Deborah Tomlinson

Effect of exercise on cancer-related fatigue: a meta-analysis.

ABSTRACT Numerous randomized controlled trials have been conducted to determine efficacy of exercise on cancer-related fatigue. However, many trials lacked sufficient power to demonstrate significant differences, and little is known about how the effect of exercise differs depending on patient- and intervention-level characteristics. A meta-analysis was performed to determine whether exercise reduces fatigue compared with usual care or nonexercise control intervention in patients with cancer. The authors searched Ovid MEDLINE, EMBASE, PsycINFO, The Cochrane Central Register of Controlled Trials, and CINAHL. Two authors independently extracted the data. Randomized controlled trials comparing exercise with control intervention in cancer patients in which fatigue was quantified were eligible. Seventy-two randomized controlled trials were identified, 71 in adults and 1 in children. Exercise had a moderate effect on reducing fatigue compared with control intervention. Exercise also improved depression and sleep disturbance. Type of exercise did not significantly influence the effect on fatigue, depression, or sleep disturbance. Exercise effect was larger in the studies published 2009 or later. There was only one pediatric study. The results of this study suggest that exercise is effective for the management of cancer-related fatigue.

Defining Bloodstream Infections Related to Central Venous Catheters in Patients With Cancer: A Systematic Review

The objective of this review was to determine whether consistent definitions were used in published studies of bloodstream infections due to central venous catheters in patients with cancer (ie, catheter-related or catheter-associated bloodstream infections). Review of 191 studies reporting catheter-related or catheter-associated bloodstream infections in patients with cancer revealed a lack of uniformity in these definitions. We grouped definitions by type, with 39 articles failing to cite or report a definition. Definitions included those of the Centers for Disease Control and Prevention (n = 39) and the Infectious Diseases Society of America (n = 18). The criteria included in the definitions in studies were also tabulated. Clinical manifestations were frequently included. Definitions used have been highly variable; comparability of risk factors, incidence, management, and outcomes of such infections is difficult to achieve across studies. Future research should focus on development of a common definition of catheter-related and catheter-associated bloodstream infections for both adults and children with cancer.

Parent Reports of Quality of Life for Pediatric Patients With Cancer With No Realistic Chance of Cure

PURPOSE To compare quality of life of children with cancer with no reasonable chance of cure reported by parents 6 months or fewer versus more than 6 months before death. PATIENTS AND METHODS This cross-sectional study included children between the ages of 2 and 18 years with cancer and no reasonable chance of cure at The Hospital for Sick Children, Toronto, Ontario, Canada. Parents reported quality of life on behalf of their children. Outcomes were the PedsQL 4.0 Generic Core Scales, Acute Cancer Module, and Multidimensional Fatigue Scale. RESULTS Seventy-three parents of children participated. Compared with children who survived more than 6 months (n = 43), those who died at 6 months or fewer (n = 30) had significantly worse physical health (mean difference, 15.9; 95% CI, 1.8 to 30.0; P = .028), more pain and hurt (mean difference, 15.5; 95% CI, 0.9 to 30.0; P = .037), and worse general fatigue (mean difference, 15.8; 95% CI, 2.4 to 29.1; P = .021) and sleep/rest fatigue (mean difference, 16.0; 95% CI, 3.5 to 28.5; P = .013). Among the entire cohort, those with leukemia/lymphoma had worse physical and psychosocial quality of life compared with those with solid or brain tumors. Recent stem-cell transplantation was associated with worse psychosocial health. CONCLUSION Parents of children with cancer reported worse physical health, pain, and fatigue proximal to death. Those with leukemia/lymphoma were at higher risk for impaired quality of life. This knowledge can help in the design of targeted interventions to improve quality of life for children dying as a result of cancer.

Chemotherapy versus supportive care alone in pediatric palliative care for cancer: comparing the preferences of parents and health care professionals

Background: The choice between palliative chemotherapy (defined as the use of cytotoxic medications delivered intravenously for the purpose of our study) and supportive care alone is one of the most difficult decisions in pediatric oncology, yet little is known about the preferences of parents and health care professionals. We compared the strength of these preferences by considering children’s quality of life and survival time as key attributes. In addition, we identified factors associated with the reported preferences. Methods: We included parents of children whose cancer had no reasonable chance of being cured and health care professionals in pediatric oncology as participants in our study. We administered separate interviews to parents and to health care professionals. Visual analogue scales were shown to respondents to illustrate the anticipated level of the child’s quality of life, the expected duration of survival and the probability of cure (shown only to health care professionals). Respondents were then asked which treatment option they would favour given these baseline attributes. In addition, respondents reported what factors might affect such a decision and ranked all factors identified in order of importance. The primary measure was the desirability score for supportive care alone relative to palliative chemotherapy, as obtained using the threshold technique. Results: A total of 77 parents and 128 health care professionals participated in our study. Important factors influencing the decision between therapeutic options were child quality-of-life and survival time among both parents and health care professionals. Hope was particularly important to parents. Parents significantly favoured chemotherapy (42/77, 54.5%) compared with health care professionals (20/128, 15.6%; p < 0.0001). The opinions of the physician and child significantly influenced the parents’ desire for supportive care; for health care professionals, the opinions of parents and children were significant factors influencing this decision. Interpretation: Compared with health care professionals, parents more strongly favour aggressive treatment in the palliative phase and rank hope as a more important factor for making decisions about treatment. Understanding the differences between parents and health care professionals in the relative desirability of supportive care alone may aid in communication and improve end-of-life care for children with cancer.

Challenges to participation in paediatric palliative care research: a review of the literature.

It has been identified that there is a need for increased palliative care research within the paediatric setting. The assessment of parental views is necessary for this population. However, the conduct of research and recruitment of participants is often challenging. While conducting a study that involved parents of children receiving palliative or end-of-life care, the authors found that there were particular challenges to recruiting these parents. This comprehensive review of the literature aims to address the ethical and recruitment issues of involving parents of children that are receiving palliative or end-of-life care. Key elements, that may maximize completion of research and a more representative sample, are also discussed. These elements include obtaining the opinions on study design and interview script from experienced families and maximizing the partnership between health care professionals and the research team. Palliative Medicine 2007; 21 : 435—440

Measurement of oral mucositis in children: a review of the literature

Goals of workThe assessment of oral mucositis is important. There is a paucity of validated oral mucositis assessment instruments for use in children. This paper reviews the available mucositis measurement tools and their applicability to a paediatric population.Materials and methodsLiterature search of PUBMED™ and bibliography searches identified articles relevant to mucositis measurement tools and the measurement of mucositis in paediatrics.ResultsThe relevant issues in the literature could be grouped into three categories: (1) development and evaluation of oral assessment tools, (2) oral assessment in the paediatric population, and (3) challenges to the assessment of oral mucositis in children. There were numerous validated mucositis assessment scales for use in adults. Only three of these scales have received limited evaluation for use in the paediatric population. The unique challenges presented by the paediatric population are excluded from much of the discussion in the literature.ConclusionThe paper demonstrates the need to consider the issues specific to children. It must be determined whether previously developed tools are ideally suited for children enrolled on mucositis clinical trials.

Complementary and alternative medicine use in pediatric cancer reported during palliative phase of disease

PurposeThe objectives of this study were to assess the frequency, types, and potential determinants of complementary and alternative medicine (CAM) use, and consideration of CAM use, collected from parents with children during the palliative phase of disease.MethodsEligible parent respondents were identified by their primary care team. Demographic information and questionnaires were completed by the parent in the presence of a research nurse (DT). We conducted univariate logistic regression to identify predictors of parents who considered CAM use and children who actually used CAM. Descriptions of types of CAM were categorized according to the National Center for Complementary and Alternative Medicine.ResultsA total of 77 parents participated. Only 22 children (29%) had received some type of CAM, with 42 parents (55%) having considered its use for their child. Whole medical systems (n = 17) and biologically based therapies (n = 15) were the most frequently considered CAM, with whole medical systems (n = 6) being the most frequently used CAM. Family and disease variables were not indicative of CAM use. However, parents with higher education and those with a family member with cancer were more likely to consider CAM use, while parents were less likely to consider CAM as children were farther from time of relapse.ConclusionsThe study provides initial insight into CAM use, and consideration of use, in children with cancer receiving palliative care. Further research is required to determine if the gap between CAM use and consideration is important, why this gap exists, and whether CAM has beneficial effects in this population.

Challenges of mucositis assessment in children: Expert opinion

Mucositis is a challenging treatment-related complication in children receiving therapy for cancer. The conduct of clinical trials that investigate mucositis prevention and treatment requires adequate evaluation of the oral cavity. However, few instruments to measure mucositis in children have been appropriately developed or evaluated. A focus group of nine health care professionals with expertise in mucositis assessment, oral assessment in children and paediatric cancer aimed to determine the challenges and possible solutions to mucositis assessment in children. The results led to the identification of several areas of concern that included: (1) challenges in oral assessment in children related to age and cooperation, (2) the need for proxy responses while recognizing the challenges of reporting pain and function attributed to oral mucositis, (3) the need for an instrument that is simple, quick to complete, and easy to use in almost all children and (4) educational considerations. The results provide a basis from which guidelines for the oral assessment of mucositis in children can begin. This information could be used to aid in the development of a new scale for the assessment of oral mucositis in children.

Refinement of the Symptom Screening in Pediatrics Tool (SSPedi)

Background:Objective was to evaluate and refine a new instrument for paediatric cancer symptom screening named the Symptom Screening in Pediatrics Tool (SSPedi).Methods:Respondents were children 8–18 years of age undergoing active cancer treatment and parents of eligible children. Respondents completed SSPedi once and then responded to semi-structured questions. They rated how easy or difficult SSPedi was to complete. For items containing two concepts, we asked respondents whether concepts should remain together or be separated into two questions. We also asked about each item’s importance and whether items were missing. Cognitive probing was conducted in children to evaluate their understanding of items and the response scale. After each group of 10 children and 10 parents, responses were reviewed to determine whether modifications were required. Recruitment ceased with the first group of 10 children in which modifications were not required.Results:Thirty children and 20 parents were required to achieve a final version of SSPedi. Fifteen items remain in the final version; the score ranges from 0 to 60.Conclusions:Using opinions of children with cancer and parents of paediatric cancer patients, we successfully developed a symptom screening tool that is easy to complete, is understandable and demonstrates content validity.

Validation of the Children's International Mucositis Evaluation Scale (ChIMES) in paediatric cancer and SCT.

Background:Objectives were to describe the reliability and validity of a new paediatric-specific mucositis scale, the Children’s International Mucositis Evaluation Scale (ChIMES).Methods:In a multi-centre prospective study, children aged 0 to ⩽18 years were eligible if they were receiving any of the following: myeloablative stem cell transplantation (SCT), ⩾60 mg m−2 course−1 doxorubicin or ⩾12 g m−2 methotrexate. Multiple measures of mucositis were included along with ChIMES. Respondents were parent proxy report for children aged <12 years, and child self-report for children aged 12–18 years and 8 to <12 years. Mucositis diaries were completed at baseline and on Days 7–17 following chemotherapy/conditioning. On Day 14, the respondent reported presence of mucositis and change since the previous day.Results:The 185 respondents included parents (N=98), children aged 12–18 years (N=66) and children aged 8 to <12 years (N=21). Test–retest reliability was excellent for ChIMES Total Score and ChIMES Percentage Score with r>0.8 for all respondent types. Criteria for construct validation were met across all measures. ChIMES also demonstrated responsiveness with significant differences between baseline and Day 14.Conclusion:ChIMES is a paediatric-specific measure of mucositis with favourable psychometric properties. It exhibits reliability, construct validity and responsiveness. ChIMES should be incorporated into clinical trials of mucositis prevention and treatment in paediatric cancer and SCT.