Health-related quality of life of pediatric patients receiving allogeneic stem cell or bone marrow transplantation: results of a longitudinal, multi-center study

Can extending time between vital sign checks improve sleep in hematopoietic stem cell transplant patients? Testing feasibility, acceptability, and preliminary efficacy

BACKGROUND

Patients undergoing hematopoietic stem cell transplant (HSCT) experience barriers to quality sleep. Frequent vital sign checks are necessary early posttransplant given risk of complications but can disrupt sleep. This study tested feasibility and acceptability of extending time between checking vitals (EVs) from every 4 to every 6 h to improve sleep.

PROCEDURE

HSCT patients ages 8-21 years (N = 50, mean age = 14.06, SD = 3.58) and their caregivers were enrolled 1-2 days prior to transplant, and 40 patients completed the 15-day study (NCT04106089). Patients wore an actigraph to estimate sleep and provided self- and caregiver-report of sleep. Sleep was observed for nights 0 to +4 posttransplant, and patients were then randomized to EVs either Days +5 to +9 or +10 to +14. Patients were assessed daily for medical eligibility to receive EVs; on days patients were eligible, nightshift nurses (N = 79) reported EV acceptability.

RESULTS

Of 200 potential nights for EVs (5 nights x 40 patients), patients were eligible for EVs on 126 nights (63% of eligible nights), and patients received EVs on 116 (92%) of eligible nights. Most patients received EVs ≥3 nights (n = 26, 65%, median = 3 nights). Most patients (85%), caregivers (80%), and nurses (84%) reported that patients used the additional 2 h during EVs for sleep, with reporters indicating moderate to high acceptability. There was preliminary evidence of efficacy indicated by caregiver-reported sleep disturbance and actigraphy-estimated improvements in sleep efficiency during EVs.

CONCLUSION

Extending time between vitals checks is highly acceptable to patients, caregivers, and nurses, and may offer a feasible approach to improve sleep in pediatric HSCT.

A prospective study of the relationship between illness perception, depression, anxiety, and quality of life in hematopoietic stem cell transplant patients

AIM

The aim of study was to investigate whether depression and anxiety symptoms and illness perception prior to hematopoietic stem cell transplantation (HSCT) predict health related quality of life (HRQOL) at Day 100 and 1 year following HSCT.

METHODS

A total of 205 patients who underwent HSCT (N = 127 autologous transplants, N = 78 allogeneic transplants) were included in this prospective study. Baseline assessment was assessed prior to transplantation and post HSCT data were collected at Day 100 and 1 year. At baseline we assessed depressive symptoms (Patient Health Questionnaire-9), anxiety symptoms (Generalized Anxiety Disorder-7), illness perception (Brief Illness Perception Questionnaire), and HRQOL (Functional Assessment of Cancer Therapy-BMT).

RESULTS

Patients who expressed a greater level of concern about the severity, course, and ability to exert control over one's illness (i.e., illness perception) and who reported a greater level of depression and anxiety symptoms prior to HSCT reported lower HRQOL at both Day 100 and 1 year posttransplant, with a similar degree of association observed at the two follow-up time points.

CONCLUSIONS

Our findings suggest that pretransplant perceptions about their illness and negative mood are significant predictors of HRQOL following HSCT. Illness perception, depression, and anxiety are potentially modifiable risk factors for less than optimal outcome after HCSCT and intervention strategies should be explored.

Application of the National Comprehensive Cancer Network-distress thermometer in pediatric patients during autologous and allogeneic hematopoietic stem cell transplantation and relationship to blood parameters of the stress axis

PURPOSE

Hematopoietic stem cell transplantations (HSCT) are extremely stressful procedures for pediatric patients. The activation of the hypothalamic pituitary adrenocortical axis (HPA) can influence the immune system negatively and therefore the overall outcome. The distress thermometer (DT) is an easy to use tool for the self-assessment of perceived distress.

METHODS

In this prospective study, a DT with an attached problem list was used in 40 pediatric patients undergoing HSCT and in one parent of each patient. The patients were aged 10-18 years. The patients' cortisol, thyroid stimulating hormone, free triiodothyronine and thyroxine levels were measured regularly during the in-patient stay.

RESULTS

After admission to the hospital, the stress levels of the pediatric patients and their parents increased and reached their maximum on the day of HSCT. The overall stress values of the parents were higher than those of their children. There was a significant difference in the parents' stress levels on the day of HSCT, as compared to their stress levels on other days. The mean cortisol values of the pediatric patients also increased after admission, reaching significant elevated levels above the upper normal limit 1 week after HSCT and on discharge day. Although the pediatric patients experienced mainly exhaustion, especially on the day of transplantation, their parents mainly felt worry and anxiety. Interestingly, the rate of worry among children increased in the post-transplant period and reached its maximum on the day of discharge.

CONCLUSIONS

In summary, a significantly increased stress level is shown for both the patients and their parents. This is reflected for the patients both in the DT scores and in the increased cortisol values. For the parents, the focus is primarily on worry and anxiety, for the patients primarily on exhaustion and worry.

Screening for distress and quality of life in pediatric patients after allogeneic or autologous hematopoietic stem cell transplantation using a self-reporting instrument, blood stress biomarkers and an expert rating scale (PO-Bado)

OBJECTIVE

Hematopoietic stem cell transplantation (HSCT) is highly distressing and potentially traumatizing for pediatric and young adult patients (PYAP). At present, there is little evidence on their individual burdens.

METHODS

In this prospective cohort study, the course of the psychological and somatic distress was investigated on eight observation days (day -8/-12, -5, 0 (day of HSCT), +10, +20, and + 30 before/after HSCT), using the PO-Bado external rating scale and the EORTC-QLQ-C15-PAL self-assessment questionnaire. Stress-associated blood parameters were determined and correlated with the results of the questionnaires.

RESULTS

A total of 64 PYAP with a median age of 9.1 years (range 0-26 years) who underwent autologous (n = 20; 31%; autoHSCT) or allogeneic (n = 44; 69%; alloHSCT) HSCT were analyzed. Both were associated with a significant reduction in QOL. The reduction in self-assessed QOL correlated with somatic and psychological distress as assessed by medical staff. While somatic distress was similar in both groups with a maximum around day+10 (alloHSCT 8.9 ± 2.4 vs. autoHSCT 9.1 ± 2.6; p = 0.69), a significantly higher level of psychological distress was seen during alloHSCT (e.g. day0 alloHSCT 5.3 ± 2.6 vs. day0 autoHSCT 3.2 ± 1.0; p < 0.0001).

CONCLUSIONS

The maximum of psychological and somatic distress, as well as the lowest quality of life, ranges between day 0 and + 10 after both allogeneic and autologous pediatric HSCT. While somatic distress is similar during autologous and allogeneic HSCT, the allogeneic group seems to be affected by higher psychological distress. Larger prospective studies are needed to evaluate this observation.

Feasibility & Acceptability of Patient and Family Directed Active Music Making during Pediatric Bone Marrow Transplant Process

(1) Background: Bone marrow transplant (BMT) is an aggressive and complex medical treatment for children with certain types of cancer and other diseases. The transplant process entails replacing the patient's diseased bone marrow with the healthy marrow of a donor. During the course of treatment, patients are isolated in their room to reduce the risk of infection. Patient's experience a variety of symptoms and side effects during the process including nausea, vomiting, diarrhea, mouth sores, fatigue, pain, discomfort, extreme muscle weakness, and emotional distress. Children often need a parent or caregiver present with them at all times throughout treatment. This process can cause significant stress and anxiety for the patient and their family. (2) Methods: This study explored the feasibility and acceptability of a patient and family directed active music making protocol during the BMT process. Ten patients, their parents, and family members participated in the study during the course of the BMT. (3) Results: Participants reported engaging in active music making 3-4 times per week and completed 121 journal forms reporting their music making experiences. They indicated using active music making to manage pain, discomfort, stress, anxiety, and boredom, foster relaxation and sleep, for enjoyment, and as a way to connect. (4) Conclusions: Patients, parents and family members reported feeling a sense of empowerment when engaged in making music to support their child or loved one.

Tisagenlecleucel for relapsed/refractory acute lymphoblastic leukemia in the Irish healthcare setting: cost-effectiveness and value of information analysis

OBJECTIVES

This study evaluates the cost-effectiveness of tisagenlecleucel (a CAR T-cell therapy), versus blinatumomab, for the treatment of pediatric and young adult patients with relapsed/refractory acute lymphoblastic leukemia (R/R ALL) in the Irish healthcare setting. The value of conducting further research, to investigate the value of uncertainty associated with the decision problem, is assessed by means of expected value of perfect information (EVPI) and partial EVPI (EVPPI) analyses.

METHODS

A three-state partitioned survival model was developed. A short-term decision tree partitioned patients in the tisagenlecleucel arm according to infusion status. Survival was extrapolated to 60 months; general population mortality with a standardized mortality ratio was then applied. Estimated EVPI and EVPPI were scaled up to population according to the incidence of the decision.

RESULTS

At list prices, the incremental cost-effectiveness ratio was EUR 73,086 per quality-adjusted life year (QALY) (incremental costs EUR 156,928; incremental QALYs 2.15). The probability of cost-effectiveness, at the willingness-to-pay threshold of EUR 45,000 per QALY, was 16 percent. At this threshold, population EVPI was EUR 314,455; population EVPPI was below EUR 100,000 for each parameter category.

CONCLUSIONS

Tisagenlecleucel is not cost effective, versus blinatumomab, for the treatment of pediatric and young adult patients with R/R ALL in Ireland (at list prices). Further research to decrease decision (parameter) uncertainty, at the defined willingness-to-pay threshold, may not be of value. However, there is a high degree of uncertainty underpinning the analysis, which may not be captured by EVPI analysis.

Addressing Common Pain Syndromes in Pediatric Stem Cell Transplant: A Review

Assessment and management of pain for pediatric patients receiving stem cell transplants can be challenging for a health care team. Diagnostic evaluation and interventions vary between institutions and individual provider practices. In this review, we investigate and describe approaches to pain management for the most common sources of pain in pediatric patients undergoing stem cell transplants. Mucositis pain, abdominal pain, and hemorrhagic cystitis emerged as the most frequent sources of acute pain in children during conditioning and transplantation periods. Furthermore, psychosocial distress and psychological pain or distress constitute significant components of the total pain experienced by children undergoing stem cell transplantation. We will expand upon appropriate usage and escalation of opioids, as well as complementary interventions and timely initiation of interventions, in order to help control pain in these clinical syndromes.

Light Therapy for QoL/Depression in AYA With Cancer: A Randomized Trial

OBJECTIVE

Secondary outcomes from a published feasibility and acceptability trial were examined to explore the effect of bright white light (BWL) on quality of life (QoL) and depressive symptoms compared to dim red light (DRL) control in adolescents and young adults (AYAs) receiving cancer-directed therapy.

METHODS

Fifty-one AYAs (12-22 years, 51% male) newly diagnosed with cancer were randomized to receive 8 weeks of BWL (n = 26) or DRL (n = 25). The CDI-2 (total score, negative mood/physical symptoms, interpersonal problems, ineffectiveness, and negative self-esteem) and parent- and self-report PedsQL (total score and subscales of physical, emotional, social, and school QoL) were completed at multiple timepoints.

RESULTS

BWL produced improvements in self-reported total depression (d = -.64; 95% confidence interval [CI] = -1.26, -0.01), negative self-esteem (d = -.80; 95% CI = -1.43, -.14), negative mood/physical symptoms (d = -.73; 95% CI = -1.36, -0.08), ineffectiveness (d = -.43; 95% CI = -1.04, .19), total self-reported QoL (d = .41; 95% CI = -.16, .96), emotional (d = .78; 95% CI = .19, 1.37), school functioning (d = .48; 95% CI = -.09, 1.04), and parent-reported school functioning (d = .66; 95% CI = 0.02, 1.33). BWL reported a greater rate of improvement than DRL for total depression (β = .49, p < .05) and self-esteem (β = .44, p < .05), and parent-reported school functioning (β = -1.68, p < .05).

CONCLUSIONS

BWL improved QoL and depressive symptoms for AYAs with cancer. These findings will inform larger randomized controlled trials.

Audit of Psychosocial and Palliative Care Support for Children Having Allogeneic Stem Cell Transplants at the New Zealand National Allogeneic Transplant Centre

Psychosocial and palliative care support during stem cell transplants (SCT) is known to improve outcomes.

AIM

evaluate the support provided to children and families at the New Zealand National Allogeneic Stem Cell Transplant unit (NATC).

METHOD

the psychosocial and palliative care support for children who received SCT between December 2012 and April 2018 was audited.

RESULTS

of the 101 children who received SCT, 97% were reviewed by the social work team (SW) and 82% by the psychiatric consult liaison team (CLT) at least once during their illness. However, pre-transplant psychological assessment only occurred in 16%, and during the SCT admission, only 55% received SW support, and 67% received CLT support. Eight out of eighty-five families (9%) were offered support for siblings. Eight of the sixteen children who died were referred for pediatric palliative care (PPC) with all supported and half the families who experienced a death (n = 8; 50%) received bereavement follow up.

CONCLUSION

although the majority received some social work and psychological support, auditing against the standards suggests the consistency of involvement could be improved. Referrals for PPC were inadequate and largely for end-of-life phase. Sibling support, in particular donor siblings, had insufficient psychological assessment and support. Key recommendations are provided to address this underperformance.

Profiles and predictors of resilient functioning in youths with pediatric cancer history

OBJECTIVE

To identify and predict resilient functioning over time among youths with pediatric cancer experience (YPCE).

DESIGN

YPCE aged 8-17 years (N = 231) were followed prospectively for 3 years. Their psychosocial adjustment was assessed using self-report and parent-report at 1 year (T2) and 3 years (T3) post-baseline.

METHODS

Latent profile analysis identified subgroups of YPCE with different patterns of adjustment over time. Self-reported factors from baseline and T2 were examined as predictors of subgroup membership.

FINDINGS

Three subgroups of youths were found. Two exhibited average (52.5% of the sample) to better-than-average (41.3%) functioning. One subgroup (6.2%) exhibited subclinical but at-risk range of adjustment. Low optimism and low connectedness to parents and school predicted membership in this group.

CONCLUSIONS

Most YPCE exhibit resilient functioning across time. However, approximately 6% report persistent maladjustment.

IMPLICATIONS

Most YPCE are well-adjusted, but those with low optimism and poor connection to parents or school may require monitoring for psychosocial difficulties.

Psychophysical effects of an exercise therapy during pediatric stem cell transplantation: a randomized controlled trial

This study evaluates the physical and psychosocial effects of an inpatient exercise program for children and adolescents undergoing hematopoietic stem cell transplantation (HSCT). Participants (n = 70) were randomized to an exercise intervention (IG: resistance, endurance, and flexibility training) or a non-exercise control group (CG: mental and relaxation training). Pre- (prior hospital admission; T0) and post- (day of discharge; T1) measurements included maximal isometric knee extension strength (KES; strain gauge force transducer), hand grip strength (HGS; JAMAR dynamometer), distance walked in 6 min (6MWD; 6-minute walk test), quality of life (QoL; KINDL-R) and medical parameters. Fifty-seven patients (IG: n = 28; 11.0 (5-17) years; CG: n = 29; 12.0 (6-18) years) completed the study. During hospitalization the IG and CG attended on average 3.1 (2-4) or 2.9 (0.3-4) training sessions weekly. KES, 6MWD, and HGS significantly decreased (p < 0.05) in the CG, while there were no changes in the IG. Pre- to post-changes in 6MWD and HGS differed significantly between groups (p < 0.05). QoL declined in both groups (p < 0.05). Our results indicate that a moderate exercise program is feasible and might counteract a treatment-associated decline of physical performance.

Female Sex is Associated With Poor Health-related Quality of Life in Children at 12 Months Post-Hematopoietic Cell Transplantation

To study the factors associated with poorer health-related quality of life at 1-year post-allogeneic hematopoietic cell transplantation (alloHCT), a secondary analysis of a prospective feasibility study was performed. Pediatric Quality of Life Inventory questionnaires were collected in 76 children undergoing alloHCT at baseline (within 30 d before transplantation), day 100, 6 months, and 12 months posttransplantation. The global score improved post-HCT (baseline: 67.1, 12 mo: 76.6). Females (odds ratio, 6.5; 95% confidence interval, 1.002-42.17; P=0.04) and patients with low baseline scores (odds ratio, 7.2; 95% confidence interval, 1.07-48.63; P=0.04) had lower scores at 12 months post-HCT and suggest a target group for early interventions such as physical exercise, stress management, and cognitive behavior therapy.

Cost-Effectiveness Analysis of an Adherence-Promotion Intervention for Children With Leukemia: A Markov Model-Based Simulation

Objective

Improving medication adherence among children with B-cell precursor acute lymphoblastic leukemia (B-ALL) has the potential to reduce relapse rates but requires an investment in resources. An economic evaluation is needed to understand the potential costs and benefits of delivering adherence-promotion interventions (APIs) as part of standard clinical care.

Methods

A Markov decision analytic model was used to simulate the potential incremental cost-effectiveness per quality-adjusted life year (QALY) to be gained from an API for children with B-ALL in first continuous remission compared with treatment as usual (TAU, no intervention). Model parameter estimates were informed by previously published studies. The primary outcome was incremental cost (2015 US$) per QALY gained for API compared with TAU.

Results

The model predicts the API to result in superior health outcomes (4.87 vs. 4.86 QALYs) and cost savings ($43,540.73 vs. $46,675.71) as compared with TAU, and simulations indicate that, across a range of plausible parameter estimates, there is a 95% chance that the API is more effective and less costly than TAU. The API was estimated to remain more effective and less costly than TAU in situations where the prevalence of nonadherence exceeds 32% and when API improves baseline adherence in at least 3% of patients.

Conclusions

Providing APIs to children with B-ALL may improve health outcomes and save costs over a 6-year period.

Caregiver Perceptions of Music Therapy for Children Hospitalized for a Blood and Marrow Transplant: An Interpretivist Investigation

Background

Despite pharmacological and psychosocial support, pediatric blood and marrow transplant (BMT) recipients typically experience heightened levels of somatic and psychological distress while undergoing transplant. Although clinicians have used psychosocial interventions to target distress, there are gaps in the literature concerning music therapy for children recovering from BMT. This is especially the case among younger children and those affected by rare genetic or metabolic disorders.

Objective

As caregivers are the primary decision makers for minor children, there is a need to understand their preferences and values as this constitutes a component of evidence-informed practice. Therefore, the purpose of this interpretivist investigation was to explore primary caregivers’ perspectives and experiences with music therapy for their children during hospitalization for BMT.

Methods

The researchers conducted semistructured phone interviews with 15 primary caregivers of children who had received music therapy services while hospitalized for BMT. Member checking was used to ensure accuracy of the transcripts and experiences, while trustworthiness was used to verify themes.

Results

Fifteen caregivers of 14 pediatric BMT recipients were interviewed by phone. The following four themes emerged: (1) music therapy motivated patients to physically engage their bodies despite symptoms; (2) music therapy elevated patients’ moods; (3) caregivers benefited from seeing their child engaged in music therapy; and (4) caregivers were appreciative for the opportunity and requested additional music therapy services.

Conclusions

Caregivers perceived music therapy to be a positive and beneficial experience for pediatric patients while hospitalized for BMT. Implications for clinical practice, limitations, and suggestions for future research are provided.

Longitudinal examination of family efficacy following pediatric stem cell transplant

OBJECTIVE

Pediatric stem cell transplant (pSCT) is emotionally demanding for families. Yet, we know little of how the family unit responds to the adversity of pSCT within the first year after transplant. Family efficacy, an indicator of family resilience, is linked to positive parent, child, and family adjustment. Better understanding the factors that promote family efficacy during this difficult time could inform modifiable intervention targets and improve child and parent adjustment. The primary objectives were to examine patterns of family efficacy beliefs and identify factors that promote or hinder family efficacy.

METHODS

Ninety caregivers (71% white, 7% black, 3% Hispanic, 4% Asian, 14% multiple ethnicities) of children receiving pSCT completed demographic forms, the Psychosocial Assessment Tool, and the Filial Parental and Collective Family Efficacy Beliefs scale prior to the family's discharge, and 1, 3, 6, and 9 months post-discharge. Latent growth curve modeling was used to examine family efficacy across time. Parent, child, and sibling distress, social support, and demographic factors served as predictors.

RESULTS

Latent growth curve modeling demonstrated that family efficacy was stable for 9 months post pSCT discharge. Social support was positively related to family efficacy beliefs. No other variables predicted family efficacy.

CONCLUSION

Most families perceive themselves as resilient following pSCT. Social relationships and support are critical in maintaining a family's sense of efficacy during the arduous pSCT course.

Impact of the initial fitness level on the effects of a structured exercise therapy during pediatric stem cell transplantation

BACKGROUND

Before and after hematopoietic stem cell transplantation (HSCT), most patients suffer from psychophysical limitations due to the treatment. Exercise interventions demonstrate beneficial effects on, for example, strength, endurance, or health-related quality of life during and after HSCT, but with a great variation among patients concerning the response to exercise. This study examines the influence of the initial fitness on the effects of an exercise therapy in pediatric HSCT.

PROCEDURE

Fifty-three children and adolescents (10.9 ± 3.5 years) scheduled for HSCT were randomized into an exercise intervention group (IG) or a control group (CG). During hospitalization, the IG performed endurance, strength, and flexibility training three times per week. The CG included a nonexercise program. A 6-min walk test was completed before and after the inpatient period. Baseline results (6-min walking distance [6MWD]) were used to split both groups into the following: IG_UNFIT , n = 14; IG_FIT , n = 12; CG_UNFIT , n = 16; CG_FIT , n = 11. Differences in outcome changes between groups were analyzed with H-test.

RESULT

Intergroup comparison revealed significant differences between IG_UNFIT and CG_UNFIT (P < 0.05). The IG_UNFIT increased their 6MWD by +8% (vs. IG_FIT , +1%); both CGs presented a decline in 6MWD (CG_UNFIT , -14%; CG_FIT , -16%). At discharge, the IG_FIT achieved 85.5 ± 10.3% of healthy reference values.

CONCLUSIONS

The current results indicate that exercise during pediatric HSCT is feasible and contributes to prevention of treatment-related loss of physical function. As seen in healthy persons, patients' benefits might depend on their initial fitness level. As a diminished physical capability may result in higher training effects, impaired especially patients should engage in exercise.

Three sides to a story: Child, parent, and nurse perspectives on the child's experience during hematopoietic stem cell transplantation

BACKGROUND

The experience of children undergoing hematopoietic stem cell transplantation (HSCT), including the ways in which different participants (ie, children, parents, and nurses) contribute to the overall picture of a child's experience, is poorly characterized. This study evaluated parent, child, and nurse perspectives on the experience of children during HSCT and factors contributing to interrater differences.

METHODS

Participants were enrolled in a multicenter, prospective study evaluating child and parent health-related quality of life over the year after HSCT. Children (n = 165) and their parents and nurses completed the Behavioral, Affective, and Somatic Experiences Scale (BASES) at baseline (before/during conditioning), 7 days after the stem cell infusion (day+7), and 21 days after the stem cell infusion (day+21). The BASES domains included Somatic Distress, Mood Disturbance, Cooperation, and Getting Along. Higher scores indicated more distress/impairment. Repeated measures models by domain assessed differences by raters and changes over time and identified other factors associated with raters' scores.

RESULTS

Completion rates were high (≥73% across times and raters). Multivariate models revealed significant time-rater interactions, which varied by domain. For example, parent-rated Somatic Distress scores increased from baseline to day+7 and remained elevated at day+21 (P < .001); children's scores were lower than parents' scores across time points. Nurses' baseline scores were lower than parents' baseline scores, although by day+21 they were similar. Older child age was associated with higher Somatic Distress and Mood Disturbance scores. Worse parent emotional functioning was associated with lower scores across raters and domains except for Cooperation.

CONCLUSIONS

Multirater assessments are highly feasible during HSCT. Ratings differ by several factors; considering ratings in light of such factors may deepen our understanding of the child's experience. Cancer 2017;123:3159-66. © 2017 American Cancer Society.

Psychopathological Aspects in Childhood Hematopoietic Stem Cell Transplantation (HSCT): The Perception of Parents and Adolescents

Background: Data about psychosocial sequelae of childhood Hematopoietic Stem Cell Transplantation (HSCT) are limited and the association with a specific donor type or other medical factors is largely unknown (Chang et al., 2012). The aim of the present study was to compare the psychological aspects of pediatric HSCT survivors with healthy peers. A secondary aim was to detect whether parents and children differed in the perception of mental health status. The influence of medical factors on psychological status was also examined. Method: Thirty seven HSCT survivors (23 males) with a mean age of 14.4 years (SD = 3.03; range 8.16-18.33) were recruited. Twenty-six patients underwent an allogenic HSCT (matched unrelated donor, n = 20; matched sibling donor, n = 6) and 11 patients received an autologous HSCT. The children psychological aspects were assessed using the Youth Self Report (YSR) (Achenbach and Rescorla, 2001) and compared to a group of matched healthy peers. At the same time, parents were requested to complete the Child Behavior Checklist 6-18 (Achenbach and Rescorla, 2001). Medical and socio-demographic data were also collected. Results: HSCT survivors reported significantly higher levels of somatic complains (t27 = 3.14; p = 0.004; mean = 3.1) when compared to healthy peers (mean = 1.5). The parent CBCL scores on "child total competence" exceeded the normative clinical cutoff in 48.6% cases. Inter-rater agreement between parent and patient reports was present only in three scales: total competence score (K = 0.06, p = 0.002), somatic complaints (K = 0.21, p = 0.003) and attention problems (k = 0.13; p = 0.02). According to Ancova models, internalizing problems were more frequent in HSCT from family donors (F2 = 3.13; p = 0.06) or in the presence of acute complications (F1 = 11.95; p = 0.003). Conclusion: In contrast to the perception of parents, pediatric HSCT survivors reported good psychological health. However, they complained about more somatic problems as compared with healthy peers. Medical aspects such as donor source and the presence of acute complications should be taken into consideration for the psychological approach in order to improve pediatric HSCT survivor care.

National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Patient-Centered Outcomes Working Group Report

In 2015, the National Institutes of Health convened six working groups to address the research needs and best practices for late effects of hematopoietic stem cell transplantation survivors. The Patient-Centered Outcomes Working Group, charged with summarizing the HRQOL evidence base, used a scoping review approach to efficiently survey the large body of literature in adult and pediatric HCT survivors over 1 year after transplantation. The goals of this paper are to (1) summarize the current literature describing patient-centered outcomes in survivors, including the various dimensions of health-related quality of life affected by HCT, and describe interventions tested to improve these outcomes; (2) highlight areas with sufficient evidence allowing for integration into standard practice; (3) address methodological issues that restrict progress in this field; (4) identify major gaps to guide future research; and (5) specify priority research recommendations. Patient-centered outcomes were summarized within physical, psychological, social, and environmental domains, as well as for adherence to treatment, and health behaviors. Interventions to improve outcomes were evaluated for evidence of efficacy, although few interventions have been tested in long-term HCT survivors. Methodologic issues defined included lack of consistency in the selection of patient-centered outcome measures, along with the absence of a standard for timing, frequency, and mode of administration. Recommendations for HCT survivorship care included integration of annual screening of patient-centered outcomes, use of evidence-based practice guidelines, and provision of treatment summaries and survivorship care plans after HCT. Three priority research recommendations included the following: (1) design and test risk-targeted interventions with dose-intensity modulation matching the needs of HCT survivors with priority domains, including sexual dysfunction, fatigue, sleep disruption, nonadherence to medications and recommended health care, health behaviors including physical inactivity and healthy eating, and psychological dysfunction, with particular consideration of novel technologies to reach HCT survivors distant from their transplantation centers; (2) design a consensus-based methodologic framework for outcomes evaluation; and (3) evaluate and compare existing practices for integrating patient-centered outcome screening and interventions across HCT survivorship programs.

Rehabilitative intervention during and after pediatric hematopoietic stem cell transplantation: An analysis of the existing literature

Hematopoietic stem cell transplantation is a therapeutic strategy for several oncohematological diseases. It increases survival rates but leads to a high incidence of related effects. The objective of this paper was to examine the existing literature on physical exercise interventions among pediatric HSCT recipients to explore the most often utilized rehabilitative assessment and treatment tools. Studies published from 2002 to April 1, 2015 were selected: 10 studies were included. A previous literary review has shown that rehabilitation programs have a positive impact on quality of life. Our analysis identified some significant outcome variables and shared intervention areas.

Predictors of health-related quality of life over time among pediatric hematopoietic stem cell transplant recipients

BACKGROUND

Advances in hematopoietic stem cell transplantation (HSCT) have contributed to increased survival for pediatric patients. However, there are inconsistent findings regarding the impact of HSCT on health-related quality of life (HRQOL) outcomes for children. This study aimed to establish trajectories of HRQOL following HSCT and identify predictors of the HRQOL course.

PROCEDURE

Ninety caregivers of a child who received HSCT (mean age = 6.42 years) for various oncologic, immunologic, and metabolic conditions completed questionnaires regarding family psychosocial functioning and child HRQOL at the time of discharge from HSCT and follow-up HRQOL at four additional time points.

RESULTS

There was a significant change in overall HRQOL in 3 months postdischarge, with the greatest improvement in physical functioning. Caregiver stress and social support, and child psychosocial problems predicted changes in HRQOL over time.

CONCLUSIONS

These results point to potentially modifiable factors that are related to the course of HRQOL following HSCT, and interventions aimed at these factors should be implemented.

Children's perspective on health-related quality of life during active treatment for acute lymphoblastic leukemia: an advanced content analysis approach

BACKGROUND

Qualitative research provides insight into the cancer experience through the perspective of the pediatric patient. However, somewhat small sample sizes can hinder full discovery of new knowledge and limit interpretation of data.

OBJECTIVE

The objective of this study was to describe health-related quality of life (HRQOL) reported by children and adolescents in responses to 2 interview questions during treatment for acute lymphoblastic leukemia (ALL) and compare their responses by age, gender, risk group, and time in treatment through a quantitative content analysis approach.

METHODS

Children and adolescents (N = 150) were asked 2 validated questions in pediatric patients receiving treatment for ALL: "What makes a good day for you?" and "How has being sick been for you?" over 6 treatment time points. Interview data were coded analyzed quantitatively.

RESULTS

Code frequencies differed significantly by age, gender, risk group, and time in treatment. Adolescents had a greater focus on being with friends, and females generally reported more codes representing negative experiences. Children and adolescents reported being affected by symptoms resulting from cancer treatment. Some adolescents described that being sick positively changed their lives and viewed their illness as a new life experience.

CONCLUSION

The 2 proposed questions are feasible to use clinically to assess HRQOL in children and adolescents with ALL, and the qualitative codes from their descriptions can be used to identify factors affecting HRQOL of children and adolescents with leukemia.

IMPLICATIONS FOR PRACTICE

Nurses can use these 2 questions to assess the HRQOL of children and adolescents during and following treatment for ALL.

The experience of survival following allogeneic haematopoietic stem cell transplantation in New South Wales, Australia

Allogeneic haematopoietic stem cell transplantation (allo-HSCT) entails long-term morbidities that impair survivors' quality of life through broad physical and psychosocial sequelae. Current data and survival measurements may be inadequate for contemporary Australian allo-HSCT recipients. This study sought to comprehensively describe survivorship in an up-to-date, local setting through validated measurements and a novel questionnaire designed to complement and address limitations of current instruments. All adults who received an allo-HSCT between 2000 and 2012 in New South Wales were eligible and included, if alive, those literate and consenting to the study, which encompassed seven survey instruments. Four hundred and forty-three survivors participated, which is 76% of contactable (n=583) and 66% of eligible survivors (n= 669). Chronic GVHD (cGVHD) and co-morbidity rates were similar to published data. Noteworthy results include prevalent sexual dysfunction (66% females, 52% males), loss of income (low income increased from 21 to 36%, P<0.001) and employment (full-time employment fell from 64 to 33%, P<0.001), suboptimal vaccination (31% complete), and health screening (≈50%). Risk factors for poor vaccination and health screening were cGVHD, younger age, less education, rural/regional residence and transplantation <2 years. This study suggests that improvement in survivorship may necessitate structural changes in the current delivery of health services.

Quality of Life in Survivors of Pediatric Cancer and Their Siblings: The Consensus Between Parent-Proxy and Self-Reports

OBJECTIVES

To examine the discrepancy between survivor-parent and sibling-parent reports of health-related quality of life (HRQL) and the level of agreement (i.e., correlation) between child reports (i.e., survivor and sibling) and parent-proxy reports of HRQL.

METHODS

Fifty-one families participated. Pediatric cancer survivors (49% male; 6-18 years of age) and one sibling (47% male; 9-18 years of age) completed a measure of their HRQL. As well, one parent (14% male; 27-65 years of age) from each family completed a proxy report of their children's (i.e., survivor and sibling) HRQL. Consensus was determined through discrepancy and agreement scores, between parent-proxy and children's (i.e., survivors and siblings) self-reports of total HRQL, and physical, emotional, social, and school functioning subscales.

RESULTS

Repeated-measures analysis of variance (ANOVA) revealed significant group differences for total HRQL (F = 6.79, P ≤ 0.01). Repeated-measure ANOVAs of subscale discrepancy scores revealed significant group differences for physical functioning scores (F = 6.39, P < 0.01). A significant interaction was also found for social functioning when age at diagnosis was considered as a covariate (F = 10.30, P < 0.01). Zero-order and intraclass correlation coefficients revealed different levels of agreement between parent and child reports. Specifically, there was poorer agreement between parent-proxy and sibling's self-reports, particularly on social and emotional subscales.

CONCLUSIONS

Discrepancy and agreement are both important indices to consider when examining consensus between parent-proxy and child self-reports. The findings from this study have important implications for future research and suggest that the impact of cancer on siblings should be further investigated.

End-of-Life Care Patterns Associated with Pediatric Palliative Care among Children Who Underwent Hematopoietic Stem Cell Transplant

Stem cell transplantation (SCT) is an intensive therapy offering the possibility of cure for life-threatening conditions but with risk of serious complications and death. Outcomes associated with pediatric palliative care (PPC) for children who undergo SCT are unknown. Therefore, we evaluated whether PPC consultation is associated with differences in end-of-life (EOL) care patterns for children who underwent SCT and did not survive. Medical records of children who underwent SCT at Boston Children's Hospital/Dana-Farber Cancer Institute for any indication from September 2004 to December 2012 and did not survive were reviewed. Child demographic and clinical characteristics and PPC consultation and EOL care patterns were abstracted. Children who received PPC (PPC group) were compared with those who did not (non-PPC group). Children who received PPC consultation (n = 37) did not differ from the non-PPC group (n = 110) with respect to demographic or clinical characteristics, except they were more likely to have undergone unrelated allogeneic SCT (PPC, 68%; non-PPC, 39%; P = .02) or to have died from treatment-related toxicity (PPC, 76%; non-PPC, 54%; P = .03). PPC consultation occurred at a median of .7 months (interquartile range [IQR], .4 to 4.2) before death. PPC consultations most commonly addressed goals of care/decision-making (92%), psychosocial support (84%), pain management (65%), and non-pain symptom management (70%). Prognosis discussions (ie, the likelihood of survival) occurred more commonly in the PPC group (PPC, 97%; non-PPC, 83%; P = .04), as did resuscitation status discussions (PPC, 88%; non-PPC, 58%; P = .002). These discussions also occurred earlier in the PPC group, for prognosis a median of 8 days (IQR, 4 to 26) before death compared with 2 days (IQR, 1 to 13) in the non-PPC group and for resuscitation status a median of 7 days (IQR, 3 to 18) compared with 2 days (IQR, 1 to 5) in the non-PPC group (P < .001 for both of the timing of prognosis and resuscitation status discussions). The PPC group was also was more likely to have resuscitation status documented (PPC, 97%; non-PPC, 68%; P = .002). With respect to patterns of care, compared with non-PPC, the PPC group was as likely to die in a medicalized setting (ie, the hospital) (PPC, 84%; non-PPC, 77%; P = .06) or have hospice care (PPC, 22%; non-PPC, 18%; P = .6). However, among children who died in the hospital, those who received PPC were more likely to die outside the intensive care unit (PPC, 80%; non-PPC, 58%; P = .03). In addition, the PPC group was less likely to receive intervention-focused care such as intubation in the 24 hours before death (PPC, 42%; non-PPC, 66%; P = .02) or cardiopulmonary resuscitation (PPC, 3%; non-PPC, 20%; P = .03) at EOL. Children who received PPC for at least a month were more likely to receive hospice care (PPC, 41%; non-PPC, 5%; P = .01). Children who underwent SCT and did not survive were likely to die in a medicalized setting, irrespective of PPC. However, PPC was associated with less intervention-focused care and greater opportunity for EOL communication and advance preparation. In the intense, cure-oriented SCT setting, PPC may facilitate advance care planning in this high-risk population.

Parent Outlook: How Parents View the Road Ahead as They Embark on Hematopoietic Stem Cell Transplantation for Their Child

Pediatric hematopoietic stem cell transplantation (HSCT) offers cure for high-risk malignancies and other conditions, but carries a risk of complications. Parental outlook regarding their child's transplantation course and future health has been largely unexplored. This report presents the Parent Outlook Scale, describes its properties, and examines the outlook of parents embarking on their child's transplantation course and the associated variables. Parents of children scheduled to undergo HSCT (n = 363) at 8 US transplantation centers completed the Parent Outlook Scale, comprising 4 items assessing frequency of the parent's thoughts about the potential difficulty of the child's transplantation (Transplant Difficult subscale) and worsened health (Health Worse subscale). Item responses were rated on a 5-point Likert scale (ranging from "none" to "all of the time") and, along with scale/subscale scores, transformed to 100-point scales, with higher scores connoting greater thought frequency. Psychometrics were explored. Multivariable models identified personal and clinical characteristics associated with scale and subscale scores. The Parent Outlook Scale (α = 0.75) and subscales were found to have sound psychometric properties. Factor loading supported the single scale with 2 subscales representing distinct aspects of overall outlook. Mean scores (Parent Outlook, 52.5 ± 21.7; Transplant Difficult, 64.4 ± 25.6; Health Worse, 40.7 ± 25.7) revealed variability within and across scale/subscales. Significantly different mean subscale scores (P < .001) indicated more frequent Transplant Difficult thoughts than Health Worse thoughts. Clinical factors (solid tumor diagnosis and unrelated donor transplant) and a parent factor (worse emotional functioning) were associated with higher scale and subscale scores. Our findings show that the outlook of parents embarking on their child's HSCT course is varied and not solely a product of clinical factors readily apparent to clinicians. Referring and transplantation clinicians should create opportunities to explore with parents their perspectives and concerns before and during the course of HSCT.

Allogeneic Hematopoietic Cell Transplantation for Children with Sickle Cell Disease Is Beneficial and Cost-Effective: A Single-Center Analysis

Limited data exist regarding health care utilization (HCU) in patients receiving allogeneic hematopoietic cell transplantation (alloHCT) for sickle cell disease. Financial data from 2002 to 2011 were analyzed for 26 alloHCT patients and 48 control subjects (referred but without alloHCT). HCU of alloHCT was determined over 3 time periods: pre-alloHCT, during alloHCT (day 0 to day +365), and post-alloHCT. The median total cost per patient during the alloHCT year was $413,000 inpatient and $18,000 outpatient. Post-alloHCT HCU decreased when compared with pre-alloHCT and control subjects. The median cost of post-alloHCT outpatient visits per patient was significantly less when compared with pre-alloHCT (P = .044). The median cost of post-alloHCT inpatient visits per patient approached significance when compared with those pre-alloHCT (P = .079). Sixteen post-alloHCT patients, 19 control subjects, and 14 unaffected siblings were surveyed using Pediatric Quality of Life Inventory and EuroQOL questionnaires; however, the questionnaire scores across all 3 patient groups were not statistically significant (P = .2638). When adjusted for health-related quality of life, the analysis suggested alloHCT has a positive impact on health-related quality of life over control subjects. These pilot data support our hypothesis that alloHCT in children with sickle cell disease reduces HCU compared with control subjects without alloHCT.

Determine the difficulties of home care in children following haematopoietic stem cell transplantation

The aim of this study was to determine the difficulties regarding the home care of children following haematopoietic stem cell transplantation (HSCT). The sample of the study includes the families of 73 children in a bone marrow transplant unit between 2010 and 2013, Turkey. Data were collected using a form included descriptive information and questions about the difficulties and complications of home care. Families were telephoned and problems they had encountered were recorded. Mann-Whitney U-test and the logistic regression analysis were used. The average age of the children was 10.65 ± 5.03 years, the average age was 8.89 ± 4.9 when HSCT was performed, and the average year after HSCT was 1.79 ± 0.74. 41.1% of the children underwent transplantation with diagnoses of anaemia. Primary physical problems that were found after discharge from the hospital were fever (43.8%), decreased appetite (37%), rash (34.2%) and pain (26%). Socially, 43.8% of families reported that their children had difficulties with school. Primary difficulties regarding care and follow-up were reported as skin care (34.2%) and catheter care (33.3%). In the post-transplantation period, it is important to provide information about potential problems and care to patients and families in order to increase the quality of life.

Health-Related Quality of Life among Children and Adolescents during Hematopoietic Stem Cell Transplant Recovery

Health-related quality of life (HRQoL) has been noted to fluctuate among children during hematopoietic stem cell transplant (HSCT) recovery; however, the specific timing and associations of these changes are poorly understood. This repeated-measures study aimed to describe HRQoL changes among children and adolescents during the first 6 months of HSCT recovery and estimate the associations of demographic factors, diagnosis, transplant information, and symptoms with HRQoL. Twenty-three children and adolescents who received an allogeneic HSCT were recruited from a pediatric teaching institution in the southern United States. Demographic, diagnosis, and transplant information was obtained from the medical record. The Memorial Symptom Assessment questionnaire and the Peds Quality of Life Cancer Module (PedsQL CM) were completed at 1 month post-HSCT and then once monthly for 5 additional months. Mean HRQoL scores fluctuated during the study with the lowest mean HRQoL noted at 1 month post-HSCT and the highest mean HRQoL noted at 4 months post-HSCT. No significant differences in HRQoL scores were noted among demographic, diagnosis, or transplant factors. Feeling tired, sad, or worried or having insomnia at 1 month post-HSCT was negatively correlated to HRQoL. Nurses have opportunities to explore important issues with patients and need to be aware of fluctuations with HRQoL and factors associated with lower HRQoL during HSCT recovery.

Nail dystrophy, edema, and eosinophilia: harbingers of severe chronic GVHD of the skin in children

The prognostic value of adnexal findings in chronic GVHD (cGVHD) has not been investigated in children. Dermatologic examinations were performed in a severe cohort of 11 children with skin cGVHD seen over a 2-year period. Findings were compared with 25 additional patients with skin cGVHD and 97 control patients. In 36 patients with skin cGVHD, nail dystrophy was present in 45% of patients, and was significantly associated with sclerotic disease and lung cGVHD. Pterygium inversum unguis (PIU) was associated with severe lung disease, with significantly lower % predicted FVC and FEV1 in those with PIU than those without. Forty-four percent of GVHD patients had preceding peripheral edema and 56% had preceding peripheral eosinophilia. Peripheral edema and eosinophilia were significantly associated with sclerotic cGVHD and persisted until the diagnosis of cGVHD in all patients. Comparison of data with control patients showed that incidence of nail dystrophy, incidence of peripheral edema and mean peak peripheral eosinophil count of patients with skin cGVHD was significantly higher than those without cGVHD. This study suggests that nail dystrophy, persistent peripheral edema and persistent peripheral eosinophilia are harbingers of severe cGVHD of the skin in children. The presence of PIU may be a harbinger of severe lung involvement.

"A day in my life" photography project: the silent voice of pediatric bone marrow transplant patients

A photovoice project was conducted with pediatric bone marrow transplant (BMT) patients to examine their coping skills and interpretation of their experience during a BMT, especially when hospitalized. We also wanted to determine how photovoice could be used within a pediatric BMT unit. Sixteen children (ages 4-14) and 2 young adults (ages 22 and 25) from a pediatric BMT unit participated in the project. Six BMT outpatients participated in the data analysis and evaluation phase. Fourteen clinical staff evaluated the impact of the project on their practice. Three primary themes emerged from the pre- and post-BMT photos, accompanying detailed notes, and BMT outpatient analysis of the photos: (a) BMT is "torture," (b) BMT is "time slipping away," and (c) BMT requires normalization, comfort, distraction, and support. BMT patients and staff concluded that photovoice helped express and release emotions regarding the challenges of BMT. BMT staff noted that the results of this project reminded them of the importance of being patient-centered and mindful of patient experience and the therapeutic relationship.

The Impact of a Web-Based Educational and Support Intervention on Parents’ Perception of Their Children’s Cancer Quality of Life

The purpose of this exploratory study was to (1) describe the development of an evidence-based web educational and support intervention for families of children with cancer and (2) assess the favorability of the website, and whether there was any impact on the cancer communication aspect of the quality of life instrument. In the study, 38 persons participated—15 mothers, 12 fathers, and 11 children. The favorability score of the website was found to be very high. The mothers rated the website most favorable, followed closely by the fathers. Furthermore, even though it was not significant, an increase was found in the mothers’ evaluation of cancer communication based on the Pediatric Quality of Life Questionnaire (PedsQL) after the intervention as compared with before. The findings suggest that the use of an evidence-based website is feasible, appears to enhance cancer knowledge and might, in that way, contribute to better management of the cancer situation for the families.

Joint models for predicting transplant-related mortality from quality of life data

PURPOSE

To test whether longitudinally measured health-related quality of life (HRQL) predicts transplant-related mortality (TRM) in pediatric hematopoietic stem cell transplant (HSCT).

METHODS

The predictors of interest were emotional functioning, physical functioning, role functioning, and global HRQL, as rated by the parent about the child up to 6 times over 12 months of follow-up and measured by the Child Health Ratings Inventories. We used joint models, specifically shared parameter models, with time to TRM as the outcome of interest and other causes of mortality as a competing risk, via the JM software package in R. Choosing shared parameter models instead of standard survival models, such as Cox models with time-dependent covariates, enabled us to address measurement error in the HRQL trajectories and appropriately handle missing data. The nonlinear trajectories for each HRQL domain were modeled by random spline functions. The survival submodels were adjusted for baseline patient, family, and transplant characteristics.

RESULTS

Hazard ratios per one-half standard deviation difference in emotional, physical, and role functioning, and global HRQL were 0.61 (95 % CI 0.46-0.81; p < 0.001), 0.70 (0.51-0.96; p = 0.03), 0.54 (0.34-0.85; p = 0.007), and 0.57 (0.41-0.79; p < 0.001), respectively.

CONCLUSIONS

HRQL trajectories were predictive of TRM in pediatric HSCT, even after adjusting the survival outcome for baseline characteristics.

Health-related quality of life in childhood cancer

OBJECTIVE

Health-related quality of life (HRQoL) has become an increasingly important measure of research and treatment outcomes across all medical specialties. However, to date, there has not been an in-depth review of research relevant specifically to HRQoL in the populations of children and adolescents with cancer. In this review, the authors examine the effects of cancer on HRQoL from diagnosis to remission/survivorship and the end of life.

DESIGN

A literature search was conducted using Medline and PsycINFO for articles published from 2002 to 2011. Studies included patients from diagnosis to remission and also the terminally ill. Twenty-nine studies specifically addressing HRQoL were selected after reaching consensus and study quality check.

RESULTS

Children who are newly diagnosed with cancer and are undergoing treatment or are terminally ill have impaired HRQoL. Survivors of childhood cancer have high HRQoL (with the exception of those who experienced medical comorbidity or PTSD). The authors found that demographic differences, cancer types, and treatment regimens, all significantly influence the negative impact of cancer on patients' HRQoL.

CONCLUSIONS

There are specific and identifiable impacts of childhood cancer on patients' HRQoL that are significant and complex across the span of the illness. There is a need for continued research in many areas related to this population, especially related to those with terminal illness in order to improve patient care.

Parental perspectives on a behavioral health music intervention for adolescent/young adult resilience during cancer treatment: report from the children's oncology group

PURPOSE

This article describes parental perspectives on the helpfulness and meaningfulness of a behavioral health music therapy intervention targeted to adolescents/young adults (AYA) with cancer undergoing stem cell transplantation. We demonstrate how qualitative methods may be used to understand critical aspects of an intervention and mechanisms by which the intervention impacts the target AYA outcomes of resilience and quality of life.

METHODS

A qualitative descriptive design was used to obtain parents' perspectives. A maximum-variation purposive sampling technique was used to sample 16 parents whose AYA had been randomized to the intervention group. A semistructured open-ended interview was conducted between 100 and 160 days after the AYA's transplant.

RESULTS

Results were grouped into three categories: (1) helpfulness and meaningfulness of the intervention to AYA adjustment to the transplantation experience; (2) helpfulness and meaningfulness of the intervention for parents; and (3) AYA ability to participate in the intervention during the acute phase of transplant.

CONCLUSIONS

Parents observed and interacted with their AYA who participated in a targeted behavioral intervention. Thus, parents were able to describe mechanisms through which the intervention was helpful and meaningful for the AYA and indirect personal benefits for themselves. The results suggest the importance of the targeted outcomes identified in the Resilience in Illness Model and mechanisms of action in the Contextual Support Model of Music Therapy, and identify approaches for future study.

Health related quality of life and emotional health in children with chronic granulomatous disease: a comparison of those managed conservatively with those that have undergone haematopoietic stem cell transplant

PURPOSE

Chronic Granulomatous Disease (CGD) is a rare primary immunodeficiency that predisposes to life-threatening infections and inflammation. Haematopoietic stem cell transplant (HSCT) can cure CGD. Chronic illness reduces quality of life. Children with haematological malignancies report improved quality of life post-HSCT. There are no data for children with CGD. This study evaluated quality of life and emotional well-being in CGD children treated conventionally or transplanted.

METHODS

Parents and children completed the Pediatric Quality of Life Inventory v4.0 (PedsQL) and Strengths and Difficulties Questionnaires (SDQ). Mean scores were compared with published UK norms. Comparisons were made for those that had or had not undergone HSCT.

RESULTS

Forty-seven parents completed PedsQL (children aged 3-15). Twenty-one were post-HSCT. Forty-two completed SDQ (children aged 3-15). Nineteen post-HSCT. Median age for non-HSCT group 9 years. Median age for post-HSCT group 10 years. The HSCT group were median 3 years post-HSCT (range 1-9 years). HSCT survival was 90 %-two died without completing questionnaires Parent and self-reported quality of life for non-transplanted children was significantly lower than healthy children. Parents reported increased emotional difficulties compared to published norms. PedsQL and SDQ scores for transplanted children were not significantly different from healthy norms.

CONCLUSIONS

This study demonstrates the quality of life is reduced in CGD. Transplanted patients have quality of life comparable to levels reported in healthy children. This data will help inform families and clinicians when deciding about treatment and may have relevance for other immunodeficiencies treated with transplant.

A multimethod assessment of psychosocial functioning and late effects in survivors of childhood cancer and hematopoietic cell transplant

Previous research in childhood cancer and hematopoietic cell transplant (HCT) survivorship has relied on the use of standardized questionnaires that assess symptoms of psychological functioning but do not sufficiently capture the cancer survivorship experience. Study aims are to quantitatively and qualitatively assess the psychosocial functioning of pediatric cancer and HCT survivors seen in a multidisciplinary survivorship clinic, determine survivorship concerns, and assess potential demographic and medical correlates of psychosocial outcomes. Data were collected using a retrospective chart review of a parent-report questionnaire of the child's psychological functioning, responses to a semistructured interview that qualitatively assessed adjustment to life after treatment, and documented medical late effects. Results indicated the majority of survivors had healthy psychological adjustment based upon a parent-report questionnaire. However, nearly 72% of survivors reported 1 or more survivorship concerns during the interview, with the primary concerns being current and future health or physical functioning, including the possibility of cancer recurrence. A content analysis of the interview responses indicated HCT survivors had more school or cognitive functioning concerns compared with survivors who did not have an HCT. Further research should use survivorship-specific measures to better identify survivors at risk and determine the impact of late effects on their quality of life.

Health-related quality of life (HRQoL): the impact of medical and demographic variables upon pediatric recipients of hematopoietic stem cell transplantation

BACKGROUND

The trajectory of Heath-Related Quality of Life (HRQoL) in pediatric recipients who have undergone hematopoietic stem cell transplantation (HSCT), as well as the demographic and medical factors that predict HRQoL, has lagged behind the adult research.

METHODS

A prospective longitudinal study of HRQoL in pediatric HSCT recipients was conducted with 95 patients at the Columbia University Medical Center between 2002 and 2009. Both children and parents completed the PedsQL 4.0 prior to HSCT and at days 100, 180, and 365-post-HSCT.

RESULTS

The majority of patients and their parents reported linear improvements in HRQoL in the first year post-transplant; however, a portion of patients were in the at-risk group at each time point. Latent growth modeling was utilized to examine demographic and medical factors that predicted initial HRQoL and its trajectory. Older age at transplant significant predicted lowered HRQoL at baseline for self- and parent-report. Female gender significantly impacted lowered self-reported physical HRQoL over time. Ethnicity was a significant predictor of HRQoL at baseline and over time for self- and parent-report, with African-American children reporting the highest HRQoL; whereas, the worst decline in psychosocial HRQoL was often reported by parents and children of Asian descent.

CONCLUSION

This research identifies the significant impact of ethnicity upon HRQoL following pediatric HSCT. It is likely that an individual's pre-morbid experiences and expectations, particularly with regard to culture, behaviors, and values, influence the parent and child's perceptions and expectations of the HSCT process.

NCI, NHLBI/PBMTC First International Conference on Late Effects after Pediatric Hematopoietic Cell Transplantation: health-related quality of life, functional, and neurocognitive outcomes

The purpose of this manuscript is to summarize issues relevant to health-related quality of life (HRQL), physical function, and neurocognitive function for survivors of pediatric hematopoietic stem cell transplantation (HCT). The physiologic and psychological demands of HCT and its sequelae have the potential to substantially alter HRQL. When compared with research on adult HCT recipients, research in pediatric HRQL following HCT has lagged considerably. Initially, this lag was because of limited validated questionnaires, small numbers of affected patients, and a general lack of salience for the topic relative to traditional endpoints, such as transplant-related toxicity and potential mortality. The percentage of childhood HCT survivors with physical disability ranges from 7% to 17% in studies where the outcome was based on clinician or self-report measures, to over 40% in studies where the outcome was based on a directly measured physical performance task. Direct and comprehensive measures of physical performance may help further clarify the proportion of individuals who have subclinical problems amenable to intervention before apparent functional loss becomes a problem. There is a need to include longer term survivors in such an assessment. In terms of neurocognitive function, the majority of reports demonstrate relatively good function in survivors. However, it is clear that little or no data on outcomes beyond 5 years posttransplant have been obtained, and clinicians working with this population remain concerned regarding the cognitive functions of these survivors. Research focused on these domains should attempt to better understand the prevalence of the problem using child self-report and direct measurements of function, standardize measurement methods, and tools across trials, obtain longer term evaluations and begin to consider interventional trials.

Health-related quality of life of hematopoietic stem cell transplant childhood survivors: state of the science

The notion of health-related quality of life (HRQoL) holds unique significance in the treatment of patients who have undergone hematopoietic stem cell transplantation (HSCT). Not only is transplant procedure inevitably associated with immediate and late medical effects along with high mortality and morbidity rates, but it can also significantly affect the HRQoL for the patient and family. This review of literature will assist advanced practice nurses and pediatric oncology nurses in distinguishing and targeting interventions for patients and families who are at high risk of encountering distress during and following HSCT. It provides information on the assessment of pre-HSCT variables to identify patient subgroups in need of more aggressive supportive care to improve HRQoL during transplant. Furthermore, it serves as a guideline for developing interventional strategies and the role of the advanced practice nurse and pediatric oncology nurse caring for the patient throughout and following transplant.

Impaired sleep affects quality of life in children during maintenance treatment for acute lymphoblastic leukemia: an exploratory study

Background

With the increase of pediatric cancer survival rates, late effects and quality of life (QoL) have received more attention. Disturbed sleep in pediatric cancer is a common clinical observation, but research on this subject is sparse. In general, sleep problems can lead to significant morbidity and are associated with impaired QoL. Information on sleep is essential to develop interventions to improve QoL.

Methods

Children (2-18 years) with acute lymphoblastic leukemia (ALL) were eligible for this multi-center study. The Children's Sleep Habits Questionnaire (CSHQ), Child Health Questionnaire (CHQ) and Pediatric Quality of Life Inventory 3.0™ Acute Cancer Version (PedsQL) were used to assess sleep and QoL halfway through maintenance therapy. Sleep and QoL were measured during and after dexamethasone treatment (on-dex and off-dex).

Results

Seventeen children participated (age 6.7 ± 3.3 years, 44% boys). Children with ALL had more sleep problems and a lower QoL compared to the norm. There were no differences on-dex and off-dex. Pain (r = -0.6; p = 0.029) and worry (r = -0.5; p = 0.034) showed a moderate negative association with sleep. Reduced overall QoL was moderately associated with impaired overall sleep (r = -0.6; p = 0.014) and more problems with sleep anxiety (r = -0.8; p = 0.003), sleep onset delay (r = -0.5; p = 0.037), daytime sleepiness (r = -0.5; p = 0.044) and night wakenings (r = -0.6; p = 0.017).

Conclusion

QoL is impaired in children during cancer treatment. The results of this study suggest that impaired sleep may be a contributing determinant. Consequently, enhanced counseling and treatment of sleep problems might improve QoL. It is important to conduct more extensive studies to confirm these findings and provide more detailed information on the relationship between sleep and QoL, and on factors affecting sleep in pediatric ALL and in children with cancer in general.

Physical activity and pediatric cancer survivorship

Owing to improved treatment pro-tocols in the last 25 years there have been dramatic improvements in the 5-year relative survival rate of the most prevalent childhood cancers. For instance, the 5-year relative survival rate among children for all cancer sites combined, improved from 58% to 80% in patients diagnosed in 1975-1977 and in 1996-2004 respectively. However, as survival rates have improved, there has been an increasing recognition of adverse short and longer term effects associated with treatment and cancer itself, which we describe in detail in this chapter. There is growing interest in those interventions that can counteract the adverse effects of treatment and cancer. Because such adverse effects are further aggravated by physical inactivity, a special emphasis is being placed on physical activity (PA) interventions. Results are promising: there is increasing evidence that regular PA can improve the overall health status, functional capacity, and quality of life (QOL) of children with cancer as well as of older survivors of childhood cancer.

Concordance of quality of life assessments following pediatric hematopoietic stem cell transplantation

PURPOSE

To examine the concordance between pediatric patient's self-report and parent-report regarding a patient's quality of life (QoL) prior to and following hematopoietic stem cell transplantation (HSCT) and to identify potential medical and demographic covariates of concordance.

PATIENTS AND METHODS

Utilizing the PedsQL 4.0, the longitudinal QoL data were obtained from 68 pediatric HSCT patient-parent dyads prior to and up to two years post-transplantation.

RESULTS

Reliability based upon Intraclass Correlation Coefficients (ICC) indicates a parabolic pattern of concordance being significantly poorer in the acute phase of treatment 3 months post-HSCT, followed by a return to pre-transplant levels at subsequent assessments and a substantial rise at one- and two-year follow-up assessments (Baseline ICC = 0.42; 3 months = 0.11; 6 months = 0.54). Paired t-tests further indicate that concordance was highest for observable domains of functioning (Physical and School) with greater inter-rater discrepancies on the subjective domains (Emotional and Social) of QoL at baseline and 6 months post-transplantation.

CONCLUSION

Children typically rated their QoL as higher than parents at all time points and in virtually all domains; however, both perspectives are vital in providing a more accurate depiction of a patient's treatment experience. Dyads speaking the same language exhibited higher levels of QoL agreement than those that did not, while concordance among female-patient-dyads was more disparate than male-patient-dyads. Such findings highlight the importance of implementing psychosocial assessments and possible interventions for patients and parents proactively during the HSCT to effectively address the impact of the treatment and recovery experiences.