Abstract
The Mission of Brave - Let's turn radiotherapy into an adventure! is a person-focused preparation and education programme developed to reduce anxiety and improve engagement among paediatric patients (aged 0–18) across seven Hungarian radiotherapy centres. From May 2023 to May 2026, 256 children participated in this nationwide initiative. The programme integrates storytelling, play-based education, and environmental transformation. Core elements include a themed gift box with a LEGO linear accelerator model, storybooks, interactive activities, personalised immobilisation mask decoration, comfort objects, and symbolic milestones. By framing radiotherapy as a heroic mission with the character ‘Brave’, the programme enhances understanding, reduces fear, and promotes cooperation through multidisciplinary staff collaboration. Notably, in 5 cases, improved procedural familiarity directly eliminated the need for general anaesthesia. Integrated into routine clinical preparation and supported by charitable donations, this programme provides a practical model for improving patient experience in paediatric radiation oncology.
Keywords: paediatric radiation therapy, radiotherapy preparation, empowering programme, patient experience, therapeutic play, person-focused care
Graphical abstract
Highlights
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A person-focused paediatric radiotherapy preparation programme was developed.
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256 children undergoing radiotherapy in Hungary have participated in the programme between 2023 and 2026.
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The programme is intended to support patient engagement and cooperation during radiotherapy procedures.
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Reduced need for general anaesthesia is a clinically relevant hypothesis for future evaluation.
Introduction
Radiotherapy is an essential component in the multi-modal management of various paediatric malignancies [1], [2]. Despite its therapeutic efficacy, the experience of radiotherapy often induces severe distress in young patients [3]. Children are routinely confronted with unfamiliar medical technology, complex positioning, restrictive immobilisation devices, and mandatory separation from parents during treatment delivery. These factors contribute to anxiety, fear, and reduced cooperation during simulation and treatment delivery [4], [5].
Paediatric patients frequently lack the cognitive development to comprehend the rationale behind high-precision treatment or the mechanics of radiation delivery. When clinical procedures are perceived as threatening or incomprehensible, emotional distress escalates. This elevated anxiety frequently necessitates pharmacological sedation or general anaesthesia to ensure the absolute immobility required for accurate imaging and radiation delivery [6], [7].
In recent years, the paradigm of person-centred care in radiation oncology has emphasised the necessity of balancing technical precision with comprehensive psychosocial support. In paediatric oncology, play-based education, therapeutic storytelling, and the introduction of familiar objects are recognised as effective modalities to enhance engagement and mitigate distress [8], [9], [10].
‘The Mission of Brave - Let's turn radiotherapy into an adventure!’ is a charitable paediatric preparation programme developed in Hungary to address these challenges. The initiative reframes radiotherapy as a heroic adventure in which children participate as active protagonists. Through narrative storytelling, interactive educational tools, and environmental modifications within the radiotherapy department, the programme aims to help children better understand the treatment process while reducing fear and promoting cooperation.
This descriptive report delineates the conceptual foundation, structural development, and nationwide clinical implementation of the programme, outlining how principles derived from therapeutic storytelling and psychosocial preparation can be translated into practical clinical workflows, rather than a formal outcome-evaluation study.
Methods
Narrative and psychosocial framework
The programme is conceptually anchored in narrative medicine and therapeutic play. Rather than presenting the radiotherapy workflow as fragmented medical tasks, the framework integrates these steps into a continuous storyline. By utilising symbolic metaphors and role-play, the clinical environment is translated into a structured narrative space. This approach enhances predictability and fosters a sense of perceived control and personal agency. Interactive tools such as the LEGO linear accelerator model and mission-oriented narrative framework allow children to actively manipulate the treatment apparatus, shifting their role from passive subjects to active participants. By reframing radiotherapy as a symbolic and playful mission, the intervention additionally supports meaning-making and emotional engagement during treatment.
Programme development
The Mission of Brave programme was initiated by medical physicist expert Georgina Fröhlich at the National Institute of Oncology in Budapest, Hungary. The concept emerged from clinical observations that young children undergoing radiotherapy often experience anxiety due to unfamiliar technology and limited understanding of the treatment process.
The programme was developed with the help of Georgina's children with the goal of transforming the perception of radiotherapy from a frightening medical procedure into an empowering experience. By introducing a fictional character named ‘Brave’ (Fig. 1), the treatment process is presented as a mission in which the child becomes a heroic astronaut fighting harmful cells threatening a planet.
Fig. 1.
Brave and Photon in their spaceship.
As the programme was originally developed as a clinical practice initiative rather than a formal research study, no prospective psychological outcome assessment was initially planned. However, observational feedback from clinical staff, children, and parents was collected during routine clinical implementation.
The preparation gift box
The central component of The Mission of Brave programme is a themed preparation gift box given to children before the start of their radiotherapy course. The box introduces the story and characters of the programme while providing educational and creative materials designed to familiarise children with the treatment process (Fig. 2).
Fig. 2.
The content of The Mission of Brave gift box.
A vital component of the box is a LEGO model of a medical linear accelerator designed by Georgina. Children assemble this model independently using clearly illustrated instructions, allowing them to explore the spatial configuration and mechanical articulation of the equipment in a non-threatening manner. Each kit features a personalised LEGO figurine configured to resemble the individual patient, reinforcing personal identification with the narrative. A QR code embedded within the kit directs families to an educational stop-motion animated short film. Filmed inside a comprehensive LEGO radiotherapy bunker, it features children explaining the imaging, positioning, and treatment environment in an accessible, reassuring vernacular [11].
Storybook and mission booklet
The gift box contains a dedicated storybook and an interactive mission booklet (Fig. 3). The narrative describes how the character Brave dreams that he is an astronaut navigating a vital cosmic mission. This planetary metaphor translates abstract biophysical concepts of ionising radiation into an understandable format: the radiation beams are framed as precise tools utilised to eliminate tumour cells. The mission booklet contains targeted cognitive exercises, including puzzles, mazes, and colouring pages that structurally reinforce the technical steps of the treatment path.
Fig. 3.
The adventure of Brave in the mission booklet.
Comfort objects
To provide emotional stabilisation during mandatory parental separation, patients receive a plush teddy bear named ‘Photon’ and a thin soft blanket. This blanket is placed directly onto the rigid treatment couch during each fraction, providing tactile comfort and reinforcing a sense of security within the shielded treatment vault.
Personalised immobilisation masks
For patients requiring head-and-neck radiotherapy, thermoplastic immobilisation masks are clinically indispensable yet represent a major source of anxiety. Within this programme, these devices are reframed as ‘Fabulous Masks’. Following the initial simulation, children select a preferred fairy-tale hero character from a catalogue. Subsequently, members of the multi-professional radiotherapy team hand-paint the chosen design directly onto the mask (Fig. 4).
Fig. 4.
The Fabulous Masks and the team that created them.
Environmental transformation
To maintain narrative continuity, the physical architecture of the radiotherapy department is dynamically altered. Clinical staff members directly engaging with paediatric patients wear custom uniforms matching the Brave motif. Furthermore, visual enhancements, including Brave astronaut-themed light painting, are deployed within the treatment room, casting comforting cosmic imagery across the walls and the linear accelerator gantry (Fig. 5).
Fig. 5.
The Brave astronaut light painting of the linear accelerator and the bunker.
Treatment milestones
Progress through the multi-week fractionated regime is reinforced via symbolic milestones. Upon completing their final fraction, patients ring the ‘Bell of Hope’, marking the successful conclusion of their cosmic mission. Graduates are presented with a large Brave plush toy and a gold medal recognising their courage.
Clinical implementation
The Mission of Brave was launched in May 2023, supported by the Richter Anna Award [12], [13]. Sustained through ongoing charitable donations, all materials are distributed entirely free of charge. The programme has been implemented as part of the routine preparation process for paediatric radiotherapy patients at all of the 7 paediatric radiotherapy centres in Hungary.
A total of 73 healthcare professionals across the seven national sites were surveyed regarding implementation, comprising 17 radiation oncologists, 15 paediatric anaesthesiologists, 27 radiation therapists (RTTs), 8 computed tomography (CT) technologists, and 9 clinical coordinators and oncology nurses. Within this collaborative network, a dedicated sub-cohort of 24 staff members actively volunteered to execute the manual artistic customisation of the immobilisation masks.
Specific protocol adjustments were mandated to preserve patient safety and clinical utility. Children under three years of age were excluded from receiving the standard intervention kit due to regulations regarding potential choking hazards from small component parts. Additionally, mask customisation was omitted for patients undergoing daily general anaesthesia, given that these patients lack the conscious visual perception required to engage with the painted designs. However, these clinical subgroups remained fully eligible for all other non-hazardous narrative, environmental, and milestone elements of the initiative.
The programme has achieved widespread national recognition for innovation in healthcare communication. The educational stop-motion film received the Humanitarian Health Award from the Hungarian affiliate of Teva Pharmaceutical Industries [14]. Furthermore, the educational curriculum was awarded the Health Literacy Award by the Association of Innovative Pharmaceutical Manufacturers [15].
Results
Between May 2023 and May 2026, a total of 256 paediatric oncology patients aged 0 to 18 years were enrolled in and completed the programme across the seven participating Hungarian centres. Within this national cohort, the mean patient age was 10.3 (0.8–18.0) years. The definitive age distribution was structured as follows: 39 patients (15.2%) were aged 0–5 years, 79 (30.9%) were aged 5–10 years, 87 (34.0%) were aged 10–15 years, and 51 (19.9%) were aged 15–18 years.
In terms of treatment delivery and technical allocation, 221 patients (86.3%) underwent treatment utilising conventional C-arm linear accelerators. High-precision specialised modalities included 5 patients (2.0%) managed via stereotactic radiotherapy on the CyberKnife system (Accuray, Sunnyvale, CA, USA) and 3 patients (1.2%) treated via online adaptive radiation therapy using the Ethos system (Varian Medical Systems, Palo Alto, CA, USA). Total body irradiation (TBI) protocols were delivered to 27 patients (10.5%) utilising a Cobalt-60 source.
A single patient (0.4%) presenting with a co-morbid diagnosis of severe autism spectrum disorder (ASD) was excluded from the final core evaluation. While this patient engaged positively with the pre-treatment gift box and plush toys, the dynamic visual stimulus generated by the environmental light painting induced acute sensory overload and hyperarousal. This hyperarousal compromised the strict immobility required for safe, high-precision radiation delivery. Consequently, the light projection component was immediately discontinued for this individual, and their data were omitted from the core descriptive analysis to preserve cohort homogeneity.
As the programme was not originally designed as a formal research intervention, no predefined quantitative endpoints were prospectively collected. However, during routine clinical implementation, several recurring clinical and behavioural domains were consistently observed by staff members, children, and parents (Table 1). Throughout routine implementation, clinical staff subjectively reported marked improvements in procedural familiarity, a noticeable reduction in acute distress behaviours (such as crying, thrashing, or verbal resistance), and enhanced positioning compliance. The cosmic ambient modifications effectively shifted the clinical atmosphere; children frequently approached the treatment table with visible curiosity rather than anticipatory dread, with several patients entering the bunker eagerly to continue their ‘mission’.
Table 1.
Observed clinical and behavioural domains associated with programme implementation.
| Clinical domain | Observed programme-related indicators |
|---|---|
| Procedural familiarity | Increased recognition of the treatment environment and equipment by children |
| Emotional distress | Reduced visible distress behaviours during preparation and treatment sessions |
| Treatment cooperation | Improved ability to remain still and engage with procedural instructions |
| Parent engagement | Reduced parental resistance and greater acceptance of the treatment process |
| Treatment acceptance | Increased willingness to attend repeated radiotherapy sessions |
| Sedation-related observations | In selected cases, staff observed that increased familiarity and cooperation has contributed to avoidance or reduction of general anaesthesia requirements |
Furthermore, the structured preparatory materials enhanced treatment literacy among parents, effectively lowering parental anxiety. This reduction in familial stress created a positive feedback loop, redirecting attention away from clinical apprehension and toward the task-oriented components of the narrative. For the clinical staff, the programme provided a unified vocabulary, enabling therapists to communicate technical commands through playful, child-centred terminology (e.g., framing the linear accelerator gantry as a responsive ‘spaceship’).
Qualitative feedback demonstrated exceptionally high levels of patient and familial satisfaction across all age groups. Notably, this high engagement extended successfully into the older adolescent cohort (aged 14 years and older). While overall compliance was uniform, distinct gender-specific preferences were observed during the initial unboxing of the materials: female patients (n = 108) predominantly gravitated toward the plush comfort objects, whereas male patients (n = 148) consistently prioritised the mechanical assembly of the LEGO model.
Within the total cohort, a sub-group of 83 patients (32.4%) required head-and-neck immobilisation masks, and 53 patients (20.7%) required daily fractionated general anaesthesia. Minimising or eliminating fractional general anaesthesia in paediatric radiotherapy yields massive clinical and structural advantages: it eliminates the metabolic stress of prolonged daily fasting, removes inherent anaesthetic medical risks, reduces pre- and post-treatment preparation times, and optimises departmental workflow efficiency. Within the highly vulnerable 4-to-6-year-old cohort of 25 cases (9.8%), the narrative and play-based conditioning protocols directly enabled five children (20.0%) to successfully transition to fully conscious, un-sedated treatment courses without compromising geographic positioning accuracy or treatment compliance.
Discussion
The integration of person-focused care principles within modern radiation oncology is critical, particularly when managing paediatric populations where technical sophistication must coexist with emotional safety [16], [17]. While technological refinements have vastly enhanced dose conformity, the raw psychological stress experienced by a child isolated inside a treatment room remains a significant clinical barrier.
Historically, various pre-treatment preparation strategies have been deployed globally, encompassing structured hospital tours, basic educational booklets, or independent child-life specialist consultations [3], [4], [5], [6], [7], [8], [9], [10]. For example, work by Susan Grissom and colleagues demonstrated that systematic behavioural preparation and therapeutic play activities can significantly enhance positional cooperation during cranial paediatric radiotherapy [8]. However, a persistent limitation of many historical frameworks is their fragmented nature—frequently focusing exclusively on distraction, baseline education, or isolated psychological support without unifying these elements across the entire clinical continuum [18], [19]. Recent global systematic reviews have continuously emphasised the acute necessity for highly integrated, multi-disciplinary psychosocial interventions that simultaneously address cognitive, emotional, and environmental factors across the entire patient pathway [8], [20], [21].
The Mission of Brave addresses this systemic gap by merging multiple modalities of person-centred support into a singular, cohesive narrative matrix. The programme seamlessly links pre-clinical preparation (the gift box with LEGO-linac), peer-to-peer education (the storybook and the stop-motion video), cognitive engagement (the mission booklet), physical coping mechanisms (the comfort objects), personalised medical hardware (the hand-painted Fabulous Masks), ambient design (cosmic light painting), and positive reinforcement (the Bell of Hope). By maintaining absolute narrative fidelity from the initial outpatient consultation through to the final treatment fraction, the character ‘Brave’ transitions from a distant storybook figure into a stable symbolic companion, transforming the intimidating radiotherapy department into a predictable, imaginative space [22].
Embedding complex physical and medical parameters within an age-appropriate cosmic metaphor effectively translates alien experiences into manageable concepts. The physical construction of the LEGO linear accelerator provides tactile mastery over the exact device that the child will encounter, effectively demystifying the massive machine. Similarly, transforming the restrictive thermoplastic mask from an instrument of sensory isolation into a superhero emblem directly mitigates the loss of perceived control and personal agency commonly associated with paediatric immobilisation.
Crucially, the clinical utility of this integrated preparation model is underscored by its capacity to reduce fractional sedation rates in specific paediatric populations [23], [24]. The successful transition of 20% of the highly vulnerable 4-to-6-year-old cohort from daily general anaesthesia to conscious cooperation represents not only a profound reduction in clinical risk and metabolic burden for these developing children but also a substantial reduction in institutional resource utilisation, anaesthetic staff workload, and scheduling complexity.
Limitations and future directions
The primary limitation of the current report is its descriptive nature; because the initiative was developed organically to address an immediate clinical need, no prospective quantitative psychological scales were systematically deployed. The clinical improvements and behavioural adaptations reported by staff remain observational (Table 1). Consequently, these findings cannot establish direct causality or definitively quantify the isolated therapeutic effect of individual programme components.
To address these limitations, future prospective, multi-centre trials are warranted. These studies should utilise validated psychometric instruments to formally evaluate changes in anxiety. Additionally, objective metrics regarding daily setup reproducibility, intra-fraction motion tracking, specific throughput times, and long-term financial cost-benefit analyses regarding avoided anaesthesia fractions should be systematically compiled. Future iterations of the programme will explore the digital expansion of the curriculum through interactive mobile applications, augmented reality (AR) simulation of the linear accelerator, and the translation of the standardised materials into other European languages.
Conclusion
The Mission of Brave successfully translates person-focused care into a nationwide clinical reality across Hungary. By unifying play-based preparation, customised immobilisation devices, and environmental design under a single narrative theme, the initiative provides a reproducible model to minimise paediatric distress. This programme demonstrates that developmentally sensitive, structured psychosocial frameworks are essential companions to high-precision physics in modern oncology.
CRediT authorship contribution statement
Georgina Fröhlich: Writing – review & editing, Writing – original draft, Visualization, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Júlia Vízkeleti: Writing – review & editing, Writing – original draft, Supervision, Investigation, Data curation. Péter Kovács: Validation. Zoltán Takácsi-Nagy: Supervision.
Ethical approval
Ethical approval was not required, as this manuscript describes a clinical practice development and does not report data from a formal research study involving human participants.
Funding
The programme is supported by charitable donations from private individuals and corporate partners.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
Acknowledgements
The authors would like to thank Georgina's 3 children, who contributed creative ideas during the development of The Mission of Brave concept, including the LEGO kit and the short film, the story elements and the visual design inspiration. Their imagination and enthusiasm played an important role in shaping the narrative framework of the programme. The authors also acknowledge the radiotherapy staff and supporters who contributed to the development and implementation of The Mission of Brave programme.
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