The power of art and the powers of adolescents with cancer: Age-specific projects at Italian pediatric oncology centers

This article describes the oncology programs developed in Italy for adolescents and young adults with cancer, with a specific focus on the local projects created in pediatric oncology centers. A common feature of such projects is the emphasis on creative and artistic activities and laboratories (involving music, photography, novel writing, fashion design, and so on) designed to give young patients innovative means of expression.This article highlights the amazing powers of adolescents involved in these projects: the power to produce beautiful things in a place that is not normally associated with the idea of beauty; the power to make their doctors smile and grasp the profound sense of life; the power to make hospitals become places for producing culture.

Making the Best in a Bad Job: A Psychoanalytic Perspective on Communication with Children and Adolescents with Severe Physical Condutions

Ill children/adolescents who suffer from severe organic diseases have to cope with their inner experiences, therapies, and the global burden of the disease. Although sometimes depression, anger, and death anxiety are openly encountered in medical settings, other times they can be partially hidden by a reactive and defensive path. In these scenarios, psychoanalysis is challenged to contribute the best comprehension of the intimate communication, maybe hidden, and the needs of the ill patients to express themselves. The best way a child can talk about himself is through spontaneous creativity. The adult's task is to facilitate the creation of an empty space and to recognize the child's mode of communication. There may be intense emotional reactions that the adult has to tolerate to not move the patient towards an over-adaptation. These over-adaptations entail the child being forced to feel good or have fun, thereby causing them to escape from their inner experience. The loss of the child's reality forms an additional burden to the child. The most valid indicator of this attitude is the ability to not take counterphobic attitudes but to allow the depression to be shared in a contact space between the child's true self and the perceived environment.

A Textual Analysis for Understanding the Relations and the Identity Construction in Adolescent Oncology Patients: Retrospective Personal Views in Order to Educate Health Professionals

Patient input is critical for all aspects of value-based healthcare design. This contribution describes the following: the specifics of communications with doctors regarding the disease in adolescents and young adults with cancer; the patients’ thoughts, emotions and changes in self-perception; “other meanings” taking shape along the treatment pathway; and reacting modes to the disease and treatments. Thirty-five Italian AYA patients in follow-up (age 18–24) were involved in a plenary interview on the cited aspects of their oncological experience. The answers were analyzed by MADIT (Analysis Methodology of Computerized Textual Data) with the software SPAD. MADIT allowed us to perform text analysis, describe the graphical outcomes and discuss the results. Respondents took a first-person perspective and their personal narrative recall had objective and unequivocal connotations. Experience was narrated mainly by maintenance repertoires that fix the reality of disease, its treatments and personal identity. The account focused on the tumor and on an agreed approach to it. The time “after” was described as a distressing space that defines them. Making sense of the events was considered a significant help. Professionals need to focus on the discursive repertoires of communication with which the inner and outer reality are built. Lastly, these patients required a two-way dialogue throughout the entire caring process.

"Based on a true story" podcast: a journey into the world of young patients with cancer

This article describes a creative project undertaken by a group of adolescent and young adult patients with cancer as part of the Milan's Youth Project, a scheme dedicated to young patients with cancer with the dual aim of optimizing medical aspects of their care and promoting a holistic approach to their needs. The project was based on audio recordings and focused on the theme of "the journey," such as a holiday or an adventure, or as a metaphor of the cancer experience. The podcast installments were published on the main streaming platforms. Talking about their disease and how they feel is of importance for young patients to process their feelings surrounding the cancer experience and to find the inner resources they need to facilitate coping.

Italian pediatric and adult oncology communities join forces for a national project dedicated to adolescents and young adults with cancer

Adolescents and young adults with cancer have substantially different clinical and psychological needs compared to those of pediatric patients and of older adult patients. We describe the development of an Italian national project dedicated to adolescents and young adults with cancer.

My mind is still mine: a self-portrait in a photography project for adolescents and young adults with cancer

This commentary describes the unusual self-portrait contributed by a 26-year-old receiving treatment for relapsing medulloblastoma to a photography project undertaken by a group of patients as part of the Youth Project, a scheme dedicated to young cancer patients with the dual aim of optimizing medical aspects of their care and promoting a holistic approach to their needs. The article briefly describes how creative projects can play an important part in giving young people with cancer new ways to tell their stories and express their feelings. There is still a limited understanding of the specific needs of adolescents and young adults with cancer, and it is important to draw attention to them and to the need to devise a person-centered approach to cancer patients in this age group.

Analysis of adolescent oncology cases from 2008 through 2018 in a tertiary-level hospital: an opportunity for improvement

Purpose: The purpose of this study was to disclose the variability of pathways currently taken in the treatment of adolescent patients from diagnosis to final follow-up with a view to developing a more homogenous system. Patients & methods: A cross-sectional, observational and retrospective study of the cancer diagnosis and assignment to medical care teams in adolescent patients (12-20 years) from January 2008 to December 2018 was conducted. A total of 345 adolescent patients aged between 12 and 20 years, diagnosed with cancer and treated at Hospital Clinico Universitario Virgen de la Arrixaca were included. Results: CNS tumors, followed by leukemia were the most frequent tumors. At the time of diagnosis, the highest incidences of patients were assisted in the pediatrics service adult oncology service (21.7%) and hematology (11%). Conclusion: Our aim is to highlight the need for a better transition for patients from pediatric to adult oncology and hematology services.

Adolescents with cancer on privacy: Fact-finding survey on the need for confidentiality and space

BACKGROUND

Cancer diagnosis and related treatment can limit young patients' privacy. Their need for private physical and psychological spaces can be impeded by limited freedom, e.g., sharing hospital rooms with others and exposing their body to their parents and doctors.

METHODS

We conducted a survey among young patients of our center to investigate how their perception of privacy changed after being diagnosed with cancer and their need for hospital dedicated physical spaces and time for patients to enjoy their privacy. A questionnaire with 16 items was developed by the staff involving psychologists and physicians. The relevance of changes before and after the cancer diagnosis was assessed by calculating two scores indicating the situation before and after diagnosis for each answer, as well as a delta score.

RESULTS

Between May and June 2020, the questionnaire was completed by 60 patients aged 16-24 years. The median delta scores describing the changes before and after diagnosis were -8 points for perception of privacy, indicating a significant decrement of the level of privacy perceived. A major issue was the constant presence of parents being perceived as intrusive. Concerning hospital dedicated physical spaces and time for patients to enjoy their privacy, respondents requested dedicated spaces (50% of patients) and opportunities to have private interviews with medical personnel (88%).

CONCLUSIONS

Our study offers a snapshot of how young people with cancer perceive the impact of the disease and its treatment on their privacy with the restrictions imposed on their individual freedom. Patients' personal needs must be taken into consideration to adopt appropriate measures and better organize wards.

Experiencing Social Isolation (Even in the Era of COVID-19 Pandemic Lockdown): Teachings Through Arts from Adolescents with Cancer

The article describes how adolescents with cancer utilized an artistic approach to discuss about their social isolation caused by disease and treatment. With the help of professionals, 17 young patients closed in their isolation room described their ideal room (a bit real, a bit of a fantasy place) producing texts and images, subsequently put together into a book. In these days when people are forced to social isolation by the lockdown related to corovavirus disease 2019 pandemic, young patients teach us meaningful life lessons: how social confinement can become an opportunity to focus on yourself, and what is really important in life.

Adolescents with Terminal Cancer: Making Good Use of Illusions

The terminal stage of disease in teenagers is extremely complex to manage. In this study, we share some stories of terminally ill adolescent patients who made use of illusion as a way to overcome their anguish in their final stages of illness. These experiences show how young patients can cope better with terminal illness by resorting to a nonrational and fictional dimension that can serve them as a psychological compromise, helping them tolerate their real everyday life by suspending their critical senses for a while. Illusions can serve as a resource for young patients and a potentially useful tool for medical professionals.

How young patients with cancer perceive the COVID-19 (coronavirus) epidemic in Milan, Italy: Is there room for other fears?

The rapid spread of coronavirus disease 2019 epidemic in Italy, in particular in the Milan focal point, required drastic measures and led to panic in the population. While in our center we did not change our approach to the treatment of our young patients with cancer, we developed a qualitative survey to assess their perception of the risk and level of stress. The survey showed that a relatively large proportion of young patients felt personally at risk of severe complications. We believe that we need to adequately inform our patients, focusing on hygienic measures and personal protection and prompt reporting of any suspicious symptoms.

Investigating sexuality in adolescents with cancer: patients talk of their experiences

Objective. The aim of the present study is to understand which areas of sexuality were regarded as most important and/or problematic among adolescents with cancer.Methods. A questionnaire was administered to adolescent and young adult patients who had been receiving treatments at the Pediatric Oncology Unit of our Institution, for at least 2 months, and those in follow-up who had completed their treatments no more than two years previously. The questionnaire was devised to investigate patients' experiences in various areas, i.e. personal relations, sexual relations; functional aspects, body image, and communication.Results. Questionnaires were given to 70 patients and completed by 66. As main results, the survey showed that disease and treatment might negatively affect patients' way of relating with others (53% of cases) and their body image (56%), though their sexual desire remains unchanged (69.7%). Most patients (67%) reported not having the chance to talk to someone about having sex while receiving their treatments; 79% of patients felt this topic deserved more attention.Conclusion. This study promotes the discussion of an important topic for young people with cancer, which is inadequately addressed today. When establishing an age-specific model of care, aspects related to sexuality should be considered and managed.

Loop: there's no going back: A Graphic Novel by Adolescent Cancer Patients on the Youth Project in Milan

The present paper describes the story of the development of a graphic novel-a story about superheroes-written by adolescent cancer patients on the Youth Project at the Istituto Nazionale Tumori in Milan (Italy). Nineteen patients from fifteen to twenty-five years old (fifteen receiving treatment for their cancer, four who had recently completed their treatments) participated in a four month creative writing laboratory managed by a professional teacher. The output from the writing laboratory was a written text that was used as the script for a graphic novel drawn by professional cartoonists and working together with the patients. Through their story, adolescent patients succeeded in voicing their dreams and fears. It was the adolescent patients themselves who explained how they had each tried to bring out the superhero inside them. This project describes the amazing powers of adolescents with cancer and opens a precious window on their inner world, enabling us to gain a better understanding of what they are really thinking and feeling through their own words.

"Summer is you": Adolescents and young adults with cancer sing about their desire for summer

Creative spirit and art are used as part of the Youth Project in Milan, a program dedicated to adolescents and young adults (AYA) with cancer. The "Summer is you" music project involved 45 patients (15-26 years old): with professional help, the patients wrote music and lyrics, sang their song, and recorded a video clip, sharing with us not only their hopes and fears, but also their romantic encounters and their urge to travel (https://youtu.be/Q5FSCMUVg0E). This project exploited the power of music to bring young people with cancer together in a novel form of support that can complement the more conventional psychological approaches.

Diary of a journey to a faraway galaxy

This article describes a brief account written by a girl treated with chemotherapy and surgery for an ovarian germ cell tumor. The brief novel was conceived in the context of the Youth Project of Milan, dedicated to helping adolescent and young adult cancer patients socialize and express themselves through group activities that focus on art and creativity. It describes the scenery of a new galaxy and is replete with images and metaphors that recall the experience of receiving anticancer treatment, touching on emotional themes including desire, isolation, fear, and hope.

The concept of friendship in adolescents with cancer: Reflections and experiences

Cancer can erupt in an adolescent's life, damaging his or her multidimensional balance with its burden of physical suffering, changes in appearance, and anxiety, interrupting their activities, keeping them away from school, and isolating them socially. It is crucially important for adolescents with cancer to be able to feel the same as before, to feel they belong to a group of schoolmates. This is not always easy to achieve. Their peers sometimes lack the necessary resources to treat adolescents with cancer as normal ones, responding instead with pity or avoidance. This article discusses the concept of friendship in adolescents with cancer, based on direct experience of being with them, personal reflections, and texts chosen and shared with the patients, as part of the cultural activities dedicated to adolescents and young adults with cancer at the Youth Area of the Centro di Riferimento Oncologico, Aviano, and the Youth Project at the Istituto Nazionale Tumori, Milan, Italy.

"What shall I do when I grow up?" Adolescents with cancer on the Youth Project in Milan play with their imagination and photography

INTRODUCTION

Adolescents diagnosed with cancer have to temporarily stop pursuing several vital needs and making plans for the future. The Youth Project in Milan, Italy, focuses on such issues in young cancer patients' personal lives. Uncertainty about the future had already emerged in several artistic projects designed to help these patients voice their emotions.

METHODS

We describe a project revolving around the question "What shall I do when I grow up?" Twenty-seven 15- to 26-year-old patients wrote a brief account of what they hoped to do as adults. Using theatrical costumes, they then dressed up in their chosen role for a photo shoot with a well-known professional photographer. The results were published in one of Italy's main national dailies.

RESULTS

Participants reacted differently: some lightheartedly, others more seriously. They often expressed the wish to help others, desiring to return the support and protection they had received as patients. Another common theme concerned their need for normality.

CONCLUSIONS

By writing about their dreams, these patients gave their doctors a glimpse of their inner world. The project proved an important complement to more conventional forms of psychosocial support and interaction with young patients.

Dreams and illusions in adolescents with terminal cancer

Being diagnosed with cancer in adolescence generally has important emotional consequences: adolescent cancer patients need to be seen as special cases with particular medical and psychosocial needs. This is especially true when a young patient is faced with a progressive, incurable disease. Herein, we report the story of a 17-year-old girl with a metastatic refractory soft tissue sarcoma who tells her dream to the psychologist of the ward. Telling this narrative is the opportunity to discuss the complex topic of how adolescent cancer patients adapt to the terminal stage of their disease; for example, the patient needs to talk to someone about their fear of dying; the healthcare operators need to be able properly listen and communicate; the patient's trust in the future despite their clinical condition; the necessity to leave space for hope; the useful role of the imagination sphere; the issue of whether and how to tell a person who is terminally ill the truth about their condition.

Cooperation between in-hospital psychological support and pastoral care providers: obstacles and opportunities for a modern approach

The meaning that patients with cancer attribute to life influences their expectations and their attitudes to the disease and its treatment. Over the centuries, religion has commonly been the answer encoded by the social setting when it came to matters of life and death. The present article analyzes the historical grounds for forms of cooperation between the scientific disciplines that focus on mental health and the approach of religion, centered on the Italian situation. Such cooperation was hard to imagine in the past, but the situation has changed considerably and cooperation is not only possible but extremely desirable. Acknowledgment of their spiritual needs helps patients to battle with their disease. The care of patients should include catering for their spiritual needs by ensuring the constant presence of a chaplain on hospital wards.

Proper use of social media by health operators in the pediatric oncohematological setting: Consensus statement from the Italian Pediatric Hematology and Oncology Association (AIEOP)

Social media are powerful means of communication that can also have an important role in the healthcare sector. They are sometimes seen with diffidence in the healthcare setting, partly because they risk blurring professional boundaries. This issue is particularly relevant to relations between caregivers and adolescent patients. The Italian Pediatric Hematology and Oncology Association created a multidisciplinary working group to develop some shared recommendations on this issue. After reviewing the literature, the working group prepared a consensus statement in an effort to suggest an analytical approach rather than restrictive rules.

A reflection on the work of Gianni Bonadonna from the viewpoint of the global challenge of adolescents and young adults with cancer

Adolescents and young adults (AYAs - ages 15 to 39) constitute approximately 40% of the world's population and contribute an estimated one million new cases of cancer annually, the great majority in low- and middle-income countries (LMICs). In high-income countries (HICs) cancer is the commonest cause of disease-related death in AYAs, though overall 5-year survival rates now exceed 80%. A very different circumstance likely holds in LMICs, but accurate assessments are not readily available.Breast cancer accounts for 40% of tumours in female AYAs and this age group includes the peak incidence of Hodgkin lymphoma. The late Professor Gianni Bonadonna contributed importantly to improved survival in patients with these two diseases. Accordingly, he would be justifiably proud of the advances in AYA oncology that are being made in Italy, especially the impact of his colleagues at the Istituto Nazionale dei Tumori (INT). The initiatives of the Associazione Italiana Ematologia Pediatrica and the Società Italiana Adolescenti con Malattie Onco-ematologiche are particularly noteworthy, with the accomplishment of productive collaboration between paediatric and adult cancer care providers serving as a model for other countries to emulate.Exporting these advances can be successful through the vehicle of "twinning": establishing sustainable cooperation between institutions in HICs and partners in LMICs. Colleagues in Monza and at INT have been leaders in such programmes for decades. Cancer in AYAs remains a global challenge to which Gianni Bonadonna surely would have risen with enthusiasm and leadership while securing measurable achievements.

Winners' Cup: A National Football Tournament Brings Together Adolescent Patients with Cancer from all over Italy

Società Scientifiche Italiane Insieme per gli Adolescenti con Malattie Onco-ematologiche (SIAMO) is an Italian nationwide scheme that focuses on adolescent patients with cancer. Some of its activities include promoting dedicated local projects at the various oncology centers all over the country and organizing events to improve awareness regarding cancer in adolescence. It is with these aims in mind that it organized the Winners' Cup, a football tournament between Italian adolescents who had (or had had) pediatric cancers. There were 144 young people 15 to 24 years old who arrived from 16 different treatment centers around the country to take part in the tournament and share their stories. Such an event had never been attempted before, in Italy at least. The Winners' Cup was a great success and an opportunity to focus attention on the particular clinical, psychological, and social needs of cancer patients in this age group.

“Christmas Balls”: A Christmas Carol by the Adolescent Cancer Patients of the Milan Youth Project

The Youth Project is a program developed at the Pediatric Oncology Unit at the Istituto Nazionale Tumori in Milan, dedicated to adolescents and young adults with cancer. Among its various goals, the Youth Project organizes structured creative activities with the support of professionals, with the objective of offering young people a new way to express their hopes and fears. This article describes a project centered around music: patients created a Christmas carol with the help of musicians and authors. The adolescents explained with their own words the meaning of the lyrics, telling the story of a Christmas spent in a cancer hospital ward.

Measuring the efficacy of a project for adolescents and young adults with cancer: A study from the Milan Youth Project

BACKGROUND

Various projects dedicated specifically to adolescents and young adults (AYA) with cancer have been developed in recent years. A critical aspect of such programs is the ability to demonstrate its value, and therefore how to measure desired outcomes.

METHODS

A list of metrics to consider for demonstrating the advantages of an AYA program was identified and used to assess the activity of the Youth Project operating at the Pediatric Oncology Unit of the Istituto Nazionale Tumori in Milan.

RESULTS

The number of newly diagnosed AYA patients seen at the Unit has increased since the formal launch of the Youth Project, from 65 to 81.2 cases/year. Concerning the 78 AYA patients presenting with malignant neoplasms in 2015, 82% were included in clinical trials (the other 18% in prospective observational studies). Fertility preservation measures were implemented for 59% of AYA patients considered at risk, and specific psychological support was provided in 70.6% of cases; 72.5% of patients actively participated in support activities. Other parameters considered were a preliminary satisfaction questionnaire administered to patients and the program's scientific recognition and acknowledgment by the community.

CONCLUSIONS

The study proposed a number of potentially reproducible, practical parameters to consider in assessing the value of a program dedicated to AYA. These metrics were examined in terms of the activities of our Youth Project, and confirmed its efficacy. To be sustainable over time, AYA projects have to be accepted as a standard of care at the community and government levels.

Adolescents' Health Awareness and Understanding of Cancer and Tumor Prevention: When and Why an Adolescent Decides to Consult a Physician

BACKGROUND

A feature often seen in adolescent patients with cancer is a lengthy symptom interval, especially in comparison with children. It has been suggested that inadequate awareness of cancer risk among adolescents may play an important role in this study.

METHODS

The Società Italiana Adolescenti con Malattie Onco-ematologiche and the Fondazione Umberto Veronesi conducted a survey to investigate health awareness among healthy adolescents and their understanding of cancer and its signs and symptoms by commissioning a specialized agency (AstraRicerche). A questionnaire was administered to 500 Italian adolescents from the age group of 15 to 19 years using the computer-aided web interviewing method.

RESULTS

Approximately 80% of the adolescents interviewed claimed to be well informed about their own health, 85% said they were aware that some lifestyle habits could influence their health, and 80% reported that they know that cancer can develop in adolescence too. It was also noted that, while some adolescents were worried about a given symptom, 22% of them reportedly preferred a wait-and-see approach (either to avoid alarming their parents, or they hoped that the symptom would be temporary).

CONCLUSIONS

This study showed that a majority of adolescents are concerned about their own health, but sometimes prefer not to report their symptoms to anyone. Hence, it is important to develop information campaigns tailored to raise awareness among this age group and help them interpret their symptoms.

Adolescents with Cancer in Italy: Improving Access to National Cooperative Pediatric Oncology Group (AIEOP) Centers

This analysis compared the numbers of patients treated at Italian pediatric oncology group (Associazione Italiana Ematologia Oncologia Pediatrica [AIEOP]) centers with the numbers of cases predicted according to the population-based registry. It considered 32,431 patients registered in the AIEOP database (1989-2012). The ratio of observed (O) to expected (E) cases was 0.79 for children (0-14 years old) and 0.15 for adolescents (15-19 years old). The proportion of adolescents increased significantly over the years, however, from 0.05 in the earliest period to 0.10, 0.18, and then 0.28 in the latest period of observation, suggesting a greater efficacy of local/national programs dedicated to adolescents.

Spiritual support for adolescent cancer patients: a survey of pediatric oncology centers in Italy and Spain

INTRODUCTION

Spirituality is a fundamental aspect of the psychological well-being of adolescents with cancer. This study reports on a survey conducted at pediatric oncology centers in Italy and Spain to examine the situation concerning the provision of spiritual support.

METHODS

An ad hoc questionnaire was distributed including multiple-choice questions on whether or not spiritual support was available; the spiritual counselor's role; how often the spiritual counselor visited the unit; and the type of training this person had received.

RESULTS

A spiritual support service was available at 24 of the 26 responding centers in Italy and 34/36 in Spain. The training received by the spiritual counselor was exclusively theological in most cases (with medical or psychological training in a few cases). In both countries the spiritual counselor was mainly involved in providing religious services and support at the terminal stage of the disease or in talking with patients and families. Cooperation with caregivers was reported by 27.3% and 46.7% of the Italian and Spanish centers, respectively, while the daily presence of the chaplain on the ward was reported by 18.2% and 26.7%.

CONCLUSIONS

The role of the spiritual counselor in pediatric oncology - in Italy and Spain at least - is still neither well-established nor based on standardized operating methods or training requirements. A model that implies the constant presence of a spiritual counselor in hospital wards may be proposed to provide appropriate spiritual support to adolescents with cancer.

“There's no Reason why”: A Campaign to Raise Cancer Awareness among Adolescents

Introduction

Adolescents with cancer often experience a longer diagnostic delay than children, mainly because they take longer to go to a doctor. The Italian Society for Adolescents with Oncohematological Diseases (SIAMO) has launched an information campaign focusing on raising adolescents’ awareness of the importance of diagnosing cancer early.

Methods

The concepts of the campaign were developed by a scientific committee of clinicians, cancer patients and their parents, and marketing experts. The title of the campaign is “There's no reason why”. A video has been launched on TV channels and the Internet, and the final frame refers viewers to the SIAMO website, which provides advice to help adolescents interpret any symptoms they experience.

Results

The video has had 12,181 views. In the 6 months following the launch of the campaign, the SIAMO website page dedicated to the campaign was opened by 9,767 viewers for a total of 13,632 views.

Conclusions

Though it remains very difficult to judge the efficacy of this initiative, the value of a campaign focusing on improving the adolescent population's cancer awareness is supported by the large number of studies published on the diagnostic delay in this age group. Our campaign goes to show the importance of ensuring cooperation between the different stakeholders involved in the global care of adolescents with cancer.

The Sooner the Better? How Symptom Interval Correlates With Outcome in Children and Adolescents With Solid Tumors: Regression Tree Analysis of the Findings of a Prospective Study

BACKGROUND

The potential impact of diagnostic delays on patients' outcomes is a debated issue in pediatric oncology and discordant results have been published so far. We attempted to tackle this issue by analyzing a prospective series of 351 consecutive children and adolescents with solid malignancies using innovative statistical tools.

METHODS

To address the nonlinear complexity of the association between symptom interval and overall survival (OS), a regression tree algorithm was constructed with sequential binary splitting rules and used to identify homogeneous patient groups vis-à-vis functional relationship between diagnostic delay and OS.

RESULTS

Three different groups were identified: group A, with localized disease and good prognosis (5-year OS 85.4%); group B, with locally or regionally advanced, or metastatic disease and intermediate prognosis (5-year OS 72.9%), including neuroblastoma, Wilms tumor, non-rhabdomyosarcoma soft tissue sarcoma, and germ cell tumor; and group C, with locally or regionally advanced, or metastatic disease and poor prognosis (5-year OS 45%), including brain tumors, rhabdomyosarcoma, and bone sarcoma. The functional relationship between symptom interval and mortality risk differed between the three subgroups, there being no association in group A (hazard ratio [HR]: 0.96), a positive linear association in group B (HR: 1.48), and a negative linear association in group C (HR: 0.61).

CONCLUSIONS

Our analysis suggests that at least a subset of patients can benefit from an earlier diagnosis in terms of survival. For others, intrinsic aggressiveness may mask the potential effect of diagnostic delays. Based on these findings, early diagnosis should remain a goal for pediatric cancer patients.