for themselves or to carry out their roles in the family, family members often step in to take up these roles. Taking on these responsibilities requires considerable adaptation (and readaptation as the course of the disease changes) on the part of family members. These experiences can add to the stress resulting from concern about the ill family member. Indeed, this stress, especially in caregivers compromised by morbidity accompanying their own aging, can be so substantial that caregivers are afflicted more by depression, other adverse health effects, and death than are patients themselves (Schultz and Beach, 1999; Kurtz et al., 2004). Caregivers who provide support to their spouse and report caregiving strain are 63 percent more likely to die within 4 years than those who do not provide care to their spouse or who provide care but report no strain (Schultz and Beach, 1999).

High stress levels in family caregivers also can interfere with their ability to provide the emotional or logistical support patients need. This can exacerbate the patient’s stress and lead to the cascading consequences of elevated stress described above. Because of the changes and necessary adaptation in the family brought about by the caregiving needs of the patient, family members are sometimes considered “second-order patients” (Lederberg, 1998).

Developmental Problems

As individuals mature, they typically master and apply certain behavioral skills in their daily life. These skills include, for example, achieving self-sufficiency and physical, emotional, financial, and social independence from parents; engaging in satisfying personal relationships of varying intimacy and in meaningful work; and performing other normative social roles. The effects of cancer and its treatment can interrupt and delay the activities in which individuals typically engage to develop these skills, or can require temporarily or permanently giving up the skills and activities. As a result, individuals can experience a range of problems manifested as developmental delays, regression, or inability to perform social roles. Cancer-induced inability to perform normative activities can occur at any age. Older adults, for example, can face unplanned retirement, limitations in grandparenting abilities, inability to act as caregiver to others in their family, or limitations in their ability to work.

Children who experience numerous and prolonged hospitalizations at critical developmental periods are at particular risk for developmental problems (IOM and NRC, 2003). Adolescents can face a significant loss of independence and disruption of their social relationships at a time when they should be developing social and relationship skills critical to successful functioning in adulthood (NCI, 2004). Physical changes resulting from cancer and its treatment—such as hearing loss and vision problems; endocrine



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