Development of a Web-Based Psychosocial Intervention for Adolescent and Young Adult Survivors of Pediatric Brain Tumor

Neurobehavioral Impairment in Pediatric Brain Tumor Survivors: A Meta-Analysis

Purpose: The neurocognitive outcomes of pediatric brain tumor survivors have been extensively studied but the risk and predictors for neurobehavioral impairment are less clearly defined. We systematically analyzed the rates of emotional, psychosocial, and attention problems in pediatric brain tumor survivors. Methods: PubMed, Web of Science, Embase, Scopus, and Cochrane were searched for articles published between January 2012 to April 2022. Eligible studies reported neurobehavioral outcomes for PBTS aged 2 to <23 years with a brain tumor diagnosis before 18 years of age. A random-effect meta-analysis was performed in R. Results: The search yielded 1187 unique publications, of which 50 were included in the quantitative analysis. The estimated risk of having emotional, psychosocial, and attention problems were 15% (95%CI 10−20%), 12% (95%CI 9−16%), and 12% (95%CI 9−16%), respectively. PBTS were more likely to have emotional difficulties (Hedge’s g = 0.43 [95%CI 0.34−0.52]), psychosocial problems (Hedge’s g = 0.46 [95%CI 0.33−0.58]), and attention problems (Hedge’s g = 0.48 [95%CI 0.34−0.63]) compared to normal/healthy control subjects. There was no significant difference in the rates of neurobehavioral impairment between children with and without history of cranial radiotherapy. Conclusions: PBTS are at elevated risk of neurobehavioral impairment. Neurobehavioral monitoring should be considered as the standard of care for PBTS.

Randomized Waitlist-Control Trial of a Web-Based Stress-Management and Resiliency Program for Adolescent and Young Adult Cancer Survivors: Protocol for the Bounce Back Study

Background

The emotional health of adolescent and young adult (AYA) cancer survivors is compromised both during and after cancer treatment. Targeted programs designed to support AYAs’ ability to cope with stress in the years following treatment completion are lacking. Mind-body programs may ameliorate the negative psychological and emotional effects of stress and assist AYAs with managing the psychosocial challenges of early survivorship.

Objective

Our randomized waitlist-control trial aims to assess the feasibility, acceptability, and preliminary efficacy of a virtual group program (Bounce Back) to promote stress management and resiliency among posttreatment AYAs.

Methods

Bounce Back is a stress management and resiliency program delivered via videoconference by a trained mental health clinician. Sessions were adapted from an evidence-based mind-body program (Stress Management and Resiliency Training - Relaxation Response Resiliency Program [SMART-3RP]) grounded in relaxation response elicitation, mindfulness, cognitive behavioral therapy, and positive psychology. Seventy-two AYAs (diagnosed with cancer between ages 14 years and 29 years and had completed cancer treatment within the last 5 years) were randomly assigned to the Bounce Back program or waitlist-control group and completed assessments at baseline, 3 months postbaseline, and 6 months postbaseline. The primary aim of the study is to determine the feasibility and acceptability of the Bounce Back program. Descriptive statistics, including means, frequencies, and ranges supplemented by qualitative exit interview feedback will be used to characterize the sample and to summarize feasibility and acceptability. The exploratory aims are to evaluate the preliminary effects of the program on stress coping and psychosocial outcome measures (ie, anxiety, depression) collected across the 3 time points.

Results

This study was funded by the National Cancer Institute in July 2017. Study procedures were approved by the Dana-Farber Harvard Cancer Center Institutional Review Board in October 2018 (Protocol 18-428). The randomized trial was conducted from July 2019 to March 2021. Quantitative data collection is complete, and qualitative exit interview data collection is ongoing. Results are expected to be published in peer-reviewed journals and presented at local, national, or international meetings in the coming years.

Conclusions

Few evidence-based programs exist that tackle the key transitional issues faced by AYA cancer survivors. Future analyses will help us determine the feasibility and acceptability of the Bounce Back program and its impact on AYA stress coping and psychological well-being.

Trial Registration

ClinicalTrials.gov NCT03768336; https://clinicaltrials.gov/ct2/show/NCT03768336

International Registered Report Identifier (IRRID)

DERR1-10.2196/34033

Adapting intervention approaches to new contexts: Three case studies of international adaptation of the Teen Online Problem Solving (TOPS) program

PURPOSE/OBJECTIVE

To describe the process of adapting the evidence-based Teen Online Problem Solving (TOPS) program, a telehealth problem-solving treatment addressing executive function and behavior regulation challenges in adolescents with traumatic brain injury, in Italy, New Zealand, and the United Kingdom. Research Method/Design: We describe the process of adapting and translating the TOPS program in 3 case studies with unique methods and samples. In Italy, 14 parents of adolescents with TBI participated in focus groups, and 2 adolescents with TBI and their parents and 2 physicians provided input on the resulting translation. In New Zealand, an independent Māori cultural advisor reviewed the content, and 6 adolescent-parent dyads and 2 health professionals completed the 10 modules independently over a five-week period to inform adaptation. In the United Kingdom, a team of neuropsychologists and a parent of an adolescent with ABI reviewed and adapted the content through successive iterations.

RESULTS

In Italy, suggested changes included greater emphasis on nonverbal communication and clearer examples of inappropriate problem-solving responses. In New Zealand, parents and adolescents rated the program as acceptable and helpful. Suggestions included incorporating familiar Māori settings, integrating religion, and developing videos with New Zealand adolescents. In the United Kingdom, iterative refinements focused on adapting TOPS for other acquired brain injuries and reflecting cross-national differences (e.g., drinking age).

CONCLUSIONS/IMPLICATIONS

These 3 case studies suggest that programs such as TOPS developed in 1 cultural context can be broadly acceptable in other contexts, with adaptations focusing on tailoring to reflect the unique cultural and linguistic setting. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Articulating viewpoints to better define and respond to the needs of adolescents and young adult survivors of pediatric brain tumors

PURPOSE

Adolescents and young adult survivors of pediatric brain tumors (AYA-PBTS) often experience difficulties with social skills, pursuit of studies and employment. This study explored pediatric long-term survivors' perspective on their post-treatment needs and ways to improve resources and interventions.

METHODS

We used an original method of three sequential focus group interviews by adding the perspectives of survivors (15-22 years), parents and health professionals (total N = 22). Participants were recruited using purposive sampling from the long-term follow-up clinic at a Canadian tertiary hospital. We used computer-assisted analysis to draw themes from each group and compare thematic content across groups.

RESULTS

Categorization of participants' responses resulted in three domains: personal life, education and work. Participants mentioned the improvement of communication tools to facilitate access to timely information, the organization of counseling to improve employment integration, and tailoring interventions to optimize the return to daily activities in aftercare. Subsequent inductive analysis revealed three overarching trends among groups: multipurpose social networking, AYA-PBTS-specific information websites and transition tools and procedures.

CONCLUSION AND IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS

This study identified solutions for AYA-PBTS' specific needs in aftercare. This population needs up-to-date post-treatment information and refined outreach procedures. Future research should define and prioritize these suggested solutions.

Interventions to address disparities and barriers to pediatric cancer survivorship care: a scoping review

PURPOSE

Many childhood cancer survivors experience disparities due to barriers to recommended survivorship care. With an aim to demonstrate evidence-based approaches to alleviate barriers and decrease disparities, we conducted a scoping review of (1) proposed strategies and (2) evaluated interventions for improving pediatric cancer survivorship care.

METHODS

We searched research databases (PubMed, CINAHL, and PsycINFO), research registries, and grey literature (websites of professional organizations and guideline clearing houses) for guidelines and published studies available through October 2020 (scoping review registration: https://doi.org/10.17605/OSF.IO/D8Q7Y ).

RESULTS

We identified 16 proposed strategies to address disparities and barriers endorsed by professional organizations including clinical practice guidelines (N=9), policy statements (N=4), and recommendations (N=3). Twenty-seven published studies evaluated an intervention to alleviate disparities or barriers to survivorship care; however, these evaluated interventions were not well aligned with the proposed strategies endorsed by professional organizations. Most commonly, interventions evaluated survivorship care plans (N=11) or models of care (N=11) followed by individual survivorship care services (N=9). Interventions predominantly targeted patients rather than providers or systems and used technology, education, shared care, collaboration, and location-based interventions.

CONCLUSIONS

Published studies aimed at overcoming disparities and barriers to survivorship care for childhood cancer survivors revealed that gaps remain between published recommendations and empirical evaluations of interventions aiming to reduce barriers and disparities.

IMPLICATIONS FOR CANCER SURVIVORS

Additional research is needed to identify evidence-based interventions to improve survivorship care for childhood cancer survivors.

Difficulties encountered by physicians and mental health professionals in evaluating and caring for affective and behavioral problems in pediatric brain tumor survivors

BACKGROUND

Pediatric brain tumor survivors (PBTS) present a high risk for emotional and behavioral disorders. When addressing these difficulties, differences in study designs; variety of and disagreement about diagnoses; and intricate links of emotional, behavioral, and cognitive issues may complicate the interpretation of studies and probably also the work of clinicians. We aimed to survey the difficulties perceived by physicians and mental health professionals in their practice and their interest in developing a new evaluative tool.

METHODOLOGY

We surveyed 29 health professionals involved in the follow-up of this population. They completed questionnaires about their clinical practice (difficulties, needs, activities) and indicated diagnosis hypotheses and treatment plans on a clinical case developed for this study.

RESULTS

Emotional and behavioral disorders were reported as difficult to assess for 93% of participants. The overlap of symptoms (90%) and the lack of an adapted diagnostic framework (90%) were the main reasons mentioned. Respectively 93%, 90%, and 65% of participants would at least "often" make referrals to psychological (93%), neuropsychological (90%), and psychiatric (65%) assessments and care. Family and group therapy were less common as was drug management. All participants were in favor of creating a tool to help with diagnosis and treatment. When responding to a clinical case, the heterogeneity of participants' responses highlighted their issues in diagnosing and managing these patients.

CONCLUSION

This survey exemplifies the difficulties of health professionals related to the evaluation and management of affective and behavioral disorders experienced by PBTS. It underlines the need to help professionals by initiating systematic assessment strategies with this vulnerable population.

Parental attitudes regarding the need for genetic services in a pediatric brain tumor survivorship program

Pediatric brain tumor survivorship populations have not been typically offered genetic services as part of routine care. Genetic services can be defined as family history collection, genetic risk assessment for a patient and family members, and coordination of genetic testing. Prior research has focused on the integration of genetic services in the general pediatric oncology survivorship population and found a need for these services to be implemented. Gathering a family history and providing a genetic risk assessment have previously been determined to be an integral step in determining if an individual's cancer was due to a hereditary predisposition. The purpose of this study was to examine parental attitudes regarding the need for genetic services in their child's pediatric brain tumor survivorship clinic. Twelve semi-structured interviews were conducted with parents participating in the Brain STAR (Survivors Taking Action and Responsibility) program at Ann and Robert H. Lurie Children's Hospital of Chicago. A grounded theory approach was used to code and analyze the results thematically. Five key themes were identified: participants' perceived benefits and barriers regarding receiving genetic services, desirable time for implementation of these services, relevance of family history, and their thoughts regarding reproductive risk. These results provide insight for genetics professionals regarding the need for genetic services in this population, and how to best implement them.

Use of telehealth platforms for delivering supportive care to adults with primary brain tumors and their family caregivers: A systematic review

OBJECTIVE

Telehealth platforms have potential utility for providing remote access to supportive care to people with brain tumour. This systematic review aimed to evaluate the feasibility, acceptability and efficacy of delivering supportive care via telehealth platforms to adults with primary brain tumour and family caregivers.

METHODS

A systematic search of PsycINFO, MEDLINE, CINAHL, Embase, Scopus and Cochrane Library was conducted from 1980 to 1st June 2020 to identify eligible studies. Methodological quality was assessed by two independent reviewers.

RESULTS

Seventeen articles, reporting on 16 studies, evaluated telephone-based support (5 studies), videoconferencing (3 studies), web-based programs and resources (7 studies) or combined use of videoconferencing and web-based modules (1 study) to deliver supportive care remotely. Caregivers were involved in 31% of interventions. Mean rates of accrual (68%) and adherence (74%) were moderate, whereas acceptability or satisfaction for those completing the interventions was typically high (M satisfied or very satisfied = 81%). Adherence rates were generally higher and clinical gains were more evident for interventions involving real-time interaction as opposed to self-guided interventions.

CONCLUSIONS

Telehealth delivery of supportive care is feasible and acceptable to a high proportion of individuals with primary brain tumour and their caregivers. It is recommended that future research focuses on implementation outcomes, including factors influencing the uptake and sustainability of telehealth platforms in practice.

The Integration of Resource Patients in Collaborative Research: A Mixed Method Assessment of the Nesting Dolls Design

OBJECTIVES

This is a quality assessment of a research design developed for a collaborative study on adolescents and young adults who survived a brain tumor.

METHODS

A descriptive and critical mixed methods approach was used to assess the design itself, the quality and information power of the database and the integration of collaborators. Project documentation, field notes and transcripts from focus groups interviews(n = 19) were used for the evaluation, which was based on the Consolidated Criteria for Reporting Qualitative Research.

RESULTS

The design proved to be pertinent to resolve methodological stakes in a "fragile field". The mobilisation of collaborators as members of a "Sherpa team" in all phases of the project helped the team create a progressive focus approach well-adapted for data gathering and analysis as well as produce a high-quality database.

CONCLUSION

The Nesting Dolls Design including the didactic approach developed along the deployment of the project helped researchers, clinicians and resource patients/parents understand the research procedures and the roles of all collaborators. This fostered a meaningful engagement in the project.

PRACTICE IMPLICATIONS

Resources and time for training, communication and supervision are necessary to reach the objectives of collaborative research involving novices and are worth the time and efforts.

Telepsychotherapy With Children and Families: Lessons Gleaned From Two Decades of Translational Research

The novel coronavirus, COVID-19, has led to sweeping changes in psychological practice and the concomitant rapid uptake of telepsychotherapy. Although telepsychotherapy is new to many clinical psychologists, there is considerable research on telepsychotherapy treatments. Nearly 2 decades of clinical research on telepsychotherapy treatments with children with neurological conditions has the potential to inform emerging clinical practice in the age of COVID-19. Toward that end, we synthesized findings from 14 clinical trials of telepsychotherapy problem-solving and parent-training interventions involving more than 800 children and families with diverse diagnoses, including traumatic brain injury, epilepsy, brain tumors, congenital heart disease, and perinatal stroke. We summarize efficacy across studies and clinical populations and report feasibility and acceptability data from the perspectives of parents, children, and psychotherapists. We describe adaptation for international contexts and strategies for troubleshooting technological challenges and working with families of varying socioeconomic strata. The extensive research literature reviewed and synthesized provides considerable support for the utility of telepsychotherapy with children with neurological conditions and their families and underscores its high level of acceptability with both diverse clinical populations and providers. During this period of heightened vulnerability and stress and reduced access to usual supports and services, telepsychotherapy approaches such as online family problem-solving treatment and online parenting skills training may allow psychologists to deliver traditional evidence-based treatments virtually while preserving fidelity and efficacy.

Severe fatigue after treatment for childhood cancer

BACKGROUND

Treatment strategies for childhood cancer are improving, resulting in higher survival rates. However, the consequences of childhood cancer do not end with the successful completion of cancer treatment. Most patients will develop late effects after cessation of treatment. Severe fatigue is seen as a common and debilitating late effect in cancer survivors. Although most research on fatigue has been performed in patients after adult-onset cancer, our review focuses on fatigue after childhood cancer.

OBJECTIVES

To estimate the prevalence of severe fatigue after treatment for childhood cancer. Secondary objectives are to describe the course of severe fatigue following cancer treatment and to examine risk factors for fatigue, or factors associated with it.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (the Cochrane Library 2019; issue 8 March 2019), MEDLINE/PubMed (from 1945 to 8 March 2019), Embase/Ovid (from 1947 to 8 March 2019), reference lists of included articles and several conference proceedings from 2011 to 2018.

SELECTION CRITERIA

Observational studies, randomised controlled trials and controlled clinical trials reporting on fatigue in participants after treatment for childhood cancer. Case series and case reports were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risks of bias. If the publication did not present the prevalence of severe fatigue, we contacted study authors for additional information.

MAIN RESULTS

We included 30 studies (18,682 participants in total). Eighteen studies contributed to the main objective and 22 studies contributed to the secondary objectives. We found substantial differences between studies in cancer diagnosis, cancer treatment, age of participants, questionnaires used to assess fatigue, and sample size. All included studies scored at least one 'Risk of bias' item as unclear or high risk. We identified both clinical and statistical heterogeneity and therefore could not pool results, so we present them descriptively. Eighteen studies (describing 14,573 survivors) reported the prevalence of severe fatigue, which ranged from 0% to 61.7%. In a subgroup of three studies including children aged up to 18 years at fatigue assessment (268 survivors), prevalence rates ranged from 6.7% to 12.5%. In comparison, in a subgroup of 12 studies including participants aged 16 and over (13,952 survivors), prevalence rates ranged from 4.4% to 61.7%. The prevalence of severe fatigue in a subgroup of survivors of haematological cancer was presented in seven studies and ranged from 1.8% to 35.9% (1907 survivors). Prevalence of severe fatigue in brain cancer survivors was presented in two studies (252 survivors) and was 14.6% and 21.1% respectively. One study presented a prevalence for bone cancer survivors of 0.0% (17 survivors). Four studies provided prevalence rates of severe fatigue in control groups of siblings or population-based controls, which ranged from 3.1% to 10.3%. In these four studies, survivors were more often fatigued than controls, but this difference was statistically significant in only two studies. Studies assessing risk and associated factors for fatigue were heterogeneous, and definitions of the factors under study were often inconsistent, with results therefore presented descriptively. They found that depression might be associated with fatigue. In contrast, age at diagnosis and education level did not seem to be associated with fatigue. We were unable to calculate any overall risk estimate for any of the reported risks and associated factors, because we could not conduct meta-analysis. One study provided information about the course of fatigue over time, and found that over the course of 2.7 years, 32 of the 102 participants (31.4%) reported persistent severe fatigue.

AUTHORS' CONCLUSIONS

It is unclear how many childhood cancer survivors suffer from severe fatigue. This review encountered several difficulties. We found statistical and clinical heterogeneity and great variation in the reporting of possible risk and associated factors. The evidence in this review is therefore weak, and the exact prevalence of severe fatigue after treatment for childhood cancer remains to be determined. This is also the case for the course of severe fatigue following treatment and the strength of the relationship between fatigue and associated and risk factors. Despite these limitations, our review does provide a comprehensive overview of the existing literature about severe fatigue after treatment for childhood cancer.

A Survivor's Journey: Preliminary efficacy of an online problem-solving therapy for survivors of pediatric brain tumor

BACKGROUND

Although pediatric brain tumor survivors are at high risk for a variety of psychosocial and neurocognitive late effects, there are few evidence-based interventions to address their needs. The purpose of this study was to test the efficacy of an online problem-solving intervention on improving the quality of life and executive dysfunction among adolescent and young adult brain tumor survivors.

PROCEDURE

A Survivor's Journey was adapted from a similar intervention for survivors of traumatic brain injuries, and involved self-guided web modules providing training in problem-solving as a tool for coping with everyday challenges, as well as weekly teleconferences with a trained therapist. Survivors (n = 19) between the ages of 13 and 25, and their caregivers, completed standardized measures of their emotional and behavioral functioning, executive functioning, and quality of life before and after the 12- to 16-week intervention.

RESULTS

Participation in the intervention led to significant improvements in self-reported overall (M_pre  = 62.03, SD_pre  = 17.67, M_post  = 71.97, SD_post  = 16.75; d = 0.58, P = 0.01) and physical quality of life (M_pre  = 63.13, SD_pre  = 21.88, M_post  = 75.00, SD_post  = 21.33; d = 0.55, P < 0.01) as well as parent-reported emotional quality of life (M_pre  = 65.00, SD_pre  = 28.72, M_post  = 76.15, SD_post  = 23.47; d = 0.43, P = 0.03). Greater improvement was noted in those who were diagnosed before the age of seven and those with average or above average estimated IQs. Current age did not moderate outcomes.

CONCLUSIONS

Online problem-solving therapy may be efficacious in improving pediatric brain tumor survivors' quality of life; however, further research with a comparison group is needed. Online interventions such as Survivor's Journey may decrease barriers to evidence-based psychosocial care for brain tumor survivors.