Patterns of symptoms and functional impairments in children with cancer

Health-related quality of life in Chinese children and adolescents with cancer

AIM

Cancer diagnosis and related treatment can have multiple impacts on children's health-related quality of life (HRQoL). This study aimed to determine profiles of HRQoL in Chinese children and adolescents with cancer based on patient-reported outcomes.

METHODS

This cross-sectional study recruited 310 pediatric patients with cancer (in treatment and survivorship) aged 8-17 years old and their family caregivers from four hospitals in China. The participants were asked to complete the PROMIS Pediatric-25 Profile 2.0, along with a demographic and clinical characteristics questionnaire, fatigue screening item, and an item assessing the family caregiver's coping style. Latent profile analysis was used to identify profiles.

RESULTS

Two profiles were identified: Profile 1, "low symptom and high function" (n = 147, 47.4%); and Profile 2, "high symptom and low function" (n = 163, 52.5%). Children reporting ≥3 on the five-point Symptom Distress Scale fatigue screening item were more likely to be in Profile 2 (OR = 1.961; 95% CI: 1.098-3.501). Participants were less likely to be in Profile 2 if they were in survivorship (OR = 0.494; 95% CI: 0.271-0.903), or their caregiver's coping style was identified as facing positively (OR = 0.439; 95% CI: 0.274-0.703).

CONCLUSION

The identified profiles demonstrate the heterogeneity in HRQoL among pediatric patients with cancer, and the importance of supporting caregivers' coping as a means of supporting the child. Knowledge of these profiles can assist clinicians in better identifying and targeting interventions for children with cancer.

Subjective Toxicity Profiles of Children With Cancer During Treatment: A Latent Class Analysis

BACKGROUND

Children and adolescents may experience a variety of subjective adverse events (AEs) caused by cancer treatment. The identification of distinct groups of patients is crucial for guiding symptomatic AE management interventions to prevent AEs from worsening.

OBJECTIVE

The aim of this study was to identify subgroups of children with cancer experiencing similar patterns of subjective toxicities and evaluate differences among these subgroups in demographic and clinical characteristics.

METHODS

A cross-sectional survey was conducted of 356 children in China with malignancies who received chemotherapy within the past 7 days using the pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events. A latent class analysis (LCA) was conducted to identify subgroups of patients with distinct profiles of symptomatic AE occurrence.

RESULTS

Nausea (54.5%), anorexia (53.4%), and headache (39.3%) were the top 3 AEs children experienced. Nearly all participants (97.8%) experienced ≥1 core AEs, and 30.3% experienced ≥5 AEs. The LCA results identified 3 subgroups ("high gastrotoxicity and low neurotoxicity" [53.2%], "moderate gastrotoxicity and high neurotoxicity" [23.6%], and "high gastrotoxicity and high neurotoxicity" [22.8%]). The subgroups were differentiated by monthly family per-capita income, time since diagnosis, and Karnofsky Performance Status score.

CONCLUSIONS

Children experienced multiple subjective toxicities during chemotherapy, especially gastrotoxicity and neurotoxicity. Heterogeneity was found in the LCA in the patients' toxicities. The prevalence of toxicities could be distinguished by the children's characteristics.

IMPLICATIONS FOR PRACTICE

The results showing different subgroups in our study may assist clinical staff in focusing on patients with higher toxicities to provide effective interventions.

Agreement and disagreement between child-caregiver symptom and function reports in pediatric oncology

BACKGROUND/OBJECTIVE

The use of patient-reported outcomes (PRO) is increasing in pediatric clinical practice and research, including in clinical trials. Treatment teams are now able to discern differences in symptom and function reports between children with cancer and their family caregivers. Few studies, however, have quantified such differences.

DESIGN/METHODS

Children and caregivers were matched to create a dyad sample, and child/caregiver agreement of responses to the Patient-Reported Outcome Measurement Information System (PROMIS) Pediatric symptom and function measures were examined using the established minimally important difference (MID) value (three points) derived from these measures. Latent class analysis (LCA) was then used to analyze the status/patterns of response agreement.

RESULTS

A total of 430 dyadic cases (dyads) were used for LCA modeling. Three classes of child-caregiver concordance resulted: (a) Agreement-caregiver and child within one MID (200 dyads); (b) Disagreement-caregiver underestimating symptoms (47 dyads with caregiver scores more than 1 MID lower than the child scores); and (c) Disagreement-caregiver overestimating symptoms (183 dyads with caregiver scores more than 1 MID higher than child scores).

CONCLUSION

As PRO use increases in pediatric oncology, clinician identification of child/caregiver differences on symptom and function reports will help to distinguish family perceptions of cancer treatment impact. The treatment goal, in addition to mitigating symptom and function treatment-related burdens for the child and caregiver, may now also be to discern the direction and clinical meaning of the difference within the child-parent dyad.

Effect of Early Physical Therapy on Children of School Age With Hematological Cancer: A Quasi-Randomized Controlled Pilot Study

PURPOSE

Although physical therapy (PT) positively impacts exercise capacity and health-related quality of life (HRQOL) in children with hematological cancers, the optimal time for intervention is unknown. We compared the effects of PT administered before and after initial cancer treatment on the exercise capacity and HRQOL of children with hematological cancer.

METHODS

The participants were allocated to early (before initiating treatment) and late PT (after initiating treatment) groups. We evaluated exercise capacity using the 6-min walking distance (6MWD) test and HRQOL using the Pediatric Quality of Life Inventory.

RESULTS

Thirteen school children (7-13 years) were included. The early PT cohort had significant improvements in Pediatric Quality of Life Inventory but not 6MWD scores from admission to the completion of initial treatment; however, both scores reduced significantly in the late PT cohort.

CONCLUSIONS

Early rather than late PT during hospitalization might prevent reduced exercise capacity and improve HRQOL in children with hematological cancers.

Paediatric end-of-life care - symptoms and problems: parent assessment

OBJECTIVE

Symptoms and problems (S&P) are under-reported in children in end-of-life care.To target future interventions, the primary aim was to examine S&P in children in end-of-life care.

METHODS

All parents, who lost a child under the age of 18 years due to life-limiting diagnoses in the period 2012-2014 in Denmark, were invited to complete a self-administered questionnaire in 2017. In all, 152 (38%) children were represented by 136 mothers and 57 fathers. In the present study, parents' assessments of S&P during the last month of life were restricted to children aged 3-18 years. Data were analyses by means of descriptive statistics.

RESULTS

Children ≥3 years at the time of death were represented by 71 parents (48 mothers and 23 fathers) representing 56 out of the 152 children. Physical fatigue (93%), sleepiness (90%), poor appetite (87%), pain (84%) and nausea (84%) were the five most frequent symptoms reported by the parents. In all, 65% of the parents reported that satisfactory pain relief was obtained and 64% of the parents reported that the healthcare services to a large extent reacted quickly, when the child and/or family needed help. However, 46% of the parents experienced 'mess-ups' or sloppy services in the primary ward and 27% experienced that the children suffered from fear of death.

CONCLUSION

According to the parents, children with life-limiting diagnosis are highly symptomatic and have substantial problems during end-of-life care. Our findings indicate that systematic screening of S&P in children should be considered.

Health-related quality of life profiles in adolescents and young adults with chronic conditions

PURPOSE

To assess health-related quality of life (HRQOL) among adolescents and young adults (AYAs) with chronic conditions.

METHODS

AYAs (N = 872) aged 14-20 years completed NIH's Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures of physical function, pain interference, fatigue, social health, depression, anxiety, and anger. Latent profile analysis (LPA) was used to group AYAs into HRQOL profiles using PROMIS T-scores. The optimal number of profiles was determined by model fit statistics, likelihood ratio test, and entropy. Multinomial logistic regression models were used to examine how LPA's HRQOL profile membership was associated with patient demographic and chronic conditions. The model prediction accuracy on profile membership was evaluated using Huberty's I index with a threshold of 0.35 for good effect.

RESULTS

A 4-profile LPA model was selected. A total of 161 (18.5%), 256 (29.4%), 364 (41.7%), and 91 (10.4%) AYAs were classified into Minimal, Mild, Moderate, and Severe HRQOL Impact profiles. AYAs in each profile had distinctive mean scores with over a half standard deviation (5-points in PROMIS T-scores) of difference between profiles across most HRQOL domains. AYAs who were female or had conditions such as mental health condition, hypertension, and self-reported chronic pain were more likely to be in the Severe HRQOL Impact profile. The Huberty's I index was 0.36.

CONCLUSIONS

Approximately half of AYAs with a chronic condition experience moderate to severe HRQOL impact. The availability of risk prediction models for HRQOL impact will help to identify AYAs who are in greatest need of closer clinical care follow-up.

Patient-Reported Outcomes Measurement Information System Pediatric Symptom Profiles of Children With Cancer in China: A Latent Profile Analysis

BACKGROUND

Unpleasant symptoms are common in children with cancer. However, research identifying subgroups of children with cancer who experience similar levels of self-reported symptoms in China is limited.

OBJECTIVES

This study aimed to classify the symptom profiles of children with cancer and detect the possible predictors of the profiles and their effect on children's quality of life (QoL).

METHODS

A total of 272 children aged 8 to 17 years completed the Chinese version of the Pediatric Patient-Reported Outcomes Measurement Information System short form measures, the Pediatric QOL Inventory general core and cancer modules. Latent profile analysis was used to identify symptom profiles, and ordinal logistic regression and analysis of variance were used to examine predictors of symptom profile membership and profile differences on QoL.

RESULTS

The best fit was a 3-profile model: low, moderate, and severe symptom distress. Children who had been inpatients in the past 7 days and were currently under treatment are more likely to have severe symptoms. Participants in the low symptom distress profile reported significantly greater QoL than those in the other profiles.

CONCLUSIONS

Children with cancer are heterogeneous in their experience of symptoms. Children's characteristics, such as inpatient history and treatment status, are predictors of profiles; different symptom profiles are associated with QoL.

IMPLICATIONS FOR PRACTICE

This study identified distinct groups of patients who predictably experience higher symptoms and their predictors, which could help to place children within a profile and perhaps allow nurses to provide targeted supportive care to match children's specific symptom profile.

Validation of the simplified Chinese version of PROMIS Parent Proxy-25 Profile in parents of children with cancer

PURPOSE

To determine the psychometric properties of the Patient-reported Outcomes Measurement Information System Parent Proxy-25 Profile (PROMIS-25) in a sample of Chinese parents of children with cancer.

DESIGN AND METHODS

A cross-sectional sample (N = 148) of parents with children aged 5-17 years living with cancer was recruited. Each participant completed sociodemographic and clinical questionnaires and PROMIS-25. The flooring and ceiling effects were calculated. Reliability was determined by the Cronbach's alpha and split-half coefficient. Factor structure was examined by factor analysis. Model fit and graphical plots were assessed to test the assumptions of Rasch model-based item response theory (IRT). Differential item functioning (DIF) was assessed in terms of gender, age, and treatment stage.

RESULTS

PROMIS-25 demonstrated some flooring and ceiling effect, excellent reliability (Cronbach's α > 0.7 for all six domains), and the six-domain factor structure was supported. The IRT assumptions were met in terms of unidimensionality, local independence, monotonicity, and measurement equivalence with acceptable DIF in terms of gender, age, diagnosis, and treatment stage.

CONCLUSION

PROMIS-25 is a highly reliable and valid instrument for evaluating children with cancer that assesses important health-related quality of life domains of child cancer.

PRACTICE IMPLICATION

Chinese parents of children with cancer and healthcare providers could use PROMIS-25 to assess the symptoms of children.

Applying latent profile analysis to identify adolescents and young adults with chronic conditions at risk for poor health-related quality of life

The impact of chronic diseases on health-related quality of life (HRQOL) in adolescents and young adults (AYAs) is understudied. Latent profile analysis (LPA) can identify profiles of AYAs based on their HRQOL scores reflecting physical, mental, and social well-being. This paper will (1) demonstrate how to use LPA to identify profiles of AYAs based on their scores on multiple HRQOL indicators; (2) explore associations of demographic and clinical factors with LPA-identified HRQOL profiles of AYAs; and (3) provide guidance on the selection of adult or pediatric versions of Patient-Reported Outcomes Measurement Information System® (PROMIS®) in AYAs. A total of 872 AYAs with chronic conditions completed the adult and pediatric versions of PROMIS measures of anger, anxiety, depression, fatigue, pain interference, social health, and physical function. The optimal number of LPA profiles was determined by model fit statistics and clinical interpretability. Multinomial regression models examined clinical and demographic factors associated with profile membership. As a result of the LPA, AYAs were categorized into 3 profiles: Minimal, Moderate, and Severe HRQOL Impact profiles. Comparing LPA results using either the pediatric or adult PROMIS T-scores found approximately 71% of patients were placed in the same HRQOL profiles. AYAs who were female, had hypertension, mental health conditions, chronic pain, and those on medication were more likely to be placed in the Severe HRQOL Impact Profile. Our findings may facilitate clinicians to screen AYAs who may have low HRQOL due to diseases or treatments with the identified risk factors without implementing the HRQOL assessment.

Effect of concurrent training on physical performance and quality of life in children with malignancy: A systematic review and meta-analysis

Objective

This study aims to evaluate the intervention effect of concurrent training on children with malignant tumors to provide evidence for prescribing exercise for children with malignant tumors.

Methods

Twelve databases were searched from inception to October 15, 2022. Two researchers independently screened the literature, evaluated the quality, extracted the data, and performed the meta-analysis using R.

Result

A total of nine randomized controlled trials involving 371 children were included in this study. The meta-analysis revealed that muscle strength was significantly greater in the exercise group compared to the usual care group [SMD = 0.26, 95% CI (0.04, 0.48), P = 0.023], with subgroup analysis showing no significant difference in upper limb [SMD = 0.13, 95% CI (−0.17, 0.43), P = 0.318] and a considerable difference in lower limb strength [SMD = 0.41, 95% CI (0.08, 0.74), P = 0.015]. Physical activity [SMD = 0.57, 95% CI (0.03, 1.1), P = 0.038], timed up and down stairs test [SMD = −1.22, 95% CI (−2.04, −0.4), P = 0.004], 6-min walking ability [SMD = 0.75, 95% CI (0.38, 1.11), P < 0.01], quality of life [SMD = 0.28, 95% CI (0.02, 0.53), P = 0.033], and cancer-related fatigue [SMD = −0.53, 95% CI (−0.86, −0.19), P = 0.002] were significantly better than the usual care group. There were no significant differences in peak oxygen uptake [SMD = 0.13, 95% CI (−0.18, 0.44), P = 0.397], depression [SMD = 0.06, 95% CI (−0.38, 0.5), P = 0.791], and withdrawal rates [RR = 0.59, 95% CI (0.21, 1.63), P = 0.308] between the two groups.

Conclusion

Concurrent training could improve physical performance for children with malignancy but had no significant effect on mental health. Because the quality level of evidence is mostly very low, future high-quality randomized controlled trials are required to confirm these findings.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=364140, identifier CRD42022308176.

Profiles of Symptom Suffering and Functioning in Children and Adolescents Receiving Chemotherapy

BACKGROUND

Some children and adolescents receiving chemotherapy experience few symptom-related adverse events, whereas others experience multiple adverse events. If oncology nurses could identify patients likely to have pronounced chemotherapy-related adverse events, tailored supportive care could be matched to these patients' symptom burdens.

OBJECTIVE

The aim of this study was to identify symptom profiles in children and adolescents before and after chemotherapy, and the sociodemographic and psychological factors associated with profile classification and change.

METHODS

Participants ranging from 7 to 18 years (n = 436) completed 6 Patient-Reported Outcomes Measurement Information System pediatric symptom measures within 72 hours preceding (T1) and 1 to 2 weeks after (T2) chemotherapy. Profile membership and change were determined by latent profile/latent transition analyses. Associations with profiles and profile transitions were examined using multinomial logit models and logistic regression.

RESULTS

Three symptom suffering profiles were identified at T1 and T2: high, medium, and low. The high symptom suffering profile included the fewest participants (T1, n = 70; T2, n = 55); the low symptom suffering profile included the most participants (T1, n = 200; T2, n = 207). Of the participants, 57% remained in the same profile from T1 to T2. Psychological stress was significantly associated with T1 and T2 profile classifications and profile transition; age was associated with profile classification at T1.

CONCLUSION

Three symptom suffering profiles existed in a sample of pediatric patients undergoing chemotherapy, indicating that children and adolescents have differing cancer treatment experiences.

IMPLICATIONS FOR PRACTICE

Oncology nurses could screen pediatric oncology patients for their symptom suffering profile membership and subsequently prioritize care efforts for those with a high suffering profile.

The predictive trifecta? Fatigue, pain, and anxiety severity forecast the suffering profile of children with cancer

BACKGROUND

Fatigue, pain, and anxiety, symptoms commonly experienced by children with cancer, may predict pediatric symptom suffering profile membership that is amenable to treatment.

METHODS

Three latent profiles (Low, Medium, and High symptom suffering) from 436 pediatric patients undergoing cancer care were assessed for association with three single-item symptoms and socio-demographic variables.

RESULTS

Pediatric-PRO-CTCAE fatigue, pain, and anxiety severity scores at baseline were highly and significantly associated with the Medium and High Suffering profiles comprised of PROMIS pediatric symptom and function measures. The likelihood of membership in the Medium Suffering group was 11.37 times higher for patients who experienced fatigue severity than those with did not, while experience of pain severity increased the likelihood of the child's membership in the Medium Suffering profile by 2.59 times and anxiety by 3.67 times. The severity of fatigue increased the likelihood of presence in the High Suffering group by 2.99 times while pain severity increased the likelihood of the child's membership in the High Suffering profile by 6.36 times and anxiety by 16.75 times. Controlling for experience of symptom severity, older patients were more likely to be in the Higher or Medium Suffering profile than in the Low Suffering profile; no other socio-demographic or clinical variables had a significant effect on the latent profile classification.

CONCLUSION

Clinician knowledge of the strong association between fatigue, pain, and anxiety severity and suffering profiles may help focus supportive care to improve the cancer experience for children most at risk from time of diagnosis through treatment.

Profile Comparison of Patient-Reported and Proxy-Reported Symptoms in Pediatric Patients With Cancer Receiving Chemotherapy

IMPORTANCE

The variability in individual symptom and adverse event reporting between pediatric patient-reports and proxy-reports is widely reported. However, the question of whether symptom profiles based on reports from children with cancer and their caregivers are similar or disparate have not yet been studied.

OBJECTIVE

To compare proxy symptom reports with patient self-reports to assess alignment.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter cohort study was conducted from October 2016 to December 2018 from data collected at 9 pediatric cancer centers. Participants were a convenience sample of family caregivers or proxies of children aged 7 to 18 years who had received disease-directed oncology treatment in the form of chemotherapy for at least 1 month. Data were analyzed identifying clusters of individuals (ie, latent profiles) based on various responses (ie, indicators) in August 2021.

EXPOSURES

The children of proxy participants received upfront chemotherapy. Children and proxies completed Patient-Reported Outcomes Measurement Information System (PROMIS) surveys at 2 time points: within 72 hours preceding treatment initiation and following the course of chemotherapy.

MAIN OUTCOMES AND MEASURES

The latent profile analysis methods were applied to caregiver-proxy reports of PROMIS Pediatric symptom and function measures (anxiety, depressive symptoms, pain interference, fatigue, psychological stress, and physical function-mobility). The instrument categorized respondents as high symptom suffering, medium symptom suffering, and low symptom suffering (hereafter, high, medium, and low symptom groups, respectively).

RESULTS

Of 580 approached proxies, 431 (368 [85.00%] were female) identified as legal guardians of children aged 7 to 18 years with a first cancer diagnosis (mean [SD] age, 13.03 [3.40] years; 235 [54.65%] were male). Proxy reports of children's experiences based on the 5 proxy PROMIS measures comprised 3 distinct symptom profiles. The most common proxy assessments of children's experiences were the moderate symptom groups (45.7% [197 of 431]) and the low symptom groups profiles (40.1% [173 of 431]). A high symptom groups profile emerged which represented 14.2% (61 of 431) of proxy assessments. The number of profiles and observed distribution of profile membership was similar between child and proxy reports. Proxy reports of individual symptoms generally recorded higher scores than child reports; however, no significant difference was observed between proxies and child profile model results for the PROMIS measures.

CONCLUSIONS AND RELEVANCE

Results of this cohort study suggest that, at the level of symptom severity profile, proxy caregiver reports may approximate the children's reports and may serve as a guide to care when the child is not able to self-report.

Can Steps per Day Reflect Symptoms in Children and Adolescents Undergoing Cancer Treatment?

BACKGROUND

Multiple symptoms occur in children receiving cancer therapy. Decreased steps per day may be associated with burdensome symptoms.

OBJECTIVE

To evaluate associations between self-reported symptoms (pain interference, anxiety, depressive symptoms, psychological stress, and fatigue) and function (physical function-mobility and physical activity) and cumulative symptom count with steps per day.

METHODS

Five sites enrolled English-speaking children, 8 to 17 years, receiving treatment for a first cancer diagnosis. Patient-reported outcome (PRO) surveys were administered before (T1) and after (T2) a course of chemotherapy. Garmin VivoFit 3 (Garmin International, Olathe, KS) accelerometers were worn 7 days prior to each data point. Univariate changes in scores over time were evaluated with dependent-sample t tests. Pearson correlations examined associations between PRO domains and step count. Multivariable mixed-effect models examined associations between steps and PROs.

RESULTS

Participants' (n = 65) steps per day decreased during treatment (4099 [T1] and 3135 [T2]; P < .01), with larger reductions observed during hospitalization and in younger children compared with adolescents. Steps significantly correlated with PROMIS (Patient-Reported Outcome Measurement Information System) Pediatric physical activity and physical function-mobility. Decreased steps per day were associated with increased fatigue and cumulative symptom count.

CONCLUSIONS

In children and adolescents with cancer, steps per day can serve as an indicator of fatigue, cumulative symptom count, physical activity, and physical functioning-mobility.

IMPLICATIONS FOR PRACTICE

Child self-reports of physical activity and physical function are valid during cancer therapy and should be captured. In the absence of self-report, decreasing step count may prompt additional assessments related to fatigue or cumulative symptom count and trigger early interventions to support physical activity and physical function-mobility.

The prevalence and risk of symptom and function clusters in colorectal cancer survivors

PURPOSE

Our purpose was to describe the prevalence and predictors of symptom and function clusters in a diverse cohort of colorectal cancer survivors.

METHODS

We used data from a cohort of 909 adult colorectal cancer survivors. Participants were surveyed at a median of 9 months after diagnosis to ascertain the co-occurrence of eight distinct symptom and functional domains. We used factor analysis to identify co-occurring domains and latent profile analysis (LPA) to identify subgroups of survivors with different symptom and function clusters. Multinomial logistic regression models were used to identify risk/protective factors.

RESULTS

Factor analysis demonstrated a single underlying factor structure that included all eight health domains with depression and anxiety highly correlated (r = 0.87). The LPA identified three symptom and function clusters, with 30% of survivors in the low health-related quality of life (HRQOL) profile having the highest symptom burden and lowest functioning. In multivariable models, survivors more likely to be in the low HRQOL profile included being non-White, female, those with a history of cardiac or mental health conditions, and chemotherapy recipients. Survivors less likely to be in the low HRQOL profile included those with older age, greater financial well-being, and more spirituality.

CONCLUSION

Nearly one-third of colorectal cancer survivors experienced a cluster of physical and psychosocial symptoms that co-occur with clinically relevant deficits in function.

IMPLICATIONS FOR CANCER SURVIVORS

Improving the identification of risk factors for having the highest symptom and lowest function profile can inform the development of clinical interventions to mitigate their adverse impact on cancer survivors' HRQOL.

Physical therapy interventions, other than general physical exercise interventions, in children and adolescents before, during and following treatment for cancer

BACKGROUND

Children and adolescents diagnosed with cancer are at high risk of experiencing severe side effects from cancer treatment, many of which are amenable to physical therapy. These side effects can negatively impact a child's quality of life and ability to participate in daily activities (e.g. play and attendance at school). Researchers have evaluated physical therapy interventions in children with cancer and childhood cancer survivors. However, factors such as small sample sizes, varying intervention protocols and differences in cancer types among trials make it difficult to draw conclusions about efficacy.

OBJECTIVES

The primary aim of this review was to evaluate the efficacy of physical therapy interventions - with a specific focus on symptom relief and compensation of therapy-related side effects - on the quality of life of children and adolescents diagnosed with cancer. Participants must be between the ages of 0 and 19 years at the time of the physical therapy intervention study. The intervention may occur prior to, during or following cancer treatment. The intervention must be compared to a control group of children receiving standard care, no physical therapy intervention or a comparison intervention. We have excluded general physical exercise studies where the primary aim was to improve physical fitness through aerobic, anaerobic, resistance exercise or combined physical exercise training regimens (i.e. combined aerobic and resistance exercise regimens). We have also intended to record the occurrence of any adverse effects resulting from physical therapy interventions. The secondary aims were to evaluate the efficacy of physical therapy on impairments of pain, peripheral neuropathy, balance, gait, functional abilities and mobility, motor function and performance, range of motion, strength and fatigue.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, ongoing trial registries, conference proceedings and the reference lists of relevant studies and reviews in March 2020. We also contacted oncology rehabilitation researchers working in paediatrics in March 2020 to identify additional studies.

SELECTION CRITERIA

The review included randomised controlled trials (RCTs), cross-over trials, and controlled clinical trials (CCTs) that compared the effects of physical therapy interventions to a control group, and involved children and adolescents diagnosed with cancer between the ages of 0 and 19 years at the time of the intervention. We excluded studies examining general physical exercise interventions where the primary aim was to improve physical fitness through aerobic exercise, resistance exercise or combined physical exercise training regimens (i.e. combined aerobic and resistance exercise regimens).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We found no RCTs, cross-over trials or CCTs comparing the effects of physical therapy interventions with a focus on symptom relief and compensation of therapy-related side effects for children and adolescents between the ages of 0 and 19 years.

AUTHORS' CONCLUSIONS

Results demonstrate that the evidence to date is inadequate to inform clinical practice. Recommendations for future research include the need for large-scale, high-quality designs that examine: (1) paediatric populations with same cancer types; (2) similar intervention protocols; (3) long-term outcomes; (4) physical therapy interventions (e.g. electrophysical modalities and sensory interventions); and (5) outcomes commonly impaired in children with cancer (e.g. peripheral neuropathy and gait deficits).

Self-reported late effect symptom clusters among young pediatric cancer survivors

PURPOSE

Most survivors of childhood cancer experience subsequent chronic conditions but little is known about concurrent symptoms. This study seeks to identify late effect symptom clusters among young pediatric cancer survivors.

METHODS

Survivors ≥ 18 or parents of survivors < 18 years enrolled in an institutional cohort study indicated (yes/no) if they experienced certain symptoms after treatment. The sample was randomly divided in half for exploratory factor analyses to identify symptom clusters followed by confirmatory factor analyses. Symptoms with ≥ 10% prevalence were included. Cluster structure generalizability across subgroups was examined using congruence coefficients.

RESULTS

The sample included 579 survivors (74% non-Hispanic white, 45% leukemia, 12.8 ± 4.5 years at survey, 5.9 ± 3.5 years since therapy). Respondents averaged three symptoms. Three clusters were identified: (1) gastrointestinal: abdominal pain, diarrhea, constipation, nausea, vomiting (Cronbach's α = 0.74); (2) psychological: depression, anxiety, memory problems, anger management problems, sleep problems (α = 0.71); and (3) neurologic: problems walking, numbness/tingling, fatigue, back pain, chronic pain, weakness/inability to move legs (α = 0.71). Confirmatory factor analysis confirmed the three-cluster structure (standardized root mean square residual: 0.09; parsimonious goodness of fit: 0.96; Bentler-Bonett normed fit index: 0.95). The gastrointestinal and psychological clusters were generalizable across most subgroups while the neurologic cluster varied across age and race/ethnicity subgroups.

CONCLUSION

Three distinct late effect symptom clusters were identified in young childhood cancer survivors with gastrointestinal and psychological clusters remaining relatively stable across subgroups. Future studies should focus on the characteristics of patients who experience these symptoms, especially those with high symptom burden, and the synergistic impact on quality of life.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment

OBJECTIVES

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care.

DATA SOURCES

Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer.

CONCLUSION

Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

Subjective Toxicity Profiles of Children in Treatment for Cancer: A New Guide to Supportive Care?

CONTEXT

Children and adolescents with cancer experience treatment-related, subjective adverse events (AEs). Identifying distinct groups of patients who predictably experience higher prevalence of AEs could guide patient care.

OBJECTIVES

Study aims were to 1) identify groups of children and adolescents reporting AEs using the Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (Ped-PRO-CTCAE); 2) determine whether demographic and clinical characteristics predict AE group membership; and 3) examine whether AE group membership was related to the distal outcome of psychological stress.

METHODS

Four hundred seventy-seven patients self-reported AEs via the Ped-PRO-CTCAE at T1 (beginning of treatment) and the PROMIS Pediatric Psychological Stress measure at T2 (7-28 days later). Latent class analysis was conducted to identify groups of patients and the relationships of the groups with demographic and clinical characteristics, and with stress.

RESULTS

Three distinct a priori unknown AE groups were identified (high AE prevalence, moderate AE prevalence, and low AE prevalence). Females, blacks, patients with high psychological stress, and patients more recently diagnosed were more likely to be in the high AE prevalence group. Gender, age, race, and time since diagnosis were associated with psychological stress.

CONCLUSION

Children with cancer are heterogeneous in experiencing subjective AEs. Gender, race, and time since diagnosis were significantly associated with higher subjective AE prevalence that may lead to psychological stress.

A pilot study of the effect of a home-based multimodal symptom-management program in children and adolescents undergoing chemotherapy

Background

Prevalent symptoms that affect children and adolescents throughout the process of cancer diagnosis and treatment include nausea and vomiting, fatigue, pain, mucositis, and anxiety.

Aim

To examine the effect of a home‐based multimodal symptom‐management program for alleviation of nausea and vomiting, fatigue, pain, mucositis, and anxiety in children and adolescents undergoing chemotherapy for hematological malignancies or solid tumors.

Methods

In an exploratory pilot randomized study with qualitative interview, patients between 10 and 18 years of age were randomly assigned to either the symptom‐management program plus usual care (intervention group) or usual care (control group). The program consisted of multiple nonpharmacological interventional components. The targeted symptoms were measured at baseline (after diagnosis), at the first 2 weeks of each cycle of chemotherapy, and at 6 months after baseline, using the Memorial Symptom Assessment Scale 10‐18 and the State Anxiety Scale for Children.

Results

Fifty children (31 boys; mean age, 13.7 years) were randomized either to the intervention group or the control group (25 each) and underwent baseline assessment. A comparison between the groups showed that the intervention group had a significant less fatigue over time (P < .05). However, no differences were found with respect to nausea and vomiting, pain, mucositis, and anxiety between groups. Both children and parents reported a positive experience with the symptom‐management program.

Conclusion

The home‐based symptom‐management program may have helped to reduce fatigue in children and adolescents undergoing chemotherapy. In addition, qualitative data support the importance of improving children and parents' knowledge, coping skills, and psychological preparation for symptoms associated with chemotherapy.

Symptom Profiles of CD and ODD Among Youth With Perinatally Acquired HIV

OBJECTIVE

Youth with perinatally acquired human immunodeficiency virus (PHIV) face increased risk for conduct disorder (CD) and oppositional defiant disorder (ODD) symptoms, and heterogeneous findings indicate that there may be subgroups of youth with PHIV differing in the quality and/or frequency of symptoms. The present study examined symptom profiles of CD and ODD among youth with PHIV and whether profiles differed in terms of parent-child and family correlates.

METHODS

Participants included 314 youth with PHIV, aged 6-17 years (M = 12.88 years, SD = 3.08; 51% male; 85% Black or Latinx), and their caregivers who were recruited from 29 clinics in the US involved in the International Maternal Pediatrics Adolescent AIDS Clinical Trials (IMPAACT) Group's P1055 study. Caregivers reported on youth CD and ODD symptoms, parent-child interactions, and family environment.

RESULTS

Latent class analysis indicated that a four-class model (i.e., moderate CD/high ODD, high ODD, moderate ODD, low CD/ODD) best fit the data. Ancillary analyses to validate these classes revealed differences for family cohesion and conflict; and child-centeredness, detachment, guilt-induced control, and consistency in parent-child interactions. The low CD/ODD class generally differed from other classes with additional differentiation between some higher risk profiles.

CONCLUSIONS

Findings suggest that homogeneous classes of CD/ODD symptoms can be identified among youth with PHIV, and these profiles differ in terms of family processes, consistent with previous work among chronically ill youth.

Promoting Emotional Well-being in Hospitalized Children and Adolescents With Virtual Reality: Usability and Acceptability of a Randomized Controlled Trial

The aim of this study was to describe and compare small-sized preliminary data on the usability and acceptability of a randomized controlled trial. This study compares a one-to-one cognitive-behavioral treatment and a virtual reality treatment for children and adolescents hospitalized for long-term physical conditions. The final sample was composed of 19 children and adolescents with chronic illness who were hospitalized. The sample was randomly allocated to two intervention groups: cognitive-behavioral usual treatment and virtual reality-based treatment. Participants in the virtual reality group demonstrated higher perceived efficacy scores for every treatment component than for traditional treatment. Statistically significant differences were found for the total usability and acceptability scores. Participants in the virtual reality group show high acceptability of all the virtual environments. The components and environments of virtual reality were well accepted. The virtual reality program received high scores in immersion, feasibility of use, and sense of reality. Technology-based treatments, that is, virtual reality, can provide motivational benefits in relation to traditional treatments.

Manifestation and parental assessment of children's cancer pain at home: An exploratory mixed-methods study

AIMS AND OBJECTIVES

To describe pain manifestation in children with cancer at home and understand how parents assess this pain.

BACKGROUND

Pain is experienced by children with cancer throughout their cancer journey. Short-term, and into survivorship, pain has negative physical and psychological consequences. Changes in treatment location mean children with cancer spend more time at home. Little is known about pain experienced by children at home or how parents assess this pain.

DESIGN

A mixed-methods convergent parallel study was reported using STROBE.

METHOD

Parents of children with cancer on active treatment were recruited from one tertiary cancer centre. Parental attitudes towards pain expression were assessed using surveys. Parents recorded their child's pain manifestation in pain diaries kept for one month. Interviews captured a deeper understanding of pain manifestation and how parents assess this pain at home. Integration occurred after each data collection method was analysed separately.

RESULTS

Predominantly children were not in pain at home. However, most children experienced at least one episode of problematic pain over the pain diary period. Surveys showed parents held misconceptions regarding children's pain expression. Interviews diverge from surveys and suggest parents used a range of information sources to assess pain.

CONCLUSION

Children with cancer may differ from one another in the manifestation of pain at home resulting in multiple pain trajectories. Parents of children with cancer are able to adequately assess their child's pain using information from multiple sources.

RELEVANCE TO CLINICAL PRACTICE

It is not currently possible to predict which children will experience problematic pain at home, so all parents require pain management education prior to discharge. Teaching parents to use bundled approaches to pain assessment may accelerate their learning. Healthcare professionals may benefit from using multiple information sources to assess pain.

Symptoms in Children Receiving Treatment for Cancer-Part II: Pain, Sadness, and Symptom Clusters

Children and adolescents receiving treatment for cancer experience multiple symptoms as a consequence of their disease and its treatment that interfere with the child's quality of life. Understanding of symptom assessment in children with cancer is foundational to the work of the Children's Oncology Group Nursing Discipline, whose research aims are to address knowledge gaps including understanding illness-related distress. This article is the second of a two-part summary of current evidence addressing the assessment of symptoms frequently reported by children and adolescents receiving treatment for cancer. Studies reporting assessment of pain, sadness, and symptom clusters published between January 2008 and May 2018 were included. Forty-three publications addressed pain. Pain was highly prevalent and distressing, varied in its trajectory across a cycle of chemotherapy and across multiple cycles of treatment, and correlated with biomarkers associated with the pain response. Consequences of pain were poorer functional status and emotional health. Twenty publications addressed sadness. Sadness was the most prevalent psychosocial symptom. Its prevalence decreased over the course of treatment and over a cycle of chemotherapy. Persistent sadness was of greater severity and distress. Eight publications addressed symptom clusters. These studies identified both groups of co-occurring symptoms and groups of patients with common symptom profiles. This two-article series provides evidence for the distressing nature of symptoms among children receiving cancer treatment. Efforts to support clinicians in routine symptom assessment are needed. Additional research directed at alleviating symptoms and building resilience among the child experiencing symptoms is needed.

Consensus Recommendations From the Children's Oncology Group Nursing Discipline's State of the Science Symposium: Symptom Assessment During Childhood Cancer Treatment

Background: Recognizing and addressing illness-related distress has long been a priority for pediatric oncology nurses and the Children's Oncology Group. Although symptoms are known to be highly prevalent during treatment for childhood cancer, there is currently no guidance for how often symptoms should be assessed, which symptoms should be prioritized for assessment, and how the data should be collected. Methods: The Nursing Discipline, within Children's Oncology Group, hosted a one-day Interprofessional seminar titled "Symptom Assessment During Childhood Cancer Treatment: State of the Science Symposium." Following the symposium, an expert panel was assembled to review all available evidence, including information presented and collected during the symposium. Consensus-building discussions were held to identify common themes and to produce recommendations for clinical practice. Results: Four recommendations emerged including (1) the identification of priority "core" symptoms for assessment; (2) inclusion of the child's voice through self-report, when possible; (3) consistent documentation and communication of symptom assessment results; and (4) implementation of patient/family education related to symptoms. Discussion: Symptom recognition, through appropriate assessment, is the first step in symptom management. The goal for developing and sharing these recommendations is to promote consistent and comparable clinical practice across institutions in regard to symptom assessment during childhood cancer therapy. Integration of these recommendations will set the stage for future studies related to the frequency of symptoms across disease groups, projection of anticipated symptom trajectories, development of evidence-based teaching tools for common symptoms, and evaluation of patient outcomes with enhanced symptom assessment and management.

Prognostic factors for pain and functional disability in children and adolescents with persisting pain: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The aim of this study was to investigate prognostic factors for pain and functional disability in children and/or adolescents with persisting pain.

DATABASES AND DATA TREATMENT

To be included, studies had to be published, peer-reviewed prospective cohort studies of children and/or adolescents with persisting pain at baseline, that reported at least one baseline prognostic factor and its relationship with pain or functional disability at least 1 month after baseline. Two reviewers independently assessed study eligibility, completed data extraction and undertook quality assessment. Meta-analyses were performed when a prognostic factor was reported in two or more studies.

RESULTS

Of 10,992 studies identified from electronic database searches, 18 were included, investigating 62 potential prognostic factors. In clinical settings, insufficient data were available for meta-analysis. Some positive associations with pain and/or disability were reported by single studies for older age, baseline pain intensity and baseline functional disability across multiple combinations of follow-up times and outcomes. In community settings, meta-analyses of two studies found that prognostic factors for the ongoing presence of pain at medium-term (1-year) follow-up were older age (OR 1.25; 95% CI = 1.05-1.47), weekly day tiredness (OR 1.69; 95% CI = 1.14-2.51), weekly abdominal pain (OR 1.44; 95% CI = 1.03-2.02) and waking during the night (OR 1.49; 95% CI = 1.05-2.13). No studies in community settings reported on prognostic factors for functional disability.

CONCLUSIONS

Prognostic factors having significant associations with future pain and disability were identified; however, as few were investigated in more than one comparable study, the results need to be interpreted with caution.

SIGNIFICANCE

Prognostic factors from across the biopsychosocial spectrum are important to consider in paediatric pain clinical practice. However, most prognostic factors that experts have previously agreed upon have not been assessed in prospective cohort studies to date. The findings may help with prioritising data to collect during clinical assessments of children presenting with pain, in the context of pain and functional disability outcomes.

Youth Victims of Violence Report Worse Quality of Life Than Youth With Chronic Diseases

OBJECTIVES

Measuring health-related quality of life (HRQOL) provides the patient's perspective of his/her well-being and offers a unique outcome measure to demonstrate the impact of violence on the victim. To date, no study has described HRQOL in youth victims of violence in the United States. The purpose of this study was to describe HRQOL in youth victims of violence as compared with healthy youth and youth with chronic disease.

METHODS

We conducted an exploratory cross-sectional study of the HRQOL of victims of violence aged 8 to 18 years. Descriptive statistics were reported for participant and injury demographics. One sample t tests were used to compare the sample population's HRQOL to known HRQOL of healthy populations and specific disease populations.

RESULTS

Fifty-eight victims of violence participated in the study. Youth victims of violence had significantly worse mean HRQOL scores (mean, 71.4) compared with healthy youth in overall functioning (mean, 83.9), P < 0.001. Youth victims of violence reported worse psychosocial (mean, 67.6), emotional (mean, 62.9), and school (mean, 63.8) functioning than youth with obesity (mean, 72.1, 68.6, 75.0, respectively) and cancer (mean, 72.1, 72.2, 68.3, respectively). Mean Patient-Reported Outcomes Measurement Information System T scores for youth victims of violence were significantly worse in anxiety (T = 51.9) and depression (T = 52.4) compared with youth with obesity (T = 48.3, 49.2), cancer (T = 47.7, 47.6), and sickle cell disease (T = 43, 44).

CONCLUSIONS

Youth victims of violence suffer significant impairment in HRQOL compared with healthy populations and youth with specific disease burdens. Future studies into violence prevention effectiveness should use HRQOL as a comparative outcome measure to better tailor post injury management and interventions.

Impact of multimorbidity subgroups on the health care use of early pediatric cancer survivors

BACKGROUND

Although pediatric cancer survivors in the United States are at an increased risk of developing chronic conditions, to the authors' knowledge there is limited information regarding the types and combinations of conditions they experience in the years immediately after the completion of cancer therapy.

METHODS

An observational cohort study of early pediatric cancer survivors (children who were ≥2 years from the end of therapy and aged ≤18 years) was conducted using the Truven Health MarketScan (r) Commercial Claims and Encounters database (2009-2014). Latent class analysis was used to identify comorbidity groups among the subset with ≥2 conditions. Group-level health care use was compared with survivors without chronic conditions using multivariate regression.

RESULTS

A total of 3687 early survivors were identified, of whom approximately 41.2% had no chronic conditions, 22.5% had 1 chronic condition, and 36.3% had ≥2 chronic conditions. Among those with ≥2 chronic conditions, 5 groups emerged: 1) general pediatric morbidity (35.4%); 2) central nervous system (CNS) (22.4%); 3) mental health conditions (22.2%); 4) endocrine (26.2%); and 5) CNS with endocrine (3.8%). The CNS group experienced the highest expenditures, at $17,964 more per year (95% CI, $1446-$34,482) compared with survivors without chronic conditions. The CNS group also had the highest odds of an emergency department visit (adjusted odds ratio, 1.71; 95% CI, 1.15-2.56). The endocrine group had the highest odds of hospitalization (odds ratio, 2.29; 95% CI, 1.24-4.22).

CONCLUSIONS

Multimorbidity is common among pediatric cancer survivors. The current study identified 5 distinct comorbidity subgroups, all of which experienced high, yet differential, rates of health care use. The results of the current study highlight the complex health care needs of early survivors and provide evidence for the design of targeted survivorship services and interventions.

Physical Activity, the Childhood Cancer Symptom Cluster-Leukemia, and Cognitive Function: A Longitudinal Mediation Analysis

BACKGROUND

Children undergoing leukemia treatment report co-occurring symptoms of fatigue, sleep disturbances, pain, nausea, and depression as a symptom cluster. Physical activity (PA) is essential for development and may influence symptom severity. Children with leukemia are at risk of cognitive impairments from central nervous system therapies. Using a longitudinal parallel-process model, relationships among function and symptom clusters were explored.

OBJECTIVE

This study examined the longitudinal mediation effects of PA on cognition via a symptom cluster during leukemia treatment.

METHODS

Symptoms, PA, and cognitive function of 327 children aged 3 to 18 years were measured over 4 intervals during the first year of leukemia treatment. Children 7 years or older self-reported and parents reported for younger children. Parents completed cognitive function measurements for all children. The influence of the first time point and the subsequent change between all 4 time points of PA on the symptom cluster were explored. Analysis determined whether the symptom cluster mediated the effect of cognition over the treatment period.

RESULTS

Patients with a higher PA at time 1 reduced their symptom cluster severity over the measurements. However, when PA increased over the measurements, symptom cluster severity also increased. When the symptom cluster was more severe at time 1, cognitive function was lower at time 1, and cognitive function decreased over time. When symptoms became more severe over time, cognitive function declined.

CONCLUSIONS

The symptom cluster acted as a mediator between PA and cognition.

IMPLICATIONS FOR PRACTICE

Symptom management during treatment may be an additional strategy for protecting cognitive function.

The longitudinal relationship between patient-reported outcomes and clinical characteristics among patients with focal segmental glomerulosclerosis in the Nephrotic Syndrome Study Network

Background

Understanding the relationship between clinical and patient-reported outcomes (PROs) will help support clinical care and future clinical trial design of novel therapies for focal segmental glomerulosclerosis (FSGS).

Methods

FSGS patients ≥8 years of age enrolled in the Nephrotic Syndrome Study Network completed Patient-Reported Outcomes Measurement Information System PRO measures of health-related quality of life (HRQoL) (children: global health, mobility, fatigue, pain interference, depression, anxiety, stress and peer relationships; adults: physical functioning, fatigue, pain interference, sleep impairment, mental health, depression, anxiety and social satisfaction) at baseline and during longitudinal follow-up for a maximum of 5 years. Linear mixed-effects models were used to determine which demographic, clinical and laboratory features were associated with PROs for each of the eight children and eight adults studied.

Results

There were 45 children and 114 adult FSGS patients enrolled that had at least one PRO assessment and 519 patient visits. Multivariable analyses among children found that edema was associated with global health (-7.6 points, P = 0.02) and mobility (-4.2, P = 0.02), the number of reported symptoms was associated with worse depression (-2.7 per symptom, P = 0.009) and anxiety (-2.3, P = 0.02) and the number of emergency room (ER) visits in the prior 6 months was associated with worse mobility (-2.8 per visit, P < 0.001) and fatigue (-2.4, P = 0.03). Multivariable analyses among adults found the number of reported symptoms was associated with worse function in all eight PROMIS measures and the number of ER visits was associated with worse fatigue, pain interference, sleep impairment, depression, anxiety and social satisfaction. Laboratory markers of disease severity (i.e. proteinuria, estimated glomerular filtration rate and serum albumin) did not predict PRO in multivariable analyses, with the single exception of complete remission and better pain interference scores among children (+9.3, P = 0.03).

Conclusions

PROs provide important information about HRQoL for persons with FSGS that is not captured solely by the examination of laboratory-based markers of disease. However, it is critical that instruments capture the patient experience and FSGS clinical trials may benefit from a disease-specific instrument more sensitive to within-patient changes.

Using PROMIS® to create clinically meaningful profiles of nephrotic syndrome patients

OBJECTIVE

Nephrotic syndrome (NS) is a kidney disease known to adversely impact health-related quality of life (HRQOL). Patient-reported outcome (PRO) measures are commonly used to characterize HRQOL and the patient disease experience. This study aims to improve the interpretability and clinical utility of the Patient-Reported Outcomes Measurement Information System® (PROMIS®) by identifying distinct meaningful HRQOL profiles in children and adults with NS.

METHOD

Patients were from 2 prospective NS cohort studies (PROMIS-II®: 121 children; NEPTUNE: 40 children and 219 adults) with data from 6 PROMIS® domains. Latent Profile Analysis was used to identify subgroups of patients based on PROMIS® score patterns. A 3-step analysis of latent profile predictors was used to determine how clinical parameters predicted HRQOL profile membership.

RESULTS

We identified 3 HRQOL profiles (Good, Average, and Poor) with strong indicators of membership classification (entropy >0.86). Complete proteinuria remission, reduction in symptoms, and shorter disease duration, were significant predictors of better HRQOL profile membership.

CONCLUSIONS

Patients with NS can be classified by HRQOL into clinically meaningful categories. Integrating this approach into clinic may help in the identification of individuals with poor HRQOL will help clinicians better manage their symptoms and researchers study the causes and possible interventions for these patients. PROMIS® HRQOL profiles were reproducible in replication cohorts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

PROMIS pediatric measures validated in a longitudinal study design in pediatric oncology

PURPOSE

This study assessed the responsiveness to change over time and theorized associations of Patient-Reported Outcomes Measurement Information System (PROMIS) pediatric measures in children and adolescents in treatment for cancer to determine measure readiness for use in cancer clinical trials.

METHODS

We administered eight PROMIS (three symptom, two psychological, and three performance) pediatric short-form measures and the Symptom Distress Scale (SDS) to 96 pediatric oncology patients at three time points during a course of chemotherapy. We assessed responsiveness using paired t tests and generalized estimating equation (GEE) models, calculated standardized response mean (SRM) values for PROMIS measures, and examined scores over three data points (T1-T3). Guided by the theory of unpleasant symptoms (TOUS), we examined associations among the PROMIS measures, the SDS, and other variables using GEE.

RESULTS

The paired t tests showed statistically significant changes in two psychological measures and one performance measure from T1 to T2; three symptom, two psychological and two performance measures from T2 to T3; and three symptom and two psychological measures from T1 to T3. Findings from GEE models indicate PROMIS pediatric measures had statistically significant short-term and long-term changes, controlling for demographic and clinical variables. One performance measure did not achieve significant change at any time point. We found positive support for theorized relationships in the TOUS.

CONCLUSIONS

Most of the PROMIS pediatric measures demonstrated changes over time and had significant relationships as theorized, thus supporting concurrent and construct validity of these measures when administered to pediatric oncology patients during a course of chemotherapy. This evidence supports the measures' readiness for use in clinical trials.

Quality of life outcomes in patients presenting for evaluation of CNS tumors

Background

We describe patient-reported outcomes (PROs) in adults with CNS tumors and evaluate their correlation with physician-reported functional status.

Methods

We completed a retrospective cohort study of patients managed at a high-volume CNS tumor institute between September 2013 and September 2014. PROs were measured using 6 domains from the PROs Measurement Information System (PROMIS): anxiety, physical function, pain interference, sleep disturbance, fatigue, and satisfaction with social roles. Physician-reported outcomes were measured using the Eastern Cooperative Oncology Group Scale of Performance Status (ECOG). We compared differences in PROMIS scores across tumor types using analysis of variance and measured the correlation between PROMIS scores and ECOG scores using spearman correlations. Finally, we compared the range of PROMIS physical function scores within each ECOG level.

Results

In a cohort of 2,828 patients, 1,284 (45.4%) completed all 6 PROMIS domains. There were significant differences in PROMIS scores across tumor types for all domains except anxiety. The strength of the correlation between PROMIS and ECOG scores was weak to moderate for all PROMIS domains (all p < 0.001). The correlation was the strongest between the physical function domain and ECOG score (ρ = -0.54), although there was a broad distribution of physical function scores within ECOG level, with scores spanning nearly 5 SDs within most ECOG levels.

Conclusions

Symptom burden was associated with tumor type. There were only weak to moderate correlations between PROMIS and ECOG scores, underscoring the importance of integrating PROs into clinical practice for patients with CNS tumors.

Childhood Cancer Symptom Cluster: Leukemia and Health-Related Quality of Life

OBJECTIVES

To examine the relationship of the Childhood Cancer Symptom Cluster-Leukemia (CCSC-L) with health-related quality of life (HRQOL).

SAMPLE & SETTING

327 children receiving treatment for acute lymphoblastic leukemia from four pediatric oncology programs across the United States.

METHODS & VARIABLES

Participants completed fatigue, sleep disturbance, pain, nausea, and depression symptom questionnaires at four time points; these symptoms comprised the CCSC-L. HRQOL was measured at the start of postinduction therapy and then at the start of maintenance therapy. Relationships between the CCSC-L and HRQOL scores were examined with longitudinal parallel-process modeling.

RESULTS

The mean HRQOL significantly increased over time (p < 0.001). The CCSC-L had a significant negative association with HRQOL scores at the start of postinduction therapy (beta = -0.53, p < 0.005) and the start of maintenance therapy (beta = -0.33, p < 0.015). Participants with more severe symptoms in the CCSC-L over time had significantly lower HRQOL at the start of maintenance therapy (beta = -0.42, p < 0.005).

IMPLICATIONS FOR NURSING

Nurses are pivotal in providing management strategies to minimize symptom severity that may improve HRQOL.

Identifying clusters from multidimensional symptom trajectories in postpartum women

Depressive symptoms, stress, fatigue, and lack of sleep are often experienced by women in the perinatal period and are potential contributors to adverse maternal and child health outcomes. To explore the evolution of symptoms and identify groups of women of similar severity and patterns, we utilized clustering of multidimensional symptom trajectories. In an observational study data were collected from pregnant women in the 3rd trimester (36 weeks prenatal) and in the postnatal period at weeks 1 and 2 as well as at 1-, 2-, 3-, and 6-months postpartum. Depressive symptoms and maternal stress were measured using the Edinburg Postnatal Depression Scale (EPDS) and the Perceived Stress Scale (PSS), respectively. Self-reported duration of sleep and levels of fatigue also were collected. A model-based clustering approach was used to classify women by their symptom severity. The sample included 151 pregnant women with a 6-month follow-up. Two clusters were identified. Cluster 1 (n = 43) comprised women with fewer depressive symptoms, less perceived stress, lower likelihood of being fatigued, increased sleep duration and a negative trend in EPDS (β = -0.05, CI [-0.09, -0.001]), and PSS (β = -0.09, CI [-0.17, -0.01]). Cluster 2 (n = 108) comprised women with higher EPDS and PSS scores, increased likelihood of fatigue and lower sleep duration with a positive trend in sleep hours (β = -0.02, CI [0.01, 0.03]). Pro-inflammatory markers interleukin-6 and tumor necrosis factor-α were associated with longer sleep duration and fewer depressive symptoms, respectively. Using this methodology in maternal and child health research can potentially predict women's risk of developing severe symptoms and help clinicians provide timely interventions.

Factors Predisposing Terminally Ill Cancer Patients' Preferences for Distinct Patterns/States of Life-Sustaining Treatments Over Their Last Six Months

CONTEXT

High-quality end-of-life (EOL) care depends on thoroughly assessing terminally ill patients' preferences for EOL care and tailoring care to individual needs. Studies on predictors of EOL-care preferences were primarily cross-sectional and assessed preferences for multiple life-sustaining treatments (LSTs), making clinical applications difficult.

OBJECTIVE/METHODS

We examined factors predisposing cancer patients (N = 303) to specific LST-preference states (life-sustaining preferring, comfort preferring, uncertain, and nutrition preferring) derived from six LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and tube feeding) in patients' last six months by multilevel multinomial logistic regression.

RESULTS

Participants with accurate prognostic awareness and physician-patient EOL-care discussions were less likely to be in life-sustaining-preferring, uncertain, and nutrition-preferring states than in the comfort-preferring state. Better quality of life (QOL) and more depressive symptoms predisposed participants to be less likely to be in the uncertain than in the comfort-preferring state. Membership in the nutrition-preferring rather than the comfort-preferring state was significantly higher for participants in the state of moderate symptom distress with severe functional impairment than in the state of mild symptom distress with high functioning.

CONCLUSION

Accurate prognostic awareness, physician-patient EOL-care discussions, QOL, depressive symptoms, and symptom-functional states predisposed terminally ill cancer patients to distinct LST-preference states. Clinicians should cultivate patients' accurate prognostic awareness and facilitate EOL-care discussions to foster realistic expectations of LST efficacy at EOL. Clinicians should enhance patients' QOL to reduce uncertainty in EOL-care decision making and provide adequate psychological support to those with more depressive symptoms who prefer comfort care only.

A Scoping Review of Physical Therapy Interventions for Childhood Cancers

Purpose: Children and adolescents undergoing cancer treatment are at high risk of developing serious adverse effects, many of which respond to physical therapy (PT). This scoping review aims to (1) outline the state of the research involving PT for children with cancer and (2) identify gaps in the literature for future research. Method: From January 2002 to October 2017, we conducted electronic searches of three major databases and conference proceedings and checked references of screened articles. Results: A total of 12 articles were included in the review: one randomized controlled trial, one pilot randomized trial, five pilot or feasibility studies, two prospective studies, one case series, one case report, and one retrospective study. The research to date supports the feasibility of PT interventions for children with cancer, but the current evidence is not yet at a level to inform clinical practice. To better elucidate treatment protocols and assess their benefits for tumour-specific impairments, research needs to examine the effects of PT on specific impairments or for specific cancer tumour types. Conclusions: Collaborative efforts to conduct multi-centre trials are needed to further the field of paediatric oncology PT.

Family Caregivers' Subjective Caregiving Burden, Quality of Life, and Depressive Symptoms Are Associated With Terminally Ill Cancer Patients' Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in Their Last Six Months of Life

CONTEXT

Family caregivers constitute a critical component of the end-of-life care system with considerable cost to themselves. However, the joint association of terminally ill cancer patients' symptom distress and functional impairment with caregivers' subjective caregiving burden, quality of life (QOL), and depressive symptoms remains unknown.

OBJECTIVES/METHODS

We used multivariate hierarchical linear modeling to simultaneously evaluate associations between five distinct patterns of conjoint symptom distress and functional impairment (symptom-functional states) and subjective caregiving burden, QOL, and depressive symptoms in a convenience sample of 215 family caregiver-patient dyads. Data were collected every 2 to 4 weeks over patients' last 6 months.

RESULTS

Caregivers of patients in the worst symptom-functional states (States 3-5) reported worse subjective caregiving burden and depressive symptoms than those in the best two states, but the three outcomes did not differ between caregivers of patients in State 3 and States 4-5. Caregivers of patients in State 5 endured worse subjective caregiving burden and QOL than those in State 4. Caregivers of patients in State 4 suffered worse subjective caregiving burden and depressive symptoms but comparable QOL to those in State 2.

CONCLUSION

Patients' five distinct, conjoint symptom-functional states were significantly and differentially associated with their caregivers' worse subjective caregiving burden, QOL, and depressive symptoms while caring for patients over their last 6 months.

What Is the Amount of Visual Field Loss Associated With Disability in Glaucoma?

PURPOSE

To propose a new methodology for classifying patient-reported outcomes in glaucoma and for quantifying the amount of visual field damage associated with disability in the disease.

DESIGN

Cross-sectional study.

METHODS

A total of 263 patients with glaucoma were included. Vision-related disability was assessed by the National Eye Institute Visual Function Questionnaire (NEI VFQ-25). A latent class analysis (LCA) model was applied to analyze NEI VFQ-25 data and patients were divided into mutually exclusive classes according to their responses to the questionnaires. Differences in standard automated perimetry (SAP) mean deviation (MD) and integrated binocular mean sensitivity (MS) values between classes were investigated. The optimal number of classes was defined based on goodness-of-fit criteria, interpretability, and clinical utility.

RESULTS

The model with 2 classes, disabled and nondisabled, had the best fit with an entropy of 0.965, indicating excellent separation of classes. The disabled group had 48 (18%) patients, whereas 215 (82%) patients were classified as nondisabled. The average MD of the better eye in the disabled group was -5.98 dB vs -2.51 dB in the nondisabled group (P < .001). For the worse eye, corresponding values were -13.36 dB and -6.05 dB, respectively (P < .001).

CONCLUSION

Application of an LCA model allowed categorization of patient-reported outcomes and quantification of visual field levels associated with disability in glaucoma. A damage of approximately -6 dB for SAP MD, indicating relatively early visual field loss, may already be associated with significant disability if occurring in the better eye.

Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in the Last Year of Life Predict Terminally Ill Cancer Patients' Survival

CONTEXT/OBJECTIVES

Our study addressed important knowledge gaps about trajectories of distinct conjoint symptom-functional states, that is, patterns for different levels of combined symptom distress and functional impairment, over cancer patients' last year and their ability to predict survival.

METHODS

We identified distinct symptom-functional states and explored their changes over 317 terminally ill cancer patients' last year by a transition model using hidden Markov modeling. These distinct symptom-functional states' ability to predict current survival probability, measured in the previous assessment, was evaluated by multivariate Cox regression models.

RESULTS

We identified five worsening, conjoint symptom-functional states: 1) mild symptom distress with high functioning, 2) moderate symptom distress with mild functional impairment, 3) severe symptom distress with moderate functional impairment, 4) moderate symptom distress with severe functional impairment, and 5) profound symptom distress and functional impairment. Trajectories of these five states differed substantially by direction (downward vs. upward) and speed. Participants in States 1-4 had substantially lower risk of subsequent death than those in State 5 (adjusted hazard ratios [95% CI] ranged from 0.048 [0.028-0.081] to 0.434 [0.316-0.579]). The risk of subsequent death differed significantly between patients in any two distinct symptom-functional states, except between those in States 3 and 4.

CONCLUSION

Our identification of five distinct symptom-functional states and their unique transition patterns and prediction of mortality provides all stakeholders with guides for end-of-life care. Goals of end-of-life care should change toward palliative care and effective symptom management for patients with at least moderate symptom distress and substantial functional impairment.

A Longitudinal Study of PROMIS Pediatric Symptom Clusters in Children Undergoing Chemotherapy

CONTEXT

Children in treatment for cancer experience multiple, troubling, and interrelated symptoms. Analyzing the interrelatedness of symptoms and how that changes during treatment could yield clinically relevant patient profiles to guide patient care.

OBJECTIVES

The aims were to identify pediatric profiles with respect to Patient-Reported Outcomes Measurement Information System^® (PROMIS^®; U.S. Department of Health and Human Services, National Institutes of Health) symptom measures, changes in profile status throughout a chemotherapy cycle, and if a baseline single-item fatigue measure could significantly predict symptom profile status and its changes.

METHODS

In a longitudinal, single-site, three data point (T1, T2, and T3) design, children between 8 and 18 years completed the PROMIS Pediatric short form measures for fatigue, depression, anxiety, and pain and one fatigue item from the Symptom Distress Scale. Latent profile analysis and latent transition analysis were conducted.

RESULTS

About 96 children participated; 58.3% were between 13 and 18 years, and 54.2% were males. Two latent profiles (less severe symptoms and severe symptoms) were identified. The prevalence of the severe symptom profile remained relatively unchanged from T1 to T2 but significantly declined at T3. The baseline single-item fatigue score significantly predicted the child's profile membership and its changes.

CONCLUSION

Children experiencing troubling symptoms during cancer treatment are heterogeneous. With respect to the PROMIS symptom measures, two a priori unknown distinct latent profiles of patients were identified in a course of chemotherapy, and the transitions in the profile status were significantly predicted by a baseline single-item fatigue measure.