Effects of Cancer Treatment on the Comfort of Children and Adolescents with Cancer: A Scoping Review

Objectives: To map and examine the scientific evidence concerning the effects of cancer treatment on the comfort of children and adolescents with cancer. Materials and Methods: This scoping review was carried out in the following electronic information resources: BVS, PubMed, Cinahl, SciVerse Scopus, Lilacs, Web of Science, and Google Scholar. Two independent reviewers analyzed the studies’ relevance. Results: The search yielded 4,295 publications, of which 20 comprised the final sample. Following evidence mapping, the effects (20; 100 %) on comfort were found, and the most prevalent were pain (12; 60 %), fear (9; 45 %), nausea (5; 25 %), difficulty eating (4; 20 %), and distress (4; 20 %). Regarding the oncologic treatment modality, antineoplastic therapy prevailed in 11 (55 %) of the selected articles. Conclusions: Cancer treatment affects the comfort of children and adolescents with cancer, causing suffering and changing their well-being. It indicates the need to evaluate its impact and take nursing care measures to reduce complications and improve these patients’ adaptation to treatment.


Introduction
"Comfort" is defined as a living being's immediate experience augmented by the need for relief, calm, and transcendence in the four contexts of experience, namely, physical, psychospiritual, sociocultural, and environmental. Furthermore, it is in line with the holistic theory, where human beings have global responses to complex stimuli, and the physical body relates to mind, spirit, emotion, environment, and society (1,2).
Studies indicate that healthcare professionals' knowledge of comfort is essential when monitoring children and adolescents undergoing cancer treatment (3). Its evaluation provides resources for managing these patients during treatment, aiming to improve their comfort and quality of life (4,5).
"Childhood and adolescence cancer" corresponds to a group of diseases that have in common the uncontrolled proliferation of abnormal cells, anywhere in the body, among children and adolescents, in the age group from 0 to 19 years (6,7). The most frequent types of cancer in childhood and adolescence are leukemia, followed by central nervous system tumors, and lymphomas. It is estimated that in Brazil, for each year from 2020 to 2022, approximately 8460 new cases of childhood and adolescence cancer will occur (4310 in males and 4150 in females) (7). Worldwide, it is estimated that approximately 400,000 new cases per year will be diagnosed among children and adolescents aged 0 to 19 years (8).
In addition, childhood and adolescence cancer causes harmful physiological changes to the body, which leads to difficulties in physical activities, functional performance, and social interaction. Even when treated successfully, it may have unfavorable physical and psychological consequences for the development of children and adolescents according to their age (9,10). Surgery, chemotherapy, and radiotherapy, which are frequent modalities in oncologic therapy for children and adolescents (6,(11)(12)(13), besides their expected benefits for the management and potential cure of the disease, may lead to adverse effects, such as clinical, functional, and labor changes in biopsychosocial aspects. These effects may result in difficulty sleeping and eating, nausea, pain, diarrhea, preoccupation, and sadness (10,14). These changes trigger distress and can escalate to impact comfort and lead to negative outcomes in the adaptation of children and adolescents to oncologic treatment (3).
Additionally, the evaluation of comfort provides healthcare professionals with more effective assistance by prioritizing health activities in patient care and improving the provision of individualized and comprehensivve care within the clinical process (15). Therefore, in the face of the effects that the oncologic treatment can have on the comfort of children and adolescents with cancer, the search for knowl-edge of this fact becomes relevant in the hope of developing strategies to promote the comfort of this population during therapy (3)(4)(5).
Thus, the following research question emerged: What is the scientific evidence available regarding the effects of cancer treatment on the comfort of children and adolescents with cancer? Therefore, this study aimed to map and examine the scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer.

Materials and Methods
This scoping review revolves around the effects of cancer treatment on the comfort of children and adolescents with cancer. For this study, a protocol was created and registered in the Open Science Framework (OSF) under the code OSF.IO/DWY9F. The OSF is an online tool that promotes workflow for researchers, promoting improvements in replicability, transparency, and research data management practices (16).
The methodological reference used was the Joanna Briggs Institute (JBI) to map the evidence that supports a certain research area. In other words it enables the possibility of describing, summarizing, and synthesizing knowledge based on the systematic selection and condensation of the health literature, in addition to identifying gaps in existing research (17). To identify scoping reviews with an objective similar to this study's, a search was carried out in the following databases: JBI Clinical Online Network of Evidence for Care and Therapeutics (COnNECT+), Database of Abstracts of Reviews of Effects (Dare), and The Cochrane Library. The results indicated that no scoping reviews on the subject existed. This report has been revised according to the Preferred Reporting Items for Systematic Reviews-Extension for Scoping Reviews (PRISMA-ScR) checklist and operationalized in six phases, namely: 1. Research question development; 2. Inclusion and exclusion criteria definition; 3. Keyword identification and Article search strategy design; 4. Database selection; 5. A screening and selection; 6. Article mapping and result synthesis (18,19).
The PCC strategy, a mnemonic acronym that helps identify the key topics, where "P" stands for population, "C" for concept, and "C" for context, was used to develop the review question (17). In this study, the following definitions were used: P -children and adolescents with cancer; C -comfort; C -cancer treatment. For the study search and selection, the following question was established: What is the scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer?
Regarding the article inclusion criteria, abstracts and objectives should correspond to the proposed subject-the effects of cancer | AÑO 22 -VOL. 22 Nº 4 -CHÍA, COLOMBIA -OCTUBRE-DICIEMBRE 2022 | e2244 8 treatment on the comfort of children and adolescents with cancer-, national and international studies, with qualitative, quantitative, and mixed methods approaches.
The exclusion criteria were literature review articles for being secondary studies, studies that included young adults in the sample, and articles that described the opinion of healthcare professionals, that is, children and adolescents were not included. No time cut was applied to the research to provide the largest number of studies on the subject.
The search strategy was developed using the Boolean operators "AND" and "OR", as follows: (criança OR adolescente) AND (conforto do paciente OR bem-estar da criança OR bem-estar do adolescente) AND (neoplasias OR oncologia OR câncer OR tumor); (child OR adolescent) AND (patient comfort OR child welfare OR adolescent welfare) AND (neoplasms OR medical oncology OR cancer OR tumor).
The literature research was conducted in the following electronic information resources: Virtual Health Library (VHL); National Institutes of Health's National Library of Medicine (PubMed); Cumulative Index to Nursing & Allied Health Literature (Cinahl); SciVerse Scopus; Latin American and Caribbean Literature on Health Sciences (Lilacs); Web of Science; Google Scholar, and references in the gray literature, available at greylit.org. This a website provides a list of recognized sources for this type of search and reference lists of selected relevant studies. The JBI recommends searching all reference lists of selected studies to identify any potential additional studies not mapped in the strategy used (17).
The searches were performed from September to October 2021, by two reviewers in a paired and independent process. The search results of both were compared in the electronic information resources, verifying the differences among the findings to encompass the largest number of information relevant to the subject. To verify if there were subsequent publications in the chronological period, a new search was performed in January 2022. After checking the studies and analyzing the results, the reviewers reached a consensus and listed the studies that comprised the final sample of this review. It was not necessary to request additional information or data from the authors of the selected studies.
The screening and selection process of evidence sources used was based on PRISMA-ScR (18), considering the four proposed steps namely: Identification, screening, eligibility, and inclusion, which aim to contribute to the quality of results in the generation of knowledge. The selected articles were read in full, identifying more precisely their relevance to the research, which resulted in the final number of texts included in the review.
The final extraction and delimitation steps of key information from the evidence were followed based on numerical descriptive analysis to categorize the studies and the selected evidence for thematic analysis. The aim was to summarize the information and align it to the study objective and guiding question.
The data from the selected articles were extracted with a tool developed by the researchers according to the JBI guidelines (17,19), which included authors, year of publication, study country, language, design, participants, treatment and the effects of cancer treatment on the comfort of children and adolescents with cancer. The studies were grouped and the synthesized data were discussed with the literature.
All ethical and scientific requirements for the research were respected based on legal regulations. We ensured methodological rigor in the data treatment and presentation and faithfulness of the information contained in the original documents that supported the results.

Results
The search resulted in 4295 articles selected, of which 52 were discarded for being duplicates in the information resources, and 4243 articles remained for title and abstract reading. In this new step, 4125 articles were excluded, which resulted in a total of 118 articles for selection regarding the inclusion and exclusion criteria. Of these, 32 articles were selected for reading in full, excluding 12 for not specifying the effects of cancer treatment on the comfort of children and adolescents with cancer. Thus, in the final sample, 20 articles were obtained to map evidence according to this study's objective, as shown in Figure 1.

Discussion
The objective of this scoping review was to map and examine the scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer. For this purpose, 20 primary studies published in various national and international settings were selected through informational resources, which indicates that nurses need to analyze the evidence presented. Moreover, it is important to relate them to the impact of changes on the comfort of children and adolescents with cancer undergoing treatment to obtain input for treatment strategies to manage the manifestations in the aforementioned population and improve the adaptation of patients throughout the cancer treatment.
Of all the articles, 12 (60 %) reported pain as the most prevalent effect of cancer treatment in children and adolescents with cancer (23-26, 28, 29, 31-34, 36, 37). These frequencies can be compared with the results of a study in Lebanon (38), in which pain was the most frequent and debilitating symptom. Thus, this symptom may lead to changes in the well-being of this population and in their adaptation to treatment.
Likewise, other evidence reports that the pain experienced by children and adolescents with cancer causes an unpleasant sensation, of a multi-factor origin, which is difficult to manage, and may lead to physical and emotional changes (11,12,39). Thus, the management of pain represents a challenge for professionals who work in the area, especially in its identification and management prior to the cancer treatment to which this population is submitted (13)(14)(15)39).
In addition to pain, in nine (45 %) mapped studies, fear had a significant frequency in the effects of cancer treatment on the comfort of children and adolescents (3,4,24,25,28,30,33,34,37). Fear means, for this population, the daily overload of negative feelings and emotions, uncertainties, and insecurity of being in an unknown world, where suffering emerges in their lives unexpectedly and with no prospect of coming to an end (5,14).
It is highlighted that the findings related to fear coincide with those of a review study, which investigated the change in the comfort of children and adolescents in critical conditions (15). The authors stated that intensive treatment in the hospital environment, the absence of close family members, and invasive procedures trigger the feeling of fear in these patients (15).
Another effect of cancer treatment that prevailed in the selected and mapped articles was nausea, which reached a citation frequency in five (25 %) of the studies (23,26,27,35,37). Nausea is one of the signs and symptoms that cause increased discomfort to patients in cancer treatment, specifically secondary to gastrointestinal toxicities stemming from antineoplastic therapy. They can affect the nu-tritional status, hydro-electrolyte balance, well-being, and quality of life of children and adolescents with cancer (40).
These findings corroborate the results of a symptom management study conducted with family caregivers of children and adolescents with cancer undergoing antineoplastic treatment (41). The authors stated that nausea was one of the most prevalent symptoms in the pediatric population, leading to changes in eating patterns, inappetence, and weight loss (41).
In addition, difficulty eating was present in four (20 %) of the studies (4,22,27,37). In this context, difficulty eating is understood as any problem that negatively affects the process of healthcare professionals, parents, or caregivers to supply food or nutrients to their children or patients (42).
Children and adolescents are used to a particular type of food at home, which regards their wishes and desires, unlike what happens in the hospital environment. The supply of inappropriate food by the family and the hospital rules regarding meals are the main difficulties, often becoming a limiting factor for accepting adequate meals (43).
Therefore, these findings corroborate a study conducted on the evaluation of the perception of parents of children diagnosed with cancer regarding the food provided in the hospital environment (44). The authors demonstrated that 76.5 % of children did not like the food taste, and 52.9 % did not like the appearance of the food plating. It has been demonstrated that an unbalanced diet can cause discomfort to patients and increase the risk of malnutrition (44).
In addition to the difficulty eating, another effect on treatment that prevailed in the selected and mapped articles was distress, which had a citation frequency in four (20 %) of the studies (25,29,34,36). Distress is triggered because children and adolescents with cancer often experience a severe and uncertain process of illness, which represents the unknown, especially because of the treatment and separation from their parents and siblings when hospitalization is necessary (25,45).
Thus, these findings are consistent with a pilot intervention study conducted in Brazil with children and adolescents with type 1 diabetes mellitus, which used a therapy toy versus standard guidelines for administering insulin (46). The authors identified that decreased parental involvement with children and adolescents in diabetes management may cause psychosocial issues such as depression symptoms and distress (46).
Evidence is consistent with a retrospective study that analyzed the clinical and epidemiological profile of children and adolescents with cancer (51). From the 146 medical records analyzed, 65 (45 %) of the patients were specifically on cancer treatment. Thus, the authors stated that antineoplastic therapy was the most prevalent therapy in this study, compared with other treatment modalities for this population, such as radiotherapy, surgery, and hematopoietic stem cell transplantation (51).
Finally, this research has as a limitation the search in seven electronic informational resources with the selected descriptors and keywords. They may not have expanded the number of eligible studies for this research, even though the terms selected cover the universe of the effects of cancer treatment on the comfort of children and adolescents with cancer.
Therefore, this review highlights the need for studies that develop indicators of the effects of cancer treatment on this population to operationalize the evaluation of the effectiveness of care provided in clinical practice. Enabling adaptation and coping by children and adolescents with cancer undergoing treatment, based on the involvement of these patients' healthcare professionals, family members, and close friends will provide them with well-being.

Conclusions
This study's findings provided scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer. Pain, fear, nausea, difficulty eating, and distress were prevalent. These effects lead to suffering, low adherence to cancer treatment, and worsened quality of life in this population. Regarding the treatment, it was found that the one with the highest prevalence among the analyzed studies was antineoplastic therapy.
For this reason, the results presented in this study may raise nurses, awareness of the effects on the comfort of children and adolescents with cancer during cancer treatment, as they are vulnerable in the care settings. Therefore, comfort is an aspect that should be routinely evaluated in clinical practice to promote the well-being of children and adolescents with cancer.

Conflicts of interest:
None declared.