The pediatric hematology/oncology fellowship program at the Children's Hospital of Philadelphia set out to create a case‐based learning curriculum for common hematologic malignancies that would apply ...principles of adult learning theory and improve fellows’ retention of information in a supportive, goal‐oriented learning environment. A framework we employed in developing this curriculum is that of “flow theory,” which parallels many of the tenets of adult learning theory. After implementing this curriculum, which we call “the unknown case,” the percentage of fellows correctly identifying a common hematopathologic diagnosis improved from 50% to 85%.
Social determinants of health (SDoH) are associated with stark disparities in cancer outcomes, but systematic SDoH data collection is virtually absent from oncology clinical trials. Trial‐based SDoH ...data are essential to ensure representation of marginalized populations, contextualize outcome disparities, and identify health‐equity intervention opportunities. We report the feasibility of a pediatric oncology multicenter therapeutic trial‐embedded SDoH investigation. Among 448 trial participants, 392 (87.5%) opted‐in to the embedded SDoH study; 375 (95.7%) completed baseline surveys, with high longitudinal response rates (88.9–93.1%) over 24 months. Trial‐embedded SDoH data collection is feasible and acceptable and must be consistently included within future oncology trials.
Abstract Introduction Disparities in relapse and survival from high‐risk neuroblastoma (HRNBL) persist among children from historically marginalized groups even in highly standardized clinical trial ...settings. Research in other cancers has identified differential treatment toxicity as one potential underlying mechanism. Whether racial and ethnic disparities in treatment‐associated toxicity exist in HRNBL is poorly understood. Methods This is a retrospective study utilizing a previously assembled merged cohort of children with HRNBL on Children's Oncology Group (COG) post‐consolidation immunotherapy trials ANBL0032 and ANBL0931 at Pediatric Health Information System (PHIS) centers from 2005 to 2014. Race and ethnicity were categorized to reflect historically marginalized populations as Hispanic, non‐Hispanic Black (NHB), non‐Hispanic other (NHO), and non‐Hispanic White (NHW). Associations between race‐ethnicity and intensive care unit (ICU)‐level care utilization as a proxy for treatment‐associated toxicity were examined with log binomial regression and summarized as risk ratio (RR) and corresponding 95% confidence interval (CI). Results The analytic cohort included 370 children. Overall, 88 (23.8%) patients required ICU‐level care for a median of 3.0 days (interquartile range IQR: 1.0–6.5 days). Hispanic children had nearly three times the risk of ICU‐level care (RR 3.1, 95% CI: 2.1–4.5; fully adjusted RR aRR 2.5, 95% CI: 1.6–3.7) compared to NHW children and the highest percentage of children requiring cardiovascular‐driven ICU‐level care. Conclusion Children of Hispanic ethnicity with HRNBL receiving clinical trial‐delivered therapy were more likely to experience ICU‐level care compared to NHW children. These data suggest that further investigation of treatment‐related toxicity as a modifiable mechanism underlying outcome disparities is warranted.
Cardiomyopathy is a leading cause of late morbidity and mortality in childhood cancer survivors (CCS). Evidence-based guidelines recommend risk-stratified screening for cardiomyopathy, but the ...management approach for abnormalities detected when screening asymptomatic young adult CCS is poorly defined.
The aims of this study were to build upon existing guidelines by describing the expert consensus–based cardiomyopathy screening practices, management approach, and clinical rationale for the management of young adult CCS with screening-detected abnormalities and to identify areas of controversy in practice.
A multispecialty Delphi panel of 40 physicians with expertise in cancer survivorship completed 3 iterative rounds of semi-open-ended questionnaires regarding their approaches to the management of asymptomatic young adult CCS at risk for cardiomyopathy (screening practices, referrals, cardiac testing, laboratory studies, medications). Consensus was defined as ≥90% panelist agreement with recommendation.
The response rate was 100% for all 3 rounds. Panelists reached consensus on the timing and frequency of echocardiographic screening for anthracycline-associated cardiomyopathy, monitoring during pregnancy, laboratory testing for modifiable cardiac risk factors, and referral to cardiology for ejection fraction ≤50% or preserved ejection fraction with diastolic dysfunction. Controversial areas (<75% agreement) included chest radiation dose threshold to merit screening, indications for advanced cardiac imaging and cardiac serum biomarkers for follow-up of abnormal echocardiographic findings, and medical management of asymptomatic left ventricular systolic dysfunction.
Expert practice is largely consistent with existing risk-based screening guidelines. Some recommendations for managing abnormalities detected on screening echocardiography remain controversial. The rationale offered by experts for divergent approaches may help guide clinical decisions in the absence of guidelines specific to young adult CCS.
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This 2012 Academic Emergency Medicine consensus conference breakout session was devoted to the task of identifying the history and current state of faculty development in education research in ...emergency medicine (EM). The participants set a future agenda for successful faculty development in education research. A number of education research and content experts collaborated during the session. This article summarizes existing academic and medical literature, expert opinions, and audience consensus to report our agreement and findings related to the promotion of faculty development.
1. Describe processes to facilitate systematic social needs evaluation in pediatric advanced cancer.
2. Define household material hardship and associations with parent outcomes.
Our data demonstrate ...that it is feasible to screen for social needs in pediatric advanced cancer and that over half of families report unmet resource needs (housing, transportation, utilities, or food) at this inflection point in care.
Parent caregivers living in poverty experience more distress during their child's cancer treatment compared to parents without poverty exposure. Our prior research demonstrates that household material hardship (HMH)– a modifiable measure of poverty including housing, food, transportation, and utility insecurities– is independently associated with severe psychologic distress among parents of children with newly diagnosed acute leukemia. The feasibility of systematic social needs screening to identify and address similar disparities in pediatric advanced cancer has not been established.
Parents of children (< 18 years) with advanced cancer (defined as poor prognosis, new relapse/progression, early phase trial enrollment, or new palliative care consult) receiving care at a large pediatric cancer center were approached for participation following permission from the primary palliative care and/or oncology teams. Enrolled participants completed a two-timepoint social needs evaluation at enrollment and 12-weeks from initial survey completion. Surveys were completed electronically and are available in English and Spanish (and other languages with an interpreter). Feasibility was defined as >75% consent rate and >75% complete HMH data.
From January through September 2023, N=37 potentially eligible participants were identified; primary teams declined approach for 5 participants. Among 32 eligible participants, 28 consented to participation (88%) and 27 have completed initial surveys (96%) with no missing HMH data. Participants include 22 mothers (81%). Self-reported racial/ethnic identities include 6 Asian participants (22%), 3 Black/African American participants (11%), and 5 Hispanic participants (19%). Over half of participants (N=14) report HMH. All eligible participants completed 12-week follow-up (N=9); 4 participants were ineligible due to their child's death.
Systematic social needs screening is feasible in pediatric advanced cancer. Over half of families in this cohort report unmet basic resource needs compared to 1 in 3 families at childhood cancer diagnosis. Interventions to address social needs are urgently needed in pediatric advanced cancer.
Scientific Research / Diversity, Equity, Inclusion, Belonging, Justice
1. Understand the relationship between household material hardship, social needs, and social determinants of health.
2. Describe the prevalence of household material hardship among families of ...children with advanced cancer care.
Unmet social needs are independently associated with severe parental distress in upfront childhood cancer treatment. We demonstrate the feasibility of systematic social needs screening in advanced cancer as an essential first step to identifying and addressing similar disparities. In this single center cohort, over half of participants have unmet needs.
Parent caregivers living in poverty experience more distress during their child's cancer treatment compared to parents without poverty exposure. Our prior research demonstrates that household material hardship (HMH) – a modifiable measure of poverty including housing, food, transportation, and utility insecurities – is independently associated with severe psychologic distress among parents of children with newly diagnosed acute leukemia. The feasibility of systematic social needs screening to identify and address similar disparities in pediatric advanced cancer has not been established.
Our primary aim was to demonstrate the feasibility of systematic social needs screening in pediatric advanced cancer. We hypothesized that systematic screening would be feasible as defined as >/= 75% consent rate and >/= 75% complete household material hardship data.
Parents of children (< 18 years) with advanced cancer (defined as poor prognosis, new relapse/progression, early phase trial enrollment, or new palliative care consult) receiving care at a large pediatric cancer center were approached for participation following permission from the primary palliative care and/or oncology teams. Enrolled participants completed a two-timepoint social needs evaluation at enrollment and 12-weeks from initial survey completion. Surveys were completed electronically and are available in English and Spanish (and other languages with an interpreter). Feasibility was defined as >75% consent rate and >75% complete HMH data. Study opened to accrual in January 2023 and is ongoing.
From January through September 2023, N=37 potentially eligible participants were identified; primary teams declined approach for 5 participants. Among 32 eligible participants, 28 consented to participation (88%) and 27 have completed initial surveys (96%) with no missing HMH data. Participants include 22 mothers (81%). Self-reported racial/ethnic identities include 6 Asian participants (22%), 3 Black/African American participants (11%), and 5 Hispanic participants (19%). Over half of participants (N=14) report HMH. All eligible participants completed 12-week follow-up (N=9); 4 participants were ineligible due to their child's death.
Systematic social needs screening is feasible in pediatric advanced cancer. Over half of families in this cohort report unmet basic resource needs compared to 1 in 3 families at childhood cancer diagnosis.
Unmet social needs are highly prevalent in families of children with advanced cancer. Interventions to address social needs are urgently needed in pediatric advanced cancer.
Pediatrics/Under served, under resourced populations
Abstract
Adult survivors of pediatric central nervous system (CNS) tumors are at the highest risk for morbidity and late mortality among all childhood cancers, partially due to chronic health ...conditions intersected with environmental and lifestyle factors. We aimed to study the prevalence of and risk factors for malnourishment (underweight, overweight, obese) amongst adult survivors of pediatric CNS tumors. We conducted a cross-sectional study assessing young adults (18-39 years) previously treated for pediatric CNS tumors who were followed in our survivorship clinic during 2016-2021. Sociodemographic, clinical, and treatment information was extracted from medical records with BMI status, per CDC guidelines, obtained from the most recent clinic visit. Data was assessed using one-way ANOVA, fishers exact test, and multivariable logistical regression. We identified 198 survivors (53% female, 84.3% white) categorized as underweight (4.0%), normal weight (40.9%), overweight (26.8%), obese (20.2%), and severely obese (8.1%). Patients were median age 8 years 4-12 at diagnosis and 24 years 20-28 at follow-up. Most common primary diagnosis and tumor location was low grade glioma (50.5%) and posterior fossa (39.4%) with 90.4% receiving surgery, 51.5% chemotherapy, and 52.5% radiotherapy. Male sex (OR 2.376, p = 0.006), hypothalamic/optic pathway tumor location (OR 2.362, P = 0.031), and radiation therapy (OR 2.844, p = 0.005) were associated with increased overweight/obesity risk, while chemotherapy (OR 0.363, p = 0.006) was associated with decreased risk. Male sex (OR 0.511, p = 0.007) and white ‘race’ (OR 0.166, p = 0.022) were associated with decreased underweight risk. The majority of young adult survivors seen in our clinic were not healthy weight by BMI, and the distribution of BMI groups appears comparable to contemporary studies of the general young adult U.S. population. The prevalence of malnourishment amongst PNO survivors warrants universal screening efforts with more accurate determinants of body composition than BMI, risk stratification, as well as targeted interventions.
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