Symptom cluster analyses based on symptom occurrence and severity ratings among pediatric oncology patients during myelosuppressive chemotherapy

Latent Profile Analysis of Symptom Clusters in Children and Adolescents With Malignant Tumors During Radiotherapy

BACKGROUND

Children undergoing treatment for cancer may experience a range of adverse symptoms, yet there is limited information on the symptoms they experience during radiotherapy and the potential heterogeneity among these symptoms.

OBJECTIVE

This study aimed to describe the symptom profiles of children during radiotherapy, identify subgroups of children with cancer experiencing similar symptom patterns, and evaluate differences in demographic and clinical characteristics across these subgroups.

METHODS

A total of 154 children were assessed using the Chinese version of the Memorial Symptom Assessment Scale 10-18. Latent profile analysis was used to identify distinct subgroups of patients based on symptom occurrence profiles with a prevalence greater than 40%.

RESULTS

Children experienced multiple adverse symptoms during radiotherapy. The best-fitting model identified 3 distinct symptom profiles: low symptom prevalence, high symptom prevalence, and high gastrointestinal symptom prevalence. Significant differences were observed among subgroups based on age, family income, demographic factors, and clinical characteristics, including treatment type, the number of patients currently receiving radiotherapy, radiotherapy site, and recent chemotherapy within the past week.

CONCLUSIONS

This study found that children experienced various adverse symptoms during radiotherapy, with notable heterogeneity in symptom profiles identified through latent profile analysis. Symptom prevalence varied according to demographic and clinical characteristics.

IMPLICATION FOR PRACTICE

This study highlights the need for healthcare providers to focus on different patient subgroups and provide targeted prevention and early intervention strategies for managing symptoms in children during radiotherapy.

Cancer Symptom Clusters in Children and Adolescents with Cancer Undergoing Chemotherapy: A Systematic Review

Objective: To synthesize and analyze the prevalence, composition, longitudinal stability, and predictors of cancer symptom clusters in children and adolescents undergoing chemotherapy. Method: A systematic literature review was conducted in accordance with the PRISMA 2020 guidelines. Evidence was sourced from MEDLINE/PubMed, Cochrane Library, Embase, PsycINFO, and Web of Science, as well as clinical trial registries (Clinical Trials WHO-ICTRP) and gray literature. The search was performed in February 2025, with no restrictions on publication date or language. Two independent reviewers screened and selected the studies. The methodological quality of the included studies was assessed using design-specific tools, and the findings were synthesized narratively. Results: A total of 6221 records were identified, with 12 studies meeting the inclusion criteria. These studies were published between 2010 and 2024 in the United States, Brazil, China, and Turkey. Cancer symptom clusters in children and adolescents followed well-defined patterns, with the gastrointestinal, emotional, fatigue-related, somatic, and self-image clusters being the most prevalent. Conclusions: Early identification of these cancer symptom clusters is essential for guiding interprofessional teams in delivering personalized, evidence-based care to children and adolescents with cancer and their families.

Differences in symptom clusters based on multidimensional symptom experience and symptom burden in stroke patients

In the study of stroke symptoms, a significant unresolved issue remains: What are the similarities and differences in the use of three symptom dimensions-occurrence, severity, and distress-and symptom burden to identify symptom clusters, and which level is recommended for constructing symptom clusters? This study aimed to identify the number and types of symptom clusters in stroke patients on the basis of these dimensions and to determine the most suitable dimension for extracting symptom clusters. Data were collected from 656 stroke patients via a convenience sampling method at a tertiary-level hospital in Wuhan, China, between August 2023 and March 2024. Exploratory factor analysis was conducted to extract symptom clusters on the basis of the three dimensions of the symptom experience scale and symptom burden. Four similar symptom clusters were identified: the mood disturbance symptom cluster, the physical symptom cluster, the cognitive dysfunction symptom cluster, and the slurred speech and choking cough symptom cluster. The symptom of "fatigue" within the physical symptom cluster was not identified only in the dimension of distress (with a percentage agreement of 83.3%), whereas the symptom composition of other clusters remained consistent across all three symptom dimensions (with a percentage agreement of 100%). Moreover, all four symptom clusters exhibited high consistency in terms of both occurrence and symptom burden, regardless of whether the symptom with the highest factor loading or the overall symptom composition was considered. The use of symptom occurrence and symptom burden is recommended for identifying symptom clusters in stroke patients. Subsequently, trajectory studies of symptom clusters and symptom network analyses should be conducted on the basis of these two dimensions to establish a solid theoretical foundation for future clinical interventions and related scientific research.

Patient-Reported Outcomes Measurement Information System Pediatric Symptom Profiles of Children With Cancer in China: A Latent Profile Analysis

BACKGROUND

Unpleasant symptoms are common in children with cancer. However, research identifying subgroups of children with cancer who experience similar levels of self-reported symptoms in China is limited.

OBJECTIVES

This study aimed to classify the symptom profiles of children with cancer and detect the possible predictors of the profiles and their effect on children's quality of life (QoL).

METHODS

A total of 272 children aged 8 to 17 years completed the Chinese version of the Pediatric Patient-Reported Outcomes Measurement Information System short form measures, the Pediatric QOL Inventory general core and cancer modules. Latent profile analysis was used to identify symptom profiles, and ordinal logistic regression and analysis of variance were used to examine predictors of symptom profile membership and profile differences on QoL.

RESULTS

The best fit was a 3-profile model: low, moderate, and severe symptom distress. Children who had been inpatients in the past 7 days and were currently under treatment are more likely to have severe symptoms. Participants in the low symptom distress profile reported significantly greater QoL than those in the other profiles.

CONCLUSIONS

Children with cancer are heterogeneous in their experience of symptoms. Children's characteristics, such as inpatient history and treatment status, are predictors of profiles; different symptom profiles are associated with QoL.

IMPLICATIONS FOR PRACTICE

This study identified distinct groups of patients who predictably experience higher symptoms and their predictors, which could help to place children within a profile and perhaps allow nurses to provide targeted supportive care to match children's specific symptom profile.

Stability of Symptom Clusters in Children With Acute Lymphoblastic Leukemia Undergoing Chemotherapy

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) experience multiple symptoms during chemotherapy. Assessing how symptoms cluster together and how these symptom clusters (SCs) change over time may lay a foundation for future research in SC management and the pathophysiological mechanisms of SCs.

OBJECTIVES

This study aimed to assess the stability of SCs in children with ALL during chemotherapy.

METHODS

A longitudinal investigation was carried out. The Chinese version of the Memorial Symptom Assessment Scale 10 to 18 was used to assess the occurrence, severity, and distress of symptoms in 134 children with ALL (8-16 years old) at the following 4 separate points: before chemotherapy (T1), start of post-induction therapy (T2), 4 months post-induction therapy (T3), and start of maintenance therapy (T4). Exploratory factor analyses were used to extract SCs.

RESULTS

Six SCs were identified. Emotional and somatic clusters were identified across all dimensions and time points. Gastrointestinal cluster was all identified except for occurrence at T1. Neurological cluster was identified at T2 and T3 for all dimensions and at T4 for severity and distress. Self-image disorder cluster was all identified except at T1. Skin mucosa cluster was identified at T2 and T3 for all dimensions. Emotional cluster exhibited common symptoms across dimensions and time points.

CONCLUSION

The number and types of SCs determined by scoring the occurrence, severity, and distress are different, but some SCs are relatively stable.

IMPLICATIONS FOR PRACTICE

Clinicians should not only focus on the common trajectory of symptoms and SCs, but also assess each child individually.

Symptom Clusters in Children With Leukemia Receiving Chemotherapy: A Scoping Review

BACKGROUND

Leukemia represents the most prevalent childhood malignancy. Understanding the symptom clusters (SCs) associated with leukemia may help develop an effective care plan for affected children.

OBJECTIVES

The aims of this study were to summarize the methods of identifying SCs; ascertain the types, attributes, and changing patterns of SCs during different chemotherapy phases; and provide a point of reference for the subsequent improvement of symptom management in pediatric leukemia.

METHODS

The methodological framework employed was the Joanna Briggs Institute Scoping Review Guide. A comprehensive search was conducted across various databases, including PubMed, EMBASE, CINAHL, Web of Science, MEDLINE, Scopus, and China National Knowledge Infrastructure from inception until July 15, 2023.

RESULTS

A total of 14 articles were included in this review, 6 in English and 8 in Chinese. The Memorial Symptom Assessment Scale 10-18 is the most commonly used instrument, whereas factor analysis is the most common statistical method for SC identification. The SCs were classified into 12 categories. The most severe SCs varied across different phases. Specifically, the emotional cluster dominated the prechemotherapy phase, the gastrointestinal cluster surfaced during postinduction therapy, and the consolidation and maintenance therapy phases revealed the self-image disorder cluster.

CONCLUSION

Various consistent and dynamic SCs manifest among pediatric patients with leukemia undergoing chemotherapy.

IMPLICATIONS FOR PRACTICE

Future research endeavors should formulate clear criteria to determine the stability and consistency of SCs, validate SC composition and characteristics, and devise precise symptom management protocols based on SC characteristics in the distinct chemotherapy phases.

Subjective Toxicity Profiles of Children With Cancer During Treatment: A Latent Class Analysis

BACKGROUND

Children and adolescents may experience a variety of subjective adverse events (AEs) caused by cancer treatment. The identification of distinct groups of patients is crucial for guiding symptomatic AE management interventions to prevent AEs from worsening.

OBJECTIVE

The aim of this study was to identify subgroups of children with cancer experiencing similar patterns of subjective toxicities and evaluate differences among these subgroups in demographic and clinical characteristics.

METHODS

A cross-sectional survey was conducted of 356 children in China with malignancies who received chemotherapy within the past 7 days using the pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events. A latent class analysis (LCA) was conducted to identify subgroups of patients with distinct profiles of symptomatic AE occurrence.

RESULTS

Nausea (54.5%), anorexia (53.4%), and headache (39.3%) were the top 3 AEs children experienced. Nearly all participants (97.8%) experienced ≥1 core AEs, and 30.3% experienced ≥5 AEs. The LCA results identified 3 subgroups ("high gastrotoxicity and low neurotoxicity" [53.2%], "moderate gastrotoxicity and high neurotoxicity" [23.6%], and "high gastrotoxicity and high neurotoxicity" [22.8%]). The subgroups were differentiated by monthly family per-capita income, time since diagnosis, and Karnofsky Performance Status score.

CONCLUSIONS

Children experienced multiple subjective toxicities during chemotherapy, especially gastrotoxicity and neurotoxicity. Heterogeneity was found in the LCA in the patients' toxicities. The prevalence of toxicities could be distinguished by the children's characteristics.

IMPLICATIONS FOR PRACTICE

The results showing different subgroups in our study may assist clinical staff in focusing on patients with higher toxicities to provide effective interventions.

Supporting data driven translational patient-centered care using network analysis to visualize symptom distress in children with serious illness

PURPOSE

There are an increasing number of techniques and tools to improve the capacity for children to relay their perceptions of their symptom experience while undergoing blood and marrow transplant (BMT). Network analysis (NA) is a tool that can illustrate associations between symptoms and the distress they cause. We aimed to develop a biopsychosocial assessment clinical analytic tool to examine symptom relationships for children undergoing BMT to find actionable relationships for intervention to improve clinical outcomes including mood.

DESIGN AND METHODS

This pilot study used an analytical mobile application tool to support a wide scope of 15 biopsychosocial symptom distress levels and five mood assessments. Children recorded their symptom distress and mood using the app. NA was used to explore relationships between symptom distress and mood.

RESULTS

Four children, 11-14 years old, undergoing BMT used the app daily during hospitalization. We found a strong presence of emotional distress and its associations symptom distress and mood. Multiple symptom associations were identified including associations between the set of symptoms difficulty breathing and fever (0.557), sad and worried (0.429). Of note, pain distress had a strong capacity to bridge other symptoms and was connected directly to many symptoms.

PRACTICE IMPLICATIONS

We found the significance of patient struggles with emotional and symptom distress and the importance of this relationship to other clinical outcomes. This provides valuable insights and an improved understanding of the child's symptoms. Our findings support early assessment, intervention, and improved symptom communication to enhance sense of well-being and the child's care experience.

Clinician perspectives on nutritional impairment in children undergoing cancer chemotherapy in Thailand: A qualitative descriptive study

Objective

This study aimed to explore the perspectives of pediatric oncology clinicians in Thailand on children's gastrointestinal ​symptoms, eating habits, and nutrition during cancer chemotherapy. Additionally, it sought to identify factors influencing children's nutritional status, including the characteristics of the children, clinician-related factors, and hospital-level factors.

Methods

The study involved pediatric oncology clinicians working at a tertiary hospital in Bangkok. Data were collected through interviews, focusing on three key areas: (1) children's gastrointestinal symptoms, eating behaviors, and nutrition, (2) clinicians' cognitions and behaviors that impact children's nutrition, and (3) environmental factors. Each participating clinician also identified a colleague who could offer additional perspectives. Interviews were conducted in the Thai language and analyzed using directed content analysis.

Results

A total of 22 participants were enrolled in the study, comprising sixteen nurses, four physicians, one child life specialist, and one Hospital Nutrition Service staff member. The majority of participants were female (95.4%), with an average age of 37.77 years and an average of 15.55 years of experience in caring for children with cancer. Factors influencing children's nutritional status included the children's cancer diagnosis, treatment exposures, and symptoms. Clinicians attributed changes in children's weight and eating patterns to these symptoms. Influential clinician-related factors included current practices that impacted children's symptoms and food intake. Hospital-level factors included both direct influences on children and those arising from clinical practices.

Conclusions

To optimize the nutritional status of Thai children undergoing chemotherapy, multi-level interventions are needed. These interventions should target children's symptoms, clinician knowledge, role norms, and address issues related to the hospital environment, specifically those elements that contribute to unpleasant experiences.

Exploring core symptoms and interrelationships among symptoms in children with acute leukemia during chemotherapy: A network analysis

PURPOSE

Children with acute leukemia have suffered from a considerable symptom burden during chemotherapy. However, few studies have focused on exploring the mechanisms among symptoms in children with acute leukemia. Our study aims to explore core symptoms and describe the interrelationships among symptoms in children with acute leukemia during chemotherapy.

METHODS

From January 2021 to March 2023, 469 children with acute leukemia were recruited from 20 Chinese cities. The Memorial Symptom Assessment Scale 10-18 (MSAS 10-18) was used to evaluate the prevalence and severity of symptoms during chemotherapy. A network analysis was performed by the R software based on 31 symptoms. Centrality indices and density were used to explore core symptoms and describe interrelationships among symptoms in the network during chemotherapy.

RESULTS

Worrying and feeling irritable were the central symptoms across the three centrality indices, including strength, closeness, and betweenness. Lack of energy was the most prevalent symptom; however, it was less central than other symptoms. The density of the "induction and remission" network significantly differed from other cycles' counterparts (p < 0.001). Global strength was greater in the " ≥ 8 years group " network than the " < 8 years group " network (p = 0.023).

CONCLUSION

Network analysis provides a novel approach to identifying the core symptoms and understanding the interrelationships among symptoms. Our study indicates the need to assess emotional symptoms in children with acute leukemia during chemotherapy, especially during the induction and remission phases, as well as in older children. Future research is imperative to construct trajectories of dynamic symptom networks and centrality indices in longitudinal data to investigate the causal relationships among symptoms.

Identifying central symptom clusters and correlates in children with acute leukemia undergoing chemotherapy: a network analysis

Background

Previous studies have examined symptom clusters in children with acute leukemia, yet a knowledge gap persists regarding central symptom clusters and their influencing factors. By identifying these central clusters and associated factors, healthcare providers can enhance their understanding and effective management of symptoms. Our study seeks to address this gap by identifying symptom clusters, exploring central clusters, and investigating the demographic and health-related factors associated with these clusters in children with acute leukemia undergoing chemotherapy.

Methods

A total of 586 children with acute leukemia from January 2021 to April 2023 were recruited from China. They were investigated using Memorial Symptom Assessment Scale 10-18 during chemotherapy. The principal component analysis was used to identify the symptom clusters. An association network was conducted to describe the relationships among symptoms and clusters. A multiple linear model was used to investigate the associated factors for the severity of overall symptoms and each symptom cluster.

Results

Five clusters were identified, including oral and skin cluster, somatic cluster, self-image disorder cluster, gastrointestinal cluster and psychological cluster. Gastrointestinal cluster was the most central symptom cluster. Age, sex, clinical classification, number of having chemotherapy and education degree and marital status of the primary caregiver are associated with the severity of these five symptom clusters.

Conclusion

Our study highlights the importance of evaluating symptom clusters in children with acute leukemia during chemotherapy. Specifically, addressing gastrointestinal symptoms is crucial for effective symptom management and overall care.

Effects of Child Life intervention on the symptom cluster of pain-anxiety-fatigue-sleep disturbance in children with acute leukemia undergoing chemotherapy

Objective

This study aims to explore the application effect of Child Life intervention on pain, anxiety, fatigue, and sleep disturbance in children with acute leukemia.

Methods

In a single-blinded, parallel-group randomized controlled trial, 96 children with acute leukemia were randomized to either the intervention group, which received Child Life intervention twice a week for 8 weeks, or the control group, which received routine care. Outcomes were evaluated at baseline and day 3 postintervention.

Results

All of the participants completed the study. Compared with the control group, the intervention group showed a significant reduction in pain, anxiety, fatigue, and sleep disturbance (P ​< ​0.001). However, no significant differences were observed in the disorders of excessive somnolence.

Conclusions

Child Life intervention can effectively improve pain, anxiety, fatigue, and sleep disturbance in children with acute leukemia undergoing chemotherapy. The results suggest that symptom cluster management intervention based on Child Life provided a promising approach for simultaneously treating multiple symptoms within a cluster.

Associations of Symptom Clusters and Health Outcomes in Adult Survivors of Childhood Cancer: A Report From the St Jude Lifetime Cohort Study

PURPOSE

To identify symptom clusters among adult survivors of childhood cancers and test associations with health-related quality of life (HRQOL) and physical and neurocognitive performance.

METHODS

This cross-sectional study included 3,085 survivors (mean age at evaluation 31.9 ± 8.3 years; mean years from diagnosis 28.1 ± 9.1) participating in the St Jude Lifetime Cohort Study. Survivors self-reported the presence of 37 symptoms capturing 10 domains (cardiac, pulmonary, sensory, motor/movement, nausea, pain, fatigue, memory, anxiety, and depression). The Short Form-36's Physical/Mental Component Summaries assessed HRQOL; the Physical Performance Test evaluated physical performance; and neurocognitive batteries tested attention, processing/psychomotor speed, memory, and executive function. Latent class analysis identified subgroups of survivors experiencing different patterns of symptom burden (ie, symptom clusters). Multivariable regression models identified risk of cluster membership and tested associations with health outcomes.

RESULTS

Four symptom clusters were identified including cluster 1 (prevalence 52.4%; low physical, somatization, and psychologic domains), cluster 2 (16.1%; low physical, moderate somatic, and high psychologic domains), cluster 3 (17.6%; high physical, moderate somatic, and low psychologic domains), and cluster 4 (13.9%; high in all three domains). Compared with cluster 1, survivors in cluster 4 were more likely to have less than high school education (odds ratio [OR], 7.71; 95% CI, 4.46 to 13.31), no insurance (OR, 1.49; 95% CI, 1.04 to 2.13), and exposure to corticosteroids (OR, 1.76; 95% CI, 1.02 to 3.03); survivors in cluster 3 were more likely to have received platinum agents (OR, 2.22; 95% CI, 1.34 to 3.68) and brain radiation ≥ 30 Gy (OR, 3.99; 95% CI, 2.33 to 6.86). Survivors in cluster 4 reported the poorest Physical Component Summary/Mental Component Summary scores (31.0/26.7) and physical and neurocognitive performance versus survivors in the other clusters (P < .001).

CONCLUSION

Nearly 50% of survivors had moderate to high multisymptom burden, which was associated with sociodemographic, treatment factors, HRQOL, and functional outcomes.

Advances in Conceptual and Methodological Issues in Symptom Cluster Research: A 20-Year Perspective

Two conceptual approaches are used to evaluate symptom clusters: "clustering" symptoms (ie, variable-centered analytic approach) and "clustering" patients (ie, person-centered analytic approach). However, these methods are not used consistently and conceptual clarity is needed. Given the emergence of novel methods to evaluate symptom clusters, a review of the conceptual basis for older and newer analytic methods is warranted. Therefore, this article will review the conceptual basis for symptom cluster research; compare and contrast the conceptual basis for using variable-centered versus patient-centered analytic approaches in symptom cluster research; review their strengths and weaknesses; and compare their applications in symptom cluster research.

Quality of Life in Adolescents and Young Adults: The Role of Symptom Burden

CONTEXT

Adolescents and young adults (AYAs) with cancer report worse health-related quality of life (HRQOL) than other age groups. Symptom burden is a modifiable predictor of HRQOL.

OBJECTIVES

The objective of this study was to identify which symptoms are most burdensome to AYAs with advanced cancer.

METHODS

In this observational study, English-speaking individuals aged 12-25 years undergoing treatment for advanced cancer completed assessments of symptom burden (Memorial Symptom Assessment Scale) and HRQOL (Pediatric Quality of Life Inventory Generic Form and Cancer Module; minimal clinically important difference 4.4). We dichotomized participants as having low (<7) or high (≥7) symptom prevalence. Mixed regression models estimated HRQOL differences between groups. For individual symptoms, unadjusted mixed models estimated HRQOL reductions.

RESULTS

N = 58 AYAs completed baseline surveys. The median age was 17 years (IQR 15-19), 58% were male, 59% identified as white, and 44% were diagnosed with leukemia/lymphoma. High symptom prevalence was associated with a mean generic HRQOL 7 points lower (95% CI: -11, -3; P < 0.01) and cancer-specific HRQOL score 12 points lower (95% CI: -17, -7; P < 0.01) than low symptom prevalence. The most prevalent symptoms were fatigue (71%), pain (58%), and difficulty sleeping (58%). Fatigue (-8), difficulty concentrating (-7), and mouth sores (-6) were associated with the greatest generic HRQOL score reductions. Dysphagia (-12), difficulty concentrating (-12), and sadness (-11) were associated with the greatest cancer-specific HRQOL score reductions.

CONCLUSION

The symptom experience among AYAs with advanced cancer is unique. Separate evaluation of AYA's symptoms may optimize management and improve HRQOL.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

Effects of cognitive-behavioural therapy on psychological, physical and social outcomes of children with cancer: A systematic review and meta-analysis

OBJECTIVE

This systematic review aimed to summarise the effects of cognitive-behavioural therapy on psychological, physical and social outcomes of children with cancer without limitations on publication date.

METHODS

Thirteen English and seven Chinese electronic databases were searched from April to June 2021. Randomised control trials, quasi-experimental studies, pre-test post-test studies with a control group, factorial or cross-over designs that included children ≤18 years old and during various stages of the cancer trajectory, who have received cognitive-behavioural therapy, and reported (anxiety, depression, stress, quality of life, self-efficacy, fatigue, pain, behavioural distress, anger, and/or academic performance) were included.

RESULTS

Eight studies with quality of evidence ranging from low to high risk of bias were included. The results show cognitive-behavioural therapy has favourable effects on anxiety, depression, pain and behavioural distress. The meta-analysis also show that it reduces anxiety (SMD = -0.89, 95% CI (-1.45, -0.32), p < 0.002), depression (SMD = -0.90, 95% CI (-1.40, -0.39), p < 0.0005), and pain (SMD = -0.56, 95% CI (-1.04, -0.08), p < 0.002). It also has a favourable effect on stress, anger and self-efficacy, though the results are drawn from a single study.

CONCLUSION

Cognitive-behavioural therapy has the potential to reduce anxiety, depression and pain for children with cancer. It also shows promise in reducing behavioural distress. Although effects on stress, anger, and self-efficacy have been found to be significant, there have been limited studies on these aspects of functioning and more research is needed. The findings are drawn from heterogeneous participants and interventions, thus emphasising the need to conduct well-designed intervention studies, including cancer survivors.

Quality of Life Outcomes With Creative Arts Therapy in Children With Cancer

Introduction: Children with cancer experience distress and decreased quality of life (QOL). Creative arts therapy (CAT) is a therapeutic modality which may improve QOL. This study examined the relationship between CAT and QOL in children and adolescents with cancer. Secondary aims explored relationships between CAT and emotional reactions, resilience, and posture (to investigate future potential as an objective biomarker of QOL). Methods: Children aged 3-18 years undergoing cancer treatments and a parent proxy completed the PedsQL3.0 Cancer Module, Faces Scale for emotional reactions, Resilience Scale in adolescents (>12 years), and an inclinometer to measure thoracic kyphosis before and after CAT. CAT exposure (number of sessions) was recorded. Results: Ninety-eight children with cancer (mean age 7.8 years, range 3-17) and parent proxy were enrolled. Of the 83 participants included in the final analysis, 18 received no CAT, 32 received low dose, and 33 received high dose CAT. A significant improvement in QOL was seen with high dose CAT in (slope change, p  =  .015), but the overall time by group interaction was not significant. Slope change response patterns suggested that CAT led to improved posture as compared to no CAT (time by group interaction, p  =  .044). Discussion: CAT may be an effective intervention to improve QOL in this population. Because initial evidence suggests that posture also improves with CAT, further investigation of posture as a potential objective biomarker of QOL is supported. Further study with a randomized controlled trial is warranted.

The predictive trifecta? Fatigue, pain, and anxiety severity forecast the suffering profile of children with cancer

BACKGROUND

Fatigue, pain, and anxiety, symptoms commonly experienced by children with cancer, may predict pediatric symptom suffering profile membership that is amenable to treatment.

METHODS

Three latent profiles (Low, Medium, and High symptom suffering) from 436 pediatric patients undergoing cancer care were assessed for association with three single-item symptoms and socio-demographic variables.

RESULTS

Pediatric-PRO-CTCAE fatigue, pain, and anxiety severity scores at baseline were highly and significantly associated with the Medium and High Suffering profiles comprised of PROMIS pediatric symptom and function measures. The likelihood of membership in the Medium Suffering group was 11.37 times higher for patients who experienced fatigue severity than those with did not, while experience of pain severity increased the likelihood of the child's membership in the Medium Suffering profile by 2.59 times and anxiety by 3.67 times. The severity of fatigue increased the likelihood of presence in the High Suffering group by 2.99 times while pain severity increased the likelihood of the child's membership in the High Suffering profile by 6.36 times and anxiety by 16.75 times. Controlling for experience of symptom severity, older patients were more likely to be in the Higher or Medium Suffering profile than in the Low Suffering profile; no other socio-demographic or clinical variables had a significant effect on the latent profile classification.

CONCLUSION

Clinician knowledge of the strong association between fatigue, pain, and anxiety severity and suffering profiles may help focus supportive care to improve the cancer experience for children most at risk from time of diagnosis through treatment.

Does Creative Arts Therapy Improve Distressing Symptoms in Children with Cancer? A Synthesis of Extant Literature

Introduction: Children with cancer experience symptom distress which has been correlated with decreased quality of life (QOL). Creative arts therapy (CAT) encompasses the therapeutic use of creative arts which may improve QOL among children with cancer by affecting symptoms. Therefore, the research question was asked: Does CAT affect symptoms of pain, nausea, fatigue, anxiety, and mood in children with cancer? Methods: Based on the study question, a comprehensive literature search of PubMed, CINAHL, PsycINFO, and Embase was completed. Inclusion criteria limited articles to specific symptom outcomes in two-group intervention studies in the English language. Selected articles were confirmed for inclusion by the study team, followed by group discussion to develop matrices with levels of evidence based on the Grading of Recommendations Assessment, Development, and Evaluation (Grade) guidelines. Results: Initial searches revealed 1,391 articles, screened to 44 for systematic review. Based on the inclusion criteria, 11 articles remained. Four studies had evidence levels graded as low, three were low to moderate, and four were moderate. Outcomes of mood and anxiety were measured in five studies, pain in four, fatigue in two, and nausea in one study. Discussion: Psychological outcomes were measured more commonly than physical outcomes. Evidence reached a moderate grade in four studies. Summary: Through this synthesis of intervention studies with CAT in children with cancer, improvement in distressing symptoms has potential, but the state of the science for symptom management with CAT could be strengthened for nurses to promote CAT to improve QOL among children with cancer.

Building capacity through integration of advanced practice nurses in research

BACKGROUND

Advanced practice nurses (APNs) are well-positioned to function in research settings, however barriers to their engagement persist. Capacity-building through multisite research opportunities is an important strategy to overcome these barriers.

PURPOSE

To describe the benefits and challenges of incorporating APNs in research and discuss opportunities for building capacity for nursing research.

METHOD

Grounded in the experience of a nurse-led multisite longitudinal observational descriptive symptom study, field notes representing the research continuum were reviewed and categorized into themes reflecting benefits and challenges.

FINDINGS

Uniform benefits of acquiring research knowledge and skills, participating in research activities, and engaging in professional development were experienced among APNs. Limited support for regulatory and research activities, inadequate financial infrastructure, and a perceived lack of value for APNs' professional growth were commonly encountered challenges.

DISCUSSION

Establishment of an infrastructure that elevates benefits and mitigates challenges is necessary to effectively incorporate APNs in a research environment, build capacity, and advance nursing science.

Self-reported late effect symptom clusters among young pediatric cancer survivors

PURPOSE

Most survivors of childhood cancer experience subsequent chronic conditions but little is known about concurrent symptoms. This study seeks to identify late effect symptom clusters among young pediatric cancer survivors.

METHODS

Survivors ≥ 18 or parents of survivors < 18 years enrolled in an institutional cohort study indicated (yes/no) if they experienced certain symptoms after treatment. The sample was randomly divided in half for exploratory factor analyses to identify symptom clusters followed by confirmatory factor analyses. Symptoms with ≥ 10% prevalence were included. Cluster structure generalizability across subgroups was examined using congruence coefficients.

RESULTS

The sample included 579 survivors (74% non-Hispanic white, 45% leukemia, 12.8 ± 4.5 years at survey, 5.9 ± 3.5 years since therapy). Respondents averaged three symptoms. Three clusters were identified: (1) gastrointestinal: abdominal pain, diarrhea, constipation, nausea, vomiting (Cronbach's α = 0.74); (2) psychological: depression, anxiety, memory problems, anger management problems, sleep problems (α = 0.71); and (3) neurologic: problems walking, numbness/tingling, fatigue, back pain, chronic pain, weakness/inability to move legs (α = 0.71). Confirmatory factor analysis confirmed the three-cluster structure (standardized root mean square residual: 0.09; parsimonious goodness of fit: 0.96; Bentler-Bonett normed fit index: 0.95). The gastrointestinal and psychological clusters were generalizable across most subgroups while the neurologic cluster varied across age and race/ethnicity subgroups.

CONCLUSION

Three distinct late effect symptom clusters were identified in young childhood cancer survivors with gastrointestinal and psychological clusters remaining relatively stable across subgroups. Future studies should focus on the characteristics of patients who experience these symptoms, especially those with high symptom burden, and the synergistic impact on quality of life.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment

OBJECTIVES

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care.

DATA SOURCES

Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer.

CONCLUSION

Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

Subjective Toxicity Profiles of Children in Treatment for Cancer: A New Guide to Supportive Care?

CONTEXT

Children and adolescents with cancer experience treatment-related, subjective adverse events (AEs). Identifying distinct groups of patients who predictably experience higher prevalence of AEs could guide patient care.

OBJECTIVES

Study aims were to 1) identify groups of children and adolescents reporting AEs using the Pediatric Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (Ped-PRO-CTCAE); 2) determine whether demographic and clinical characteristics predict AE group membership; and 3) examine whether AE group membership was related to the distal outcome of psychological stress.

METHODS

Four hundred seventy-seven patients self-reported AEs via the Ped-PRO-CTCAE at T1 (beginning of treatment) and the PROMIS Pediatric Psychological Stress measure at T2 (7-28 days later). Latent class analysis was conducted to identify groups of patients and the relationships of the groups with demographic and clinical characteristics, and with stress.

RESULTS

Three distinct a priori unknown AE groups were identified (high AE prevalence, moderate AE prevalence, and low AE prevalence). Females, blacks, patients with high psychological stress, and patients more recently diagnosed were more likely to be in the high AE prevalence group. Gender, age, race, and time since diagnosis were associated with psychological stress.

CONCLUSION

Children with cancer are heterogeneous in experiencing subjective AEs. Gender, race, and time since diagnosis were significantly associated with higher subjective AE prevalence that may lead to psychological stress.

Identification of Symptom Clusters Among Midlife Menopausal Women with Metabolic Syndrome

The aim of this study was to identify and compare symptom clusters in midlife menopausal women with and without metabolic syndrome based on symptom occurrence and severity dimension through secondary data analysis of the Study of Women's Health Across the Nation. Exploratory factor analysis was used to group symptoms that are highly correlated with each other and verified by confirmatory factor analysis. Midlife menopausal women with metabolic syndrome (n = 424) experienced mental health, vasomotor, and somatic cluster across both symptom dimensions. In contrast, midlife menopausal women without metabolic syndrome (n = 1022) experienced mental health/sleep/urinary, vasomotor, and somatic cluster for symptom occurrence dimension and mental health/sleep, vasomotor/genital, and somatic cluster for symptom severity dimension. This is the first study to identify symptom clusters in midlife menopausal women with metabolic syndrome, who are at risk for experiencing complex symptoms associated with menopause transition and metabolic syndrome, and to compare symptom clusters to those without metabolic syndrome.

Correlation Between Symptom Clusters and Quality of Life in Children With Acute Leukemia During Chemotherapy

BACKGROUND

Children with acute leukemia experience various distressing symptoms due to the disease and its treatment during chemotherapy. These symptoms cluster together and have negative impacts on patient outcomes.

OBJECTIVE

The aim of this study was to examine symptom clusters that children with acute leukemia undergoing chemotherapy are experiencing and the impact of these symptom clusters on their quality of life.

METHODS

A cross-sectional study design was used, and 184 Chinese children with acute leukemia who were undergoing chemotherapy were invited to participate in the study. Memorial Symptom Assessment Scale 10-18 and Pediatric Quality of Life Inventory General Core Module version 4.0 were applied. Exploratory factor analysis and multiple regression were used to identify symptom clusters and their influence on the quality of life.

RESULTS

Six symptom clusters were identified as gastrointestinal, emotional, neurological, skin mucosal, self-image disorder, and somatic cluster. The severity of each symptom cluster was negatively correlated with quality of life. Among them, gastrointestinal, emotional, and somatic clusters were significant predictors of quality of life.

CONCLUSIONS

There are multiple symptom clusters in children with acute leukemia, which seriously affect children's quality of life. To relieve symptom burden and improve quality of life, nursing and medical staff should pay attention to the symptom management and control in a symptom cluster perspective.

IMPLICATIONS FOR PRACTICE

The results of this study will provide suggestions for the healthcare provider to plan for these symptoms and manage any concurrent symptoms for the successful promotion of children's quality of life.

Manifestation and parental assessment of children's cancer pain at home: An exploratory mixed-methods study

AIMS AND OBJECTIVES

To describe pain manifestation in children with cancer at home and understand how parents assess this pain.

BACKGROUND

Pain is experienced by children with cancer throughout their cancer journey. Short-term, and into survivorship, pain has negative physical and psychological consequences. Changes in treatment location mean children with cancer spend more time at home. Little is known about pain experienced by children at home or how parents assess this pain.

DESIGN

A mixed-methods convergent parallel study was reported using STROBE.

METHOD

Parents of children with cancer on active treatment were recruited from one tertiary cancer centre. Parental attitudes towards pain expression were assessed using surveys. Parents recorded their child's pain manifestation in pain diaries kept for one month. Interviews captured a deeper understanding of pain manifestation and how parents assess this pain at home. Integration occurred after each data collection method was analysed separately.

RESULTS

Predominantly children were not in pain at home. However, most children experienced at least one episode of problematic pain over the pain diary period. Surveys showed parents held misconceptions regarding children's pain expression. Interviews diverge from surveys and suggest parents used a range of information sources to assess pain.

CONCLUSION

Children with cancer may differ from one another in the manifestation of pain at home resulting in multiple pain trajectories. Parents of children with cancer are able to adequately assess their child's pain using information from multiple sources.

RELEVANCE TO CLINICAL PRACTICE

It is not currently possible to predict which children will experience problematic pain at home, so all parents require pain management education prior to discharge. Teaching parents to use bundled approaches to pain assessment may accelerate their learning. Healthcare professionals may benefit from using multiple information sources to assess pain.

Taking on enduring distress: Building a concept to lead a program of research

Concept building consists of a 10-phase approach using a practice story as the first step in developing a defined concept supported by both scientific and experiential evidence. The purpose of concept building is to guide development of a program of research that informs nursing knowledge and evidence-based practice. Thus, concept building can serve as a teaching strategy for early-stage doctoral students to initiate scholarly inquiry. In this example, the process of concept building occurred as a nurse practitioner in a doctor of philosophy program began to transition ideas that stemmed from practice into phenomenon for scholarly research. The practice story for the concept taking on enduring distress stems from a patient encounter in the nurse practitioner's adolescent headache clinic. Information gained from concept building laid the foundation for an adolescent headache program of research. The purpose of this paper is to demonstrate a step-by-step approach using Liehr and Smith's 10-phase process for concept building and to describe the program of research that followed.

Symptoms in Children Receiving Treatment for Cancer-Part II: Pain, Sadness, and Symptom Clusters

Children and adolescents receiving treatment for cancer experience multiple symptoms as a consequence of their disease and its treatment that interfere with the child's quality of life. Understanding of symptom assessment in children with cancer is foundational to the work of the Children's Oncology Group Nursing Discipline, whose research aims are to address knowledge gaps including understanding illness-related distress. This article is the second of a two-part summary of current evidence addressing the assessment of symptoms frequently reported by children and adolescents receiving treatment for cancer. Studies reporting assessment of pain, sadness, and symptom clusters published between January 2008 and May 2018 were included. Forty-three publications addressed pain. Pain was highly prevalent and distressing, varied in its trajectory across a cycle of chemotherapy and across multiple cycles of treatment, and correlated with biomarkers associated with the pain response. Consequences of pain were poorer functional status and emotional health. Twenty publications addressed sadness. Sadness was the most prevalent psychosocial symptom. Its prevalence decreased over the course of treatment and over a cycle of chemotherapy. Persistent sadness was of greater severity and distress. Eight publications addressed symptom clusters. These studies identified both groups of co-occurring symptoms and groups of patients with common symptom profiles. This two-article series provides evidence for the distressing nature of symptoms among children receiving cancer treatment. Efforts to support clinicians in routine symptom assessment are needed. Additional research directed at alleviating symptoms and building resilience among the child experiencing symptoms is needed.

How Does Creative Arts Therapy Reduce Distress for Children With Cancer? A Metasynthesis of Extant Qualitative Literature

Introduction: As more children survive cancer, attention must be paid to their quality of life (QOL). Integrative therapies are an ideal modality for nurses to advocate for reducing distress and improving QOL for children with cancer. Creative arts therapy is a type of integrative health that may improve QOL in this population. Therefore, the research question was asked, "For children with cancer, what opportunities exist for creative arts therapy to reduce distress?" Method: A metasynthesis of the extant qualitative research was conducted to answer the research question. Seven qualitative studies were identified, which included 162 participants. New themes were identified through rigorous analyzation by the study team of each study as individual data. Results: Four derived analytic themes emerged through the analysis: (a) connection is established through creative expression, (b) coping is facilitated by creative arts, (c) communication is enabled by creative arts interventions, and (d) continuance (the concept of time) is experienced through creative arts. Examples of each theme with subthemes are delineated, including expressive quotes. Summary: Through this qualitative synthesis of studies with creative arts therapy, evocative opportunities to reduce the distress associated with the disease experience are revealed. Nurses are called now to promote creative arts therapy to improve the symptoms in children with cancer.

Symptom Clusters in Patients With Gastrointestinal Cancers Using Different Dimensions of the Symptom Experience

CONTEXT

Patients with gastrointestinal (GI) cancers undergoing chemotherapy (CTX) experience multiple cooccurring symptoms.

OBJECTIVES

The aim of this study was to describe the occurrence, severity, and distress of 38 symptoms and to identify symptom clusters based on three symptom dimensions (i.e., occurrence, severity, and distress) in patients with GI cancers receiving CTX (n = 399). We compared whether the numbers and types of symptom clusters differed based on the dimension of the symptom experience used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence, severity, and distress of 38 symptoms before the initiation of the patient's next dose of CTX. Exploratory factor analysis was used to determine the symptom clusters.

RESULTS

These patients experienced 13.0 (±7.1) symptoms before their second or third dose of CTX. For all three symptom dimensions, four symptom clusters were identified, namely psychological distress, CTX-related, GI, and weight change. The number and types of symptom clusters were relatively similar using all three symptom dimensions. However, some variability was found in the specific symptoms within each of the clusters.

CONCLUSION

Our findings suggest that patients with GI cancers experience multiple cooccurring symptoms. Consistent with previous studies of patients with a variety of cancer diagnoses, psychological and GI clusters are common. Clinicians need to assess for and tailor interventions for these symptom clusters.

Influence of Inflammatory and Oxidative Stress Pathways on Longitudinal Symptom Experiences in Children With Leukemia

PURPOSE

The purpose of this study was to explore the influence of oxidative stress (F2-isoprostanes) and inflammatory (interleukin [IL]-8) biomarkers on symptom trajectories during the first 18 months of childhood leukemia treatment.

METHOD

A repeated-measures design was used to evaluate symptoms experienced by 218 children during treatment. A symptom cluster (fatigue, pain, and nausea) was explored over four time periods: initiation of post-induction therapy, 4 and 8 months into post-induction therapy, and the beginning of maintenance therapy (12 months postinduction). F2-isoprostanes and IL-8 were evaluated in cerebrospinal fluid (CSF) samples collected at baseline (diagnosis) and then at the four time periods. The longitudinal relationships of these biomarkers with the symptom cluster were examined using the longitudinal parallel process.

RESULTS

Pain and fatigue levels were highest during the post-induction phases of treatment and decreased slightly during maintenance therapy, while nausea scores were relatively stable. Even in the later phases of treatment, children continued to experience symptoms. CSF levels of the biomarkers increased during the post-induction phases of treatment. Early increases in the biomarkers were associated with more severe symptoms during the same period; patients who had increased biomarkers over time also experienced more severe symptoms over time.

CONCLUSIONS

Findings reveal that children experienced symptoms throughout the course of leukemia treatment and support hypothesized longitudinal relationships of oxidative stress and inflammatory biomarkers with symptom severity. Activation of the biomarker pathways during treatment may explain underlying mechanisms of symptom experiences and identify which children are at risk for severe symptoms.

Consensus in Identification and Stability of Symptom Clusters Using Different Symptom Dimensions in Newly Diagnosed Acute Myeloid Leukemia Patients Undergoing Induction Therapy

CONTEXT

An unresolved issue in symptom cluster (SC) research is that the numbers and types of SCs vary based on the multiple dimensions of the experienced symptoms that are used for SC identification.

OBJECTIVE

This study aimed to identify SCs using the ratings of occurrence, severity, and distress in newly diagnosed acute myeloid leukemia (AML) patients at three stages of their induction therapy (i.e., T1, T2, and T3). Then, we evaluated the consensus among the numbers and types of symptoms in each SC identified by multiple dimensions over time.

METHOD

The Chinese version of the Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, and distress ratings of 32 symptoms in patients newly diagnosed with AML during their induction therapy. Exploratory factor analysis was used for SCs identification.

RESULTS

Using the three dimensions in the AML patients (n = 126), four SCs were identified at T1 and T3 and three SCs were identified at T2. The number of symptoms in individual SCs varied over time, whereas the specific symptoms in SCs remained similar over time. The severity ratings fit the data better than did the ratings of occurrence and distress.

CONCLUSION

These findings provided insights into the most common SCs in AML patients undergoing induction therapy by multidimensional evaluation and could lay the foundation for future targeted symptom interventions. Further studies are needed to explore the mechanisms of SCs in AML patients undergoing the chemotherapy.

Childhood Cancer Symptom Cluster: Leukemia and Health-Related Quality of Life

OBJECTIVES

To examine the relationship of the Childhood Cancer Symptom Cluster-Leukemia (CCSC-L) with health-related quality of life (HRQOL).

SAMPLE & SETTING

327 children receiving treatment for acute lymphoblastic leukemia from four pediatric oncology programs across the United States.

METHODS & VARIABLES

Participants completed fatigue, sleep disturbance, pain, nausea, and depression symptom questionnaires at four time points; these symptoms comprised the CCSC-L. HRQOL was measured at the start of postinduction therapy and then at the start of maintenance therapy. Relationships between the CCSC-L and HRQOL scores were examined with longitudinal parallel-process modeling.

RESULTS

The mean HRQOL significantly increased over time (p < 0.001). The CCSC-L had a significant negative association with HRQOL scores at the start of postinduction therapy (beta = -0.53, p < 0.005) and the start of maintenance therapy (beta = -0.33, p < 0.015). Participants with more severe symptoms in the CCSC-L over time had significantly lower HRQOL at the start of maintenance therapy (beta = -0.42, p < 0.005).

IMPLICATIONS FOR NURSING

Nurses are pivotal in providing management strategies to minimize symptom severity that may improve HRQOL.

Síntomas en niños con cáncer y estrategias de cuidado familiar

Introducción: Los síntomas de dolor y náusea vómito en los niños con cáncer son ocasionados por la enfermedad o tratamiento de quimioterapia. El manejo de estos síntomas es un reto en los familiares. Objetivos: Describir y analizar la relación entre los síntomas de dolor y náusea vómito en los niños con cáncer y describir las estrategias de cuidado familiar ante estos síntomas. Materiales y Métodos: Estudio descriptivo correlacional, con muestra de 31 niños y familiares de una clínica oncopediatrica de Veracruz México. Diligenciaron los instrumentos Escala de dolor con caras-Revisada, Clasificación de Náusea-Vómito Inducido por Quimioterapia y Cuestionario de estrategias de cuidado familiar para el manejo de síntomas. Los datos se analizaron con estadística descriptiva e inferencial con Rho de Spearman, utilizando el programa SPSS 20.0. Resultados: Los niños padecen dolor moderado (48%), leve (29%) e intenso (23%).  Tienen náusea-vómito agudo (74%), anticipatorio (16%) y retardado (10%). Existe asociación entre la náusea-vómito retardado con el anticipatorio (r =435<0,05). Los familiares contrarrestan el dolor del niño con estrategias de espiritualidad, distracción y fármacos. Ante la náusea-vómito evitan ambientes con olor a comida y consumo de líquidos calientes. Discusión: Según el tipo de cáncer y tratamiento, es la intensidad del dolor en el niño. La náusea-vómito se considera el síntoma más problemático durante la quimioterapia. Conclusiones: La investigación aporta datos científicos para indagar a futuro estos síntomas y posibles secuelas físicas y psicológicas (depresión, ansiedad) en los niños con cáncer, así como la efectividad de las estrategias familiares para tratar estos síntomas.Como citar este artículo: Díaz-Morales K, Reyes-Arvizu J, Morgado-Nájera K, Everardo-Domínguez D. Síntomas en niños con cáncer y estrategias de cuidado familiar. Rev Cuid. 2019; 10(1): e597. http://dx.doi.org/10.15649/cuidarte.v10i1.597

Latent Transition Analysis of the Symptom Experience of Cancer Patients Undergoing Chemotherapy

BACKGROUND

Symptom clusters reflect the person's experience of multiple cooccurring symptoms. Although a variety of statistical methods are available to address the clustering of symptoms, latent transition analysis (LTA) characterizes patient membership in classes defined by the symptom experience and captures changes in class membership over time.

OBJECTIVES

The purposes of this article are to demonstrate the application of LTA to cancer symptom data and to discuss the advantages and disadvantages of LTA relative to other methods of managing and interpreting data on multiple symptoms.

METHODS

Data from a total of 495 adult cancer patients who participated in randomized clinical trials of two symptom management interventions were analyzed. Eight cancer- and treatment-related symptoms reflected the symptom experience. Latent transition analysis was employed to identify symptom classes and evaluate changes in symptom class membership from baseline to the end of the interventions.

RESULTS

Three classes, "A (mild symptoms)," "B (physical symptoms)," and "C (physical and emotional symptoms)," were identified. Class A patients had less comorbidity, better physical and emotional role effect, and better physical function than the other classes did. The number of symptoms, general health perceptions, and social functioning were significantly different across the three classes and were poorest in Class C. Emotional role functioning was poorest in Class C. Older adults were more likely to be in Class B than younger adults were. Younger adults were more likely to be in Class C (p < .01). Among patients in Class C at baseline, 41.8% and 29.0%, respectively, transitioned to Classes A and B at the end of the interventions.

DISCUSSION

These results demonstrate that symptom class membership characterizes differences in the patient symptom experience, function, and quality of life. Changes in class membership represent longitudinal changes in the course of symptom management. Latent class analysis overcomes the problem of multiple statistical testing that separately addresses each symptom.

Cumulative Burden of Morbidity Among Testicular Cancer Survivors After Standard Cisplatin-Based Chemotherapy: A Multi-Institutional Study

Purpose In this multicenter study, we evaluated the cumulative burden of morbidity (CBM) among > 1,200 testicular cancer survivors and applied factor analysis to determine the co-occurrence of adverse health outcomes (AHOs). Patients and Methods Participants were ≤ 55 years of age at diagnosis, finished first-line chemotherapy ≥ 1 year previously, completed a comprehensive questionnaire, and underwent physical examination. Treatment data were abstracted from medical records. A CBM score encompassed the number and severity of AHOs, with ordinal logistic regression used to assess associations with exposures. Nonlinear factor analysis and the nonparametric dimensionality evaluation to enumerate contributing traits procedure determined which AHOs co-occurred. Results Among 1,214 participants, approximately 20% had a high (15%) or very high/severe (4.1%) CBM score, whereas approximately 80% scored medium (30%) or low/very low (47%). Increased risks of higher scores were associated with four cycles of either ifosfamide, etoposide, and cisplatin (odds ratio [OR], 1.96; 95% CI, 1.04 to 3.71) or bleomycin, etoposide, and cisplatin (OR, 1.44; 95% CI, 1.04 to 1.98), older attained age (OR, 1.18; 95% CI, 1.10 to 1.26), current disability leave (OR, 3.53; 95% CI, 1.57 to 7.95), less than a college education (OR, 1.44; 95% CI, 1.11 to 1.87), and current or former smoking (OR, 1.28; 95% CI, 1.02 to 1.63). CBM score did not differ after either chemotherapy regimen ( P = .36). Asian race (OR, 0.41; 95% CI, 0.23 to 0.72) and vigorous exercise (OR, 0.68; 95% CI, 0.52 to 0.89) were protective. Variable clustering analyses identified six significant AHO clusters (χ² P < .001): hearing loss/damage, tinnitus (OR, 16.3); hyperlipidemia, hypertension, diabetes (OR, 9.8); neuropathy, pain, Raynaud phenomenon (OR, 5.5); cardiovascular and related conditions (OR, 5.0); thyroid disease, erectile dysfunction (OR, 4.2); and depression/anxiety, hypogonadism (OR, 2.8). Conclusion Factors associated with higher CBM may identify testicular cancer survivors in need of closer monitoring. If confirmed, identified AHO clusters could guide the development of survivorship care strategies.

Symptom Monitoring in Pediatric Oncology Using Patient-Reported Outcomes: Why, How, and Where Next

Symptom monitoring using patient-reported outcomes (PROs) is not common in pediatric oncology, despite interest from stakeholders-including patients, families, clinicians, and regulatory organizations-and proven clinical benefit in adult oncology. This article examines the foundational data for patient-reported symptom reporting in this population and posits the next investigative steps toward the implementation of patient-reported symptom monitoring in the care and research of pediatric oncology patients. The reasoning behind, and feasibility of, monitoring symptoms in pediatric oncology patients using PRO measures are discussed, as well as specific tools that have been developed to track symptoms in this population, including innovative electronic self-reporting platforms built to engage children in the symptom reporting process. Aspects of engaging both patients and clinicians in the symptom self-report process are reviewed, as are the experiences of "early adopters" of this process in pediatric oncology and across pediatrics. It is clear that there are key issues that remain regarding the use of PROs for symptom monitoring, including selection of specific outcomes to monitor, how to resolve discrepant reports, and determination of benefit. The next steps for investigation of these issues are discussed. Unanswered questions notwithstanding, work should continue to make patient-reported symptom monitoring an established, evidence-based part of routine and research practice in pediatric oncology.

How Can We Use Symptom Clusters in Nursing Care of Children with Leukemia?

The incidence of childhood cancers has been gradually rising worldwide. The rate of leukemia, which is the most common cancer type in childhood, has been increasing as well. In recent years, multiple chemotherapeutic agents, radiotherapy and bone marrow transplantation have been using in leukemia treatment. Children receiving treatment for leukemia may experience many symptoms due to the disease and its treatment. These concurrent symptoms may have a complex relationship. The aim of this paper is to review and compile current literature data related to symptom clusters used to explain multiple symptoms that occur in a complex structure due to leukemia and its treatment. Symptom clustering is used in oncology nursing to explain the complex relationship among multiple symptoms and to find out the effects that symptoms have on each other and patient outcomes. There are generally two statistical approaches to modeling symptom clusters. One is to establish the symptom clusters by grounding on clinical experiences, while the other is to establish them according to the results of statistical analysis and then clinical experiences. With the latter method, symptom clusters can be established more objectively and more number of symptoms can be assessed. In the literature, there are four instruments available for the measurement of a large number of symptoms in children. It is important to increase use of symptom clusters in nursing care for a better understanding of the relationship among multiple symptoms experienced during leukemia treatment, a more effective symptom management, and a more holistic care.

New Trends and Recent Care Approaches in Pediatric Oncology Nursing

Increased incidence of children diagnosed with cancer and survivors was an impact on changes in pediatric hemato-oncology nursing care. In this review article, it is aimed to investigate the new trends and recent care approaches in pediatric oncology nursing. The recent care topics were common in the literature as family-centered care, technology-based care, program development, primary care of child, health-care provider, survivors and home care, and nonpharmacological care. All of the topics contribute to perform evidence-based care for health promotion and well-being in pediatric hemato-oncology nursing. Research reviews showed that many current topics for the care of children and their parents have entered in the literature. There is a need for more randomized controlled studies to improve the level of evidence of new nursing approaches.

Differences in Symptom Clusters Identified Using Ratings of Symptom Occurrence vs. Severity in Lung Cancer Patients Receiving Chemotherapy

CONTEXT

An important question in symptom clusters research is whether the number and types of symptom clusters vary based on the specific dimension of the symptom experience used to create the clusters.

OBJECTIVES

Given that lung cancer patients undergoing chemotherapy (CTX) report an average of 14 co-occurring symptoms and studies of symptom clusters in these patients are limited, the purpose of this study, in lung cancer patients undergoing CTX (n = 145), was to identify whether the number and types of symptom clusters differed based on whether symptom occurrence rates or symptom severity ratings were used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess for the occurrence and severity of 38 symptoms, one week after the administration of CTX. Exploratory factor analysis was used to extract the symptom clusters.

RESULTS

Both the number and types of symptom clusters were relatively similar using symptom occurrence rates or symptom severity ratings. Five symptom clusters were identified using both symptom occurrence rates and severity ratings (i.e., sickness behavior, lung cancer specific, psychological, nutritional, and epithelial). Across these two dimensions, the specific symptoms within each of the symptom clusters were relatively similar.

CONCLUSIONS

Identification of symptom clusters in patients with lung cancer may assist with the development of more targeted symptom management interventions. Future studies are warranted to determine if symptom clusters change over a cycle of CTX in patients with lung cancer.

Promotion of Well-being During Treatment for Childhood Cancer: A Literature Review of Art Interventions as a Coping Strategy

BACKGROUND

Scientific literature suggests that art interventions can assist children with cancer cope with physical and psychosocial difficulties associated with cancer treatment. Little is known about how the making of tangible visual art can be helpful and which proposed therapeutic mechanisms are clinically important.

OBJECTIVE

The purpose of this literature review is to assess and synthesize the research evidence regarding the role of art therapy/art-making interventions for promoting the well-being of children with cancer undergoing treatment.

METHODS

A search of electronic databases (MEDLINE [PubMed], CINAHL, PsycINFO) and EBM Reviews including Cochrane Database of Systematic Reviews (OVID) and manual review of references in articles accessed were undertaken. Inclusion criteria were as follows: research studies of any design; children with cancer undergoing treatment (2-21 years old), and art therapy/art-making intervention. Data extraction and quality appraisal were undertaken. Data were analyzed with an author-developed review sheet and synthesized into a table.

RESULTS

Six articles reporting 6 studies met the inclusion criteria. Studies were based on qualitative (n = 3) and mixed quantitative/qualitative (n = 3) methodologies. Three outcome categories emerged that outline potential therapeutic roles of art interventions.

CONCLUSIONS

Though sparse and developmental in nature, the existing evidence suggests that art interventions may potentially promote the well-being of children undergoing cancer treatment by reducing anxiety, fear, and pain and promoting collaborative behaviors; enhancing communication with the treatment team; and counteracting the disruption of selfhood that cancer treatment evokes.

IMPLICATIONS FOR PRACTICE

Further and higher-quality research is warranted before routinely integrating standardized art interventions into the treatment protocols for children with cancer.

Retracted: Symptom trajectories and occurrence in older Saudi children with cancer during a course of chemotherapy

This research aimed to describe changes in symptom occurrence and severity of the 31 symptoms during the chemotherapy cycle at three time points. This descriptive, longitudinal study investigated Saudi children who underwent a cycle of chemotherapy (n = 132) in four tertiary hospitals. The Arabic version of the Memorial Symptom Assessment Scale, Karnofsky Performance Status and a demographic questionnaire were used. More than 30% of children reported 10 or more symptoms during the cycle. Symptom occurrence trajectories were analysed using multilevel logistic regression. Six symptoms (i.e. fatigue, sadness, irritability, worrying, weight loss, sweating) showed a decreasing linear trend. Significant quadratic patterns of change were found for feeling drowsy, nausea and vomiting. No significant differences, over time were found in any of the symptom severity scores by using multilevel negative binomial regression. This study is the first to examine the trajectory of multiple symptoms that children experience during a cycle of chemotherapy in Saudi Arabia. Children in this study reported a high number of symptoms across the entire cycle of chemotherapy. Intervention studies are needed to improve care for these symptoms.

Symptom Trajectories in Children Receiving Treatment for Leukemia: A Latent Class Growth Analysis With Multitrajectory Modeling

CONTEXT

Cancer treatment symptoms play a major role in determining the health of children with cancer. Symptom toxicity often results in complications, treatment delays, and therapy dose reductions that can compromise leukemia therapy and jeopardize chances for long-term survival. Critical to understanding symptom experiences during treatment is the need for exploration of "why" inter-individual symptom differences occur; this will determine who may be most susceptible to treatment toxicities.

OBJECTIVES

This study examined specific symptom trajectories during the first 18 months of childhood leukemia treatment. Symptom measures included fatigue, sleep disturbances, pain, nausea, and depression.

METHODS

Symptom trajectories of 236 children with leukemia three to 18 years old were explored prospectively over four periods: initiation of post-induction therapy, four and eight post-induction therapy, and the last time point was at the beginning of maintenance/continuation therapy. Latent class growth analysis was used to classify patients into distinctive groups with similar symptom trajectories based on patients' response patterns on the symptom measures over time.

RESULTS

Three latent classes of symptom trajectories were identified and classified into mild, moderate, and severe symptom trajectories. The only demographic characteristic with a significant relationship to membership in the latent class symptom trajectories was race/ethnicity. All other demographic characteristics including leukemia risk levels showed no significant relationships.

CONCLUSION

This study is unique in that groups of patients with similar symptoms were identified rather than groups of symptoms. Further research using latent class growth analysis is needed.

National nursing science priorities: Creating a shared vision

BACKGROUND

Nursing science is essential to advance population health through contributions at all phases of scientific inquiry. Multiple scientific initiatives important to nursing science overlap in aims and population focus.

PURPOSE

This article focused on providing the American Academy of Nursing and nurse scientists in the Unites States with a blueprint of nursing science priorities to inform a shared vision for future collaborations, areas of scientific inquiry, and resource allocation.

METHODS

The Science Committee convened four times and using Delphi methods identified priorities with empirical evidence and expert opinion for prioritization, state of the science, expert interest, and potential target stakeholders.

DISCUSSION

Nursing science priorities for 2017 were categorized into four themes including: (a) precision science, (b) big data and data analytics, (c) determinants of health, and (d) global health.

CONCLUSION

Nurse scientists can generate new knowledge in priority areas that advances the health of the world's populations.

Differences in symptom clusters identified using symptom occurrence rates versus severity ratings in patients with breast cancer undergoing chemotherapy

PURPOSE

One of the unanswered questions in symptom clusters research is whether the number and types of symptom clusters vary based on the dimension of the symptom experience used to create the clusters. Given that patients with breast cancer receiving chemotherapy (CTX), report between 10 and 32 concurrent symptoms and studies of symptom clusters in these patients are limited, the purpose of this study, in breast cancer patients undergoing CTX (n = 515), was to identify whether the number and types of symptom clusters differed based on whether symptom occurrence rates or symptom severity ratings were used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess for the occurrence and severity of 38 symptoms, one week after the administration of CTX. Exploratory factor analysis was used to extract the symptom clusters.

RESULTS

Both the number and types of symptom clusters were similar using symptom occurrence rates or symptom severity ratings. Five symptom clusters were identified using symptom occurrence rates (i.e., psychological, hormonal, nutritional, gastrointestinal, epithelial). Six symptom clusters (i.e., psychological, hormonal, nutritional, gastrointestinal, epithelial, chemotherapy neuropathy) were identified using symptom severity ratings. Across the two dimensions, the specific symptoms within each of the symptom clusters were similar.

CONCLUSIONS

Identification of symptom clusters in patients with breast cancer may be useful in guiding symptom management interventions. Future studies are warranted to determine if symptom clusters remain stable over a cycle of CTX in patients with breast cancer.

Development of a mHealth Real-Time Pain Self-Management App for Adolescents With Cancer: An Iterative Usability Testing Study [Formula: see text]

PURPOSE

A user-centered design approach was used to refine the mHealth Pain Squad+ real-time pain self-management app for adolescents with cancer for its usability (defined as being easy to use, easy to understand, efficient to complete, and acceptable).

METHOD

Three iterative usability testing cycles involving adolescent observation and interview were used to achieve this objective. During each cycle, adolescents used the app while "thinking aloud" about issues encountered. Observed difficulties and errors were recorded and a semistructured interview about the experience was conducted. Using a qualitative conventional content analysis approach, themes related to app usability were identified.

RESULTS

Participants required an average of 4.3 minutes to complete the pain assessment component of Pain Squad+. Overall, the app was acceptable. Problematic issues related to software malfunction, interface design flaws, and confusing text. Software revisions were made to address each issue.

CONCLUSION

The multifaceted usability approach used provided insight into how a real-time app can be made acceptable to adolescents with cancer and succeeded in developing a Pain Squad+ app that is fit for future effectiveness testing.