Pediatric radiotherapy preparation: a scoping review

Introduction

Radiotherapy (RT) is a vital component of comprehensive cancer treatment, including for pediatric patients (1-4). A large-scale study discovered that about 33% paediatric cancer patients require radiotherapy, indicating the potential impact and significance of preparatory RT service (5). However, delivering RT to children presents unique challenges. Young children often find it difficult to remain still and alone during the numerous treatment sessions required—typically 25 to 30 fractions (6,7)—due to the unfamiliar and often intimidating environment of the RT vault and imaging suites.

To ensure patient compliance and immobilization, healthcare teams frequently utilize general anesthesia (GA) or sedation (8-10). Yet these approaches carry significant risks, including airway obstruction, apnea, and desaturation, particularly for children under 6 years of age (11). Mitigating such complications requires extensive emergency preparation, continuous monitoring, qualified anesthesia staff, and extensive clinical follow-up (1)—all of which strain healthcare resources.

To address these concerns and reduce reliance on GA and sedation, a holistic approach is needed that combines physical and psychological preparation of patients, along with comprehensive patient education (12-14). Strategies may include creating child-friendly environments, using age-appropriate distractions, integrating child life specialists, and developing customized immobilization devices.

This scoping review is crucial for identifying the key challenges and evaluating existing supportive strategies in the preparation of pediatric cancer patients for RT. By comparing service delivery models and pinpointing critical gaps, this review will provide essential insights that can drive the development of more effective, personalized support tools for pediatric cancer management. The findings from this review have the potential to not only improve the outcomes for children undergoing RT but also to be applied across other pediatric healthcare domains, ultimately enhancing the quality of care for this vulnerable population. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-24-95/rc).

Methods

This study adopted a scoping review approach following the Preferred Reporting Items for Systematic reviews and Meta-Analyzes (PRISMA) guidelines (Figure 1). The review process encompassed identifying relevant literature through a comprehensive search strategy, screening articles based on predefined inclusion and exclusion criteria, and extracting key data from the included studies.

Figure 1 PRISMA flow diagram. RT, radiotherapy.

A comprehensive search strategy was employed to identify relevant studies for this scoping review. Systematic searches were conducted across electronic databases, including PubMed, Embase, Scopus, and Science Direct, covering literature published between 2000 and 2023. Search terms were meticulously selected and combined to ensure a thorough and comprehensive search. The following key words were used in the search string in the field of title or abstract: paediatric/pediatric, RT/radiation therapy, anaesthesia/anesthesia, and sedation/sedative. Detailed search strings are shown in Table 1. The search strategy was customized for each database, employing Boolean operators (AND, OR) and wildcard symbols as needed. It was iteratively refined through pilot testing and team discussions to ensure the optimal retrieval of relevant articles. The screening process was conducted in two stages: title/abstract screening followed by full-text screening. Inclusion and exclusion criteria were rigorously applied to identify articles that aligned with the objectives of this scoping review. The inclusion criteria were:

• Studies focusing on pediatric patients undergoing RT.
• Articles discussing preparatory measures aimed at enhancing patient compliance, anxiety control, and psychological well-being.
• Full-text article is available.
• Studies published in English between January 2000 and 2023.

The inclusion criteria were intentionally limited to full-text articles published in English to ensure a comprehensive understanding and accurate interpretation of the findings. Abstract-only submissions were excluded to prioritize studies with complete data and methodological details, which are essential for conducting a thorough and reliable scoping review.

The exclusion criteria applied during screening were as follows:

• Studies not directly related to pediatric patients or their preparatory measures in radiation therapy.
• Articles unrelated to pediatric cancers or those unavailable as full-text in English, or inaccessible through institutional subscriptions.

An initial search yielded 1,020 records based on the predefined search strings, as shown in the PRISMA flow chart in the Figure 1. The research team screened the titles and abstracts of the retrieved articles to determine their eligibility for full-text review. Any discrepancies were resolved through consensus via discussion or consultation with a third reviewer. Full texts of the selected articles were then obtained and assessed for final inclusion. Non-English full-text articles were excluded.

A standardized data extraction form was developed to systematically capture relevant information from the included studies. This form encompassed the following key elements:

• Demographics: age range, gender, disease, staging.
• Stakeholders: patients, carers, healthcare professionals, child life specialists.
• Preparatory measures: service support conducted before or during treatment, techniques, or strategies employed.
• Outcomes: patient compliance, anxiety control, psychological well-being, GA or sedation adoption.

The research team conducted the data extraction process, resolving any discrepancies or uncertainties through discussion and consensus. The data extraction form is available as supplementary information in Figure S1.

Results

The scoping review yielded a total of 73 publications from both developed and developing countries. Several key findings related to pediatric cancer care and treatment preparation services were identified. The following sections provide an overview of the current challenges, rates/risks of GA complications, psychological distress from patients and carers, and a comparison and categorization of current services.

Current challenges in pediatric cancer care

The reviewed literature highlighted several challenges faced by pediatric cancer patients and their carers throughout the treatment journey. These challenges included the anxiety and distress associated with the unknowns of RT, as well as the emotional and psychological impact of the diagnosis on both the patients and their carers. Financial burdens and resource limitations were also identified as challenges, particularly in developing countries.

Rates and risks of GA complications

GA or sedation is commonly used to ensure accurate and precise RT in pediatric cancer care. However, the literature reveals varying rates and associated risks of GA complications, which differ across countries and healthcare settings. These complications are primarily related to neurocognitive and brain development, with additional impacts on respiratory function, cardiovascular health, and risks such as nausea, vomiting, and airway obstruction. It is important to acknowledge that both cranial RT and anesthetic agents can contribute to neurocognitive effects, which may act as confounding factors in assessing outcomes. A detailed summary of these complications is provided in Table 2.

Psychological distress from patients and carers

The psychological distress experienced by pediatric cancer patients and their carers was a common theme in the reviewed literature. The emotional impact of the diagnosis, treatment-related fears and anxieties, and the disruption of normal life were reported as significant sources of distress. For the children, typical anxieties included fear of being alone in the treatment vault, fear of the immobilization device, and the RT procedure. For parents or carers, anxieties stemmed from being separated from their children during RT, unfamiliarity with the RT procedure, anxiety about GA adoption, and the financial burden of hospital treatment. The psychological distress reported by patients and carers is provided in Table 3.

Comparison of treatment preparation services

The scoping review identified a range of treatment preparation services employed in pediatric cancer care. These services encompassed various strategies, including pre-treatment visits, involvement of child life specialists, virtual reality (VR) simulation, mask making, play therapy, and non-medication distraction techniques. The different services implemented in the reviewed studies is presented in Table 4.

To assess the variations and similarities in the provision of treatment preparation services, a comparison and categorization of the identified services were conducted. The services were categorized based on their approach, such as psychological support, educational preparation, and procedural support.

Several identified treatment preparation services share common goals of reducing anxiety, improving patient cooperation, and minimizing the need for GA or sedation during RT. However, they differ in their approaches and implementation.

Pre-treatment visits and VR simulations are both designed to familiarize children with the RT environment. Pre-treatment visits provide children with the opportunity to explore the treatment area and understand the procedures in a controlled, non-threatening manner. In contrast, VR simulations deliver an immersive, technology-driven experience tailored to each child’s needs, offering a virtual walkthrough of the RT process to help them visualize what to expect. Both methods have demonstrated effectiveness in reducing anxiety and enhancing cooperation, but VR simulations stand out for their engaging and interactive nature.

Play therapy and non-medication distraction techniques, such as iPads or audio-visual systems, aim to engage children and redirect their attention during RT. While both approaches are effective in reducing distress and promoting compliance, play therapy offers a personalized, therapeutic experience, whereas distraction techniques provide a simpler, more readily accessible solution.

The involvement of child life specialists and mask-making sessions focuses on psychological support to make the treatment process less intimidating. Child life specialists offer continuous support throughout the treatment journey, addressing anxiety and fostering resilience. Mask-making sessions, on the other hand, are single-session activities designed to help children feel more involved and comfortable by personalizing their immobilization devices. Both strategies aim to reduce anxiety and enhance patient cooperation, each contributing uniquely to the child’s overall experience.

Discussion

This scoping review examined the existing literature on interventions targeting psychological distress in pediatric cancer patients and their carers during RT. The findings revealed a diverse range of strategies and services implemented to address the unique challenges faced by this population.

Preparatory interventions

Preparatory interventions emerged as a key strategy for reducing anxiety and improving the treatment experience for pediatric patients. Studies emphasized the importance of both educational and psychological interventions prior to treatment initiation. Scott et al. implemented an educational program designed to familiarize children with the treatment environment and procedures through interactive tours and child-friendly materials (23,37). This program integrates the expertise of child life specialists, educational videos, and hands-on activities, effectively addressing the service gap in pediatric RT preparation.

In contrast, Klosky et al. focused on psychological strategies, including cognitive-behavioral therapy and relaxation techniques, to alleviate fear and improve understanding. These approaches are tailored to the individual psychological needs of the children, targeting pre-treatment anxiety through personalized sessions with psychologists and trained therapists (36,38). The active involvement of parents in these sessions has been a critical component, fostering a supportive and collaborative environment.

Tailored psychoeducational programs were also effective in providing coping strategies and crucial information to children and their families, reinforcing the value of preparation before RT (35,39).

Creative arts and technological interventions

Creative arts therapy was identified as a valuable tool in mitigating psychological distress. Filin et al. demonstrated the effectiveness of guided play processes led by creative arts therapists, which empowered children and minimized trauma during RT (35). Similarly, technological interventions, including audio-visual systems and video-based distraction techniques, were shown to engage pediatric patients effectively. For example, Willis and Barry utilized audio-visual systems that allowed children to watch videos or listen to carers during treatment (40), while Holt et al. explored the use of VR and video-based distraction devices like Oculus Go and iPads to reduce anxiety (47).

Role of child life specialists

Certified child life specialists played a crucial role in supporting pediatric patients and their parents throughout the treatment process. Studies by Scott et al. and Ntoukas et al. highlighted the importance of these specialists in providing interactive activities, medical play sessions, and individualized approaches such as music therapy and guided imagery (19,23). These interventions helped establish rapport, alleviate anxiety, and enhance coping skills, underscoring the need for specialized psychosocial support in pediatric RT.

Service gaps in pediatric RT

Despite the variety of interventions available, several service gaps were identified that hinder the provision of comprehensive care. A significant gap is the lack of multidisciplinary collaboration among key stakeholders, including anesthesiologists, radiation oncologists, pediatric oncologists, psychologists, and radiation therapists (28,29,44,52). Effective communication and teamwork among these professionals are essential for cohesive and coordinated care.

Another gap is the limited integration of non-pharmacological interventions, such as VR, music therapy, and mindfulness-based approaches, within the RT suite for pediatric patients. These techniques have shown promise in other medical settings but remain underutilized in pediatric RT (53). Additionally, the scarcity of dedicated pediatric RT facilities, particularly those capable of providing treatment without sedation, poses challenges to collaborative efforts and contributes to elevated patient dropout rates (54-57).

The review also highlighted the insufficiency of psychosocial support services. While a multidisciplinary approach is necessary to address the emotional, psychological, social, financial, and educational aspects of pediatric RT, the availability of psychosocial clinicians, such as child life specialists and psychologists, remains limited (28,35). This scarcity is compounded by a tendency to prioritize adult patients over pediatric patients in resource allocation, leading to a lack of appropriate support tailored specifically to the needs of children (47).

Finally, challenges in effectively communicating late effects and surveillance guidelines from pediatric oncologists to patients and their families have been identified as a significant issue. These gaps can hinder patients’ and families’ understanding of long-term care needs, complicating the transition from pediatric to adult healthcare providers. This challenge highlights the critical importance of clear, comprehensive communication from oncologists to ensure continuity of care and to empower patients and families with the knowledge needed for effective long-term health management. Addressing these communication barriers is essential to improving the quality of care for pediatric patients undergoing RT and ensuring a smoother transition to adult healthcare services.

Technological innovations in pediatric RT preparation

The integration of advanced technology, such as the Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) system, offers significant potential for enhancing the preparation process. By creating immersive and interactive environments, technology-based systems like AVATAR can alleviate anxiety and fear in children undergoing RT. These systems allow for personalized and interactive experiences, which can divert children’s attention from the treatment setting and reduce distress.

A collaborative approach involving child life specialists, radiation therapists, and the treatment team is fundamental to the successful integration of the AVATAR system. This teamwork ensures that the preparation process is comprehensive, consistent, and tailored to each child’s developmental stage and individual preferences. By familiarizing children with the RT environment, equipment, and procedures through VR simulations and interactive engagement, the AVATAR system can help reduce anxiety and promote a positive treatment experience.

Promising outcomes and future directions

Several preparatory strategies are well-supported in the literature and demonstrate significant potential for improving pediatric RT outcomes. Virtual reality (VR) simulations have been shown to substantially reduce the need for GA by creating immersive and engaging environments that help children understand and acclimate to the treatment process (58,59). Similarly, play therapy employs structured, child-focused sessions to familiarize children with medical procedures, effectively reducing anxiety and fostering cooperation (28,52).

Distraction techniques, such as audio-visual systems and interactive devices like iPads, have also proven effective in redirecting children’s attention during RT, leading to improved compliance and decreased distress. These strategies not only address the psychological needs of pediatric patients but also enhance the overall treatment experience by reducing dependence on GA and sedation. By integrating detailed evidence and descriptions of these methods, the manuscript aims to present a more comprehensive and robust discussion of effective preparation approaches in pediatric RT.

In Hong Kong, an educational workshop utilizing semi-immersive VR technology has shown promising results in preparing pediatric cancer patients for RT. Led by the undergraduate students of the radiation therapy programme and supervised by academic staff, these workshops use gamified environments to engage patients and caregivers, with positive feedback indicating reduced need for GA.

The gamified workshop takes place within a Hybrid Immersive Virtual Environment (HiVE), which provides a highly realistic treatment setting without requiring VR goggles. This innovative approach enables children to engage with a lifelike environment in a way that feels natural and interactive. The workshop begins with personalized ice-breaking games, designed to help children build rapport with the RT team and alleviate initial anxiety.

As the session progresses, engaging activities capture the children’s interest and subtly introduce key treatment concepts. This leads into an educational segment where children learn the importance of staying still during treatment, with storytelling elements making the process both relatable and enjoyable. The workshop culminates in a realistic treatment rehearsal, seamlessly integrated into the narrative, where children practice cooperation and familiarize themselves with the treatment process in a safe and supportive environment.

By combining immersive technology and gamification, this approach effectively reduces anxiety and minimizes the need for GA by helping children feel comfortable and prepared for their treatment (58).

These findings suggest that VR-based educational strategies hold potential for minimizing the requirement for sedation among pediatric cancer patients (58,59).

Further research and implementation studies are necessary to evaluate the effectiveness, feasibility, and acceptance of these innovative approaches in clinical practice. The integration of advanced technology, psychosocial support, and multidisciplinary collaboration offers a comprehensive and patient-centered approach to pediatric RT preparation, which could significantly improve the treatment experience for children and their families.

Conclusions

This scoping review highlights the challenges faced by pediatric cancer patients and their carers during RT, assesses existing support strategies, compares service models, and identifies critical service gaps. The findings emphasize the importance of preparatory interventions in reducing anxiety and the need for GA. While significant progress has been made, there remains a clear need for further research, improved multidisciplinary collaboration, and the integration of innovative technologies to enhance the care and experience of pediatric patients undergoing RT.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://cco.amegroups.com/article/view/10.21037/cco-24-95/rc

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-24-95/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-24-95/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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