A typology of fatigue in children with cancer

Assessing fatigue in children and adolescents: Psychometric validation of the German version of the PROMIS® Pediatric Short Form v2.0 - Fatigue 10a in school children and pediatric chronic pain patients

Purpose

Fatigue is a common symptom in children and adolescents. Its negative impact on health outcomes is even more pronounced in those with chronic pain. There is currently no fatigue measurement tool in German that is validated for both children and adolescents with and without chronic pain. Therefore, this study aimed to gather quantitative validity evidence to support the use of the German version of the PROMIS^® Pediatric Short Form v2.0 - Fatigue 10a (PROMIS^® F-SF) in the German pediatric general population as well as in German pediatric chronic pain patients.

Methods

The 10-item self-assessment questionnaire was validated in a sample of N = 1348 school children (9–18 years; 52.4% female) and N = 114 pediatric chronic pain patients (8–17 years; 63.3% female). Construct and convergent validity, reliability, and item and scale characteristics were examined.

Results

Confirmatory factor analyses showed sufficient model fit for the 1-factor model of the questionnaire (school sample: CFI = 0.94, RMSEA = 0.10, SRMR = 0.04; patient sample: CFI = 0.90, RMSEA = 0.14, SRMR = 0.05). Convergent validity was supported by weak-to-large significant correlations with sleep quality, health-related quality of life (HRQoL), and pain characteristics. The questionnaire had excellent internal consistency in both samples (α = 0.92 and α = 0.93). Sex differences and age distributions of the PROMIS^® F-SF showed that girls reported significantly higher fatigue than boys and that fatigue increased with age.

Conclusion

The PROMIS^® F-SF is a reliable instrument with good psychometric properties. Preliminary evidence is provided that the questionnaire validly measures fatigue in children and adolescents with and without chronic pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03032-8.

Symptoms in Children Receiving Treatment for Cancer-Part I: Fatigue, Sleep Disturbance, and Nausea/Vomiting

Children and adolescents with cancer often undergo intensive chemotherapy treatment to obtain remission and long-term survival. The pursuit of successful treatment outcomes may lead to high levels of symptom distress related to treatment side effects and toxicities. The Children's Oncology Group Nursing Discipline held a State of the Science Symposium "Symptom Assessment During Childhood Cancer Treatment" in 2018 that included reviews of evidence regarding key symptoms. The purpose of this review is to summarize and synthesize the evidence presented about the prevalence, relationships, trajectories, and associated biomarkers of selected symptoms experienced by children and adolescents during cancer treatment. Five symptoms were selected, with the focus on fatigue, sleep disturbance, and nausea/vomiting and included in Part I of the review. Using Ovid-Medline, studies published between 2008 and 2018 that focused on these specific symptoms during active chemotherapy treatment were selected. Fatigue interferes with normal developmental activities and is associated with sleep disturbances, and its pattern changes within a cycle of chemotherapy as well as across the treatment trajectory. Sleep is disrupted by the hospital environment, treatment medications, and changes in normal childhood and schedules. Disturbances of sleep persist during treatment, preventing recovery from poor quality sleep. Although pharmacologic interventions have advanced for treatment of nausea and vomiting, children and adolescents continue to struggle with this symptom. Its trajectory changes with the intensity of treatment, and over half of the patients report that they experience nausea and/or vomiting. Future research is needed to advance identification of biologic risk factors for symptoms and test effectiveness of symptom-related interventions.

The Effect of Fatigue-Related Education on Pediatric Oncology Patients' Fatigue and Quality of Life

The identification of cancer-related fatigue as a clinical problem in pediatric oncology is an important phenomenon, and there are limited number of studies about raising the awareness of pediatric oncology patients and their parents. Fatigue-related education for patients and their parents before and during cancer treatment reduces the fatigue levels of patients. This study aims to analyze the effect of fatigue-related education for pediatric oncology patients aged 7-12 and their parents on their fatigue and quality of life. This study was conducted with 80 children with cancer and their parents who were assigned to either the control group (n = 40) or the experimental group (n = 40). The experimental group received a fatigue-related educational program. The data were collected three times: prior to the program, 3 months later, and 6 months afterwards. Multidimensional variance analysis, the Bonferroni adjusted t test and regression analysis were used to analyze the data. A significant difference was found among the experimental and the control group for total mean scores and the mean scores of subdimensions of the Scale for the Assessment of Fatigue-Child Form in terms of the interactions of group, time, and group*time (p < 0.05). Significant differences were found among the experimental and control groups' mean scores on the Scale for the Quality of Life-Child and Parents Form in terms of the interactions of group, time, and group*time (p < 0.05). Fatigue-related education is an effective education model as a way to reduce fatigue and increase the quality of life of children with cancer. The use of fatigue-related education by nurses in pediatric oncology clinics will have positive effects on children and their parents.

Physical Activity and Quality of Life of Healthy Children and Patients with Hematological Cancers

The aim was to assess the level of physical activity and the quality of life of children undergoing cancer treatment, during and after the completion of the treatment. Eighty-eight children aged 11–15 were enrolled. Three groups of children were assessed, i.e., children undergoing cancer treatment (n = 30), children after cancer treatment (n = 28), and healthy children (n = 30). The level of physical activity in children was assessed using the questions from the Health Behavior in School-Aged Children (HBSC) questionnaire. The assessment of children’s quality of life was conducted using the KIDSCREEN-10 Index. The chi-square test was used to assess the statistical significance of the differences in the results between the study groups in the case of both HBSC and KIDSCREEN-10 questionnaires. Children undergoing cancer treatment did not perform any physical activity of at least 60 min (in total) per day, during the week. Therefore, they did not meet the recommendations related to the appropriate level of daily physical activity (Moderate-to-Vigorous Physical Activity; MVPA). Children after cancer treatment and healthy children significantly more frequently undertook physical activity. The quality of life of children with cancer is significantly lower and different from the quality of life of healthy children.

Fatigue in pediatric liver transplant recipients and its impact on their quality of life

The aim of the study was to investigate the occurrence of fatigue in 100 pediatric liver transplant recipients aged 2-18 years and its impact on their health-related quality of life (HRQL). HRQL and fatigue were measured using the PedsQL 4.0 Inventory and the PedsQL Multidimensional Fatigue Scale, which encompasses three subscales: general fatigue, sleep/rest fatigue, and cognitive fatigue. The impact of the different domains of fatigue and of clinical and sociodemographic factors on the HRQL was identified with stepwise multiple regression analyses. Parent proxy-reports were available for all 100 participants (2-18 years), and child self-reports were available for 71 patients (8-18 years). Across all domains, participants and their parents reported significantly more fatigue than healthy peers in a large PedsQL validation study. Thirty-seven percent of patients and 57% of parents scored clinically relevant levels of fatigue. In the multiple regression analyses, none of the clinical and sociodemographic factors contributed to the HRQL for child self-report. Only general and cognitive fatigue were significant predictors of patients' HRQL, explaining 66% of the variance in the PedsQL total score. For parent proxy-report, general and cognitive fatigue also significantly predicted child's HRQL. Further predictors were child's age and family income. The regression model explained 65% of the variance. These findings demonstrate the importance of assessing fatigue during regular follow-up examinations. Further research is urgently needed to better understand the underlying mechanisms of fatigue. Improvement of fatigue symptoms is essential for better HRQL, for cognitive functioning, and for school achievement.

Childhood Cancer-Related Fatigue and Day-to-Day Quality of Life

Childhood cancer-related fatigue is often viewed as an inevitable symptom of cancer and cancer treatment leading to underassessment by health care providers and self-management by families in the home and hospital environment. Parents' perspectives of the influence of childhood cancer-related fatigue on their child's day-to-day life is needed to understand how parents may or may not prioritize, report, and/or manage the fatigue symptom. This qualitative study used conventional content analysis to describe parents' observations and perspectives on the influence of fatigue in their child's day-to-day quality of life (QOL). Eleven interviews were gathered from parents. The concept childhood cancer-related fatigue and domains of QOL in pediatric oncology patients were used to guide the study, construct interview questions, and conduct conventional content analysis. A synthesis of three categories and seven codes led to three major findings: (a) parents perceive their child's symptoms as co-occurring not as a discrete entity of fatigue, (b) parents accept the child's behavior as a "new normal," and (c) parents recognize fatigue as a warning sign. The study findings reveal differences in how parents observe childhood cancer-related fatigue and how they perceive the symptom influences day-to-day QOL. Findings of this study support current guidelines underscoring the importance of multidimensional fatigue care. Additionally, the findings suggest a standardized multiple symptom instrument may be helpful in assessing symptom experience.

Fatigue following Paediatric Acquired Brain Injury and its Impact on Functional Outcomes: A Systematic Review

Fatigue is a commonly reported sequela following an acquired brain injury (ABI), and can have a negative impact on many areas of a child's life. However, there is minimal research that focuses on fatigue specifically, and so factors such as its occurrence, duration, and impact on functioning remain uncertain. This systematic review aims to provide a comprehensive summary of the research to date, bringing together a number of studies with a focus on paediatric ABI and fatigue. Terms were searched in relevant databases (PsycInfo, Medline, CINAHL), and articles were included or excluded based on specified criteria. Of the 1177 papers identified in the original search, a total of 9 papers met inclusion criteria, and were categorised as traumatic brain injury (TBI; n = 4), meningitis and meningococcal disease (n = 2), brain tumours (n = 2), and mixed ABI group (n = 1). Key findings suggest that fatigue is a problem encountered by a significant proportion of patients in all the studies reviewed, and often occurred regardless of the cause; fatigue was also associated with poor academic achievement, limited physical activity, and social and emotional problems. Injuries of greater severity were associated with higher levels of fatigue and worse outcomes. Several management options were suggested, though their efficacy was not reported. Future research is required with a suggested focus on using multiple time points to better understand the trajectories of fatigue following childhood ABI, and to build an evidence base to determine which management options are most suitable.

Non-pharmacological interventions for management of fatigue among children with cancer: systematic review of existing practices and their effectiveness

OBJECTIVES

Fatigue is common among children living with cancer, particularly in advance stages. Little is known about the effectiveness of non-pharmacological approaches to manage this complex and distressing symptom among children. Thus, the present paper aim to critically examine the effectiveness and setting for non-pharmacological interventions to manage fatigue among children with cancer.

METHODS

Six electronic databases were screened first in February 2013 and at second instance in March 2015. They include PsycINFO, Medline, EMBASE, CINAHL, Scopus and Cochrane library. All databases were systematically searched for literature on fatigue and cancer, limited to children (as age group) and English language.

RESULTS

1498 articles were identified, of which six were reviewed. Three types of interventions for managing fatigue were identified including (1) complementary and alternative medicine (healing touch/massage therapy), (2) exercise-based interventions and (3) nursing-based interventions. Most interventions were delivered during active treatment and in hospital settings where parents were involved to optimise participation. Despite fatigue scores being lower among intervention groups, no study findings were observed as being statistically significant.

CONCLUSION

Fatigue is common among children treated for and living with cancer. The most appropriate setting to deliver non-pharmacological interventions to manage fatigue appears to be in hospital. However, in absence of any strong evidence, professionals need to be cautious about existing non-pharmacological interventions. Future research must adopt more rigorous research designs that are adequately powered using validated measures to identify potential benefits. In addition, researchers may wish to test psychosocial interventions shown to be of benefit in adults.

Does socioeconomic status impact physical activity and sleep among children with cancer?

BACKGROUND

Compared with healthy children, pediatric oncology patients have impaired sleep and engage in less physical activity (PA). Socioeconomic status (SES) may be one determinant of PA and sleep among pediatric oncology patients.

PROCEDURE

Between November 12, 2009 and March 27, 2013, 50 pediatric oncology patients between the ages of 8 and 18 years were recruited from an urban children's hospital. PA and sleep were assessed by actigraphy and diaries over 7 days. Fatigue was assessed using the Fatigue Scale. SES was defined by primary payer status of insurance (state or private) and by Median Household Income (MHI) obtained from 2010 U.S. Census block data for residences. MHI was compared to Connecticut state median income ($67,000). Multivariate regression models examined the relationship between SES and PA, sleep and fatigue.

RESULTS

PA and sleep efficiency were strongly correlated (r = 0.31, P = 0.03). Children with state insurance had higher average PA (P = 0.004) than children on private insurance. There were no significant differences in PA or sleep efficiency by block MHI. The 7-day fatigue score was lower among the participants aged 8-12 years in the group with MHI less than $67,000 (P = 0.03), although there was no significant difference among participants aged 13-18 years in the group. There was no difference in mean fatigue scores by insurance status.

CONCLUSIONS

Participants on state insurance had higher PA than those with private insurance. Although block MHI did not influence PA or sleep efficiency among children with cancer, participants aged 8-12 years in a lower MHI block had less fatigue. Future research is needed to further understand how SES influences PA.

Striving to Survive: Families’ Lived Experiences When a Child Is Diagnosed With Cancer

When a child is ill with cancer, this affects the whole family for long periods. The aim of this study was to elucidate the family’s lived experience when a child in the family was diagnosed with cancer. A descriptive inductive design with a hermeneutic phenomenological approach including interviews with 17 families (parents, children, and siblings) was chosen. The families’ lived experience was described as a 2-fold essential theme comprising “a broken life world” and an immediate “striving to survive.” The families’ secure everyday life disappeared and was replaced by fear, chaos, and loneliness. When striving to make the child and the family survive, family members strove to feel hope and have a positive focus, to gain control, and to feel close to other people. Phenomenological human science research can deepen the understanding of the meaning of being a family with a child who is ill with cancer and can help pediatric oncology staff become increasingly thoughtful, and thus better prepared to take action to diminish the chaos occurring in the family.

An Examination of Fatigue in Advanced Childhood Cancer

Fatigue is a complex phenomenon without a widely accepted definition, and is one of the least explained phenomena of advanced disease. A great deal of work and research has been done to explore the experience, incidence, and management of fatigue in children with cancer. Fatigue remains, however, a source of suffering for children with advanced disease and their families. The knowledge we have gained from the study of fatigue in children receiving antineoplastic therapy can be applied to children during this phase of their illness. The goal of this article is to address the incidence of fatigue in the advanced stage of illness, review the literature regarding fatigue in pediatric oncology, and propose how such findings may be applicable to children in the later stages of their illness.

Quality of Life among Childhood Leukemia Patients

The purpose of this qualitative descriptive study was to allow childhood leukemia patients to describe their quality of life (QoL) in their own words. These personal accounts provide an opportunity for health care personnel to understand the impact that leukemia has on these children. A total of 13 children in three focus group interviews participated. They ranged in age from 5 to 9 years and were either off therapy or had completed at least 6 months of treatment. Four semistructured interview questions were used to guide the interviews. Each question related to a domain identified in previous research as having an effect on QoL. Thus, the areas explored in this study were (a) physical well-being and symptoms, (b) psychological well-being, (c) social well-being, and (d) spiritual well-being. Five themes were identified: (a) fatigue, (b) the effect on activities, (c) medication and treatment effects, (d) relationship changes, and (e) hair loss.

Symptom Management Research in Children With Cancer

A review of the clinical research studies published within the past 5 years revealed that efforts to manage symptoms of cancer and its treatments have not kept pace with new advances in the cure for cancer. Children with cancer continue to experience distressing physical symptoms caused by the disease and treatment. The purpose of this article is to provide a concise overview of the most common symptoms experienced by children with cancer. These symptoms include pain, nausea and vomiting, nutritional concerns, mucositis, and fatigue experienced by the child with cancer. Recommendations for future research are addressed.

Pilot Study of Massage to Improve Sleep and Fatigue in Hospitalized Adolescents With Cancer

BACKGROUND

Adolescents with cancer experience many troubling symptoms, including sleep disruptions that can affect mood and quality of life. Massage is a safe and popular intervention that has demonstrated efficacy in pediatric and adult patients with cancer. This study aimed to assess the feasibility of conducting a massage intervention to help with sleep in hospitalized adolescent oncology patients.

PROCEDURE

Adolescents ages 12-21 with cancer who were expected to be hospitalized for at least four consecutive nights were recruited from the inpatient unit at Children's National Health System and randomized to either massage intervention or a waitlist control. Patients in the intervention group received one massage per night, for two or three nights. Sleep was measured with actigraphy and patient and proxy reported instruments were used to measure fatigue, mood, and anxiety.

RESULTS

The majority (78%) of patients approached for the study consented, and almost all patients in the intervention group (94%) received at least one massage, 69% received two, and rates of completion of instruments among adolescents were high demonstrating feasibility. There were trends toward increased night time and overall sleep in the intervention group compared with standard of care, but no differences between groups in the patient reported outcome measures. Participant and parent feedback on the intervention was positive and was the impetus for starting a clinical massage service at the hospital.

CONCLUSIONS

Massage for hospitalized adolescents with cancer is feasible, well received, and can potentially improve patients' sleep. A randomized multicenter efficacy study is warranted.

Explaining antiretroviral therapy adherence success among HIV-infected children in rural Uganda: a qualitative study

High adherence is critical for achieving clinical benefits of HIV antiretroviral therapy (ART) and particularly challenging for children. We conducted 35 qualitative interviews with caregivers of HIV-infected Ugandan children who were followed in a longitudinal study of real-time ART adherence monitoring; 18 participants had undetectable HIV RNA, while 17 had detectable virus. Interviews blinded to viral suppression status elicited information on adherence experiences, barriers and facilitators to adherence, and social support. Using an inductive content analytic approach, we identified 'lack of resources,' 'Lazarus effect,' 'caregiver's sense of obligation and commitment,' and 'child's personal responsibility' as categories of influence on adherence, and defined types of caregiver social support. Among children with viral suppression, high hopes for the child's future and ready access to private instrumental support appeared particularly important. These findings suggest clinical counseling should explore caregivers' views of their children's futures and ability to access support in overcoming adherence barriers.

Yoga for Children and Adolescents After Completing Cancer Treatment

Survivors of childhood cancer may experience persistent symptoms, including fatigue, sleep disturbance, and balance impairment. Yoga is a complementary therapy that improves fatigue, sleep, and quality of life in adult cancer survivors. Using a one group, repeated measures design, we evaluated the feasibility of a yoga program and assessed if cancer survivor participants ages 10 to 17 years (n = 13) had significantly less fatigue and anxiety, and better balance and sleep, after a 6-week yoga intervention compared with a 6-week pre-intervention wait period. Study recruitment was challenging with a 32% enrollment rate; yoga attendance was 90%. None of the scores for anxiety, fatigue, sleep, and balance had significant changes during the wait period. After the 6-week yoga program, children (n = 7) had a significant decrease in anxiety score ( P = .04) while adolescent scores (n = 7) showed a decreasing trend ( P = .10). Scores for fatigue, sleep, and balance remained stable post-intervention. Fatigue and balance scores were below norms for health children/adolescents while sleep and anxiety scores were similar to healthy peers.

Initial Validation of the HIV Treatment Regimen Fatigue Scale for Adults Prescribed Antiretroviral Therapy

Clinical observations have linked antiretroviral nonadherence to treatment regimen fatigue in persons living with HIV (PLWH). Although nonadherence appears to be a consequence of treatment regimen fatigue, little is known about the onset, course, and duration of this construct. Our study developed and evaluated psychometric properties of a measure of treatment regimen fatigue for PLWH. Based on a recent review, the concept was hypothesized to reflect decreased motivation, treatment cynicism, and low self-efficacy to adhere to treatment. Items comprising these factors were generated based on measures of similar constructs in the literature. Exploratory factor analyses suggested that a two-factor solution best fit the data and accounted for 35.8% of the variance. Our study supported a two-factor model of treatment regimen fatigue consisting of Treatment Cynicism and Self-Efficacy. The scale provides a new tool to assess treatment regimen fatigue in PLWH and can be used to inform and improve treatment of HIV.

A qualitative assessment of barriers to antiretroviral therapy adherence among adolescents in western Kenya

Antiretroviral therapy (ART) requires nearly perfect adherence to be effective. This study aims to identify key factors identified by HIV-infected adolescents on ART as contributing to medication adherence in western Kenya. Using a qualitative study design, three adolescent focus groups discussions were conducted at an urban and rural clinic site in western Kenya. The study population included HIV-infected adolescents receiving ART through the USAID-AMPATH HIV care system. A trained facilitator conducted groups in Kiswahili using a semi-structured interview guide probing multiple aspects of experience of taking medicines. Transcribed focus group dialogues were analyzed using constant comparison, progressive coding, and triangulation. The adolescents described a context of negative societal beliefs about HIV, necessitating a lifestyle of secrecy and minimizing the information shared about HIV or ART. Assessing and addressing adolescents' fears and behaviors regarding medication secrecy and disclosure may enable more accurate monitoring of adherence and development of intervention strategies.

Fatigue and carnitine levels over multiple cycles of chemotherapy in children and adolescents

PURPOSE

Fatigue in childhood cancer is a pervasive and distressing symptom described as a "lack of energy". Carnitine is a micronutrient used to transport long chain fatty acids into muscle mitochondria. Some chemotherapy drugs interfere with the carnitine network. Both carnitine and fatigue relate to physical energy and may be influenced by chemotherapy. Using a repeated measures design, change in carnitine levels and change in fatigue in childhood cancer patients receiving ifosfamide, cisplatin, or doxorubicin were examined over multiple chemotherapy cycles. The influence of carnitine levels on fatigue was evaluated.

METHODS AND SAMPLE

Fifty-eight patients, between ages 3 and 18 years, within two months from diagnosis and receiving cisplatin, doxorubicin, and/or ifosfamide chemotherapy drugs, participated. Measurements included carnitine plasma levels and self-reported fatigue using established child or adolescent fatigue scales and were collected during the 2nd cycle of chemotherapy, and repeated on alternating cycles up to cycle 8. The Parent Fatigue Scale was used for children under age 7.

KEY RESULTS

Total and free carnitine levels did not change significantly for the group. Fatigue decreased significantly in children age 7-12 (p = 0.04). Relationships between fatigue and carnitine were not significant.

CONCLUSIONS

Changes in carnitine plasma levels were not significant in this sample of patients. The carnitine levels remained within the reference values for children and were not associated with fatigue levels. School-age children may be more resilient to fatigue over the trajectory of treatment. Further research is needed into the biologic mechanisms of fatigue.

Assessment of physical performance using the 6-minute walk test in children receiving treatment for cancer

BACKGROUND

The study of physical performance in children with cancer is emerging as an important variable in symptom research. Studies have shown that children with cancer experience deficits in physical performance during treatment that may be present years after therapy.

OBJECTIVE

The aim of this study was to determine if distance on the 6-minute walk test (6MWT) changed in children during the first 3 cycles of cancer treatment and to compare the distances walked with healthy norms.

METHODS

This is a secondary data analysis of 19 boys and 10 girls, aged 6 to 17 years, who were newly diagnosed with cancer and were part of a larger study that measured changes in fatigue and physical performance during the first 3 cycles of chemotherapy. Participants performed the 6MWT between days 15 and 29 of the first and third cycles of chemotherapy.

RESULTS

Pediatric cancer patients did not have a significant change in the distance walked at cycle 3 of chemotherapy compared with cycle 1. When compared with 2 different normative data sets for healthy children, most children with cancer performed significantly below their peers.

CONCLUSIONS

Children had poor strength and endurance after 3 cycles of chemotherapy even when their disease was responding to treatment. Interventions are needed to promote rehabilitation and maintenance of physical performance, as both are important to quality of life and ongoing child development.

IMPLICATIONS FOR PRACTICE

Children receiving cancer treatment who are ambulatory may appear to be functioning normally but are in fact severely deconditioned compared with their healthy peers.

Children's lived experiences of hematopoietic stem cell transplantation

Although hematopoietic stem cell transplantation is a valuable treatment in many life-threatening pediatric disorders, a large number of children who receive hematopoietic stem cell transplantation are faced with a variety of physical and psychological problems throughout this process. In this study, we explored the lived experiences of these children during their treatment to provide a better understanding of their main concerns, emotions, and expectations. The participants were six children, aged between 6 and 17 years, who underwent hematopoietic stem cell transplantation. Data were collected through individual, in-depth, and semistructured interviews. Using interpretive phenomenological analysis, the findings revealed that the children experienced "transplantation rejoicing" in this "difficult passage", which was associated with "deepening of family ties". Awareness of these experiences, feelings, and concerns can help in the development of more professional interventions to provide children with holistic care during their hospitalization.

A pilot exploration of symptom trajectories in adolescents with cancer during chemotherapy

BACKGROUND

Chemotherapy is frequently administered in repetitive cycles. Adolescents with cancer have multiple symptoms related to chemotherapy, but knowledge of symptom trajectories across a cycle is limited. Examining trajectories over a cycle may reveal key periods to manage symptoms.

OBJECTIVES

The aims of this pilot were to describe the trajectory of symptoms (pain, sleep, appetite, nausea, fatigue) and biological and behavioral variables (anxiety, stress, hematologic function) across 1 cycle and examine relationships between variables.

METHODS

Nine adolescents with cancer within 6 months of diagnosis participated. Data were collected by surveys, chart review, and biologic measures on days 1 and 2 of the cycle, 1 week later (nadir), and day 1 of the following cycle. To evaluate the trajectory, a simple random-effects repeated-measures analysis was computed.

RESULTS

The significant trajectories were fatigue (P = .003), difficulty sleeping (P = .032), and nausea (P = .04). Most of the adolescents reported some anticipatory anxiety about receiving chemotherapy. Significant correlations between symptoms and biobehavioral variables included anticipatory anxiety and nausea (r = .86, P = .003), trait anxiety and fatigue (r = -0.82, P < .001), and stress and pain (r = 0.78, P = .039).

CONCLUSIONS

Multiple symptoms were experienced across the cycle. Three symptoms displayed significant trajectories indicating that patterns of symptoms may be anticipated.

IMPLICATIONS FOR PRACTICE

Pilot findings suggest that monitoring symptoms, stress, and anxiety across a cycle is important, not only during chemotherapy administration, but also prior to being admitted for chemotherapy.

Pediatric chronic illness (cancer, cystic fibrosis) effects on well siblings: parents' voices

This study is a secondary analysis of data gathered during baseline data collection prior to a cognitive-psychosocial-respite intervention provided in a randomized controlled trial (RCT). Content analysis was used to identify themes in parents' responses to an open-ended item about their perceptions of the effects on siblings of having a brother or sister who has either cancer or cystic fibrosis (CF). Of 91 themes tallied in the cancer group (n = 29), 74.5% reflected negative manifestations of increased risk in siblings, 1.1% no risk; and 24.2%, positive outcomes. Of 53 themes tallied in the CF group (n = 15), the same three categories had 67.9 %, 0%, and 32.1%, respectively. Contemporary life in these families portrayed in parents' descriptions not only validate the rationale for the RCT done, but also suggest the need in ambulatory pediatrics for intervention research on these vulnerable populations.

Review of symptom experiences in children and adolescents with cancer

BACKGROUND

Inadequate symptom relief in children and adolescents with cancer leads to unnecessary suffering. This review assesses research on children and adolescents with cancer that had been published from 2002 to 2010.

OBJECTIVES

The review identifies the symptom experiences of children and adolescents undergoing treatment and describes the progress that has been made since Docherty's 2003 systematic review of nurse researcher published studies from 1990 to 2002, which identified gaps in research on the symptoms of pediatric oncology patients.

METHOD

A computerized search of medical and nursing literature produced 50 published studies and 2 dissertations that addressed the symptom experiences of children and adolescents receiving treatment for cancer.

RESULTS

Pain from cancer-related procedures and fatigue were the most frequently identified symptoms, followed closely by nausea and vomiting. More preschool-aged subjects and nonwhite subjects need to be assessed, distinctions between age groups and gender should be explored, and instrumentation for the prereading group must be developed.

CONCLUSIONS

Research on symptoms experienced by children and adolescents has gained momentum within the last 10 years, and some of the gaps identified by Docherty have been addressed. Multicenter trials would increase sample sizes and decrease enrollment time.

IMPLICATIONS FOR PRACTICE

By synthesizing research completed from 2002 to 2010 on symptoms of children who had cancer, new ideas can be generated and shared with clinical nursing staff to improve patient care. Gaps to further direct research are also identified.

Symptoms in children with advanced cancer: child and nurse reports

BACKGROUND

Systematic studies on the specific symptom experience in children with advanced cancer are limited.

OBJECTIVE

The objective of the study was to examine the common symptoms and to explore commonly occurring symptoms over time.

METHODS

A prospective and longitudinal study design was used. Data were collected at 10 data points from 60 children over a 5-month period. Children ranged from 6 to 17 years old, spoke English or Spanish, were diagnosed with advanced cancer, and were receiving healthcare in 1 of 4 Southern California hospitals. Nurses' documentations of symptoms were examined.

RESULTS

The study sample was composed of children 6 to 12 years old (52%) and 13 to 17 years old (48%); 42% were female, and 58% were male. Fifty-five percent were Latino, and 30% were Caucasian. Pain, nausea, drowsiness, and energy loss were reported by children in more than 50% of the interviews. Children's and nurses' reports of symptoms were similar except children reported significantly more frequency and intensity of pain.

CONCLUSION

Children with advanced cancer were able to report and describe their symptoms. There were few differences by gender, age, and ethnicity.

IMPLICATIONS FOR PRACTICE

It is important that children's symptoms are clearly communicated to nurses, and these study findings may be used to anticipate and manage the symptoms experienced by children with advanced cancer.

Fatigue in survivors of childhood acute lymphoblastic and myeloid leukemia in Japan

BACKGROUND

Fatigue in cancer survivors is a serious problem in pediatric oncology, but reports on this issue are limited, especially in Asian countries.

METHODS

Sixty-three patients with acute lymphoblastic leukemia and 18 patients with acute myeloid leukemia who attended a follow-up outpatient clinic were enrolled. Participants were required to be >8 years of age, in remission, and without any cancer treatment for at least the previous 1 year. A control group consisted of 243 subjects whose age and gender were matched with the patient group. A questionnaire consisting of 12 items was devised for fatigue measurement.

RESULTS

Principal factor analysis identified three dimensions, defined as physical fatigue, decreased function, and altered mood. The mean total and the three fatigue dimension scores tended to be higher in the control group, but significant differences between the scores were seen only in the total and physical fatigue scores. Multiple regression analysis indicated an association of present older age or shorter duration after completion of treatment with total and physical fatigue, and an association of presence of total body irradiation with decreased function.

CONCLUSION

Pediatric leukemia survivors in Japan experience equal or less fatigue compared with that of controls in different fatigue dimensions. Elucidation of underlying mechanisms of cancer-related fatigue including the differences of cultural background among different countries is necessary for future study of this issue.

Fatigue in young survivors of extracranial childhood cancer: a Finnish nationwide survey

PURPOSE/OBJECTIVES

To evaluate self-reports of fatigue by young cancer survivors (aged 11-18 years), to compare young survivors' fatigue scores with the scores of a healthy control group and of the parent proxy evaluation, and to analyze whether demographic or disease-related factors are associated with young survivors' fatigue.

DESIGN

Cross-sectional quantitative study.

SETTING

An urban hospital in southwestern Finland.

SAMPLE

384 survivors diagnosed with an extracranial malignancy at age 16 or younger, who have survived four or more years postdiagnosis, and who are free of cancer. General matched population controls were randomly selected from the Finnish Population Registry.

METHODS

Demographic data and a self-report written fatigue questionnaire.

MAIN RESEARCH VARIABLES

Total fatigue (TF), general fatigue (GF), sleep or rest fatigue (SF), and cognitive fatigue.

FINDINGS

The control populations reported significantly more issues with TF, GF, and SF than did the survivor population. In survivors, older age, the need for remedial education at school, and a sarcoma diagnosis were associated with increasing fatigue, whereas female gender, better school grades, and greater health-related quality-of-life (HRQOL) scores were associated with lower fatigue. The study variables explained 49%-65% of the variation in fatigue scores.

CONCLUSIONS

Although survivors and their matched controls seem to have similar fatigue, subgroups of survivors do experience excessive fatigue, which may have an impact on their HRQOL.

IMPLICATIONS FOR NURSING

This study increases the knowledge about fatigue levels of young survivors of extracranial malignancies and identifies the need for instruments specifically designed to assess fatigue in this population. The healthcare team should pay attention to the fatigue level of young survivors, particularly SF.

Exercise Recommendations for Cancer-Related Fatigue, Cognitive Impairment, Sleep problems, Depression, Pain, Anxiety, and Physical Dysfunction: A Review

Cancer and its treatments produce a myriad of burdensome side effects and significantly impair quality of life (QOL). Exercise reduces side effects and improves QOL for cancer patients during treatment and recovery. Exercise prior to, during, and after completion of cancer treatments provides numerous beneficial outcomes. Exercise represents an effective therapeutic intervention for preparing patients to successfully complete treatments, for reducing acute, chronic and late side effects, and for improving QOL during and after treatments. This overview of exercise oncology and side-effect management summarizes existing evidence-based exercise guidelines for cancer patients and survivors.

Sleep-wake patterns of school-age children and adolescents before diagnosis and during induction chemotherapy for acute lymphocytic leukemia

Sleep disturbances are commonly reported by children receiving chemotherapy for leukemia. Sleep patterns before diagnosis and during induction chemotherapy were evaluated in 38 children (7 to 18 years old). Child Sleep Assessment (CSA) was used to evaluate sleep patterns prior to diagnosis. Sleep diaries and actigraphy were used during chemotherapy. Adolescents went to bed later and awakened later than school-age children before diagnosis and during chemotherapy. During chemotherapy, children averaged 60 minutes of nighttime wake time. The early recognition of sleep problems associated with disease, treatment, and age is important for school-age children and adolescents with leukemia.

Psychometric and clinical assessment of the 13-item reduced version of the fatigue scale-adolescent instrument

Fatigue is one of the most common and distressing symptoms experienced by adolescents during and after treatment for cancer. The lack of reliable and valid instruments has prevented an accurate assessment of the trajectory of fatigue among adolescent oncology patients. The purposes of this study were to identify the items on the Fatigue Scale-Adolescent (FS-A) that distinguished adolescents with high fatigue and to identify the most sensitive and specific score ("cut score") in order to identify those in need of a fatigue intervention. Rasch methods were used to identify FS-A items that distinguished adolescents with high cancer-related fatigue, and results indicated that the 14-item FS-A could be reduced to 13 items. The 13-item FS-A was assessed for its psychometric properties, with application of the receiver operating characteristics curve analysis to the responses from 75 adolescents. The internal consistency coefficient was .87, and a 4-factor confirmatory analysis achieved good fit coefficients. The identified cut score was 31, with 66.6% sensitivity and 82.6% specificity; 16 (21.33%) of the patients scored 31 or higher. The 13-item FS-A has acceptable psychometric properties and is able to identify adolescent oncology patients with high fatigue.

Children receiving treatment for cancer and their caregivers: a mixed methods study of their sleep characteristics

BACKGROUND

Sleep has a significant impact on the daily functioning of children and their parents. The purpose of this study was to describe and gain an understanding of the sleep characteristics of children receiving treatment for cancer and their caregivers using a mixed methods concurrent triangulation design.

PROCEDURE

Data were collected from questionnaires completed by 35 caregivers of children receiving treatment for cancer and compared to similar data from 64 caregivers of healthy children.

RESULTS

There was considerable variability in the sleep characteristics of the children receiving treatment for cancer as reported by their caregivers. However, as a group, the magnitude of their sleep problems, particularly among the adolescents, was significantly greater than that of the comparison group and had the potential to impact negatively on their participation in everyday life. They had poorer sleep efficiency. Many impairments, particularly pain, nightmares, and symptoms associated with steroid administration, impacted their sleep. Their caregivers also experienced an increased prevalence of sleep issues, which impacted their daytime functioning. Suggestions to prevent and treat the sleep issues of children receiving treatment for cancer focused on practicing good sleep habits, ensuring a safe, secure, and comfortable sleep environment, and using non-pharmaceutical and pharmaceutical interventions to address impairments interfering with sleep. Caregivers noted that it was important to take care of themselves by getting sufficient sleep and accepting help from others.

CONCLUSIONS

Sleep issues are prevalent in families of children receiving treatment for cancer and should be assessed routinely and addressed.

Health Professionals’ Estimation of Cancer-Related Fatigue in Children

Many studies show that cancer-related fatigue is one of the most common symptoms experienced by children as a side effect of cancer therapy. This problem has grown considerably in recent years; the exact mechanisms underlying fatigue remain unclear. Therefore, assessing and managing this symptom can be problematic. This article describes the findings from a survey evaluating how health professionals (n = 56) at the Pediatric Oncology Centers in Izmir currently define and assess cancer-related fatigue. The results demonstrate that while the problems associated with fatigue are acknowledged, assessment tools are not widely used, and the majority of health professionals report that they would benefit from further education on the subject to assist in the care of patients.

Patterns of fatigue in adolescents receiving chemotherapy

PURPOSE/OBJECTIVES

To describe patterns of fatigue in adolescents and the impact of fatigue during one month of chemotherapy, to explore variables that affect fatigue, and to explore the feasibility of collecting daily self-report data in this population.

DESIGN

Longitudinal, descriptive.

SETTING

Two pediatric oncology centers in central Virginia.

SAMPLE

20 adolescents with a variety of cancer diagnoses receiving chemotherapy.

METHODS

Adolescents described daily fatigue for one month using rating scales and qualitative diaries.

MAIN RESEARCH VARIABLES

Fatigue severity.

FINDINGS

Adolescents commonly reported a peak in fatigue in the days immediately following chemotherapy administration. The most common pattern for adolescents who received chemotherapy on a schedule every three to four weeks was a "declining rollercoaster" pattern, with fatigue severity alternating on a daily basis but gradually declining until chemotherapy was scheduled again. Adolescents who received chemotherapy weekly showed more frequent peaks and troughs (the "yo-yo" pattern) that did not diminish in severity over the weeks of the study. Adolescents associated fatigue with other symptoms, particularly sleep-wake disturbances, pain, and nausea, and frequently reported that fatigue interfered with daily activities.

CONCLUSIONS

Fatigue commonly bothers adolescents receiving chemotherapy, particularly in the days following chemotherapy administration and when other symptoms are present. Although fatigue interfered with the adolescents' abilities to maintain their usual lifestyles, many still participated in the typical activities of adolescence.

IMPLICATIONS FOR NURSING

Fatigue is a complex and dynamic symptom. Oncology clinicians and researchers should frequently assess fatigue in adolescents receiving chemotherapy and apply timely and tailored interventions to match the factors that contribute to fatigue and influence fatigue severity. Management of fatigue during treatment will help adolescents stay involved in age-related activities and meet developmental milestones.

A glimpse into the lives of 3 children: their cancer journey

Three stories of children with advanced cancer are presented in this article. The goal was to ascertain what these children were experiencing and thinking as well as what interventions were helpful. Interviews used open-ended questions as well as the Memorial Symptom Assessment Scale, Symptom Management Record, the Body Outline, Child Depression Inventory, Revised Children's Manifest Anxiety Scale, Pediatric Quality of Life Inventory, Common Toxicity Criteria, Lansky's Play Performance Scale, and Spirituality quality of life (QOL) and provided an opportunity for the children to describe their symptoms and QOL. The findings illustrated that the child's social, psychological, and spiritual concerns are important for nurses to address along with the child's physical needs.

The stories of young people living with a liver transplant

Adolescence is a difficult time for those with chronic illness because of the constraints of the illness on developmental tasks. Little is known about the impact liver transplantation has during adolescence. In this study we aimed to explore, in their own words, young people's lived experience of life after transplantation. We used semistructured interviews to collect narrative data, and used a purposive sample of 14 young people in early, middle, and late adolescence, transplanted for a range of chronic, acute, and metabolic liver diseases. We analyzed the transcripts using a framework in which analysis progresses through a five-stage process of matrices. Six main themes emerged, related to relationships, affect on schooling, tiredness and fatigue, acceptance of the burden of medication, communication with health professionals, and view of the future. These findings add new insight into the transplantation experience, which might lead to improvements in care and help direct further research in this important aspect of clinical care.

Pediatric adherence to HIV antiretroviral therapy

More than 2 million children are infected with HIV globally. Pediatric antiretroviral therapy (ART) adherence is complex, and current levels are often suboptimal. As established treatment programs in developed settings struggle with chronic therapy and nascent treatment programs in resource-limited settings expand, the importance and challenges of good adherence to ART are becoming ever more clear. Adherence behavior is influenced by many factors, which may be categorized as characteristics of the child, the caregiver(s) and family, the regimen, and society and culture. Many of these influences complicate measurement of pediatric adherence, and there is no gold standard. This article provides a conceptual framework and evidence-based look at the factors influencing ART adherence in children and aims to identify areas for intervention for this vulnerable population in need.

How children with cancer communicate and think about symptoms

BACKGROUND

For clinicians to effectively help children with their illness and symptoms, it is important to communicate with them in a language they can understand.

METHODS

This study investigates how well children with cancer and healthy children understood 44 symptom terms; their thoughts about these symptoms in terms of causes, consequences, and cures; and what other terms the children use to express these symptoms. It also explores if there are differences in understanding and thoughts about symptoms between children who have the experience of cancer and those who do not. In all, 6 children with cancer and 8 healthy children participated in semistructured interviews.

RESULTS

Children demonstrated a good understanding of symptom terms, yet were not always able to explain the symptoms. They had a rich vocabulary to talk about symptoms but did not use childish terms. Children with cancer had a more varied vocabulary for symptoms, but they did not use more medical terms. This study contributes to knowledge about children's understanding of symptoms that can be helpful to clinicians when communicating with children about their illness.

The experiences of cancer-related fatigue among Chinese children with leukaemia: a phenomenological study

BACKGROUND

Although cancer-related fatigue has been given priority status for study in Western countries, unfortunately, it has not received enough attention in China. Based on a different cultural perspective, qualitative study regarding cancer-related fatigue in China can provide a cultural context for enriching the system of knowledge about fatigue.

OBJECTIVES

To explore the real-life experiences of fatigue from the perspectives of Chinese Children with leukaemia.

DESIGN

A phenomenological study.

SETTING

A paediatric haematology oncology department of a regional tertiary children's hospital in Shanghai, China.

PARTICIPANTS

A total of 14 children and adolescents with leukaemia, aged 7-18 years old, without known psychiatric or developmental disorders, was selected by purposive sampling.

METHODS

Four focus group interviews were conducted with nine open-ended, semi-structured questions.

FINDINGS

Cancer-related fatigue is a common and distressing issue for Chinese children and adolescents with leukaemia. Three themes were finally generated: 'fatigue is an open interpretation among children and adolescents', 'fatigue is not a single-dimensional aspect', and 'struggles with fatigue and balancing life suffering'. Fatigue, which is closely related to physical, psychological and situational factors, has negative affects on the participants physically, psychologically and on their cognitive well-being, and can impact the family, school and social interaction of children with leukaemia.

CONCLUSIONS

Children and adolescents could easily distinguish cancer-related fatigue from normal fatigue. The participants' message to health professionals is that fatigue is a multidimensional and multifactorial symptom that should be comprehensively understood and managed. The findings provide insight and direction for clinical practice and research regarding intervention development and education plans for cancer-related fatigue for paediatric oncology patients.

Approaches to measure sleep-wake disturbances in adolescents with cancer

Sleep-wake disturbances commonly occur in healthy adolescents. Although diminished sleep and sleepiness seem normal for healthy adolescents, adolescents with chronic illnesses face additional disruption in the quantity and quality of their sleep as a result of the disease process, ongoing treatment, and associated symptoms. Little is known about how sleep in adolescents is affected by cancer, cancer treatment, and concurrent symptoms or about the consequences of sleep disruption for these patients. Although there is limited evidence to guide sleep measurement in adolescents with cancer, researchers may learn effective strategies from sleep studies completed with adolescents with other conditions. This systematic review examines how researchers have measured sleep using actigraphy, diary, and/or self-report questionnaires in diverse samples of healthy and ill adolescents. Psychometric properties are reported for nine self-report sleep questionnaires that were used in studies with mostly healthy adolescent samples. Nineteen studies provide evidence that actigraphy can be successfully and reliably used as an effective objective method to measure sleep in adolescents, including those with chronic illness. Daily sleep diaries were used less frequently to collect data from adolescents. The suitability of these techniques for the study of cancer-related sleep-wake disturbances in adolescents as well as strategies to enhance the reliability, validity, and feasibility of these measures will be discussed. Future sleep research in adolescents affected by cancer can be strengthened by the consistent use of sleep terminology, measurement of key sleep parameters, and efforts to develop and use psychometrically sound instruments. Oncology clinicians should be ready to add emerging evidence from sleep research to their care of adolescents with cancer.

Fatigue in children with long-term conditions: an evolutionary concept analysis

AIM

This paper is a report of a concept analysis of fatigue in children with long-term conditions.

BACKGROUND

There is little research focused on the experience of fatigue in children. Previous work has focused primarily on children living with cancer. It is necessary to clarify and refine the concept, and add to the knowledge base that supports ongoing theoretical work in order to improve the clinical care of children with long-term conditions who experience fatigue.

METHOD

English language literature published from 1989 to 2007 was searched using the CINAHL, Medline and PsychINFO data bases. Sixty-two papers and two book chapters were used in this concept analysis. Rodgers' method of evolutionary concept analysis was used. This inductive method helps us to view the concept in a sociocultural and temporal context.

FINDINGS

The number of publications focusing on fatigue in children is increasing. The analysis yielded two surrogate terms, five attributes, three antecedents and seven consequences. Based on this analysis, fatigue in children with long-term conditions appears to be a subjective experience of tiredness or exhaustion that is multidimensional and includes physical, mental, and emotional aspects.

CONCLUSIONS

Evidence suggesting children with long-term conditions experience fatigue is increasing, but conceptual gaps remain. This analysis has yielded a view of fatigue in children that illustrates healthcare professionals' limited yet growing awareness of the symptom. Ongoing study as a means to refine our understanding of the concept could potentially lead to important contributions to clinical care of children with long-term conditions.

The complexity of symptoms and problems experienced in children with cancer: a review of the literature

To adequately help children with cancer, care providers need to understand the complexity of symptoms and problems associated with the illness that children are experiencing, which can enable them to better tailor patient care individually to each child. In this integrative literature review, we identified the types of symptoms and problems that children with cancer can experience during treatment and rehabilitation; the terms/expressions they use to describe their symptoms and problems; how children's symptoms and problems vary during the course of their illness; and how they vary and co-vary with age, gender or race. Of the 1175 titles identified, 110 articles met the inclusion criteria and were included in the review. Seventy-eight were research-based. A total of 219 distinct symptoms or problems were identified in the literature either as the main problem or a symptom of the main problem. There is significant evidence that children and adolescents experience numerous and complex symptoms, and problems during and after treatment for cancer. Children use many different expressions to talk about their symptom experiences. However, few articles looked at how children's symptoms and problems varied during the course of their illness or the variations in symptom severity and degree of bother, or examined the relationship between children's symptom experience and age, gender, or race. Most instruments that were used to measure symptoms were interviewer-administered questionnaires, often adaptations from adult versions, and in younger children, symptoms were often obtained from adult informants. The insights gained from this review can be helpful to researchers and clinicians who wish to better understand how symptoms and problems are experienced from the children's own perspective. However, more research is needed: to better understand differences in symptom experiences among different age groups; to identify differences among children from distinct cultural, ethnic, or socio-economic backgrounds; to clarify how symptoms and problems interfere with daily life; and to refine assessment methods that allow even younger children to communicate their symptom experiences in an age-adjusted manner.

Impact of effective nursing interventions to the fatigue syndrome in children who receive chemotherapy

This experimental, randomized controlled study was conducted for children with cancer who are 7 to 12 years of age and receiving chemotherapy treatment to detect the impact of appropriate nursing interventions on decreasing the fatigue syndrome. The research sample is composed of a total of 60 children with cancer, with 30 children being included in the experimental group and 30 children included in the control group with their mothers. In the experimental group, after the 7th to 10th day of the chemotherapy treatment, throughout a week, the researcher conducted the effective nursing interventions every day for 45 to 60 minutes. In the control group, routine nursing interventions were carried out. The experimental and control group children's mean scores for the Fatigue Scale-Child and those of mothers for Fatigue Scale-Parent were compared. A statistically significant difference was found between the Fatigue Scale-Child and Fatigue Scale-Parent mean scores of the experimental and the control group children (P < .00). These results suggest that fatigue of children with cancer can be reduced by implementing appropriate nursing interventions.

Developmental diversity in symptom research involving children and adolescents with cancer

The purpose of this literature review was to evaluate developmental diversity in studies describing physical symptoms in children and adolescents receiving cancer treatment. Developmental diversity was conceptualized as individual differences based on normal stages of human development, including cognitive, psychosocial, and physiologic aspects. Searches of Medline and the Cumulative Index of Nursing and Allied Health Literature identified 53 articles published between January 1986 and November 2006. Most studies addressed symptoms in school-aged children and adolescents; few compared symptoms across age groups. Additional measures are needed to describe younger children's symptoms. Alternate research methodologies may be appropriate to describe their symptom experiences.

Health-related quality of life relates to school attendance in children on treatment for cancer

The aims of this study are to follow health-related quality of life (HRQOL), school attendance, and social interaction with friends in children with cancer and to explore potential relationships between HRQOL and school attendance. The study also describes self-reported reasons for not attending school and not meeting friends. During a 2-year period, all schoolchildren in Sweden starting treatment for cancer were invited to participate in the study. Participants (N = 101) were assessed 3 times during the first 5 months of treatment using 2 questionnaires: DISABKIDS Chronic Generic Module (DCGM-37) and a study-specific questionnaire. The results indicate a diminished HRQOL that remained stable over the study period, with girls rating worse HRQOL compared with boys. School attendance significantly increased over time, and approximately half of the children attended school 5 months after start of treatment. Self-reported HRQOL was positively correlated to days of school attendance. The results emphasize the importance of psychosocial care and nursing for children diagnosed with cancer, especially for girls. Research to further explore gender differences in HRQOL among children diagnosed for cancer is recommended.