Pediatric Cancer Symptom Management

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Design and Participants: This cluster randomized trial determined whether symptom screening with symptom feedback and management care pathways, vs usual care, improves overall self-reported symptoms in patients with cancer aged 8 to 18 years. Patients newly diagnosed receiving any cancer treatment were enrolled between 2021 and 2023 from 20 US cancer centers. Symptom screening included providing thrice-weekly symptom screening prompts to participants, email alerts to the healthcare team, and locally adapted symptom management care pathway implementation. The primary outcome was self-reported total Symptom Screening in Pediatrics Tool (SSPedi) score at 8 weeks (range=0-60; higher indicates more bothersome). Secondary outcomes were Patient-Reported Outcomes Measurement Information System Fatigue score (mean=50 [SD=10]; higher indicates >fatigue), Pediatric Quality of Life 3.0 Acute Cancer Module scores (range=0-100; higher indicates >health), symptom documentation and interventions at 8 weeks, and unplanned healthcare encounters. Linear and logistic regression were used.

Results: Participants (n=221 at intervention sites, n=224 at control sites) were aged median 15 years [range=8.1-19]; 59% male; and 1.3% American Indian/Alaska Native, 4.5% Asian, 6.1% Black, 3.4% Pacific Islander, and 58% White. The mean 8-week SSPedi score was 7.9 (SD=7.2) in intervention vs 11 (8.7) in control. Intervention was associated with better total SSPedi score (adjusted mean difference=−3.8 [95% CI=−6.4 to −1.2]) and less bothersome individual symptoms (12/15 symptoms reduced). There was no difference in fatigue or quality of life. The mean number of emergency department visits was 0.77 (SD=1.1) in intervention and 0.45 (0.81) in control. There were more emergency department visits in intervention (rate ratio=1.7 [1.0-2.9]).

Commentary: Poor symptom management among children with cancer is well documented.1,4 Assessing symptom burden is challenging because it’s subjective, and compared to self-reporting children with cancer, clinicians underestimate symptom burden while caregivers overestimate.5,6 This cluster randomized trial assessing the impact of regular self-reporting of symptoms by children with cancer paired with care pathways to address symptoms led to decreased symptom burden, highlighting the importance of the child’s voice in determining how cancer- and treatment-related symptoms are identified and addressed. Direct integration of patient-reported outcomes tools in clinical visits may improve these effects.7 Regardless, seeking the direct report of the child who is actually experiencing symptoms is imperative if we are to optimally reduce suffering caused by cancer and its treatment.

Bottom Line: The integration of structured symptom self-reporting tools increases symptom intervention and reduces overall symptom burden among children with cancer.

Reviewer: Scott H. Maurer, MD, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA

References:

1. Hyslop S, Davis H, Duong N, et al. Symptom documentation and intervention provision for symptom control in children receiving cancer treatments. Eur J Cancer. 2019;109:120-128. doi:10.1016/j.ejca.2019.01.002.

2. Hyslop S, Tomlinson D, Baggott C, et al. Feeling scared or worried self-report in children receiving cancer treatments using the Symptom Screening in Pediatrics tool (SSPedi). Support Care Cancer. 2021;29(6):3137-3144. doi:10.1007/s00520-020-05818-x.

3. Johnston DL, Hyslop S, Tomlinson D, et al. Describing symptoms using the Symptom Screening in Pediatrics tool in hospitalized children with cancer and hematopoietic stem cell transplant recipients. Cancer Med. 2018;7(5):1750-1755. doi:10.1002/cam4.1433.

4. Wolfe J, Grier H, Klar N, et al. Symptoms and suffering at the end of life in children with cancer. NEJM. 2000;342(5):326-33. doi:10.1056/NEJM200002033420506.

5. Freyer DR, Lin L, Mack J, et al. Lack of concordance in symptomatic adverse event reporting by children, clinicians, and caregivers: implications for cancer clinical trials. J Clin Oncol. 2022;40(15):1623-1634. doi:10.1200/JCO.21.02669.

6.Mack JW, McFatrich M, Withycombe JS, et al. Agreement between child self-report and caregiver-proxy report for symptoms and functioning of children undergoing cancer treatment. JAMA Pediatr. 2020;174(11):e202861. doi:0.1001/jamapediatrics.2020.2861.

7. Basch E, Deal A, Kris M, et al. Symptom monitoring with patient-reported outcomes during routine cancer treatment: a randomized controlled trial. J Clin Oncol. 2016;34(6):557-65. doi:10.1200/JCO.2015.63.0830.

Source: Dupuis LL, Vettese E, Grimes AC, et al. Symptom screening linked to care pathways for pediatric patients with cancer: a randomized clinical trial. JAMA. 2024;332(23):1981-1991. doi:10.1001/jama.2024.19585.

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