Communication in pediatric oncology: State of the field and research agenda

Communicating with families of young people with hard-to-treat cancers: Healthcare professionals' perspectives on challenges, skills, and training

OBJECTIVES

Hard-to-treat childhood cancers are those where standard treatment options do not exist and the prognosis is poor. Healthcare professionals (HCPs) are responsible for communicating with families about prognosis and complex experimental treatments. We aimed to identify HCPs' key challenges and skills required when communicating with families about hard-to-treat cancers and their perceptions of communication-related training.

METHODS

We interviewed Australian HCPs who had direct responsibilities in managing children/adolescents with hard-to-treat cancer within the past 24 months. Interviews were analyzed using qualitative content analysis.

RESULTS

We interviewed 10 oncologists, 7 nurses, and 3 social workers. HCPs identified several challenges for communication with families including: balancing information provision while maintaining realistic hope; managing their own uncertainty; and nurses and social workers being underutilized during conversations with families, despite widespread preferences for multidisciplinary teamwork. HCPs perceived that making themselves available to families, empowering them to ask questions, and repeating information helped to establish and maintain trusting relationships with families. Half the HCPs reported receiving no formal training for communicating prognosis and treatment options with families of children with hard-to-treat cancers. Nurses, social workers, and less experienced oncologists supported the development of communication training resources, more so than more experienced oncologists.

SIGNIFICANCE OF RESULTS

Resources are needed which support HCPs to communicate with families of children with hard-to-treat cancers. Such resources may be particularly beneficial for junior oncologists and other HCPs during their training, and they should aim to prepare them for common challenges and foster greater multidisciplinary collaboration.

Stress Factors for the Paediatric and Adult Palliative Care Multidisciplinary Team and Workplace Wellbeing Solutions

BACKGROUND

Palliative care is a challenging specialty, especially when it comes to caring for children with serious life-limiting conditions and supporting their families. Workers face significant challenges and experience major impacts on their wellbeing. We conducted a qualitative study to understand the sources of stress in the palliative care team, their work expectations, and how they can cope with the demands.

METHODS

We used an online questionnaire about the causes of stress, the impact of the COVID-19 pandemic and the ways in which support is needed in the workplace.

RESULTS

Of the 56 palliative care professionals who participated in the survey, 57.1% considered the main causes of stress to be high workload, difficult emotional burdens (55.4%) affecting their outlook on life (61.2%), the death of patients (46.4%), and communication with patients' families (26.8%). The COVID-19 pandemic increased stress levels for the majority of respondents (89.3%). The need for specialised training (53.6%), support groups, psychological counselling and adapted organisational policies was highlighted.

CONCLUSIONS

The study demonstrates the importance of understanding the needs of both paediatric and adult palliative care staff in order to provide optimal care and support their balance in this demanding area of the healthcare system.

Factors Associated With Transitions to Adult Care Among Adolescents and Young Adults With Medical Complexity

Introduction: Thanks to advances in healthcare and technology, adolescents with medical complexity (AMC) and life-threatening conditions are living longer lives and may be expected to transition to adult health care. Yet, current systems and policies of transition care may not reflect their needs, those of their family, or the impact of social determinants of health. The goal of this study was to describe the relationship between social determinants of health and high-quality transition care. Methods: Retrospective cohort study of the 2019-2020 National Survey of Children's Health. The main outcome variable was any support for transition to adult health care. Independent variables were based on a social determinants of health framework. Weighted logistic regression was used to evaluate the association between social determinants and any support for transition to adult health care. Results: Final weighted sample included 444,915 AMC. AMC were distributed across income levels, most commonly lived in the South, and in supportive, resilient communities. More than 50% experienced adverse childhood events and less than 50% had adequate insurance. Less than one third received any transition support from providers; those who did reported time alone with the provider or active management. Social determinants related to missed days of school, community support/family context, and poverty were associated with both receipt and absence of transition care. Conclusion: AMC and their families navigate complex environments and associated stressors. Social determinants of health, particularly economic, community/social, and healthcare exert significant and nuanced influence. Such impacts should be incorporated into transition care.

Developing and evaluating a cancer communication picture book for children, families, and health care professionals: A mixed-methods feasibility study

Objective

Effective communication about cancer with children is a significant challenge for healthcare professionals and families. This study aimed to create a picture book as a tool for facilitating communication about cancer and to assess its feasibility. It also demonstrated the use of mixed methods and convergent designs for intervention development.

Methods

The study included healthcare professionals (n = 14), children without cancer (aged 4-8 years; n = 21) and their families (n = 18), as well as children with various types of cancer, undergoing maintenance therapy or follow-up (aged 4-12 years; n = 3) and their families (n = 3). Quantitative and qualitative data were separately analyzed, and meta-inferences were made using a joint display. The picture book was refined based on feedback from healthcare professionals, and a similar iterative process was carried out with children and their families.

Results

Over 85% of the participants considered the picture book, along with a side book, feasible. The picture book was found to be helpful for discussing the topic of cancer with children. It also significantly improved the knowledge of children without cancer (P < 0.01). Most children expressed interest in reading it and believed it was useful for talking to others about cancer. However, some concerns were raised regarding the context and expressions in the picture book.

Conclusions

This study successfully assessed the feasibility of the developed picture book using a mixed methods approach, offering valuable insights into its implementation and refinement. Further research is needed to evaluate the effectiveness of its use and gather user feedback.

A Systematic Review of Experimental Studies on the Impact of Empowerment-Based Interventions on Child and Parent Outcomes in the Pediatric Oncology Setting

Background

Cancer has an impact not only on children but also on parents. Parents play the most crucial role in cancer's symptom control and management. However, as the primary caretakers, parents are frequently unprepared or engage in inappropriate behavior when caring for their children. Increasing parents' role through empowerment is critical in pediatric cancer care.

Purpose

This systematic review aimed to identify the effect of empowerment interventions on parent and child outcomes in pediatric oncology.

Methods

In this review, studies published between 2013 and 2023 in The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, Medline, and Scopus databases were identified using a search strategy to identify relevant studies that determined empowerment-based intervention for parents in the pediatric oncology. This study used the Joanna Briggs Institute (JBI) critical appraisal tools to assess the quality of the studies. This systematic review followed the recommended reporting items for systematic reviews and meta-analysis (PRISMA) standards.

Results

Seven studies met the inclusion criteria: four randomized and three non-randomized experimental studies. Children range in age from 1-14 years. The intervention is mostly delivered through face-to-face learning using booklets or modules as a learning tool. The intervention is delivered in 2-6 sessions over 1-8 weeks, lasting 20-45 minutes each. In most studies, the interventions positively affect parents' outcomes (knowledge, caring behavior, distress, care burden, quality of life) and children's outcomes (oral mucositis, gastrointestinal complications, quality of life). The intervention, however, has no significant effect on the coping style. Barriers to implementation include parent-nurse commitment, the retention of parent-nurse participation, and more time spent to provide interventions.

Conclusion

Our study highlights that empowerment-based interventions positively impact parents and children. These findings suggest that an empowerment-based intervention should be developed to provide better cancer care for a parent and their children.

Systematic Review Registration

PROSPERO registration number was CRD42023422834.

Designing and validating novel communication measures for pediatric, adolescent, and young adult oncology care and research: The PedCOM measures

BACKGROUND

High-quality communication in pediatric and adolescent cancer is the standard of care. Yet, we lack pediatric-specific communication measures. We designed self-report and caregiver-report communication measures for use in pediatric oncology settings.

METHODS

We recruited adolescent and young adults (AYAs; 12-24 years) with cancer and parents of children and AYAs between 1 month post-diagnosis and 2 months after completing treatment. Participants completed measures including 58 questions addressing eight previously characterized communication functions. For each function, we conducted factor analysis, and assessed reliability and construct validity. Based on psychometric properties, we created final long-form (31 items) and short-form (eight items) communication measures (PedCOM) for both self- and caregiver-report.

RESULTS

Participants included 200 parents and 88 AYAs. The final 31-item and eight-item PedCOM measures for parents and AYAs demonstrated good unidimensional model fit. Each communication function (e.g., building relationships) demonstrated high reliability, coefficient alphas ranged from .83 to .93 for parents and .85 to .93 for AYAs. The overall 31-item and eight-item PedCOM measures also demonstrated high reliability (alphas >.9). For construct validity, PedCOM-Parent-31 and PedCOM-Parent-8 correlated positively with satisfaction with care, trust, emotional self-management, and decisional satisfaction, and negatively with anxiety and caregiver burden. PedCOM-AYA-31 and PedCOM-AYA-8 correlated positively with satisfaction with care, trust, emotional self-management, symptoms self-management, and decisional satisfaction, and negatively with anxiety.

DISCUSSION

We developed valid and reliable measures of communication functions for parents and AYAs with cancer. These measures can support organizations and stakeholder groups that are striving to improve the quality of cancer care.

Parents' and adolescents' perspectives and understanding of information about childhood cancer precision medicine

BACKGROUND

Precision medicine is projected to become integral to childhood cancer care. As such, it is essential to support families to understand what precision medicine entails.

METHODS

A total of 182 parents and 23 adolescent patients participating in Precision Medicine for Children with Cancer (PRISM), an Australian precision medicine clinical trial for high-risk childhood cancer, completed questionnaires after study enrollment (time 0 [T0]). Of the parents, 108 completed a questionnaire and 45 completed an interview following return of precision medicine results (time 1 [T1]). We analyzed the mixed-methods data comprising measures exploring families' perceptions and understanding of PRISM's participant information sheet and consent form (PISCF), and factors associated with understanding.

RESULTS

Most parents were satisfied with the PISCF, rating it as at least "somewhat" clearly presented (n = 160/175; 91%) and informative (n = 158/175; 90%). Many suggested improvements including the use of clearer language and a more visually engaging format. Parents' actual understanding of precision medicine was low on average, but scores improved between T0 and T1 (55.8/100-60.0/100; p = .012). Parents from culturally and/or linguistically diverse backgrounds (n = 42/177; 25%) had lower actual understanding scores than those from a Western/European background whose first language was English (p = .010). There was little correlation between parents' perceived and actual understanding scores (p = .794; Pearson correlation -0.020; 95% CI, -0.169 to 0.116). Most adolescent patients read the PISCF either "briefly" or "not at all" (70%) and had a perceived understanding score of 63.6/100 on average.

CONCLUSIONS

Our study revealed gaps in families' understanding of childhood cancer precision medicine. We highlighted areas for potential intervention such as through targeted information resources.

PLAIN LANGUAGE SUMMARY

Precision medicine is projected to become part of the standard of care for children with cancer. Precision medicine aims to give the right treatment to the right patient and involves several complex techniques, many of which may be challenging to understand. Our study analyzed questionnaire and interview data from parents and adolescent patients enrolled in an Australian precision medicine trial. Findings revealed gaps in families' understanding of childhood cancer precision medicine. Drawing on parents' suggestions and the literature, we make brief recommendations about improving information provision to families, such as through targeted information resources.

"I won't get to live my life the way I planned it": A qualitative analysis of the experiences of adolescents and young adults with advanced cancer

BACKGROUND

Individuals with advanced cancer face complex challenges, including prognostic uncertainty and evolving goals of care. Despite the unique psychosocial support needs of adolescents and young adults (AYAs), few studies have specifically examined AYA perspectives of and experiences with advanced cancer. The objective of this study was to describe the experience, needs, and perspectives of pediatric AYAs with advanced cancer.

PROCEDURE

We invited English-speaking AYAs (age 14-25 years) who were receiving treatment for advanced cancer at our single tertiary pediatric cancer center to participate in semi-structured interviews. We used directed content analysis for codebook development and then applied in-depth thematic network analysis to describe their perspectives and experiences with advanced cancer.

RESULTS

A total of 32 AYAs (86% of approached) completed interviews. A slight majority were male (59%) and non-Hispanic White (56%). Most were diagnosed with leukemia/lymphoma, had recurrent disease (84%), and were a mean 53 months from initial diagnosis. Organizing themes of "not being able to beat this," "not wanting to miss out," and "living each day" generated the global theme "do I have a future?" "Making tough medical decisions," "adjusting life/plans/perspectives," and "decisions about dying" were organized into the global theme "those decisions … were really hard." "Feeling like there is no one to talk to," "being away from family and friends," and "feeling like a burden" generated the global theme "I felt very alone."

CONCLUSIONS

Pediatric AYAs with advanced cancer describe unique challenges. Psychological support interventions are needed to empower AYAs to navigate difficult decisions and to cope with isolation.

Prognosis Communication in Pediatric Oncology: A Systematic Review

BACKGROUND

While communication plays an important role in medicine, it also often represents a challenge when the topic at hand is the prognosis of a high-risk condition. When it comes to pediatric oncology, the challenge becomes even greater for physicians who have to adapt their discourse to both the child and their family.

METHODS

Following the PRISMA guidelines, an advanced search on PubMed, Scopus and the Cochrane Library was performed, from 1 January 2017 to 31 October 2022. Demographic data for caregivers, pediatric patients and physicians were extracted, as well as diagnosis, prognosis, presence at discussion, emotional states and impact on life, trust, decision roles, communication quality and other outcomes.

RESULTS

A total of 21 articles were analyzed. Most studies (17) focused on caregivers, while only seven and five studies were focused on children and physicians, respectively. Most parents reported high trust in their physicians (73.01%), taking the leading role in decision making (48%), moderate distress levels (46.68%), a strong desire for more information (78.64%), receiving high-quality information (56.71%) and communication (52.73%). Most children were not present at discussions (63.98%); however, their desire to know more was expressed in three studies. Moreover, only two studies observed children being involved in decision making. Most physicians had less than 20 years of experience (55.02%) and reported the use of both words and statistics (47.3%) as a communication method.

CONCLUSIONS

Communication research is focused more on caregivers, yet children may understand more than they seem capable of and want to be included in the conversation. More studies should focus on and quantify the opinions of children and their physicians. In order to improve the quality of communication, healthcare workers should receive professional training.

[The announcement of treatment resistance in pediatric oncology: Understanding parents' experiences and influencing factors with a mixed methodology]

OBJECTIVE

The announcement of a resistance to treatment in pediatric oncology occurs within the framework of an established parent-pediatrician relationship. The aim of this study was to understand the parents' experience of this announcement and the relational and communicational factors likely to impact it.

METHOD

A mixed-methods study was conducted in a pediatric oncology department with 15 parents of a child with treatment-resistant cancer, with an average age of 40.8years. The parents completed three questionnaires to assess their anxiety and depression (HADS) and their information needs (EORTC - QLQ Info 25 and PTPQ). Semi-structured interviews were conducted and a content analysis was performed.

RESULTS

The majority of parents have "suspected" or "proven" anxiety and/or depressive disorders. The experience of this announcement was influenced by the quality of the parent-pediatrician relationship, the perceived quality of the management, the anticipation of the announcement, the context of the announcement, and the experience of previous announcements. The parents interviewed were very satisfied with the informational exchanges. This satisfaction was underpinned by honest communication and by the responsiveness and availability of the pediatricians.

DISCUSSION

The establishment of a relationship of trust between the family and the pediatrician throughout the course of care plays a major role in the parents' experience of the announcement of resistance to treatment.

The 2023-2026 Hospice and Palliative Nurses Association Research Agenda

The Hospice and Palliative Nursing Association established the triannual research agenda to ( a ) provide focus for researchers to conduct meaningful scientific and quality improvement initiatives and inform evidence-based practice, ( b ) guide organizational funding, and ( c ) illustrate to other stakeholders the importance of nursing research foci. HPNA Research Agendas are developed to give direction for future research to continue advancing expert care in serious illness and ensure equitable delivery of hospice and palliative care.

Managing Prognosis in Precision Medicine: Utility, Imagination, and Communication

Research on how physicians predict and communicate prognosis focuses primarily on end-of-life care. Unsurprisingly, as genomic technology gains traction as a prognostic tool, the focus has also been on terminality, with research focused on how genetic results may be used to terminate pregnancies or redirect care towards palliation for neonates. However, genomic results also have powerful impacts on how patients who live prepare for their futures. Genomic testing provides broad-reaching and early—albeit complex, uncertain, and shifting—prognostic information. In this essay, we argue that as genomic testing occurs earlier and increasingly in a screening context, researchers and clinicians must strive to understand and manage the prognostic implications of results. While our understanding of the psychosocial and communicational aspects of prognosis in symptomatic populations is incomplete, it has progressed further than our understanding in a screening context and therefore provides useful lessons and feasible opportunities for further research. By providing an interdisciplinary and inter-specialty perspective on the psychosocial and communicational aspects of prognosis in genetics, we discuss prognostication with respect to genetics from the neonatal period through adulthood, highlighting medical specialties and patient populations that are especially informative for considering the longitudinal management of prognostic information in genomic medicine.

Communication with parents and young adult patients affected by complex vascular malformations

BACKGROUND

Vascular malformations (VMs) are rare disorders that can cause pain, coagulopathy, disfigurement, asymmetric growth, and disability. Families affected by complex VMs experience misdiagnosis, limited trustworthy information, delayed or inappropriate treatments, and persistent uncertainty. However, more research is needed to understand the communication experiences of these families during clinical encounters.

PROCEDURE

We performed semi-structured interviews with 34 parents of children with VMs (18% men; 82% women; mean age = 41 years) and 25 young adults with VMs (8% men; 88% women; 4% nonbinary; mean age = 29) living in the United States, recruited through four patient advocacy groups. We performed thematic analysis to assess communication experiences, using a previously developed functional model of communication in pediatric oncology as an a priori framework.

RESULTS

We identified evidence of eight communication functions previously identified in pediatric oncology: building relationships, exchanging information, enabling self-management, managing uncertainty, responding to emotions, making decisions, providing validation, and supporting hope. Uncertainty was pervasive through participants' experiences and seemed to influence the fulfillment of communication functions. Fewer participants seemed to highlight the role of clinicians in responding to emotions or supporting hope, compared to other communication functions.

CONCLUSION

Interviews with parents and young adult patients with VMs provided evidence for eight functions of communication. While exchanging information and building relationships were described by nearly every respondent, supporting hope and responding to emotions were mentioned less frequently. Future studies should develop patient-reported communication measures to quantify the fulfillment of these functions and to identify areas of communication in need of intervention.

Health-related Internet Use by Caregivers of Children and Adolescents With Cancer

Caregivers of children with cancer have needs for information and social support related to their child's diagnosis. The internet serves as a resource to help meet these needs. There is growing interest in health-related internet use (HRIU) by caregivers of pediatric patients as the internet rapidly evolves. This survey study describes patterns of internet use by caregivers of children with cancer and examines associations between socioeconomic status and internet use. 114 caregivers participated between 2014 and 2016. The majority (82%) reported frequent general internet use, but fewer (25-54%) reported frequent HRIU. Very few respondents (4%) reported difficulty accessing the internet; those reporting difficulty were more likely to report lower income, public/no insurance, and lower educational attainment. There were no consistent associations between socioeconomic status variables and frequency of HRIU. Less than half (43%) of caregivers reported that their internet use raised questions that they discussed or planned to discuss with the child's nurse or doctor, and only 4% reported having changed medical decisions based on information found on the internet. We conclude that caregivers of children with cancer engage in HRIU, and this is an area for improvement in oncology anticipatory guidance and family-centered care.

"There's no playbook for when your kid has cancer": Desired elements of an electronic resource to support pediatric cancer communication

INTRODUCTION

Acute lymphoblastic leukemia (ALL), the most common childhood malignancy, has a relatively favorable long-term prognosis. Yet the complexity of treatment and the emotionality of the diagnosis leave families feeling unprepared for many aspects of therapy. This qualitative study aimed to identify desired elements and format of a communication resource to support patients and families facing a diagnosis of ALL.

METHODS

Semi-structured interviews of 12 parents of children receiving ALL treatment, 10 parents of survivors of ALL, and eight adolescent and young adult (AYA) survivors of ALL were conducted between February and June 2021. The interviews focused on communication experiences throughout treatment and identified domains to be addressed in a resource in development.

RESULTS

All participants supported the development of an interactive, electronic health (eHealth) resource to help navigate ALL treatment. They felt a website would be helpful in addressing information gaps and mitigating pervasive feelings of overwhelm. Participants specifically sought: (a) information resources to address feelings of cognitive overload; (b) practical tips to help navigate logistical challenges; (c) clear depictions of treatment choices and trajectories to facilitate decision-making; and (d) additional psychosocial resources and support. Two overarching themes that families felt should be interwoven throughout the eHealth resource were connections with other patients/families and extra support at transitions between phases of treatment.

CONCLUSIONS

A new diagnosis of ALL and its treatment are extremely overwhelming. Patients and families unanimously supported an eHealth resource to provide additional information and connect them with emotional support, starting at diagnosis and extending throughout treatment.

Navigating prognostic communication when children with poor-prognosis cancer experience prolonged disease stability

BACKGROUND

Most pediatric patients and families want clear prognostic information across the illness course. Yet when children with poor-prognosis cancer experience prolonged disease stability, uncertainty can make communication particularly challenging. In this study, we aimed to (i) assess how frequently oncologists communicate about prognosis when high-risk cancer does not progress, and (ii) describe prognostic communication patterns in the context of disease stability.

PATIENTS AND METHODS

In this prospective, longitudinal, mixed-methods study, we audio-recorded serial disease re-evaluation conversations between children with poor-prognosis cancer, their families, and their primary oncologists. For this secondary analysis, we conducted content analysis across serial conversations among 16 patient-parent-oncologist triads for whom the patient's disease remained stable over the 24-month study period.

RESULTS

Prognostic communication was absent in >50% of recorded conversations. Overall, it comprised only 4% of dialog time, nearly 90% of which was dialog about prognostic uncertainty; discussion of curability occurred infrequently. Three distinct patterns for prognostic communication emerged: (a) "Don't know" statements, avoiding or deferring prognostication; (b) "Worry" statements, preparing families for possible future disease progression; and (c) relief-caveat statements, celebrating disease stability while balancing positivity with caution.

CONCLUSIONS

Oncologists seldom talked about prognosis with high-risk patients during periods of disease stability; yet when they did, they used thoughtful and effective strategies to prepare families for possible future disease progression. Further research is needed to better understand if, how, and when patients and families with stable disease who are high risk for future disease progression prefer to receive information about prognosis.

Fifteen years of shared care for paediatric oncology, haematology and palliative patients across Queensland: The role of Regional Case Managers

OBJECTIVE

A shared care model was implemented in 2006 in Queensland to facilitate paediatric oncology, haematology and palliative care patients receiving care as close to home as possible. Following initial diagnosis, care planning and treatment at the tertiary children's hospital, appropriate local care was coordinated by Regional Case Managers (RCMs) established at each of 10 Shared Care Units (SCUs). This enabled safe and quality regional care supported by a statewide network providing clinical governance and education. This paper examines learnings from 15 years of this shared care.

SETTING

Ten hospitals throughout Queensland facilitated a statewide model of shared care for paediatric oncology, haematology and palliative care patients, supported by a tertiary hub in Brisbane.

PARTICIPANTS

Regional Case Managers in Shared Care Units and their supporting staff.

DESIGN

Staff from SCUs were surveyed and focus group interviews conducted.

RESULTS

The paper reviews the attributes, knowledge and experience required for RCMs. Standards of care were supported through education workshops, clinical placements, chemotherapy credentialing, guidelines and standards. RCMs facilitated communication and information sharing with the tertiary centre, advocated for their cohort of patients locally and streamlined and supported the family's experience of care.

CONCLUSION

The RCM role provided invaluable clinical leadership for the care of paediatric oncology, haematology and palliative patients across Queensland. As new treatments evolve, the expertise and coordination provided by the RCMs will be even more critical. Achieving high-quality shared care outcomes is underpinned by the RCMs drive to achieve statewide safety and support for this cohort of children.

Family-centered communication in pediatric sickle cell disease

BACKGROUND

Individuals with sickle cell disease (SCD) experience systemic barriers in accessing high-quality care. Research suggests that patient/family-provider relationships are an important indicator of healthcare quality and can influence disease self-management and outcomes. The Patient Centered Communication (PCC) framework holds that patient/family-centered communication (e.g., eliciting, understanding, and validating patients' perspectives within their unique psychosocial contexts) contributes to improved family-provider relationships, as well as self-efficacy for disease management, adherence, and health outcomes. While the PCC framework has been useful in guiding the evaluation of patient/family-provider communication in other pediatric populations, it has not yet been applied in the context of pediatric SCD. This study aimed to use this framework to examine patient and family perceptions of communication with pediatric SCD healthcare providers.

PROCEDURE

Total 17 caregivers (82% mothers, 94% Black/African American) and eight patients (62% female, aged 13-19 years, M = 16.50) completed semi-structured interviews. The PCC framework informed the development of a preliminary codebook. Thematic content analysis summarized family perspectives regarding communication with providers.

RESULTS

For youth with SCD and their caregivers, specific themes related to family-centered communication included: reducing patient/family distress, supporting disease self-management efforts, facilitating information exchange and decision-making, and fostering positive and trusting relationships with providers.

CONCLUSIONS

This study helps to address gaps in the literature related to patient/family-provider communication within pediatric SCD. Results underscore the importance of patient- and family-centered communication across pediatric SCD care. These findings can inform future research and clinical care initiatives to improve patient/family-provider interactions and health outcomes for this underserved population.

Oncologist approaches to communicating uncertain disease status in pediatric cancer: a qualitative study

Background

Most patients with cancer and their caregivers desire honest, clear prognostic communication, yet oncologists often disclose prognosis inconsistently. Prognostic communication becomes even more challenging when disease progression is unclear or equivocal. Presently, oncologist approaches for discussing uncertain disease findings are poorly understood.

Methods

In this prospective, longitudinal study, we audio-recorded serial disease reevaluation conversations between children with high-risk cancer, their families, and their primary oncologists over 24 months and conducted content analysis at recorded timepoints when oncologists categorized disease progression as equivocal.

Results

Of the 265 medical discussions recorded across the illness course for 33 patient-parent dyads, a total of 40 recorded discussions took place at equivocal timepoints, comprising > 500 min of medical dialogue. Prognosis talk encompassed < 3% of dialogue and was absent in nearly half of equivocal discussions (17/40, 42.5%). Curability statements were identified in only two conversations. Inductive content analysis of dialogue revealed four distinct patterns for communicating equivocal disease status: (1) up-front reassurance, (2) softening the message, (3) describing possible disease progression without interpretation, (4) expressing uncertainty without discussing the bigger picture.

Conclusion

Oncologists rarely discuss prognosis with children with high-risk cancer and their families at timepoints when disease progression is not definitive. Formal guidance is needed to better support oncologists in navigating uncertainty while sharing honest, person- and family-centered information about prognosis.

Supplementary information

The online version contains supplementary material available at 10.1186/s12885-022-10190-6.

How do you tell parents whose child has cancer that the treatment has failed: A qualitative study on pediatric oncologists' practices

Announcing drug resistance is complex for pediatric oncologists because they have to provide a substantial amount of medical information while taking a major emotional impact on the parents into account. This study aimed to understand how these announcements are currently conducted and how pediatric oncologists adapt the information given to each family in situations where there is resistance to treatment. Semi-structured interviews were conducted with 15 pediatric oncologists (66.7% women, aged 44.7 years on average). Interviews were audio-recorded and a thematic content analysis was conducted. Announcements of drug resistance are stressful, as they are not well codified, difficult to anticipate, and pediatric oncologists have many issues about how best to behave and which words to choose. The majority of them believe that the severity, or even the incurability of the disease, and the offer of a therapeutic alternative are essential components of the information to pass on. Pediatric oncologists describe how they adapt their communication to each family, particularly in relation to parents' questions, and also to their reactions during the announcement. They also need to adapt to the prior acquaintance they may have with the families, and to previous exchanges. Finally, pediatric oncologists acknowledge their subjectivity when estimating the parents need in terms of information. Understanding the course of these announcements gives us another point of view at the issues involved in this announcement. Proposals to support pediatric oncologists in this difficult moment can be suggested: communication support tool, work in pairs and discussion group.

[Announcing treatment resistance in pediatric oncology: A qualitative study of nurses' experiences]

INTRODUCTION

The announcement of treatment resistance is a key moment in the management of children treated for cancer. Although nurses are present at various stages of this announcement, few studies have examined their role and experience. This study proposes to enhance understanding of the experience of nurses at this time of the pediatric cancer trajectory in France.

METHOD

A qualitative study was conducted in two pediatric oncology departments. Semi-structured research interviews were conducted with seven pediatric nurses (five women) with an average age of 36.9 years.

RESULTS

Nurses report not being systematically present during announcements of treatment resistance but being present with the families before and after these announcements. Nurses described their role at this point in the management process as multifaceted. The emotional burden associated with these announcements is significant: nurses must manage their own emotions when faced with the discovery of resistance to treatment, those of the families, and must often answer difficult questions about the prognosis or end of life. In this context, teamwork is an important support.

DISCUSSION

Better awareness and recognition of the role of nurses and the associated emotional burden would enable them to fully carry out their missions.

Cancer treatment decision-making among parents of paediatric oncology patients in Guatemala: a mixed-methods study

OBJECTIVES

To examine treatment decision-making priorities and experiences among parents of children with cancer in Guatemala.

SETTING

This study was conducted at Guatemala's National Pediatric Cancer Center in Guatemala City.

PARTICIPANTS

Spanish-speaking parents of paediatric patients (≤18 years of age) diagnosed with any form of cancer within the 8 weeks prior to study enrolment. The quantitative portion of this study included 100 parent participants; the qualitative component included 20 parents. Most participants were Catholic or Evangelical Spanish-speaking mothers.

OUTCOMES

Priorities and experiences of cancer treatment decision-making including decision-making role and experienced regret.

RESULTS

A range of paediatric ages and cancer diagnoses were included. Most Guatemalan parents surveyed (70%) made decisions about their child's cancer together and almost all (94%) without input from their community. Surveyed parents predominately preferred shared decision-making with their child's oncologist (76%), however 69% agreed it was best not to be provided with many options. Two-thirds of surveyed parents (65%) held their preferred role in decision-making, with fathers more likely to hold their preferred role than mothers (p=0.02). A small number of parents (11%) experienced heightened decisional regret, which did not correlate with socio-demographic characteristics or preferred decision-making role. Qualitative results supported quantitative findings, demonstrating a decision-making process that emphasised trust and honesty.

CONCLUSIONS

Guatemalan parents preferred to make decisions with their medical team and appreciated providers who were honest and inclusive, but directive about decisions. This study reinforces the importance of the provider-parent relationship and encourages clinicians in all settings to ask about and honour each parent's desired role in decision-making.

Silence in Conversations About Advancing Pediatric Cancer

Background and Objectives

Skillful use of silence by clinicians can support patient-centered communication. However, what makes a period of silence feel meaningful is not well understood. This study aimed to characterize profound, skillful silences during difficult conversations between pediatric oncologists, children with advancing cancer, and their families.

Methods

We audio-recorded serial disease reevaluation discussions between pediatric oncologists, patients with high-risk cancer, and their families across 24 months or until death, whichever occurred first. Using an inductive process, we performed content analysis across all dialogue recorded at timepoints of disease progression to examine types of silence.

Results

17 patient-parent dyads with disease progression yielded 141 recorded conversations. Inductive coding yielded a layered typology of silence, including “intentional silence” (≥5 seconds), “profound silence” (≥5 seconds following receipt of difficult information, juxtaposed with statements of shared understanding, emotion, or enlightenment), and “stacked silence” (series of silences juxtaposed within dialogue). Intentional silence lasting ≥5 seconds occurred 238 times in 35/49 “bad news” recordings; nearly half (103/238) of these silences were identified as profound silence, in which silences appeared to create space for processing, allowed for questions to emerge, and synergized with empathic and affirmational statements. In most cases, profound silences involved the juxtaposition, or stacking, of multiple silences close together.

Conclusions

Profound silences occur often during conversations about advancing pediatric cancer and share distinct characteristics. Opportunities exist to teach clinicians to use profound and stacked silences with intention during difficult conversations as a fundamental aspect of communication.

The Family Talk Intervention in Pediatric Oncology: Ill Children's Descriptions of Feasibility and Potential Effects

Background: There are few scientifically evaluated psychosocial interventions in pediatric oncology, despite the needs for families. The family-based psychosocial intervention "The Family Talk Intervention" (FTI) has shown promising results in other care contexts and was therefore pilot-tested in pediatric oncology. In this study, we examined the experiences of participating in FTI from ill children's perspectives regarding feasibility and potential effects. Methods: This pilot study involved 26 families in pediatric oncology that had participated in FTI. The paper is focused on those ill children who answered surveys (n = 19) and/or participated in interviews (n = 11) when FTI had ended. Data were analyzed with descriptive statistics and thematic analysis. Results: For most ill children, FTI came at the right time, included a reasonable number of meetings, and the length of the meetings was appropriate. The children felt listened to and understood by the interventionists and almost all children reported that FTI had helped them in some way. The children's perceptions indicated that FTI improved communication within the family and strengthened family relations. Children reported that the parents and their siblings seemed to feel better after participation and became more understanding. Discussion: The findings of this pilot study indicated that a full-scale study could be valuable from the ill children's perspective, as FTI was reported as feasible and had positive effects. The findings showed that FTI gave families an opportunity to open up communication about the illness, adjust their behaviors, and strengthen family relationships. Trial registration: ClinicalTrials.gov Identifier NCT03650530.

The Impact of Hispanic Ethnicity and Language on Communication Among Young Adult Childhood Cancer Survivors, Parents, and Medical Providers and Cancer-Related Follow-Up Care

PURPOSE

The triad of communication between young adult childhood cancer survivors (YACCSs), their parents, and their medical providers is an important process in managing health care engagement. This study sought to identify communication patterns among this triad, factors associated with communication, and engagement of survivorship care.

METHODS

We analyzed data from Project Forward, a population-based study that surveyed YACCSs and their parents. YACCSs were on average age 20 years, 7 years from diagnosis, 50% female, and 57% identified as Hispanic/Latino (N = 160 dyads). Latent class analysis of nine communication indicators from parent and YACCS surveys identified distinct classes of communication between YACCSs, parents, and medical providers. Associations between resulting classes and YACCS/parent characteristics were examined using multinomial logistic regression. Logistic regression was used to examine the association between communication classes and cancer-related follow-up care.

RESULTS

Latent class analysis identified three classes of triad communication: (1) high health care-focused communication (37.5%), (2) high comprehensive communication (15.6%), and (3) overall low communication (46.9%). After adjusting for covariates, greater time since diagnosis was associated with reduced odds of membership in class 2 while dyads with Spanish-speaking Hispanic parents were more likely to be in class 2 (v class 3). Additionally, YACCSs who were in either of the high communication groups were more likely to have received recent follow-up care.

CONCLUSION

Examining language preference provides an important contextual understanding as we found Spanish-speaking Hispanic parents engaged in high communication, which was associated with cancer-related follow-up care. Yet, our results also support the need to enhance communication between this triad to improve outcomes.

"Some things are even worse than telling a child he is going to die": Pediatric oncology healthcare professionals perspectives on communicating with children about cancer and end of life

INTRODUCTION

This study explored pediatric oncology healthcare professionals' (HCPs) perspectives on direct communication with children with advanced disease about their disease, palliative care, and end-of-life (EOL) communication.

METHODS

Forty-six pediatric oncologists, nurses, psychosocial team members, and other HCPs from six hospital centers in Israel participated in semi-structured interviews. The Grounded Theory method was used. Data were analyzed line-by-line with codes and categories developed inductively from participants' narratives.

RESULTS

HCPs viewed communication about disease progression and EOL as vital because children were often aware of their prognosis, because lack of communication could lead to emotional distress, and because communication is a prerequisite for shared decision-making. HCPs identified several barriers for communication including HCP barriers (such as emotional strains, lack of training), parental barriers, guardianship law, and language and culture. HCPs also described strategies to promote EOL communication. Direct strategies include tailoring communication, allowing for silence, echoing children's questions, giving information gradually, and answering direct questions honestly. Indirect strategies included encouraging parents to talk to their children and teamwork with colleagues.

CONCLUSIONS

Open communication with children who have cancer is essential. Nevertheless, multiple barriers persist. The rising accessibility of online information calls for urgent training of HCPs in communication so that children will not turn to unmediated and potentially misleading information online in the absence of HCP communication. Evidence-based effective communication training modules and emotional support should be offered to HCPs. Knowledge about children's development, age-appropriate communication, and cultural sensitivity should be included in this training.

The announcement of treatment resistance from the pediatric oncologist's point of view: a qualitative study

Breaking bad news in pediatric oncology covers widely diverse clinical situations. The aim of this study was to highlight the specificities of the announcement of treatment resistance as perceived by pediatric oncologists, particularly in comparison with the disclosure of a cancer diagnosis. Semi-structured interviews were conducted in two pediatric oncology departments in France, with 15 pediatric oncologists (66.7% were women, aged 44.7 years on average). Interviews were audio-recorded and transcribed and a thematic content analysis was conducted. Most pediatric oncologists reported emotional difficulties in announcing treatment resistance. Some of them mentioned a personal need to accept resistance to treatment and to mourn the child's chances of recovery, and reported feelings of medical failure. This disclosure was considered more difficult than the announcement of the cancer diagnosis because it was associated with less optimism and more complex and fewer therapeutic options. The attachment bond created with families in the course of treatment seemed to exacerbate the emotional difficulties associated with this announcement. In conclusion, resistance to treatment has an impact on prognosis. It makes it more uncertain. Its announcement for pediatric oncologists is a turning point that affects their initial optimistic perspective. Their emotional difficulties are accentuated by the attachment that has been created with the families. Focusing on difficulties experienced by pediatricians could help to improve parent-pediatrician communication.

A proposed global framework for pediatric cancer communication research

The authors introduce a functional communication framework that can be used for global pediatric cancer research.

End of life communication among caregivers of children with cancer: A qualitative approach to understanding support desired by families

OBJECTIVES

Clinicians and parents are encouraged to have open and honest communication about end of life with children with cancer, yet there remains limited research in this area. We examined family communication and preferred forms of support among bereaved caregivers of children with cancer.

METHODS

Bereaved caregivers were recruited through a closed social media group to complete an online survey providing retrospective reports of end of life communication with their child and preferences for communication support from health-care providers. The sample of 131 participants was mostly female (77.9%; n = 102) with an average age of 49.15 (SD = 8.03) years. Deceased children were of an average age of 12.42 years (SD = 6.01) and nearly 90% of children died within 5 years of diagnosis.

RESULTS

Most caregivers spoke with their child about their prognosis (61.8%; n = 131) and death (66.7%; n = 99). Half of children (48%; n = 125) asked about death, particularly older children (51.9% ≥12 years; p = 0.03). Asking about dying was related to having conversations about prognosis (p ≤ 0.001) and death (p ≤ 0.001). Most caregivers (71.8%; n = 94) wanted support to talk to their children. Fewer wanted providers to speak to children directly (12.2%; n = 16) or to be present while caregivers spoke to the child (19.8%; n = 26). Several themes emerged from a content analysis of open-ended responses regarding preferences for provider support.

SIGNIFICANCE OF RESULTS

Most caregivers discussed issues pertaining to end of life irrespective of demographic or medical factors. Qualitative themes provide insight into support desired by families to help with these difficult conversations.

Designing Dynamic Interventions to Improve Adherence in Pediatric Long-Term Treatment - The Role of Perceived Value of the Physician by Primary Caregivers

Primary Caregivers are the fulcrum in the physician-caregiver-child triad. Existing literature discusses static multi-component interventions in detail. In long-term treatments, dynamic intervention design is needed as the environment and situations of the families are dynamic. The objectives of this study are (a) to identify the components of the primary caregiver's perception of the physician's value with reference to the effectiveness of consultation and relationships with the former and with the child; (b) to establish the role of this perception in designing dynamic interventions, and (c) to describe the perception's potential influence on adherence. A PRISMA, chronological, and morphological analysis of the literature is carried out about caregivers' adherence in the pediatric long-term treatment context. We define communication and consultation as the functional, whereas relationship as the emotional component of the caregiver's perception of the physician. We propose a theoretical model that incorporates intervention as an integral component of care. Adherence happens as a response to changing situations and hence fluctuates. Hence, a dynamic intervention design to benefit the child should be incorporated into care through the caregiver-physician bridge. Future research should explore how intervention needs change and the driving reasons for understanding the static and dynamic components of interventions.

Communication Priorities and Experiences of Caregivers of Children With Cancer in Guatemala

PURPOSE

Although > 90% of children with cancer live in low- and middle-income countries, little is known about communication priorities and experiences of families in these settings. We examined communication priorities and the quality of information exchange for Guatemalan caregivers of children with cancer during diagnostic communication.

METHODS

A cross-sectional survey including items used in pediatric communication studies from high-income countries and novel questions was verbally administered to 100 caregivers of children with cancer in Guatemala.

RESULTS

Guatemalan caregivers prioritized communication functions of exchanging information (99%), fostering healing relationships (98%), decision making (97%), enabling self-management (96%), and managing uncertainty (94%) over responding to emotions (66%) and cultural awareness (48%). Almost all caregivers wanted as many details as possible about their child's diagnosis and treatment (96%), likelihood of cure (99%), and late effects (97%). Only 67% were always given the information they needed without asking for it, and most caregivers sometimes (56%) or always (18%) had questions they wanted to discuss but did not. Approximately half of the caregivers (54%) correctly identified their child's diagnosis, primary site, disease extent (localized v metastatic), proposed treatment length, and treatment intent (curative v palliative). Caregivers of children with leukemia were more likely to correctly identify all attributes than those whose children had solid tumors (P < .001).

CONCLUSION

Caregivers in Guatemala prioritize many of the same aspects of diagnostic communication as parents in the United States, and experience similar challenges. Shared communication values offer potential for adaptation of communication interventions across settings with varying resources and diverse cultures.

Communication priorities and experiences of caregivers of children with cancer in Guatemala similar to those in US.

Parental views on communication between children and clinicians in pediatric oncology: a qualitative study

PURPOSE

Communication is essential to providing family-centered care in pediatric oncology. Previously, we developed a functional model of communication between parents and clinicians. Prior research has not examined the domains and purposes of communication between children and clinicians. We explored parental perspectives to begin understanding this communication.

METHODS

Secondary analysis of semi-structured interviews with 80 parents of children with cancer across 3 academic medical centers during treatment, survivorship, or bereavement. We employed semantic content analysis, using the functional model of parental communication as an a priori framework.

RESULTS

We identified 6 distinct functions of communication in child-clinician interactions: building relationships, promoting patient engagement, addressing emotions, exchanging information, managing uncertainty, and fostering hope. These communication functions were identified by parents of older (> 13 years old) and younger (< 12 years old) children, although the specific manifestations sometimes differed by age. Notably, age was not always an indicator of the child's communication needs. For example, some parents noted older children who did not want to discuss difficult topics, whereas other parent described younger children who wanted to know every detail. Two functions from the previous parental model of communication were absent from this analysis: supporting family self-management and making decisions.

CONCLUSION

Interviews with 80 parents provided evidence for 6 distinct functions of communication between children and clinicians. These functions apply to older and younger children, although specific manifestations might vary by age. This functional model provides a framework to guide clinicians' communication efforts and future communication research.

"Don't be afraid to speak up": Communication advice from parents and clinicians of children with cancer

BACKGROUND

Parents and clinicians of children with cancer can provide advice to improve communication that reflects lessons learned through experience. We aimed to identify categories of communication advice offered to parents of children with cancer from clinicians and other parents.

PROCEDURE

(1) Semi-structured interviews with 80 parents of children with cancer at three sites; (2) single-item, open-ended survey administered following 10 focus groups with 58 pediatric oncology clinicians at two sites. We asked participants for communication advice to parents, and analyzed responses using semantic content analysis.

RESULTS

Parents provided five categories of communication advice to other parents. Advocacy involved asking questions, communicating concerns, and speaking up for the child. Support involved pursuing self-care, seeking and accepting help, and identifying supportive communities. Managing information involved taking and organizing notes, remaining open to difficult truths, and avoiding inaccurate information. Partnership involved establishing open lines of communication with clinicians, making the family's values and priorities known, and trusting the clinical team. Engaging and supporting the child involved, understanding and incorporating the child's preferences and values, and creating a loving environment. Clinicians' advice addressed similar categories, although only one clinician described engaging and supporting the child. Furthermore, parental advice expanded beyond interactions with the clinical team, whereas clinician advice focused more on the role of clinicians.

CONCLUSIONS

Parents and clinicians of children with cancer provided five categories of communication advice. With these data, clinicians, health care organizations, support groups, and patient advocates could offer experience-informed advice to parents who are seeking information and support.

Qualitative Study of Pediatric Early Warning Systems' Impact on Interdisciplinary Communication in Two Pediatric Oncology Hospitals With Varying Resources

PURPOSE

Hospitalized pediatric oncology patients are at high risk of deterioration and require frequent interdisciplinary communication to deliver high-quality care. Pediatric early warning systems (PEWS) are used by hospitals to reduce deterioration, but it is unknown how these systems affect communication about patient care in high- and limited-resource pediatric oncology settings.

METHODS

This qualitative study included semistructured interviews describing PEWS and subsequent team communication at 2 pediatric cancer centers, 1 in the United States and 1 in Guatemala. Participants included nurses, and frontline and intensive care providers who experienced recent deterioration events. Transcripts were coded and analyzed inductively using MAXQDA software.

RESULTS

The study included 41 providers in Guatemala and 42 providers in the United States (33 nurses, 30 ward providers, and 20 pediatric intensive care providers). Major themes identified include “hierarchy,” “empowerment,” “quality and method of communication,” and “trigger.” All providers described underlying medical hierarchies affecting the quality of communication regarding patient deterioration events and identified PEWS as empowering. Participants from the United States described the algorithmic approach to care and technology associated with PEWS contributing to impaired clinical judgement and a lack of communication. In both settings, PEWS sparked interdisciplinary communication and inspired action.

CONCLUSION

PEWS enhance interdisciplinary communication in high- and limited-resource study settings by empowering bedside providers. Traditional hierarchies contributed to negative communication and, in well-resourced settings, technology and automation resulted in lack of communication. Understanding contextual elements is integral to optimizing PEWS and improving pediatric oncology outcomes in hospitals of all resource levels.

[Palliative care in hematopoietic stem-cell transplanted patients: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

Allogeneic hematopoietic cell transplantation (allo-HCT), the only curative therapy for numerous hematological malignancies, carries a significant risk of morbidity and mortality. The patients and families' expectations regarding the procedure, the prognosis uncertainties, as well as the existence of potential new therapeutic possibilities, lead to frequent use of intensive care. Even though the transplant physicians are highly skilled in acute care, their knowledge of palliative approach is limited, making the use of palliative care insufficient and often late. By promoting reflection on the proportionality of care and the patients' quality of life, palliative care may contribute to the allo-HCT patients management. Nevertheless, obstacles to this approach remain. The objective of this work is to propose recommendations to promote the implementation of palliative care into transplant units.

Prognostic Communication Between Oncologists and Parents of Children With Advanced Cancer

BACKGROUND AND OBJECTIVES

Parents of children with cancer perceive deficits in quality of prognostic communication. How oncologists disclose information about disease progression and incurability and how prognostic communication impacts parental understanding of prognosis are poorly understood. In this study, we aimed to (1) characterize communication strategies used by pediatric oncologists to share prognostic information across a child's advancing illness course and (2) explore relationships between different communication approaches and concordance of oncologist-parent prognostic understanding.

METHODS

In this prospective, longitudinal, mixed-methods study, serial disease reevaluation conversations were audio recorded across an advancing illness course for children with cancer and their families. Surveys and interviews also were conducted with oncologists and caregivers at specific time points targeting disease progression.

RESULTS

Seventeen children experienced advancing illness on study, resulting in 141 recordings (40 hours). Fewer than 4% of recorded dialogue constituted prognostic communication, with most codes (77%) occurring during discussions about frank disease progression. Most recordings at study entry contained little or no prognosis communication dialogue, and oncologists rated curability lower than parents across all dyads. Parent-oncologist discordance typically was preceded by conversations without incurability statements; ultimately, concordance was achieved in most cases after the oncologist made direct statements about incurability. Content analysis revealed 3 distinct patterns (absent, deferred, and seed planting) describing the provision of prognostic communication across an advancing pediatric cancer course.

CONCLUSIONS

When oncologists provided direct statements about incurability, prognostic understanding appeared to improve. Further research is needed to determine optimal timing for prognostic disclosure in alignment with patient and family preferences.

Listening to the experts: Parents' perspectives around infection risk and returning to education and social activities following their child's diagnosis of acute lymphoblastic leukemia

Background

During a child's prolonged treatment for acute lymphoblastic leukemia (ALL), there is a need to balance their increased risk of developing infection‐related complications with meeting their educational and social needs.

Aims

To determine the safe timing of return to social activities for children undergoing treatment for ALL and to determine how parents perceive and act on advice related to infection risk while navigating their child's “return to normal.”

Methods and results

Medical and educational attendance records were reviewed for 47 children who were diagnosed with ALL and 24 semi‐structured qualitative interviews were conducted with a representative sample of their parents. The majority of children (69%) did not return to education prior to the start of maintenance therapy regardless of the advice that the families received from their healthcare team. Those who returned earlier were at no greater risk of major infection complications (mean = 0.5) than those who did not return until after commencing maintenance (mean = 0.4, P = .74). Parents spoke of the difficulty in obtaining practical, consistent, and timely advice and of balancing infection risk with a desire to return to normalcy. Inconsistent advice and constant vigilance placed a burden on parents which often profoundly affected their mental wellbeing. Overall, parents wanted to make their own decisions about how and when their child returned to education and social activities. They made these decisions based on many factors, of which infection risk was just one.

Conclusion

Following the study conclusion, a national working group was established—including parent representatives—to implement the study recommendations. This includes the development of a range of practical resources to better support families. Health professional guidelines provide quantitative data pertaining to infection risk, while emphasizing that the returning decisions ultimately rest with the families. This research demonstrates that listening to parents—who are the experts through their lived experiences—is a critical element in creating policies that are responsive, meaningful, and widely accepted.

Characteristics of uncertainty in advanced pediatric cancer conversations

OBJECTIVES

To describe the initiation, response, and content of communication about uncertainty in advanced pediatric cancer.

METHODS

Qualitative analysis of 35 audio-recorded outpatient consultations between physicians and families of children whose cancer recently progressed. We defined uncertainty as "future-oriented lack of clarity in which answers are unknown to all participants involved in the conversation."

RESULTS

Conversations contained a median of 14 (interquartile range 8.5-19) uncertainty statements related to 6 topics: appropriateness of treatments, acute toxicities and morbidities, prognosis or response to treatment, diagnostic uncertainty, logistical uncertainty, and long-term toxicities. Physicians initiated 63 % of statements (303/489), parents initiated 33 % (165/489), and children initiated 2% (10/489). We identified 14 unique responses to uncertainty: 11 responses provided space for discussion, 3 responses reduced space. Physicians most commonly responded by providing additional information (38 %, 361/947). Parents most often responded with continuing statements, such as "um" or "yeah" (50 %, 313/622). Children seldom responded (<1%, 12/1697).

CONCLUSION

Physicians initiated most uncertainty discussions, and their responses often provided space for further discussion. Children were seldom involved in these conversations.

PRACTICE IMPLICATIONS

Clinicians should consider maintaining open conversations about uncertainties in advanced pediatric cancer, and consider engaging children in these discussions.

Survivor and parent engagement in childhood cancer treatment in Iran

In Iran (with a population of 83 million), 19,973 children were diagnosed with cancer from 2009 to 2019 (MAHAK Charity). This study was part of the International Society of Paediatric Oncology, Paediatric Oncology in Developing Countries Committee, ‘Patient, Family and Stakeholder Engagement Task Force’ engagement study in ten low- and middle-income countries in 2019. We documented childhood cancer survivors and parents’ experiences and quality of engagement, including perceptions and expectations, during their cancer treatment journey in Iran. Fourteen in-depth interviews and three focus group discussions were conducted by three Iranian qualitative researchers with 29 participants: recent adolescent/young adult survivors (12–20 years), long-term survivors (21–30 years) and parents [36–61 years (six mothers and four fathers)] from diverse socio-economic and ethnic backgrounds. Data were recorded, transcribed and analysed, and then translated from Farsi into English. Participants’ expectations included inter alia improved communication and information flow among the key stakeholders including doctors, nurses, parents and patients. A need for improved patterns of doctor–patient relationships and communication, more effective psychosocial support and the importance of peer support groups (for survivors and parents) were reported. Participants identified areas of satisfaction and dissatisfaction regarding their actual engagement and decision-making. The dominance of a medical-only approach instead of multidisciplinary approach in care, the shortage of psychosocial support, the lack of an integrated system for providing information and delivering a package of printed material about the treatment journey and the absence of patient navigator in childhood cancer care systems were among obstacles for successful engagement of patients and parents throughout their cancer journey.

Assume It Will Break: Parental Perspectives on Negative Communication Experiences in Pediatric Oncology

PURPOSE

Communication breakdowns in pediatric oncology can have negative consequences for patients and families. A detailed analysis of these negative encounters will support clinicians in anticipating and responding to communication breakdowns.

METHODS

Semistructured interviews with 80 parents of children with cancer across three academic medical centers during treatment, survivorship, or bereavement. We analyzed transcripts using semantic content analysis.

RESULTS

Nearly all parents identified negative communication experiences (n = 76). We identified four categories of contributors to negative experiences: individual (n = 68), team (n = 26), organization (n = 46), and greater health care system (n = 8). These experiences involved a variety of health care professionals across multiple specialties. Parents reported 12 personal consequences of communication breakdowns: emotional distress (n = 65), insufficient understanding (n = 48), decreased trust or confidence (n = 37), inconvenience (n = 36), medical harm (n = 23), decreased self-confidence (n = 17), decreased emotional support (n = 13), decreased engagement (n = 9), false hope (n = 9), decreased hope (n = 7), financial insult (n = 7), and decreased access to resources (n = 3). We identified five categories of supportive responses from clinicians: exploring (n = 8), acknowledging (n = 17), informing (n = 27), adapting (n = 27), and advocating (n = 18). Parents often increased their own advocacy on behalf of their child (n = 47). Parents also identified the need for parental engagement in finding solutions (n = 12). Finally, one parent suggested that clinicians should assume that communication will fail and develop contingency plans in advance.

CONCLUSION

Communication breakdowns in pediatric oncology negatively affect parents and children. Clinicians should plan for communication breakdowns and respond by exploring, acknowledging, informing, adapting, advocating, and engaging parents in finding solutions.

[Emotions Associated with Breaking Bad News in Pediatric Oncology and Parents-Pediatrician Communication: A Status Report]

This literature review aims to explain how the emotions aroused by the announcement of bad news in pediatric oncology affect communication between parents and pediatric oncologists. In the first part, we summarize the parents' expectations regarding communication with the pediatrician at this critical time in their child's care. Then, in a second part, we specify the influence that the emotions of pediatric oncologists and parents during these announcements can have on parent-pediatrician communication. In this context, the emotions and defense mechanisms of pediatric oncologists, parental distress as expressed by parents and as perceived or feared by pediatricians, are discussed. For this synthesis, we have endeavoured to select studies including both mothers and fathers. On the basis of the observations carried out in this review, we conclude by suggesting avenues for the practical implications and for future research. The continuation of research including both parents appears necessary to allow for a closer adaptation of the reactions and needs of each parent, particularly at key moments in the child's care, such as the announcement of bad news. Encouraging exchanges on the emotions felt within the medical and care team, particularly with the department psychologist, could be an opportunity for pediatricians to question their experience of the announcement of bad news and could promote the circulation of emotions in the parent-pediatrician relationship and communication.

Communication of Pharmacogenomic test results and treatment plans in pediatric oncology: deliberative stakeholder consultations with parents

Background

Effective communication in support of clinical decision-making is central to the pediatric cancer care experience for families. A new laboratory derived pharmacogenetic test (LDT) that can diagnose difficult-to-treat brain cancers has been developed to stratify children based on their ability to respond to available treatment; however, the potential implementation of the LDT may make effective communication challenging since it can potentially remove the option for curative treatment in those children identified as non-responders, i.e. those with a catastrophic diagnosis.

Objective

We solicited the perspectives of parents of children with difficult-to-treat brain cancer on communication preferences surrounding the potential implementation of the LDT in standard care using deliberative stakeholder consultations.

Methods

Eight bereaved parents of children who succumbed to difficult-to-treat brain cancer, and four parents of children currently undergoing treatment for similar cancers attended separate small-group deliberative consultations – a stakeholder engagement method that enables the co-creation of recommendations following the consideration of competing arguments and diverse opinions of parents with different experiences. In the small-group consultations (Phase I), parents discussed four questions about potential communication issues that may arise with the LDT in practice. In Phase II, a total of five parents from both stakeholder groups (4 bereaved and 1 in current treatment) attended a consultation, known as the ‘mixed’ consultation, with the purpose of co-developing concrete recommendations for implementation of the LDT.

Results

Explaining the risks, benefits, and accuracy of the LDT were considered essential to parents. Once an LDT-based diagnosis/prognosis can be made, parents valued honesty, empathy, and clarity in communication. Parents also requested that all results and treatment options be presented to them in measured doses, and in an unbiased manner over the course of several meetings. This communication strategy allowed sufficient time to understand and accept the diagnosis/prognosis, particularly if it was catastrophic. Continuous access to the appropriate psychological and social support or counselling at and post-diagnosis was also strongly recommended.

Conclusions

Deliberants co-created family-centered recommendations surrounding communication issues of the LDT, providing guidance to pediatric oncologists that could implement the test in practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00709-2.

Pediatric cancer communication in low- and middle-income countries: A scoping review

The burden of global childhood cancer lies in low- and middle-income countries (LMICs). Communication is essential to pediatric cancer care, and the National Cancer Institute (NCI) has defined 6 functions of communication between patients, family members, and providers, including 1) fostering healing relationships, 2) responding to emotions, 3) exchanging information, 4) making decisions, 5) managing uncertainty, and 6) enabling self-management. Nevertheless, communication needs and practices in LMICs remain incompletely understood. For this review, the Web of Science, Scopus, PubMed, and Turning Research Into Practice databases were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews. Searching identified 2988 articles, with 11 added through snowballing. Forty articles met the inclusion criteria. Two reviewers extracted data on study characteristics, communication functions, enablers, barriers, and additional major themes. This review included work from 17 countries. Most studies (85%) used qualitative methodology; the number of participants ranged from 7 to 304. All 6 of the NCI-defined communication functions were identified in included studies, with rates ranging from 100% of studies for information exchange to 28% of studies for decision making. Communication barriers included cancer misconceptions, stigma, and hierarchy between parents and providers. Provider training and community education facilitated communication. Additional themes included disclosure to children, family dynamics, and the multidisciplinary health care team. In conclusion, all 6 of the communication functions defined by the NCI were applied by pediatric cancer researchers in LMICs. Additional barriers, enablers, and communication themes noted in LMICs deserve further exploration, and a relative paucity of research in comparison with high-income countries highlights the need for further work.

Much is left unspoken: Self-reports from families in pediatric oncology

BACKGROUND

Communication about illness-related subjects is complex and difficult. To support entire families in pediatric oncology, health care professionals need to know what family members think, but leave unspoken. The aim of this study was to explore how families in pediatric oncology experienced illness-related information and communication with professionals and within the family.

PROCEDURE

A cross-sectional web survey was used. Families were recruited from one pediatric oncology center in Sweden, 2-3 months after diagnosis. One hundred eighteen family members (ill children, siblings, and parents) representing 27 families filled out age-adapted surveys.

RESULTS

Eighty-six percent of the parents and 71% of the siblings reported that they had not received enough or any information about how the cancer and its treatment could affect the child's psychological health. The families reported that they did not dare ask professionals questions about psychosocial issues and future-related subjects. Nor did they talk with one another, even though 55% of the parents and 24% of the children wanted to reveal more about how they felt to someone in the family. The parents reported the lowest family communication, and few families had all members reporting the same perception of family communication.

CONCLUSIONS

Much is still left unspoken in pediatric oncology and the needs of the families are prominent. Assessments of each family member's needs might form a basis for professionals to give each person adequate information and family support. An increased awareness in families about family members' different needs might lead to mutual understanding.

Communication in Pediatric Oncology: A Qualitative Study

BACKGROUND

When children are seriously ill, parents rely on communication with their clinicians. However, in previous research, researchers have not defined how this communication should function in pediatric oncology. We aimed to identify these communication functions from parental perspectives.

METHODS

Semistructured interviews with 78 parents of children with cancer from 3 academic medical centers at 1 of 3 time points: treatment, survivorship, or bereavement. We analyzed interview transcripts using inductive and deductive coding.

RESULTS

We identified 8 distinct functions of communication in pediatric oncology. Six of these functions are similar to previous findings from adult oncology: (1) building relationships, (2) exchanging information, (3) enabling family self-management, (4) making decisions, (5) managing uncertainty, and (6) responding to emotions. We also identified 2 functions not previously described in the adult literature: (7) providing validation and (8) supporting hope. Supporting hope manifested as emphasizing the positives, avoiding false hopes, demonstrating the intent to cure, and redirecting toward hope beyond survival. Validation manifested as reinforcing "good parenting" beliefs, empowering parents as partners and advocates, and validating concerns. Although all functions seemed to interact, building relationships appeared to provide a relational context in which all other interpersonal communication occurred.

CONCLUSIONS

Parent interviews provided evidence for 8 distinct communication functions in pediatric oncology. Clinicians can use this framework to better understand and fulfill the communication needs of parents whose children have serious illness. Future work should be focused on measuring whether clinical teams are fulfilling these functions in various settings and developing interventions targeting these functions.

Specialist paediatric palliative care for children and young people with cancer: A mixed-methods systematic review

BACKGROUND

Specialist paediatric palliative care services are promoted as an important component of palliative care provision, but there is uncertainty about their role for children with cancer.

AIM

To examine the impact of specialist paediatric palliative care for children and young people with cancer and explore factors affecting access.

DESIGN

A mixed-methods systematic review and narrative synthesis (PROSPERO Registration No. CRD42017064874).

DATA SOURCES

Database (CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO) searches (2000-2019) identified primary studies of any design exploring the impact of and/or factors affecting access to specialist paediatric palliative care. Study quality was assessed using The Mixed Methods Appraisal Tool.

RESULTS

An evidence base of mainly low- and moderate-quality studies (n = 42) shows that accessing specialist paediatric palliative care is associated with less intensive care at the end of life, more advance care planning and fewer in-hospital deaths. Current evidence cannot tell us whether these services improve children's symptom burden or quality of life. Nine studies reporting provider or family views identified uncertainties about what specialist paediatric palliative care offers, concerns about involving a new team, association of palliative care with end of life and indecision about when to introduce palliative care as important barriers to access. There was evidence that children with haematological malignancies are less likely to access these services.

CONCLUSION

Current evidence suggests that children and young people with cancer receiving specialist palliative care are cared for differently. However, little is understood about children's views, and research is needed to determine whether specialist input improves quality of life.

Impact of Videotaped Information on the Experience of Parents of Children with Acute Lymphoblastic Leukemia

Videotaped information has been shown to be effective in reducing parental anxiety and facilitating knowledge transfer in various clinical settings. There is lack of literature on the use of videotaped information during the pediatric oncology initial family disclosure meeting. The purpose of this study was to deliver an informative DVD, highlighting information on childhood acute lymphoblastic leukemia (ALL), to parents of children with newly diagnosed ALL and to assess if the DVD provided increased levels of satisfaction and decreased levels of anxiety in parents around the time of diagnosis. We surveyed 24 parents of children on active treatment for ALL, diagnosed between the ages of 1 and 18 years from 2008 to 2016 at The Hospital for Sick Children, Toronto, Canada. Parents were provided a survey questionnaire assessing levels of satisfaction with information communicated by the healthcare team and anxiety following verbal disclosure and were asked to report satisfaction and anxiety levels immediately following viewing the DVD intervention. Twenty-three/24 (95.8%) parents surveyed reported seeking information from additional resources after disclosure. Of the 24 parents who watched the DVD, 12 (50.0%) watched it once, while 12 (50.0%) watched it twice or more. All parents were satisfied with DVD information, and there was a significant decrease in anxiety after viewing (P = 0.03). All 24 parents felt that the DVD was a useful educational tool. Videotaped information after verbal disclosure is an effective educational resource and is associated with reduced anxiety among parents of children with ALL.