A systematic review of nonpharmacological interventions to reduce procedural anxiety among patients undergoing radiation therapy for cancer

Procedural anxiety is a concern for a number of patients undergoing radiation therapy. While procedural anxiety is often treated pharmacologically, there is a clinical need for effective alternative strategies for patients who are contraindicated from medication use, and those who prefer not to take unnecessary medications.

OBJECTIVES

The primary objective was to assess the efficacy of nonpharmacological interventions delivered to adults with cancer, in the radiation oncology department, just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety. The secondary objectives were to assess the efficacy of these interventions in reducing physiological symptoms of procedural anxiety and anxiety-related treatment disruptions.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Cochrane Central Register of Controlled Trials) were searched from inception up until February 2022.

INCLUSION CRITERIA

Population: Adult patients with cancer undergoing external beam radiation therapy.

INTERVENTION

Nonpharmacological interventions delivered within the radiation therapy department. Comparison: standard care controls, or standard care plus an alternative intervention.

OUTCOMES

level of self-reported procedural anxiety (primary), physiological symptoms of anxiety (secondary) and measures of anxiety-related treatment disruptions (secondary).

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted data. A meta-analysis was originally planned but deemed not feasible as the studies could not be confidently pooled for meta-analysis, due to the variability in the interventions, study designs and the generally low number of studies. Therefore, a narrative synthesis is presented.

RESULTS

Screening of 2363 records identified nine studies that met inclusion criteria: six studies of music interventions, two of video-based patient education and one of aromatherapy. Overall, three studies received a global rating of strong methodological quality and low risk of bias. Three studies reported a significant effect of the intervention on reducing the primary outcome of self-reported procedural anxiety: two music interventions (both strong methodological quality), and one video-based patient education (moderate methodological quality). One of the studies (a music intervention) also reported a significant reduction in the secondary outcome of physiological symptoms of procedural anxiety (systolic blood pressure).

CONCLUSIONS

The evidence for nonpharmacological interventions delivered to adults with cancer just prior to, or during radiation therapy, in reducing levels of self-reported procedural anxiety is limited, with very few well-designed studies. There is a need for interventions for procedural anxiety during radiation therapy to be evaluated through rigorous randomised controlled trials.

Communication Tools Used in Cancer Communication with Children: A Scoping Review

Simple Summary

Despite the potential benefits of effective communication, telling children about unpredictable and life-threatening conditions such as cancer is challenging. This scoping review aimed to map the potential communication tools for children with cancer, their families, and healthcare professionals. We found 25 studies and 21 communication tools. Communication tools might support children to improve their knowledge and psychological outcomes. However, we found a lack of communication tools that were (1) accessible and validated, (2) designed for healthcare professionals, (3) targeted children, families, and healthcare professionals, and (4) were designed to meet the needs of children and families. This review identified areas for further research.

Abstract

Background: Although communication tools might guide healthcare professionals in communicating with children about cancer, it is unclear what kind of tools are used. This scoping review aimed to map the communication tools used in cancer communication among children with cancer, families, and healthcare professionals. Methods: A comprehensive search using PubMed (including MEDLINE), Embase, CENTRAL, PsycINFO, and CINAHL was conducted on 1 August 2021. We mapped communication tools and their impacts. Results: We included 25 studies (9 experimental studies and 16 feasibility studies) of 29 reports and found 21 communication tools. There was a lack of communication tools that were (1) accessible and validated, (2) designed for healthcare professionals, (3) targeted children, families, and healthcare professionals, and (4) were designed to meet the needs of children and families. Experimental studies showed that the communication tools improved children’s knowledge and psychological outcomes (e.g., health locus of control, quality of life, self-efficacy). Conclusion: We mapped communication tools and identified areas that needed further research, including a lack of tools to guide healthcare professionals and share information with children and families. Further research is needed to develop and evaluate these communication tools. Moreover, it is necessary to investigate how communication tools support children, families, and healthcare professionals.

The efficacy of interactive group psychoeducation for children with leukaemia: A randomised controlled trial

OBJECTIVE

To evaluate an interactive group psychoeducation programme for children treated for leukaemia.

METHODS

A longitudinal randomised controlled study across four UK hospitals with an immediate (N = 26) and delay control group (N = 32). The intervention covered the pathophysiology of leukaemia, its treatment, side effects and the importance of positive health behaviours. Primary outcomes were parent-reported child health related quality of life (HRQoL) and behavioural difficulties. Secondary outcomes were child-reported HRQoL, cancer-specific HRQoL, child confidence, caregiver burden, and treatment anxiety. Measures were completed pre- and immediately post-intervention, and at 13 and 26-weeks follow-up. Change over time was analysed using multilevel modelling. Acceptability questionnaires rated the intervention on benefits, recommendations, and barriers to participation.

RESULTS

The intervention significantly improved parent-reported child HRQoL but did not have a significant effect on other outcomes. Acceptability of the intervention was high.

CONCLUSIONS

This study provides initial evidence that interactive group psychoeducation is acceptable to families and improves HRQoL in children with leukaemia. Difficulties with recruitment removed power to detect effect sizes that are plausible for psychoeducational interventions.

PRACTISE IMPLICATIONS

Further studies to explore the potential of psychoeducation to improve outcomes for children with leukaemia and an examination of barriers to participation within this population are warranted.

Changing healthcare provider and parent behaviors in the pediatric post-anesthesia-care-unit to reduce child pain: Nurse and parent training in postoperative stress

BACKGROUND

Children who undergo surgery experience significant pain in the post anesthesia care unit. Nurse and parent behaviors in the post anesthesia care unit directly impact child postoperative pain. Therefore, we have developed and evaluated (Phase 1) and then tested (Phase 2) the feasibility of a new intervention (Nurse and Parent Training in Postoperative Stress) to alter parent and nurse behaviors in a way consistent with reducing child postoperative pain.

METHODS

In Phase 1, a multidisciplinary team of experts (physicians, nurses, and psychologists) developed an empirically-based intervention which was then evaluated by experienced nurses (N = 8) and parents (N = 9) during focus groups. After revising the intervention based on focus group feedback, it was tested in Phase 2 using a pre-post study design. Nurses (N = 23) who worked in the recovery room were recruited to be part of both pre- and post-intervention data collection periods. Parents were recruited to be part of either the pre- (N = 52) or post-intervention (N = 60) data collection periods. Nurses and parent-child dyads were recorded in the post anesthesia care unit and videos were coded for the desired (ie, behaviors that may decrease child pain) and non-desired (ie, behaviors that may increase child pain) behaviors. Pain data was collected from the children's medical records to assess pain after surgery. The intervention was given to the nurses and parents in the post-intervention data collection period.

RESULTS

Nurses significantly increased their rate of desired behaviors by 231% (P = 0.001; Somer's D = 1) and significantly decreased their rate of non-desired behaviors by 62% (P = 0.004, Somer's D = -0.88, 95% CI [-1.74, -0.03]). Parents significantly increased their rate of desired behaviors by 124% (P = 0.033). Moreover, the intervention significantly decreased child pain in the post anesthesia care unit (b = -2.19, SE = 0.63, z = -3.46, P = 0.001, 95%CI [-3.43, -0.95]).

CONCLUSION

The intervention was effective in changing nurse and parent behaviors as well as child pain after surgery.

Enfrentamento do Câncer Infantil e Intervenções Psicológicas: Uma Revisão da Literatura

Resumo O presente estudo consiste em uma revisão integrativa de pesquisas que investigaram o enfrentamento ao câncer infantil, com destaque para propostas de intervenção visando o seu favorecimento. Realizou-se uma busca bibliográfica nas bases de dados Web of Science, PubMed e PsychNet. Foram selecionados 80 artigos que atenderam aos critérios gerais de inclusão e 22 estudos tendo como foco específico propostas de intervenção. Os estudos selecionados avaliaram os resultados das intervenções realizadas ou a intervenção em si, discutindo aspectos particulares das mesmas e avaliando sua viabilidade. Todos os estudos qualificaram a intervenção proposta como viável, sendo que em sua maioria relataram benefícios aos participantes, o que destaca a relevância das iniciativas.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVES

To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013.

SELECTION CRITERIA

We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention.

AUTHORS' CONCLUSIONS

We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

Procedural Preparation and Support as a Standard of Care in Pediatric Oncology

Youth with cancer undergo many repeated and invasive medical procedures that are often painful and highly distressing. A systematic review of published research since 1995 identified 65 papers (11 review articles and 54 empirical studies) that investigated preparatory information and psychological interventions for a variety of medical procedures in pediatric cancer. Distraction, combined cognitive-behavioral strategies, and hypnosis were identified as effective for reducing child pain and increasing child coping. Low- to high-quality evidence informed strong recommendations for all youth with cancer to receive developmentally appropriate preparatory information and psychological intervention for invasive medical procedures.

A critical review of the use of technology to provide psychosocial support for children and young people with long-term conditions

Advances in technology have offered health professionals alternative mediums of providing support to patients with long-term conditions. This critical review evaluated and assessed the benefit of electronic media technologies in supporting children and young people with long-term conditions. Of 664 references identified, 40 met the inclusion criteria. Supportive technology tended to increase disease-related knowledge and improve aspects of psychosocial function. Supportive technology did not improve quality of life, reduce health service use or decrease school absences. The poor methodological quality of current evidence and lack of involvement of users in product development contribute to the uncertainty that supportive technology is beneficial.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This review is an updated version of the original Cochrane review published in Issue 4, 2006. Needle-related procedures are a common source of pain and distress for children. Our previous review on this topic indicated that a number of psychological interventions were efficacious in managing pediatric needle pain, including distraction, hypnosis, and combined cognitive behavioural interventions. Considerable additional research in the area has been published since that time.

OBJECTIVES

To provide an update to our 2006 review assessing the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

Searches of the following databases were conducted for relevant randomized controlled trials (RCTs): Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; PsycINFO; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Web of Science. Requests for relevant studies were also posted on various electronic list servers. We ran an updated search in March 2012, and again in March 2013.

SELECTION CRITERIA

Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only RCTs with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed trial quality and a third author helped with data extraction and coding for one non-English study. Included studies were coded for quality using the Cochrane Risk of bias tool. Standardized mean differences with 95% confidence intervals were computed for all analyses using Review Manager 5.2 software.

MAIN RESULTS

Thirty-nine trials with 3394 participants were included. The most commonly studied needle procedures were venipuncture, intravenous (IV) line insertion, and immunization. Studies included children aged two to 19 years, with the most evidence available for children under 12 years of age. Consistent with the original review, the most commonly studied psychological interventions for needle procedures were distraction, hypnosis, and cognitive behavioural therapy (CBT). The majority of included studies (19 of 39) examined distraction only. The additional studies from this review update continued to provide strong evidence for the efficacy of distraction and hypnosis. No evidence was available to support the efficacy of preparation and information, combined CBT (at least two or more cognitive or behavioural strategies combined), parent coaching plus distraction, suggestion, or virtual reality for reducing children's pain and distress. No conclusions could be drawn about interventions of memory alteration, parent positioning plus distraction, blowing out air, or distraction plus suggestion, as evidence was available from single studies only. In addition, the Risk of bias scores indicated several domains with high or unclear bias scores (for example, selection, detection, and performance bias) suggesting that the methodological rigour and reporting of RCTs of psychological interventions continue to have considerable room for improvement.

AUTHORS' CONCLUSIONS

Overall, there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents, with no evidence currently available for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality. Additional research is needed to further assess interventions that have only been investigated in one RCT to date (that is, memory alteration, parent positioning plus distraction, blowing out air, and distraction plus suggestion). There are continuing issues with the quality of trials examining psychological interventions for needle-related pain and distress.

Exploring the needs and resources of children in a haematology-oncology unit

Too often a child’s body is restored to health in the hospital, but the child is sent home with emotional wounds. This study explored the needs of children in a haematology-oncology unit as well as the resources that could be mobilised in order to address these needs by firstly carrying out a literature review. A field study was then conducted in order to prioritise the resources according to their importance for children in a haematology-oncology unit. A definite trend could be found in the way that the children responded to the request to prioritise the resources. The first three resources, as chosen by the children, all concerned the external social environment of the child. It could therefore be concluded that support from parents and other people of significance are most important to the child and should be taken into account when facilitating support for children in a haematology-oncology unit. It could also be concluded that these children do not experience sufficient control in their situation and it could therefore be suggested that children in a haematology-oncology unit should experience more control and power in their situation.OpsommingSo dikwels word ‘n kind se liggaam genees in die hospitaal, maar hierdie selfde kind gaan huis toe met emosionele wonde. Die behoeftes van kinders in ‘n hematologie-onkologie eenheid is ondersoek asook die hulpbronne wat gemobiliseer kan word om hierdie behoeftes aan te spreek deur gebruik te maak van ‘n literatuurstudie. Daarna is ‘n veldstudie gedoen om hierdie hulpbronne te prioritiseer volgens die belangrikheid daarvan vir kinders in ‘n hematologieonkologie eenheid. Die manier waarop die kinders die hulpbronne geprioritiseer het, het ‘n definitiewe tendens getoon. Die eerste drie hulpbronne wat deur die kinders gekies is, is al drie hulpbronne wat die eksterne sosiale omgewing van die kind behels. Die gevolgtrekking kan dus gemaak word dat die ondersteuning van ouers en ander persone wat belangrik is vir die kind, van uiterste belang is en in aanmerking geneem behoort te word in die fasilitering van ondersteuning van kinders in ‘n hematologie-onkologie eenheid. Die gevolgtrekking wat gemaak kan word is dat hierdie kinders nie genoeg beheer ervaar in hulle situasie nie en daarom word voorgestel dat kinders in ‘n hematologie-onkologie eenheid meer bemagtig behoort te word gegewe hulle omstandighede.