Symptom Clusters in Children and Adolescents with Cancer

Cancer symptom cluster research in pediatric oncology: a work in progress

In the 21st century, advances in basic research have provided new insights in the field of pediatric oncology. Pediatric patients tend to experience higher levels of distressing symptoms, which together form a symptom cluster. In clinical practice, these symptom clusters are reported daily by children and adolescents with cancer. Translational research has emerged as the translation of new knowledge from basic science into clinical practice. Understanding how neuroimmunoendocrine pathways regulate cancer development and the aspects underlying the specific therapies, such as chemotherapy and immunotherapy, is an important frontier for future research in pediatric oncology. The goal of translational research is to show how different variables in tumor and patient characteristics explain the differential effects of interventions, as translational research provides new insights into the management of cancer symptoms in children and adolescents with cancer. Together, this approach could lead to improvements in pediatric oncology care worldwide.

Multi-omics analysis of the gut microbiome and metabolites associated with the psychoneurological symptom cluster in children with cancer receiving chemotherapy

BACKGROUND

Children with cancer receiving chemotherapy commonly report a cluster of psychoneurological symptoms (PNS), including pain, fatigue, anxiety, depression, and cognitive dysfunction. The role of the gut microbiome and its functional metabolites in PNS is rarely studied among children with cancer. This study investigated the associations between the gut microbiome-metabolome pathways and PNS in children with cancer across chemotherapy as compared to healthy children.

METHODS

A case-control study was conducted. Cancer cases were recruited from Children's Healthcare of Atlanta and healthy controls were recruited via flyers. Participants reported PNS using the Pediatric Patient-Reported Outcomes Measurement Information System. Data for cases were collected pre-cycle two chemotherapy (T0) and post-chemotherapy (T1), whereas data for healthy controls were collected once. Gut microbiome and its metabolites were measured using fecal specimens. Gut microbiome profiling was performed using 16S rRNA V4 sequencing, and metabolome was performed using an untargeted liquid chromatography-mass spectrometry approach. A multi-omics network integration program analyzed microbiome-metabolome pathways of PNS.

RESULTS

Cases (n = 21) and controls (n = 14) had mean ages of 13.2 and 13.1 years. For cases at T0, PNS were significantly associated with microbial genera (e.g., Ruminococcus, Megasphaera, and Prevotella), which were linked with carnitine shuttle (p = 0.0003), fatty acid metabolism (p = 0.001) and activation (p = 0.001), and tryptophan metabolism (p = 0.008). Megasphaera, clustered with aspartate and asparagine metabolism (p = 0.034), carnitine shuttle (p = 0.002), and tryptophan (p = 0.019), was associated with PNS for cases at T1. Gut bacteria with potential probiotic functions, along with fatty acid metabolism, tryptophan, and carnitine shuttle, were more clustered in cancer cases than the control network and this linkage with PNS needs further studies.

CONCLUSIONS

Using multi-omics approaches, this study indicated specific microbiome-metabolome pathways linked with PNS in children with cancer across chemotherapy. Due to limitations such as antibiotic use in cancer cases, these findings need to be further confirmed in a larger cohort.

Gaps in Parental Understanding of Sleep Disturbances During Maintenance Therapy for Pediatric Acute Lymphoblastic Leukemia

Background: Acute lymphoblastic leukemia (ALL) is the most common cancer in childhood, with survival rates approaching 90%. Sleep disturbance is common among ALL patients, often developing during the initial stages of chemotherapy treatment. While there have been significant efforts to understand and intervene in this issue during survivorship, there is far less research on children who are actively receiving treatment. In the current study, we sought to better understand the parent's experience in the sleep domain during maintenance therapy, including their perceptions of how their child's medical team had managed sleep disturbances, and recommendations for how to improve sleep management. Method: Fifteen parents of pediatric ALL patients (aged 4-12 years) completed semistructured interviews. Interview content was analyzed using a multistage thematic analysis. Results: Parents consistently expressed feeling unprepared to manage the sleep disruptions that arose during treatment, often reporting that they did not recall being told this would be a side effect. They were enthusiastic about learning how to improve their child's sleep, though they did not want pharmacotherapeutic interventions or additional medical/psychosocial appointments to address this. Conclusion: Despite consistent provider communication on sleep, parents report limited knowledge of the issue. This provides an obvious intervention target to improve treatment-related sleep disturbances. Clear messaging may help direct parents' attention and expectations regarding their child's treatment and potential for disturbed sleep, possibly in the form of a behavioral intervention that empowers parents with information about how to support their child's sleep health while they are undergoing treatment for ALL.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

Identifying central symptom clusters and correlates in children with acute leukemia undergoing chemotherapy: a network analysis

Background

Previous studies have examined symptom clusters in children with acute leukemia, yet a knowledge gap persists regarding central symptom clusters and their influencing factors. By identifying these central clusters and associated factors, healthcare providers can enhance their understanding and effective management of symptoms. Our study seeks to address this gap by identifying symptom clusters, exploring central clusters, and investigating the demographic and health-related factors associated with these clusters in children with acute leukemia undergoing chemotherapy.

Methods

A total of 586 children with acute leukemia from January 2021 to April 2023 were recruited from China. They were investigated using Memorial Symptom Assessment Scale 10-18 during chemotherapy. The principal component analysis was used to identify the symptom clusters. An association network was conducted to describe the relationships among symptoms and clusters. A multiple linear model was used to investigate the associated factors for the severity of overall symptoms and each symptom cluster.

Results

Five clusters were identified, including oral and skin cluster, somatic cluster, self-image disorder cluster, gastrointestinal cluster and psychological cluster. Gastrointestinal cluster was the most central symptom cluster. Age, sex, clinical classification, number of having chemotherapy and education degree and marital status of the primary caregiver are associated with the severity of these five symptom clusters.

Conclusion

Our study highlights the importance of evaluating symptom clusters in children with acute leukemia during chemotherapy. Specifically, addressing gastrointestinal symptoms is crucial for effective symptom management and overall care.

Stability of Symptom Clusters in Children With Acute Lymphoblastic Leukemia Undergoing Chemotherapy

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) experience multiple symptoms during chemotherapy. Assessing how symptoms cluster together and how these symptom clusters (SCs) change over time may lay a foundation for future research in SC management and the pathophysiological mechanisms of SCs.

OBJECTIVES

This study aimed to assess the stability of SCs in children with ALL during chemotherapy.

METHODS

A longitudinal investigation was carried out. The Chinese version of the Memorial Symptom Assessment Scale 10 to 18 was used to assess the occurrence, severity, and distress of symptoms in 134 children with ALL (8-16 years old) at the following 4 separate points: before chemotherapy (T1), start of post-induction therapy (T2), 4 months post-induction therapy (T3), and start of maintenance therapy (T4). Exploratory factor analyses were used to extract SCs.

RESULTS

Six SCs were identified. Emotional and somatic clusters were identified across all dimensions and time points. Gastrointestinal cluster was all identified except for occurrence at T1. Neurological cluster was identified at T2 and T3 for all dimensions and at T4 for severity and distress. Self-image disorder cluster was all identified except at T1. Skin mucosa cluster was identified at T2 and T3 for all dimensions. Emotional cluster exhibited common symptoms across dimensions and time points.

CONCLUSION

The number and types of SCs determined by scoring the occurrence, severity, and distress are different, but some SCs are relatively stable.

IMPLICATIONS FOR PRACTICE

Clinicians should not only focus on the common trajectory of symptoms and SCs, but also assess each child individually.

Informing Parents as Caregivers With a Symptom Assessment App Developed for Children With Cancer

Background: Mobile health technologies can assist children to communicate their symptom experiences in a developmentally appropriate format. However, few investigations have examined how mHealth resources may also assist parents in their caregiver role. The purpose of this study was to explore how a symptom assessment app designed for school-age children with cancer could further inform parents as caregivers. Methods: Nineteen parents (18 mothers; median 35 years old, range 26-48 years) of children (6-12 years of age) receiving cancer treatment participated in the feasibility/acceptability trial of a game-based symptom assessment app. Acceptability interviews with parents were completed after each child's trial with the app. We completed a secondary analysis of the parent interviews using thematic analysis to examine how the app could support parents in their caregiving role. Results: Parents perceived the app to (1) elicit the child's voice about his/her symptom experience; (2) provide a supportive and safe environment for the child to report symptoms; and (3) create an opportunity to facilitate communication between the child, parent, and clinical team. Parents expressed a willingness for their child to represent his/her experience with the app so that they could make informed decisions regarding symptom care. Discussion: Perceived benefits of the app extended to parents as they described developing further insight into their child's cancer experience. The knowledge gained allowed parents the potential to enhance symptom communication and supportive care strategies. Future research should further evaluate how mHealth tools facilitate shared symptom management between children receiving treatment for cancer and their caregivers.

Metabolic Pathways Associated With Psychoneurological Symptoms in Children With Cancer Receiving Chemotherapy

CONTEXT

Children with cancer undergoing chemotherapy experience a cluster of psychoneurological symptoms (PNS), including pain, fatigue, anxiety, and depressive symptoms. Metabolomics is promising to differentiate metabolic pathways associated with the PNS cluster.

OBJECTIVES

Identify metabolic pathways associated with the PNS cluster in children with cancer before and after chemotherapy.

METHODS

Pain, fatigue, anxiety, and depressive symptoms were assessed using the Pediatric PROMIS scales. T-scores were computed and divided dichotomously by a cutoff point of 50; the PNS cluster was a sum of the four symptoms ranging from 0 (all T-scores <50) to 4 (all T-scores ≥50). Serum metabolites were processed using liquid chromatography mass-spectrometry untargeted metabolomics approach. Linear regression models examined metabolites associated with the PNS cluster. Metabolic pathway enrichment analysis was performed.

RESULTS

Participant demographics (n = 40) were 55% female, 60% white, 62.5% aged 13-19 years, and 62.5% diagnoses of Hodgkin's lymphoma and B-cell acute lymphocytic leukemia. Among 9276 unique metabolic features, 454 were associated with pain, 281 with fatigue, 596 with anxiety, 551 with depressive symptoms, and 300 with the PNS cluster across one chemotherapy cycle. Fatty acids pathways were associated with pain: de novo fatty acid biosynthesis (p < .001), fatty acid metabolism (p = .001), fatty acid activation (p = .004), and omega-3 fatty acid metabolism (p = .009). Tryptophan amino acid pathway was associated with fatigue (p < .001), anxiety (p = .015), and the PNS cluster (p = .037). Carnitine shuttle was associated with the PNS cluster (p = .015).

CONCLUSION

Fatty acids and amino acids pathways were associated with PNS in children undergoing chemotherapy. These findings require further investigation in a larger sample.

The Development of an mHealth Tool for Children With Long-term Illness to Enable Person-Centered Communication: User-Centered Design Approach

BACKGROUND

Children with long-term illnesses frequently experience symptoms that could negatively affect their daily lives. These symptoms are often underreported in health care. Despite a large number of mobile health (mHealth) tools, few are based on a theoretical framework or supported by scientific knowledge. Incorporating universal design when developing a product can promote accessibility and facilitate person-centered communication.

OBJECTIVE

The aim of this study is to identify the symptom-reporting needs of children with cancer and congenital heart defects that could be satisfied by using a mobile app. Another aim is to evaluate how the child might interact with the app by considering universal design principles and to identify parents' views and health care professionals' expectations and requirements for an mHealth tool.

METHODS

User-centered design is an iterative process that focuses on an understanding of the users. The adapted user-centered design process includes 2 phases with 4 stages. Phase 1 involved interviews with 7 children with long-term illnesses, 8 parents, and 19 health care professionals to determine their needs and wishes for support; a workshop with 19 researchers to deepen our understanding of the needs; and a workshop with developers to establish a preliminary tool to further investigate needs and behaviors. Phase 2 involved interviews with 10 children with long-term illnesses, 9 parents, and 21 health care professionals to evaluate the mock-up (prototype) of the mHealth tool. Data were synthesized using the interpretive description technique.

RESULTS

A total of 4 aspects of needs emerged from the synthesis of the data, as follows: different perspectives on provided and perceived support; the need for an easy-to-use, non-clinic-based tool to self-report symptoms and to facilitate communication; the need for safety by being in control and reaching the child's voice; and a way of mapping the illness journey to facilitate recall and improve diagnostics. The children with long-term illnesses expressed a need to not only communicate about pain but also communicate about anxiety, fatigue, fear, and nausea.

CONCLUSIONS

The findings of this study indicated that the PicPecc (Pictorial Support in Person-Centered Care for Children) app is a potential solution for providing communicative support to children with long-term illnesses dealing with multiple symptoms and conditions. The interview data also highlighted symptoms that are at risk of being overlooked if they are not included in the mobile app. Further studies are needed to include usability testing and evaluation in hospitals and home care settings.

Technology-Assisted Psychosocial Interventions for Childhood, Adolescent, and Young Adult Cancer Survivors: A Systematic Review and Meta-Analysis

Purpose: Technology-assisted interventions are essential in supporting cancer survivors' psychosocial outcomes, especially for childhood, adolescent, and young adult (AYA) cancer survivors, a tech-savvy generation. This study aims to systematically evaluate review and meta-analyze technology-assisted interventions for childhood and AYA cancer survivors. Methods: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, the study team used a pre-set of key words and searched studies across 11 electronic databases and 4 professional websites, and conducted a manual search of reference lists from published reviews. Meta-analysis of small sample size corrected Hedges' g was conducted using meta-regression with robust variance estimation. Results: Final analysis included a total of 28 clinical trials, including 237 effect sizes reported an overall statistically significant treatment effect of technology-assisted psychosocial interventions for childhood and AYA cancer survivors, g = 0.382, 95% confidence interval (CI) 0.243 to 0.521, p < 0.0001. Subgroup analysis revealed that distraction-based interventions and interventions for psychosocial and emotional health were overall statistically significant, whereas interventions for childhood and AYA cancer survivors' cancer knowledge outcomes and physical and functional health outcomes were statistically nonsignificant. Moderator analysis found intervention target was a significant moderator. Conclusions: Technology-assisted interventions for childhood and AYA cancer survivors were overall effective across domains of survivorship outcomes. Favorable evidence was found primarily for childhood cancer survivors with limited support for AYA cancer survivors. Implications for Cancer Survivors: Although existing technology-assisted interventions are overall promising, research support for cancer survivors from different age groups and with different psychosocial challenges varies and should be considered individually.

Compreensão dos adolescentes sobre eventos adversos relacionados à quimioterapia: um estudo de elicitação de conceitos

Resumo Objetivo: documentar a compreensão dos adolescentes sobre os principais eventos adversos relacionados à quimioterapia a partir da versão Pediátrica dos Desfechos Relatados pelo Paciente (Patient-Reported Outcomes) dos Critérios de Terminologia Comum para Eventos Adversos (Common Terminology Criteria for Adverse Events), e assim iniciar o processo de validação dos itens desta ferramenta com adolescentes brasileiros. Método: trata-se de um estudo prospectivo, qualitativo, de elicitação de conceitos. Participaram do estudo 17 adolescentes de 13 a 18 anos, submetidos à quimioterapia em três hospitais da cidade de São Paulo-SP, Brasil. Foram realizadas entrevistas cognitivas com perguntas baseadas em eventos adversos relacionados à quimioterapia. Os dados foram analisados quanto à responsividade e ausência de resposta. Resultados: os adolescentes puderam e estavam dispostos a fornecer informações descritivas sobre seus eventos adversos quimioterápicos, incluindo eventos físicos e emocionais. Alguns participantes sugeriram nomes alternativos para os eventos adversos e alguns usaram termos mais complexos, mas a maioria ficou satisfeita com aqueles utilizados pelos pesquisadores. Conclusão: este estudo representa os primeiros passos para entender como os adolescentes com câncer identificam, nomeiam e descrevem esses eventos por meio de entrevistas cognitivas para ajudar a criar futuros instrumentos de avaliação focados nessa faixa etária.

Adolescents’ understanding of chemotherapy-related adverse events: a concept elicitation study

Objective:

to document adolescents’ understanding of chemotherapy-related core adverse events from the Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events and thus begin the validation process of this tool’s items with Brazilian adolescents.

Method:

this is a prospective, qualitative study of concept elicitation. The participants were 17 adolescents aged 13-18 years and undergoing chemotherapy in three hospitals in São Paulo - SP, Brazil. Cognitive interviews were conducted with questions based on chemotherapy-related adverse events. Data were analyzed for responsiveness and missingness.

Results:

adolescents could and were willing to provide descriptive information about their chemotherapy adverse events, including physical and emotional events. Some participants suggested alternative terms to name the adverse events and some used more complex terms, but most were satisfied with the primary terms used by the researchers.

Conclusion:

this study represents the first steps towards understanding how adolescent cancer patients identify, name, and describe these events by cognitive interviewing to help design future assessment instruments focused on this age group.

La comprensión de los adolescentes de los efectos adversos relacionados con la quimioterapia: un estudio de elicitación de conceptos

Resumen Objetivo: documentar la comprensión de los adolescentes de los principales eventos adversos relacionados con la quimioterapia a partir de la versión de los Criterios Terminológicos Comunes para Eventos Adversos reportados por los pacientes pediátricos y así iniciar el proceso de validación de los ítems de esta herramienta con adolescentes brasileños. Método: este es un estudio prospectivo y cualitativo de elicitación de conceptos. Los participantes fueron 17 adolescentes de entre 13 y 18 años de edad que recibían quimioterapia en tres hospitales de São Paulo-SP, Brasil. Se realizaron entrevistas cognitivas con preguntas basadas en eventos adversos relacionados con la quimioterapia. Los datos se analizaron en función de la presencia y ausencia de respuesta. Resultados: los adolescentes podían y estaban dispuestos a proporcionar información descriptiva sobre los efectos adversos de la quimioterapia, incluidos los físicos y emocionales. Algunos participantes sugirieron términos alternativos para denominar los eventos adversos y otros utilizaron términos más complejos, pero la mayoría se mostró satisfecha con los términos principales utilizados por los investigadores. Conclusión: este estudio representa los primeros pasos hacia la comprensión de cómo los pacientes adolescentes con cáncer identifican, nombran y describen estos eventos mediante entrevistas cognitivas para ayudar a diseñar futuros instrumentos de evaluación centrados en este grupo de edad.

Symptom Clusters in Head and Neck Cancer: A Systematic Review and Conceptual Model

OBJECTIVE

The two approaches to symptom-cluster research include grouping symptoms and grouping patients. The objective of this systematic review was to examine the conceptual approaches and methodologies used in symptom-cluster research in patients with head and neck cancer.

DATA SOURCES

Articles were retrieved from electronic databases (CINAHL, MEDLINE via Ovid, APA PsycINFO, Scopus, Embase, and Cochrane Central Register of Controlled Trials-CENTRAL), five grey literature portals, and Google Scholar. Seventeen studies met the eligibility criteria. Eight studies grouped symptoms to identify symptom clusters, of which two used qualitative methods. The number of symptom clusters ranged from two to five, and the number of symptoms in a cluster ranged from 2 to 11. Nine studies grouped patients based on their experiences with multiple symptoms. Cluster analysis and factor analysis were most commonly used. Despite variable names and composition of symptom clusters, synthesis revealed three prominent symptom clusters: general, head and neck cancer-specific, and gastrointestinal. Being female and quality of life were significantly associated with high symptom group or cluster severity. Biological mechanisms were sparsely examined.

CONCLUSION

Symptom cluster research in head and neck cancer is emerging. Consensus on nomenclature of a symptom cluster will facilitate deduction of core clinically relevant symptom clusters in head and neck cancer. Further research is required on understanding patients' subjective experiences, identifying predictors and outcomes, and underlying mechanisms for symptom clusters.

IMPLICATIONS FOR NURSING PRACTICE

Identification of clinically relevant symptom clusters would enable targeted symptom assessment and management strategies, thus improving treatment efficiencies and patient outcomes.

Management of chemotherapy-related symptoms in children and adolescents: family caregivers' perspectives

OBJECTIVE

To describe the chemotherapy-associated symptoms and the strategies used for their management from the perspective of pediatric cancer patients' family caregivers.

METHODS

This is a descriptive study with qualitative data analysis. Data collection took place in a pediatric hospital, from December 2017 to December 2018, with family caregivers of pediatric patients undergoing chemotherapy. Semi-structured interviews, subjected to inductive content analysis, were carried out. Concepts from the Symptom Management Theory were used to discuss the results.

RESULTS

Eighteen family caregivers participated. The participants mentioned: physical symptoms, especially weakness, alopecia, low immunity, pain, mucositis, constipation, nausea, and vomiting; emotional or psychosocial symptoms such as sadness and mood changes; and constitutional symptoms such as loss of appetite and fever. Pharmacological and non-pharmacological measures were mentioned in the management of symptoms and adverse effects.

CONCLUSION

Participants demonstrated skills to identify and manage symptoms of chemotherapy. Knowing the experience of these families can help nurses in planning care and interventions to minimize these events.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pain Reported by Chinese Children During Cancer Treatment: Prevalence, Intensity, Interference, and Management

BACKGROUND

Pain is a frequently reported and distressing symptoms during cancer treatment. However, there is limited evidence on pain reported by Chinese children with cancer.

OBJECTIVES

This study aimed to investigate the prevalence, intensity, interference, and management of pain reported by Chinese children during cancer treatment and explore the predictors of pain interference.

METHODS

We conducted a cross-sectional survey to investigate the pain intensity, pain interference, co-occurring symptoms (anger, anxiety, depression, fatigue), and pain management strategies reported by children 8 years and older undergoing active cancer treatment in 4 Chinese hospitals.

RESULTS

Data were analyzed for 187 children. The prevalence of moderate to severe pain (≥4/10) was 38.50%, with an average pain interference score of 52.97 out of 100. Approximately 24% of children were prescribed pain medicine. Pain interference and pain intensity were marginally correlated (r = 0.047, P < .01) and were both positively correlated with pain duration and co-occurring symptoms and negatively correlated with perceived pain alleviation (all P < .01). Multiple regression analyses suggested that severe pain intensity (B = 2.028, P = .003) and fatigue (B = 0.440, P < .001) significantly predicted higher levels of pain interference (R2 = 0.547, F = 23.102, P < .001).

CONCLUSION

Chinese children with cancer reported a low pain intensity score but a relatively high level of pain interference. According to the children's reports, pain has not been sufficiently addressed through Chinese pediatric oncology supportive care.

IMPLICATIONS FOR PRACTICE

There is an urgent requirement for comprehensive pain assessment and standardized, targeted interventions in Chinese pediatric oncology pain management.

Effectiveness of complementary therapies for the management of symptom clusters in palliative care in pediatric oncology: a systematic review

OBJECTIVE

To evaluate the effectiveness of complementary therapies in the management of symptom clusters in children and adolescents with cancer undergoing palliative care.

METHOD

Systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, resorting to the databases MEDLINE, Web of Science, Central Cochrane, and PsycINFO. The identification, selection, inclusion, extraction, and methodological assessment were conducted by two independent reviewers.

RESULTS

Five quasi-experiments met the eligibility criteria. The heterogeneous characteristics of the studies made meta-analysis impossible. Two studies used therapeutic massage, one used Reiki, one used boswellic acid, and one used Cannabis sativa; three of them (therapeutic massage and Reiki) presented statistically significant results for the management of the cluster pain-anxiety-worry-dyspnea. Most studies presented a moderate risk of bias as per ROBINS-I tool.

CONCLUSION

Therapeutic massage and Reiki may be effective for the symptom clusters management, especially the pain-anxiety-worry-dyspnea cluster in children and adolescents undergoing palliative care.

Nutritional Screening and Assessment, and Quality of Life in Children with Cancer: A Cross-Sectional Study in Mainland China

PURPOSE

To apply Screening Tool for Risk on Nutritional status and Growth (STRONGkids) and the subjective global nutritional assessment (SGNA) for evaluating nutritional status, to identify the disease-related and demographic-related factors of malnutrition, and to examine the relationship between nutritional status and quality of life (QOL) in children with cancer during chemotherapy in mainland China.

DESIGN AND METHODS

Children, ages 2-18, with a leukemia, lymphoma, or solid tumor diagnosis were recruited from a top cancer center in Guangzhou, China. Socio-demographic information, clinical information were collected, while nutritional status using SGNA, malnutrition risk using STRONGkids, and QOL of these children were measured. Descriptive analyses, Chi²-tests, ANOVA and logistic regression analysis were used to analyze data.

RESULTS

Among included participants, 55.8% of them were malnourished, and 74.2% of them had moderate to high risk of malnutrition. The overall QOL and subscales were associated with nutritional status. In the logistic-regression model, high malnutrition risk, patients' mother having primary school education or less, worse physical functioning quality of life, and lower BMI level were strongly associated with malnutrition.

CONCLUSIONS

The prevalence of malnutrition in children with cancer is high, which related to worse QOL. Patients' BMI, physical functioning QOL and mothers' educational level could help to predict their nutritional status.

PRACTICE IMPLICATIONS

STRONGkids and SGNA could be widely used in mainland China. Health professionals should pay attention to patients with lower BMI and physical functioning scores, and patients' mother having primary school education or less.

Correlation Between Symptom Clusters and Quality of Life in Children With Acute Leukemia During Chemotherapy

BACKGROUND

Children with acute leukemia experience various distressing symptoms due to the disease and its treatment during chemotherapy. These symptoms cluster together and have negative impacts on patient outcomes.

OBJECTIVE

The aim of this study was to examine symptom clusters that children with acute leukemia undergoing chemotherapy are experiencing and the impact of these symptom clusters on their quality of life.

METHODS

A cross-sectional study design was used, and 184 Chinese children with acute leukemia who were undergoing chemotherapy were invited to participate in the study. Memorial Symptom Assessment Scale 10-18 and Pediatric Quality of Life Inventory General Core Module version 4.0 were applied. Exploratory factor analysis and multiple regression were used to identify symptom clusters and their influence on the quality of life.

RESULTS

Six symptom clusters were identified as gastrointestinal, emotional, neurological, skin mucosal, self-image disorder, and somatic cluster. The severity of each symptom cluster was negatively correlated with quality of life. Among them, gastrointestinal, emotional, and somatic clusters were significant predictors of quality of life.

CONCLUSIONS

There are multiple symptom clusters in children with acute leukemia, which seriously affect children's quality of life. To relieve symptom burden and improve quality of life, nursing and medical staff should pay attention to the symptom management and control in a symptom cluster perspective.

IMPLICATIONS FOR PRACTICE

The results of this study will provide suggestions for the healthcare provider to plan for these symptoms and manage any concurrent symptoms for the successful promotion of children's quality of life.

A musicoterapia em oncologia: percepções de crianças e adolescentes em cuidados paliativos

Resumo Objetivo analisar as percepções de crianças e adolescentes com câncer em cuidados paliativos sobre a musicoterapia. Método pesquisa de campo, com abordagem qualitativa, realizada com sete crianças e adolescentes hospitalizadas. A técnica de desenho-estória foi realizada inicialmente a partir do desenho sobre os sentimentos diante da hospitalização e a estória do desenho. Em seguida, houve a interação musical, desenho sobre o significado da música diante do processo de hospitalização, e a estória do desenho. Para análise, utilizou-se a técnica de análise de conteúdo. Resultados antes da musicoterapia, crianças e adolescentes expressaram sentimentos de tristeza, medo e saudade relacionados ao rompimento do vínculo familiar durante o processo de hospitalização. Após receberem a musicoterapia, elas expressaram as sensações de prazer e bem-estar que essa vivência pode proporcionar, permitindo-lhes a expressão dos sentimentos mais profundos. Conclusão a musicoterapia pode beneficiar a criança e o adolescente com câncer uma vez que permite a expressão de sentimentos, possibilita o resgate de lembranças e proporciona esperança diante da situação vivenciada, além do alívio da dor. Implicações para a prática a musicoterapia contribui no processo paliativista, podendo conferir uma melhor qualidade de vida às crianças e adolescentes com câncer.

Effectiveness of hospital clowns for symptom management in paediatrics: systematic review of randomised and non-randomised controlled trials

OBJECTIVE

To evaluate evidence from randomised controlled trials and non-randomised controlled trials on the effectiveness of hospital clowns for a range of symptom clusters in children and adolescents admitted to hospital with acute and chronic conditions.

DESIGN

Systematic review of randomised and non-randomised controlled trials.

DATA SOURCES

Medline, ISI of Knowledge, Cochrane Central Register of Controlled Trials, Science Direct, Scopus, American Psychological Association PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature.

STUDY SELECTION

Randomised and non-randomised controlled trials were peer reviewed using the following eligibility criteria: children and adolescents who were admitted to hospital for acute conditions or chronic disorders, studies comparing use of hospital clowns with standard care, and studies evaluating the effect of hospital clowns on symptom management of inpatient children and adolescents as a primary outcome.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently screened studies, extracted data, and appraised the risk of bias. Methodological appraisal was assessed by two investigators independently using the Jadad scale, the revised Cochrane risk-of-bias tool for randomised controlled trials (RoB 2), and the risk of bias in non-randomised studies (ROBINS-I) tool for non-randomised controlled trials.

RESULTS

24 studies (n=1612) met the inclusion criteria for data extraction and analysis. Most studies were randomised controlled trials (n=13). Anxiety was the most frequently analysed symptom (n=13), followed by pain (n=9), psychological and emotional responses and perceived wellbeing (n=4), stress (n=4), cancer related fatigue (n=3), and crying (n=2). Five studies used biomarkers, mainly cortisol, to assess stress or fatigue outcome following hospital clowns. Most of the randomised controlled trials (n=11; 85%) were rated as showing some concerns, and two trials were rated with a high risk of bias. Most non-randomised controlled trials (n=6; 55%) were rated with a moderate risk of bias according to ROBINS-I tool. Studies showed that children and adolescents who were in the presence of hospital clowns, either with or without a parent present, reported significantly less anxiety during a range of medical procedures, as well as improved psychological adjustment (P<0.05). Three studies that evaluated chronic conditions showed favourable results for the intervention of hospital clowns with significant reduction in stress, fatigue, pain, and distress (P<0.05).

CONCLUSIONS

These findings suggest that the presence of hospital clowns during medical procedures, induction of anaesthesia in the preoperative room, and as part of routine care for chronic conditions might be a beneficial strategy to manage some symptom clusters. Furthermore, hospital clowns might help improve psychological wellbeing in admitted children and adolescents with acute and chronic disorders, compared with those who received only standard care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018107099.

Perspectives of Childhood Cancer Symptom-Related Distress: Results of the State of the Science Survey

Management of symptom-related distress is an important area of pediatric oncology nursing. Participants who attended the Children's Oncology Group (COG) State of the Science Symposium on symptom distress completed an anonymous survey. The purpose was to explore participant perceptions of symptom distress experienced by children receiving cancer treatment on clinical trials, determine how symptom distress is currently assessed at COG institutions, and to identify what interventions are used to reduce symptom distress for these children. Among the 90 symposium attendees, 72% completed the survey, the majority (92%) of whom were nurses. The five most distressing symptoms in children with cancer enrolled on clinical trials identified by survey respondents were nausea/vomiting, fatigue, pain, anxiety, and sleep disturbances. Results from our survey also suggest that symptom distress may differ by disease type. For example, symptoms associated with leukemia/lymphoma included steroid side effects, procedural pain, and neuropathy. The majority of respondents (90%) also reported that symptoms go unrecognized by health care providers. The most commonly described unrecognized symptoms were behavioral (i.e., sadness, anxiety, fear, depression, and emotional needs; 45%) and fatigue (19%). Key focus areas reported by respondents included informal and inconsistent symptom assessment, the need for uniform measurement tools, and improved documentation of symptom-related distress. Management of symptom-related distress is an important aspect of pediatric oncology nursing. Further exploration of symptom distress experienced by children with specific types of cancers, and the development of standardized symptom assessment processes, will provide a foundation for developing future interventions aimed at alleviating symptom-related distress.

The Longitudinal Parallel Process Analysis of Biomarkers of Oxidative Stress, Symptom Clusters, and Cognitive Function in Children With Leukemia

Background: During treatment for acute lymphoblastic leukemia (ALL), children report co-occurring symptoms of fatigue, sleep disturbance, pain, nausea, and depression as a symptom cluster. Central nervous system-directed ALL therapies also put children at risk for cognitive impairments. Cancer therapies can cause an increase in oxidative stress, which may contribute to treatment-related symptoms. This study examined the longitudinal relationships between biomarkers of oxidative stress in the cerebrospinal fluid, the Childhood Cancer Symptom Cluster-Leukemia (CCSC-L), and cognition, in children over the first year of ALL treatment. Methods: Glutathione (GSH) biomarkers of oxidative stress were measured in cerebrospinal fluid collected during treatment lumbar punctures. GSH biomarkers, symptoms, and cognitive function of 132 children aged 3 to 18 years were evaluated at four time points during the first year of leukemia treatment. Participants, 7 years and older, completed self-report measures, and parents reported for younger children. Cognitive function measurements for all participants were completed by parents. A longitudinal parallel-process model was used to explore the influence of the initial measurement and the subsequent change over four time points of the GSH biomarkers on the CCSC-L and cognition. Results: GSH biomarkers increased over the four time points indicating decreasing oxidative stress. When GSH biomarkers were higher (less oxidative stress) at the initial measurement, the CCSC-L severity was lower, cognition was better, and cognition improved over the four measurements. Screening children for high levels of oxidative stress would be a foundation for future intervention studies to address symptom distress and cognitive impairments.

Priority Symptoms, Causes, and Self-Management Strategies Reported by AYAs With Cancer

CONTEXT

Cancer and symptom experiences of adolescents and young adults (AYAs) with cancer can be highly variable, creating challenges for clinicians and researchers who seek to optimize AYAs' health outcomes. Understanding the heuristics AYAs use to designate priority symptoms can provide insight into the meaning they assign to their symptoms and self-management behaviors.

OBJECTIVES

This study described the frequency and characteristics of priority symptoms. It qualitatively explored reasons for a symptom's designation as a priority symptom, perceived causes of priority symptoms, and strategies AYAs use to manage priority symptoms.

METHODS

Participants in this single-group, longitudinal study reported symptoms using a heuristics-based symptom reporting tool, the Computerized Symptom Capture Tool, at two scheduled visits for chemotherapy. AYAs designated priority symptoms and responded to three short answer questions: What makes this a priority symptom?, What do you think causes it?, and What do you do to make it better?

RESULTS

Eighty-six AYAs, 15-29 years of age (median 19 years), identified 189 priority symptoms. Priority symptoms were of greater severity (t = 3.43; P < 0.01) and distress (t = 4.02; P < 0.01) compared with nonpriority symptoms. Lack of energy, nausea, difficulty sleeping, and pain comprised 39% of priority symptoms. Reasons for priority designation included the impact of the symptom and the attributes of the symptom. Categories of self-management strategies included "Physical Care Strategies," "Things I take (or not)," and "Psychosocial Care Strategies."

CONCLUSION

Supporting AYAs to identify their priority symptoms may facilitate a more personalized approach to care. Seeking the patient's perspective regarding priority symptoms could enhance patient-clinician collaboration in symptom management.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

The Theory of Unpleasant Symptoms in Pediatric Oncology Nursing: A Conceptual and Empirical Fit?

Symptom management knowledge is a priority for pediatric oncology nursing research. Theories and models can frame the studies of symptoms experienced during childhood cancer. This article describes and analyzes the middle-range theory, theory of unpleasant symptoms (TOUS), for its conceptual and empirical fit with pediatric oncology nursing based on its current use in adult oncology research and its limited use to date in pediatric oncology. Searches in PubMed and CINAHL databases using the keywords theory of unpleasant symptoms and cancer and covering the time period 2000 to 2017 yielded 103 abstracts for review. Twenty published reports met eligibility criteria for review; only one included pediatric oncology patients. No study to date has tested all the components of the TOUS in pediatrics. The TOUS component of performance appears to be underaddressed across completed studies that instead include a focus on patient-reported quality of life rather than on perceived behavioral or performance indicators concurrent with the subjective symptom reports. Additionally, the influence of family, essential in pediatric oncology, is absent in the majority of studies guided by the TOUS. The TOUS is a structurally complicated framework that would be a conceptual fit for pediatric oncology if family influence and perceived function were included. Studies across this population and guided by the TOUS are needed, although testing all the theorized linkages in the TOUS would likely require a large sample size of patients and, thereby, multisite approaches given that cancer is a rare disease in childhood.

Pain, sleep patterns and health-related quality of life in paediatric patients with cancer

PURPOSE

To compare sleep and health-related quality of life (HRQOL) in children and adolescents with cancer who had pain, with those who had no pain during hospitalisation.

METHOD

A prospective comparative study was used to collect data from paediatric oncology units in three countries (Portugal, Brazil, USA). Participants (n = 118; 8-18 years) completed the Quality of Life Inventory (PedsQL) Cancer module, which includes a pain subscale, and wore a wrist actigraph for at least 72 hr.

RESULTS

Almost half of the participants (48.3%) reported having pain. Sleep patterns were not affected by pain. Girls, adolescents and patients diagnosed with leukaemia/lymphoma who reported pain, had significantly lower HRQOL scores. Low sleep duration and HRQOL were found, irrespectively of pain status.

CONCLUSIONS

The low sleep duration and HRQOL score in children and adolescents with cancer highlight the importance of physical and psychosocial nursing interventions during hospitalisation. The mediating effect of gender, age and diagnoses on the relation between pain and HRQOL needs to be further understood.

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

OBJECTIVES

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

SAMPLE & SETTING

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

METHODS & VARIABLES

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

RESULTS

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

IMPLICATIONS FOR NURSING

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

The association of age, literacy, and race on completing patient-reported outcome measures in pediatric oncology

PURPOSE

Age is often used to determine when children can begin completing patient-reported outcome (PRO) instruments or transition to adult instruments. This study's purpose was to determine relationships between literacy, age, and race and their influence on a child's ability to understand and complete a PRO instrument.

METHODS

The Wide Range Achievement Test was used to evaluate literacy in children and young adults with cancer, participating in a cognitive interview for the Pediatric PRO-CTCAE instrument. 140 participants (7-20 years) were recruited from 8 sites. Logistic regression and multivariable liner regression were used to examine relationships among key variables.

RESULTS

Higher literacy scores were significantly associated with fewer PRO-CTCAE items being identified as "hard to understand" (p = 0.017). Literacy scores increased with age, but older participants were more likely to fall behind expected reading levels compared with US norms. A 1-year increase in age was associated with a 19% increase in the likelihood for being below the expected WRAT word reading score (OR 1.19; 95% CI 1.06-1.33, p = 0.003). No associations were found between race and literacy.

CONCLUSIONS

Wide variations in literacy were noted across age groups. All participants were able to complete the Pediatric PRO-CTCAE, although most 7 year olds (63%) required reading assistance. Those with lower literacy skills were able to understand items suggesting that multiple factors may be involved in comprehension (developmental stage, concentration, vocabulary, or prior health experiences). Risk for falling below expected literacy levels increased with age implying a need for literacy consideration for cancer patients.

Validation of Clinical Indicators of the Nursing Diagnosis of Ineffective Protection in Adolescents With Cancer

PURPOSE

To validate the clinical indicators of the nursing diagnosis of Ineffective protection in adolescents with cancer based on diagnostic accuracy measurements.

DESIGN AND METHODS

Measurements of sensitivity and specificity for the indicators were calculated using latent class analysis with random effects in a sample of 127 adolescents between 10 and 19 years of age.

RESULTS

The prevalence of diagnosis was estimated at 93.7%. The indicators deficient immunity and weakness showed higher sensitivity values, whereas opportunistic infections, recurrent infections, insomnia, mucosal lesions, and coughing showed high specificity.

CONCLUSIONS

Seven indicators were clinically validated.

PRACTICE IMPLICATIONS

The validation of clinical indicators provides nurses with the knowledge of useful signs and symptoms to identify early spectra of a nursing diagnosis or confirm their presence in a specific population. In clinical practice, this knowledge contributes to an accurate diagnostic inference and the planning of nursing interventions directed to the idiosyncrasies of individuals.

Los grupos de síntomas en personas con cáncer: una revisión integrativa

Objetivo: explorar el estado actual de desarrollo investigativo del área temática de grupos de síntomas en adultos con cáncer. Método: revisión integrativa de producción científica generada entre 2001 y 2016. Se incluyeron 61 artículos por su aporte en la comprensión del área temática. Resultados: el estudio de los grupos de síntomas en personas con cáncer se consolida como un área temática novedosa, pertinente y necesaria para la investigación y práctica de enfermería en oncología, con tendencias y retos que incluyen: (1) El desarrollo de marcos conceptuales que aporten a la fundamentación, atributos y efectos (2) La determinación de métodos y formas de crearlos y clasificarlos (3) La generación de estudios con poblaciones específicas por tipos de cáncer y tratamiento y la consolidación de intervenciones de enfermería. Conclusiones: los pacientes con cáncer experimentan múltiples síntomas de forma simultánea durante las distintas fases de la enfermedad. Es incipiente el estudio de este fenómeno, los retos para la enfermería se centran en la generación de respuestas que alivien la carga de los grupos de síntomas y mejoren la calidad de vida de estos pacientes. Es necesario validar escalas de carga del síntoma y explorar los grupos de síntomas incluyendo variables clínicas ligadas a los tratamientos oncológicos.

Symptom Trajectories in Children Receiving Treatment for Leukemia: A Latent Class Growth Analysis With Multitrajectory Modeling

CONTEXT

Cancer treatment symptoms play a major role in determining the health of children with cancer. Symptom toxicity often results in complications, treatment delays, and therapy dose reductions that can compromise leukemia therapy and jeopardize chances for long-term survival. Critical to understanding symptom experiences during treatment is the need for exploration of "why" inter-individual symptom differences occur; this will determine who may be most susceptible to treatment toxicities.

OBJECTIVES

This study examined specific symptom trajectories during the first 18 months of childhood leukemia treatment. Symptom measures included fatigue, sleep disturbances, pain, nausea, and depression.

METHODS

Symptom trajectories of 236 children with leukemia three to 18 years old were explored prospectively over four periods: initiation of post-induction therapy, four and eight post-induction therapy, and the last time point was at the beginning of maintenance/continuation therapy. Latent class growth analysis was used to classify patients into distinctive groups with similar symptom trajectories based on patients' response patterns on the symptom measures over time.

RESULTS

Three latent classes of symptom trajectories were identified and classified into mild, moderate, and severe symptom trajectories. The only demographic characteristic with a significant relationship to membership in the latent class symptom trajectories was race/ethnicity. All other demographic characteristics including leukemia risk levels showed no significant relationships.

CONCLUSION

This study is unique in that groups of patients with similar symptoms were identified rather than groups of symptoms. Further research using latent class growth analysis is needed.