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Pediatric Supportive Care (PDQ®): Supportive care – Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Improvements in survival for all childhood cancers combined have increased between the mid-1970s and today, with overall survival approximating 83% and some children with certain diseases approaching or exceeding 90% long-term survival. Overall survival rates vary depending on cancer type, cancer stage, patient age, and other patient characteristics.[1] With these improved outcomes, the focus of research and expectations of patients, parents, and health care providers has increasingly emphasized reducing the burden of cancer and its treatment for these children during treatment, after the completion of treatment, and as adult survivors.
Cancer treatment for children differs in many ways from treatment for adults. Some of the principal differences include the following:
- Intensity. In general, treatment of childhood cancer is more intense. Because the dose-limiting toxicities of most chemotherapy and radiation treatments are generally reached at higher doses, more-intensive chemotherapy and radiation therapy are feasible for children than would be possible for adults.
- Toxicity. Some of the toxicities of treatment have a much more significant and lasting effect on children than on adults because of the active development of nearly all organ systems during childhood and adolescence.
- Supportive Care. Developmental differences extend to the types of supportive care that children may receive. Medications that represent standards of care for adult cancer supportive care may be contraindicated for children because of adverse toxicities that are associated with specific periods of childhood development.
Fundamental to these differences is the clear recognition that children are not small adults and that even the term children is not all-encompassing. Treatment and supportive care require different approaches across the spectrum from newborn through young adult age groups, and the outcomes of both cancer survivorship (control of disease) and quality of survivorship (impact of toxicities) differ with the age of a child at the time of treatment.
Equally important is the recognition that treatment of childhood cancer inevitably occurs in the context of a family. Frequently, the impact of an adult's cancer treatment focuses on one or two key adults in the cancer patient's life. In childhood cancer, the effects are often felt by more individuals, including one or both parents, one or more siblings who are themselves children or adolescents, grandparents, aunts and uncles, teachers, friends, and other individuals who may be directly involved in the care or life experience of the child. Furthermore, because children are not considered legally competent exclusively on the basis of age, most decisions about cancer treatment are made by proxy. Instead of children making decisions about their own care, their parents or guardians make these decisions for them. The large number of people involved, legal issues related to decision making about minors by others, and ethical concerns about informed consent and assent involving children add extra layers to the complexity of treatment for children.
In this pediatric supportive care summary, issues specifically related to children and adolescents will be reviewed. Evidence and recommendations may differ significantly from information provided about supportive care for adults.
Refer to the following sections of this summary for more information:
- Siblings subsection in the Families section.
- Psychological Adjustment section.
- End of Life section.
The following topics will be added to this summary:
- Growth and development.
- School issues/cognition.
Refer to the Prevalence of Late Effects in Childhood Cancer Survivors section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for pediatric-specific information about cancer survivorship.
- American Cancer Society: Cancer Facts and Figures 2019. Atlanta, Ga: American Cancer Society, 2019. Available online. Last accessed January 23, 2019.
Psychological Adjustment
Treatment of childhood cancer is a highly stressful experience, challenging and disruptive to children and their family members. It is therefore assumed that children undergoing cancer treatment are at significantly higher risk for depression, anxiety, and other indicators of psychological distress. However, the empirical evidence to support this assumption is weak. Overall, studies suggest that children treated for cancer and children who are long-term survivors of cancer experience few significant psychological adjustment problems.[1,2,3]
There is evidence that children experience distress during the cancer treatment process. Distress appears to be most significant early in therapy, typically when frequent hospitalizations are necessary, with a pattern of less distress occurring over time.[4,5] One group of 39 families of children newly diagnosed with leukemia was compared with a group of 49 families of healthy children. While parents and the children treated for cancer reported higher levels of distress immediately following diagnosis, these levels of distress decreased over 4 years of follow-up, and there were no significant differences in psychological distress compared with the healthy comparison cohort.[4] Similar findings have been reported across cultures.[6]
The validity of obtaining accurate reports of psychologic distress in this population has been questioned. One investigation of whether psychological defensiveness might mask the reporting of depression and other symptoms of psychological distress studied 107 children treated for cancer and 422 healthy controls who completed a series of measures of depression and anxiety.[7][Level of evidence: II] Children treated for cancer reported significantly fewer depressive symptoms than did healthy children, and defensive style was not related to report of depression. Another study of 205 children and 321 parents of children with either cancer, asthma, or no significant health problem also found no significant levels of depression in children treated for cancer. However, parents of children with cancer attributed more cheerful characteristics to their children than did the parents of children in the other groups.[8][Level of evidence: II]
Studies have reported no differences from controls on the following measures:
One group of investigators [10] found that teachers perceived children with cancer as more social and less aggressive, and peers rated them as less aggressive and having greater social acceptance than other peers. It may make a difference who is reporting: parents of children report more limitations in their children than the children themselves report,[11] although children do report lower satisfaction with athletic competence than do their peers.[10]
Differences in Adjustment
Diagnosis and type of treatment appear to make a difference in adjustment in specific subgroups of children with cancer.[12]
Solid tumors
Children treated for solid tumors not involving the central nervous system (CNS) appear to have minimal psychological distress, and this is maintained after treatment.[13]
Acute lymphoblastic leukemia or lymphoma
Children treated for acute lymphoblastic leukemia (ALL) or lymphoma report poorer emotional functioning, cognitive skills, autonomy, and family interaction than do children treated for non-CNS solid tumors.[13]
CNS tumors
For children whose disease or treatment directly involves the CNS, the risk of developing social and emotional problems appears much greater. Children with brain tumors are seen by their peers as being sick, fatigued, absent from school, and socially isolated and are less likely to be endorsed as friends by their peers.[14]
Stem cell transplantation
Children receiving hematopoietic stem cell transplantation (HSCT) are likely to experience declines in both social competence and self-concept over time.[15]
Ethnicity can also play a role in quality of life.[16]
Family Factors
Family factors appear to play a large role in child adjustment, with family cohesion and expressiveness associated with better outcomes and family conflict associated with poorer outcomes, particularly for children experiencing more-intensive treatment.[15] Younger (pre-school) children are more likely to experience higher levels of externalizing behavior problems (e.g., aggression, impulsivity, or disruptive behavior) during treatment than do adolescents, but overall health-related quality of life (HRQL) reported by parents is better for younger children than for adolescents.[17] Age may also serve as a mediator in the approach to coping and perceived level of control experienced by children being treated for cancer. While one group of researchers found that children with cancer reported significantly more use of avoidant coping strategies than did healthy children, regardless of age,[18] another group found that the relationship between perceived control and problem-focused or emotion-focused coping (problem-focused coping related to higher appraisals of control) was mediated by age.[19] A limited number of studies has been conducted in this area, and there are likely a number of additional mediators of adjustment-coping relationships that have not yet been examined.
Childhood Cancer Survivor Study
The Childhood Cancer Survivor Study (CCSS) is a large, ongoing, multicenter study of more than 10,000 long-term survivors of childhood cancer and a comparison sibling control population. Using extensive survey methodology that links reports of current functioning to diagnosis, types of treatment, and other health factors associated with cancer and its treatment, the CCSS has selectively looked at long-term adjustment in large samples of young adults treated for similar childhood cancers. In one CCSS report, 2,778 survivors of solid tumors diagnosed in childhood and 2,925 siblings were surveyed using a standardized long-term follow-up questionnaire. Symptoms associated with depression, somatization, and anxiety were reported, along with demographic, health, and medical information. Few, if any, symptoms of psychological distress were reported by the cancer survivors, although survivors of solid-tumor cancers reported higher levels of global distress than did their siblings. There were no differences on these measures from population norms. For both cancer survivors and their siblings, female gender, lower education and income attainment, perceived poor health status, and reports of current health problems were all associated with higher levels of psychological distress symptoms.[20][Level of evidence: II]
Positive findings also have been reported by the CCSS for young adults who are survivors of leukemias and lymphomas. Follow-up questionnaires about psychological adjustment were administered to 5,736 young adult survivors of leukemia, non-Hodgkin lymphoma, and Hodgkin disease and to 2,565 adult siblings. Survivors reported higher levels of depressive symptoms and somatic distress than did siblings, but scores for neither group fell within the clinically significant range for the general population. Sociodemographic factors such as gender and socioeconomic status were associated with reports of depressive symptoms, regardless of treatment status. The only disease-related factor associated with psychological distress was intensive chemotherapy, which was associated with an increase in somatic complaints.[2][Level of evidence: II] Similar outcomes were reported for survivors of brain cancers. Brain tumor survivors reported higher levels of depressive symptomatology than did siblings, but the rates for both groups were similar to rates for the general population.[3][Level of evidence: II] A summary of the main psychosocial outcomes reported by the CCSS is available.[21][Level of evidence: II] Other reports from the CCSS address alcohol consumption,[22] the role of physical limitations on HRQL,[23][Level of evidence: II] fatigue, and sleep.[24]
Depression and Suicide
Young adult survivors of childhood cancer may have an elevated risk for suicidality. A report from Eastern Europe compared the responses of 228 long-term survivors of childhood cancer with those of 127 controls to the Center for Epidemiologic Studies Depression Scale (CES-D) and the Suicidal Ideation and Behaviour Questionnaire. The rates of depressive symptoms reported by the childhood cancer survivors were three times the rates reported by the controls, with 13% indicating some level of suicidal ideation.[25] Similarly, 226 adult survivors of childhood cancer seen in a survivor clinic completed the Short Form-36 (SF-36), the Beck Depression Inventory (BDI), and suicide items from the Symptom Checklist-90-Revised (SCL-90-R) and the Beck Scale for Suicide Ideation (BSS). The measures assessed whether the survivors had ever attempted suicide or whether they had experienced significant suicidal ideation within the past week; 29 participants (12.83%) reported suicidality. Suicidality was associated with younger age at diagnosis, longer time since diagnosis, cranial radiation therapy, a diagnosis of leukemia, pain, and concerns about physical appearance. Current physical condition, including pain, was associated with suicidality.[26][Level of evidence: II] These studies represent relatively small samples with small comparison groups and may reflect a reporting bias represented in individuals who actively attend follow-up clinics. Nonetheless, while these results are inconsistent with other findings related to psychological distress, they do suggest the need for ongoing monitoring and surveillance of adults who are survivors of childhood cancer.
Significant concern about the potential for suicide as a side effect of selective serotonin reuptake inhibitors (SSRIs) has led the U.S. Food and Drug Administration (FDA) to issue a caution about their use that includes the importance of careful monitoring of potential risks.[27] Before this FDA Health Advisory was issued, clinical experience and the results of small clinical trials suggested that antidepressants can be safely administered to adult cancer patients, although there are no controlled clinical trials to support this position. The risk/benefit ratio for use of SSRIs may not be as favorable for children and adolescents. Several multicenter, double-blind, randomized, placebo-controlled clinical trials using SSRIs with children and adolescents with major depressive disorder but not cancer found modest improvements for fluoxetine,[28,29] paroxetine,[30] and sertraline.[31][Level of evidence: I] Balancing these improvements were reports of serious adverse events that included worsening of psychiatric symptoms, increased suicidal ideation and gestures, increased conduct problems or hostility with paroxetine,[30] and suicide and suicide attempts with sertraline.[31][Level of evidence: I]
None of these clinical trials have included or focused on children and adolescents being treated for cancer. Risk/benefit concerns have reached the level of international regulatory concern. The Medicines and Healthcare Products Regulatory Agency of Great Britain has recommended that most of the drugs in the SSRI category not be used with children and adolescents,[32] and the FDA raised similar concerns in a Talk Paper and subsequently issued a "black box" warning.[27] A major meta-analysis published in the Journal of the American Medical Association reanalyzed the data from the child and adolescent studies [33][Level of evidence: I] (including seven studies not included in the initial meta-analysis [34][Level of evidence: I]) using a random-effects model. While this reanalysis found an overall increased risk of suicidal ideation/suicide attempt consistent with the initial meta-analysis, the pooled risk differences were found to be smaller and statistically insignificant.[33] Furthermore, another study examining the U.S. and Dutch data suggests a drop in SSRI prescriptions for children and adolescents and a simultaneous increase in suicide rates in this patient population since the FDA Health Advisory was issued.[35]
In summary, the risk/benefit equation favors appropriate use of antidepressants with careful monitoring for suicidality.[36] The British Committee on Safety of Medicines considered only one of the SSRIs (fluoxetine) to have a favorable balance of risks and benefits, but it is only considered beneficial in approximately one in ten patients.[37] Consistent with this finding, age-stratified analyses of the child and adolescent studies found that for children younger than 12 years who have major depression, only fluoxetine showed benefit over placebo.[33]
As noted, none of the children or adolescents in these studies had cancer, so there are no reports available that address whether there are additional increased risks of adverse events associated with the use of SSRIs following exposure to different chemotherapeutic agents and/or CNS radiation treatment. Frontline, alternative, effective, behavioral, and pharmacologic treatments for depression should be used for children and adolescents being treated for cancer. However, if the risks of depression are significant and SSRIs are considered, consultation with a child psychiatrist or neurologist is essential, and close monitoring of potential adverse events is crucial.
Post-traumatic Stress Disorder and Post-traumatic Stress Symptoms
The cancer treatment experience may be considered a significant traumatic event, given the nature of diagnosis, the number of invasive and painful procedures, and the often long hospitalizations that children and their families must experience. On the basis of this exposure model, a number of studies have examined whether children treated for cancer are at a significantly higher risk for the development of symptoms of post-traumatic stress disorder (PTSD). The results of these studies have been mixed.[38] One study reported that children and adolescents who were undergoing treatment reported some symptoms of post-traumatic stress; however, for most children these symptoms did not meet the criteria for a diagnosis of PTSD, and the symptoms diminished over time.[39][Level of evidence: II]
Other studies suggest that survivors of childhood cancer have an increased risk for post-traumatic stress symptoms and PTSD after treatment is finished. In a study of 78 adults aged 18 to 41 years who had been treated for childhood cancer, 20.5% met the criteria for a diagnosis of PTSD at some time since the end of their treatment. Clinically significant events of intrusive symptoms (9%) and avoidant symptoms (16.7%) were reported in the sample, and the symptoms were associated with elevated reports of anxiety and other measures of psychologic distress.[40][Level of evidence: II] Survivors who report higher levels of uncertainty about their disease and future appear to be more likely to have elevated reports of post-traumatic stress symptoms.[41][Level of evidence: II][42] A study of 182 adolescent and young adult cancer survivors who were more than 5 years from diagnosis and more than 2 years from completion of cancer treatment also found that 16% met the criteria for PTSD. A relationship between PTSD and higher levels of other psychological problems was also reported.[43] When survivors meet the criteria for PTSD, they are more likely to experience depression and negative affect, lower satisfaction with life, and poorer reported HRQL, as well as difficulty performing developmental tasks.[44][Level of evidence: II]
- Eiser C, Hill JJ, Vance YH: Examining the psychological consequences of surviving childhood cancer: systematic review as a research method in pediatric psychology. J Pediatr Psychol 25 (6): 449-60, 2000.
- Zebrack BJ, Zeltzer LK, Whitton J, et al.: Psychological outcomes in long-term survivors of childhood leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma: a report from the Childhood Cancer Survivor Study. Pediatrics 110 (1 Pt 1): 42-52, 2002.
- Zebrack BJ, Gurney JG, Oeffinger K, et al.: Psychological outcomes in long-term survivors of childhood brain cancer: a report from the childhood cancer survivor study. J Clin Oncol 22 (6): 999-1006, 2004.
- Sawyer M, Antoniou G, Toogood I, et al.: Childhood cancer: a 4-year prospective study of the psychological adjustment of children and parents. J Pediatr Hematol Oncol 22 (3): 214-20, 2000 May-Jun.
- Varni JW, Katz E: Stress, social support and negative affectivity in children with newly diagnosed cancer: a prospective transactional analysis. Psychooncology 6 (4): 267-78, 1997.
- Chao CC, Chen SH, Wang CY, et al.: Psychosocial adjustment among pediatric cancer patients and their parents. Psychiatry Clin Neurosci 57 (1): 75-81, 2003.
- Phipps S, Srivastava DK: Approaches to the measurement of depressive symptomatology in children with cancer: attempting to circumvent the effects of defensiveness. J Dev Behav Pediatr 20 (3): 150-6, 1999.
- Grootenhuis MA, Last BF, van der Wel M, et al.: Parents' attribution of positive characteristics to their children with cancer. Psychol Health 13: 67-81, 1998.
- Ritchie MA: Self-esteem and hopefulness in adolescents with cancer. J Pediatr Nurs 16 (1): 35-42, 2001.
- Noll RB, Gartstein MA, Vannatta K, et al.: Social, emotional, and behavioral functioning of children with cancer. Pediatrics 103 (1): 71-8, 1999.
- Levi RB, Drotar D: Health-related quality of life in childhood cancer: discrepancy in parent-child reports. Int J Cancer Suppl 12: 58-64, 1999.
- Armstrong FD, Toledano SR, Miloslavich K, et al.: The Miami pediatric quality of life questionnaire: parent scale. Int J Cancer Suppl 12: 11-7, 1999.
- Calaminus G, Weinspach S, Teske C, et al.: Quality of life in children and adolescents with cancer. First results of an evaluation of 49 patients with the PEDQOL questionnaire. Klin Padiatr 212 (4): 211-5, 2000 Jul-Aug.
- Vannatta K, Gartstein MA, Short A, et al.: A controlled study of peer relationships of children surviving brain tumors: teacher, peer, and self ratings. J Pediatr Psychol 23 (5): 279-87, 1998.
- Phipps S, Mulhern RK: Family cohesion and expressiveness promote resilience to the stress of pediatric bone marrow transplant: a preliminary report. J Dev Behav Pediatr 16 (4): 257-63, 1995.
- Casillas JN, Zebrack BJ, Zeltzer LK: Health-related quality of life for Latino survivors of childhood cancer. J Psychosoc Oncol 24 (3): 125-45, 2006.
- Barrera M, Wayland LA, D'Agostino NM, et al.: Developmental differences in psychological adjustment and health-related quality of life in pediatric cancer patients. Child Health Care 32 (3): 215-32, 2003.
- Phipps S, Fairclough D, Mulhern RK: Avoidant coping in children with cancer. J Pediatr Psychol 20 (2): 217-32, 1995.
- Sorgen KE, Manne SL: Coping in children with cancer: examining the goodness-of-fit hypothesis. Child Health Care 31 (3): 191-207, 2002.
- Zebrack BJ, Zevon MA, Turk N, et al.: Psychological distress in long-term survivors of solid tumors diagnosed in childhood: a report from the childhood cancer survivor study. Pediatr Blood Cancer 49 (1): 47-51, 2007.
- Zeltzer LK, Lu Q, Leisenring W, et al.: Psychosocial outcomes and health-related quality of life in adult childhood cancer survivors: a report from the childhood cancer survivor study. Cancer Epidemiol Biomarkers Prev 17 (2): 435-46, 2008.
- Lown EA, Goldsby R, Mertens AC, et al.: Alcohol consumption patterns and risk factors among childhood cancer survivors compared to siblings and general population peers. Addiction 103 (7): 1139-48, 2008.
- Ness KK, Gurney JG, Zeltzer LK, et al.: The impact of limitations in physical, executive, and emotional function on health-related quality of life among adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Arch Phys Med Rehabil 89 (1): 128-36, 2008.
- Mulrooney DA, Ness KK, Neglia JP, et al.: Fatigue and sleep disturbance in adult survivors of childhood cancer: a report from the childhood cancer survivor study (CCSS). Sleep 31 (2): 271-81, 2008.
- Svetičič J, Jereb B, Bucik V, et al.: Suicidal behaviour in long-term survivors of childhood cancer. [Abstract] Psychiatr Danub 18 (Suppl 1): 39-40, 2006.
- Recklitis CJ, Lockwood RA, Rothwell MA, et al.: Suicidal ideation and attempts in adult survivors of childhood cancer. J Clin Oncol 24 (24): 3852-7, 2006.
- U.S. Food and Drug Administration: Antidepressant Use in Children, Adolescents, and Adults. Rockville, Md: Food and Drug Administration, Center for Drug Evaluation and Research, 2007. Available online. Last accessed March 1, 2019.
- Emslie GJ, Rush AJ, Weinberg WA, et al.: A double-blind, randomized, placebo-controlled trial of fluoxetine in children and adolescents with depression. Arch Gen Psychiatry 54 (11): 1031-7, 1997.
- Emslie GJ, Heiligenstein JH, Wagner KD, et al.: Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial. J Am Acad Child Adolesc Psychiatry 41 (10): 1205-15, 2002.
- Keller MB, Ryan ND, Strober M, et al.: Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry 40 (7): 762-72, 2001.
- Wagner KD, Ambrosini P, Rynn M, et al.: Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials. JAMA 290 (8): 1033-41, 2003.
- Safety Review of Antidepressants Used by Children Completed. London, UK: Medicines and Healthcare Products Regulatory Agency, 2003. Available online. Last accessed March 1, 2019.
- Bridge JA, Iyengar S, Salary CB, et al.: Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 297 (15): 1683-96, 2007.
- Hammad TA, Laughren T, Racoosin J: Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 63 (3): 332-9, 2006.
- Gibbons RD, Brown CH, Hur K, et al.: Early evidence on the effects of regulators' suicidality warnings on SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry 164 (9): 1356-63, 2007.
- Leon AC: The revised black box warning for antidepressants sets a public health experiment in motion. J Clin Psychiatry 68 (7): 1139-41, 2007.
- Ramchandani P: Treatment of major depressive disorder in children and adolescents. BMJ 328 (7430): 3-4, 2004.
- Bruce M: A systematic and conceptual review of posttraumatic stress in childhood cancer survivors and their parents. Clin Psychol Rev 26 (3): 233-56, 2006.
- Phipps S, Long A, Hudson M, et al.: Symptoms of post-traumatic stress in children with cancer and their parents: effects of informant and time from diagnosis. Pediatr Blood Cancer 45 (7): 952-9, 2005.
- Hobbie WL, Stuber M, Meeske K, et al.: Symptoms of posttraumatic stress in young adult survivors of childhood cancer. J Clin Oncol 18 (24): 4060-6, 2000.
- Lee YL: The relationships between uncertainty and posttraumatic stress in survivors of childhood cancer. J Nurs Res 14 (2): 133-42, 2006.
- Santacroce SJ, Lee YL: Uncertainty, posttraumatic stress, and health behavior in young adult childhood cancer survivors. Nurs Res 55 (4): 259-66, 2006 Jul-Aug.
- Rourke MT, Hobbie WL, Schwartz L, et al.: Posttraumatic stress disorder (PTSD) in young adult survivors of childhood cancer. Pediatr Blood Cancer 49 (2): 177-82, 2007.
- Schwartz L, Drotar D: Posttraumatic stress and related impairment in survivors of childhood cancer in early adulthood compared to healthy peers. J Pediatr Psychol 31 (4): 356-66, 2006.
A commonly repeated idea in the cancer community is that cancer is a family disease; this concept is clearly supported by parents and siblings of children who are being treated for cancer. However, the effects of having a child or sibling with cancer are not uniform, either for all family members or at all points in the treatment process, and the literature reflects the variability of each family member's experience.
The diagnosis of childhood cancer represents the start of a period of substantial distress for parents, who report shock, emotional pain, difficulty coping with the necessary procedures performed on their child, rumination, and high levels of information seeking accompanied by a sense of lack of control.[1,2,3] One study found that all but one participant in a sample of 119 mothers and 52 fathers of children undergoing cancer treatment reported traumatic stress symptoms such as intrusive thoughts, physiologic arousal, and avoidance.[4] When parents of children undergoing treatment (n = 175) were compared with parents of children who had completed treatment (n = 238), symptoms of traumatic stress (intrusion, arousal) were reported more frequently by the parents during the acute phase of treatment than by the parents after treatment, though some parents reported these symptoms after treatment. Some demographic factors may play a role in the degree to which parents experienced significant stress that impairs function. Mothers were more likely to report higher levels of stress than were fathers, and parents with fewer years of formal education and lower socioeconomic status were more likely to experience traumatic stress at any time.[5]
Patterns of parental stress in families of children treated for cancer differ from those in families of children treated for other diseases. In one large study of 675 parents of children who were treated for cancer or diabetes or who were healthy, parents of children with cancer reported significantly higher levels of distress—as indicated in the specific areas of anxiety, physical and psychological distress, depression, and loneliness—than did parents of children with diabetes. Distress levels of parents of patients with cancer matched those in parents of patients with diabetes in measures of uncertainty, loss of control, self-esteem, disease-related fear, and sleep disturbances. Distress levels for parents of children with cancer decreased in intensity with longer time since diagnosis.[6]
At the same time that they are dealing with increased distress, parents of children with cancer report wanting to remain strong and optimistic for their children.[7] One study found no differences in multiple measures of family distress and psychological functioning between families of children with cancer and families with healthy children.[8]
Several factors appear to be predictive of long-term parental adjustment. Better short- and long-term adjustment is experienced by parents who:[9,10,11]
- Are employed.
- Have social support from family, friends, and health care team members.
- Experience lower levels of parenting stress.
- View their children's quality of life positively.
- Have positive expectations for treatment outcome.
Factors associated with poorer parental adjustment include the following:[12,13]
- Low parental expectations for positive outcomes.
- Feelings of helplessness, uncertainty, and anxiety.
- Low levels of social support.
- Negative interactions with health care team members.
- Negative assessment of the child's quality of life.
Race [14] and parent gender [15] may affect the intensity of the effect of these factors on parental functioning. In rare circumstances, the stress of coping with pain, adverse side effects, lack of control or understanding of information or outcomes, and conflicts with health care professionals may lead parents to drop out of cancer treatment for their children.[16]
Most studies suggest that over time, maternal affective distress and perceived stress have been shown to decline, but the perceived burden of caring for a child with cancer remains stable, as do positive characteristics such as parental control, nurturance, and responsiveness.[14] This pattern may be related to the high levels of social support provided at the time of diagnosis, with a gradual decrease in the quantity of support but stable perceived quality of support across all phases of cancer treatment.[15] In general, parents are seen as resilient,[12][Level of evidence: II] but parental loneliness and continued uncertainty may last far beyond the treatment phase if there are ongoing late effects of treatment for the child.[17][Level of evidence: II] A few studies have found that a substantial number of parents (30%–36%) of long-term cancer survivors may experience intense long-term stress-related symptoms that fall below the threshold for a diagnosis of post-traumatic stress disorder (PTSD) but that are nevertheless a significant problem for these parents.[18,19][Level of evidence: II] Symptoms were severe enough that in 20% of families, at least one parent met the criteria for a diagnosis of PTSD.[19]
The challenges of dealing with the diagnosis and treatment of childhood cancer also has implications for the coping and adjustment of siblings. During treatment, siblings of children with cancer may report:
- Higher levels of anxiety and loneliness than experienced by siblings of healthy children.[20][Level of evidence: II]
- Post-traumatic distress symptoms (reported by approximately 50% of siblings).[21][Level of evidence: II]
- Distress about family disruptions and separations.[21]
- Lack of attention associated with the focus of other family members on the ill child.[21]
- Negative interactions with family members.[21]
- Fear of the sibling's death.[21]
Siblings of children with cancer also report becoming more compassionate and perceiving that their families are drawn closer together through the experience.[22]
The risk to families increases with the following conditions:
- Younger patient age.[22]
- Longer duration of cancer treatment.[20]
- Whether the child with cancer dies.[23]
For siblings of children who undergo allogeneic hematopoietic stem cell transplantation, the risk for anxiety and lower self-esteem is higher for siblings who serve as hematopoietic stem cell donors, while non-donors are at higher risk of developing school problems.[24] Social support programs such as sibling groups [25] or summer camp experiences [26] appear to result in reductions in reported anxiety and improved self-esteem in siblings of children treated for cancer.
- McGrath P: Treatment for childhood acute lymphoblastic leukaemia: the fathers' perspective. Aust Health Rev 24 (2): 135-42, 2001.
- Levi RB, Marsick R, Drotar D, et al.: Diagnosis, disclosure, and informed consent: learning from parents of children with cancer. J Pediatr Hematol Oncol 22 (1): 3-12, 2000 Jan-Feb.
- Goldbeck L: Parental coping with the diagnosis of childhood cancer: gender effects, dissimilarity within couples, and quality of life. Psychooncology 10 (4): 325-35, 2001 Jul-Aug.
- Kazak AE, Boeving CA, Alderfer MA, et al.: Posttraumatic stress symptoms during treatment in parents of children with cancer. J Clin Oncol 23 (30): 7405-10, 2005.
- Norberg AL, Lindblad F, Boman KK: Parental traumatic stress during and after paediatric cancer treatment. Acta Oncol 44 (4): 382-8, 2005.
- Boman KK, Viksten J, Kogner P, et al.: Serious illness in childhood: the different threats of cancer and diabetes from a parent perspective. J Pediatr 145 (3): 373-9, 2004.
- Young B, Dixon-Woods M, Windridge KC, et al.: Managing communication with young people who have a potentially life threatening chronic illness: qualitative study of patients and parents. BMJ 326 (7384): 305, 2003.
- Noll RB, Gartstein MA, Hawkins A, et al.: Comparing parental distress for families with children who have cancer and matched comparison families without children with cancer. Fam Syst Med 13 (1): 11-27, 1995.
- Rourke MT, Stuber ML, Hobbie WL, et al.: Posttraumatic stress disorder: understanding the psychosocial impact of surviving childhood cancer into young adulthood. J Pediatr Oncol Nurs 16 (3): 126-35, 1999.
- Kazak AE, Barakat LP: Brief report: parenting stress and quality of life during treatment for childhood leukemia predicts child and parent adjustment after treatment ends. J Pediatr Psychol 22 (5): 749-58, 1997.
- Grootenhuis MA, Last BF: Predictors of parental emotional adjustment to childhood cancer. Psychooncology 6 (2): 115-28, 1997.
- Dockerty JD, Williams SM, McGee R, et al.: Impact of childhood cancer on the mental health of parents. Med Pediatr Oncol 35 (5): 475-83, 2000.
- Santacroce S: Uncertainty, anxiety, and symptoms of posttraumatic stress in parents of children recently diagnosed with cancer. J Pediatr Oncol Nurs 19 (3): 104-11, 2002 May-Jun.
- Steele RG, Long A, Reddy KA, et al.: Changes in maternal distress and child-rearing strategies across treatment for pediatric cancer. J Pediatr Psychol 28 (7): 447-52, 2003 Oct-Nov.
- Hoekstra-Weebers JE, Jaspers JP, Kamps WA, et al.: Psychological adaptation and social support of parents of pediatric cancer patients: a prospective longitudinal study. J Pediatr Psychol 26 (4): 225-35, 2001.
- Yeh CH, Lin CF, Tsai JL, et al.: Determinants of parental decisions on 'drop out' from cancer treatment for childhood cancer patients. J Adv Nurs 30 (1): 193-9, 1999.
- Van Dongen-Melman JE, Pruyn JF, De Groot A, et al.: Late psychosocial consequences for parents of children who survived cancer. J Pediatr Psychol 20 (5): 567-86, 1995.
- Brown RT, Madan-Swain A, Lambert R: Posttraumatic stress symptoms in adolescent survivors of childhood cancer and their mothers. J Trauma Stress 16 (4): 309-18, 2003.
- Kazak AE, Alderfer M, Rourke MT, et al.: Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors. J Pediatr Psychol 29 (3): 211-9, 2004 Apr-May.
- Hamama R, Ronen T, Feigin R: Self-control, anxiety, and loneliness in siblings of children with cancer. Soc Work Health Care 31 (1): 63-83, 2000.
- Alderfer MA, Labay LE, Kazak AE: Brief report: does posttraumatic stress apply to siblings of childhood cancer survivors? J Pediatr Psychol 28 (4): 281-6, 2003.
- Sargent JR, Sahler OJ, Roghmann KJ, et al.: Sibling adaptation to childhood cancer collaborative study: siblings' perceptions of the cancer experience. J Pediatr Psychol 20 (2): 151-64, 1995.
- MacLeod KD, Whitsett SF, Mash EJ, et al.: Pediatric sibling donors of successful and unsuccessful hematopoietic stem cell transplants (HSCT): a qualitative study of their psychosocial experience. J Pediatr Psychol 28 (4): 223-30, 2003.
- Packman W: Psychosocial impact of pediatric BMT on siblings. Bone Marrow Transplant 24 (7): 701-6, 1999.
- Houtzager BA, Grootenhuis MA, Last BF: Supportive groups for siblings of pediatric oncology patients: impact on anxiety. Psychooncology 10 (4): 315-24, 2001 Jul-Aug.
- Murray JS: Self-concept of siblings of children with cancer. Issues Compr Pediatr Nurs 24 (2): 85-94, 2001 Apr-Jun.
End of Life
Despite significant improvements in long-term, disease-free survival in children treated for cancer,[1] cancer is the leading disease-related cause of death for children in the United States.[2] For more than half of children for whom frontline treatment fails, treatment using relapse and disease recurrence clinical trials (phase I and phase II) and unrelated hematopoietic stem cell transplantation is common.[3] For children, this strategy is sometimes effective in providing prolonged remissions with patient-valued quality of life.[4] For these reasons, many children treated for cancer in the United States and around the world die in inpatient settings while receiving active cancer treatment.[5] Clinical practice and experience is the driving force in this field; unfortunately, very few empirical studies have been published to guide practice.
Considering End-of-Life Issues
Planning for a child's death is often a very uncomfortable topic for parents, other family members, and members of the health care team. Children are not supposed to die. Although there has been a significant emphasis on better understanding the decision-making process and the care provided for children at the end of life,[6] many parents choose to continue active cancer treatment until death.
One hundred forty-one parents who had lost a child to cancer were asked whether their children benefited or suffered from treatment with no realistic expectation of success. Thirty-eight percent of the parents indicated that their children continued to receive cancer-directed therapy, even after the parents recognized that there was no realistic chance of success. Sixty-one percent of these reported that their child experienced some suffering, and 57% reported little or no benefit from the continued treatment. Despite these experiences, 57% reported that they would recommend standard chemotherapy during the end-of-life phase, and 33% would recommend experimental (phase I and phase II) treatment. Parents who felt that their child suffered at the end of life were less likely to recommend additional chemotherapy. However, even those who did not personally support using standard chemotherapy at the end of life (91%) felt that physicians should offer this as an option.[7]
Parent and physician perspectives on quality of care at the end of life do not always match. Parents of children who died from cancer reported focusing primarily on relationship issues, with higher ratings for physician care when oncologists:[8]
- Provided clear information.
- Communicated with care and sensitivity.
- Communicated directly with the child when appropriate.
- Prepared parents for the circumstances around the child's impending death.
Oncologists based care ratings on biomedical measures such as lower ratings of pain by parents and fewer days of hospitalization.
Support for End-of-Life Care
Resources to support palliative care and end-of-life care for children treated for cancer are often quite limited. A survey of member institutions of the Children's Oncology Group (81% response rate) found that only 58% had a pediatric palliative care team available to families,[9] although the following related services were available:
- Pain service, 90%.
- Hospice, 60%.
- Psychosocial support team, 80%.
- Bereavement program, 59%.
Complementary and alternative medicine services were available in 39% of institutions and in 95% of communities served by the institutions. Support for other family members, particularly siblings, is often missing from these programs.[5]
Hospice care
Referrals to hospice care are often limited by hospice policies that do not accept patients still receiving active chemotherapy. Twelve hundred pediatric oncologists in the Children's Oncology Group were surveyed about hospice referral practices (67% response rate). Hospice referrals were limited by lack of access to inpatient hospice programs. However, pediatric oncologists indicated that if the hospice program accepted children still receiving chemotherapy, referrals were more likely and the children were also more likely to die at home than in hospitals.[10]
Complementary and alternative therapies
Despite broad popular interest in complementary and alternative therapies, few children are offered access to this treatment. A study of Children's Oncology Group institutions in Canada found that complementary and alternative therapies were offered at only 18% of treating institutions, although these were available in 94% of communities. Direct referrals were only provided to 6% of families, and only 20% of institutions had developed any guidelines for the use of complementary and alternative therapies.[11] To address this issue, studies are in progress to examine the integration of complementary and alternative therapies with conventional treatment in the Children's Oncology Group.[12]
Personal discussions
Despite the relative absence of structured palliative care and end-of-life care for children treated for cancer, personal discussions about palliation and end-of-life care between oncologists and parents nevertheless take place. A study of 140 parents whose children died of cancer found that if the primary oncologist discussed options and if home health support were available, 88% of parents planned how they wanted their child's end-of-life care to be provided, and 97% accomplished their plan. This was associated with more home deaths (72% vs. 8% who did not plan); fewer hospital admissions (54% vs. 98%); parents feeling more prepared (37% vs. 12%) and comfortable with the process (84% vs. 40%); and, for those who died in the hospital, fewer deaths in the intensive care unit (92% vs. 33%) and with intubation (21% vs. 48%).[13]
Strategies for Improving End-of-Life Care
Care of children at the end of their lives is complex. A comprehensive summary of pediatric palliative care has highlighted the following general issues that need to be considered:[14]
- Communication (verbal and nonverbal) with children and families should be caring, sensitive to individual and family concerns, and provided within the context of a child's age and developmental level.
- Palliative care should specifically include strategies for assessing and managing pain and other symptoms associated with the end of life. Medications and other supportive care interventions should be provided for pain, agitation, pruritus, nausea and vomiting, seizures, and secretions. For children for whom bleeding is a disturbing end-of-life consequence, platelet transfusions may also be appropriate.
- The emotional and spiritual needs of families and children should be identified and addressed. Families are composed of individuals, and there are usually variations in how individual family members cope with impending death; cultural beliefs and practices may also influence this process. Being aware of factors that contribute to this variation and tailoring interventions to individual families are important aspects of end-of-life care.
- Structured support for bereavement care should be provided. Some institutions support bereavement teams who provide families with items such as handprints of the child, photo albums, and quilts to facilitate transition at the time of the child's death. Other institutions provide parents with information about what may occur at the time of death and common experiences of family members in the hours, days, weeks, and months following the death. Some also provide one to three sessions of bereavement support for family members after the child's death. (Refer to the PDQ summary on Grief, Bereavement, and Coping With Loss for more information.)
- Parents should be engaged in early discussion about advance care planning. It has been suggested that this discussion begin at the time of diagnosis for all children who have a survival prognosis lower than 50%, although others prefer to delay this discussion until the time of relapse or disease progression. Advanced care planning includes discussion about the use of standard or experimental treatments, preferred location for the child's death, whether to involve hospice, funeral arrangements, and whether a Do Not Resuscitate (DNR) order is to be implemented in inpatient and outpatient settings. Depending on their developmental and cognitive capacities, some children who are dying benefit from being included in these advance care decisions.
Other Issues
Many aspects of end-of-life care for adults and children with cancer overlap. At the same time, specific developmental, family, and even legal issues are unique to children and require careful consideration. State laws related to withdrawal or withholding of care vary, and end-of-life care may be affected by whether a child is in the custody of biologic parents or legal guardians or is a ward of the state. Some states do not permit DNR decisions to be made for children in their care. Health care teams have a responsibility to be aware of state laws, hospital policies, and ethical standards in their community and integrate this information into end-of-life care. Ultimately, the challenge is to balance available intervention and support with unique family, child, and physician concerns in a way that optimizes quality of life for the child and family.[15] (Refer to the PDQ summary on Last Days of Life for more information.)
- Linabery AM, Ross JA: Childhood and adolescent cancer survival in the US by race and ethnicity for the diagnostic period 1975-1999. Cancer 113 (9): 2575-96, 2008.
- Kochanek KD, Kirmeyer SE, Martin JA, et al.: Annual summary of vital statistics: 2009. Pediatrics 129 (2): 338-48, 2012.
- Hechler T, Blankenburg M, Friedrichsdorf SJ, et al.: Parents' perspective on symptoms, quality of life, characteristics of death and end-of-life decisions for children dying from cancer. Klin Padiatr 220 (3): 166-74, 2008 May-Jun.
- Berg SL, Chamberlain MC: Systemic chemotherapy, intrathecal chemotherapy, and symptom management in the treatment of leptomeningeal metastasis. Curr Oncol Rep 5 (1): 29-40, 2003.
- Friedrichsdorf SJ, Menke A, Brun S, et al.: Status quo of palliative care in pediatric oncology-a nationwide survey in Germany. J Pain Symptom Manage 29 (2): 156-64, 2005.
- Field MJ, Behrman RE, eds.: When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington, DC: Institute of Medicine, National Academies Press, 2003. Also available online. Last accessed March 1, 2019.
- Mack JW, Joffe S, Hilden JM, et al.: Parents' views of cancer-directed therapy for children with no realistic chance for cure. J Clin Oncol 26 (29): 4759-64, 2008.
- Mack JW, Hilden JM, Watterson J, et al.: Parent and physician perspectives on quality of care at the end of life in children with cancer. J Clin Oncol 23 (36): 9155-61, 2005.
- Johnston DL, Nagel K, Friedman DL, et al.: Availability and use of palliative care and end-of-life services for pediatric oncology patients. J Clin Oncol 26 (28): 4646-50, 2008.
- Fowler K, Poehling K, Billheimer D, et al.: Hospice referral practices for children with cancer: a survey of pediatric oncologists. J Clin Oncol 24 (7): 1099-104, 2006.
- Johnston DL, Nagel K, O'Halloran C, et al.: Complementary and alternative medicine in pediatric oncology: availability and institutional policies in Canada–a report from the Children's Oncology Group. Pediatr Blood Cancer 47 (7): 955-8, 2006.
- O'Mara A: Complementary and alternative medicine research and cooperative groups: can it happen? J Pediatr Oncol Nurs 23 (5): 258-60, 2006 Sep-Oct.
- Dussel V, Kreicbergs U, Hilden JM, et al.: Looking beyond where children die: determinants and effects of planning a child's location of death. J Pain Symptom Manage 37 (1): 33-43, 2009.
- Himelstein BP, Hilden JM, Boldt AM, et al.: Pediatric palliative care. N Engl J Med 350 (17): 1752-62, 2004.
- Friedman DL, Hilden JM, Powaski K: Issues and challenges in palliative care for children with cancer. Curr Pain Headache Rep 9 (4): 249-55, 2005.
Changes to This Summary (03 / 06 / 2019)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
Added cancer stage as a factor that affects overall survival (cited American Cancer Society 2019 as reference 1).
This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® – NCI's Comprehensive Cancer Database pages.
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about supportive care issues related to treatment in children and adolescents. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
- be discussed at a meeting,
- be cited with text, or
- replace or update an existing article that is already cited.
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Pediatric Supportive Care are:
- Tammy I. Kang, MD (Texas Children's Pavilion for Women)
- Shefali Parikh, MD (Children's Hospital of Philadelphia)
Any comments or questions about the summary content should be submitted to Cancer.gov through the NCI website's Email Us. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
PDQ® Supportive and Palliative Care Editorial Board. PDQ Pediatric Supportive Care. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/childhood-cancers/pediatric-care-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389208]
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Managing Cancer Care page.
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More information about contacting us or receiving help with the Cancer.gov website can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the website's Email Us.
Last Revised: 2019-03-06
This information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. Learn how we develop our content.


text:
August 2016 update: This is one of my most popular summer recipes, which men seem to especially love. Click here to read a sampling of rave reviews from the comments section. Thanks so much to all of you who take the time to come back and report on my recipes. And thanks for pinning them on Pinterest too!
Sometimes it's good to be alone in the kitchen. That way, when you pull a pie like this out of the oven and are standing there staring at it while it cools on the counter, mouth watering, stomach rumbling, fingers twitching, you don't have to worry about losing control and getting your hand slapped because you can't resist it.
You can simply tear off a piece of that warm, golden crust and pop it into your mouth and nobody will ever know, because pieces of crust break off pies all the time.
Of course if you end up nibbling off five or six inches around the edge, you're going to have to come up with a good explanation as to why it is missing. Pets can be quite handy for this.
If the pie is just for you, then you'll be forced to face the fact that you just gobbled up the very best part off a large portion of your pie.
This recipe is actually a combination of four things that I love. The first is homemade pizza. The second is homemade Pecorino Romano crackers, which I don't make very often because my hunky farmguy Joe doesn't care for them so I have to eat them all myself, and I have no self-control when they're around. I've had entire meals that consisted of nothing but these crackers.
The third thing is a similar pie I've made with tomatoes, cheddar cheese and fresh basil using a recipe from a 1998 issue of Country Home magazine. And the fourth thing is something I invented on a whim years ago when I had my little bakery cafe in Northern California. It was basically a free form calzone made with a biscuit-type crust and filled with sliced Roma tomatoes, mozzarella cheese, and pesto.
I called them pesto piezones, and each one was about the size of both of my hands put together with my fingers spread apart. I sold them for four dollars apiece, and they were usually all spoken for well before lunchtime. Until the other day I'd forgotten all about them.
Now this may look like a pie, and I may even be calling it a pie, but it's really not a pie. So those of you who are afraid of pies can keep reading.
And now I'm going to say this again in a slightly different way because people who are afraid of making pies have often been tricked into making them and then suffered traumatic experiences: This is not a pie crust.
It's made with a biscuit dough, but, for those of you who are afraid of making biscuits, it is not actually made from biscuits.
This dough is easy to work with. This pie is quick and easy to make. That—for anyone who is still suspicious—means that this is by no means a difficult culinary endeavor. You can make this pie. Yes, you. And when you do, if you decide to share it, it will most likely make whomever you feed it to immediately smile with delight and love you even more than they already do. And you certainly can't beat that.
Purchased pesto works fine in this recipe, but if you have 20 minutes to spare and can get your hands on some beautiful fresh basil, I say make your own.
Use your favorite pesto recipe or try mine below. It calls for roasted and salted almonds instead of pine nuts, less olive oil than most pesto recipes, and fresh tomatoes, which give the pesto a subtle new flavor while replacing some of the olive oil and making it thin enough to be spreadable.
You can save time by making the pesto a day or two ahead. Or you can make the entire pie ahead of time and simply reheat it in the oven. Individual leftover slices can be wrapped in foil and reheated in the oven or toaster oven, although it isn't too bad cold either. If you are very, very gentle, you can heat a slice in the microwave.
What I like most about this recipe is that although the tomatoes are cooked, they manage to maintain their fresh-from-the-garden taste. Yes, I've gone from Summer in a Bowl to summer in a crust.
I like to use the meaty plum tomatoes, sometimes called paste or Roma tomatoes (although Roma is actually a specific variety of plum tomato), as 'regular' tomatoes may be too juicy and could make your pie soggy.
August 2011 update: My pal Finny, who has been making this pie since 2006, routinely uses Better Boys and Brandywines from her garden. Here's what she says:
"Any tomato that's suitable for a sandwich would, I imagine, be good in this pie. The crust is the key thing though, because the biscuit nature of it (rather than flaky pastry) makes it sturdier for the purposes of holding in all that tomato goodness. I also tend to make my pesto a bit on the drier side. And it helps to slice the tomatoes and let them sit on paper towels for a few minutes to leech out a tiny bit of juice."
And Molly reported that, "I didn't have the plum tomatoes, but I just seeded and drained the ones that had grown last week, and it was delightful."
Finny also adds crumbled and cooked Italian sausage to her pies. How brilliant is that? If you want to try adding some, too, you'll find my easy recipe for homemade Italian sausage here (no casings required!), and there are helpful step-by-step photos of Finny's version of this pie here (warning: Finny uses bad words).
As always, I urge you to seek out local and organic ingredients; they really do make a difference.
Don't let the lengthy instructions scare you away. This really is an easy recipe and everything comes together quickly.
Farmgirl Susan's Savory Tomato and Basil Pesto Pie
Makes one 9-inch pie
**Click here to print this recipe**
For the pesto:
Makes about 1½ cups (you'll need 1 cup for this recipe)
When portioning out basil (and so many other ingredients), it works best if you weigh it rather than pack it into measuring cups. A digital kitchen scale is such a useful investment that once you have one, you may wonder how you ever lived without it. I often use my Oxo 11-pound kitchen scale several times a day.
1/3 cup (about 1½ ounces) roasted & salted whole almonds
3 to 6 cloves garlic, peeled
4 ounces fresh basil leaves (about 4 cups packed)
1 ounce (about 1/2 cup) finely grated Pecorino Romano (or other hard cheese)
10 ounces fresh tomatoes (about 3 smallish) any kind, quartered
1/2 teaspoon salt
1/3 cup extra-virgin olive oil, or more if desired
In the bowl of a food processor,use the S-blade to whiz the almonds and garlic until finely chopped.
Add the basil, cheese, tomatoes, and salt, and process until thoroughly combined and the consistency you like.
With the motor running running, slowly drizzle the olive oil through the chute. Salt to taste and add more olive oil if desired. Store your pesto in the refrigerator for several days or freeze it. A light coating of olive oil over the top of the pesto will help keep it from discoloring.
Heat the oven to 375°.
For the crust:
2 cups organic all-purpose flour
4 teaspoons baking powder (make sure it's fresh!)
1 teaspoon salt
1/2 cup (1 stick/ 4 ounces) cold organic butter
1 cup (about 2½ ounces) finely grated Pecorino Romano (or other hard cheese, such as Parmesan)
3/4 cup organic milk
Combine the flour, baking powder, and salt in a medium bowl. Mix in the butter using a pastry blender, fork, or your fingers until the largest pieces are pea-size. Stir in the Pecorino Romano.
Pour in the milk and use a fork to gently form a soft dough. Do not overmix. Divide the dough in two pieces, making one slightly larger than the other.
On a generously floured surface, use a rolling pin to gently roll out the larger piece of dough into a circle about 12 inches across, rolling from the center outward. Sprinkle dough with flour if sticky.
Gently fold the dough in half and transfer into a 9-inch pie pan. If the dough tears, simply press it back together with your fingers.
Roll out the remaining piece of dough into a slightly smaller circle and set aside (or wait until you have the filling in the pan and then roll it out).
Assembling the pie:
1 cup pesto, divided
2½ pounds of the best plum tomatoes you can find, sliced lengthwise into 4 or 5 slices each (I used San Marzanos & Golden Romas to add extra color as well as more flavor)
8 ounces mozzarella, grated or thinly sliced (I use slices from a fresh log)
1/2 cup (about 1¼ ounces) finely grated Pecorino Romano (or other hard cheese such as Parmesan)
Optional: About 12 ounces crumbled and cooked Italian sausage (my easy recipe for homemade Italian sausage is here)
Using a spoon, spread 1/2 cup of pesto over the bottom layer of dough in the pie pan. Layer about half of the tomatoes over the pesto. (If you're adding the Italian sausage, layer half of it over the tomatoes here.) Cover the tomatoes with about 2/3 of the mozzarella.
Layer on the rest of the tomatoes (you may not need them all to fill the pan). Carefully spread the remaining 1/2 cup of pesto over the tomatoes. (Add the other half of the Italian sausage here.) Cover with the remaining mozzarella and the Pecorino Romano.
Roll out the second piece of dough if you haven't already, and carefully place it over the pie. Fold the edge of the bottom piece over the top piece and press together to seal.
Use your fingers to make a crimped design around the edge. If any dough falls apart, simply press it back together with your fingers. Don't worry if it isn't perfect. The handmade look has much more charm.
Cut four slits in the top of the pie for steam to escape. Bake at 375° in the center of the oven until the crust is golden brown, about 40 minutes. Cover the edge with foil if it starts to brown too quickly.
Let cool on a wire rack for at least 15 minutes before serving. Crust edges may be sampled much sooner. (As with nearly any fruit pie, if you cut into it while it's still warm, some juice will seep out. If you plan to store any leftover pie right in the pan, simply drain off the juice so the bottom crust doesn't become soggy.) Or cool pie completely, cover, and refrigerate.
You can also freeze this pie. I wrapped a hunk in foil then put it in a zipper freezer bag and tossed it into the freezer. I defrosted the whole piece overnight in the refrigerator, then cut it in half and reheated the slices in my little toaster convection oven for 15-20 minutes at 325°, each on a fresh piece of foil and covered lightly with the foil so the tops wouldn't brown too quickly.
The bottom crust was a little soggy, but I'm pretty sure that was because I let the pie sit in the fridge three days before deciding to freeze it. Otherwise it looked and tasted as if it had just come out of the oven the first time.
Hint: If you plan to freeze the entire pie and don't want to freeze it in the pan, use a disposable pie pan or line your pan with a piece of heavy duty foil so you can simply lift the whole cooled pie out of the pan.
Other Ideas:
—Use arugula pesto or spinach pesto instead of basil pesto.
—Omit the Pecorino Romano from the crust, and use cilantro pesto (thinned with salsa, if desired) and jalapeno jack cheese in place of the basil pesto and mozzarella.
© FarmgirlFare.com, the totally tomato foodie farm blog where Farmgirl Susan shares recipes, stories, and photos from her crazy country life on 240 remote Missouri acres.

subset: commoncrawl


text:
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text:
1For, not thinking rightly, they said among themselves:*
"Brief and troubled is our lifetime;a
there is no remedy for our dying,
nor is anyone known to have come back from Hades.
2For by mere chance were we born,
and hereafter we shall be as though we had not been;
Because the breath in our nostrils is smoke,
and reason a spark from the beating of our hearts,
3And when this is quenched, our body will be ashes
and our spirit will be poured abroad like empty air.b
4Even our name will be forgotten in time,
and no one will recall our deeds.
So our life will pass away like the traces of a cloud,
and will be dispersed like a mist
Pursued by the sun's rays
and overpowered by its heat.
5For our lifetime is the passing of a shadow;
and our dying cannot be deferred
because it is fixed with a seal; and no one returns.c
6Come, therefore, let us enjoy the good things that are here,
and make use of creation with youthful zest.d
7Let us have our fill of costly wine and perfumes,
and let no springtime blossom pass us by;
8let us crown ourselves with rosebuds before they wither.
9Let no meadow be free from our wantonness;
everywhere let us leave tokens of our merriment,
for this is our portion, and this our lot.e
10Let us oppress the righteous poor;
let us neither spare the widow
nor revere the aged for hair grown white with time.f
11But let our strength be our norm of righteousness;
for weakness proves itself useless.
12* Let us lie in wait for the righteous one, because he is annoying to us;
he opposes our actions,
Reproaches us for transgressions of the law*
and charges us with violations of our training.g
13He professes to have knowledge of God
and styles himself a child of the LORD.h
14To us he is the censure of our thoughts;
merely to see him is a hardship for us,i
15Because his life is not like that of others,
and different are his ways.
16He judges us debased;
he holds aloof from our paths as from things impure.
He calls blest the destiny of the righteous
and boasts that God is his Father.j
17Let us see whether his words be true;
let us find out what will happen to him in the end.k
18For if the righteous one is the son of God, God will help him
and deliver him from the hand of his foes.l
19With violence and torture let us put him to the test
that we may have proof of his gentleness
and try his patience.
20Let us condemn him to a shameful death;
for according to his own words, God will take care of him."m
21These were their thoughts, but they erred;
for their wickedness blinded them,n
22* And they did not know the hidden counsels of God;
neither did they count on a recompense for holiness
nor discern the innocent souls' reward.o
23For God formed us to be imperishable;
the image of his own nature he made us.p
24But by the envy* of the devil, death entered the world,
and they who are allied with him experience it.q
* [2:1–20] In this speech the wicked deny survival after death and indeed invite death by their evil deeds.
* [2:12–5:23] From 2:12 to 5:23 the author draws heavily on Is 52–62, setting forth his teaching in a series of characters or types taken from Isaiah and embellished with additional details from other texts. The description of the "righteous one" in 2:12–20 seems to undergird the New Testament passion narrative.
* [2:12] Law: the law of Moses; "training" has the same meaning.
* [2:22] This verse announces the subject of the next section.
* [2:24] Envy: perhaps because Adam was in the image of God or because Adam had control over all creation. Devil: the first biblical text to equate the serpent of Gn 3 with the devil.
d. [2:6] Is 22:13; 1 Cor 15:32.
f. [2:10] Ex 22:21–23; Lv 19:32.
h. [2:13] Mt 27:43; Jn 8:55; 10:36–39.
l. [2:18] Ps 22:9; Is 42:1; Mt 27:43; Jn 5:18.
o. [2:22] Ps 18:24–25; Prv 11:18; Mt 11:25.
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It's been a long time since I made strudel dough and it's been even longer since I made it for our own eating pleasures. When I first moved to the US, one of my first pastry jobs was at a German bakery where we would make strudel dough by the buckets, starting fresh and early around 3am. I made so much strudels in that one year there that I overdosed a little and never made it at home after that. When I saw that the Daring Bakers challenge for May was strudel I had a split reaction. A "meh" followed by "oh wait I have always wanted to do this and this and this…"
The instructions were to make the strudel dough per the recipe given but allowed us to get creative as far as the fillings, shapes and sizes. I started with one idea and as (most) usual, I ended up with three. My first idea was not to make a traditional strudel and I blame Richard Leach for that. I have been itching to make his Ricotta Cheese Tarts in Strudel Rings since the first day I flipped the pages of his book "Sweet Seasons". I refrained from it up until now because of that studel making overdose mentionned above. Ha! No more! I had the perfect opportunity!
For the strudel rings, I rolled and stretched the dough until I could see through it and cut four 1 1/2-inch strips that I rolled around a 3-inch cake rings about 3-4 times. I baked them just until the rings were golden brown. I let them slide of the cake rings and let them cool while I prepared the mascarpone tart base. It is really like a light cheesecake baked right inside the rings. Once they were cooled, I placed them inside the strudel rounds and plated some with fresh cherries and others with lemon balm infused cherries. Both versions were equally good but my heart goes toward the lemon balm one.
Of course the strudel dough recipe would give me a lot more than the quantity necessary for the strudel rings. I used the same technique to make slightly higher rings with the intention to use them as baskets for ice cream or sorbet. I even made handles for them but a mini trip over pupp Bailey and the handles flew across the room and broke to pieces. Sorbet cups would have to do. I made Garrett's rhubarb sorbet over the weekend and it was a wonder there was enough left to fill the cups. If you have the chance, run to make it! Absolutely delightful. My only change to his recipe is that I did not strain the rhubarb but pureed the heck out of it. Worked like a charm. Pink, smooth and creamy all at once.
I still had plenty of dough to make a traditional strudel like most of my Daring Bakers partners. I filled this one with roasted quince that I had in the freezer and fresh roasted white peaches. I sprinkled a basic hazelnut crumble on the dough before layering the fruits and rolled the dough in a log. In the cacophony of friends coming over for brunch, I completely forgot to take pictures of the log and had just a split moment to take pictures of the small strudel bites I cut for everybody to sample.
I found the dough a litte bland at first but paired with a punch of flavors it really took a life of its own and today I am glad to have leftovers of all three desserts to chose from after dinner!
See below for all the recipes and my notes.
The May Daring Bakers' challenge was hosted by Linda of make life sweeter! and Courtney of Coco Cooks. They chose Apple Strudel from the recipe book Kaffeehaus: Exquisite Desserts from the Classic Cafés of Vienna, Budapest and Prague by Rick Rodgers.
One year ago: Daring Bakers' Lavender White Chocolate Opera
Strudel dough
from "Kaffeehaus – Exquisite Desserts from the Classic Cafés of Vienna, Budapest and Prague" by Rick Rodgers
Notes: I used a printed tablecloth so I could see better how thin the dough was getting and how much I could keep on stretching. I found out that no pleats or wrinkles was much better or the dough will take on those at the same time you roll.
Use plenty (and more) flour to roll and instead of rubbing my hands on the cloth to make the flour stick down, I rolled my rolling pin over a few times. Do not refrain from kneading a full 8 to 10 minutes. It will develop all the gluten strands necessary to make this dough stretch like a breeze
1 1/3 cups (200 g) unbleached flour
1/8 teaspoon salt
7 tablespoons (105 ml) water, plus more if needed
2 tablespoons (30 ml) vegetable oil, plus additional for coating the dough
1/2 teaspoon cider vinegar
Combine the flour and salt in a stand-mixer fitted with the paddle attachment. Mix the water, oil and vinegar in a measuring cup. Add the water/oil mixture to the flour with the mixer on low speed. You will get a soft dough. Make sure it is not too dry, add a little more water if necessary.
Take the dough out of the mixer. Change to the dough hook. Put the dough ball back in the mixer. Let the dough knead on medium until you get a soft dough ball with a somewhat rough surface.
Take the dough out of the mixer and continue kneading by hand on an unfloured work surface. Knead for about 2 minutes. Pick up the dough and throw it down hard onto your working surface occasionally.
Shape the dough into a ball and transfer it to a plate. Oil the top of the dough ball lightly. Cover the ball tightly with plastic wrap. Allow to stand for 30-90 minutes (longer is better).
It would be best if you have a work area that you can walk around on all sides like a 36 inch (90 cm) round table or a work surface of 23 x 38 inches (60 x 100 cm). Cover your working area with table cloth, dust it with flour and rub it into the fabric. Put your dough ball in the middle and roll it out as much as you can.
Pick the dough up by holding it by an edge. This way the weight of the dough and gravity can help stretching it as it hangs. Using the back of your hands to gently stretch and pull the dough. You can use your forearms to support it.
The dough will become too large to hold. Put it on your work surface. Leave the thicker edge of the dough to hang over the edge of the table. Place your hands underneath the dough and stretch and pull the dough thinner using the backs of your hands. Stretch and pull the dough until it's about 2 feet (60 cm) wide and 3 feet (90 cm) long, it will be tissue-thin by this time. Cut away the thick dough around the edges with scissors. The dough is now ready to be filled.
To make strudel rings and cups:
Cut four 1.5-inch strips of dough, brush them with melted butter and roll them around cake rings. Bake at 350F until golden brown, about 15 minutes.
Cut four 2-inch strips for the sorbet cups. Proceed as with the rings.
For the hazelnut crumble, quince and white peach filling:
Notes: this will make enough for 1/3 of the dough. Adapt if necessary.
2 white peaches, cur in half and pitted
1 large quince, peeled and cored
2 tablespoons (25gr) sugar
equal parts light brown sugar, flour, butter (cut in 1/4-inch cubes) and chopped hazelnuts (I did 50gr of each)
Place the peaches and the quince in a medium baking pan lightly sprayed with cooking spray and roast at 350F for 30 to 40 minutes until caramelized. Check at half time and add 1/4 cup of water to the pan is necessary to prevent them from scortching. Once baked, let cool completely to room temperature. Slice the fruits thin.
In a large bowl, stir together all the crumble ingredients and mix with your fingertips until the mixture forms pea size crumbs.
Fill the strudel with a layer of crumble and top with the roasted fruit. Roll from the short end, lightly brush with melted butter and bake at 350 for 30 minutes (more if you are doing the whole quantity of dough as a regular strudel).
Mascarpone Ricotta Cheese Tarts In Strudel Rings, adapted from Richard Leach.
Makes 4
Tart Rings:
See above
For Lemon Balm Cherries:
2 cups (290gr) pitted and halved cherries
1/2 cup (125ml) water
juice of 1/2 lemon
1/2 cup (100gr) sugar
4 leaves lemon balm, roughly chopped
For the Mascarpone-Ricotta Tarts:
3/4 cup (180gr) mascarpone cheese, at room temperature
1/4 cup + 2 tablespoons (90gr) ricotta cheese
1/4 cup (50gr) sugar
1/2 vanilla bean, split in half and seeded
1 whole egg
1 egg white
1/4 cup (60ml) heavy cream
Prepare the cherries:
Place all the ingredients in a heavy saucepan and bring to a boil over high heat. Reduce heat to medium and simmer 5 minutes. Remove from the heat and let cool. Strain to discard the lemon balm. Use to decorate the tarts.
Prepare the tarts:
Wrap four 3-inch dessert rings with foil and place them on baking sheet. Lightly spray the inside with cooking spray.
Preheat the oven to 350F and position a rack in the middle.
In a mixer fitted with the paddle attachment, whip together the mascarpone, ricotta, sugar and vanilla bean seeds at medium speed, until smooth, about 2 minutes. Reduce the speed to low and add the egg and egg white and beat until smooth, scraping the sides and bottom of your bowl if necessary. Still on low speed, add the heavy cream and whip until incorporated.
Divide the mxiture evenly among the prepared cake rings and bake for 20 minutes or until just set. Let cool completely.
Once cooled, place a strudel ring around each tart and spoon some marinated cherries around the tarts.
Rhubarb Sorbet For Strudel Cups, adapted from Garrett's.
3 1/2 cups of chopped fresh rhubarb (4-5 stalks)
2 1/2 cups of water
1 2/3 cups of sugar
2 teaspoons of lemon zest
2 tablespoons of corn syrup (I used glucose)
Placethe rhubarb, sugar, water, and lemon zest in a large and heavy saucepan. Bring to a boil over high heat. Reduce heat to low, and simmer 5 minutes, uncovered.
Let cool to room temperature. Working in batches, purée the mixture in a blender until smooth. Stir in the glucose. Cover and refrigerate until completely cold, preferably overnight.
Process the ice cream according to your machine's manufacturer's instructions. The sorbet will have a soft texture right out of the ice cream maker. Freeze a couple of hours before serving.


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Today's last word in business is busting the doorbusters.
Shoppers are heading out to stores today. Many went shopping overnight to seize those Black Friday bargains. But are the deals really unbeatable?
No. Not according to an analysis by pricing research firm Decide Incorporated and The Wall Street Journal. They found that many products with so-called doorbuster deals had deals that were available at even lower prices at other times of the year - even at the same retailer.
WERTHEIMER: For example, the department store Sears advertised a mixer on sale for Black Friday at only $319.99. But researchers found the same item was $20 cheaper back in March.
INSKEEP: They found more examples at Target, Home Depot and Best Buy, among others. So while many products are steeply discounted, it may not be the best deal ever.
WERTHEIMER: Analysts say it's always good to check prices. And that's the business news on MORNING EDITION from NPR News. Transcript provided by NPR, Copyright NPR.