix factors. Conclusion: Many TYA patients received little or no inpatient treatment at a TYA age-specialist center during their treatment. The variation between diagnostic groups suggests that factors other than distance to the closest center are affecting the likelihood of admission and demonstrates the potential need to consider improvements to the structured referral practice for this unique group of patients.