disturbances resulting in short stature, delayed puberty, and reproductive problems; and impaired sexual functioning—also can occur at any age and interfere with successful development. Adolescents and adult cancer survivors report difficulties in knowing how to plan for the future, for example, in establishing educational and career aspirations (NCI, 2004). Adolescents and young adults may have less work experience because of their illness and be at a competitive disadvantage in the labor market. This situation can be compounded if their illness or treatment causes disfigurement or requires some accommodation in the workplace. Revealing a history of cancer to a prospective employer may result in discrimination. Research has also identified some limitations in the social functioning of school-age cancer survivors (IOM and NRC, 2003). Children may return to their social network at school and beyond without hair, with amputations, or with weight gain or other physical changes resulting from their disease or its treatment. They also may have developmental problems that require attention and need help in reentering social relationships.
The physical and psychological problems described above can be exacerbated by or produce significant new social problems. Financial stress resulting from low income, the cost of health care, or a lack of health insurance, as well as reduced employment and income, can result in substantial stress. While the fundamental resolution of such social problems is beyond the abilities of health care providers,8 evidence described below and in the next chapters shows why attention to these problems is an integral part of good-quality health care and how they can be addressed within the constraints of clinical practices.
In 2003, nearly one in five (12.3 million) people with chronic conditions9 lived in families that had problems paying medical bills (Tu, 2004); 63 percent of these individuals also reported problems in paying for rent, their mortgage, transportation, and food as a result of medical debt (May and Cunningham, 2004). Consistent with these findings, CancerCare, a nonprofit agency supporting individuals with cancer, reports that of those to whom it provides financial grants to pay for transportation, 18 and 11