Strategies to improve communication about neurocognitive impacts in pediatric oncology: Quality improvement findings.

BACKGROUND: Neurocognitive deficits are common among children who receive central nervous system (CNS)-directed therapy for childhood cancer. Parents report that they lack information from and communication with oncology providers about neurocognitive impacts of therapy. Furthermore, oncology providers report they lack training and institutional support to appropriately address the neurocognitive needs of these patients/families. METHODS: A parent/provider stakeholder informed, quality improvement (QI) project was conducted to educate providers about neurocognitive impacts, increase parent/provider communication, and improve adherence to supportive care guidelines for neuropsychological assessment for children receiving CNS-directed therapy. A 1-h Continuing Medical Education (CME) course was developed to educate providers about neurocognitive impacts and their relation to schooling. A provider-focused electronic medical record (EMR) strategy was used to deliver parent stakeholder-informed return-to-school "roadmaps," with prompts to scaffold parent/provider communication and enhance documentation of findings. RESULTS: Hospital-based CME sessions were attended by 76% (41 out of 54) of providers from our institution. Among the 34 who completed both pretest and posttest, the mean knowledge score improved from 56% at pretest to 74% at posttest. Compliance with the EMR strategy was 80% and there was a 42% increase in neuropsychological assessment referrals. CONCLUSIONS: We conclude that this QI project is an example of a successful parent/provider stakeholder collaboration that achieved demonstrable positive change in the areas of provider knowledge, patient/provider communication, and alignment of neuropsychological assessment referrals with existing guidelines. Our results confirm that improving knowledge, communication, and compliance with neuropsychological standards of care is possible with this evidence-based approach.

Anti-inflammatory mouthwashes for the prevention of oral mucositis in cancer therapy: an integrative review and meta-analysis.

PURPOSE: Mucositis is severely painful and often reported as one of the most distressing adverse effects of cancer therapy; it is a significant threat to quality of life as well as life itself. Anti-inflammatory agents may modulate physiologic mechanisms that perpetuate mucositis and be useful in prevention efforts. Because systemic anti-inflammatory agents are not appropriate for many patients, locally acting agents (mouthwashes) may be more feasible for use. This review and meta-analysis evaluates the role that anti-inflammatory mouthwashes have in preventing or reducing oral mucositis associated with chemotherapy and radiation therapy. METHODS: A systematic literature review was conducted to identify studies evaluating the efficacy of anti-inflammatory mouthwashes to prevent therapy-associated mucositis. Meta-analysis was conducted to determine efficacy in preventing any mucositis and dose-limiting mucositis. RESULTS: Eight peer-reviewed publications were identified; corticosteroid and nonsteroidal anti-inflammatory mouthwashes are effective in reducing overall incidence of mucositis and are associated with lower severity of mucositis. Meta-analysis reveals significant reduction in symptomatic mucositis incidence (OR 6.00, 95% CI 4.39-8.20, p < 0.0001) and reduction of dose-limiting mucositis (OR 2.12, 95% CI 1.07-4.28, p = 0.032). CONCLUSION: Mouthwashes containing anti-inflammatory agents are a potential effective means to prevent or reduce mucositis associated with cancer therapy. There are limited adverse effects from these agents, and adherence is high, indicating safety and feasibility of use. Anti-inflammatory mouthwashes should be considered for supportive care in persons at risk for mucositis and must be further evaluated to investigate efficacy across multiple chemotherapy agents, adverse effects, and impacts on symptoms, pain, and quality of life.

Childhood Cancer Survivors and Distance Education Challenges: Lessons Learned From the COVID-19 Pandemic.

OBJECTIVE: Pediatric cancer survivors have historically struggled to receive adequate educational supports. In Spring 2020, the COVID-19 pandemic forced an emergency switch from traditional in-person education models to distance education, but little information is available regarding experiences of pediatric survivors' coping with schooling since that time. METHODS: This article presents exploratory mixed methods findings from a quality improvement project including qualitative interviews and a quantitative survey conducted with parents of pediatric oncology survivors identified through neuropsychological assessment, and the use of school-based services as having educationally relevant neurocognitive impacts of disease or treatment. The interviews explored experiences of education and instructional delivery during the COVID-19 school closures in spring of 2020 and the beginning of the 2020-2021 school year and served as the foundation for a quantitative survey to determine the generalizability of findings. RESULTS: Qualitative interviews highlighted 3 emergent themes regarding the shared experiences of distance schooling for children with cancer during the COVID-19 school closures: (a) attention, (b) mental health, and (c) access to instruction. A follow-up quantitative survey supported the qualitative findings and their generalizability to the schooling experiences of other children with cancer during the pandemic. CONCLUSION: This article describes and explores each theme and offers suggestions for pediatric supports and changes to provider service delivery (including weblinks to access project-developed resources) as a result of ongoing pandemic-related schooling needs.

Study Protocol to Evaluate Influences of Stress and Inflammation on Mucositis in Adolescents and Young Adults With Cancer.

BACKGROUND: Adolescent and young adult (AYA) cancer diagnoses are rising, and gains in survivorship are falling behind for this age group. Dose-limiting toxicities of therapy, including mucositis, are more frequent in this age group and may be contributing to poorer survivorship. Animal models and observational studies suggest that stress and inflammation may be contributing to the high prevalence of dose-limiting mucositis in this age demographic. The AYA oncology population has been an overlooked and underresearched oncology demographic, leading to poor understanding of why this age group has high side-effect burdens and poorer cancer survival. OBJECTIVES: This article describes a novel, prospective clinical study in AYAs receiving chemotherapy designed to evaluate if stress at the time of chemotherapy administration predicts the development of dose-limiting mucositis and determines if stress-induced inflammatory profiles mediate this relationship. This is the first study to translate these stress and inflammation findings from animal models to a nurse-centered research design in humans. METHODS: Persons aged 15-39 years who are receiving chemotherapy with a significant (>20%) risk of developing mucositis will be recruited for a prospective study. Baseline stress is measured through participant questionnaires, and blood is collected to analyze for inflammatory markers. Participants receive chemotherapy as clinically planned and complete a daily survey of mucositis symptoms for 14 days after chemotherapy. Regression and mediation analysis will determine if stress and inflammatory profiles predict the development of dose-limiting mucositis. RESULTS: This model of inquiry through a nursing framework uses a biobehavioral model that considers physiological and psychological risk factors for chemotherapy toxicities. This study is also an important translational science study essential in bringing data from laboratory studies to the clinical arena. The study may also be important to implementation science because assessing the ability of critically ill individuals to participate in low-burden clinical studies may yield essential findings to improve care delivery. DISCUSSION: Findings from this work will identify potentially modifiable factors that may be manipulated to minimize chemotherapy toxicities and lead to improved survival. Data from this study will inform larger research endeavors to better understand symptom development in this high-risk oncological population.

Bisphosphonate Therapy for Treating Osteonecrosis in Pediatric Leukemia Patients: A Systematic Review.

BACKGROUND: Despite improved outcomes in children with leukemia, complications such as osteonecrosis are common. We conducted a systematic review to investigate the role of bisphosphonates in reducing pain, improving mobility, and stabilizing lesions in pediatric leukemia survivors. METHODS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched the PubMed, Embase, Cochrane, Web of Science, Scopus, CINAHL, and ClinicalTrials.gov databases. Five of 221 articles retrieved met our inclusion criteria. RESULTS: Bisphosphonates, especially when combined with dietary calcium and vitamin D supplements and physical therapy (supplements/PT) were associated with improved pain and mobility in 54% and 50% of patients, respectively. A significantly greater proportion of patients treated with bisphosphonates (83%) reported mild/moderate pain or no pain compared with those with supplements/PT alone (36%) (P<0.001). Sixty-six percent of patients treated with bisphosphonates achieved improved/full mobility compared with 27% of those treated with supplements/PT alone (P=0.02). However, 46% of patients showed progressive joint destruction despite bisphosphonate therapy. No adverse events were reported, except for acute phase reactions to intravenous therapies. CONCLUSIONS: Bisphosphonates, when combined with supplements/PT, were associated with less pain and improved mobility, but not prevention of joint destruction in pediatric leukemia patients with osteonecrosis.

Self-efficacy in symptom management for adolescents and young adults with cancer: a systematic review.

BACKGROUND: Adolescents and young adults (AYAs) have more frequent and intense adverse effects from cancer therapy than other age groups. Self-efficacy, the ability for persons to maintain health-related behavior change, may assist with symptom management but the role it plays in AYAs with cancer has not been thoroughly investigated. This review explores the role that self-efficacy has in symptom management for AYAs with cancer and provides guidance for clinicians to utilize self-efficacy as a means to reduce side effects of therapy. METHODS: A systematic review of peer-reviewed literature was conducted to identify works discussing self-efficacy and symptom management for AYAs with cancer. Five databases were searched with key terms and articles that discussed relationships between self-efficacy and cancer therapy symptoms were retained for analysis. FINDINGS: Twelve manuscripts representing 1180 individuals age 12 to 43 years were identified. Self-efficacy was found to be related to (1) health management behaviors, (2) psychosocial health, (3) sexual and reproductive health, and (4) physical symptoms. Self-efficacy had direct correlations with physical activity, nutritional intake, symptom regulation, mental health, sexual health, and fertility preservation. The included studies did not find significant relationships with medication adherence or pain management. DISCUSSION: Self-efficacy is an attribute that impacts behavior change, health maintenance, and overall wellness and can be changed over time and through interventions to improve symptoms of cancer therapy. Self-efficacy should be evaluated as a construct in relevant studies aimed at improving side effects of cancer therapy to better understand outcomes from interventions. Symptoms, toxicities, and adverse effects of cancer therapy may be improved by increasing self-efficacy of patients.

Educating Childhood Cancer Survivors: a Qualitative Analysis of Parents Mobilizing Social and Cultural Capital.

Childhood cancer impacts the child patient as well as the family and caregivers throughout diagnosis, treatment, and survivorship. Secondary analysis of qualitative data revealed the critical role of parents' adaptability and flexibility when navigating advocacy decisions about their child's schooling following diagnosis and through survivorship. After cancer, adjusting to school means adjusting to a new normal creating challenges related to curriculum, peers, and educators that can affect quality of life. Critically, parents' adjustment to a new advocacy role emerged as an important consideration. Concepts of social and cultural capital aid in understanding the experiences of parents whose children have returned to school following their successful treatment for pediatric cancer. Framed in this way, how parents mobilize (or do not mobilize) these forms of capital as they devise strategies to support their children are understood. This study interprets parent reports and actions as taken often in the hope that they will help both their own child and others that follow, creating mutual benefit for the network of people touched by cancer.

Pediatric oncology provider perspectives and practices: Supporting patients and families in schooling after cancer diagnosis.

BACKGROUND: Cognitive limitations are common after childhood cancer and require assessment and support in the medical and school setting. Pediatric oncology providers are tasked with educating families about the side effects of disease/treatment, and supporting families as they navigate the associated challenges. Despite this important role, little is known about the training, practice, and knowledge of providers in the domain of cognitive/school impacts. METHODS: An online survey was emailed to Children's Oncology Group (COG) member physicians in the United States. The survey consisted of 42 questions about training and practice, and 4 knowledge questions about neurocognitive impacts and school supports. RESULTS: Surveys were completed by 282 physicians representing 64% of COG institutions and a diverse group of experience and institution size. The pediatric oncologist was reported most frequently (93%) as the person at their institution to provide information to families on this topic, yet 54% reported receiving no specific training in this area and the majority (66%) reported to only "somewhat" understand the issues pediatric oncology patients face when returning to school. A minority reported available institutional guidelines (42%) or screening tools (19%) to assist in making referrals or assessments. Knowledge questions concerning health conditions qualifying children for school supports received the fewest correct answers. The majority (77%) thought more training would be helpful. CONCLUSIONS: Additional training about cognitive impacts and schooling challenges associated with childhood cancer is needed to prepare providers to support parents/children. In addition, establishing policy guidelines and screening procedures may help support providers in providing care.

Assessment of Online Resources for Returning to School During and After Treatment of Childhood Cancer.

To evaluate current online parent education resources for children returning to school after a cancer diagnosis. Online search was conducted using 3 search engines and terms recommended by affected families. Sites were evaluated by 3 reviewers for understandability and actionability (scored 0-100%) using the Patient Education Materials Assessment Tool (PEMAT). Readability was assessed using Flesch-Kincaid (grade K-12) and content comprehensiveness by a clinical expert review for 5 late effect domains (scored 0-100%). A total of 56 unique online resources were evaluated. Mean understandability and actionability scores were 54% (range 17-83) and 36% (range 0-83) respectively. The mean Flesch-Kincaid grade level was 10th grade (mode 12th). Comprehensiveness of domain coverage was 34% (mode 20%). Some high-quality materials for this topic are available, but generally low scores on the PEMAT scales and high reading level estimates on Flesch-Kincaid indicate parents may have difficulty understanding and using the information. The low scores for comprehensiveness of information indicate parents will likely need to access multiple sources for complete information. A table provides the names, website (URL), and scoring for the 24 top-rated sites and can be used to make recommendations to parents with improved confidence in quality.

Schooling in survivorship: Understanding caregiver challenges when survivors return to school.

OBJECTIVE: Schooling after treatment can hold challenges for survivors of childhood cancer and caregivers who may need to act as advocates on their behalf. This study seeks to understand caregiver experiences of survivor's school-related challenges. This understudied area is critical given the 85% survivor rate for those diagnosed with childhood cancer and the disproportionate risk of learning difficulties faced by those with brain tumor or who receive therapy that targets the central nervous system. METHODS: Affected caregivers participated in open-ended interviews addressing school experiences during survivorship. Following preliminary analysis using a grounded theory approach, interviewees and other stakeholders from education, medical, and foundation communities participated in focus groups. Member-check activities explored the validity of identified themes and a model derived from interview data describing schooling challenges during survivorship. RESULTS: Caregivers reported schooling-related experiences were often stressful and such stressors recurred during survivors' ongoing education. They reported a lack of appropriate knowledge among themselves, school staff, and clinicians about issues their survivor faced as well as concerns about communication and uncertainties about the processes required to attain appropriate services. These themes of knowledge, communication, and process issues were embedded within family approaches to coping with difficulties as well as the specific types of late effects each survivor faced. CONCLUSIONS: The proposed model and clinical implications provide a foundation for future research and intervention development. Such work is needed to more effectively support survivors and their caregivers with difficulties that arise during schooling following treatment for childhood cancer.

Parent perspectives on oncology team communication regarding neurocognitive impacts of cancer therapy and school reentry.

BACKGROUND: Neurocognitive deficits are common after childhood cancer and impact academic performance. Parents need to be knowledgeable of long-term complications impacting school and the resources necessary to support educational achievement. The oncology team plays an important role in preparing parents for the challenges of returning to school after treatment. METHODS: An online survey developed by parents and stakeholders was used to assess parent experiences and preferences associated with oncology team support around neurocognitive deficits and school transition. Recruitment included social media sites, foundation contacts, and clinic/event flyers. Topics included information content, timing, and frequency of information; and utility or perceived value of information. Inclusion criteria included respondent identifying as a parent (caregiver) of child treated for cancer who has returned to school. RESULTS: Surveys from 203 parents were completed representing diverse geographic locations. Nearly half (48%) did not recall receiving information about neurocognitive deficits. The most frequently reported time to receive this information was at diagnosis, but parents reported a need for conversations throughout the cancer trajectory, especially at transition to survivorship and school reentry. In addition, half of the parents (51%) felt inadequately prepared for the return to school. Information about neuropsychological testing, resources for learning difficulties, educational terms, and legal rights related to school services were the topics most inadequately provided. CONCLUSIONS: Parents feel inadequately prepared by their oncology team for their child's return to school. Research is needed to identify effective oncology team approaches to fill the gaps in knowledge around school reentry after cancer treatment.

Postchemotherapy Immunization Practices for Non-HSCT Pediatric Oncology Patients.

Pediatric oncology patients treated with antineoplastic therapy have impaired immune systems that lead to loss of protective antibodies. They require reimmunization to protect against vaccine-preventable diseases. There are a paucity of studies on the clinical practice of pediatric oncologists and the available recommendations are heterogenous. This study describes current reimmunization practices among pediatric oncologists. We surveyed the Children's Oncology Group (COG)-identified principle investigators to capture clinical practices among pediatric oncologists within their institutions regarding reimmunization of non-hematopoietic stem cell transplantation patients. The majority of respondents did not routinely assess vaccine-related immune status; those who did most frequently assessed 6 months after cessation of therapies. Methods of assessment included type of therapy received, vaccine titers, and absolute lymphocyte counts. Providers from smaller institutions were more likely to check vaccine titers than those from larger institutions. More than half of the surveyed institutions did not have standardized guidelines available for practitioners. There are variations in reimmunization practices among pediatric oncologists despite available guidelines on recommended schedules. Further research is needed to identify the safest and most cost-effective way to insure immunity to infectious disease after the treatment of childhood cancer.

Automated Functional Imaging by 2D Speckle Tracking Echocardiography Reveals High Incidence of Abnormal Longitudinal Strain in a Cohort of Pediatric Oncology Patients.

BACKGROUND: Automated functional imaging (AFI) was introduced to two-dimensional speckle-tracking echocardiography to facilitate strain assessment in the clinical settings. In patients treated with cardiotoxic anthracyclines, AFI may be helpful in the detection of early myocardial injury when left ventricular ejection fraction (LVEF) remains normal. METHODS: We retrospectively assessed feasibility of AFI in 143 echocardiograms on 102 subjects aged 0.4-22 years (mean 12.3) obtained over a 12-month period. We computed a Z-score for apical four-chamber longitudinal strain using published normal data to assess for abnormal strain in patients with and without previous exposure to anthracyclines. RESULTS: AFI was feasible in 95.1% of echocardiograms, with low inter- and intraobserver variability. There was a statistically significant association between abnormal longitudinal strain Z-score (SZ < -2.0) and depressed LVEF (<55%, P < 0.001). However, 46% of echocardiograms with normal LVEF had abnormal SZ; half of which had no prior anthracycline exposure. The correlation between SZ and LVEF was strongest in subjects exposed to anthracyclines (r(2) = 0.12, P < 0.01). Increasing age was associated with decreasing SZ. Total cumulative dose, after adjusting for age, was inversely associated with SZ (r(2) = 0.42, P < 0.001). Time from last dose of anthracycline had no significant association with SZ. CONCLUSIONS: AFI is highly feasible in the clinical settings. The observed high prevalence of abnormal longitudinal strain in our cohort emphasizes the importance of obtaining baseline measurements prior to anthracycline treatment. The effects of anthracycline on longitudinal strain may be dose and age dependent, with younger children less likely to show abnormalities.

Endothelial health in childhood acute lymphoid leukemia survivors: pilot evaluation with peripheral artery tonometry.

BACKGROUND: Childhood cancer survivors are a growing population at risk for poor cardiac outcomes. Acute lymphoid leukemia (ALL) survivors are among those at increased risk of cardiovascular complications. Early identification of impaired vascular health may allow for interventions to improve these outcomes. The purpose of this study was to evaluate vascular health using peripheral artery tonometry in ALL survivors and compare results with healthy siblings. PROCEDURE: Sixteen ALL survivor, healthy sibling pairs, aged 8 to 20 years, were evaluated for vascular health and cardiovascular risk factors (body mass index, central adiposity, blood pressure, and fitness). One-tailed paired t test was used to compare the groups. RESULTS: Survivors were similar to siblings in cardiovascular risk measures but had poorer vascular health as measured by reactive hyperemia index (survivor RHI 1.54 vs. sibling 1.77; P=0.0474). CONCLUSION: This study reveals that even among survivors who are comparable to their healthy siblings in other traditional cardiovascular risks, there is evidence of poorer vascular health.

Pain Management for Children during Bone Marrow and Stem Cell Transplantation.

Pain management for children during bone marrow and stem cell transplantation is a significant clinical challenge for the health care team. Pain management strategies vary by institution. This paper reports on the use of a pediatric pain management service and patient- and caregiver-controlled analgesia for children undergoing transplant. This 2-year retrospective chart review examined the pain management practices and outcomes of children undergoing bone marrow and stem cell transplants in a large urban teaching hospital during 2008 and 2009. We concluded that patient- and caregiver-controlled analgesia is a well-tolerated modality for pain control during hospitalization for transplantation at this institution.

Oral and dental late effects in survivors of childhood cancer: a Children's Oncology Group report.

PURPOSE: Multi-modality therapy has resulted in improved survival for childhood malignancies. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers provide practitioners with exposure- and risk-based recommendations for the surveillance and management of asymptomatic survivors who are at least 2 years from completion of therapy. This review outlines the pathophysiology and risks for oral and dental late effects in pediatric cancer survivors and the rationale for oral and dental screening recommended by the Children's Oncology Group. METHODS: An English literature search for oral and dental complications of childhood cancer treatment was undertaken via MEDLINE and encompassed January 1975 to January 2013. Proposed guideline content based on the literature review was approved by a multi-disciplinary panel of survivorship experts and scored according to a modified version of the National Comprehensive Cancer Network "Categories of Consensus" system. RESULTS: The Children's Oncology Group oral-dental panel selected 85 relevant citations. Childhood cancer therapy may impact tooth development, salivary function, craniofacial development, and temporomandibular joint function placing some childhood cancer survivors at an increased risk for poor oral and dental health. Additionally, head and neck radiation and hematopoietic stem cell transplantation increase the risk of subsequent malignant neoplasms in the oral cavity. Survivors require routine dental care to evaluate for potential side effects and initiate early treatment. CONCLUSIONS: Certain childhood cancer survivors are at an increased risk for poor oral and dental health. Early identification of oral and dental morbidity and early interventions can optimize health and quality of life.

Mechanisms of sleep disturbances in long-term cancer survivors: a childhood cancer survivor study report.

BACKGROUND: Sleep problems following childhood cancer treatment may persist into adulthood, exacerbating cancer-related late effects and putting survivors at risk for poor physical and psychosocial functioning. This study examines sleep in long-term survivors and their siblings to identify risk factors and disease correlates. METHODS: Childhood cancer survivors (≥5 years from diagnosis; n = 12 340; 51.5% female; mean [SD] age = 39.4 [9.6] years) and siblings (n = 2395; 57.1% female; age = 44.6 [10.5] years) participating in the Childhood Cancer Survivor Study completed the Pittsburgh Sleep Quality Index (PSQI). Multivariable Poisson-error generalized estimating equation compared prevalence of binary sleep outcomes between survivors and siblings and evaluated cancer history and chronic health conditions (CHC) for associations with sleep outcomes, adjusting for age (at diagnosis and current), sex, race/ethnicity, and body mass index. RESULTS: Survivors were more likely to report clinically elevated composite PSQI scores (>5; 45.1% vs 40.0%, adjusted prevalence ratio [PR] = 1.20, 95% CI = 1.13 to 1.27), symptoms of insomnia (38.8% vs 32.0%, PR = 1.26, 95% CI = 1.18 to 1.35), snoring (18.0% vs 17.4%, PR = 1.11, 95% CI = 1.01 to 1.23), and sleep medication use (13.2% vs 11.5%, PR = 1.28, 95% CI = 1.12 to 1.45) compared with siblings. Within cancer survivors, PSQI scores were similar across diagnoses. Anthracycline exposure (PR = 1.13, 95% CI = 1.03 to 1.25), abdominal radiation (PR = 1.16, 95% CI = 1.04 to 1.29), and increasing CHC burden were associated with elevated PSQI scores (PRs = 1.21-1.48). CONCLUSIONS: Among survivors, sleep problems were more closely related to CHC than diagnosis or treatment history, although longitudinal research is needed to determine the direction of this association. Frequent sleep-promoting medication use suggests interest in managing sleep problems; behavioral sleep intervention is advised for long-term management.

Biobehavioral Influences of Stress and Inflammation on Mucositis in Adolescents and Young Adults with Cancer: Results from a Pilot Study.

Purpose: Chemotherapy-induced mucositis is a prevalent and burdensome toxicity among adolescent and young adults (AYAs) with cancer and impedes the delivery of optimal therapy. Its development is not well understood, but baseline stress and inflammation may be contributory factors. This pilot study evaluates stress and inflammation as risk factors for mucositis, identifies effect size estimates, and evaluates the feasibility of a prospective study to investigate mucositis development. Methods: Thirty AYAs receiving chemotherapy with substantial risk of mucositis completed baseline stress measures, and serum was collected for inflammatory biomarker analysis. Regression and mediation analyses determined the relationship between stress/inflammation and mucositis. Results: Stress appears to be a significant risk factor for incidence of mucositis (odds ratio 1.13, p = 0.125) and predicts total mucositis score (ß = 0.281, p = 0.023) as well as peak incidence (ß = 0.052, p = 0.018). Baseline levels of interleukin (IL)-1a and epidermal growth factor (EGF) predicted mucositis development, and EGF and IL-8 may mediate the relationship between stress and mucositis. Findings suggest that stress-induced inflammation exacerbates symptom development. Conclusion: Results from this pilot study inform mucositis symptom models, suggesting that psychosocial and physiologic factors are involved in development. Importantly, this pilot study provides initial effect size estimates, including magnitude and direction of relationships, that are essential to informing larger, more robustly powered studies. High enrollment, low attrition, and minimal missing data in this study suggest this model is feasible for research in this population. Importantly, this work is a first step in identifying new risk factors for mucositis and targets for nurse-led interventions to prevent toxicity development.

Developing a Tool for Measuring Parent Knowledge and Barriers to Supportive School Integration After Diagnosis of Childhood Cancer.

Background: Children treated for cancer are at risk for long-term neurocognitive late effects that can impact school attainment, employment, and quality of life. Obtaining formal education support can be critical to later success but may depend upon parent knowledge and ability to access needed support. The purpose of this study was to develop and evaluate the psychometric properties of a scale to measure the perceived support that parents received upon their child's return to school during or after cancer treatment. Methods: Exploratory factor analyses evaluated the construct validity of survey items. Cronbach's alpha was used to test the internal consistency and independent t-tests evaluated the concurrent criterion validity of resulting subscales. Results: The exploratory factor analyses resulted in two subscales, Barriers to Supportive School Integration (13 items) and Parent School Integration Knowledge (three items). All items loaded at least 0.49 onto each factor, with Cronbach's alpha values of 0.927 and 0.738, respectively. The Knowledge subscale additionally demonstrated concurrent criterion validity; higher Knowledge subscale scores were found among parents who reported receiving information about treatment-related cognitive/school problems from healthcare providers (p < .001). Discussion: The Parent School Integration Knowledge and Barriers to Supportive School Integration subscales demonstrated preliminary evidence for good construct validity and internal consistency. These subscales may be used in future research to assess parent knowledge, barriers to receiving support, and overall experience of supportive school integration after the diagnosis of pediatric cancer.

A Rocky Landscape: Challenges with College Transition and Completion for Adolescents and Young Adults with Cancer.

Purpose: Adolescents and young adults with cancer have lower college attendance and graduation rates than their peers, but the reasons for this and extent to which cancer impacts college is unknown. This study explores post-high school experiences of young adults with cancer, detailing impacts of diagnosis and treatment on higher education attainment. Materials and Methods: A convergent mixed-methods design disseminated nationally obtained data regarding post-high school transition experiences in adults diagnosed with cancer before age 25. Results: Participants (n = 47) indicated struggles with employment and education; 81% attended some college, but 44% have not completed their degree, citing logistic challenges and lasting effects of therapy as major barriers. Nearly 20% of participants reported that cancer made higher education too difficult, so they did not attend, and most of these individuals (66.6%) are unemployed. Qualitative findings detail that accessing appropriate accommodations was made difficult by a lack of understanding from college faculty and staff. Conclusion: For many, cancer presents a barrier to higher education attainment; changing course of studies, repeating classes, and switching majors may impact degree completion. A minority of students with cancer access educational supports or get assistance obtaining these resources from their medical or high school team. Changes to clinical practice to ensure supports for young adults transitioning from high school have the potential to create improved pathways to higher education success. Additionally, supporting college faculty and staff understanding of cancer and its late effects may be a low-cost, high-impact way to improve adolescent/young adult college success.