Basic research in childhood cancer: Progress and future directions in China

Can performance status mediate the relationship between therapy-related symptoms and health-related quality of life in children with cancer? A mediation model

PURPOSE

Understanding the interplay among health-related quality of life (HRQoL), therapy-related symptoms, and performance status can offer insights into potential strategies to enhance HRQoL for pediatric cancer patients. This study aimed to examine the mediating effect of performance status on the relationship between symptom burden and HRQoL in children and adolescents with cancer.

METHOD

A cross-sectional study was conducted. Participants were recruited from two tertiary hospitals located in Guangzhou, China. HRQoL, therapy-related symptoms, and performance status were assessed using the DISAKIDS Chronic Generic Measure (DCGM-37), Therapy-Related Symptom Checklist for Children (TRSC-C), and Lansky Play Performance Scale (LPPS), respectively.

RESULTS

A total of 287 children with cancer (aged 11.08 ± 2.34 years) were included. The DCGM-37 scores were 59.70 ± 9.64. Emotion (56.45 ± 14.56) and physical limitations (58.59 ± 15.38) were the most affected domains. The number of symptoms experienced was 12.49 ± 5.95. The DCGM-37 demonstrated strong negative correlations with the TRSC-C (r = -0.60, P < 0.001) and number of symptoms (r = -0.62, P < 0.001), but mild-to-moderate negative correlations (r -0.16∼ -0.42, P < 0.05) with individual symptoms. The TRSC-C demonstrated an indirect effect on the DCGM-37 via the LPPS (Bootstrap-corrected standardized β = -0.05, 95 % CI -0.10∼ -0.01; SE = 0.02). Additional analysis showed that tripping/falling (OR = 4.02, 95 % CI 2.02-7.98; P < 0.001) and sore mouth (OR = 2.38, 95 % CI 1.56-3.64; P < 0.001) were associated factors for presenting poor performance status in children undergoing acute chemotherapy.

CONCLUSIONS

The accumulated symptom burden, rather than individual symptoms, weighs heavily on the HRQoL. Performance status partially mediated the relationship between symptom burdens and HRQoL among these patients.

Challenges and opportunities in rare cancer research in China

Cancer is one of the major public health challenges in China. Rare cancers collectively account for a considerable proportion of all malignancies. The lack of awareness of rare cancers among healthcare professionals and the general public, the typically complex and delayed diagnosis, and limited access to clinical trials are key challenges. Recent years have witnessed an increase in funding for research related to rare cancers in China. In this review, we provide a comprehensive overview of rare cancers and summarize the status of research on rare cancers in China and overseas, including the trends of funding and publications. We also highlight the challenges and perspectives regarding rare cancers in China.

Head and neck carcinoma in children: A clinicopathological study of 42 cases

Background/purpose

Cancer is an important part of the global burden of childhood diseases. Head and neck carcinoma in children is rare and related research is limited. This study aimed to investigate the clinicopathological features of childhood head and neck carcinoma.

Materials and methods

Forty-two cases of childhood head and neck carcinoma treated in our institution were reviewed and analyzed.

Results

Median age overall was 11 years. Twenty-three patients (54.8%) were male and 19 (45.2%) were female. Parotid gland location was most common (54.8%). Mucoepidermoid carcinoma and squamous cell carcinoma were the most common histological types (57.1% and 11.9%, respectively). Two patients had a history of bone marrow transplantation and two had a history of odontogenic keratocyst. The recurrence rate after treatment was 8.6%.

Conclusion

Early diagnosis and treatment and close follow-up of childhood head and neck carcinoma are warranted to prevent recurrence and improve clinical outcome.

BPTF in bone marrow provides a potential progression biomarker regulated by TFAP4 through the PI3K/AKT pathway in neuroblastoma

BACKGROUND

Neuroblastoma (NB) is the most common extracranial malignant solid tumor in children, which is highly prone to bone marrow (BM) metastasis. BM can monitor early signs of mild disease and metastasis. Existing biomarkers are insufficient for the diagnosis and treatment of NB. Bromodomain PHD finger transcription factor (BPTF) is an important subunit of the chromatin-remodeling complex that is closely associated with tumors. Here, we evaluated whether BPTF in BM plays an important role in predicting NB progression, and explore the molecular mechanism of BPTF in NB.

METHODS

The clinical relevance of the BPTF was predicted in the GEO (GSE62564) and TARGET database. The biological function of BPTF in NB was investigated by constructing cell lines and employing BPTF inhibitor AU1. Western blot was used to determine the changes of BPTF, TFAP4, PI3K/AKT signaling and Epithelial-mesenchymal transition (EMT) related markers. A total of 109 children with newly diagnosed NB in Beijing Children's Hospital from January 2018 to March 2021 were included in this study. RT-PCR was used to measure the BPTF and TFAP4 expression in BM. The cut-off level was set at the median value of BPTF expression levels.

RESULTS

Databases suggested that BPTF expression was higher in NB and was significantly associated with stage and grade. Proliferation and migration of NB cells were slowed down when BPTF was silenced. Mechanistically, TFAP4 could positively regulate BPTF and promotes EMT process through activating the PI3K/AKT signaling pathway. Moreover, detection of the newly diagnosed BM specimens showed that BPTF expression was significantly higher in high-risk group, stage IV group and BM metastasis group. Children with high BPTF at initial diagnosis were considered to have high risk for disease progression and recurrence. BPTF is an independent risk factor for predicting NB progression.

CONCLUSIONS

A novel and convenient BPTF-targeted humoral detection that can prompt minimal residual and predict NB progression in the early stages of the disease were identified. BPTF inhibitor AU1 is expected to become a new targeted drug for NB therapy. It's also reveal previously unknown mechanisms of BPTF in NB cell proliferation and metastasis through TFAP4 and PI3K/AKT pathways.

The Therapy-Related Symptom Checklist for Children as a Method for Monitoring Symptoms in Chinese Children With Cancer: Linguistic Validation and Cross-Cultural Adaptation

BACKGROUND

Children with cancer commonly experience severe symptoms. These may be managed by routine monitoring of their occurrence andseverity using a validated tool.

AIM

This study aimed to translate and culturally validate a simplified Chinese version of the Therapy-Related Symptom Checklist for Children (TRSC-C).

DESIGN

Qualitative method.

PARTICIPANTS AND SETTING

We recruited children with cancer from a pediatric department of a tertiary hospital in Guangzhou, China.

METHODS

We used forward and backward translation by bilingual translators and standardized cognitive interviewing for linguistic validation and to check cross-cultural adaptation. A panel of experts assessed content validity.

RESULTS

Agreement was reached on cultural applicability, suitability for intended purpose, and clarification of the pre-test version. The content validity was good (indices ranged from 0.80-0.90). Fifteen Chinese children with cancer (aged 8-18 years) were included in cognitive interviews. The cognitive debriefing showed that the instrument was easy to understand and appropriate for monitoring symptoms in children with cancer. Some words were adjusted following participants' comments.

CONCLUSIONS

The simplified Chinese version of the TRSC-C was semantically and conceptually equivalent to the original version. Children between 8-18 years old can use this instrument to report symptoms and share their experiences about their disease and treatment.

The systematic analysis and 10-year prediction on disease burden of childhood cancer in China

Background

There is a lack of in-depth analysis regarding the disease burden of childhood cancer in China. Indeed, this is the first time the topic has been addressed in detail. Drawing on population-based data for the past 30 years, this study systematically analyzes the composition and long-term trend of this disease burden in China.

Methods

GBD 2019 contained population-based data from 1990 to 2019 and was prepared using Microsoft Excel 2016. We used AAPC and ARIMA models for trend analysis and prediction formulation.

Results

In 2019, there were 45,601 new cases, 9,156 cancer deaths, and 782,530 DALYs in China. From 1990 to 2019, leukemia, together with brain and CNS cancer, invariably ranked highest in terms of new cases, cancer deaths, and DALYs. Leukemia accounted for more than 50%, but decreased over time. By contrast, the proportions for brain and CNS cancer increased. There were significant decreases in the overall incidence, mortality, and DALY rates in China, but these were still higher than the corresponding global average levels. Considering all types of childhood cancer, the incidence rate of testicular cancer showed the biggest increase, and the mortality and DALY rates of leukemia showed the largest decrease. In terms of different age groups, the overall incidence rate of childhood cancers increased in 0 to 4 age group, but it decreased in 5 to 14 age groups. The overall mortality and DALY rates of childhood cancers decreased in all four age groups. Over the next 10 years, the overall incidence rate of childhood cancer will increase, but the overall mortality and DALY rates will decrease. The increase in malignant skin melanoma will comprise the largest rise in the incidence, while the decrease for leukemia will be the largest fall in the incidence, cancer deaths, and DALYs.

Conclusion

The disease burden of all childhood cancers in China remains highly serious, especially for certain types of cancer and certain age groups. China should focus more emphatically on the incidence of childhood cancer in future, and it must consistently strengthen investment in the relevant research and medical resources to reduce the disease burden in this field.

[Application of "kindergarten effect" in radiotherapy for children with tumor aged 3-5 years]

OBJECTIVES

To study the clinical application effect of "kindergarten effect" in radiotherapy for children with tumor based on the psychology of preschool children aged 3-5 years.

METHODS

A total of 30 children, aged 3-5 years, who were admitted to the Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, from January 2020 to August 2021 were enrolled in this prospective study. The children were randomly divided into a control group and a test group, with 15 children in each group. The children in the test group were treated in "kindergarten mode", i.e., all children were treated together at a specified time and left together after all children completed treatment. Those in the control group were treated alternately with adult patients according to the treatment time based on the type of radiotherapy fixation device. The treatment compliance was evaluated for both groups, and the two groups were compared in terms of the setup errors in the superior-inferior (SI), left-right (LR), and anterior-posterior (AP) directions.

RESULTS

Compared with the control group, the test group showed a significantly shorter time for finishing the treatment (P<0.05) and a significantly lower proportion of children with treatment interruption (P<0.05). Compared with the control group, the test group showed smaller mean errors in the SI, LR and AP directions after image-guided radiotherapy, with significant differences in the mean errors in the SI and LR directions (P<0.05).

CONCLUSIONS

With the application of the "kindergarten effect", most children can actively cooperate in radiotherapy, and it can also improve the accuracy and repeatability of positioning and help to achieve the desired treatment outcome.

Psychometric validation of the simplified Chinese version of the therapy-related symptom checklist in children with cancer

PURPOSE

To validate a simplified Chinese version of the therapy-related symptom checklist for children (TRSC-C) in children with cancer.

METHODS

Reliability was assessed by internal consistency and test-retest coefficients. Dimensionality and construct validity were clarified using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Pearson's correlation coefficient was calculated between the TRSC-C and the PedsQL 3.0 cancer model (PedsQL 3.0) and the Lansky Play Performance Scale (LPPS) to test concurrent validity. A Student's t-test was used to compare the scores of the simplified Chinese version of the TRSC-C subscales by gender, age groups, and functional status to test sensitivity of the TRSC-C.

RESULTS

A sample of 170 children with cancer was recruited (11.27 ± 2.31 years). Cronbach's alpha (0.89) and interclass correlation coefficient (0.98) were acceptable. Seven factors with eigenvalues >1 explained 56.86% of the total variances. CFA demonstrated an acceptable model (CFI = 0.93, RMSE = 0.04). Concurrent validity was supported by moderate to high correlations between the TRSC-C and both the PedsQL 3.0 (r = -0.71) and LPPS (r = -0.43). The TRSC-C scores significantly differed by age groups and functional status (effect size 0.40-0.93), indicating adequate sensitivity.

CONCLUSION

The simplified Chinese version of the TRSC-C demonstrated acceptable reliability, validity, and sensitivity to support its use in clinical practice and future studies.

Childhood cancer drugs in China: An overview and comparison of regulatory approvals in China and the United States

Different from less developed countries, 80% of children with cancers in the United States are cured. Traditional chemotherapy drugs are the mainstay of therapies; new targeted medications have become available recently. Using publicly available data, we created a database of cancer drugs with paediatric malignancy indications approved by 31 October 2020 in China and the United States. We compared numbers, type, indications and listing on the World Health Organization Model List of Essential Medicines for Children (WHO EMLc) between the two countries, assessed the correlation between paediatric indications and cancer incidences, and described evidence supporting approvals of targeted medications in the two settings. Our study showed that by 31 October 2020, 31 and 39 cancer drugs available in China and the United States were approved for use in children, corresponding to 137 and 102 paediatric cancer indications, respectively. About half of these drugs (17 in China and 18 in the United States) were listed on the WHO EMLc. The correlation between indications and burden of disease was higher in the United States (r = 0.68) than China (r = 0.59). More traditional chemotherapy drugs were approved in China (n = 27) than the United States (n = 19). Of 20 targeted childhood anticancer medicines approved in the United States, mainly on the basis of single arm trials (27/32 indications, 84.4%), only four were approved for paediatric indications in China, at a median of 2.8 years after US Food and Drug Administration approval. A harmonised, evidence-based regulatory framework is needed to ensure approvals of needed, safe and efficacious childhood cancer drugs across the world.