When children speak, listening heals: advancing symptom screening in pediatric oncology

Among people with cancer, unspoken symptoms can be more profound or impactful than symptoms that are expressed openly. Children, especially, can experience a wide range of treatment-related symptoms-pain, anxiety, nausea, fatigue- that go undetected or unheard. These symptoms can change daily and profoundly impact quality of life (1-3). Yet, among children with cancer, symptom assessment is often inadequately addressed and poorly documented (4). Although evidence from proactive symptom screening among adults has improved accurate clinician documentation of patient-reported symptoms, reduced symptom burden among patients, and improved quality of life, symptom screening among pediatric populations with cancer has lagged behind, partly due to a lack of developmentally appropriate screening tools (5-9). Robust evidence supports electronic patient-reported outcomes integration in clinical practice. Studies show the positive effects of proactively treating symptoms, including reduction of symptom burden and improvement in patient activation and patient-provider communication. This results in more individualized and effective care plans through real-time reporting of symptoms that aid in treatment decisions (5,8,10). Such proactive approaches are crucial among pediatric populations, as they may not be able to verbalize how they are feeling and they may not report symptoms unless asked (2). Furthermore, there may be discrepancies in symptom severity between the patient and their parent as well as between the patient and their clinician, thereby resulting in inadequate documentation and inappropriate management (2,3,11). Implementation of electronic-based assessments, however, can be extremely challenging due to the age and developmental stages of the pediatric patient population. At the same time, it can be advantageous and serve as a way to capture the child’s unique symptom experience. This is especially true if the tool used is age-appropriate and user-friendly (2,9). Electronic-based approaches are crucial for ensuring that all patients have a voice that might otherwise go unheard and can lead to improvement in symptom management. Pediatric oncology has wrestled with the challenges of recognizing and intervening on symptoms experienced by pediatric cancer patients on active treatment (11). The randomized clinical trial by Dupuis et al. (2025a) published in the Journal of the American Medical Association Pediatrics (JAMA Pediatr) represents a pivotal shift in proactive patient-centered care and provides evidence that use of the Symptom Screening in Pediatrics tool (SSPedi) for symptom screening has positive effects on symptom burden. Use of SSPedi also showed improvement in clinician responsiveness and documentation of interventions, which led to improvement in patient outcomes and delivery of care (12). SSPedi is a validated, 15-item questionnaire designed for pediatric cancer patients aged 8–18 years and its reliability and clinical usability underscore the potential positive impact of proactive symptom management (1,13). The study findings closely align with the results from other bodies of evidence that highlight the importance and usefulness of patient-reported outcomes in managing symptoms experienced by patients with cancer (7,14,15). This may result in the adoption of standardized screening tools such as SSPedi into clinical practice, ensuring clinicians have the information they need to intervene timely and effectively.

Dupuis et al. (2025a) randomized 345 patients aged 8–18 years of age from eight Canadian centers who were actively undergoing anti-cancer treatment and expected to be hospitalized or who were scheduled for a clinic visit for at least 5 consecutive days. Patients were randomized to either a control group receiving usual care or to an intervention group consisting of completing SSPedi daily for 5 days, with symptom reports provided to the bedside nurse and clinician along with email alerts to clinicians of participants’ bothersome symptoms on days 1 and 3. The trial tested whether completion of SSPedi daily with real-time alerts to clinicians resulted in a reduction of overall symptom burden compared to usual care among hospitalized pediatric oncology patients, with the primary endpoint of SSPedi mean score on day 5. The participants rated the 15 symptoms experienced “yesterday or today” on a 5-point Likert scale with 0 meaning “not at all bothered” to 4 meaning “extremely bothered” with a total possible score across the SSPedi on day 5 ranging from 0 meaning “no bothersome symptoms” to 60 meaning “worst bothersome symptoms”. By day 5, participants who completed the SSPedi had significantly lower mean symptom scores for all 15 symptoms [adjusted mean difference −2.5; 95% confidence interval (CI), −3.8 to −1.2], with 8 of the 15 symptoms having a statistically significant reduction as compared to the control group. Secondary outcomes consisted of individual SSPedi symptom scores, quality of life, pain, documentation and symptom intervention. Documentation and intervention for 5 symptoms (pain, changes in hunger, peripheral neuropathy, constipation, and anger) were also significantly increased in the intervention group as compared to the control group. There was no significant difference between the two groups in terms of pain score using Faces Pain Scale-Revised (FPS-R) and quality of life measured using the PedsQL 3.0 Acute Cancer Module (12). These results move beyond feasibility towards efficacy, demonstrating that patient-reported outcomes using SSPedi lead to measurable improvements in symptom burden, documentation and symptom intervention. The study was specifically notable for its child-centered design, multi-site collaboration, and emphasis on use of patient-reported outcomes. By using the SSPedi to focus on the patient’s voice, the authors challenge the paradigm of standard clinician-led symptom, assessment where there is often discordance of symptom severity between patient and clinician (3). This should implore clinicians to implement interventions that incorporate patient voices in pediatric oncology rather than relying on the clinician or the parent to report symptom severity. Such an approach not only ensures that symptoms are accurately captured and reported but also that the interventions are timely. Severe symptom email alerts prompt real-world action and a call to action is what is needed among the pediatric patient population. Action to implement, action to listen, and most importantly, action to respond are crucial steps towards improving symptom management and quality of care. Dupuis et al. (2025a) extend the positive effects of electronic patient-reported outcomes into pediatric oncology and show how proactive symptom screening can be feasibly implemented with positive impacts on clinical outcomes.

This robust, randomized clinical trial was conducted across eight tertiary Canadian care centers, which increases the internal and external validity of the results. The design minimized bias, which allowed for causal inference between the intervention and outcome and ensured generalizability across healthcare settings. The use of the SSPedi is a key strength as it is a child-centered, validated scale, developmentally appropriate for patients 8–18 years of age. Its usefulness in clinical practice not only empowers the patient to express their symptoms but also empowers the clinician to respond more effectively and timely to symptoms driven by actionable alerts by integrating symptom reports directly into daily workflow, prompting real-time action by the clinicians (12). Allowing children to have a voice by self-reporting symptoms daily removes the potential misrepresentation of symptoms if reported by caregiver proxy and clinicians, as shown in other studies (3). The trial results align with those seen in adult studies showing that screening tools for patient-reported outcomes improve symptom burden and symptom documentation and intervention (5,9,14).

Some questions remain. The intervention period was only for 5 days, which raises the question of whether the intervention can be sustained long-term. What effects would this intervention have on the workload of the providers long-term and could the long-term workload ultimately impact symptom control and treatment outcomes? Children under the age of 8 years and those with cognitive or communication impairments were excluded, which leaves a gap among this broader and very important population. Allocation of participants to the intervention or usual care group was initially blinded but after enrollment into the web-based platform, some clinicians were no longer blinded to the participants completing SSPedi. This could have introduced performance bias in which clinicians’ heightened response to actionable alerts contributed to the observed effect and effect size. Long-term outcomes were not evaluated, such as survival, cost savings, and healthcare utilization, which could impact implementation. Adult trials using patient-reported outcomes to assess symptoms have shown increased survival, but data in pediatric oncology are still emerging (10,11,16,17). Although the proportion of missing day 5 patient-reported outcome responses was only 3.8%, challenges to adherence still have to be taken into consideration. Younger age and having high distress levels negatively impact the ability to complete screenings timely or at all, which highlights the need for more supportive care for these patients (6). To improve adherence, some studies have looked at how other digital tools, such as apps, wearables, and game-based apps, have transformed symptom screening tools from a task to an experience (2,9). These questions should spark further research to ensure scalability and inclusion of diverse patient populations and care settings.

Overall, Dupuis et al. (2025a) study findings add to the growing body of evidence on pediatric symptom screening and management. As the field of pediatric oncology continues to grow and as more patients are diagnosed with cancer, integration of tools such as SSPedi into clinical practice holds promise for improving cancer care for these populations.

Acknowledgments

Microsoft Copilot (version 1.25121.84.0) was used to look up articles to support sentences or evidence and also to refine certain sentences for clarity. This was done on February 15, 2026 at 10:00 am and February 16, 2026 at 8:00 am. The final interpretations and conclusions are my own. The following prompts were used to generate new text or research results: Articles to support this sentence, a different word for, or a different way to say.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Translational Pediatrics. The article has undergone external peer review.

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-aw-689/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-aw-689/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.

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