Nonpharmacological interventions in the improvement of quality of life in children and adolescent cancer patients

Xavier, Welker da Silva; Pacheco, Sandra Teixeira de Araújo; Silva, Liliane Faria da; Nascimento, Lucila Castanheira; Lopes-Junior, Luís Carlos; Araújo, Barbara Bertolossi Marta de; Nunes, Michelle Darezzo Rodrigues

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Acta Paulista de Enfermagem

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Integrative Review • Acta Paul Enferm 33 • 2020 • https://doi.org/10.37689/acta-ape/2020AR0022 copy

Nonpharmacological interventions in the improvement of quality of life in children and adolescent cancer patients

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To identify, in both the Brazilian and international literature, studies about the efficacy of nonpharmacological interventions oriented toward improving quality of life in children and adolescents with cancer.

Methods

Integrative review whose search process was carried out in September and October 2018 in the following databases: PsycINFO, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Latin America and Caribbean Center on Health Sciences Information, Índice Bibliográfico Español de Ciencias de la Salud, Banco de Dados em Enfermagem, and MEDLINE®. The guiding question was “What are the nonpharmacological interventions available in the literature used to improve quality of life in children and adolescents with cancer?”. Original articles published between 2013 and 2018 in English, Portuguese, or Spanish were included. Studies that focused on other subjects or adult population and review articles, dissertations, and theses were excluded.

Results

The sample was 22 articles, which were grouped, according to their similarities, into three categories. The described interventions consisted of: exclusive physical activity (6); physical activity combined with another intervention (8); and psychological interventions (8). Among these interventions, 13 showed significant differences in the improvement of quality of life.

Conclusion

The nonpharmacological interventions that applied physical exercise or were combined with another intervention were the most effective. The present review helps raising awareness of professionals of the importance of the subject and provides resources to plan strategical actions, in the context of pediatric nursing, that include nonpharmacological interventions, together with the standard treatment, to improve quality of life in children and adolescents with cancer. The results must be evaluated with caution, given that a variety of interventions, protocols, and number of participants was identified in the sample, which hinders the generalization of the findings.

Child; Adolescente; Neoplasms; Quality of life; Pediatric nursing

Citation/Year/Country/ Area of activity	Participants	Methods	Main results	Level of evidence
Interventions based exclusively on physical activity
Tanir; Kuguoglu⁽¹²⁾ 2013 Peru Nursing	40 children between 8 and 12 years old with ALL	Randomized clinical trial Intervention group (n=19) Intervention: physical activity, such as walking and climbing Control group (n=21) Instruments: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	Pain scores, injuries, nausea, and anxiety related to the procedure did not show significant differences when the intervention and control groups were compared. However, the group that participated in the intervention experienced a significant increase in these scores.	II
Beulertz et al.⁽¹³⁾ 2016 Germany Medicine	33 children between 4 and 17 years old with cancer under outpatient treatment	Randomized clinical trial Intervention group (n=20) Intervention: physical activity over six months, once a week, for 60 minutes Control group (n=13) Instrument: KINDL® questionnaire	Significant differences were found in the physical and emotional well-being when the groups were compared. Additionally, there was a significant difference in the emotional well-being since the beginning of the intervention until the post-intervention period, favoring those who practiced the exercises.	II
Müller et al.⁽¹⁴⁾ 2016 Germany Medicine	150 children between 4 and 18 years old after treatment for leukemia, lymphoma, brain tumor, or sarcoma	Non-randomized controlled trial (quasi-experiment) Intervention: physical activity over four weeks Instrument: KINDL® questionnaire	Immediate and persistent effects on HRQL were identified in children and adolescents with different types of cancer. However, patients with sarcoma reported higher global and physical well-being scores in comparison with patients with leukemia and lymphoma.	III
Khodashenas et al.⁽¹⁵⁾ 2017 Iran Medicine	20 children between 5 and 12 years old with cancer	Randomized clinical trial Intervention group (n=10) Intervention: aerobic physical activity Control group (n=10) Instruments: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	Improvement in the well-being of children with cancer, demonstrated in the improvement in the pain and injury subscale, in addition to a better performance at school according to the parents’ report.	II
Mendoza et al.⁽¹⁶⁾ 2017 United States Medicine	59 adolescents between 14 and 18 years old with a post-cancer treatment period longer than 1 year	Randomized clinical trial Intervention: physical activity (walking) over ten weeks using a tracking device (Fitbit Flex) and a virtual support group based on a Facebook group Instruments: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	Significant decrease in social functioning and absence of alterations in the other scale domains. There was good acceptability and an increase in the motivation for the intervention.	II
Sparrow et al.⁽¹⁷⁾ 2017 United States Medicine	9 children between 2 and 12 years old diagnosed with brain tumor and hemiplegia after the end of the therapy	Non-randomized controlled trial (quasi-experiment) Intervention: physical activity (movement therapy), with 15 therapy sessions, each lasting three hours Instruments: PedsQL SF15 and PedsQL 4.0 Generic Core (parents’ report)	Despite the higher HRQL scores obtained after the intervention, the difference was not significant.	III
Howell et al.⁽¹⁸⁾ 2018 United States Psychology and medicine	78 children between 11 and 15 years old with cancer	Randomized clinical trial Intervention group (n=53) Intervention: physical activity; the group received educational materials, a device to monitor the activities, and access to an interactive website designed to encourage physical activity by providing rewards Control group (n=25) Instrument: PedsQL 4.0 Generic Core	Groups that performed physical activity showed better general HRQL results and better scores in the physical performance subscale.	II
Interventions based on physical and educational activities
Li et al.⁽¹⁹⁾ 2013 Japan Nursing	71 children between 9 and 16 years old who survived cancer	Randomized clinical trial Experimental group (n=34) Intervention: four-day training integrated program based on adventure and health education Control group (n=37) Instrument: PedsQL 4.0 Generic Core	There was no statistically significant change in the children’s quality of life.	II
Chung et al.⁽²⁰⁾ 2015 Japan Nursing	69 survivors with an average age of 12.6 years	Non-randomized controlled trial (quasi-experiment) Intervention group (n=33) Intervention: physical activity and health education Control group (n=36) Regular medical care Instrument: PedsQL 4.0 Generic Core	Improvement in HRQL, especially in the physical and emotional functioning.	III
Lam et al.⁽²¹⁾ 2018 China Nursing	70 children between 9 and 18 years old with cancer	Randomized clinical trial Intervention group (n = 37) Intervention: 15 minutes of health education and physical activity Control group (n = 33) 15 minutes of health education and playing cards or chess, in addition to receiving health advice on how to prevent the flu and the importance of a healthy diet Instrument: PedsQL 3.0 Cancer Module	Participants in the intervention group showed a better quality of life when compared with participants in the control group over the nine-month follow-up.	II
Li et al.⁽²²⁾ 2018 Japan Nursing	222 children between 9 and 16 years old who survived cancer	Randomized controlled trial Intervention group (n=117) Intervention: physical activity (based on adventures), four times a week, over 12 months Control group (n=105) Leisure activity, four times a week, over six months Instrument: PedsQL 4.0 Generic Core	The participants in the intervention group reported a better quality of life than those in the control group.	II
Interventions based on physical and psychological activities
Wurz et al.⁽²³⁾ 2014 Canada Psychology and medicine	8 children between 5 and 17 years old with cancer	Non-randomized controlled trial (quasi-experiment) Intervention: supervised yoga sessions, twice a week, over 12 weeks Instrument: PedsQL 4.0 Generic Core	Significant improvement in the total HRQL score and the psychosocial subscale, in addition to an improvement in the physical functioning and the performance at school according to the parents’ report.	III
Van Dijk-Lokkart et al.⁽²⁴⁾ 2015 Netherlands Psychology and medicine	68 children between 8 and 18 years old with cancer	Randomized clinical trial Intervention group (n=30) Intervention: physical exercises (45 minutes over 12 weeks) and psychosocial intervention Control group (n=38) Instruments: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	No effect on HRQL was identified in the children’s self-report. However, the parents’ report revealed a significant improvement in the score in the pain subscale, less anxiety in the short term, and less nausea in the long term.	II
Van Dijk-Lokkart et al.⁽²⁵⁾ 2015 Netherlands Psychology and medicine	61 children between 8 and 18 years old with cancer	Randomized clinical trial Intervention: physical and psychosocial intervention program Instrument: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	The results did not show the efficacy of the intervention in improving HRQL in children and adolescents with cancer.	II
Orsey et al.⁽²⁶⁾ 2017 United States Psychology and medicine	20 children and adolescents between 8 and 18 years old under cancer treatment and their parents	Non-randomized controlled trial (quasi-experiment) Intervention: yoga over eight weeks Instruments: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	It identified a significant increase in the emotional and social function and an improvement in HRQL.	III
Exclusively psychological interventions
Akard et al.⁽²⁷⁾ 2015 United States Nursing and medicine	28 children between 7 and 17 years old with cancer	Randomized clinical trial Intervention group (n=15) Intervention: legacy-making; individual interviews with children with advanced cancer addressing what they would like their relatives and friends to remember about them. The children wrote some words or made something special to give to somebody significant to them Control group (n=13) Instrument: PedsQL 4.0 Generic Core	There was not a significant difference in HRQL scores, although the parents perceived that the intervention facilitated the communication between them and their children. It was a coping strategy and it helped the children deal with the disease and feel better emotionally, socially, physically, and spiritually.	II
Malboeuf-Hurtubise et al.⁽²⁸⁾ 2016 Germany Psychology	14 adolescents between 11 and 18 years old with cancer	Non-randomized controlled trial (quasi-experiment) Intervention: mindfulness Instrument: PedsQL 3.0 Cancer Module	All the participants reported that they liked the group. There was a reduction in stress before the treatments, ease to fall asleep more quickly, and no report of sadness or depression. However, the differences between pre- and post-intervention were not significant regarding QL.	III
Shoshani et al.⁽²⁹⁾ 2016 Israel Psychology	66 children between 5 and 12 years old with cancer and showing risk of death	Randomized controlled trial Intervention group (n=32) Intervention: Make-a-Wish; evoking hope and joy to cope with the disease, indulging the children’s greatest wish Control group (n=34) Instrument: PedsQL 4.0 Generic Core	Children in the intervention group showed a significant reduction in general distress, depression, and anxiety symptoms, in addition to improved HRQL and greater hope and positive affection.	II
McCullouh et al.⁽³⁰⁾ 2017 United States Nursing, medicine and veterinary medicine	106 children between 3 and 17 years old newly diagnosed with cancer	Randomized clinical trial Intervention group (n=60) Intervention: animal-assisted therapy Control group (n=46) Instruments: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	There were no significant differences between the groups over time.	II
Barrera et al.⁽³¹⁾ 2018 Canada Psychology	91 children between 8 and 16 years old with brain/spinal tumor	Randomized clinical trial Intervention group (n=43) Intervention: social skills (friendship, cooperation, management of teasing and bullying, conflict resolution, empathy, and affirmation) Control group (n=48) Instrument: PedsQL 4.0 Generic Core	There was no significant difference in quality of life.	II
Silva; Osório⁽³²⁾ 2018 Brazil Medicine	24 children between 6 and 12 years old with a solid tumor or ALL	Non-randomized controlled trial (quasi-experiment) Intervention: animal-assisted therapy Instrument: Quality of Life Evaluation Scale	There was no significant difference in the quality of life scores.	III
Uggla et al.⁽³³⁾ 2018 Sweden Psychology and medicine	29 children between 0 and 17 years old submitted to a hematopoietic stem cell transplantation	Randomized clinical trial Intervention group (n=14) Intervention: music therapy Control group (n=15) Instrument: PedsQL 4.0 Generic Core and PedsQL 3.0 Cancer Module	Significant improvement in all the domains of the generic scale, except the school one, and significant improvement in the subscales related to anxiety associated with the treatment, concerns, cognitive problems, and communication in the cancer module.	II

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[1] Corresponding author. Michelle Darezzo Rodrigues Nunes https://orcid.org/0000-0001-7685-342X Email: mid13@hotmail.com