Over the past 5 decades, pediatric cancer outcomes have significantly improved, with diseases such as acute lymphoblastic leukemia (ALL) seeing survival rates soar from approximately 59% in 1975 to around 90% in 2020. This progress is largely due to advancements in treatment protocols and supportive care, including the revolutionary impact of immunotherapy on aggressive leukemias and lymphomas. Despite these strides, certain pediatric cancers, such as brain tumors and bone sarcomas, have not experienced similar improvements, prompting a dual research focus: reducing long-term treatment complications for high-survival cancers and exploring new therapeutic avenues for those with stagnant outcomes.1
Given these complexities, the role of the more than 500,000 pediatric oncology nurses in the United States is crucial.2 Their expertise in evidence-based practice (EBP) is essential for integrating the latest research into clinical care, ensuring optimal patient outcomes, and advancing the field. This process involves 7 steps: formulating a clear clinical question; searching for the best available evidence; critically evaluating the evidence for validity and relevance; integrating the evidence with clinical expertise and patient preferences to make a practice decision; evaluating the outcomes of the decision; sharing the results with others; and ensuring the practice change is maintained over time.3 Studies suggest that EBP, fostered by a caring and supportive health system, enhances clinical decision-making and yields positive patient outcomes.4
However, pediatric malignancies only comprise 1% of all cancers.5 Paradoxically, the research-to-clinical practice gap in pediatric oncology is significantly shorter than for adults (5 to 24 months vs about 17 years).5,6 This accelerated pace is largely due to the collaborative efforts of cooperative group trials, such as those led by the National Cancer Institute–sponsored Children’s Oncology Group (COG) , which facilitate rapid dissemination and implementation of new treatments. For pediatric oncology nurses, this means they must continuously adapt to new therapies and protocols at a much faster rate than nurses caring for adults with cancer, requiring ongoing education and training to stay current with the latest advancements. This rapid translation can be both a boon and a challenge, as it allows for quicker integration of cutting-edge therapies but also demands a high level of agility and commitment to lifelong learning to ensure consistent and high-quality patient care.
This is hard to accomplish when the body of high-quality pediatric oncology evidence skews toward more frequent pediatric cancers such as ALL, rhabdomyosarcoma, and neuroblastoma, and there are simply no standardized treatment guidelines for very rare pediatric malignancies.5
Similarly, there is a paucity of personalized, evidence-based interventions that incorporate patient-reported outcomes, standardized educational programs, and multidisciplinary collaboration to ensure holistic, family-centered care.7
Even if personalized, pediatric oncology EBP protocols were abundant, their effective implementation hinges on nurses’ ability to engage with research, critically appraise evidence, and translate findings into practice. This remains an aspirational quest, as these nurses may be focused on managing a multidisciplinary team and navigating the tough emotional terrain that comes with family-centered care.
In addition to dealing with complex emotions like anxiety, compassion fatigue, and grief over unexpected losses, nurses also face heavy workloads and may find it challenging to communicate with the child and family when drafting a care plan together.8
Despite these challenges, there remains a critical need for a road map on how technology-enabled, EBP implementation could flourish across different health settings. This article aims to provide an EBP overview, empowering pediatric oncology nurses to deliver high-quality, evidence-based care, and ultimately improving outcomes for their patients during and after treatment.
In addressing how the nursing profession can promote EBP competence among nurses, researchers identified key components needed for an organizational culture supportive of EBP, for example including EBP into the organization’s vision and goals, supporting clinical inquiry, providing EBP mentors, valuing and supporting EBP leadership, and recognizing EBP achievements. With this framework in mind, COG launched an EBP initiative in 2011 that aimed to create standardized tools and guidelines based on the best available research to ensure high-quality, consistent care. The project involved selecting important topics, forming expert teams, and disseminating their findings. To date, the initiative has produced 15 publications involving 90 authors, fostering professional growth among nurses and developing useful tools for patient care.9 Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) and the University of Texas MD Anderson Cancer Center have also jointly developed guidelines for the management of pediatric patients with ALL receiving CAR T-cell therapy.10
Researchers have explored targeting a variety of tumors and surface molecules with this genetically engineered technology. However, the most thoroughly investigated application in pediatric patients involves CAR T cells directed at CD19, a surface receptor on B cells. Numerous research groups have documented substantial remission rates (70%-90%) in both children and adults with refractory B-cell ALL. Some studies have shown that CAR T cells can persist and maintain remission for over 6 months in most patients. Nonetheless, early loss of CAR T cells has been linked to relapse, and the optimal use of this therapy—whether as a bridge to transplant or as definitive treatment—is a subject of ongoing study.11
Nurses have played an important role in the application of CAR T-cell therapy in practice. From the perspective of a hematology/oncology nurse, the management of pediatric patients treated with CAR T-cell therapy, including addressing reversible acute toxicities such as cytokine release syndrome (CRS), is not simple.12,13 However, the best available current evidence has been summarized to guide nursing staff through actions to be taken when they are assisting a pediatric patient receiving CAR T-cell treatment.12 Nurses need to watch for CRS symptoms, such as fever and low blood pressure, and provide supportive care, including fluids, oxygen, and medications like tocilizumab and corticosteroids. By doing so, they help improve the probability of positive patient outcomes.14
In addition, the contributions of pediatric oncology nurses have significantly advanced care among children and adolescents with cancer. The Association of Pediatric Hematology/Oncology Nurses and the International Society of Paediatric Oncology have played pivotal roles in establishing specialized training, global standards, and advocacy efforts. Despite this progress, there are disparities in receipt of treatment and clinical trial enrolment among groups. Black children enrolled in COG clinical trials from 2010 to 2018 involving physician-preferred treatment were less likely to receive proton radiotherapy compared with non-Hispanic White children. Although another project found no racial or ethnic disparities in clinical trial enrolment, factors such as trial complexity, travel difficulties, and language barriers were linked to lower enrolment rates.15
Engaging in EBP fosters critical thinking and lifelong learning among nurses, promoting their professional growth. It enhances the use of proven interventions, decreasing unnecessary procedures and resource utilization. EBP also increases the probability of safe and effective care, reducing complications and improving patient outcomes.16 That is why nursing education programs are increasingly incorporating EBP into their curricula, teaching students how to locate, appraise, and apply research evidence into clinical practice. This includes training in the use of the PICO(T) framework for formulating clinical questions, searching for evidence, and critically appraising research studies.
Many nursing programs now also require students to complete EBP projects where they identify a clinical program, search for the best available evidence, and develop recommendations for practice.17 While US hematology/oncology fellowships provide specialized training for nurses, there is a need for greater emphasis on survivorship and long-term care follow-up.18 Such care is contingent upon appropriate discharge, and research teams forming part of the Parent Educational Discharge Support Strategies nursing study showed enthusiasm and found the intervention easy to deliver to patients.19
The implementation of EBP by pediatric oncology nurses is a complex and multifaceted process that requires the integration of communication, education, and leadership. Although the United States has made great strides in promoting EBP, challenges remain. By addressing these challenges through enhanced communication, improved education, and strong leadership, nurses can play a pivotal role in providing high-quality, patient-centered care to pediatric patients with cancer.
Zeena Nackerdien, PhD, is a scientist and medical writer at Montefiore Medical Center’s Department of Nursing in the Bronx, NY.
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