Quality of Life in Survivors of Pediatric Cancer and Their Siblings: The Consensus Between Parent-Proxy and Self-Reports

Quality of life in children and adolescents after treatment for acute lymphoblastic leukemia according to the NOPHO ALL2008 protocol

BACKGROUND

The improved outcome of childhood acute lymphoblastic leukemia (ALL) over the last decades has increased the importance of assessing late effects and health-related quality of life (HRQoL), particularly when evaluating and comparing outcomes in clinical trials. This study aimed to assess HRQoL in children treated for ALL according to the NOPHO ALL2008 protocol.

PROCEDURE

Children, aged 1 to less than 18 years at diagnosis, alive in first remission, and their parents, were asked to complete PedsQL 4.0 Generic Core Scales (self- and proxy-report) at ≥6 months after end of therapy. Data on socioeconomic factors and parent-reported toxicity were collected through a study-specific questionnaire, and the NOPHO ALL2008 database was used to identify eligible families and add additional disease- and treatment-related data. HRQoL data were collected during 2013-2019 in Sweden, Finland, and Denmark.

RESULTS

A total of 299 children were included. The older children (8 years and older) reported similar HRQoL scores compared to Finnish reference data, except lower scores for School Functioning in high-risk patients. Scores from the parent-proxy and self-reports from 5-7-year olds were notably lower than reference. Parent-reported toxicity was associated with lower total and physical HRQoL scores in adjusted models for younger as well as older children in the self-report and parent-proxy versions, and also with lower psychosocial score in the parent-proxy.

CONCLUSIONS

Self-reported HRQoL was similar to reference population. The most important determinant for HRQoL after end of ALL treatment was parent-reported toxicity during treatment. Thus, minimizing complications is an obvious focus for future treatment protocols.

Agreement between quality of life assessed using family proxy and child self-reports among children with hematologic malignancy

Evidence-based literature recognizes that the different degrees of agreement between a child self-report and a proxy-report depend on the characteristics of the domains, the child's age and illness, the proxy's own perspective on QoL, and family attendance during the child's hospitalization. This study aims to determine the degree of agreement between proxy-reports and child self-reports on quality of life (QoL) for children with hematologic malignancy ranging in age from 5 to 18 years who are undergoing treatment. We retrieved clinical QoL data from a study titled "Dynamic change in QoL for Vietnamese children with hematologic malignancy" from April 2021 to December 2022. To evaluate the magnitude of agreement between self-reports and proxy-reports, intraclass correlation coefficients (ICCs) for 259 pairs of measurements were quantified. Using independent t tests, the mean differences between self-reports and proxy-reports were tested. Moderate agreement was consistent through all age groups for five subscales, including physical, psychosocial, pain, nausea, and procedural anxiety (ICCs ranged from 0.53 to 0.74). The weakest agreement appeared in two groups, subjects aged 5-7 years and 13-18 years on six domains (school, treatment anxiety, worry, cognitive problems, perceived physical appearance, and communication) (-0.01 to 0.49). Child self-rating was consistently higher than that of proxies for the physical, emotional, and nausea domains among children aged 5-7 years and for procedural anxiety, treatment anxiety, and cognitive problems among children aged 8-12 years.    Conclusion: The agreement level of self-reports and proxy-reports was differently distributed by child age and the PedsQL domains. The proxy children agreement on QoL among children with hematologic malignancy was divergent according to the different age groups, which could potentially be explained by proxy-child bonding at different stages of childhood development. Our recommendation for future studies is to explore children's age as a potential factor influencing proxy agreement on QoL among children with cancer. What is Known: • Children and their proxies may think differently about quality of life (QoL). • Comparing two sources of data (i.e., child and proxy) on aspects of QoL can help identify the discrepancies between children's perceptions of their QoL and their parents' perceptions. This can be useful in terms of identifying potential areas for improvement or concern and may also be helpful in making decisions about treatment and care. What is New: • Our study results demonstrated that proxies who comprised children aged 5-7 years or 13-18 years reported differently among domains that cannot be expressed verbally or with body language, including cognitive problems, perceived physical appearance, and communication. • Children generally perceived their QoL to be better than their proxies. Therefore, a more comprehensive understanding of children's QoL may require the consideration of multiple sources of data from various perspectives.

Psychosocial functioning of adult siblings of Dutch very long-term survivors of childhood cancer: DCCSS-LATER 2 psycho-oncology study

OBJECTIVE

To describe psychosocial outcomes among adult siblings of very long-term childhood cancer survivors (CCS), to compare these outcomes to reference populations and to identify factors associated with siblings' psychosocial outcomes.

METHODS

Siblings of survivors (diagnosed <18 years old, between 1963 and 2001, >5 years since diagnosis) of the Dutch Childhood Cancer Survivor Study DCCSS-LATER cohort were invited to complete questionnaires on HRQoL (TNO-AZL Questionnaire for Adult's HRQoL), anxiety/depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Self-Rating Scale for Post-traumatic Stress Disorder), self-esteem (Rosenberg Self-Esteem Scale) and benefit and burden (Benefit and Burden Scale for Children). Outcomes were compared to a reference group if available, using Mann-Whitney U and chi-Square tests. Associations of siblings' sociodemographic and CCS' cancer-related characteristics with the outcomes were assessed with mixed model analysis.

RESULTS

Five hundred five siblings (response rate 34%, 64% female, mean age 37.5, mean time since diagnosis 29.5) of 412 CCS participated. Siblings had comparable HRQoL, anxiety and self-esteem to references with no or small differences (r = 0.08-0.15, p < 0.05) and less depression. Proportions of symptomatic PTSD were very small (0.4%-0.6%). Effect sizes of associations of siblings' sociodemographic and CCS cancer-related characteristics were mostly small to medium (β = 0.19-0.67, p < 0.05) and no clear trend was found in the studied associated factors for worse outcomes.

CONCLUSIONS

On the very long-term, siblings do not have impaired psychosocial functioning compared to references. Cancer-related factors seem not to impact siblings' psychosocial functioning. Early support and education remain essential to prevent long-term consequences.

Emotional and behavioral problems of pediatric cancer survivors and their siblings: Concordance of child self-report and parent proxy-report

OBJECTIVE

Childhood cancer confronts families with major challenges. The study aimed at developing an empirical and multi-perspective understanding of emotional and behavioral problems of cancer survivors diagnosed with leukemia and brain tumors and their siblings. Further, the concordance between child self-report and parent proxy-report was examined.

METHODS

140 children (72 survivors, 68 siblings) and 309 parents were included in the analysis (respond rate: 34%). Patients, diagnosed with leukemia or brain tumors, and their families were surveyed on average 7.2 months after the end of intensive therapy. Outcomes were assessed using the German SDQ. Results were compared with normative samples. Data were analyzed descriptively, and group differences between survivors, siblings, and a norm sample were determined using one-factor ANOVA followed by pairwise comparisons. The concordance between the parents and children was determined by calculating Cohen's kappa coefficient.

RESULTS

No differences in the self-report of survivors and their siblings were identified. Both groups reported significantly more emotional problems and more prosocial behavior than the normative sample. Although the interrater reliability between parents and children was mostly significant, low concordances were found for emotional problems, prosocial behavior (survivor/parents), and peer relationship problems (siblings/parents).

CONCLUSION

The findings point out the importance of psychosocial services in regular aftercare. These should not only focus on survivors, but additionally address the siblings' needs. The low concordance between the parents' and the children's perspectives on emotional problems, prosocial behavior, and peer relationship problems suggests the inclusion of both perspectives to allow needs-based support.

Why Psychosocial Care Matters: Parent Preparedness and Understanding Predict Psychosocial Function When Children Return to School After Cancer

Introduction: Psychosocial impacts of cancer are well-recognized for pediatric patients but few studies examine challenges specific to schooling after diagnosis and caregiver-related factors that may influence coping. This study describes caregiver experiences of school-related psychosocial functioning and how caregiver preparedness and understanding of these challenges influence coping. Methods: Caregivers of 175 childhood cancer survivors completed a nationally disseminated survey related to caregiver preparedness, clinician-provided education, and school-related experiences. Caregiver-reported preparedness and understanding were evaluated as predictors of psychosocial coping; factor analysis was performed to identify compound scales of preparedness and understanding. Results: Caregivers reported that the cancer treatment experience resulted in their children being more stressed and anxious about returning to school (60.2% and 70.2%, respectively) and more sensitive to peers (73.4%). It also made it harder for them to socialize and fit in with peers (58.2% and 49.7%, respectively). Caregiver preparedness and understanding predicted improved psychosocial coping with regard to child stress regarding socialization, fitting in, and anxiety but not sensitivity to peers. Teacher supportiveness and caregiver perception of clinician understanding also correlated with function. Discussion: Findings highlight the importance of caregiver education and preparedness as these reliably predict child psychosocial function and coping as they return to school after a cancer diagnosis and that all children are at risk for psychosocial challenges following a cancer diagnosis. Opportunities exist for clinicians to provide more education and anticipatory guidance to families as a potential means to reduce poor coping when a child returns to school following cancer.

Ten Considerations for Integrating Patient-Reported Outcomes into Clinical Care for Childhood Cancer Survivors

Patient-reported outcome measures (PROMs) are subjective assessments of health status or health-related quality of life. In childhood cancer survivors, PROMs can be used to evaluate the adverse effects of cancer treatment and guide cancer survivorship care. However, there are barriers to integrating PROMs into clinical practice, such as constraints in clinical validity, meaningful interpretation, and technology-enabled administration of the measures. This article discusses these barriers and proposes 10 important considerations for appropriate PROM integration into clinical care for choosing the right measure (considering the purpose of using a PROM, health profile vs. health preference approaches, measurement properties), ensuring survivors complete the PROMs (data collection method, data collection frequency, survivor capacity, self- vs. proxy reports), interpreting the results (scoring methods, clinical meaning and interpretability), and selecting a strategy for clinical response (integration into the clinical workflow). An example framework for integrating novel patient-reported outcome (PRO) data collection into the clinical workflow for childhood cancer survivorship care is also discussed. As we continuously improve the clinical validity of PROMs and address implementation barriers, routine PRO assessment and monitoring in pediatric cancer survivorship offer opportunities to facilitate clinical decision making and improve the quality of survivorship care.

Psychosocial outcomes and quality of life among school-age survivors of retinoblastoma

BACKGROUND

Retinoblastoma is the most common intraocular childhood cancer and is typically diagnosed in young children. With increasing number of survivors and improved medical outcomes, long-term psychosocial impacts need to be explored. Thus, the current study sought to assess functioning in school-aged survivors of retinoblastoma.

PROCEDURE

Sixty-nine survivors of retinoblastoma underwent a one-time evaluation of psychosocial functioning. Survivors (Mage = 10.89 years, SD = 1.07 years; 49.3% male; 56.5% unilateral disease) and parents completed measures of quality of life (QoL; PedsQL) and emotional, behavioral, and social functioning (PROMIS [patient-reported outcome measurement information system] Pediatric Profile, BASC-2 parent report). Demographic and medical variables were also obtained.

RESULTS

On the whole, both survivors and caregivers indicated QoL and behavioral and emotional health within the typical range of functioning. Survivors reported better physical QoL compared to both parent report and a national healthy comparison sample, whereas caregivers reported that survivors experienced lower social, school, and physical QoL than a healthy comparison. Regarding behavioral and emotional health, survivors indicated more anxiety than a nationally representative sample. Parents of female survivors endorsed lower adaptive scores than parents of male survivors.

CONCLUSIONS

Results indicated that survivors of retinoblastoma reported QoL and behavioral and emotional health within normal limits, although parents appear to perceive greater impairment across several assessed domains. Understanding both survivor and parent reports remains important for this population. Future research should explore psychosocial functioning of these survivors as they transition to adolescence and early adulthood, given the increased independence and behavioral and emotional concerns during these developmental periods.

Hearing-related quality of life in children and adolescents in rural Alaska

Objective

This study evaluated the Hearing Environments and Reflection on Quality of Life (HEAR-QL) questionnaire in rural Alaska, including an addendum crafted through community feedback to reflect the local context. The objectives were to assess whether HEAR-QL score was inversely correlated with hearing loss and middle ear disease in an Alaska Native population.

Methods

The HEAR-QL questionnaires for children and adolescents were administered as part of a cluster randomized trial in rural Alaska from 2017 to 2019. Enrolled students completed an audiometric evaluation and HEAR-QL questionnaire on the same day. A cross-sectional evaluation of questionnaire data was utilized.

Results

A total of 733 children (ages 7-12 years) and 440 adolescents (ages ≥13 years) completed the questionnaire. Median HEAR-QL scores were similar among children with and without hearing loss (Kruskal-Wallis, p = .39); however, adolescent HEAR-QL scores significantly decreased with increasing hearing loss (p < .001). Median HEAR-QL scores were significantly lower in both children (p = .02) and adolescents (p < .001) with middle ear disease compared with those without. In both children and adolescents, the addendum scores were strongly correlated with total HEAR-QL score (ρ_Spearman = 0.72 and 0.69, respectively).

Conclusions

The expected negative association between hearing loss and HEAR-QL score was observed in adolescents. However, there was significant variability that could not be explained by hearing loss, and further investigation is warranted. The expected negative association was not observed in children. HEAR-QL scores were associated with middle ear disease in both children and adolescents, making it potentially valuable in populations where the prevalence of ear infections is high.

Level of Evidence

Level 2 Clinicaltrials.gov registration numbers: NCT03309553.

Survivorship, Quality of Life, and Transition to Adult Care for Pediatric and Adolescent Thyroid Cancer Survivors

The importance of long-term survivorship care to reduce survivor and family anxiety and burden, decrease emergency visits and health care costs, improve knowledge, as well as implement timely surveillance is widely accepted. Most childhood cancer survivors suffer from an increased number of medical and psychosocial comorbidities as they age and are at a higher risk for early mortality, which differs by cancer diagnosis. Childhood thyroid cancer survivors fall within this spectrum. Some have significant complications and/or late effects from treatment, whereas others have no long-term medical late effects, but almost all will require life-long thyroid hormone replacement therapy. Therefore, providing survivorship and transitional care, including a survivorship and/or transitional care plan (SCP/TCP), as well as periodically assessing the needs and quality of life for the patient and their family, should be implemented for our young thyroid cancer survivors.

El hermano del niño con cáncer merece ser visible

El hermano sano en situaciones de cáncer infantil es con frecuencia un sujeto invisible para su familia, los profesionales de la salud y las instituciones. El objetivo de este trabajo fue mapear e integrar la literatura científica acerca de la experiencia del hermano del niño diagnosticado con cáncer. Se desarrolló una Scoping Review de 28 artículos publicados entre 2016 y 2020, en los idiomas español, inglés y portugués. Se incluyeron 12 estudios cualitativos, 15 cuantitativos y un estudio mixto. Frente a los hallazgos, se identificó que hay cambios en las relaciones entre hermanos, parentales y sociales, además de cambios personales y una oferta limitada de apoyo a los hermanos del niño con cáncer. Se concluye que el cáncer infantil afecta directamente a los miembros de la familia, incluido al hermano sano, quien enfrenta cambios drásticos en su vida que implican nuevas necesidades, sentimientos y conductas de riesgo. Se requiere una mayor investigación y abordaje acerca del impacto del cáncer infantil en hermanos sanos, así como el diseño de intervenciones que pongan de manifiesto la necesidad de hacer visible a este sujeto que sufre el daño colateral del cáncer infantil y que ha sido descuidado por su familia y por los profesionales en salud.

EQ-5D-Y-3L and EQ-5D-Y-5L proxy report: psychometric performance and agreement with self-report

BACKGROUND

Self-report is the standard for measuring people's health-related quality of life (HRQoL), including children. However, in certain circumstances children cannot report their own health. For this reason, children's HRQoL measures often provide both a self-report and a proxy-report form. It is not clear whether the measurement properties will be the same for these two forms. We investigated whether it would be beneficial to extend the classification system of the EQ-5D-Y proxy questionnaire from 3 to 5 response levels. The agreement between self-report and proxy-report was assessed for both EQ-5D-Y measures.

METHODS

The study included 286 pediatric patients and their caregivers as proxies. At three consecutive measurements-baseline, test-retest and follow-up-the proxies assessed the child's HRQoL using the EQ-5D-Y-3L, EQ-5D-Y-5L, the PedsQL Generic, and matched disease-specific instruments. The proxy versions of EQ-5D-Y-3L and EQ-5D-Y-5L were compared in terms of feasibility, distribution properties, convergent validity, test-retest and responsiveness. Agreement between both EQ-5D-Y proxy versions to their respective self-report versions was assessed at baseline and follow-up.

RESULTS

The proportion of missing responses was 1% for the EQ-5D-Y-3L and 1.4% for the EQ-5D-Y-5L. The frequency of health state with no problems in all dimensions (11111) was slightly lower for the EQ-5D-Y-5L (21.3% vs 16.7%). Regarding the convergent validity with the PedsQL and disease-specific measures, the proxy versions of EQ-5D-Y-3L and EQ-5D-Y-5L had similar magnitudes of associations between similar dimensions. The means of test-retest coefficients between the two versions of the EQ-5D-Y proxy were comparable (0.83 vs. 0.84). Regarding reported improved conditions, responsiveness of the EQ-5D-Y-5L proxy (26.6-54.1%) was higher than that of the EQ-5D-Y-3L proxy (20.7-46.4%). Except for acutely ill patients, agreement between the EQ-5D-Y-5L proxy and self-reports was at least moderate.

CONCLUSIONS

Extending the number of levels of the proxy version of EQ-5D-Y can improve the classification accuracy and the ability to detect health changes over time. The level structure of EQ-5D-Y-5L was associated with a closer agreement between proxy and self-report. The study findings support extending the EQ-5D-Y descriptive system from 3 to 5 levels when administered by a proxy, which is often the case in the pediatric population.

Morbidity and health care use among siblings of children with cancer: A population-based study

BACKGROUND

Childhood cancer impacts the entire family unit. We sought to investigate its impact on the long-term physical health outcomes of siblings of children with cancer.

PROCEDURE

Pediatric cancer patients diagnosed in Ontario, Canada between 1988 and 2016 were linked to biological siblings. Sibling cases were matched to population controls based on sex, age, geographic location, and number of other children in the family. After individual linkage to health services data, we compared several outcomes between sibling cases and controls: (a) physical health conditions (such as diabetes, hypertension, and death); (b) acute health care use (hospitalization, low- and high-acuity emergency department [ED] visits); and (c) preventive health care use (periodic health checkups, influenza vaccinations). Cox proportional hazards, recurrent event, or logistic regression models were used as appropriate.

RESULTS

We identified 8529 sibling cases and 30,364 matched controls (median age at index: 6 years, median age at last follow-up 17 years). Compared to controls, siblings were at increased risk of hypertension (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.1-2.9; p = .01), had higher rates of low- and high-acuity ED visits (rate ratio 1.1; 95% CI 1.1-1.2; p < .001), and increased risk of hospitalization (HR 1.1; 95% CI 1.1-1.2; p < .001). Sibling cases were also more likely to receive preventive health care (p < .05).

CONCLUSION

Increased risk of hypertension, high-acuity ED visits, and hospitalizations suggest that siblings may experience poorer health compared to controls. Counseling families about this potential increased risk and long-term follow-up of siblings to monitor their physical health may be justified.

Social adjustment across the lifespan in survivors of pediatric acute lymphoblastic leukemia (ALL): a systematic review

PURPOSE

The objectives of this review were to (1) summarize studies that described social adjustment in survivors of pediatric ALL across the lifespan, (2) summarize social adjustment outcomes reported across studies, and (3) examine associations between social adjustment and disease/treatment- and non-treatment-related factors.

METHODS

Searched databases included EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (EBSCO Information Services), and Web of Science (Thomson Reuters). Eligible studies included: (1) original research; (2) published in English; (3) a diagnosis of cancer between 0 and 21 years; (4) survivors at least 5 years from diagnosis and/or 2 years from therapy completion; and (5) quantitative assessment of social adjustment.

RESULTS

The literature search yielded 3698 articles of which 43 were included in the final review. Risk of bias was assessed using domains adapted from the Cochrane risk-of-bias tool. Quality of evidence was evaluated following the Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria. There was some evidence that school-aged and adolescent/young adult survivors experienced worse social adjustment compared to controls. There was some evidence suggesting cranial radiation therapy (CRT) is associated with social adjustment difficulties among young adult survivors. Inconsistent evidence was found for relapse, age at diagnosis and study, sex, and late effects in relation to social adjustment.

CONCLUSION

Survivors of pediatric ALL were at higher risk of social adjustment difficulties compared to controls. However, evidence for treatment and non-treatment risk and resilience factors require stronger evidence.

IMPLICATIONS FOR CANCER SURVIVORS

Information on modifiable factors that modulate social adjustment may influence targets of intervention and follow-up guidelines.

Psychological Adjustment of Children with Cancer: Relapse and Survival Perspectives

Abstract In Brazil, few studies have investigated the psychological aspects of childhood cancer. The aim of this article was to compare the psychological adjustment of children with cancer from different survival perspectives with that of children without cancer, besides examining potential risk factors. The sample consisted of 179 participants (6-14 years-old) recruited in two Brazilian public hospitals and three schools, and divided in three groups (relapsed, survivors and control). Children answered orally the self-reported Behavior Assessment Scale for Children, the Revised Children’s Manifest Anxiety Scale and Piers-Harris’ Self-Concept Scale. No differences were found between groups regarding school and clinical maladjustment, personal adjustment, emotional symptoms and self-concept. Findings also showed positive associations between psychological maladjustment and gender, younger age, lower household income, single parenthood and lower levels of parental education. Conclusions indicate that children with cancer adapt well to the disease and do not present more psychological problems than controls.

Social adjustment in survivors of acute lymphoblastic leukemia without cranial radiation therapy

OBJECTIVE

To evaluate group differences in social adjustment in survivors of pediatric acute lymphoblastic leukemia (ALL) compared to survivor siblings and controls; identify disease-related predictors of social adjustment in survivors; and explore whether executive functioning explained differences in social adjustment across groups and between disease-related predictors.

METHODS

Survivors of pediatric ALL (n = 38, average age at diagnosis = 4.27 years [SD = 1.97]; average time off treatment = 4.83 years [SD = 1.52]), one sibling (if available, n = 20), and one parent from each family were recruited from a long-term survivor clinic. Healthy age- and sex-matched controls (n = 38) and one parent from each family were recruited from the community. Parents completed the Behavioral Assessment System for Children, Parent Rating Scale (BASC-3) Social Withdrawal subscale as a measure of social adjustment, and the Behavior Rating Inventory of Executive Functions (BRIEF-2) as a measure of executive function for each of their children. Multilevel modeling and mediation analysis were used to achieve the study aims.

RESULTS

Parents reported that survivors had significantly worse social adjustment compared to controls (b = 6.34, p = .004), but not survivor siblings. Among survivors, greater time off treatment (b = 2.06, p = .058) and poorer executive functioning (b = 0.42, p = .006) were associated with worse social adjustment. Executive function did not mediate differences in social withdrawal between survivors and controls or the relationship between time off treatment and social withdrawal among survivors.

CONCLUSIONS

Survivors of pediatric ALL presenting to follow-up programs should be screened for difficulties with social adjustment. Future research should examine treatment- and nontreatment-related factors contributing to poorer social outcomes.

Long-term health-related quality of life in young childhood cancer survivors and their parents

PURPOSE

Few studies have investigated the health-related quality of life (HRQoL) of young childhood cancer survivors and their parents. This study describes parent and child cancer survivor HRQoL compared to population norms and identifies factors influencing child and parent HRQoL.

METHODS

We recruited parents of survivors who were currently <16 years, and >5 years postdiagnosis. Parents reported on their child's HRQoL (Kidscreen-10), and their own HRQoL (EQ-5D-5L). Parents rated their resilience and fear of cancer recurrence and listed their child's cancer-related late effects.

RESULTS

One hundred eighty-two parents of survivors (mean age = 12.4 years old and 9.7 years postdiagnosis) participated. Parent-reported child HRQoL was significantly lower than population norms (48.4 vs. 50.7, p < .009). Parents most commonly reported that their child experienced sadness and loneliness (18.1%). Experiencing more late effects and receiving treatments other than surgery were associated with worse child HRQoL. Parents' average HRQoL was high (0.90) and no different to population norms. However 38.5% of parents reported HRQoL that was clinically meaningfully different from perfect health, and parents experienced more problems with anxiety/depression (43.4%) than population norms (24.7%, p < .0001). Worse child HRQoL, lower parent resilience, and higher fear of recurrence was associated with worse parent HRQoL.

CONCLUSIONS

Parents report that young survivors experience small but significant ongoing reductions in HRQoL. While overall mean levels of HRQoL were no different to population norms, a subset of parents reported HRQoL that was clinically meaningfully different from perfect health. Managing young survivors' late effects and improving parents' resilience through survivorship may improve HRQoL in long-term survivorship.

Evaluation of the functional capacity and quality of life of children and adolescents during and after cancer treatment

Objective:

To evaluate the functional capacity and quality of life of children and adolescents during cancer treatment and post-treatment.

Methods:

Cross-sectional study of patients during cancer treatment and post-treatment, assessed by the 6-minute walk test (6MWT) and the Pediatric Quality of Life ™ questionnaire (cancer module).

Results:

Sixty-five patients, aged 11.2±3.5 years, mostly males (50.8%) and white (90.8%), with high incidence of hematological cancers (81.5%) participated in the study. The performance in the 6MWT was 23.1% inferior comparing the mean predicted and achieved (584.3±5 and 447.7±78.6 m, respectively). The percentage difference between the predicted and achieved 6MWT, and the different phases of cancer treatment were significantly different between patients in treatment (73.7±12.8) and post-treatment (84.5±9.1). When grouped by the different diagnoses, it was possible to observe that the distance covered by the patients with leukemia showed results closer to that predicted (80.7±11.7). Regarding the health-related quality of life questionnaire (HRQL), the child’s perception (78.0±14.56) was better than that reported by their parents (72.4±17.74). However, when we compared HRQL with the 6MWT, there was no association between them (p=0.597).

Conclusions:

Children and adolescents undergoing cancer treatment or post-treatment showed a 23% deficit in functional capacity. In relation to HRQL results, children’s perception was higher than that of their parents.

Concordance of Child Self-Reported and Parent Proxy-Reported Posttraumatic Growth in Childhood Cancer Survivors

Simple Summary

In pediatric cancer settings, parents can be asked to provide information about the impact of cancer on the child. However, their assessment of the child may not be accurate. Research has shown that parents tend to underestimate the quality of life of their child following pediatric cancer. Little is known about the accuracy of parental reports of posttraumatic growth (PTG) as a consequence of pediatric cancer. Our study aimed to examine concordance of parent- and child-reported PTG with taking into account the parents’ own level of PTG. We found poor parent–child concordance, with parents reporting higher levels of PTG for their children than the children themselves. When assessing their child’s PTG, parents are influenced by their own level of PTG. These findings provide implications for the research on psychosocial outcomes of pediatric cancer using a multi-informant perspective as well as for the topic of veracity of PTG in general.

Abstract

This article aimed to analyze concordance of parent- and child-reported child posttraumatic growth (PTG) following pediatric cancer, the influence of the parents’ own level of PTG on the level of concordance and the influence of the parents’ and the child’s own level of PTG on the parents’ proxy reports of PTG in the child. The sample included 127 parent–child dyads. The children provided self-reports of PTG and the parents provided reports of their own as well as the child’s PTG. Overall, the results showed poor parent–child agreement on the child PTG, with the parents proxy-reporting higher levels of PTG than the children. The parents’ proxy reports of the child PTG were the most accurate at the lowest levels of the parents’ own level of PTG. The parents’ own level of PTG was a stronger predictor of the parents’ proxy reports than the child self-reported PTG. The results suggest that parents are not very accurate reporters of PTG in the child; therefore, their reports should be completed with child self-reports whenever possible.

Perceived Health among Adolescent and Young Adult Survivors of Childhood Cancer

Survivors of childhood cancer (SCCs) are at increased risk of late effects, which are cancer- and treatment-related side-effects that are experienced months to years post-treatment and encapsulate a range of physical, cognitive and emotional problems including secondary malignancies. Perceived health can serve as an indicator of overall health. This study aims to (1) understand how a patient reported outcome (PRO) of perceived health of SCCs compares to controls who have not had a cancer diagnosis and (2) examine the relationships between perceived health and demographic and clinical variables, and health behavior. A total of 209 SCCs (n = 113 (54.10%) males; median age at diagnosis = 6.50 years; median time off treatment = 11.10 years; mean age at study = 19.00 years) were included. SCCs completed annual assessments as part of Long-Term Survivor Clinic appointments, including a question on perceived health answered on a five-point Likert scale. Data were collected retrospectively from medical charts. Perceived health of SCCs was compared to a control group (n = 836) using data from the 2014 Canadian Community Health Survey. Most SCCs (67%) reported excellent or very good health. The mean perceived health of SCCs (2.15 ± 0.91) was not statistically different from population controls (2.10 ± 0.87). Pain (B = 0.35; p < 0.001), physical activity (B = −0.39; p = 0.013) and concerns related to health resources (B = 0.59; p = 0.002) were significant predictors of perceived health. Factors shown to influence SCCs’ perceived health may inform interventions. Exploration into how SCCs develop their conception of health may be warranted.

Reasons for disagreement between proxy-report and self-report rating of symptoms in children receiving cancer therapies

PURPOSE

To qualitatively describe reasons for disagreement in ratings of bothersome symptoms between child self-report and parent proxy-report.

METHODS

We enrolled child and parent dyads, who understood English and where children (4-18 years of age) were diagnosed with cancer or were hematopoietic stem cell transplantation (HSCT) recipients. Each child and parent separately reported symptoms using self-report or proxy-report Symptom Screening in Pediatrics Tool (SSPedi). We then used semi-structured interviews to elicit reasons for discrepancies in symptom reporting.

RESULTS

We enrolled 12 dyads in each of four age cohorts, resulting in 48 dyads. Forty-one dyads (85.4%) had disagreement in rating the presence or absence of at least one symptom. Themes identified as reasons for disagreement included (1) perception, differing perception of symptom or availability or palatability of intervention; (2) understanding, difficulty orienting to time frame or concept of bother; (3) lack of communication, including child not acknowledging or talking about experiences; (4) projection, of how the parent felt or how they assumed the child would feel; and (5) discrepancy, in how the amount of symptom bother that was initially reported on SSPedi, by either child or parent, did not align with what was reported during the dyad discussion.

CONCLUSION

We identified themes that explained disagreement in ratings of bothersome symptoms between child self-report and parent proxy-report. Some disagreement may be reduced by enhancing communication about symptom reporting between child and parent. Future research should focus on methods of symptom screening that encourage communication between children with cancer and their caregivers.

Comparison of child and family reports of health-related quality of life in pediatric acute lymphoblastic leukemia patients after induction therapy

BACKGROUND

This study aims at determining the health-related quality of life (HRQOL) of children with acute lymphoblastic leukemia (ALL) after the induction therapy, assessing the agreement between child self-reports and family proxy-reports HRQOL, and determining the factors related to this agreement, especially child age, family attendance, and children's social relationships beyond the family.

METHODS

We analyzed questionnaire data (2012-2017) from the Japanese Pediatric Leukemia/Lymphoma Study Group's clinical study (ALL-B12). Participants were children with B-cell precursor ALL aged 5-18 and their family members, who mostly took care of the child during hospitalization. Participants answered the Pediatric Quality of Life Inventory™ (PedsQL™) Generic Core Scales (PedsQL-G), and Cancer Module (PedsQL-C) to measure pediatric HRQOL. We calculated the differences between child self-reported and family proxy-reported subscale scores along with intraclass correlation coefficients (ICC). We conducted multiple regression analyses according to all participant pairs and age groups (young children, school age, and adolescents), with ICCs for all PedsQL-G subscales (ICC-G) and all PedsQL-C subscales (ICC-C) as the outcome variables.

RESULTS

Five hundred twenty-two pairs of children and their families were analyzed. We observed a moderate level of agreement on most PedsQL subscales between child self-reports and family proxy-reports; however, worry had the weakest agreement for all PedsQL subscales (ICC = .32, 95% confidence interval = .24-.40). The agreement of ICC-C was positively related to family attendance in the hospitalization, only for the young children group (B = .185, p = .003).

CONCLUSIONS

We observed some differences between child self-reports and family proxy-reports of HRQOL of children with ALL. Both child self-reports and family proxy-reports captured HRQOL in the induction therapy. We suggest that attending to young children's hospitalization affects the level of agreement between reports on their HRQOL.

Sleep Disturbances in Survivors of Pediatric Acute Lymphoblastic Leukemia and Their Siblings

OBJECTIVE

Sleep disturbances have been identified by patients with cancer as common and distressing; however, conflicting evidence about the prevalence of these outcomes exists for survivors of childhood cancers. Additionally, little is known about how the experience of cancer might impact survivor siblings' sleep. The current study compared the sleep of survivors of acute lymphoblastic leukemia who were 2-7 years off therapy and their siblings to healthy control/sibling dyads.

METHODS

Participants (survivors, n = 45; survivor siblings, n = 27; controls, n = 45; control siblings, n = 41; 58% male) aged 8-18 (m = 11.64) completed a 7-day sleep diary and seven consecutive days of actigraphy. Parents (n = 90) completed the Children's Sleep Habits Questionnaire for each of their children.

RESULTS

No between-group differences were found on measures of sleep diaries or actigraphy. Parents reported that survivor siblings had significantly poorer sleep habits than survivors or controls. For survivors, greater time off treatment and younger age at diagnosis were associated with less total sleep time, more wake after sleep onset, and decreased sleep efficiency via actigraphy.

CONCLUSION

Sleep across all groups was consistent and below national guidelines. Although the survivor group did not have poorer sleep compared to their siblings or matched controls, within the survivor group, those who were diagnosed at an earlier age and those who were further off treatment had more disrupted sleep. Parent reports suggested that survivor siblings may be at risk for sleep problems.

Quality of life and associated factors in siblings of children with severe motor and intellectual disabilities: A cross-sectional study

This study examined quality of life and its associated factors in siblings of children with severe motor and intellectual disabilities in Japan. The participants were 789 siblings of children with a disability and their primary caregivers. We used the Kinder Lebensqualität Fragebogen questionnaire to assess the quality of life of siblings. The mean age of the siblings was 12.21 ± 3.07 years, and the mean quality of life score was 69.63 ± 12.55 points, which is higher than that of the general population of children of the same age. It was revealed that the following factors contributed to higher quality of life scores: a closer relationship with the child with a disability, younger age, the primary caregiver's lower care burden, later birth order of siblings (i.e., younger siblings), higher family empowerment, and female gender of siblings. The relationship with the child with a disability had the strongest influence on siblings' quality of life. Our study suggests the need for nursing interventions that focus on the whole family to enhance siblings' quality of life.

The Paediatric Haemophilia Activities List (pedHAL) in routine assessment: changes over time, child-parent agreement and informative domains

Introduction

The Paediatric Haemophilia Activities List (pedHAL) assesses self‐reported limitations in activities and participation in children with haemophilia.

Aim

To assess longitudinal changes, child‐parent agreement and to identify which pedHAL domains yielded most information in boys with access to early prophylaxis.

Methods

The pedHAL (53 items, 7 domains, optimum 100) was completed annually at the Van Creveldkliniek by boys aged 4‐18 years with moderate/severe haemophilia and their parents. Development of the pedHAL in relation to bleeds, changes per domain over 3‐5 years, child‐parent agreement (% difference child‐parent≤|5|) per domain and domain scores (limitations defined as ≤ 95) were determined.

Results

Seventy‐three patients and their parents (92% severe haemophilia, median age 13.1 years [range 5.4;18.0]) completed ≥1 pedHAL. Median (IQR) pedHAL sum score was 99.5 (95.2;100.0) for children and 99.6 (95.8;100.0) for parents. If patients scored >95 and had no joint and/or muscle bleed, 90.9% of the patients scored >95 at the next assessment. The median change in sum score was 0.0 for both the 3‐ and 5‐year interval. Child‐parent agreement varied between domains from 92% (‘self‐care’) to 71% (‘sitting/kneeling/standing’). Most limitations were reported in the domains ‘sitting/kneeling/standing’, ‘functions of the legs’ and ‘leisure activities and sports.’

Conclusion

In routine clinical practice in Dutch children on prophylaxis, pedHAL scores were high and remained stable in 3‐5 years at group level. In individual patients without joint and/or muscle bleeds, pedHAL scores remained high after 1 year. Child‐parent agreement was not optimal which indicated that both child report and parent proxy should be reported.

Physical activity and fitness among pediatric cancer survivors: a meta-analysis of observational studies

PURPOSE

The number of pediatric cancer survivors has increased dramatically over recent decades. Prior studies involving pediatric cancer survivors have reported reduced physical activity and fitness levels. Thus, the aim of this meta-analysis was to synthesize previous findings on physical activity and fitness levels of pediatric cancer survivors, who had completed cancer treatment and are in complete remission compared with age-matched, non-athletic healthy controls with no history of cancer diagnosis.

METHODS

Three electronic databases (PubMed, Web of Science, and EBSCO) were searched using a combination of 24 terms. Observational studies examining the post-treatment physical activity and/or fitness levels of pediatric cancer survivors compared with that of non-cancer controls and published in peer-reviewed, English-language journals before August 22, 2018 were eligible. Random-effect models were used in Comprehensive Meta-Analysis software for effect-size estimations of eight studies for physical activity and eight for fitness.

RESULTS

The studies included a total sample of 2628; 1413 pediatric cancer survivors and 1215 non-cancer controls. Both physical activity and fitness were significantly lower in childhood cancer survivors than in non-cancer controls (g = - 0.889; 95% confidence interval [CI] = - 1.648 - 0.130; p = 0.022) and (g = - 1.435; 95% CI = - 2.615 - 0.225; p = 0.017), respectively, with high heterogeneity.

CONCLUSIONS

Pediatric cancer sequelae and its treatment may limit participation in physical activity and fitness activities by survivors of pediatric cancer. Accentuating the need to incorporate physical activity and fitness into treatment protocols and post-treatment recommendations may improve pediatric cancer survivors' health and well-being.

Quality of life in pediatric cancer survivors: contributions of parental distress and psychosocial family risk

Background

Pediatric survivors of childhood cancer are at increased risk of poor quality of life and social-emotional outcomes following treatment. The relationship between parent psychological distress and child adjustment in pediatric cancer survivors has been well established. However, limited research has examined the factors that may buffer this association. The current study examined the associations between psychosocial family risk factors, parental psychological distress, and health-related quality of life (hrql) in pediatric cancer survivors.

Methods

Fifty-two pediatric cancer survivors (34 males, 18 females, mean age = 11.92) and their parents were recruited from a long-term cancer survivor clinic. Children and their parents who consented to participate completed the Pediatric Quality of Life Inventory 4.0. Parents completed a demographic information form, the Psychosocial Assessment Tool (pat 2.0) and the Brief Symptom Inventory (bsi). The Intensity of Treatment Rating (itr-3) was evaluated by the research team.

Results

Multiple regression analyses revealed that parental psychological distress negatively predicted parent-reported hrql, while treatment intensity, gender, and psychosocial risk negatively predicted parent and child-reported hrql. Psychosocial risk moderated the association between parent psychological distress and parent-reported child hrql (p = 0.03), whereby parents with high psychological distress but low levels of psychosocial risk reported their children to have higher hrql.

Conclusion

Low levels of family psychosocial risk buffer the impact of parent psychological distress on child hrql in pediatric cancer survivors. The findings highlight the importance of identifying parents and families with at-risk psychological distress and psychosocial risk in order to provide targeted support interventions to mitigate the impact on hrql.

Social adjustment and repressive adaptive style in survivors of pediatric cancer

PURPOSE

The aim of the study was to explore the relationship between repressive adaptive style and self-reports of social adjustment in survivors of pediatric cancer compared to their siblings. We hypothesized that there would be a greater proportion of repressors among survivors of pediatric cancer compared to siblings, and that repressive adaptive style would be significantly associated with more positive self-reports of social adjustment.

METHODS

We utilized a cross-sectional approach. Seventy-seven families participated. Survivors of pediatric cancer (n = 77, 48% male; 8-18 years of age) and one sibling (n = 50, 48% male; 8-18 years of age) completed measures assessing repressive adaptive style and social adjustment. As well, one parent from each family completed a socio-demographic questionnaire. Questionnaire packages were mailed to eligible families who agreed to participate, and were mailed back to investigators in a pre-addressed, pre-stamped envelope.

RESULTS

Chi-square analyses revealed there was no significant difference in the proportion of repressors among survivors and siblings. Social adjustment scores were subjected to a two (group: survivor, sibling) by two (repressor, nonrepressor) ANCOVA with gender and age as covariates. There was a significant main effect of repressive adaptive style (F = 5.69, p < .05, η² = 0.05) with a modest effect. Survivors and siblings with a repressive style reported significantly higher social adjustment scores (M = 106.91, SD = 11.69) compared to nonrepressors (M = 99.57, SD = 13.45).

CONCLUSIONS

Repressive adaptive style explains some of the variance in survivors and siblings' self-reports of social adjustment. Future research should aim to better understand the role of the repressive adaptive style in survivors and siblings of children with cancer.

Could we use parent report as a valid proxy of child report on anxiety, depression, and distress? A systematic investigation of father-mother-child triads in children successfully treated for leukemia

BACKGROUND

Systematic assessment of emotional distress is recommended in after care. Yet, it is unclear if parent report may be used as a proxy of child report. The aim of this study was to assess agreements and differences and explore possible moderators of disagreement between child and parent ratings.

METHODS

Sixty-two young survivors treated for acute lymphoblastic leukemia (9-18 years) and both parents responded to the Beck Youth Inventory (anxiety and depression) and the distress rating scale on the child's status. Parents completed the Brief Symptom Inventory-18 on their own psychological status. Systematic analyses of agreement and differences were performed.

RESULTS

Mother-child and father-child agreements were fair on anxiety, depression, and distress (median intraclass correlation coefficient = 0.37). Differences between parents and children were medium sized (median d = 0.55) with parents giving higher scores than their children on anxiety, depression, and distress. Mothers reported distress more frequently than fathers (39 vs. 17%) when children reported none. The child being female and lower parental income were associated with lower agreement in fathers when rating child distress. Higher levels of parental psychological symptoms were consistently associated with lower agreement.

CONCLUSIONS

Parent-child differences when rating adolescent survivors' difficulties may be more important than previously thought. Parent report probably cannot be considered as a valid proxy of older child report on such internalized domains as anxiety, depression, or distress in the after-care clinic. Parents' report is also likely to be influenced by their own mood, a factor that should be corrected for when using their report.

Systematic review and meta-analysis of health-related quality of life in pediatric CNS tumor survivors

BACKGROUND

Pediatric central nervous system (CNS) tumor survivors are at high risk for numerous late effects including decreased health-related quality of life (HRQOL). Our objective was to summarize studies describing HRQOL in pediatric CNS tumor survivors and compare HRQOL outcomes in studies that included a comparison group.

PROCEDURE

EMBASE, MEDLINE, and PsychINFO were used to identify relevant articles published until August, 2016. Eligible studies reported outcomes for pediatric CNS tumor survivors diagnosed before age 21, at least 5 years from diagnosis and/or 2 years off therapy and used a standardized measure of HRQOL. All data were abstracted by two reviewers. Random-effects meta-analyses were performed using Review Manager 5.0.

RESULTS

Of 1,912 unique articles identified, 74 were included in this review. Papers described 29 different HRQOL tools. Meta-analyses compared pediatric CNS tumor survivors to healthy comparisons and other pediatric cancer survivors separately. HRQOL was significantly lower for CNS (n = 797) than healthy comparisons (n = 1,397) (mean difference = -0.54, 95% confidence interval [CI] = -0.72 to -0.35, P < 0.001, I² = 35%). HRQOL was also significantly lower for CNS (n = 244) than non-CNS survivors (n = 414) (mean difference = -0.56, 95% CI = -0.73 to -0.38, P < 0.00001, I² = 0%).

CONCLUSIONS

Pediatric CNS tumor survivors experience worse HRQOL than healthy comparisons and non-CNS cancer survivors. Future HRQOL work should be longitudinal, and/or multisite studies that examine HRQOL by diagnosis and treatment modalities.